Health Care Advocacy Project Procedures Manual
Please click on a topic below for information
- MESSAGE FROM CCCIL
- STAFFING THE HEALTH CARE ADVOCACY PROJECT
- CREATING AN ADVISORY BOARD
- NETWORKING WITH COMMUNITY ORGANIZATIONS
- MAKING A PRESENTATION
- IDENTIFYING POTENTIAL CONSUMERS
- Sample Radio Ad
- Sample Billing Dept. Letter
- Sample Phone Script
- Sample Newsletter Article
- Sample Press Release
- TEACHING SELF ADVOCACY SKILLS
- CREATING AN INTAKE SHEET
- DEVELOPING A DATABASE TRACKING MAJOR HEALTH CARE PLANS
- DEVELOPING A COMPREHENSIVE DATABASE
- EVALUATING PROGRESS
- HANDOUTS DISTRIBUTED – English
- HANDOUTS DISTRIBUTED - Spanish Agendas
- Handouts Distributed in Spanish – Explanation of Benefits
- Handouts Distributed in Spanish – Glossary of Insurance Terms
- Handouts Distributed in Spanish – Types of Insurance
- Administration: Functions as the first point of contact for consumers calling the service. Responsible for maintaining information on all HMOs and PPOs to include plan profiles, policies, and coding systems. Responsible for creating consumers’ medical histories, record keeping, quarterly report statistics, etc.
- Advocacy: Under direction from the Project Director, advocates for individual consumers according to the strategy developed with the Project Director. Develops productive relationships with various HMO and PPO staff. Records case histories and all communications related to each consumer. Reports successes and problems to the Project Director. Coordinates educational workshops for consumers on their health insurance issues. Conducts trainings to various organizations on HCAP services.
- Support: Provides administrative and clerical support to the Project Director as required. Compiles statistics, financial data, and other information for quarterly reports to the funding agency. Compiles data for a Procedures Manual that describes how a Health Care Advocacy Service operates successfully. (This is a grant requirement; the service is a pilot project that may be replicated elsewhere.)
- Technical: Designs brochures, flyers and certificates using Microsoft Publisher. Works closely with computer consultant to develop an HCAP database system. Organizes and maintains consumer and insurance information through a database system.
- Follows CCCIL policies and procedures.
- Maintain practices that protect the confidentiality, safety and health of consumers and co-workers.
- Be available to work occasional weekends and evenings.
- Provide own transportation to areas not served by public transportation, to run errands and attend meetings and trainings.
- Do word processing on a computer.
- Local Medical Society (Executive Director)
- Area Hospitals (ask for Managed Care or Claims Department)
- American Association for Retired Persons
- Chamber of Commerce
- Legal Aide
- Various health related organizations such as the American Cancer Society
- Health Related Support Groups (contacting the local hospital should help with this)
- City or County Boards serving health and human services issues
- An Audio tape version
- An ASCII version on computer disk
- A Large print version (16pt. Bold, sans serif font )
- A Braille version (if requested by a participant)
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OVERHEAD PROJECTIONS
- Use 14 pt. Bold, sans serif font (Arial). Underline all headings. When using color, choose high contrast combinations. Black and white is best. Blue on yellow will also work. Consult with you meeting coordinator if you have any questions about color choices.
- Printed copies of the overheads must be available for individuals who are visually impaired and unlikely to see the screen. This will allow them to follow along more easily.
- Read aloud and describe charts, tables or graphics for the benefit of those who cannot see.
- When using flip charts, write in large letters. Always print.
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ASSISTIVE LISTENING DEVICES
Presenters may be required to use a microphone as part of an assistive listening system for hearing impaired participants. The meeting coordinator will arrange for assistive listening devices when needed. The coordinator will check and adjust sound levels with the assistance of the presenter before beginning the meeting. -
SIGN LANGUAGE INTERPRETERS
Presenters who need an interpreter should inform the meeting coordinator at least one week before the meeting. Please provide the coordinator with any preferences regarding the type of interpreter or working style you have.
Always speak at a normal pace and use a normal tone of voice when responding to a hearing impaired individual. Speak directly to that individual - not to the interpreter. Most hearing impaired participants will still want to read lips. Always face the group while speaking. Do not speak while reading from overhead projections or while facing charts, etc. -
EQUIPMENT & ROOM ARRANGEMENTS
The meeting coordinator is responsible for choosing a site that is accessible for people using mobility devices (wheelchairs, crutches, canes, service dogs, etc). When setting up overhead projectors or other equipment, please keep in mind the need to allow room for those individuals to move about freely. Securely tape all cables and cords to the floor so they are not a hazard. Allow room among the chairs at tables for people using wheelchairs. -
SCENT FREE POLICY
All training and meetings are conducted in a scent free environment in order to accommodate those with chemical sensitivities. Please refrain from using scented personal products when participating in one of these events. - Employee who has private insurance through their employer
- Spouse who is covered under private insurance through their spouse’s insurance
- Retired person who has private insurance as part of their retirement benefit package
- Individual who has private insurance through an individual plan offered by an insurance broker
- Learn how to organize medical bills and other documents
- Receive the medical treatment to which you are entitled
- Learn how to advocate for yourself and your family
- Receiving the medical treatment to which they are entitled
- Being compensated/reimbursed to the fair levels allowed under their coverage
- Learning how to organize medical bills, documents and other correspondence
- Learning tips on how to advocate for themselves and their families
- Your primary insurance is private (not Medicare) including coverage through an employer, spouse or individual plan such as a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO).
- You live with a long-term illness, chronic pain or a physical or psychiatric disability.
- You need to resolve a conflict over coverage with your current insurance provider.
- You reside in Monterey, San Benito or Santa Cruz counties.
- It’s your Health
- Your Rights as an HMO patient
- Protect Your Group Health Coverage
- Wellness Guide
- Medi-Cal
- Medicare and You 2002
- Consumer Complaint Process
- Independent Medical Review Process
- Do You Find Health Care Coverage Confusing
- The Keys to Managed Care
MESSAGE FROM CCCIL
By Elsa Quezada, Executive Director
The Central Coast Center for Independent Living (CCCIL) is excited to provide you with the Health Care Advocacy Project Procedures Manual. This manual is designed to be an instructional resource for those interested in developing health care advocacy services within their organization.
