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| Integrated Systems Keep You Connected |
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If you’re like most people, you “touch” the health care system only a few times a year. Beyond an annual exam, your experience may involve only a minor injury, brief illness or prescription.
It’s different if you have a chronic condition such as heart disease, diabetes or asthma. Then, your experience may tell you the “system” isn’t a system at all, but an array of unconnected components. It’s up to you to put all the pieces together. If you struggle to navigate this complex system, the outcome can mean complications, emergency department visits, hospitalizations and disability.
Putting the Pieces Together
That’s why the Board is asking the medical plans to provide more assistance coordinating patient care. They want your health plan to re-focus the system around the patients, allowing them to be more successful at managing their condition and ultimately, enjoying healthier lives.
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Measuring Progresss
Accepted standards of care exist for many chronic conditions. The most widely used measures are reported through HEDIS - Health plan Employer Data Information Sets. This information is used to see how plans are improving care.
HEDIS reports allow PEBB to see if plans are meeting clinical measures for chronic disease patients. This allows the Board to compare plan progress with previous performance and with national measures.
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Making it Easier to Manage
You know you’ll always have a role in managing your condition; it just shouldn’t be so hard. For example, you should have a coordinated team of healthcare professionals, all of whom share information about you and your condition. Information technology should keep you – and them – focused on how you’re doing, along with what care you need and when.
Each of PEBB’s plans is making progress in connecting the parts. For example, both the Kaiser and Providence plans provide a medical home for patients – a team of professionals well-versed on the highest standards of care. Their information systems track when you need tests or screenings, what the results are, and what you can do to improve them – including using your medicine wisely. Team members then reach out to help you overcome hurdles to better self-care.
Medical professionals in Advicare, the Regence chronic disease management team, review claims data to identify PEBB members with chronic illness. They send these members self-care advice, along with surveys, plans and assessments. Members can connect directly with RNs, whose advanced expertise can bolster self-care efforts, and health coaches, who help them set and meet goals.
As a community-based health plan, Samaritan Select reaches out to chronically ill patients and their families through all of its hospitals, clinics and providers. Support groups and classes reinforce “what works” and keep patients connected with plan resources.
Take the First Step
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| Shall We Dance? |
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If you caught even a few minutes of Emmitt Smith on last season’s “Dancing with the Stars,” you saw proof that dancing does more than do a body good – it’s fun! The NFL career-rushing leader wore a huge smile all the while he and his partner beat out a multitude of rhythms – and the competition.
You don’t have to be in top athletic condition to dance. Even if your couch and backside are a little too well acquainted, moving to the beat can be a great way to start getting into shape, while having a good time.
Kick Up Your Heels for Health
Dancing burns about the same number of calories as swimming, walking or riding a bike (up to 400 per hour). Regular dancing can also:
- Lower blood pressure and cholesterol
- Build heart strength and stamina
- Strengthen bones and muscles
- Improve posture, balance, flexibility and agility.
It does good things for your mind, as well. Like other types of mind-body routines (think Yoga), it relieves stress. Researchers are learning that it may keep your brain healthy, too. Thinking about steps, patterns and combinations can boost brainpower.
Choose a Style
Don’t know what type of dance you might like? Experiment a little. Many health clubs, community colleges, recreation centers and studios offer a variety of classes. Popular group and couples styles include:
- Square dancing
- Swing (from big-band to country)
- Line dance
- Folk (African rhythm, clogging, Irish-step, circle dancing)
- Ballroom (two-step, waltz, fox-trot and tango range from easy to challenging)
- Salsa – a style that’s becoming popular worldwide.
Those who prefer to go solo might try belly dancing, flamenco, jazz, tap, ballet, hip-hop or modern.
All Together Now – or Not
When you dance in a group, you may find that you enhance your social skills with your dance skills. But if you prefer to face the music on your own:
- Close the shades after a hard day’s work, put on your favorite tunes, and just let the music move you.
- Check out a dance tape or DVD from the library, and hold personal practice sessions until you’re ready to go public.
- Buy or rent a dance video, and invite your kids, partner or friend to dance (and giggle) along with you.
Get Started, Have Fun, Be Well
Unlike many sports, you don’t have to be in top fitness to dance. Even if you’re really out of shape, you can start slow and bump up the tempo gradually. Just remember to follow fitness guidelines:
- Aim for 20 to 30 minutes of movement, three to five times a week.
- Warm up at the start, and cool down at the end.
- If anything hurts, stop and pay attention to it.
The important thing is to find a routine you like, because you’re more likely to stick with it. If, after a few classes or sessions, you think a style isn’t right for you, try another until you find your own personal groove.
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| Valentine's Treats |
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On Valentine's Day, a little dancing and a little chocolate can both be healthy treats. Recent studies have shown that chocolate (the darker the better) contains antioxidants and flavonoids, which may help prevent heart disease. Of course you know that chocolate packs a big punch of calories along with its rich aroma and flavor. So, go easy on the sweets and do a few more turns around the floor.
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| February 2: Wear Red Day! |
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Friday, Feb. 2, 2007, is National Wear Red Day – a day when Americans nationwide will take women’s health to heart by wearing red to show their support for women’s heart disease awareness.
According to the National Institutes of Health, heart disease is the number-one killer of women in America. Yet only about half of American women make the connection between risk factors and their personal risk of developing heart disease.
