INSIDE:
• Employee Spotlight
• Annual Eye Exam
• Managing Your Cholesterol
• Need a Ride?
Happy Birthday to You!
Starting this past April, Community Health
Group began offering home delivered meals
to Cal MediConnect members in their birthday
month.
Since the program began, we have called over
1,400 Cal MediConnect members to wish them
a happy birthday – and offer them a meal
during their birthday month!
During the summer months, we have been
delivering a refreshing salad and sandwich
meal. We hope to deliver a meal to you soon!
Both our members and employees have
enjoyed this service!
“When I called the member to say happy
birthday, he was really appreciative of the
phone call. He told me that CHG is so nice
and thoughtful, and thanked me very
much for wishing him a happy birthday.
That was my favorite part of the calls.”
Medicare Services Specialist
“Thank you so very much for your
kindness …I feel so delightful and very
appreciative of you doing this for me.”
CHG Cal MediConnect member
Summer 2016
Employee Spotlight
My name is Yali Mendoza. I joined
Community Health Group in September
2003. During my time at CHG I have
worked in many different departments.
I have worked in the Referrals Department, the Behavioral Health Department, the High Risk Case Management
Department, and most recently, the
Medicare Services Department. In these
past 13 years, I have worked with both
providers and members to help coordinate health services.
One of my favorite quotes by Confucius
is “Choose a job you love and you will
never have to work a day in your life.”
This year, I joined the Medicare Services
Department as a Medicare Service Specialist. I feel that this role gives me the
chance to fully enjoy what I do every
day!
Being a Medicare Service Specialist
gives me the opportunity to connect
with members and learn with them
along the way. It gives me and Community Health Group the opportunity to
offer and provide assistance with care
coordination and resources available in
our community.
I want to empower our members and
help them access health care on their
own. It is extremely gratifying for me to
see the smile on their faces when they
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are taking steps towards their goals,
making progress, and meeting their personal goals of living a healthy and
happy life!
Annual Eye Exam
An annual eye exam helps detect the signs of health
conditions like high blood pressure, diabetes, and high
cholesterol—along with other eye and health issues.
Schedule your eye exam today!
Eye Exam Benefits - 2016
Type of Visit
Find a Doctor:
Exam and
Glaucoma
Screening
Vision Service Plan
(800) 438-4560
www.VSP.com
Additional Benefit
Coverage
$100 plan coverage
for eye glasses
every two years
If you need help making an appointment or have any questions,
please call our Customer Service Department at 1-888-244-4430.
They are available to help you, 24 hours a day, 7 days a week.
Managing your cholesterol
Managing cholesterol levels lowers the risk for heart disease — the leading
cause of death in the United States. Cholesterol levels are different for everyone.
Your doctor can determine the correct levels for you and if you need medication
to help control your levels. Statins are drugs that can lower your cholesterol.
A healthy lifestyle is the best way to control your cholesterol. Here are some
helpful tips:
• Eat fresh fruits and vegetables.
• Eat foods that are low in salt (sodium),
total fat, saturated fat and cholesterol.
• Be active. Exercise daily.
• Do not smoke. If you do smoke and want
to quit, ask to your doctor for help.
If your doctor has prescribed you medicine to help with your cholesterol, be sure
to take it as often as directed.
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Get the shot, not the flu!
Who should not get a flu shot?
Children less than 6 months of age
cannot receive the influenza
vaccination.
What should I do to prepare for the
flu season?
Everyone over 6 months of age should
get a yearly flu vaccine.
Please check with your doctor
before getting your flu shot if you:
• Are allergic to eggs
• Have had a severe (very bad)
reaction to a flu shot in the past
• Have illness with a fever
• Have a history of Guillain-Barre
Syndrome
What can I do to prevent the flu?
You and your family can help prevent
the flu by:
• Staying away from sick people
• Covering your mouth when you
cough
• Washing your hands to reduce the
spread of germs.
When should I get vaccinated?
Flu season runs from October until May.
Get the flu vaccine as soon as it is available. Once you get the vaccine, it takes
about two weeks for antibodies to
develop and protect against the flu.