CCCIL is an advocacy and information organization serving people with disabilities in California’s Santa Cruz, Monterey and San Benito counties. The California Endowment awarded CCCIL a three-year grant to fund The Health Care Advocacy Project. The Health Care Advocacy Project establishes a model advocacy and mediation service for health care consumers living with long-term illnesses, chronic pain or a physical or psychiatric disability.
The Health Care Advocacy Project had four key objectives to achieve:
1. Develop a database of all HMOs, PPOs and other related plans serving the target community.
2. Assist 100 clients with their health care insurance claims during the first year, to increase to 300 in the second and third years, with targeted 60% rate of success during the first year, to improve to 80% in the subsequent years.
3. Develop a health care consumer empowerment program consisting of training workshops, individual consultation and instructional materials.
4. Develop a prototype for sharing and replication with other disability and advocacy organizations. Tools and resources to be developed and shared with other agencies will include a procedures manual and the database of health plans represented in the area.
The Procedures Manual takes you through the entire process of how CCCIL developed the project. It is our goal to provide a model that can be duplicated throughout California. If you have any questions, or would like additional information please feel free to call us at 831-757-2968 (Voice), 831-757-3949 (TDD) or www.cccil.org. Thank you.
Health Care Advocacy Project
STAFFING THE HEALTH CARE ADVOCACY PROJECT
CCCIL hired a Project Director and a Health Care Advocate to fulfill the grant requirements of the Health Care Advocacy Project. Once the project was established, CCCIL’s staff were cross-trained to ensure more consumers would be served.
Please see the job qualifications for the Project Director and Health Care Advocate.
JOB TITLE: PROJECT DIRECTOR - Exempt
JOB SUMMARY: The Project Director reports to CCCIL’s Executive Director. He/she is in charge of implementing and administering the Health Insurance Advocacy Service, a grant‑supported project to provide improved health care access to people living in Monterey, Santa Cruz and San Benito counties. Staff will advocate on behalf of clients with their health plans, insurance companies, physicians and/or health care providers to: 1) assist consumers understanding about how their health plan works and what their coverage entails, 2) what services they are eligible for and any limitation or cost-sharing responsibilities they may have, 3) how to access services, 4) assist them accessing care and services they are entitled to, and 5) assist them in obtaining refunds if they have paid for covered service.
ESSENTIAL DUTIES
1) Administration: Hires and supervises Health Care Advocate. Responsible for budget, program development, program evaluation, record keeping, and quarterly status reports to funding agencies. Coordinates the work of the Advisory Board.
2) Advocacy: Responsible for establishing productive relationships with various health plans, insurance companies, physicians and/or other health care providers; reviews case histories of clients and formulates appropriate strategies in each case. When required, intercedes directly with health plans to advocate for client or assist with the grievance process with the client. Is responsible for the successful resolution of each case, or referral to appropriate licensing, administrative or judicial body for adjudication.
3) Documentation: Responsible for development of Procedures Manual which describes how a Health Insurance Advocacy Service operates successfully.
(This is a grant requirement; the service is a pilot project
that may be replicated elsewhere.)
Builds and maintains insurance company contacts who assist
with the resolution of access and benefit payment issues.
4) Education and Outreach: Responsible for developing the contents and format of the consumer empowerment education program, and for designing and delivering the outreach campaign. Will establish collaborative relationships with other agencies serving clients with similar needs and with health care providers in the area. Will research the Internet for similar programs and services that will lead to the evolution and strategies of the position.
DESIRABLE CHARACTERISTICS: The Project Director must be a self‑starter-capable of working with minimal supervision. The Director must be assertive and at the same time, tactful. The job requires a commitment to helping people work through the bureaucracies of their insurance companies. The Project Director must be well organized, have excellent oral and written communication skills including negotiation skills, and be comfortable advocating deftly but firmly with insurance companies.
EXPERIENCE: Ideally, the Project Director will have administrative experience in health care, particularly with insurance claims and processing. The Director will have had significant levels of responsibility.
REQUIREMENTS: Candidates may have several types of degrees, licenses or certifications. For example, an RN with experience in hospital billing or administrative background with an insurance company may be appropriate. A candidate with a business degree and experience in the health and/or insurance fields may also be qualified. Bilingual skills desirable (English/Spanish). Must have the ability to maintain confidentiality.
APTITUDES/TEMPERAMENTS: Sensitivity to issues concerning diverse cultures and people with diverse disabilities; ability and willingness to work with a wide range of people with disabilities.
Health Care Advocacy Project
STAFFING THE HEALTH CARE ADVOCACY PROJECT
JOB TITLE
JOB SUMMARY: Under the Supervision of the Project Director, staffs the Health Care Advocacy Project (HCAP), a grant‑supported project to provide improved health care access to people with disabilities living in Monterey, Santa Cruz and San Benito counties. The Health Care Advocate will advocate on behalf of consumers with their insurance companies (HMOs, PPOs) to: 1) help consumers receive the medical treatments to which they are entitled, and 2) have them be compensated/reimbursed to the levels allowed under their insurance coverage.
ESSENTIAL DUTIES
Other:
SECONDARY DUTIES
Ability to operate standard office equipment (including fax machine, photocopier, TDD, typewriter)
JOB SPECIFICATIONS
EXPERIENCE/KNOWLEDGE REQUIRED: Excellent written and oral communication language skills in English and Spanish. The Health Care Advocate must be well organized and have excellent administrative/clerical skills. He/she will spend a considerable amount of time on the telephone, talking to potential consumers, recording case histories, discussing individual cases with representatives of various HMOs and PPOs, and reporting findings to consumers. Experience in the health field and/or with insurance firms and insurance claims processing. A background in advocacy or a willingness to advocate on behalf of consumers is essential. High-level clerical skills and computer experience are required. Minimum of 3 years related work experience.
Health Care Advocacy Project
CREATING AN ADVISORY BOARD
An Advisory Board can be an important tool for consumer groups seeking to improve health care quality.
