Healthy Advantage (HMO) Medicare -
Quality Assurance

Improving Services to Healthy Advantage (HMO) Medicare Members

The Quality of Care You Receive is Important to Us

Healthy Advantage (HMO) Medicare wants you and your family to receive the best care. We have a Quality Improvement (QI) Program to ensure you get quality care. Each year Healthy Advantage (HMO) Medicare sets goals to improve our services. One goal is to help you take better care of yourself and your family. We measure how well we are providing care by sending you surveys to fill out. We look at what you say to find ways to improve.

The QI Program:
  • Evaluates providers to be sure you have access to a qualified health care team.
  • Investigates and takes action when you have an issue with the quality of care you have been provided.
  • Promotes safety in health care through education for you and our providers.
  • Publishes Preventive Health Guidelines to help you know what services you need and when.
  • Evaluates the quality of your healthcare through HEDIS (Healthcare Effectiveness Data and Information Set). These scores tell us when you have received the type of care you need. The scores look at how often you receive services such as flu shots, immunizations, eye tests, cholesterol tests, and pre-natal care if you are pregnant.
  • Surveys members´ satisfaction with care. One type of survey is called CAHPS (Consumer Assessment of Healthcare Providers and Systems). This tells us if you are happy with your care and your provider. It also tells us what we can make better for you. Some things are getting your appointment faster and having more providers to take care of you.

To learn more or to request a copy of our QI program, call Member Services, 1-877-644-0344 (TDD/TTY 1-800-346-4128) 8 a.m. - 8 p.m., Monday through Friday. (local time)

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Managing Your Medications Is Important To Us


Healthy Advantage (HMO) Medicare has established quality assurance measures and systems in order to make sure that medications are used in a safe and effective manner. Our goal is to prevent medication errors and adverse drug reactions.

Our Quality Assurance program includes the following:

  • Drug utilization review systems designed to ensure that a review of your drug therapy is performed before each prescription is dispensed, such as potential drug therapy problems due to over-utilization, under-utilization, drug-drug interactions, and drug-allergy interactions.
  • Computerized drug utilization review systems designed to ensure ongoing periodic examination of prescription data and other records in order to identify drug therapy problems among Healthy Advantage (HMO) Medicare members.
  • Dose checks to ensure that medications are used within guidelines set by the Food and Drug Administration (FDA).
  • Reporting of our quality assurance practices to the Centers for Medicare & Medicaid Services.

Medication Therapy Management Program and Drug Utilization Management


Healthy Advantage (HMO) Medicare offers medication therapy management programs for members who meet specific criteria. This is not part of your benefit structure, but rather a program to help you understand what your medications are doing for you and to help you take control over your medications. The following criteria are used to identify eligible participants in the MTMP:

Member must have two or more of the following chronic conditions: Diabetes, Hypertension, Ischemic Heart Disease, Heart Failure, Hyperlipidemia, Asthma, or Chronic Obstructive Pulmonary Disease (COPD).

In addition to having two or more of the listed chronic conditions, member must also meet the following:

  • Member has filled six or more Part D prescriptions for chronic medications in 30 days, and
  • Member is projected to exceed annual prescription medication costs of $4,000. Medication cost will be calculated based on annualizing one month of pharmacy claims data.

Members will be informed of their selection for this special program and have the opportunity to decline entirely or participate in the program at a lower level of intervention.

*Paper copies of information posted on our web site are available upon request.