What are the risks?
- High blood pressure
- High cholesterol
- Diabetes
- Smoking
- Being overweight
- Being physically inactive
- Having a family history of early heart disease
- Age (55 or older for women).
You can't change your family history, but you can do something about the other risks.
First, work with your doctor to find out if you have high blood pressure, cholesterol or blood sugar (diabetes risk) levels. Learn what normal levels are and how you can reach them – through exercise and diet, or medications, or all three.
If you smoke, call Free and Clear and ask about the Quit for Life tobacco cessation program (see below). It’s a covered PEBB benefit for you and your dependents.
Check your body mass index (BMI) using an easy, online calculator. Just enter your height and weight, and the calculator does the rest. Compare your result with normal. If your BMI is higher, support from your medical plan can help you improve your diet and find the kind of physical activities that will get you going and keep you motivated.
Source: National Institutes of Health
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| Quit Smoking to Give Your Heart a Break |
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Smoking causes damage to your heart and can make heart disease worse. Quit smoking, today and give your heart a break.
When you stop smoking:
- You are less likely to die from heart disease the longer you stay quit.
- Your blood pressure and heart rate go down.
- You have less chance of getting a heart attack the longer you stay quit.
- The clogging of your blood vessels will not get worse and may get better over time.
- Your family and friends breathe cleaner air. They can also worry less about you and your health.
The Free & Clear Quit For Life Program can help you quit successfully. The program’s professionally trained Quit Coaches know how hard it is to quit without help – many were former smokers themselves. With the Quit For Life Program, your chances of quitting successfully are six times better than quitting on your own.
To register, call 1-866-QUIT-4-LIFE (784-8454) or register online. Be sure to tell them you’re a PEBB member so you get the full benefit.
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| Hot Benefits Topic: PEBB Appeals |
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by Bobbie Barott, Benefits Manager
As a PEBB member, you have the right to appeal (in writing) any eligibility issue to PEBB. Examples of eligibility issues include:
- Who is an eligible member or dependent
- When coverage begins or ends
- When members may make changes to plan choices
- Enrollment processing errors (within given time frames).
Be sure that your appeal includes all information and documentation that may help explain your situation. When PEBB doesn’t receive all the necessary information, time is lost requesting the information from you or your agency. Also, remember to state clearly in your appeal what you are asking of PEBB.
When your appeal arrives in the office, PEBB staff assign a case number and send you a written notice of this number for your records. If you need to contact PEBB about your appeal, please use this case number. Your appeal is assigned to a benefit analyst to review and to make a case decision. Appeal decisions should take 45 days or less; if your appeal will take longer you will receive an extension notice.
When reaching a decision in an appeal case, analysts must interpret and apply federal and state laws, administrative rules and policy. These regulations ensure fair and equal treatment for you and every PEBB member.
PEBB notifies you as soon as possible when a decision is reached. In most instances, your agency will also receive notification. If denied, the benefit analyst will send you a letter explaining the reasons for the denial. If denied, you may submit your case through each of the following levels: benefits manager, administrator, Operations Committee, Board. In all cases, state and federal regulations, administrative rules, and policy will determine and guide the results.
Your final appeal opportunity after a Board denial is under the Oregon Administrative Procedures Act, ORS Chapter 183.
If you believe your plan unfairly denied a claim, contact the plan’s customer service number and review your plan handbook for the plan’s appeal process to follow. Each plan has a state-approved grievance and appeal process. The plan will give you a written description of the process and keep you informed of your options.
PEBB cannot influence a plan’s decision. For example, it cannot weigh in on plan decisions about co-pay exceptions for non-preferred brand prescription drugs. Nor can the Board ask plans to cover something excluded by contract. See your plan’s member handbook for more information.
For questions on eligibility appeals, contact your payroll or benefits office or PEBB. Access the PEBB appeals form online. Read a detailed description of the PEBB appeals process. For information on claims denials, contact the plan directly.
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| FSA Takes Care of Dependent Care |
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Thousands of PEBB member enroll for dependant care flexible spending accounts (FSAs) annually. This benefit allows you to have a family deduction of up to $5,000 annually deducted pre-tax from your monthly pay to reimburse yourself for eligible dependent care expenses. You can enroll in an FSA as a newly hired employee, during Open Enrollment or if you experience a qualified status change that changes your eligibility status.
You can set up a dependent care FSA if you are:
- Single with an eligible dependent, and the expenses are necessary for you to work
- Married with an eligible dependent, and the expenses are necessary for both you and your spouse to work
- Married with an eligible dependent, and your spouse is either disabled, actively seeking employment or a full-time student at least five months during the year.
You can use the account to reimburse yourself for:
- The care and well-being of dependent children under the age of 13
- Care of a disabled dependent, who is incapable of self-care and who spends at least eight hours per day in your home.
Most PEBB members use the accounts to pay for child care. Examples of eligible expenses:
- A licensed or registered day care facility or nursery school
- In-home care for a dependent who spends at least eight hours in your home
- Before- and after-school care.
Reimbursement will be made only for services already provided. If you pre-pay for day care, you can claim expenses only after the services have been provided.
FSAs are governed by IRS rules, which can be complex. BenefitHelp Solutions (BHS) administers PEBB FSAs, including claims. For more information, contact BHS at (800) 556-2230 or online.
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