The Health Care Advocacy Project (HCAP) Advisory Board was formed to oversee the service delivery system and is responsible for evaluating the data gathered and submitting recommendations to modify the service, as required. Data collected from HCAP included case histories and success rates, the number of consumers who participate in their own advocacy through pre and post service surveys and consumer satisfaction data.
The members of the Project Advisory Board are leaders in their field and community who can offer a valuable resource to CCCIL staff establishing the Health Care Advocacy Project. Members of HCAP’s Advisory Board consisted of a physician, an attorney, a member of CCCIL's Board of Directors, an insurance broker, management staff of the local Medi-Cal agency and an RN/ Operations Manager of a local hospital. The Advisory Board oversaw the service delivery system and was responsible for evaluating the data gathered and submitting recommendations to modify the service, as required.
For the HCAP Advisory Board, no formal by-laws or procedures were created.
The primary role of the Advisory Board was to provide guidance to staff by giving input and answering questions on how to make the Health Care Advocacy Project successful. It is important to use the Advisory Board for its expertise. HCAP did not regularly conduct a meeting every month to meet with the Advisory Board. It did, however, update the Advisory Board on a regular basis through phone calls or written correspondence. Individual Advisory Board members were contacted for guidance on particular issues when their technical experience was needed.
In addition to giving guidance, the Advisory Board evaluated the performance of HCAP. It reviewed its progress of completing the first six-month pilot. It also provided a final evaluation at the end of the three-year project.
Sample Advisory Board Invitation Letter
Dear Ms. Potential:
It was great having the opportunity to speak to you. We discussed a lot of these issues over the phone, but I thought you might find it useful having the information in writing.
Please take a moment to learn more about this exciting project involving the Central Coast Center for Independent Living (CCCIL). CCCIL is a 501(c)3 non-profit, advocacy and information organization serving Santa Cruz, Monterey and San Benito counties. Understanding that many people with disabilities are excluded from full participation in society, CCCIL's mission is to empower people with disabilities with the information and skills necessary to open the doors of access to our communities.
In continuing the tradition of empowering consumers, CCCIL was awarded a three-year grant from The California Endowment to fund The Health Care Advocacy Project in order to improve health care access to an underserved population in the three counties it serves.
The Health Care Advocacy Project will establish a model advocacy and mediation service for health care consumers living with long-term illnesses, chronic pain or a physical or psychiatric disability. I was hired by CCCIL in September. I am responsible for developing a project to educate and empower consumers to receive the required medical care and the coverage to which they are entitled under their medical insurance plan. As the project grows, a successful model will be developed that can be replicated throughout the state.
The Health Care Advocacy Project began as a pilot in December 2000 assisting twelve consumers. The Project Advisory Board will evaluate the pilot in May 2001. In June 2001, after the evaluation is complete and recommendations are made, the Health Care Advocacy Project will begin to assist 100 consumers with their health care claims within one year.
Members of the Project Advisory Board will be leaders in their field and community who can offer a valuable resource to CCCIL staff establishing the Health Care Advocacy Project. The members of the Advisory Board will consist of a physician, an attorney, one member of CCCIL's Board of Directors, an insurance broker, management staff of local social security/Medi-Cal agencies and an executive director of local nonprofit agency that serve clientele with similar needs.
The primary role of the Advisory Board will be to provide guidance to staff by giving input and answering questions on how to make the Health Care Advocacy Project successful. Board members will not be expected to attend numerous meetings, read countless documents and commit a large portion of their time.
The Board initially met in December. Future meetings will be held during the lunch hour where food and drink will be provided. Periodic meetings and updates will take place between February and May when the Advisory Board will evaluate the pilot.
The Health Care Advocacy Project has four key objectives:
Develop a database of all HMOs, PPOs and other related plans serving the target community.
Assist 100 clients with their health care insurance claims during the first year, to increase to 300 in the second and third years, with targeted 60% rate of success during the first year, to improve to 80% in the subsequent years.
Develop a health care consumer empowerment program consisting of training workshops, individual consultation and instructional materials.
Develop a prototype for sharing and replication with other disability and advocacy organizations. Tools and resources to be developed and shared with other agencies will include a procedures manual and the database of health plans represented in the area.
I will be contacting you within the next week to discuss the opportunity of you serving on the Health Care Advocacy Advisory Board. Input and guidance from you will ensure the success of Health Care Advocacy Project. Please call me at 831-757-2968 ext. *814 with any questions you may have. Thank you.
Sincerely,
Nicole Johnston
Project Director
Health Care Advocacy Project
Health Care Advocacy Project
NETWORKING WITH COMMUNITY ORGANIZATIONS
It is important to establish a working relationship with other non-profit organizations, community groups and government agencies. By establishing a relationship, community organizations will be aware of the service.
It is however, equally important to evaluate making presentations to a group who may not need the Health Care Advocacy Project service. For example, it might not make sense to make a presentation to a group whose primary insurance is Medicare (since we focus on the primary insurance being an HMO or PPS)
When looking to contact potential organizations, there are several things you can do:
Use your contacts through your current organization
Ask co-workers if they have any contacts with other organizations
Look in the phone book under “Associations” and send letters of introduction and phone calls.
Important people to contact are:
Once you contact the various groups, set up a time to meet with its members. These meetings can initially be with the Director or Manager but after that follow through to arrange for a presentation in front of a larger audience. The more people you can reach the better the referral system will be.
Health Care Advocacy Project
MAKING A PRESENTATION
When making a presentation, it is important to have handouts for your audience to follow. It is also important to present information in alternative formats such as cassette and large print. Call the coordinator of the group ahead of time to see if there are special accommodations that need to be made (see “Guidelines for Presenters” for detailed information).
For the presentations we made, we let the audience know the guidelines for consumers to qualify for the Health Care Advocacy Project service. We also provided the audience with fliers describing the project that included all of the contact email and phone information.
CCCIL made many public presentations of the Health Care Advocacy Project that turned out very well. Although there are many types of presentations that can be made, we found it was effective to follow this format:
Introduction
Discuss a story or experience to grab the audience’s
attention. We begin our presentations
by describing a typical experience that one of our consumers may have. After
getting the audience’s attention, it is important to mention the four or five
points of what the presentation will be about. Keep in mind your audience and
center your topic on issues that interest them. For example, we made a presentation to a group of 30 Executive
Directors of Independent Living Centers. Instead of discussing our goals and measurable outcomes, we focused on
how the Health Care Advocacy Project can benefit other Independent Living
Centers.
