Agent Update

Top-Ranked Health Plan in Michigan, for the second year in a row!
WOW update!
Care Choices Underwriting Guidelines
Improving Access to Care
New Medical Technology
Member Portal
Reminder about Private Health Information for your Student
Health Risk appraisals

Top-Ranked Health Plan in Michigan, for the second year in a row!

At Care Choices, we take your health care personally.  We partner with our doctors, hospitals and other health care providers to ensure our members get the care they need.   Every year, we voluntarily report clinical data according to a set of national, standardized performance measures known as the Health Plan Employer Data and Information Set (HEDIS®). In 2006, we were one of over 250 health plans that voluntarily submitted their data to the National Committee for Quality Assurance (NCQA).   We also participate in the nationally recognized Consumer Assessment of Healthcare Providers and Systems  (CAHPS®) survey. The HEDIS and CAHPS results are compiled into the Quality Compass® report published annually by NCQA.

Once again this year, NCQA collaborated with U.S. News & World Report to rank the nation’s commercial, Medicare and Medicaid health plans in a report called the U.S. News and World Report/NCQA “America’s Best Health Plans” 2006. According to this report, Care Choices HMO is ranked #12 among 253 of the nation’s commercial health plans and Care Choices is the top-ranked health plan in Michigan for the second year in a row!  America’s Best Health Plans ranks health plans in every state in the nation based upon their clinical performance, patient experience and satisfaction as well as the plan’s NCQA Accreditation status.   This ranking incorporates performance on 42 separate indicators of clinical and service quality in four categories:  access to care, overall member satisfaction, prevention and treatment. 

As the top-ranked health plan in Michigan for the second year in a row, you have come to rely on our high quality, cost-effective health care.  With Care Choices our employer groups can expect that: 

• Their employees to have access to a comprehensive network of physicians and hospitals close to their home or office as well as specialty care, that Care Choices members ranked #1 in the nation.
• It is easier for their employees to obtain information they need regarding their health care from our secure member portal, Internet Self-Service, where they have access to plan information 24 hours, 7 days a week.
• There are a variety of programs to help their employees manage their medical conditions and improve their quality of life. 

For more information on our quality ratings, view the enclosed 2006-2007 Care Choices Quality Report Card on our website. This report card contains highlights of the HEDIS and CAHPS results from the past several years.  These results demonstrate the progress that Care Choices has made in meeting some of our quality goals. The tables include some of the highlights from the Quality Compass 2006 report.  Ratings for additional measures and information about our Quality Improvement Program can be found on our website at www.carechoices.com.  A paper copy of the information posted on the website can be obtained by calling our Customer Service Department.

We thank you for your ongoing commitment to Care Choices. We will continue to work and live by our mission: “We serve together to provide the care and choices that make a difference in the health and well-being of the lives we touch.”

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WOW! Update

The Care Choices WOW campaign launched on September 21st and we continue to receive positive feedback from our agent partners. Quote activity has exceeded activity from prior years and favorable industry activity is on the rise.

We now have our second winner for the monthly quote activity drawing– Congratulations to Karole Jensen, Michigan Chamber Services – November’s winner.  We have a good start on entries for the month of December.  The next drawing will take place the first week of January for December quote activity.

For those of you not familiar with the Quoting Bonus Program - here’s how it works.

As an incentive for agent quoting activity, Care Choices will hold a drawing for a flat screen LCD television once a month through January 2007.  An agent will receive one entry for each Care Choices HMO, Care Choice PPO or Preferred Choices PPO quote for a group with 2-50 eligibles and two entries for each Care Choices HMO, Care Choices PPO or Preferred Choices PPO quote for groups with 51+ eligibles.

Quotes generated by the Care Choices Sales and Business Support team will automatically be entered into the drawing.  Quotes generated externally using the Care Choices small group rate model must be submitted using the Quoting Bonus Program Submission Sheet.  Both the Quoting Bonus Program Submission Sheet and a copy of the quote MUST be submitted for entry in the drawing. 

Please contact the Care Choices Business Support department at 1-800-261-3452 if you have any questions.

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Care Choices Underwriting Guidelines

Care Choices commitment to quality and integration of health care services is the driving force of our company.  Through our fully integrated network of physicians, hospital and other health care professionals we share a strong commitment to improving the health status of the communities we serve by delivering effective and affordable health care.

