Our quality standards
Our quality standards: Striving to do better, every day
Your health is important to us. We work hard to make sure you can get great care when you need it. We do this by:
- Having programs and services to help make sure the quality of health care you get is even better
- Finding local programs in your community to help you get the services you need
- Hosting events to help you learn about your plan and get the most out of it
- Following state and federal rules
- Looking at our quality reports to find new ways to offer better care
Learn more about Quality Management
If you have questions about the Quality Management program, contact us. The phone number for your plan is on our Contact us page.
We can talk to you about:
- What quality management is
- How we are doing and what our goals are
- How we are working to make things better for you
We can also send you information on our Quality Management program.
Case management: Helping you manage
all the moving pieces
Health care can be overwhelming. Our case managers can help make it easier. Your doctors know how to help you with your care. It really helps if you know how to care for yourself, too. That’s what our case managers can help you do.
As a Simply member, we offer many different types of services. Your case manager works with you and your doctor to set up a plan of care. You may already be working with a case manager and know how to contact them.
If you think you need case management services or need help contacting your case manager, call Member Services. The phone number for your plan is on our Contact us page.
Our case managers may also call if:
- You or your doctor thinks case management might help you
- You’ve just gotten out of the hospital and need help with follow-up visits to other doctors
- You’re going to the emergency room (ER) often for nonurgent care that could be handled by your doctor
- You call our 24-hour Nurse HelpLine and need more follow-up for ongoing care
- You have serious physical problems and need more help
- You have behavioral health problems and need more help working with all of your doctors
Your case manager can also help with:
- Setting up health care services
- Getting referrals and prior authorizations (approvals)
- Checking your plan of care
- Transitioning to new healthcare providers
If we call you, a nurse or social worker will:
- Always identify themselves with their name, title and position with Simply
- Tell you about what we offer
- Talk to you about your health and how you’re handling different parts of your life
Utilization management: How we
make choices on care and services
Sometimes, we need to make choices about how we pay for care and services. This is called Utilization Management (UM).
Our UM program:
- Looks at what, when and how much of our services are medically needed
- Always strives for the best possible health outcomes for our members
Our UM program does not:
- Tell doctors to withhold or give you fewer services limiting or denying care
- Stop certain people from getting services
- Reward doctors for limiting or denying care
Getting in touch with our Utilization Management staff
Some Simply services and benefits need prior approval. This means your doctor must ask Simply to approve the services he or she wants you to have. Emergency care does not need prior approval.
Our Utilization Review team looks at approval requests. The team decides if:
- The service is medically needed
- The service is one that is included in your Simply benefits
What should you do if Simply won’t approve care you think you need?
You or your doctor can ask us to take another look. We’ll let you and your doctor know when we get your request. You can ask us to take another look at services that:
- Are not approved
- Have been limited in the amount or length of time from what was requested
Do you have questions about an approval or a denial you got? Call Member Services. Our Utilization Review team or your Case Manager can help answer your questions.
Your opinion matters!
Every year, we survey our members about the benefits we offer. If you get a survey in the mail, by email or phone, please complete it. Help us make your plan better.
New technology in medicine and care
To make sure we are always using the latest medical treatment and equipment to help you feel your best, our medical director and doctors look at all the latest medical changes. They look at:
- Medical treatment and services
- Behavioral health treatment and services
They also look at the most up-to-date medical and scientific writings. With all this data, they consider:
- If the changes are safe and helpful
- If these changes offer the same or better results than what is used today
This work is done to help us decide if a new treatment or care should be added to your benefits.
You have rights and responsibilities
As a Simply member, you have rights and responsibilities. They are listed in your Evidence of Coverage. Do you need a printed copy of your Evidence of Coverage? Call Member Services. The phone number for your plan is on our Contact us page.
Providers are required to adhere to Centers for Medicare & Medicaid Services (CMS) and Simply requirements concerning issuing letters and notices.
Simply members have the right to timely quality care and treatment with dignity and respect. Each member receives a copy of the Explanation of Coverage which outlines the member’s rights and responsibilities. Providers must respect the rights of all Simply members.
Members have the right to:
- Be treated with dignity, respect and fairness at all times
- Receive information about the health plan, services, practitioners, providers and member rights and responsibilities
- Receive information in a way that works for them (in languages other than English spoken in the plan service area, in Braille, large print or other alternate formats)
- Ensure the privacy of their medical records and personal health information
- Choose a plan provider
- Receive care from a women’s health care provider
- Have timely access to their providers and to receive services from specialists when appropriate
- Obtain information from providers and be advised about all medically appropriate or necessary treatment options available for their condition, regardless of cost or benefit coverage
- Participate fully in decisions about their health care and be informed about any risks involved in their care
- Refuse treatment, leave a hospital or medical facility or stop taking medications; the member must accept responsibility and the consequences of his or her decision
- Complete an advance directive (living will or power of attorney) to help them with decisions related to their health care if they are unable
- Voice complaints or appeals about the health plan or the care provided
- Make recommendations regarding the health plan’s member rights and responsibilities policy
- Receive information about the appeals and grievances members have filed against Simply in the past
- Receive information about the Medicare Advantage plan, plan providers, drugs, health care coverage and costs, including an explanation about any bills received for services or drugs not covered
- Request information regarding provider compensation by Simply
- Receive a written or binding advance-coverage determination for health care services, even if the care is requested from a nonparticipating provider
Members have the responsibility to:
- Be familiar with their coverage and the rules they must follow to obtain health care
- Notify Simply if they have additional health insurance coverage
- Notify providers when seeking care that they are Medicare members and present their Simply Medicare member ID cards
- Provide the health plan, doctors and practitioners with accurate information to render care and follow the treatment plans and instructions they agreed to with the provider
- Understand their health problems and participate in identifying mutually agreed-upon treatment goals to the extent possible
- Treat their doctor, their doctor’s staff and Simply employees with respect and dignity
- Not be disruptive in the doctor’s office
- Pay their copayment for covered services
- Notify Simply if they have questions, concerns, problems or suggestions. The phone number for your plan is on our Contact us page.