Body
In the body of the presentation, expand on the four
or five points that were mentioned in the introduction. Maintain confidentiality but use personal
examples of the consumers served.
Conclusion
The conclusion should be a recap of the introduction.
Reiterate the four or five key points. Provide the audience with information on how to contact you for further
information. Leave at least five
minutes at the end of the presentation to answer and questions the audience may
have.
Power Point Presentations are an excellent way to make a presentation. Even if you don’t have a laptop and projector, you can use the Power Point format to make slides or overheads.
GUIDELINES FOR PRESENTERS
The following guidelines have been prepared to familiarize trainers and other presenters with the accommodations that are required by the California Foundation for Independent Living Centers (CFILC). By adhering to these guidelines, your presentation will be universally accessible to people with a variety of disabilities.
HANDOUT MATERIALS
A. Use 14 pt. bold, sans serif font (Arial). Underline all headings.
B. If you decide to provide your own alternate formats of handouts, please make the materials available in:
Consult with your meeting coordinator to determine quantities of each format that will be needed.
Health Care Advocacy Project
IDENTIFYING POTENTIAL CONSUMERS
Since the target consumer is a person who has private insurance, it is important to identify groups or organizations that serve those individuals.
Examples of individuals covered under private insurance:
Once potential consumers have been identified, target marketing efforts toward them. This can be done through personal contacts, letters to businesses/organizations serving them, press releases, newsletter articles, radio Public Service Announcements, etc.
Sample Radio Ad Promoting the Health Care Advocacy Project
Do you have a disability or chronic illness? Do you have a private insurance plan through your spouse or employer? Have you been denied for services? Do you have unpaid medical bills? Do you find the entire insurance process confusing? If you answered yes, then you can get help from the Health Care Advocacy Project through the Central Coast Center for Independent Living. Please call 757-2968.
The Health Care Advocacy Project helps with your private health insurance questions. We are a free service that helps people living with a long-term illness, chronic pain or physical or psychiatric disability. 757-2968
You can:
The California Endowment funds The Health Care Advocacy Project. Please call 757-2968 or www.cccil.org
Sample Billing Department Letter to Identify Consumers
Dear Ms. Jones:
Does your office deal with unpaid medical bills? Do your patients need to talk to someone about medical coverage questions? Do your patients find their health insurance confusing? If you answered yes, please take a moment to learn more about this exciting project involving the Central Coast Center for Independent Living (CCCIL). CCCIL is a 501(c)3 non-profit, advocacy and information organization for people with disabilities serving Santa Cruz, Monterey and San Benito counties.
CCCIL was awarded a three-year grant from The California Endowment to fund The Health Care Advocacy Project. The Health Care Advocacy Project is a free service that assists people with disabilities with their private insurance health plans. We have been successful in resolving billing disputes and appealing for necessary medical coverage. We understand the policies of each health plan, the medical coding system and the established process through which health care coverage claims are filed.
The Health Care Advocacy Project has established a model advocacy and mediation service for health care consumers living with long-term illnesses, chronic pain or a physical or psychiatric disability. Your patients can benefit from the Health Care Advocacy project by:
The Health Care Advocacy Project has already resolved thousands of dollars in disputed claims. All information is confidential. If you know someone who can benefit from our services, please contact our office at 831-757-2968 (Voice) or 831-757-3949 (TDD).
Sincerely,
Lupe Serna
Health Care Advocate
Central Coast Center for Independent Living
Sample Phone Script to Identify Potential Consumers
This is the script for participating in the Health Care Advocacy Project. Make SURE you say the full name. We don't want people to confuse us with HICAP.
My name is ________ and I am calling from the Central Coast Center for Independent Living.
We are starting a new project called the Health Care Advocacy Project. The Health Care Advocacy Project will help people understand their insurance policies and assist in helping people appeal benefit decisions.
If this is something you think you may be interested in participating, do you mind if I ask you a couple of questions?
Is your current primary insurance provider a Health Maintenance Organization (HMO), a Preferred Provider Organization (PPO) or another form of private insurance?
Do you need to resolve a conflict over your benefits with your current private insurance provider? And would you like to learn the skills to advocate for yourself?
Are you living with a long-term illness, chronic pain or a physical or psychiatric disability?
Do you live in Monterey, San Benito or Santa Cruz County?
The Health Care Advocacy Project is beginning as a pilot this December in which it will assist twelve consumers. We will be having an informational meeting on "Understanding Your Benefits" at the end of November where refreshments will be served. Are you interested in participating? Can we send you written material? Can someone contact you for more information?
Sample Newsletter Article Promoting the Health Care Advocacy Project
AREA ORGANIZATION HELPS PEOPLE WITH HMOs.
The Central Coast Center for Independent Living (CCCIL) is looking for people with disabilities or chronic illnesses to participate in an exciting and free pilot project called the Health Care Advocacy Project. The Health Care Advocacy Project will help people understand their insurance policies and assist in helping people appeal benefit decisions.
The Health Care Advocacy Project can help you if you meet all of the following guidelines:
If you meet the above criteria, please contact the Health Care Advocacy Project at 831-757-2968 extension *826 (voice) or 831-757-3949 (TDD) and ask for Health Care Advocate Lupe Serna.
Sample Press Release Promoting Consumer Workshop
For Immediate Release:
For More Information Contact:
Nicole Johnston Zipsie
831-757-2968
LEARN MORE ABOUT HEALTHCARE AND RECEIVE $100
September 27, 2001 - People with disabilities or chronic illnesses who have private insurance can earn $100 for participating in four workshops. The Health Care Advocacy Project, a program from the Central Coast Center for Independent Living (CCCIL) is hosting four consumer workshops on understanding health insurance issues.
The first workshops will take place Thursday, October 11th 1:30pm – 3:00pm at the Watsonville Community Hospital, 75 Nielson Street in Conference Room 1 and Friday, October 12th 1:30pm – 3:00pm at the Hollister Community Center, 300 West Street. The other workshops will take place in January, April and July of 2002, location and times to be determined.