Where can I get the flu shot?
You can get the vaccine through your
primary care physician or pharmacy.
There is no charge for this shot.
Who should get a flu shot?
• Anyone over 6 months old. Children
between 6 months of age and 8
years of age may need two doses to
be fully protected. Check with your
child’sdoctor.
• Pregnant women
• People 65 years of age and older
• People with chronic health conditions
like asthma, COPD, diabetes and lung
disease
•People who live in nursing homes and
other long-term care facilities.
Please stay home from school or work
if you or your child has the flu.
Don’t spread it to others!
If you have any questions or need
help making an appointment,
call Customer Service.
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Customer Service
1-888-244-4430
24 hours a day
7 days a week.
Need a ride?
Community Health Group can help you can get to your medical appointments.
Your health plan covers a taxi benefit of 15 round trip taxi rides per year (or 30
one-way taxi rides per year). These taxi rides are at no cost to you.
To request a taxi ride to a medical
appointment, call Customer Service
at 1-888-244-4430. Please call at least
5 days before your appointment.
You will need to tell us the date and
time of your appointment. We will
also need the doctor’s name, address
and phone number.
Model of Care
for Cal MediConnect Members
Community Health Group’s Cal MediConnect care model assesses and
addresses the needs of our dual eligible
Medicare members. Our chief goal is to
improve the care for Cal MediConnect
members through enhanced coordination and continuity of care. Community
Health Group is able to combine benefits available through Medicare and Medi-Cal in a way that is seamless for our
members.
The Centers for Medicare and Medicaid
Services (CMS) requires health plans to
make available annual training to practitioners on our model of care. We are
required to retain records to evidence
that contracted practitioners receive
training each year.
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Medical Bills
If you get a medical bill in the mail, don’t
ignore it! Call Customer Service.
We will find out why you received the bill
and help resolve the issue. If the bill is for a
service covered by your health plan, you
should not be billed.
Don’t let unpaid medical bills get reported
to a collection agency and show up on your
credit report. Call Customer Service as soon
as you can.
Call Customer Service
1-888-244-4430
24 hours a day, 7 days a week
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Your Rights as a Health Plan Member
Member Rights
You have the right to:
• Get information about CHG, its
services and its doctors and other
doctors in a way that may be easily
understood.
• Ask someone to explain or translate
if you don’t understand something
that is said or written. Providing
translation services would be at no
cost to you.
• Get information about your rights
and responsibilities as a CHG
member.
• Request an interpreter at no charge
to you.
• Use interpreters who are not your
family members or friends.
• Be treated with respect and dignity.
• Privacy.
• File a complaint if your linguistic
needs are not met.
• Choose a primary care doctor from
within our network of contracted
doctors.
• Prepare Advance Directives.
• Have your health records kept private.
• Participate with your doctor in
decision making about your health
care, and to refuse treatment.
• See your health records.
• Make recommendations about CHG’s
rights and responsibilities policies.
• An open and honest discussion of
your treatment options in spite of
cost or health plan benefits.
• Be free from any form of restraint or
seclusion used as a means of
coercion, discipline, convenience,
or retaliation.
• Get appointments within a reason
able amount of time.
• Complain about CHG or the care you
have gotten.
• Exercise these rights without
adversely affecting how you are
treated by CHG, its doctors,
or the State.
• Appeal when you don’t agree with a
decision CHG has made.
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Your Responsibilities as a Health Plan Member
Member Responsibilities
You have the responsibility to:
• Give correct information to CHG, its
doctors and other doctors so that
they can care for you.
• Keep follow-up visits with your doctor.
• Follow the plans and care directions
that you have agreed to with your
doctor and others who provide care
to you.
• Make and be on time for health
appointments or cancel appointments
at least one business day ahead of
time.
• Know your doctor’s name.
• Treat all CHG personnel and health
care doctors respectfully & courteously.
• Tell your doctor if you don’t want to
follow a treatment plan.
• Present your member ID card(s)
when getting health care. If you have
other insurance, take that card too.
• Go with your children who are under
age 18 (if they are enrolled in the plan)
when they are getting health care.
