What is Medicare Part C?

Medicare Part C or Medicare Advantage Plan is an alternative offered just by private companies approved by Medicare. Acts as a Health Maintenance Organization (HMO) or as a Preferred Providers Organization (PPO). This plan includes all the services of Original Medicare except the hospice care.

Eligible is the patient:

  • Of 65 years or more
  • Of 65 years or less with certain disability
  • That has Medicare Part A and Part B
  • That lives in the plan service area
  • That doesn’t suffer of End Stage Renal Disease (ESRD)

In and Out-of-Network Coverage

Providers

What does “network providers” mean?

They are all providers inside our service area that agree to provide the attention and medical services to the Constellation Health’s affiliates.

Why do you need to know which providers are part of our network?

It is important to know which providers are part of our network because while you are a beneficiary of our plan, you should receive all the routine services through Constellation Health’s provider network. In some special circumstances, you could obtain services of the out-of-network providers, for example:

  • When you have an emergency or urgency out of our service area
  • Dialysis services out of the service area
  • The cases that the plan authorizes the use of providers that do not belong to the network

When you become a beneficiary of our plan, you have to select from our Directory of Providers and Pharmacies a provider to be your Primary Care Physician (PCP). A Primary Care Physician is a completely licensed doctor to practice medicine in Puerto Rico, which would provide evaluation, treatment and coordination for the medical services you need.

Out-of-Network Providers

Out-of-Network Providers are those who we haven’t agreed coordinate neither proportionate covered services to our plan’s beneficiaries. Out-of-Network provider are not employed, doesn’t belong, not operates with our plan, neither have a contract to offer medical covered services. If you choose to visit out-of-network providers, you’ll pay more for the services; this charges aren’t refundable.

Pharmacies

What are Network Pharmacies?

Network pharmacies are all of those pharmacies inside our service area that agreed to cover the prescription drugs to Constellation Health’s affiliates.

Out-of-Network Pharmacies

They are the pharmacies that don’t have any contract with our plan to coordinate o supply covered drugs to the beneficiaries of our plan. Most of the drugs you receive from out-of-network pharmacies aren’t covered by covered by our plan, unless certain conditions apply.

In special circumstances your prescription can be covered by out-of-network pharmacies:

  • Illness
  • Emergency or urgency
  • Loss of prescription drugs when you travel out of our service area of our plan

In these situations, it is important that you first consult Customer Service to verify is there is a close pharmacy inside of our network.

When you use an out-of-network pharmacy to obtain a prescription drug

If you try to use your beneficiary card in an out-of network pharmacy to obtain a prescription drug, it is possible that the pharmacy can’t send the payment request directly to our plan. When this happens, you should pay the prescription total cost.

  • Keep the receipt and send us a copy when you request us the refund of the part of the cost that belongs to us.  (Applies just in some specials situations)

Directory of Providers and Pharmacies

Our Directory of Providers and Pharmacies provide you a complete list of providers and pharmacies of our network that works with us to provide you a medical service and cover you the prescriptions drugs. You can request more information about the providers, including its titles to our Customer Service.

If you don’t have the Directory of Providers and Pharmacies, you can request a copy to our Customer Service (787-304-4040 o 1-866-714-0724). Also, you can download from our website www.constellationhealthpr.com. Customer service and the website can offer you updated information about the changes of our providers and pharmacies of our network.

Quality Assurance Policy

Constellation Health is obligated to ensure the best quality of care practices for our enrollees’ healthcare. We are qualified to track and monitor beneficiaries’ drug utilization to prevent possible adverse reactions and/or dangerous interactions they might have with certain drugs.

Reimbursement Policy

Constellation Health evaluates every request for reimbursement received from medical services rendered by its beneficiaries or their authorized representatives and decides if it will be granted or not. To obtain a reimbursement form click hereOnce completed and signed, please send your request for reimbursement, along with your bill and documentation of any payment you have made. Please, keep a copy of your bill and receipts for your records.

Mail your medical or vision reimbursement request along with any bills or receipts to us at the following this address:

Constellation Health
Customer Service
PO Box 364547
San Juan, PR 00936-4547

Mail your reimbursements requests of Dental Services along with any bills or receipts to us at this address:

Delta Dental Puerto Rico
PO Box 9020992
San Juan, PR 00902-0992

You may also submit your reimbursement request in persons by visiting our offices located at #1064 Ave. Ponce de Leon, Suite 500, San Juan, PR, 00907 and they will be processed for evaluation.

Mail your request for payment for Pharmacy Services together with any bills or receipts to us at this address:

Constellation Health
Pharmacy Department
PO Box 364547
San Juan, PR 00936-4547

You must submit your claim to us within 180 days of the date you received the service, item, or drug.

Quality Improvement Program

Program Description

Constellation Health is a Medicare Advantage Organization (MAO) created by a group of health care executives concerned by the lack of significant improvement in the quality of care standards in the Commonwealth of Puerto Rico. This group, composed of professionals with ample experience in the healthcare field, established Constellation Health, LLC based on the improvement of quality of care as its guiding principle.