Our commitment to the agent community remains strong and we look to our agent partners to do their part to uphold and follow the underwriting and administrative guidelines in writing and administering group health care business with Care Choices.  There are many ways that agents can help Care Choices remain profitable and promote affordable health care.

What are Care Choices requirements?

Employers with a true employer-employee relationship are eligible to enroll in Care Choices.

What is a bonafide employer? Any firm, corporation, partnership, limited liability company actively engaging in business with 2 or more employees on at least 50% of the working days during preceding and current calendar year.  

Who is eligible to enroll:

Owners/Officers are eligible to enroll in Care Choices provided:

• They have a direct and active interest in the group.
• Receive their major source of employment income from the group.
• Physically report at least once a week to their place of business and have a direct voice in all major decisions.

Employees who are eligible to enroll in Care Choices include:

• Full-time employees working a minimum of 30 hours per week.
• Part-time employees working a minimum of 17.5 hours per week when it has been specified in the Group Operating Agreement and applies uniformly to all part time-employees.

Dependents who are eligible to enroll in Care Choices include:

• Spouse, legally married husband or wife of the employee.
• Dependent Children – this category includes children of the subscriber or spouse by birth, legal adoption, legal guardianship or children from a former marriage of whom the subscriber has custody. 

Retired Employees

• Consideration for enrollment for retiree segments will be given to employers with a formal employee retirement program where the employer contributes to the cost of the retiree plan (retirees cannot exceed ten percent of the total employer group).

Participation Requirements

Group Size	Participation Requirement
2-10	100% of those seeking coverage
11-25	75% of those seeking coverage
26-50	50% of those seeking coverage
51+	Minimum of 15 enrolled contracts

How does Care Choices monitor compliance with the above guidelines in the 2-50 group segment?

At the time of initial enrollment and on an annual basis thereafter, Care Choices will certify compliance by requiring submission of documents including Quarterly Wage and Detail Reports, Employee Waiver Forms, Roster of Employee, Declaration page of Workers Compensation Policy and signature of a qualified company designee.  Documents are reviewed and compliance is confirmed or denied.  If a group is non-compliant with these requirements, Care Choices may decline to enroll or renew an employer group.  When an enrolled group is non-compliant they are subject to termination in accordance with the terms of Care Choices Group Operating Agreement.

Note: If individual coverage is paid for by the employer group it is not a valid waiver for participation purposes.

For groups of 51+ the certification activity is a part of the Care Choices resell process conducted by the Sales Associates.

Care Choices may request an audit of an employer’s group records in accordance with the terms of Care Choices Group Operating Agreement.  If, as a result of a group audit, it is discovered that a group has breached the GOA and/or violated any representations, agreement or warranty, the group will may be termed for cause and subject to additional legal action.  If it is discovered that the agent misrepresented Care Choices, the agent’s appointment will be revoked for cause and notification will be sent to the Office of Finance and Insurance Services.

Group Operating Agreement changes

Care Choices Group Operating Agreement has been changed to an evergreen agreement and will automatically renew unless the group fails to meet participation or eligibility requirements.   Group conversion rights and privilege language has been added as well.

Reminder: the employer group must submit all member additions, deletions and changes within 30 days of the event.  Changes should be immediately faxed to Care Choices Membership Operations Department at 248-489-5299.   All membership changes should be submitted on the Care Choices Enrollment Application and Change Form.

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Improving Access to Care

We work with our participating physicians to improve our member’s access to care.  We maintain an adequate network of primary care, specialty care, and behavioral health practitioners and monitor how effectively this network meets the needs and preferences of our membership.  To meet these objectives, we:

• Annually analyze our performance against the standards established for primary care, specialty care, and behavioral health providers. 
• Assure that our clinical and administrative services are sensitive to the cultural and linguistic needs and expectations of our membership. 
• Annually assess the cultural and linguistic diversity of our membership and adjust the availability of providers within our network if necessary.

Because of this evaluation, we continuously add primary care and specialist physicians to our network.