You can sign a form that allows the
child to be treated without you there.
• Use emergency services only in cases
of an emergency or as directed by
your doctor.
• Help CHG maintain accurate and
current records by providing timely
information about changes in address,
family status and other health coveage.
• Remember what your doctor tells
you about your health problem.
• Understand your health problems
and participate in developing
treatment goals.
• Notify CHG as soon as possible if you
get a doctor’s bill or if you have a
complaint.
• Ask questions if you don’t
understand what you are told.
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Your
Privacy
Utilization
Management Program
The privacy of your Protected Health
Information is important. We safeguard this information as it is collected, used and disclosed. We protect
information that is spoken, written or
put into electronic form. These rules
apply throughout our health plan and
at provider offices.
How your health plan makes decisions
Our decisions are based on making sure
our members have appropriate care and
services.
We use and disclose your health
information to:
• Provide treatment
• Pay providers for health care services
• Conduct usual health plan
operations.
If we want to share information with
anyone else or for any other reason,
we ask your permission in writing. The
only exceptions are those required or
allowed by law.
Our decision-making is based only on:
• Is the care or service appropriate?
• Is the care or service a covered
benefit of your specific health plan?
When we deny a request for services,
we send you and your provider a
written notice. The notice states why
the request was denied.
We review and update the clinical
criteria we use in making these
decisions at least once a year or as
needed. We add new developments in
clinical practice to our criteria.
We want our criteria to be up-to-date
and appropriate for our health plan
members.
You have the right to:
• Limit the use and sharing of your
Protected Health Information
beyond the reasons of treatment,
For more information about
payment or usual health plan
Utilization Management,
operations.
call Customer Service.
• Review your health information and
ask for amendments or additions
to it.
• Ask for a list of providers or others we
have shared your Protected Health
Information with.
• Receive a copy of our Notice of
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Privacy Practices.
Telephone Advice Nurse
Our Telephone Advice Nurse is like having a nurse in the family!
Call our nurses with your questions:
• How to take care of a problem at home
• Where to get urgent care
• How to get a prescription filled
Telephone Advice Nurse
24 hours a day, 7 days a week
1-800-647-6966
ER
or Urgent Care?
When to go to Urgent Care:
• Minor sprains
• Ear ache
• Fevers, colds or bronchitis
• Insect bites
• Mild asthma attacks
• Diarrhea
• Minor cuts
• Back pain
It can be hard to decide where to go if
you need quick medical care. Should
you go to the Emergency Room or an
Urgent Care Center?
When to go to the emergency room:
An emergency is a medical problem or
injury that puts a person’s life in
danger.
Some examples:
• Chest pain
• Trouble breathing
• Head injury
• Bleeding or vomiting that does not
stop
• Loss of consciousness
• Poisoning
• Major burns
• Choking
Call your doctor first!
It is best to call your family doctor for
non-emergency care. If you can’t reach
your doctor or don’t know his or her
name, call Customer Service. You also
can call our Telephone Advice Nurse
with your medical questions. Remember, we are available 24 hours a day, 7
days a week.
Customer Service
1-888-244-4430
In a medical emergency, go to the
nearest Emergency Room or call 911.
Please keep in mind that we have the
right to request that you dis-enroll from
our health plan if you use the ER for
non-emergency services.
Telephone Advice Nurse
1-800-647-6966
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Report Health Care Fraud!
Help us save valuable health care resources
by reporting fraud. If you think a
Community Health Group employee,
member or provider is involved in fraud,
we urge you to report it.
Fraud & Abuse Hotline
1-800-651-4459
You can leave a message 24
hours a day, 7 days a week.
A couple examples of fraud are:
• Using someone else’s card to get care or services.
• Doctors giving care that is not needed
Please report anything
that does not seem right
to you
How long do you have to wait for an appointment?
Your patience doesn’t need to last for too long! Here are the standards for waiting times.
