Your WEA Trust Health Plan - Welcome Maddy Provider Network High Value Care Options Pharmacy Preventive Care - Stevens Point Area Public School ...
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Your WEA Trust Health Plan A G U I D E T O YO U R B E N E F I T S : Welcome Maddy Pharmacy Provider Network Preventive Care High Value Care Options Member Benefits
Welcome to WEA Trust There are a few things you need to know about getting started with your plan. This guide will provide you with a quick overview of the following: ▸▸ Your ID Cards ▸▸ Harmony Care Management ▸▸ Maddy (Member Portal) ▸▸ Pharmacy Information ▸▸ Where to go for Care ▸▸ Enhanced Care Solutions ▸▸ Health Insurance 101 ▸▸ Legal Information ▸▸ Preventive Care ▸▸ Privacy Practices You will find helpful links throughout this booklet to make it more convenient to find what you’re looking for online, quickly and easily. Questions? We are here to help! If you have questions about your current plan, we’ll get you the answers you need. Speak to one of our Customer Service Representatives: 1.800.279.4000 Monday – Friday, 7:30 a.m. - 5:00 p.m. online at: WEAtrust.com/contact-us or MaddyPortal.com 2 | Welcome to WEA Trust
Your WEA Trust ID Card Your ID card represents the commitment of everyone who works at WEA Trust to provide the best possible service to you. You’ll receive copies of your ID card in the mail before the start date of your benefits. Please begin using your new cards on your effective date. You can print or order additional ID cards for you and your family from our online member portal, Maddy. To access or create your account, visit MaddyPortal.com. Maddy Member Portal You can access all the important information about your benefits online on our member portal, Maddy. C R E AT E A M A D DY A C C O U N T: ▸▸ Make sure you have your WEA Trust ID Card with you ▸▸ Go to MaddyPortal.com ▸▸ Register for an account WITH MADDY, YOU’LL BE ABLE TO QUICKLY AND EASILY: ▸▸ Review Your Benefits ▸▸ Look Up Drug Coverage ▸▸ View Your Recent Claims ▸▸ View Deductible Progress ▸▸ Find a Doctor ▸▸ Message Customer Service To create your member portal account, visit: MaddyPortal.com and download the app in the App Store or Google Play Store. WEA Trust ID Cards & Maddy | 3
Find a Doctor Subscriber: Jo ID#: 000000 hn Member 00 Network: Tr 0 Group#: 000.00 ust Preferre When looking for a doctor, we always Subscriber / Dependen ts: d Issued: 07 /01/16 John Memb er Jane Memb recommend first making sure that er 00000000 0-01 00000000 1-02 doctor is in WEA Trust’s Network. You Copays: NE TWORK: PC can search for a provider by going to UC: $150 P $25 / SP | ER $250 EC $50 | NO N-NETWOR K: PCP $50 / SPEC $10 0 WEAtrust.com/doctors and then What Network do you selecting your network. have? Check your ID card. Where To Go For Care COST CONDITION EXAMPLES CARE OPTION ESTIMATE TIPS Minor Acute • Sore throat 24/7 Amwell $ To learn more about Conditions • Ear infections Urgent Care Amwell or to sign • Pink eye E-Visits up, visit WEAtrust.com/ Amwell Routine Care • Preventive Primary Care $$ To see if your doctor exams is in network, visit • Chronic WEAtrust.com/ conditions FindADoc • Immunizations Urgent • Minor burns Urgent Care $$$$ Select “urgent care” Conditions • Sprains Center under “care type” on • Cuts WEAtrust.com/Find • Rashes ADoc to find a • Fractures location near you Emergencies • Heart attack Emergency $$$$$ Select “hospital” on • Stroke Room WEAtrust.com/Find • Head trauma ADoc to find a location near you 4 | Where to Go For Care
Health Insurance 101 We all know how complex and confusing health insurance can be. Below are some common terms and descriptions to help you better understand what you have to pay and when. Please look at your plan documents for specific plan information. Benefit year: a benefit year, also called a plan year, is a 12-month period of time during which you have insurance coverage. To find out when your plan year begins, you can check your plan documents, ask your employer, or call WEA Trust Customer Service. Premium: a monthly payment made to your insurance company for your health insurance coverage. You may pay the insurance company directly, or your employer may deduct money from your paycheck and pay the premium to the insurance company for you. Maximum Out of Pocket: the maximum out of pocket amount is the most money you will have to pay each benefit year for covered medical expenses as outlined in your plan document. This includes the amounts you pay for copays, deductibles, and coinsurance. It does not include your monthly premium. Once the amount of money you have paid equals your maximum out of pocket amount for that benefit year, you do not have to pay anymore deductibles, copays, or coinsurance. Your WEA Trust health plan will pay 100% of allowed amounts for covered services for the remainder of the benefit year. Health Insurance 101 | 5
