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Quality Assurance | Appointing a Representative | Plan Transition Process

FamilyCare is committed to quality and utilizes multiple business processes to measure, assess and ensure we are providing quality service. We have outlined below key aspects of the services used to ensure we provide efficient and effective care and that we respond to you our customer.

Member Rights & Responsibilities

As a FamilyCare Health Plans member, you have the right to:

Timely, Quality Care

• Choice of a qualified Contracting Primary Care Provider and Contracting Hospital.
• Candid discussion of appropriate or Medically Necessary treatment options for your condition, regardless of cost or benefit coverage.
• Timely access to your Primary Care Provider and Referrals and recommendations to Specialists when medically necessary.
• Receive Emergency Services when you, as a prudent layperson, acting reasonably would have believed that an Emergency Medical Condition existed and payment will not be withheld in cases where you seek Emergency Services.
• Actively participate in decisions regarding your own health and treatment options.
• Receive urgently needed services when traveling outside the FamilyCare Health Plan’s service area or in the FamilyCare Health Plan’s service area when unusual or extenuating circumstances prevent you from obtaining care from your Primary Care Provider.
• Request the number of grievances and appeals and dispositions in aggregate.
• Request information regarding provider compensation.
• Request the financial condition of FamilyCare Health Plans.

Treatment with Dignity and Respect

• Be treated with dignity and respect and to have your right to privacy recognized.
• Exercise these rights regardless of your race, physical or mental ability, ethnicity, gender, sexual orientation, creed, age, religion or your national origin, cultural or educational background, economic or health status, English proficiency, reading skills, or source of payment for your care. Expect these rights to be upheld by both FamilyCare Health Plans and contracting Participating Providers.
• Confidential treatment of all communications and records pertaining to your care.
• You have the right to access your medical records and request amendments to your records. FamilyCare Health Plans must provide timely access to your records and any information that pertains to them. Written permission from you or your authorized representative shall be obtained before medical records can be made available to any person not directly concerned with your care or responsible for making payments for the cost of such care.
• Extend your rights to any person who may have legal responsibility to make decisions on your behalf regarding your medical care.
• Refuse treatment or leave a medical facility, even against the advice of Participating Providers (if you accept the responsibility and consequences of the decision).
• Complete an Advance Directive, living will or other directive to your Contracting Medical Participating Providers.

Confidentiality and Security

FamilyCare Health Plans is committed to preserving member/patient privacy through policies and procedures and systems that support confidentiality and security of information.

Responsibility is assigned to an oversight body, a privacy officer, an information security officer, providers and practitioners, managers, and users of information and information systems.

If you have any questions or concerns about healthcare privacy or security contact our Customer Service Department at 866-798-2273, Monday through Friday, 8:00 a.m. to 8:00 p.m. (TTY: 800-735-2900).

Definitions:
Personal Information - Information which is identifiable with an individual, which is gathered in connection with an insurance transaction and from which information judgments can be made about the individual’s character, habits, avocations, finances, occupations, general reputation, credit, health or any other personal characteristics. "Personal information" includes an individual’s name and address, an individual’s policy number or similar form of access code for the individual’s policy and "medical record information" but does not include "privileged information" except for privileged information which has been disclosed in violation of ORS 746.665. "Personal information" does not include information that a licensee has a reasonable basis to believe is lawfully made available to the general public from federal, state or local government records, widely distributed media or disclosures to the public that are required by federal, state or local law.

Personal Representative - A person who has the legal authority to act for a member or patient for health care decisions.
Privacy Officer – an individual responsible for the development and implementation of the privacy policies and procedures of a healthcare organization.
Protected Health Information (PHI) - Individually identifiable health information that is or has been electronically transmitted or electronically maintained by a covered entity and includes such information in any other form. Individually identifiable health information in FamilyCare Health Plans employment records is not PHI; however, it may be subject to other state and federal privacy protections.

Security officer – an individual responsible for the development and implementation of the security policies and procedures of a company.

Treatment – The provision of health care by, or the coordination of health care (including health care management of the individual through risk assessment, case management, and disease management) among, health care providers; the referral of a Member from one provider to another; or the coordination of health care or other services among health care providers and third parties authorized by the health plan or the individual.

Unemancipated Minor - A member or patient who is not an adult under state law, and therefore, generally does not yet have the right to make health care decisions for him or herself.

Fraud, Waste and Abuse
FamilyCare Health Plans monitors for fraud, waste and abuse through internal and external activities and monitors. These activities are outlined in our Compliance Plan, Code of Conduct and written policies and procedures.

FamilyCare Health Plans has a hotline for receiving complaints and protecting the identity of the person reporting the complaint (as appropriate) to prevent retaliation.

A designated Compliance Officer works with the management team to provide training, education, and reviews and monitors the activities. The Compliance Officer reports directly to the CEO of FamilyCare Health Plans and the FamilyCare, Inc. Board of Directors.

The FamilyCare Health Plans Compliance Officer can be reached by calling 503-471-2123.

If the Compliance Officer is unavailable, you may leave a confidential message by calling 503-345-5777 or for long distance 1-800-335-3205 and enter extension 5777.

All investigations, findings and actions are documented and reported both internally and externally per policy and procedures.

Definitions:
Abuse (of Enrollee by Provider): Infliction of physical harm, injury caused by negligent acts or omissions, unreasonable confinement, sexual abuse or sexual assault.

Abuse (by Provider): Provider practices that are inconsistent with sound fiscal, business or medical practices and result in an unnecessary cost to FamilyCare Health Plans enrollees or reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.
Fraud: An intentional deception or misrepresentation, whether by act or omission, made by a person with the knowledge that the deception could result in some benefit to himself/herself or some other person. It includes any act that constitutes fraud under applicable state or federal law.

Incident: A situation of possible fraud, abuse, or waste.

Waste: An incident or practice that is inconsistent with accepted and sound medical business or fiscal practices that directly results in unnecessary cost to Medicaid, Medicare, FamilyCare Health Plans or enrollee.

What is a Medication Therapy Management (MTM) Program?
A Medication Therapy Management (MTM) Program is a free service we may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate, but it is recommended that you take full advantage of this covered service if you are selected.

Our Health Services Team will target the following disease states for Medication Therapy Management Services:

• Hyperlipidemia
• Asthma
• Diabetes

If you have two of the above disease states and are taking at least 5 medications combined for these disease states, you will be considered for MTM.

When a member is eligible for MTM they will be contacted by mail that they are eligible for these services.
To find out more about this program, please call our Customer Service Department toll-free at 866-798-2273. We are here for your Monday-Friday, 8:00 a.m. to 8:00 p.m. (TTY: 800-735-2900).

Quality and Utilization Management
The Medical Management program explains the structure and the processes for Quality and Utilization Management at FamilyCare Health Plans. Monitors are identified and reviewed annually for each operational area. The specific monitors are defined by individual programs, departments or committees to ensure compliance with regulatory guidelines.

Supervisors and Managers for departments and programs have the day to day responsibility for the ongoing monitoring, review and reporting of quality and utilization measures.

All complaints about payment, services, and problems in getting health care or the quality of healthcare received are reviewed, documented and addressed following established policies and procedures. If you have any complaints, please call our Customer Services Department toll free at 866-798-2273. We are here for you Monday-Friday, 8:00 a.m. to 8:00 p.m. (TTY: 800-735-2900)

The Utilization and Compliance Committee and the Quality Management Committee (QMC) regularly review reports on quality and utilization monitoring and ensure that the programs address all services.

FamilyCare Health Plans complies with CMS requirements to maintain an agreement with an external independent quality review organization which is approved by CMS for Oregon.