TYPE OF APPOINTMENT
STANDARD
Within 10 working days
of your request
Routine doctor visits
Physical exams and wellness checkups
Within 30 calendar days
of your request
Initial Prenatal visit
Within 10 working days
of your request
Specialty care
Within 15 working days of
identifying your need to see a
specialist
Urgent care
Within 48 hours of your request
In an emergency, call 911 or go to the nearest emergency room.
Please call Customer Service if you have waited too long for
access to health care.
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Your Drug Benefit
Community Health Group has a
formulary for each health plan we
offer. A formulary is a list of drugs that
are covered by your health plan.
We review and revise this list at least
four times per year to stay up-to-date.
• Visit our website at www.chgsd.com,
or
• Call Customer Service to have a copy
mailed to you.
For questions about
your formulary
or drug benefit,
call Customer
Service.
To see the current formulary for your
health plan:
Language
Assistance Program
Health Plan Information
Community Health Group materials
are available in English, Arabic, Spanish, Tagalog and Vietnamese. We also
provide our materials in enlarged print
format, audio recordings and braille.
Community Health Group offers
language assistance at no charge to
our members. These free services
include:
Interpretation Services
We provide face-to-face translation
services and translation over the telephone. Please allow for three days
advance notice to arrange for
face-to-face interpreter services.
Please call us if we can
help you with language services!
Customer Service Department
1-888-224-4430
7 days a week – 24 hours a day
Teletypewriter (TTY)
To access our toll-free teletypewriter
(TTY) services, call Customer Service
at (855) 266-4584.
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Medication Therapy Management Program
for Cal MediConnect Members
If you are a Cal MediConnect member
and you take medications for different
medical conditions, you may be
eligible to get services, at no cost
to you, through a medication therapy
management (MTM) program.
This program helps you and your
provider make sure that your
medications are working to improve
your health. A pharmacist or other
health professional will give you a
comprehensive review of all your
medications and talk with you about:
• How to get the most benefit from
the drugs you take
• Any concerns you have, like
medication costs and drug reactions
• How best to take your medications
• Any questions or problems you
have about your prescription and
over-the-counter medication
about your action plan and medication
list. Bring your action plan and medication list with you to your visit or anytime
you talk with your doctors, pharmacists,
and other health care providers. Also,
take your medication list with you if you
go to the hospital or emergency room.
You’ll get a written summary of this discussion. The summary has a medication
action plan that recommends what you
can do to make the best use of your
medications. You’ll also get a personal
medication list that will include all the
medications you’re taking and why you
take them.
Medication therapy management programs are voluntary and free to members that qualify. If we have a program
that fits your needs, we will enroll you in
the program and send you information.
If you do not want to be in the program,
please let us know, and we will take you
out of the program.
It’s a good idea to schedule your medi- If you have any questions about these
cation review before your yearly “Well- programs, please contact Customer Serness” visit,so you can talk to your doctor vice or your personal care coordinator.
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Community Health Group’s Affirmative
Statement about Financial Incentives
Community Health Group affirms that:
• Utilization Management (UM) decision-making is based only on appropriateness
of care and service, and existence of coverage.
• We do not specifically reward practitioners or other individuals conducting
utilization review for issuing denials of coverage, service, or care.
• Financial incentives for UM decision-makers do not encourage decisions that
result in underutilization.
For more information about Community Health Group’s UM decision-making
process, please contact Yousaf Farook, FMG, Utilization Management Manager
at (619) 498-6423.
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Community Health Group Formularies
For any questions regarding the formulary or your drug benefit, contact
our Customer Service Department at
(888) 244-4430. You may also request
that a copy of the formulary be mailed
to you.
Community Health Group has a special formulary for our Cal MediConnect members. A formulary is a list of
medicines approved to treat our plan
members. We review and revise this
list at least four times per year.
The most up-to-date version is posted
on our website (www.chgsd.com). Additions, changes and updates can be
found just before the Index. Future
Part D formulary changes are posted
on our Cal MediConnect web page.
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Customer Service Dept. #23
2420 Fenton Street, Suite 100
Chula Vista CA 91914
Change Service Requested
PRSRT STD
U.S. POSTAGE
PAID
PERMIT NO.2114
SAN DIEGO, CA