Co-pay: a fixed dollar amount that you pay for certain services (i.e. office visits, prescriptions) each time you have that service. For example, if your insurance plan includes a $30 office visit co-pay, you will pay $30 at the doctor’s office each time you see your doctor, until you reach your maximum out of pocket amount. Deductible: the amount you pay to your doctor or pharmacy for covered services each benefit year before your WEA Trust health insurance begins to pay. Coinsurance: a percentage of the allowed cost of a covered service that you pay to your doctor. Your WEA Trust health plan pays the remaining share. For example, if a benefit plan includes a 10% coinsurance and the doctor charges $100, you will pay $10 (10%) and WEA will pay $90 (90%). You do not start to pay coinsurance until after you have finished paying your deductible. Other costs you may also be charged for: ▸▸ Services or items that are not covered by your benefit plan ▸▸ Services that were not pre-approved, but that require pre- approval in order to be covered by your health insurance plan ▸▸ Services performed by an out of network provider, depending on the amount your health insurance plan covers for services performed by these providers 6 | Health Insurance 101
Preventive Care Preventive care helps you stay healthy and helps to identify any potential health care concerns. WEA Trust follows federal guidelines for defined preventive services, outlined by the U.S. Preventive Services Task Force (USPSTF). Your plan covers 100% of the cost of preventive services, as long as the service is: ▸▸ Provided by a Network provider ▸▸ Performed for preventive (not diagnostic) reasons ▸▸ The service meets the specified age and/or time criteria and is on the list defined by the USPSTF, available at WEAtrust.com/prevent Be sure to ask your doctor or call WEA Trust customer service if you have questions about preventive care. DIAGNOSTIC CARE So what is diagnostic care and how is it different from preventive care? A service is considered diagnostic when the individual has signs or symptoms or an existing health issue is being monitored. Here’s an example using a mammogram: MARY ABBY Mary is 41 years old and had her Abby is 48 years old and yearly mammogram in January has no symptoms of breast which was normal. In July, she cancer but has a routine finds a lump and schedules a mammogram to screen for mammogram to check it out. problems. Diagnostic Preventive Cost-sharing applies 100% Covered Preventive Care | 7
Harmony Care Management A single point of contact to help in your medical care. W H AT I S H A R M O N Y ? When you have a healthcare need, someone you can count on should be there for you. That’s why our Harmony Care Management program provides a single point of contact to help in your medical care. Your Harmony nurse will help you navigate the healthcare system and receive the best quality care. Harmony Can Help With: CHRONIC CONDITION MANAGEMENT From diabetes to high blood pressure, our nurses are ready to help FINDING A PROVIDER Simplify the process of finding the right doctor for you H O S P I TA L S TAY S Take the stress out of a planned stay Preauthor iza t io n Some services require preauthorization before you receive them to make sure they are medically necessary and appropriate. If you don’t contact us for preauthorization, you could be denied coverage or pay a penalty. ▸▸ Go to WEAtrust.com/preauthorization to view the full list 8 | Harmony Care Management and Preauthorization
Pharmacy Benefits When you join the Trust, if a medication you’re taking requires authorization or is subject to step therapy, both you and your doctor will receive a letter explaining your options. You may be approved for one refill as you transition to the new medication or verify authorization for your current medication. T H R E E T H I N G S TO K N O W A B O U T YO U R W E A T R U S T D R U G P L A N 1. Save with the Value Choice Drug Plan If you’re on our Essential Health Plan, these effective drugs are available to you at a $0 copay. If you’re on an Essential Qualified Plan, you’ll find that these drugs are some of the best value options. ▸▸ View the full list at WEAtrust.com/VCDP 2. Save time with home delivery In addition to our broad retail pharmacy network, you also have access to mail order prescription services. ▸▸ Learn more at WEAtrust.com/mail 3. Check your copay, find a pharmacy & more You can access a great set of pharmacy tools by logging in to your Maddy account and selecting MedImpact from the quick links menu.
