CIGNA-HEALTHSPRING'S QUALITY IMPROVEMENT PROGRAM

Cigna-HealthSpring Quality Improvement program helps to improve the medical care we provide our customers. It’s our aim to help customers feel better, which leads to a better quality of life. There are many ways we evaluate our Quality Improvement program. Throughout the year, we ask you to submit customer surveys and complete preventive health screenings to show us how you’re doing. By comparing those results to the Quality Improvement goals, we are able to see how our program helps our customer’s health. We’ve put together a quick summary of some of the focus areas of our Quality Improvement program.

Cigna-HealthSpring Quality Improvement program focuses on many preventive screenings. In this report, we will focus on three:

  • Breast cancer screening
  • Colorectal cancer screening
  • Diabetic retinal eye exam (for customers with diabetes)

Breast cancer screening
In 2016, Cigna-HealthSpring aimed to have 84% of women complete a breast mammogram. Eleven markets either declined or remained the same in mammogram completion compared to 2015, and two markets reached the 84% goal.

Colorectal cancer screening
Colorectal cancer screenings are very important because it is usually difficult to know if you have symptoms for colorectal cancer. It was our goal for 81% of our customers to have a colorectal cancer screening in 2016. While six markets reached our goal, twelve markets improved in these screenings from 2015. Three markets decreased from the previous year.

Diabetic retinal eye exam
Customers with diabetes should have a retinal eye exam every year. If you had a diabetic eye exam this year and you do not have any problems with retinal eye changes, you can wait two years to have your next exam. Our goal was for 83% of our customers with diabetes to complete this eye exam. Eleven markets saw improvements with increased diabetic eye examinations. Three markets reached the 83% goal. Cigna-HealthSpring is aware of how important it is for customers to get preventive screenings and will be working towards improving these rates in the coming year.

Cigna-HealthSpring recognizes the importance of customers understanding and managing their own health care. Our Quality Improvement program attempts to help track this in many different methods. In this report, we will focus on high blood pressure.

High blood pressure screening
Blood pressure control scores showed improvement in most markets in 2016. Thirteen markets had improvement over 2015, with one reaching our goal of 84%. This is measured by evaluating the health of each customer with high blood pressure, including but not limited to healthy diet, exercising, and taking prescribed blood pressure medications from their doctor.

2016 Assessment of Customer Experience
In 2016, customer survey responses showed areasthat we have made improvements overall. However, Cigna-HealthSpring is committed to providing you with the best quality of care for the best health outcomes. Our committee will continue to focus on improvement in customer satisfaction in customer satisfaction in the following areas:

  • Getting appointments with specialists easily
  • Keeping your doctor informed about the care you receive from specialists
  • Getting needed tests, care or treatment
  • Making sure that your doctor discusses taking medicines with you
  • Getting seen within 15 minutes of appointment time
  • Filling prescriptions by mail easily
  • Giving you the information you need when you call us

 

If you have any questions, or to find results specific to your region, please call Customer Service.

Cigna-HealthSpring must provide in a timely manner a written organization determination to enrollees who request this information. A written organization determination is a determination by the plan prior to a provider furnishing a service confirming whether that service is both medically necessary and a plan-covered service and in consequence will be paid for by the MA plan.

Asking for a coverage decision
Start by calling, writing, or faxing our plan to make your request for the type of coverage decision you want. You, your doctor, or a representative can do this. If your health requires a quick response, you should ask our plan to make a Fast Decision. To get a Fast Decision, you must meet two requirements:

  1. You are asking for coverage for medical care or a drug you have not yet received; and
  2. Using the standard deadlines could cause serious harm to your health or hurt your ability to function. If your doctor tells us that your health requires a Fast Decision, we will automatically agree to give you a Fast Decision. If you ask for a Fast Decision on your own, our plan will decide whether your health requires that we give you a Fast Decision. Unless you ask for a Fast Decision, we will use the Standard Decision deadlines for giving you our decision. The following table shows when you can expect our plan to give you a decision:

 

Decisions about Medical Care

  • Standard decision: 14 Days
  • Fast decision: 72 hours*

Decisions about Part D Prescription Drugs

  • Standard decision: 72 hours
  • Fast decision: 24 hours*

*We will give you an answer sooner if your health requires us to do so.

If you disagree with a coverage decision we have made, you can appeal our decision. For more information about organization determinations, coverage determinations, and appeals, see your Evidence of Coverage.

Cigna-HealthSpring Utilization Management associates base utilization decisions on the clinical needs of the members, benefit availability, and appropriateness of care. Objective, scientifically-based clinical criteria and treatment guidelines such as InterQual criteria and Medicare National Coverage Guidelines, in the context of provider or member-supplied clinical information, guide the decision-making process. Cigna-HealthSpring in no way rewards or incentivizes, either financially or otherwise, practitioners, utilization reviewers, case managers, physician advisers, or other individuals involved in conducting utilization review, for issuing denials of coverage or service, or inappropriately restricting care.

The Pharmacy & Therapeutics Committee and Clinical Guidelines Committee carefully review new medications, medical and behavioral procedures, and devices as potential benefit additions for our customers. The Cigna-HealthSpring Pharmacy & Therapeutics Committee is made up of practicing physicians and pharmacists from various clinical specialties, including experts regarding care of the elderly or disabled individuals. Together, these professionals review new medications, as well as evaluate new Food and Drug Administration approved uses of medications. The Pharmacy & Therapeutics Committee considers whether a particular drug is better than, the same as, or worse than the medical benefit and safety of other available drugs within the same drug class. The Pharmacy & Therapeutics Committee looks at scientific studies and standards of care, including clinical guidelines and current medical and drug studies. Based on this review, the Pharmacy & Therapeutics Committee votes on whether medications work better than, as well as, or worse than other treatments in terms of medical benefit and safety. This decision is used to help determine what drugs are listed on the formulary.

TennCare is not responsible for payment for these benefits, except for appropriate cost sharing amounts. TennCare is not responsible for guaranteeing the availability or quality of these benefits.