The workshops will be bi-lingual. English and Spanish speaking people with disabilities are encouraged to attend. The first workshop will be titled “How To Organize Your Medical Bills”. In addition to receiving $100 after attending the four workshops, participants will be given resources and informational tools to organize their healthcare materials.
Only 10 people will be selected based on the criteria of having a disability or chronic illness and having private insurance such as an HMO or PPO. Interested participants should call CCCIL at 831-757-2968 (voice) or 831-757-3949 (TDD).
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Health Care Advocacy Project
TEACHING SELF-ADVOCACY SKILLS
When advocating for a consumer, it is important to get all of the necessary information ahead of time. This helps resolve the issue faster but it also involves the consumer in the process.
Ask the consumer…
What insurance company are you covered under?
Do you have a copy of your Evidence of Coverage?
If you don’t have a copy of the EOC, what plan is it
(i.e. small employer, large employer, individual, etc.)
Do you have Medicare as a supplemental insurance?
One of the Health Care Advocacy Project’s goals was to teach self-advocacy skills. This was done on an individual basis and through group workshops. Instead of having a single workshop, CCCIL conducted a series of workshops with different information.
SELF-ADVOCACY WORKSHOPS
In October 2002, CCCIL conducted a series of self-advocacy workshops that took place in South Monterey County. The Health Care Advocate conducted these workshops. The workshops focused on providing in-depth information on managed care to farm workers. All materials for the workshops were translated into Spanish grade level 5. Materials from Department of Managed Health Care, Health Insurance & Counseling Advocacy Program, Office of the Patient Advocate, National Cancer Institute, and the Central Coast Alliance for Health were distributed. Each workshop featured a Power Point Presentation. Workshop materials included brochures, booklets, informational flyers and a passbook for organizational purposes.
These are examples of the various handouts that were provided in a binder:
The Health Care Advocacy Project targeted the local agricultural companies to put flyers/inserts into their payroll checks informing their employees of the workshops. The Health Care Advocate visited six of the largest employers South Monterey. HCAP Brochures and flyers were distributed to the local South Monterey County Pharmacy, along with detailed information about the HCAP program. Brochures were also taken to markets that cater to the Latino community and posted at community Laundromats.
A pre/post workshop evaluation was created. The pre-evaluation was given to each workshop attendee to measure the level of understanding before the workshop. This post-evaluation was given to the attendees at the final workshop. The evaluations were compared to determine the level of understanding the consumer received.
SELF-ADVOCACY WORKSHOP CURRICULUM:
Workshop 1: Healthcare overview
The workshop began with an overview of all four workshops so the consumers knew what to expect. The first workshop discussed what a consumer should do to be effective in self-advocating. It explained how to create a medical history and what documents to keep. It also gave information on finding a doctor that would best work with their disability.
Other topics that were discussed highlighted the following:
“Your Disability and Your Rights as a Person with
Pain”
“You are the Expert”
“Know what kind of plan you have”
“HMO, PPO, POS”
“2 or more payers- Medi-Cal, Medicare”
“Find the right doctor”
“Keep accurate records”
“Plan ahead- Meds, TARs (Treatment Authorization
Request), Referrals”
“Establish an inside connection”
Workshop 2: The anatomy of a health plan
The second workshop focused on “Understanding your Benefits”. This workshop explained the difference between an HMO, a PPO, a Trust and other types of insurance types. The later portion of the workshop focused on the anatomy of the Health Care system. It explained what an Independent Physician’s Association (IPA) is and the relationship between the health insurance companies and the IPAs. A list of definitions was given to the group that explained healthcare terminology. An in-depth discussion using overheads on the Explanation of Benefits was presented. The consumers were encouraged to bring their bills and Evidence Of Coverage to the next workshop. The consumers were also encouraged to give examples of when their plan didn’t work for them and what action they took.
Workshop 3: Laws to protect your health benefits.
This workshop highlighted the laws that govern health plans such as HIPPA, Cobra and ERISA. A list of departments such as Department of Managed Care, Dept of Corp/Insurance and California Office of the Ombudsman and their functions was given to the consumers. Health Maintenance Organizations and the laws that govern them was the main topic of this workshop. Problems with healthcare, appeals and the independent medical review were discussed at length. A brief discussion provided information on laws that govern all health plans and the consumer’s rights. At the end of the workshop two volunteer participants provided examples on how to resolve health care issues by way of role-playing. The scenarios used were based on two consumers who had been denied services or whose medical bills were not paid. The scenarios included phone calls to a fictitious insurance company.
Workshop 4: Options people with disabilities and summary
The fourth workshop provided information on what a consumer can do if they lose their private healthcare benefits. An explanation of Major Risk Medical Insurance Program (MRMIP), Medicare and MediCal was given. Medi-gap was briefly reviewed. Special MediCal programs that pay for Medicare premiums were also discussed. COBRA benefits were explained and the timelines that apply to the different scenarios that could occur under COBRA law. An in-depth explanation on qualifying for Medicare benefits was presented followed by a description of benefits under Medi-Care coverage. A portion on Medi-Cal qualifications and benefits was given to the group and how the benefits are administered.
In addition, each workshop had an agenda and a closing evaluation. A survey was created to gather information on how much knowledge the consumer had before and after the series of workshops. CCCIL continues to track all of the workshop participants and evaluate if they assisted traditionally underserved monolingual Spanish-speaking people with disabilities. CCCIL also tracked how many people the Health Care Advocacy Project have assisted with their private insurance conflicts and how long it takes for the issues to be successfully resolved. Based on initial evaluation of closing surveys all participants significantly improved their knowledge of the medical benefits they were entitled to and how to advocate for themselves.
Health Care Advocacy Project
CREATING AN INTAKE SHEET
The consumer intake sheet is the most important document you will use. It creates a record of that individual for the database and prompts the staff person, who is making the initial contact, to compile vital information for the case.
There are three types of information that are recorded in the intake sheet: the first is vital statistics. This information helps to identify the client, for example name, date of birth, the address or social security number. This type of information will never or rarely change.
The second type of information is the case history, which includes the date, the case summary, consumer’s diagnosis, name of the consumer’s doctor or the name of the health plan.