WEA Trust Telehealth Powered by Amwell, WEA Trust Telehealth provides access to board-certified healthcare professionals from anywhere you need care. Urgent Care See a doctor online 24/7 with WEA Trust Telehealth. In less than ten minutes, you can start a doctor e-visit on your smartphone, tablet or computer. 1. Enroll Go to WEAtrust.com/Amwell on your computer or search for Amwell in the App Store or Google Play on your mobile device. ▸▸ Important: Enter the service key “trust” DON’T WAIT UNTIL YOU’RE SICK, DOWNLOAD THE AMWELL APP RIGHT AWAY 10 | Telehealth Powered by Amwell
Online Therapy With the addition of online therapy to the Amwell web and mobile app, you can now see a psychologist or therapist to address common behavioral health challenges—all from the privacy of your own home. ONLINE THERAPY VISITS ARE: ▸▸ 45-minute, video-based appointments ▸▸ Licensed and specially-trained therapists or psychologists ▸▸ Available seven days a week, from 7am to 11pm ▸▸ Affordable, with copays as low as $0 depending on your plan ▸▸ An alternative to in-person behavioral health visits W H AT T H E Y S AY: “The best way I’ve described it to people is that it’s like FaceTime with a doctor. I was able to give [the doctor] some of my symptoms, and she was able to make a determination for me in five minutes.” Gayle Lassen, West Salem School District Telehealth Powered by Amwell | 11
High Value Care Options Our high value care options offer exceptional quality at a cost- concious price for WEA Trust members. Eligibility for these providers is dependent on your plan’s Network. Smart Choice MRI A N A F F O R D A B L E , H I G H Q UA L I T Y O P T I O N The average MRI in Wisconsin costs about $3,000. As a Trust member, you can use Smart Choice MRI for a fraction of the cost. Smart Choice MRI uses the leading MRI technology and all exams are interpreted by radiologists at the Cleveland Clinic (a top five U.S. Hospital). We also provide our members with a $100 Visa Incentive Card for using Smart Choice MRI. Here’s what you do if you need an MRI: ▸▸ Tell your doctor you’ll be using Smart Choice MRI. Don’t worry, you’ll be able to take your results back to them. ▸▸ Schedule your MRI at smartchoicemri.com. Preauthorization is required for some MRI’s. Call WEA Trust to confirm if your MRI needs preauthorization. Find a Location Smart Choice MRI WI Smart Choice MRI MN & IL 12 | Smart Choice MRI
S AV E M O N E Y W I T H BUNDLED PROCEDURES F R O M N OV O H E A LT H At the Trust, we strive to offer the highest-value care. We’ve partnered with top providers to offer bundled pricing on more than 50 procedures, from orthopedic surgeries to breast reconstruction. What does bundled pricing with NOVO mean for you? If you need surgery, the Trust’s partnership with NOVO provides an option for a unified care experience. For example, if you need Outpatient knee replacement surgery and choose to have it done at a NOVO facility, your surgery roadmap is already laid out. The surgery, recovery, and any necessary physical therapy are included in one coordinated bundle. With priority scheduling, you can get better, faster, and your outpatient procedure may qualify you for a $250 Visa Debit Card as a reward for choosing a high-value care option. Providers participating in the NOVO Bundled Procedures for the Trust include: • Advanced Physical Therapy & Sports Medicine • The Center for Aesthetics and Plastic Surgery SC (surgery center) • Neuroscience Group of Northeast Wisconsin SC • NeuroSpine Center of Wisconsin SC • Orthopedic & Sports Institute of the Fox Valley (surgery center) • Sports Medicine Center SC (surgery center) Quality Guarantee NOVO is so confident in the quality of their care and outcomes that their work comes with a 90-day limited warranty. ▸▸ To learn more and schedule an appointment, go to WEAtrust.com/NOVO NOVO Health | 13
WEA Trust Diabetes Management A free program, powered by Livongo for diabetes, is tailored to you making it easier to manage and live with diabetes. W H AT YO U ’ L L G E T Livongo provides valuable tools that make living with diabetes easier, including the easy-to-use In Touch® Blood Glucose Monitoring System, unlimited test strips and monitoring supplies at no cost to you. The Livongo connected meter gives instant feedback ENROLLING IS EASY If you have a Type 1 or Type 2 diabetes, then you qualify to participate in WEA Trust’s Livongo for Diabetes program. To enroll: ▸▸ Go to WEAtrust.com/livongo ▸▸ Click “Enroll Now” and fill out your information ▸▸ Enter registration code TRUSTDM. 14 | Livongo
