2017 No. 3 • Get Healthy Bulletin | 1CeltiCareHealth.com

BULLETIN

2017 Vol. 2, No. 3

Get the Right Care We want you to get the right care, at the right time, and in the right place. Utilization Management is how we make decisions about paying for care and services. Your doctor will tell us about why you need a service. CeltiCare Health clinical staff will make a decision based on:

▪ What is covered ▪ If the service is needed

▪ If the service works well ▪ If the service is right for you

We will make a decision as soon as possible based on your med-ical condition. Covered Services that you get must be Medically Necessary. CeltiCare Health uses standard guidelines to check Medical Necessity.

CeltiCare Health has policies in place to ensure:

▪ Decisions are made based on the appropriateness of the care and service, and that coverage is in place.

▪ The organization does not reward its Network Providers or their staff to deny coverage, service, or care.

▪ Financial incentives for decision makers do not encourage decisions that result in denying needed treatment. CeltiCare Health does not reward doctors or staff for saying “no” to care.

When we make a choice to deny, reduce, or stop certain services, we will write to you and your doctor. This letter will explain our choice. It will also tell you how to tell us if you are unhappy with the choice. This is called “appealing” the decision. If you decide to appeal, you will not be treated differently.

Want to talk to someone in Utilization Management? Call 1-855-678-6975 for more information: Monday through Wednesday 8 a.m. to 8 p.m. and Thursday through Friday 8 a.m. to 5 p.m.

Tobacco CessationReady to quit tobacco? CeltiCare Health can help!

As part of your coverage, CeltiCare Health works with health coaches to provide you with a personalized plan to help you quit tobacco. The Tobacco Cessation Program also includes coverage for counseling sessions and drug therapy. Contact Member Services at 1-855-678-6975 for details.

2017 Vol.2, No. 3 • Get Healthy Bulletin | 2CeltiCareHealth.com

Fall into Good HealthFall may bring apple picking and colorful leaves, but it also means that cold and flu season has arrived. Luckily, a flu shot and good health habits can help you avoid getting sick. Follow these steps:

Get your flu shot. Everyone 6 months and older should get the flu shot. It’s a smart way to help you, your family, and your community stay healthy. New research shows that when healthy children and adults get vaccinated, it reduces the spread of the flu. It’s especially important for these people to get a flu vaccine:

▪ Adults 50 and older

▪ Adults with chronic conditions such as asthma or heart disease

▪ Pregnant women

▪ People who live in or work at a nursing home

Wash your hands. The next best thing you can do to protect yourself from flu and colds is to wash your hands regularly with soap and water. Scrub your hands for at least 20 seconds, and be sure to scrub between your fingers and under your nails.

Don’t touch your face. There are more than 200 viruses that cause the common cold. They live on everything you touch, including doorknobs, railings, and shopping carts. To limit the spread of germs, keep your hands away from your eyes, nose, and mouth.

Avoid big crowds. If cold and flu are going around in your community, limit your time in public spaces or big gatherings. Also try to avoid con-tact with people who might be sick with cold or flu until they feel better.

Eat healthy foods. Help fight cold and flu naturally by eating plenty of vitamin-rich fruits and vegetables. Eat foods that are high in vitamin C, such as red bell peppers and broccoli, to boost your immune system.

Get your sleep. Lack of sleep weakens your body’s natural defens-es against illness. Aim to get 7 to 8 hours of sleep each night. To wind down, turn off TVs, phones, and computers 1 hour before bedtime.

Prior Authorization for ServicesWhen you need care, always start with a call to your healthcare Provider. Some Covered Services or drugs may need Prior Authorization. Some may need review by CeltiCare Health before services or prescriptions are provided. This includes services or visits to:

▪ An out of Network Provider

▪ Some Specialists

▪ Home health services

▪ Certain surgeries

▪ Certain medications

Your healthcare Provider can tell you if a service or prescription needs Prior Authorization before you can get it. For more information visit CeltiCare Health’s website at CeltiCareHealth.com. You can also call Member Services at 1-855-678-6975.

How We Evaluate New Healthcare SolutionsCeltiCare Health is always looking at new technology, including medical procedures, drugs and devices to find ways to make you healthier. The medical staff at CeltiCare Health will decide if changes should be made to your plan based on new information. To learn more about this process, visit CeltiCareHealth.com or check out your Member Handbook.

We Care About Your PrivacyWe know you want your medical information to stay private. Your medical information is called protected health information and we want to keep it safe for you.