The third type of information is statistical. This would include demographic information such as the ethnicity of the consumer, the county or city where the consumer lives, the age of the consumer or the income level.
The fields in the statistical section depend on the data that the funding source requires you to provide for your program. At times it may be necessary to gather information that is not required by your funding sources in order to develop areas of need for future potential funding. CCCIL was not required to provide all of the information requested but we found it useful in laying the foundation for establishing the need of the service. When creating an intake sheet, it is necessary to create a list of fields that would give you enough information to begin a plan of action.
Another area of consideration when creating an intake sheet is the initial contact. If a receptionist will make the initial contact, then most likely that person will only gather the information given to them and an intake sheet will prompt them with the questions they need to ask. On the other hand, if an intake worker is the initial contact person, it will be necessary to determine the extent to which that intake worker will help that consumer. If the staff person’s responsibility is only to take the information from the caller, then the fields produced will prompt the worker the same as a receptionist. When an intake worker’s duty is to initially work with a consumer and at a later date pass the case on to an ongoing Health Care Advocate, it may be necessary to add fields to the intake sheet to indicate that the case has been transferred. In this situation the intake sheet will serve only as history for the case manager.
When creating the actual document it will be easiest to use a word program or software that can create forms. It will be necessary to first make a list of fields that will make up the document. If the client will complete the initial document, then the intake sheet must be easy to understand and will need to be available in different languages, fonts and alternative formats. The intake sheet must include an intake summary section. This section is for documentation and establishes case history. Below are examples of field entries that can be used for a new intake sheet:
| Case number | Home phone |
| Referred by | Work phone |
| Application date | Email address |
| Case manager | Alternate contact |
| First name | Occupation |
| Last name | Income (range or actual) |
| Date of birth | Insurance plan |
| Social security number | Insurance type (HMO/PPO/EPO) |
| Ethnicity | Diagnosis |
| Address | Intake Summary |
| City | Problem category |
| State | Payment amount |
| Zip code | Payment date |
| County | Payment method |
| Marital status |
These are a few examples of fields that can be used. The information required by each grant will vary. The space allowed for each field will be determined by the data that will be entered in that field, for example the “Date of Birth” field will require less space than the “Intake Summary” field.
Health Care Advocacy Project
DEVELOPING
A DATABASE TO TRACK THE
MAJOR HEALTH CARE PLANS
One of the requirements of Health Care Advocacy Project grant was to develop a database of major health plans in San Benito, Santa Cruz and Monterey counties. This turned out to be a challenging task. There are many health plans depending on factors such as a size of a business, the type of deductible, pre-existing conditions, etc. Originally, CCCIL thought they could get this information from the state. No state entity has a comprehensive list of health plans separated by county.
Through research, CCCIL developed its own list. The list, however, is rarely used for reference. In the current health care client, plans continue to leave the community and the contact information has to constantly be updated. The Health Care Advocacy Project found it more beneficial to collect information on the health plans consumers had by requesting the Evidence of Coverage and using it as a reference guide for the particular issue.
Please see the printed database of the health plans in, San Benito, Santa Cruz and Monterey counties that fulfilled the grant requirement.
|
Health Plan Name |
Type of Plan |
County |
|---|---|---|
|
Health Net |
PPO Value Basic 1000 |
Santa Cruz |
|
Health Net |
PPO Value Basic 2500 |
Santa Cruz |
|
Health Net |
PPO Value Basic 500 |
Santa Cruz |
|
Health Net |
PPO Value Basic 4000 |
Santa Cruz |
|
Health Net |
PPO Value 30 |
Santa Cruz |
|
Health Net |
PPO Value 400 |
Santa Cruz |
|
Health Net |
HMO 40 |
Santa Cruz |
|
Health Net |
PPO Value 25 |
Santa Cruz |
|
Health Net |
PPO Value 750 |
Santa Cruz |
|
Health Net |
HMO 15 |
Santa Cruz |
|
Health Net |
Elect Open Access 15 |
Santa Cruz |
|
Health Plan Name |
Type of Plan |
County |
|
BC Life and Health Insurance |
Basic PPO 1000 |
Santa Cruz |
|
BC Life and Health Insurance |
PPO Saver |
Santa Cruz |
|
|
|
|
|
Health Plan Name |
Type of Plan |
County |
|
|
|
|
|
Blue Shield of Ca |
Preferred Savings Plan |
Santa Cruz |
|
Blue Shield of Ca |
Preferred Savings Plan 1700 |
Santa Cruz |
|
Blue Shield of Ca |
Deductible Plan 2000 |
Santa Cruz |
|
Blue Shield of Ca |
Deductible Plan 1500 |
Santa Cruz |
|
Blue Shield of Ca |
Deductible Plan 750 |
Santa Cruz |
|
Blue Shield of Ca |
Deductible Plan 500 |
Santa Cruz |
|
Blue Shield of Ca |
Access+ HMO 1500 |
Santa Cruz |
|
|
|
|
|
|
|
|
|
Health Plan Name |
Type of Plan |
County |
|
Blue Cross of California |
BC Life PPO Share 5000 |
Santa Cruz |
|
Blue Cross of California |
PPO Share 2500 |
Santa Cruz |
|
Blue Cross of California |
EPO |
Santa Cruz |
|
Blue Cross of California |
PPO Share 1500 |
Santa Cruz |
|
Blue Cross of California |
PPO Share 1000 |
Santa Cruz |
|
Blue Cross of California |
HMO Saver |
Santa Cruz |
|
Blue Cross of California |
PPO Share 500 |
Santa Cruz |
|
Blue Cross of California |
Individual HMO |
Santa Cruz |
|
|
|
|
|
Health Plan Name |
Type of Plan |
County |
|
Pacific Care Health Systems |
PPO 3000 |
Santa Cruz |
|