We are here for you - No person should ever fight cancer alone. WEA Trust + CancerCARE In partnership with INTERLINK® COE Networks & Programs, WEA Trust members have access to a high-quality cancer program designed to improve outcomes for those with a cancer diagnosis. W E A T RU S T + C A N C E R C A R E Today there are many uncertainties one can face when receiving a diagnosis of cancer. The number of treatment options available are increasing day-by-day, and choosing the right option can be overwhelming and difficult. W I T H W E A T RU S T + C A N C E R C A R E YO U W I L L WO R K W I T H H I G H LY T R A I N E D O N C O L O GY E X P E RT S T H AT W I L L : ▸▸ Provide a second opinion and ensure an accurate diagnosis ▸▸ Work collaboratively with your doctor to ensure you are receiving the highest quality care ▸▸ Offer you support and guidance with your own personal oncology nurse case manager If you have a diagnosis of cancer, call WEA Trust at 800.279.4000 to learn more about the program. Questions? Call our Customer Service at 800.279.4000 or learn more at weatrust.com/cancercare WEA Trust + CancerCARE | 15
A NEW WAY TO MANAGE YOUR LOW BACK PAIN 80% of participants experience a reduction in low back pain. --Kiio research data WEA Trust Low Back Pain Program Our WEA Trust Low Back Pain Program, powered by Kiio, is a mobile app designed specifically for you. This free program takes you through a sequence of exercise routines created to strengthen your back and decrease your pain. The WEA Trust Low Back Pain Program can: ▸▸ Intervene before your pain becomes chronic ▸▸ Reduce missed days at work ▸▸ Increase your day-to-day productivity ▸▸ Improve your overall health ▸▸ Reduce your costs To learn more and sign up visit www.weatrust.com/kiio. 16 | WEA Trust Low Back Pain Program
Important Legal Information The following information is provided to all WEA Trust members to help communicate your legal rights under both Federal and Wisconsin State Law. YO U R R I G H T S U N D E R T H E W O M E N ’ S H E A LT H A N D C A N C E R RIGHTS ACT OF 1998 If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: ▸▸ All stages of reconstruction of the breast on which the mastectomy was performed; ▸▸ Surgery and reconstruction of the other breast to produce a symmetrical appearance; ▸▸ Prostheses; and ▸▸ Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Please consult your policy and Benefit Summary for the deductible and coinsurance applicable to these benefits. If you would like more information on WHCRA benefits, call our Customer Service Department at (800) 279-4000. Women’s Health and Cancer Rights | 17
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The Wisconsin Education Association Insurance Trust and the WEA Insurance Corporation, collectively referred to as the Trust, are affiliated entities. This Notice applies to health, vision, and long term care policies offered by the WEA Insurance Corporation and the associated activities of the Wisconsin Education Association Insurance Trust. We are required by federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice is effective July 14, 2016, and will remain in effect until we replace it. It describes the practices we follow in administering our policies. We reserve the right to change our privacy practices and to amend this Notice at any time, as long as such changes are consistent with applicable law. We reserve the right to make changes in our privacy practices and this Notice effective for all health information that we maintain, including health information we created or received before we made the changes. If we make material changes to our practices, we will promptly revise our Notice and make it available to you on our Web site, WEAtrust.com. We will also mail a copy of the revised Notice to you at your last known address on file, with our next annual mailing. H OW W E M AY U S E A N D D I S C L O S E YO U R H E A LT H I N F O R M AT I O N We may use and disclose your health information under certain circumstances, without your permission, to perform payment activities and health care operations, or when we are allowed or required by law to do so. 18 | Notice of Privacy Practices