Constellation Health is structured to provide a coordinated framework for ensuring access to and supporting the care coordination of quality, cost effective, and efficient health care services to Dual Eligible Special Needs Plan members in Puerto Rico.  In Puerto Rico there are over 200,000 dual eligible Medicare/Medicaid recipients. Many of them are vulnerable, disabled, frail adults over the age of 65 with chronic medical conditions that require a complex array of services from multiple providers.

Target Population

Constellation Health has analyzed data related to the target population of over 200,000 members in the Dual Eligible population that shows 75% of the members are over the age of 65 and the majority are female, non-English speaking (the majority are Spanish speaking), physically challenged, chronically ill and living below the poverty level. Over 15% of our current population lives alone. Approximately 70% of the dual eligible members live in rural areas. In these areas access to care is sometimes very difficult.

The data provides a profile of the clinical care needs of the over 65 dual eligible in Puerto Rico that includes:

  • Higher incidence of diabetes, when compared to the US mainland
  • High incidence of cardiovascular disease
  • Lower income levels

Given the needs of this population, Constellation Health has developed care management strategies that include assigning each member with a care manager who will coordinate their care, ensure they have access to care, provide them with referrals to community resources as needed and provide them with the information necessary to self-manage their condition. Constellation Health will use the Model Output Report (MOR) to identify the most prevalent conditions in the enrolled membership. Additionally, Constellation Health will develop care management strategies specifically for uncontrolled diabetes with multiple co morbidities since this condition has a high prevalence in the island.

Purpose

The purpose of Constellation Health’s Quality Improvement (QI) Program is to ensure highquality of care and services to the Dual Eligible population with special interest in the chronically ill, disadvantaged, elderly and/or disabled portion of that population. It will also provide the infrastructure for the monitoring and evaluation of the quality of care and service provided to the beneficiaries. Results of this monitoring and evaluation will be used to promote continuous quality improvement. The Quality Improvement Program is designed to objectively, systematically and continuously monitor, evaluate and improve the delivery of health care and services provided to its target population.

QI Program and Objectives

The goal of Constellation Health’s QI Program is to promote the continuous improvement of the quality of care and service provided to the target population.

This goal is supported by the following objectives:

  • Maintain an organizational and functional structure dedicated to the continuous  monitoring of the quality of care and service provided to beneficiaries
  • Ensure that the QI Program is supported by all levels of the organization in order to facilitate the deployment of company resources for the achievement of QI Program’s goals
  • Provide a forum of discussion for QI initiatives and for tracking and trending of established QI goalsComply with all regulatory standards regarding QI activities
  • Identify opportunities for quality improvement across all services especially those rendered to the medically indigent, frail, disabled, near end-of life and those with multiple or severe chronic conditions
  • Ensure corrective actions are implemented when issues affecting quality of care and/or service have been identified
  • Encourage provider participation in the design and review of the QI Program
  • Collaborate with the Quality Improvement Organization (QIO) in quality improvement activities and studies being promoted
  • Monitor the performance of delegated entities regarding quality improvement, when applicable.
  • Measure performance of clinical and nonclinical services.
  • Establish and maintain a program, which continuously improves the quality of the clinical care and services provided to members.
  • Evaluate and analyze services rendered to members by physicians and providers in a systematic and continuous manner, communicate findings and initiate a corrective action plan.
  • Ensure that health care and services are accessible and available to members.
  • Assure the value of care is maximized.
  • Establish a mechanism to assess, monitor and improve the members and providers satisfaction with the plan.
  • Monitor internal practices to improve processes that better address member and provider's needs.
  • Implement corrective action when care and/or services delivered are identified to be of questionable quality and to monitor the effectiveness of these actions.
  • Provide oversight and development of a systematic approach to identify and address issues that present as potential risks; address grievances, complaints and appeals; and monitor the outcomes of grievances filed by members and participating providers.
  • Contribute to the member's perceptions of their wellbeing and mental health through of immediately services evaluation, and satisfy theirs needs of care.
  • Maintain with the providers an effective and confidential communication related to the members' clinical care information.

Scope of the Quality Improvement Program

The QI Program is designed to monitor the quality of care and service provided to beneficiaries within the following areas:

  • Facilities, including: in-patient, ambulatory, mental health, substance abuse, rehabilitation and others
  • Individual practitioners, including: primary care physicians (PCP's), specialists and subspecialists, allied health professionals.
  • Constellation Health’s Chronic Care Improvement Program (CCIP)
  • Constellation Health’s Model of Care (MOC)
  • Beneficiaries and Providers complaints and grievances
  • Availability and accessibility of care
  • Continuity and Coordination of Care
  • Customer Service
  • Enrollment and Eligibility
  • Claims Processing
  • Sales and Marketing
  • Pharmacy Benefit
  • Utilization Management Program
  • Credentialin
  • System interventions, including the establishment or review of practice guidelines
  • Improving performance
  • Systematic and periodic follow-up on the effect of the interventions