Pacific Care Health Systems |
PPO 1500 |
Santa Cruz |
|
Pacific Care Health Systems |
PPO 1000 |
Santa Cruz |
|
Pacific Care Health Systems |
HMO Plan 15 |
Santa Cruz |
|
Pacific Care Health Systems |
HMO Plan 10 |
Santa Cruz |
|
|
|
|
|
UCSC Health Services |
HMO |
Santa Cruz |
|
Take Care |
HMO |
Santa Cruz |
|
Take Care |
HMO |
Santa Cruz |
|
Cigna |
PPO Plus |
Santa Cruz |
|
Cigna |
EPO 3 |
Santa Cruz |
|
Cigna |
HMO Saver |
Santa Cruz |
|
United Medical Carolina B/C |
EPO |
Santa Cruz |
|
SMAART B/C B/S Chicago |
Self Insured |
Santa Cruz |
|
Hartford |
Trust/Self-Insured |
Santa Cruz |
|
B/C B/S of Rochester |
PPO |
Santa Cruz |
|
West Coast Aggregates B/S |
Trust/Self-Insured |
Santa Cruz |
|
Aetna |
PPO |
Santa Cruz |
|
Northwest National |
Trust/Self-Insured |
Santa Cruz |
|
Tri-Care |
HMO |
Santa Cruz |
|
Prudential Health Care |
POS 3-Tier |
Santa Cruz |
|
Kaiser Permanente |
HMO |
Santa Cruz |
|
AIM |
|
Santa Cruz |
|
Healthy Families |
|
Santa Cruz |
|
University Health Care |
Trust/Self-Insured |
Santa Cruz |
|
Guardian Life |
Trust/Self-Insured |
Santa Cruz |
|
High Options |
Fee for Service |
Santa Cruz |
|
UC Care |
POS |
Santa Cruz |
|
Core |
Fee for Service |
Santa Cruz |
|
Blue Premier |
HMO |
Santa Cruz |
|
|
|
|
|
Health Plan Name |
Type of Plan |
County |
|
Health Net |
PPO Value Basic 1000 |
Monterey |
|
Health Net |
PPO Value Basic 2500 |
Monterey |
|
Health Net |
PPO Value Basic 500 |
Monterey |
|
Health Net |
PPO Value Basic 4000 |
Monterey |
|
Health Net |
PPO Value 30 |
Monterey |
|
Health Net |
PPO Value 400 |
Monterey |
|
Health Net |
PPO Value 25 |
Monterey |
|
Health Net |
PPO Value 750 |
Monterey |
|
|
|
|
|
|
|
|
|
|
|
|
|
BC Life and Health Insurance |
Basic PPO 1000 |
Monterey |
|
BC Life and Health Insurance |
PPO Saver |
Monterey |
|
|
|
|
|
|
|
|
|
Health Plan Name |
Type of Plan |
County |
|
Blue Shield of Ca |
Preferred Savings Plan |
Monterey |
|
Blue Shield of Ca |
Preferred Savings Plan 1700 |
Monterey |
|
Blue Shield of Ca |
Deductible Plan 2000 |
Monterey |
|
Blue Shield of Ca |
Deductible Plan 1500 |
Monterey |
|
Blue Shield of Ca |
Deductible Plan 750 |
Monterey |
|
Blue Shield of Ca |
Deductible Plan 500 |
Monterey |
|
|
|
|
|
Health Plan Name |
Type of Plan |
County |
|
Blue Cross of California |
BC Life PPO Share 5000 |
Monterey |
|
Blue Cross of California |
PPO Share 2500 |
Monterey |
|
Blue Cross of California |
EPO |
Monterey |
|
Blue Cross of California |
PPO Share 1500 |
Monterey |
|
Blue Cross of California |
PPO Share 1000 |
Monterey |
|
Blue Cross of California |
HMO Saver |
Monterey |
|
Blue Cross of California |
PPO Share 500 |
Monterey |
|
Blue Cross of California |
Individual HMO |
Monterey |
|
|
|
|
|
|
|
|
|
Health Plan Name |
Type of Plan |
County |
|
Pacific Care Health Systems |
PPO 3000 |
Monterey |
|
Pacific Care Health Systems |
PPO 1500 |
Monterey |
|
Pacific Care Health Systems |
PPO 1000 |
Monterey |
|
Pacific Care Health Systems |
HMO Plan 15 |
Monterey |
|
Pacific Care Health Systems |
HMO Plan 10 |
Monterey |
|
|
|
|
|
|
|
|
|
United Health Care |
POS |
Monterey |
|
United Health Care |
EPO |
Monterey |
|
JFK |
PPO |
Monterey |
|
MIA |
CMSP |
Monterey |
|
Pers Choice |
PPO |
Monterey |
|
Great West |
PPO |
Monterey |
|
Coastal Health Care |
PPO |
Monterey |
|
TriCare |
HMO |
Monterey |
|
MCSIG |
HMO |
Monterey |
|
Western Growers |
PPO |
Monterey |
|
|
|
|
|
|
|
|
|
|
|
|
|
Health Plan Name |
Type of Plan |
County |
|
|
|
|
|
Health Net |
PPO Value Basic 1000 |
San Benito |
|
Health Net |
PPO Value Basic 2500 |
San Benito |
|
Health Net |
PPO Value Basic 500 |
San Benito |
|
Health Net |
PPO Value Basic 4000 |
San Benito |
|
Health Net |
PPO Value 30 |
San Benito |
|
Health Net |
PPO Value 400 |
San Benito |
|
Health Net |
PPO Value 25 |
San Benito |
|
Health Net |
PPO Value 750 |
San Benito |
|
|
|
|
|
|
|
|
|
Health Plan Name |
Type of Plan |
County |
|
|
|
|
|
BC Life and Health Insurance |
Basic PPO 1000 |
San Benito |
|
BC Life and Health Insurance |
PPO Saver |
San Benito |
|
|
|
|
|
Health Plan Name |
Type of Plan |
County |
|
|
|
|
|
Blue Shield of Ca |
Preferred Savings Plan |
San Benito |
|
Blue Shield of Ca |
Preferred Savings Plan 1700 |
San Benito |
|
Blue Shield of Ca |
Deductible Plan 2000 |
San Benito |
|
Blue Shield of Ca |
Deductible Plan 1500 |
San Benito |
|
Blue Shield of Ca |
Deductible Plan 750 |
San Benito |
|
Blue Shield of Ca |
Deductible Plan 500 |
San Benito |
|
|
|
|
|
|
|
|
|
|
|
|
|
Health Plan Name |
Type of Plan |
County |
|
|
|
|
|
Blue Cross of California |
BC Life PPO Share 5000 |
San Benito |
|
Blue Cross of California |
PPO Share 2500 |
San Benito |
|
Blue Cross of California |
EPO |
San Benito |
|
Blue Cross of California |
PPO Share 2500 |
San Benito |
|
Blue Cross of California |
PPO Share 1500 |
San Benito |
|
Blue Cross of California |
PPO Share 1000 |
San Benito |
|
Blue Cross of California |
PPO Share 500 |
San Benito |
|
Blue Cross of California |
HMO Saver |
San Benito |
|
Blue Cross of California |
Individual HMO |
San Benito |
|
|
|
|
|
Health Plan Name |
Type of Plan |
County |
|
|
|
|
|
Pacific Care Health Systems |
PPO 3000 |
San Benito |
|
Pacific Care Health Systems |
PPO 1500 |
San Benito |
|
Pacific Care Health Systems |
PPO 1000 |
San Benito |
|
Pacific Care Health Systems |
HMO Plan 15 |
San Benito |
|
Pacific Care Health Systems |
HMO Plan 10 |
San Benito |
|
|
|
|
|
Carpenters Union Fund |
Trust/Self-Insured |
San Benito |
|
|
|
|
|
|
|
|
|
CMSP |
CMSP |
San Benito |
|
Medicare |
|
|
|
MediCal |
|
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Health Care Advocacy Project
DEVELOPING A COMPREHENSIVE DATABASE
The need for comprehensive health care advocacy services to people with disabilities prompted CCCIL to fully integrate Health Care Advocacy Project into one of its core services of “benefits counseling”. Although it was not a grant requirement, CCCIL integrated the HCAP information into its File Management System (FMS) database. FMS tracks consumer information and records necessary data for all of CCCIL’s funding sources.