Examples of permitted or required uses and disclosures include, but are not limited to, those provided in the following section. PAY M E N T A C T I V I T I E S We may use or disclose your information to pay or reimburse for your covered benefits. For example, we may use your information to: ▸▸ Pay claims from physicians, facilities, or other providers of services that are covered by your policy. ▸▸ Obtain premiums, determine your eligibility for benefits, and allowable amounts for reimbursement. ▸▸ Coordinate benefits with other plans. ▸▸ Determine the medical necessity of services you receive. H E A LT H C A R E O P E R AT I O N S We may use and disclose your health information for a variety of insurance- related activities such as: ▸▸ Quality assessment and improvement activities. ▸▸ Activities designed to improve health or reduce health care costs, including sharing information with regional or national health information organizations. ▸▸ Clinical guideline and protocol development, case management, and care coordination. ▸▸ Credentialing activities. ▸▸ Enrollment, premium rating, and other activities relating to the creation, renewal, or replacement of a contract of health coverage. ▸▸ Conducting or arranging for medical review, legal services, and auditing, including fraud and abuse detection programs. ▸▸ Business management and general administrative activities, such as customer service and resolution of internal grievances or appeals. Important note: The Trust underwrites coverage for late enrollees in certain plans. However, we will not use or disclose your genetic information for underwriting purposes. Notice of Privacy Practices | 19
PUBLIC BENEFIT We may use and disclose your health information as authorized by law for the following purposes deemed to be in the public interest or benefit: ▸▸ As required by law; for example, when required by a court order in medical malpractice litigation. ▸▸ Health oversight activities such as audits,investigations, inspections, licensure, and other proceedings related to oversight of the health care system. ▸▸ To law enforcement officials; for example, in response to a valid subpoena, to identify a crime victim, or locate a missing person. ▸▸ To avert a serious threat to health or safety. ▸▸ To researchers for certain projects such as those to improve quality of care or the safe and efficient delivery of health care services. ▸▸ As authorized by state worker’s compensation or similar laws. D ATA S H A R E A G R E E M E N T S We may share information about you and about others for payment or health care operations activities with other entities, including health care providers, in accordance with executed data share agreements. Business Associates. We may contract with individuals or entities known as Business Associates to perform various functions on our behalf. In order to perform these functions, Business Associates will receive, create, maintain, transmit, use, and/or disclose your protected health information, but only after they agree with us in writing to implement appropriate safeguards regarding your protected health information. For example, we may disclose your protected health information to a Business Associate to process your claim for plan benefits or to provide support services such as pharmacy benefit management. D I S C L O S U R E T O YO U R E M P L OY E R I F YO U R C O V E R A G E I S P R OV I D E D U N D E R A G R O U P P L A N . We may disclose enrollment and dis-enrollment information to your employer to carry out plan administration functions. 20 | Notice of Privacy Practices
In certain cases, we may need to disclose your health information to your employer for legitimate administrative purposes, such as auditing or monitoring payment of benefits under the plan. Before we may do that, your employer must amend its coverage contract with us to establish the limited uses and disclosures it may make with your health information. Your employer must implement its own privacy policies and procedures consistent with state and federal law and may not use the information for any employment-related decision. We will not disclose your individually identifiable health information to your employer unless you expressly authorize us to do so in writing. H E A LT H - R E L AT E D P R O D U C T S O R S E RV I C E S We may use your health information to contact you about other available coverage products that could enhance or replace your existing coverage, or concerning health-related products or services that add value to, but are not part of, your current plan of benefits. We may also use your health information to communicate with you for medical case management or to direct or recommend alternative medical treatments, therapies, health care providers, or health care settings. We will not disclose your health information to other entities for their marketing purposes. RESTRICTIONS ON OTHER USES OR DISCLOSURES WITHOUT YO U R W R I T T E N AU T H O R I Z AT I O N Except as described in this Notice and as allowed or required by law, we will not use or disclose your health information without authorization from you. Most uses and disclosures of psychotherapy notes, uses and disclosures of protected health information for marketing purposes, and disclosures that constitute a sale of protected health information require authorization. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time, and we will no longer use or disclose your health information for the purpose you previously authorized. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Notice of Privacy Practices | 21
