Category: Uncategorized

When the President, Governor or Secretary of Health and Human Services declares an emergency, disaster or a public health emergency Triple-S Advantage takes the following actions to ensure affiliates can get health care needed.

a) Medical Benefits (Part C)

i. Allow Part A/B and supplemental Part C plan benefits to be furnished at specified non-contracted facilities (note that Part A/B benefits must, per 42 CFR § 422.204(b) (3), be furnished at Medicare certified facilities).

ii. Waive in full, requirements for referrals and prior authorizations where applicable.

iii. Temporarily reduce plan-approved out-of-network cost sharing to in-network cost-sharing amounts.

b) Pharmacy Benefits (Part D):

i. Triple-S Advantage has a process through its Pharmacy Benefit Manager (PBM), to lift “refill-too-soon” edits during a disaster or emergency as long as access to Part D drugs is provided at the point-of-sale and allows an affected enrollee to obtains the maximum extended day supply, if requested and available at the time of refill. Triple-S Advantage may lift other edits as a protection to our affiliates for access to drugs.

ii. Triple-S Advantage lifts these edits, until the termination of a public health emergency or the end of a declared disaster or emergency. In the case of a public health emergency, it terminates when it no longer exists or upon the expiration of the 90-day period beginning from the initial declaration, whichever occurs first.

iii. In the absence of a Presidential major disaster or emergency declaration or a public health emergency, Triple–S Advantage lifts the edits — for instance, in advance of an impending disaster — if they determine it is appropriate to do so to ensure pharmacy access. However, at all times, and especially in disaster and/or public health emergency situations, Triple-S Advantage ensures, that their affiliates have adequate access to covered Part D drugs dispensed at out-of-network pharmacies when those enrollees cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy, and when such access is not routine.

c)      These actions remains in effect until:

i. Triple-S Advantage pay particular attention to the closure of disaster incident periods listed in the Disaster Federal Register Notice section on Federal Emergency Management Agency’s (FEMA’s Web site http://www.fema.gov/news/disasters.fema)  noting that in circumstances in which the incident period has not officially closed 30 days from the initial Presidential declaration.

ii. If, the disaster or emergency timeframe has not been closed 30 days from the initial declaration, and if CMS has not indicated an end date to the disaster or emergency, Triple-S Advantage should resume normal operations 30 days from the initial declaration. Triple-S Advantage not being able to resume normal operations after 30 days should notify CMS and ASES.

d) Contact Information:

i. Affiliates may contact Triple-S Advantage at:

• Call Center: 1-888-620-1919 (Monday to Sunday de 8:00 a.m. – 8:00 pm)
• TTY : 1-866-620-2520
• Teleconsulta (Health helpline available 24 hours a day, 7 days a week).
• Your calls to Teleconsulta are toll-free, and you may call from anywhere in Puerto Rico or the United States. The number appears on the back of your Triple-S Advantage plan membership card. Remember to always have your plan membership card at hand when you call Teleconsulta. Teleconsulta nursing professionals will be happy to answer all your health-related questions.

If you have a medical emergency:

• Get help as quickly as possible.
• Call 911 for help or go to the nearest emergency room or hospital.
• Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP.

Triple-S Advantage has a Protocol for the Prevention and Detection of Financial Exploitation of Senior Citizens and Adults with Disabilities.

According with this Protocol, Triple-S Advantage employees who have knowledge of any situation that may lead to the suspicion of this type of exploitation must notify the Compliance Department at Triple-S Advantage.

If you are victim of financial exploitation and this event is related to your health plan, you can notify the Compliance Department at Triple-S Advantage by filling out the referral form by regular mail or fax. Download the Referral From below to file your report.

Download PDF Document

Complete and send the form to:

Triple-S Advantage, Inc.

Compliance Department

PO BOX 11320
San Juan, PR 00922
Email: moc.r1779178585psss@1779178585ecnai1779178585lpmoc1779178585ast1779178585
Secure Fax: 787-993-3260

The Triple-S Advantage Compliance Department will refer potential cases of financial exploitation to the relevant governmental agency within no more than five (5) business days after the date of identification.

Definition

A medication error is any preventable event that could hurt you or make your treatment not work properly. This error can happen when your healthcare provider, you, or someone else is in charge of your medications.

The most common causes of medication errors are:

• Hard-to-read prescriptions: If your doctor’s handwriting is hard to read, it can lead to mistakes.
• Incorrect medication: It can be harmful if you get the wrong medication.
• Incorrect diagnosis: If your doctor doesn’t diagnose your condition correctly, you might get the wrong medication.
• Incorrect doses: Taking too much or too little medication can be harmful.
• Miscalculated doses: This can cause incorrect dosing.
• Incorrect administration method: Medications administered the wrong way can cause harm.
• Free samples from your doctor: These might not be labeled clearly, which can lead to mistakes.

How can you report medication errors?

The tool provided by the FDA to report these medication errors is known as MedWatch. The MedWatch program is used to report safety information and adverse effects.

You may voluntarily report serious adverse effects, problems with product quality, and therapeutic equivalence failure of products regulated by the FDA.

To get more information or report a medication error you may access https://www.accessdata.fda.gov/scripts/medwatch or you can complete our medication error report sheet and email it to moc.e1779178585gatna1779178585vdass1779178585s@mar1779178585gorpr1779178585ud1779178585. You may also print it and send it via fax to 787-522-4005.