Since the Health Care Advocacy Project is part of an Independent Living Center, we thought it would be important to create a database that tracks the information required by the State 204 and Federal 704 Reports.
CCCIL’s current FMS fields track the consumers served during the same reporting period as the 704 and 204. It also tracks how active the file is, the age, gender, ethnicity, race and disability. Instead of tracking the specific disability, we thought it would be better to keep it the same as required in the state and federal reports (such as cognitive, mental/emotional, physical, hearing, vision or multiple disability)
We ask all of the potential consumers of Health Care Advocacy Project the same questions we ask all CCCIL consumers. Again, this is part of integrating health care advocacy as a core service. In addition to the data collected for the state and federal government, CCCIL came up with additional database fields. In determining the new health related fields we wanted, we tried to anticipate the data we wanted to document. When making changes in policy, it is critical that data is available to back up the claims of a need.
Demographic information is recorded but instead of duplicating the information and asking it multiple times, CCCIL has the information “carry over” so the staff person has access to the information. There are separate “HCAP database screens” that include the following fields:
Health Insurance y/n - This asks if the consumer has insurance
Type of Health Insurance - This asks to check the kind of insurance the consumer has. Consumers can have more than one kind of insurance:
HMO Other Private Insurance Medicare MediCal Healthy Families Other Publicly Funded Insurance (boxes by each so more than one can be marked)
Is this a COBRA or CALCOBRA? y/n - This asks if the consumer has a question about their COBRA or CALCOBRA health plan. COBRA is offered to employees after they leave the company or organization
Primary Health Plan Name - This asks for the name of the main health plan. It is generally the first health plan that is billed.
Secondary Health Plan Name - This asks for the name of an additional health plan
Subscriber Name - This asks for the name of the person who has the health plan
Primary Subscriber ID - This is the identification number that is on the insurance card
Dependent Plan y/n - This asks if the plan is for a child or spouse (someone different then the main person who the health plan is under
Date of enrollment - This asks for the date the health plan became effective
Medical release y/n - This ask for a medical release from the consumer to CCCIL
Provided EOC - This asks if the Evidence of Coverage, or the book that explains the health plan, was provided by the consumer to CCCIL
Provided EOB - This asks if the Explanation of Benefits was provided. It usually looks like an invoice or a bill
Medical Bills Provided - This asks if the consumer gave the medical bills to CCCIL
Problem Category – The reason the consumer is contacting CCCIL.
Listed so more than one can be marked to indicate
multiple issues.
Choosing a Health Plan – Problem with deciding on a particular health plan
Specialty Care – Problem with a specialist or receiving specialty care
Care/Treatment Inappropriate or Inadequate – received unsatisfactory care
Physician Issue – Problem with doctor
Prescription Issue – Problem with affording prescription or receiving prescription
No Insurance – Calling because consumer has no insurance coverage
Losing Insurance – consumer is going to lose insurance coverage
Accessibility Issue – Problem with physical (building) or programmatic (interpreters, etc)
Rehab Services – Problem with receiving rehabilitative care
Dispute Over Coverage (service not yet rec’d) – Problem with insurance denying procedure that is needed. It has not been approved and has not yet taken place
DME Issue – Problem receiving or paying for Durable Medical Equipment
COBRA Issue – Problem with COBRA coverage
HIPAA – Problem with the Health Insurance Portability & Accountability Act
Billing Dispute (service rec’d) – Procedure has already taken place and the insurance company will not pay for it
Communication Barrier – relating to spoken communication or print material
Primary & Secondary Coverage Issues – Denial of bill payments or service from Primary or secondary insurance company
Other – type in other issue that might not be covered under the above categories
By creating these fields, we have the capability of generating a report based on that information. The database cannot generate a report of what you want if you don’t have the proper fields available.
Health Care Advocacy Project
EVALUATING PROGRESS
When evaluating the progress of a project, it is important to get input from the consumers being served. The Health Care Advocacy Project received input from the Advisory Board when developing the questions for the Consumer Survey. We made sure that the surveys were all within a 7th grade reading level. After getting feedback from the Advisory Board, we sent the evaluation to the first twelve consumers we served. In addition to completing the survey, we asked them to make changes to the actual evaluation in order to improve it. The final version of the consumer survey is included into the manual and can be used by all agencies in evaluating the Health Care Advocacy Project.
Health Care Advocacy Project sent a consumer survey to every consumer that we saw. We sent a letter with each survey asking consumers to complete the information and return it in the posta