YO U R I N D I V I D UA L R I G H T S W I T H R E S P E C T T O YO U R H E A LT H I N F O R M AT I O N Please see the contact information at the end of this Notice about how to exercise these rights. ACCESS You have the right to inspect and/or receive a copy of the health information that we have used to make decisions about you. You must make such a request in writing. We have the right to charge you a reasonable fee for expenses associated with your request. We encourage you to contact us to clarify the scope of the information you may be requesting. AMENDMENT If you believe that your health information records are inaccurate or incomplete, you may request that we amend those records. Your request must be in writing and must explain why the information should be amended. We may deny your request for certain reasons; for example if the information was not created by us, or if we determine that the information is correct and accurate. If we deny your request, we will provide you with a written explanation and you may respond with a statement of disagreement which will be appended to the information you want amended. RESTRICTIONS You have the right to request additional restrictions on the uses and disclosures of your health information. Your request must be in writing. We are not required to agree to those restrictions. C O N F I D E N T I A L C O M M U N I C AT I O N You have the right to request that we communicate with you about your health information by reasonable alternative means or at an alternative location if our normal means of communication endangers you. We will honor reasonable requests for alternative confidential communications. ACCOUNTING OF DISCLOSURES We are required to keep a record of certain disclosures of your health information, and you have a right to request a list of these disclosures. This 22 | Notice of Privacy Practices
list is called an Accounting of Disclosures. This accounting would include, for example, the types of disclosures identified above under the “Public Benefit” section, if any such disclosures have occurred. Your request must be in writing. We will provide one list per 12-month period free of charge; we may charge you for additional lists. PA P E R C O P Y O F N O T I C E You have a right to request and receive a paper copy of this Notice at any time. You may also obtain a copy of the current version of this Notice at our Web site, WEAtrust.com. Breach Notification. You have the right to receive notifications of breaches of your unsecured protected health information. COMPLAINTS If you believe we may have violated your privacy rights, or if you disagree with a decision we made about any of the rights described in this Notice, you may file a complaint with us using the contact information available in this Notice. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. We support your right to have your health information treated in a private fashion. We will not retaliate in any way if you choose to file a complaint. C O N TA C T I N F O R M AT I O N If you have questions about this Notice, please contact our Customer Service Department at (800) 279-4000, or alternately our Office of General Counsel at the same number. For TrustSecure, please contact our Business Associate Educators Benefit Consultants at (888) 507-6053. Notice of Privacy Practices | 23
Quick Start Guide O N LY H AV E A F E W M I N U T E S ? G E T S TA RT E D W I T H YO U R W E A T RU S T B E N E F I T S N OW. Register for Maddy Go to MaddyPortal.com with your ID card and register for an account to check claim status, view benefits, and order more ID cards. Sign up for Amwell You can easily see a doctor or therapist online using WEA Trust Telehealth, powered by Amwell. Go to WEAtrust.com/amwell to sign up. Follow us Stay connected with us on Facebook and Twitter. We’ll keep you up-to-date on new programs you can use to stay healthy. Do You Have Other Health Insurance? Then you need to fill out a coordination of benefits form and either mail it to us or send it via the Maddy portal. ▸▸ Download the form at WEAtrust.com/COB 45 Nob Hill Rd, Madison, WI 53713 800.279.4000 WEAtrust.com MPD 1233-1218
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