Your benefits and how to get medical care
Are you looking to learn more about our services and benefits? Refer to your Evidence of Coverage. You can read about:
- Preventive health care: Find out how to help prevent many health issues and how to live a healthier life.
- Preventive health care for women: Learn how to get access to women’s health specialists for regular and preventive health care services.
- Benefits and access to care: Find out more about your benefits and how to get medical care.
- Language help: Learn how to get our information in the language you use at home.
- Case management: Partner with a case manager to learn more about ways to get care for your health issues.
- Member rights and responsibilities: Read about your rights and responsibilities.
- Notice of Privacy Practices: Learn more about how we keep your private information safe.
- Medical necessity: Find out how we decide if care is right for you based on the right coverage and correct levels of care and service.
- Advance directives: Learn more about your right to use an advance directive (living will), to have one on file or on hand if you can’t tell others about the care you want to keep you alive. Your doctor has advance directive forms and more information.
It may be time for a new PCP or behavioral health provider
It’s important for you to get the right care from your providers. You can choose to change to a provider who specializes in care specific to your needs, including physical and behavioral health. We can help if you want to change. We can also help you transfer your medical records.
Start by asking your current PCP or behavioral health provider for a recommendation for a new adult PCP or behavioral health provider. We’re here to help, too. You can change your PCP or behavioral health provider at any time. It's easy by calling Member Services.
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Our Notice of Privacy Practices
The notice tells you about how we may use and share your health data. It also tells you how to get this data. The notice follows the Privacy Rule set by the Health Insurance Portability and Accountability Act (HIPAA). View the Notice of Privacy Practices or find it in your member handbook. Call Member Services if you want a copy of the Notice of Privacy Practices mailed to you. The phone number for your plan is on our Contact us page.
Simply Healthcare Plans wants to make sure that the health care services you receive are the best in quality care. For this reason, Simply Healthcare collects HEDIS performance measures and Agency defined measures. These measures are reported to the Agency for Healthcare Administration (AHCA) and to NCQA annually.
HEDIS measures are developed by the National Committee for Quality Assurance (NCQA), which is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. NCQA develops quality standards and performance measures for health care entities. These are the measures and standards that Simply Healthcare Plans and AHCA use to help identify where we need to improve.
Visit www.healthinsuranceratings.com to see Simply’s as well as all other Medicare health plans performance.
These measures include:Adult BMI Assessment
The percentage of members 18-74 years of age who had an outpatient visit and who had their body mass index documented during the measurement year or the year prior.Colorectal Cancer Screening
The percentage of members 50–75 years of age who had appropriate screening for colorectal cancer.Controlling High Blood Pressure
The percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria:
- Members 18–59 years of age whose BP was <140/90 mm Hg.
Care of Older Adults
The percentage of adults 66 years and older who had each of the following during the measurement year:
- Advance care planning
- Medication review
- Functional status assessment
- Pain assessment
Medication reconciliation Post-Discharge
The percentage of discharges from January 1–December 1 of the measurement year for members 18 years of age and older for whom medications were reconciled the date of discharge through 30 days after discharge (31 total days).Breast Cancer Screening
The percentage of women 40-69 years of age who had a mammogram to screen for breast cancer.Comprehensive Diabetes - Eye Exam
A retinal or dilated eye exam by an eye care professional was done during the measurement year OR a negative retinal exam was done by an eye professional in the year prior to the measurement year.Comprehensive Diabetes - Good Control
The most recent HbA1c level is <8.0%Comprehensive Diabetes - HbA1C Poor Control (Inverse Measure)
The most recent HbA1C level is >9.0% or is missing or was not done during the measurement year.Comprehensive Diabetes - HbA1C Testing
HbA1C test was performed during the measurement year.Comprehensive Diabetes - LDL Screening
An LDL-C test was performed during the measurement year.Comprehensive Diabetes - LDL-C Control
The most recent LDL-C level performed during the measurement year is <100 mL.Comprehensive Diabetes – Nephropathy
A urine micro-albumin test was done during the measurement year OR there is evidence of nephropathy during the measurement year.Controlling Blood Pressure – Total
The number of members with hypertension whose most recent BP is <140/90.Follow-Up after Hospitalization for Mental Illness
7 Day The percentage of discharges for members 6 years and older who were hospitalized for a mental health disorder and who had an outpatient visit, an intensive outpatient encounter, or a partial hospitalization with a mental health practitioner within 7 days.Follow-Up after Hospitalization for Mental Illness
30 Day The percentage of discharges for members 6 years and older who were hospitalized for a mental health disorder and who had an outpatient visit, an intensive outpatient encounter, or a partial hospitalization with a mental health practitioner within 30 days.Readmission Rate (Inverse Measurement)
The percentage of enrollees who were hospitalized for a mental health diagnosis and were discharged to the community from an acute care facility and were readmitted for a mental health diagnosis within 30 days.
Y0114_19_107379_U CMS ACCEPTED 4/29/2019