Care Choices also ensures that there is adequate accessibility to primary care services, behavioral health services and member/enrollee services.  To that end, we conduct an annual evaluation to measure our performance against access standards related to:

• Regular and routine care appointments
• Urgent care appointments
• After-hours care
• Telephone service

This process helps identify access related barriers and opportunities for improvement for Care Choices and its providers.  As a result of this evaluation, the following activities were implemented to help improve member access.

• Communicated the Care Choices access standards to all participating physicians via newsletters and physician office manuals.
• Care Choices Provider Relations staff periodically visit high volume physician offices and hold group presentations where they:
  • Communicate the results of the annual member access survey questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®). 
  • Reinforce Care Choices access standards.
• The Internet Self Service (ISS) provider portal was implemented allowing providers to check member eligibility, view their claims, check status of referrals, and submit referrals.  This information is real time and therefore improves member service since the physician office has access to updated information.  Physicians know whether they can see the member or not.  The referral processing quicker helps the member get the services they need quicker. 
• The ISS member portal was implemented allowing members to complete the following functions on-line:  change primary care physician, order ID cards, view benefit documents (Subscriber Certificate and Member Handbook), check claims and referrals, etc.
• Care Choices meets with physician office staff to discuss member access issues and determines opportunities for improvement activities.
• Contracted with additional urgent care centers, freestanding radiology centers, and ambulatory surgical sites.

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New Medical Technology

Researchers are finding new ways to treat illnesses and injuries every day.  However, not all new medical treatments and procedures are safe and effective.  For this reason, Care Choices HMO has a process to evaluate new technological medical advances.  This process includes reviewing information and studies from the current published medical literature, a nationally recognized technology assessment organization, and information available from government regulatory bodies such as the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention. 

One component of the decision-making process used to determine benefit coverage is the strength of the evidence suggesting that the new technology will improve health outcomes and is of greater value than conventional therapy.  Care Choices HMO also considers input from clinical specialists.

After the new medical technology review process, Care Choices may determine that the treatment, supply, device or drug is “investigational and experimental.”  This means that there is not enough medical literature or other information to prove that the new technology will produce better health outcomes compared to conventional therapy.  It also means that the new technology is not recognized as acceptable medical practice by an appropriate specialty organization. Unproven, investigational and experimental services are not a covered benefit. The only exception to the above is in the area of cancer medication.    

You can rest assured that Care Choices HMO is doing its homework when it comes to new medical technology and your health.  After all, we take your health care personally.

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Member Portal

Just a reminder – Care Choices members have access to their plan information, 24 hours a day, seven days a week through our secure member portal, Internet Self-Service (ISS).  Members can view eligibility, claims, referrals and benefit documents.  These benefit documents outline what is included and excluded from their coverage, as well as applicable copayments.  These documents – Subscriber Certificate, Schedule of Benefits and Care Choices Member Handbook can be found on ISS or members may contact Customer Service for a paper copy. 

In addition, members can:

• Search our provider directory
• Print maps and directions to provider locations
• Change your primary care physician

Request ID cards and more

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Reminder about Private Health Information for your Student

To ensure compliance with HIPAA privacy standards, Care Choices requires all member issues be coordinated exclusively through our Customer Service department.  If members call on behalf of another family member age 18 or older, they should be aware that we are unable to discuss any issues that involve Private Health Information (PHI) unless we have written permission from the member. This includes PHI for college-age students living away from home.

Members who want someone else to communicate with Care Choices on their behalf must complete and return a Care Choices Member Authorization for Release of Protected Health Information Form.  A copy of this form, along with more information about the Health Information Portability and Accountability Act (HIPAA), can be found on our website at www.carechoices.com.  Members may also contact our Customer Service department at 800-852-9780 if they want to this form sent to them.

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Health Risk Appraisals

Care Choices offers “How’s Your Health?” an interactive questionnaire that can help members identify health risks and take control of their health.  The survey, developed by Dartmouth Medical School, takes about 10 minutes to complete. 

After members complete the survey, they will get a summary of their results and tips on how to manage their health and take action to reduce their risk factors for disease. They will also receive an “Action Form” that they can take to their doctor or nurse as a starting point for discussing their medical care.

For members who do not have Internet access, they may contact the Care Choices Health and Lifestyles department toll-free at 877-890-2045 and a Health Management Coordinator will help them complete the assessment and mail them a paper copy of the results.

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