We follow state laws and federal laws to keep it private. You can read the full text of our notice of privacy prac-tices in your Member Handbook. For other questions about your privacy:

▪ Visit our website at CeltiCareHealth.com.

▪ Call CeltiCare Health Member Services at 1-855-678-6975.

2017 Vol.2, No. 3 • Get Healthy Bulletin | 3CeltiCareHealth.com

Improving the Quality of Your Health PlanCeltiCare Health cares about you and the healthcare you get. We have many quality improvement projects to help us know if the services we are providing are good for you. We want to tell you how we’re doing this year and what we’re doing to improve your health now. Visit CeltiCareHealth.com and go to the Quality Improvement Program page to learn about our projects!

Urgent CareAn Urgent Care condition is a health problem that is serious—but that you do not think is an Emergency. Your PCP must see you within 48 hours after your request for an Urgent Care appointment. Your Behav-ioral Health Provider must also see you within 48 hours for Urgent Care for Behavioral Health conditions.

If your Urgent Care condition gets worse before you see your PCP or Behavioral Health Provider, you can go to an Emergency room. Even if you are out of town or out of the Service Area, you should call your PCP if an Urgent Care condition occurs.

When you need Urgent Care, follow these steps:

▪ Call your PCP. The name and phone number are on the Welcome Letter in your Welcome Packet. Your PCP may give you directions over the phone.

▪ If you have changed your PCP since you first got your ID Card, refer to the PCP Change Notification that you were sent upon changing your PCP to find the contact information for your current PCP.

▪ If it is after hours and you cannot reach your PCP, the PCP office voice mail will either have another number for you to call for after-hours coverage or you will reach an answering service and another covering Provider will call you back.

▪ You can always call our after-hours nurse line at 1-855-678-6975 (TDD/TTY 1-866-614-1949). You will be connected to a nurse. Have your CeltiCare Health ID card number handy. The nurse may help you over the phone or direct you to other care.

Get to Know Your Health Plan Knowing your plan benefits is important. One easy way to learn more is to visit our website, CeltiCareHealth.com. You can also review your Member Handbook. Both resources provide information about:

▪ Member Benefits

▪ How to access emergency care and other medical services

▪ How to file an appeal

▪ Your rights and responsibilities

▪ The quality improvement program.

If you would like a hard copy of your Member handbook or have any questions you can call Member Services: Monday through Wednesday 8 a.m. to 8 p.m. and Thursday through Friday 8 a.m. to 5 p.m.

Enrollment and Disenrollment There will be an annual open enrollment period for Massachusetts Medicaid Care Management program members that the Massachusetts Executive Office for Health & Human Services and MassHealth will tell you about. During this period, you may choose another MCO health plan for any reason. If you want to change your health plan during open enrollment, please contact the Enrollment Center at 1-800-841-2900. You can also visit the state website at www.mass.gov/masshealth.

Disenrollment is the process of changing your health plan or coverage. That could mean you choose to sign up with another health plan, or when you are no longer eligible for Medicaid coverage.

You can ask to disenroll with or without cause. You must follow MassHealth processes to make this change. Reach out to MassHealth directly by calling or writing. We will ensure that your right to switch is not restricted in any way. Contact MassHealth Client Services at 1-800-841-2900 or in writing to:

MassHealth Enrollment CenterMA Executive Office for Health and Human Services45 Spruce StreetChelsea, MA 02150

For more information about enrollment and disenrollment, please refer to your Member Handbook.

How to Get InformationYou are always welcome to call Member Services with any questions you have. Did you know there is also information on CeltiCareHealth.com that can answer many of your questions?

On the website you can find:► Your Member Handbook ► How to find a doctor► Your member benefits ► How to file an appeal► How to access emergency care and other medical services► Your rights and responsibilities

More questions? Want a hard copy of your Member Handbook or other materials? Call Member Services: Monday through Wednesday 8 a.m. to 8 p.m. and Thursday through Friday 8 a.m. to 5 p.m. at 1-855-678-6975 TTY/TDD 1-866-614-1949.

Disclosure of Non-Discrimination: CeltiCare Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

CeltiCare Health cumple con las leyes de derechos civiles federales aplicables y no discrimina basándose en la raza, color origen nacional, edad, discapacidad, o sexo.

A CeltiCare Health cumpre com as leis federais de direitos civis aplicáveis e não discrimina com base em raça, cor, nacionalidade, idade, deficiência ou sexo.

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CeltiCare Health Plan of Massachusetts, Inc.™ (CeltiCare Health) is a managed care organization that provides health insurance to eligible residents of Massachusetts.

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