What is the Medication Therapy Management Program?

The Medication Therapy Management Program (MTM) is aimed at improving your health and quality of life by ensuring safe and effective medication use and preventing medication-related issues.

The Triple-S Advantage (TSA) MTM Program is managed by a diverse group of healthcare professionals, composed of case managers, health educators, pharmacists and doctors. They will work in collaboration with you to obtain the maximum benefit from your medications, guaranteeing they are safe, appropriate and are working properly.

This Program is not part of your plan benefits package.

Who is eligible to participate in the MTM Program?

Beneficiaries who satisfy the following three (3) criteria are eligible to participate:

• Have three (3) or more chronic diseases (such as those from bone disease-arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis), congestive heart failure (CHF), diabetes, dyslipidemia, respiratory disease (including chronic obstructive pulmonary disease (COPD) and asthma), hypertension, Alzheimer’s Disease, end-stage renal disease (ESRD), Human immunodeficiency virus/Acquired immunodeficiency syndrome (HIV/AIDS), and those classified as mental health (including depression, schizophrenia, and bipolar disorder);
• Use eight (8) or more Medicare Part D drugs related to the chronic conditions named above;
• Utilize more than $1,276 in total Part D drug costs per year.

Furthermore, if you are an at-risk beneficiary enrolled in a drug management program (DMP) you will be eligible to participate without satisfying the criteria stated above.

How much does the Program cost?

The MTM Program is offered at no additional cost to those beneficiaries who are eligible.

How does the MTM Program work?

With the goal of helping you learn more about your health condition, you will receive orientation, and follow-up calls from our case managers and health educators.

In addition, a pharmacist will work with you, either in person or through telephone calls, to assess your medication therapy.

What services does the MTM Program provide?

• Comprehensive review of your medications (CMR), including medications prescribed by your doctor and over-the-counter medications like vitamins and herbal supplements. This review is conducted minimum once a year and will take about 30 minutes of your time for completion. You will receive this document within 14 days from the date your medication review was completed.
• A list of your medications that will explain how to take them correctly and will help you monitor your treatment. You may print this list, fill in the information and take it with you when you visit your physician (view example).
• As ongoing monitoring, Targeted Medication Reviews (TMRs) are sent on a quarterly basis immediately upon enrollment in the MTM program with follow-up interventions when necessary. If potential or specific medication-related problems are identified, follow-up calls may be scheduled more often as needed to address these.
• Evaluates the risk of potential drug interactions.
• Ensure you are not experiencing any side effects from your medications.
• Recommends more cost-effective medication alternatives.
• Reach out to your healthcare provider when a potential medication related problem is identified.

How can I participate in the Program?

Once the eligible beneficiaries are identified by the TSA system, they are automatically enrolled in the program and will receive detailed information by mail within 60 days to invite you to participate in the MTM program.

If you have questions regarding our MTM Program or would like to receive additional information, please contact us at 1-855-831-3592, Monday through Friday from 8:00am to 5:00p.m. TTY users please call 1-855-296-8965.

Triple-S Advantage is an independent licensee of BlueCross BlueShield Association.

Enrollment

You are eligible for membership in our plan as long as:

1. 1 You live in our geographic service area
2. 2 You have both Medicare Part A and Part B
3. 3 You meet the eligibility requirements to enroll in a special needs plan / if applicable.

Important Information About the Enrollment Periods

Instructions to fill out the Triple-S Advantage Enrollment Form

• Please read this information carefully, write clearly, press hard, and use only blue or black ink
• Write the numbers and uppercase letters legibly in the boxes
• Write only one letter per box
• If you make a mistake, write in the space above or below
• When writing dates, use the month/day/year format. No need to include dashes or blank spaces
• Select the Plan you want to enroll in
• Complete your personal information as it appears on your Medicare Card (name, Medicare number, effective date of Medicare Part A and/or B, etc.). If your home and/or mailing address is different from the one on your Medicare Card, make sure to include your current address not the one on your Medicare Card
• Select your preferred payment method (if applicable)
• Provide the information of any other health plan you may have (if any)
• Read the terms and conditions
• Verify that you have completed all the information in the application
• Sign and date the enrollment form
• Keep a copy for your reference
• Mail or fax the form to the provided address/fax number

If you have any questions regarding the Enrollment Form or the enrollment process, please contact our Customer Service Department.

Disenrollment

Member and Plan Rights and Responsibilities upon Disenrollment
If you are a member of Triple-S Advantage and wish to disenroll from the Plan, you should contact our Customer Service Department to receive a complete orientation of the disenrollment process. To disenroll, you must send a written request for disenrollment, including your reason to disenroll. It is important that this request is signed by the member or his/her authorized representative.

Types of Disenrollment

If you decide to change over to Original Medicare, you might be temporarily entitled obtain a Medigap policy (Medicare supplemental insurance), even if you have health problems. For example, if you are age 65 or older and you enrolled in Medicare Part B within the past 6 months, or if you move out of the service area, you may have this special right. Federal law requires the aforementioned protections to be available. Puerto Rico may have other laws that provide more Medigap protections.

If you have questions about Medigap or Medigap Rights in Puerto Rico, you may contact your State Health Insurance Program (SHIP), the Oficina del Procurador de Personas de Edad Avanzada, at 787-721-6121. You may also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week for more information. TTY/TDD users should call 1-877-486-2048.