abc emp and retiree health welfare training
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Employee and Retiree Healthand Welfare Benefits Program2015 Plan Year
Agency Benefits Coordinator TrainingAugust 2014
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Agenda
Medical Plans Wellness Program
Dental Plans
SLEOLA Carve-Out Open Enrollment
Subsidized health benefits for certain
contractual employees
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The Times They Are A-Changing
New medical and dental contracts beginJanuary 1st
POS plans eliminated
Aetna EPO eliminated
UCCI DHMO eliminated
APS eliminated
Kaiser added
Delta Dental DHMO added
SLEOLA plans - one carrier for all three plans
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Medical Plans
Five medical plansCareFirst EPO, CareFirst PPO
Kaiser
United Healthcare EPO, United Healthcare PPO
Behavioral health added back in
All medical plans will use their own BH network
Possible disruption
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Medical Plans Benefit Updates
RFP
GID coverage added
Acute inpatient rehab for stroke and brain injury added
Mental Health Parity
Residential treatment centers covered Services/Supplies provided as a result of failure or refusal to
obtain treatment or follow prescribed treatment no longer
excluded
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State of the States Population
Treatment non-complianceincreases costs Increased usage of ER
Increase in large claimants
Increase in ESRD
Majority of population notobtaining age appropriatescreenings for breast cancer,colorectal cancer, etc.
Aging population Actives average age = 37.1
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Chronic Diseases Per Person Annual CostBreakdown
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Chronic Diseases Annual Costs
State Program continues to pay higheramounts for costly members with chronic
conditions totals below include all
medical/Rx costs associated with a member
that has been identified as having a chronic
condition.- $722.6 million in FY 2012
- $683.7 million in FY 2011- $660.5 million in FY 2010
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Chronic Diseases Annual Costs
Underlying factors driving cost increases:- Few members complete preventive screenings- Many members are not currently treatment compliant
- Low out-of-pocket health care costs
- No incentive to change
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Wellness Program - Goals
Improve overall population health Flatten trend line without cost shifting to
participants
Promote employee/retireewellness and personalresponsibility
Incentivize plans to focus on quality of care
provided and patient outcomes
Enhance participant awareness of differences incost/quality
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Wellness Program Plan Features
Affordable Access to Care All lab and x-ray covered with no copay or
coinsurance for all participants (in-network)
Copays for primary care visits waived if healthrisk assessment completed and discussed with
physician
Continue waiving drug copays for genericdrugs targeting certain chronic conditions
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Wellness Program Plan Features
Education and Resources Weight management, nutrition education, tobacco
cessation provided at no cost to participant
Offer online resources allowing members to compare
providers based on quality and efficiency
Provide reports on provider outcomes
Offer online tools for members for pricing basic
services, tests and procedures
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Wellness Requirements Phased-in 2015 2020
2015:
Communicate the coming health initiatives under the value basedbenefit design that will go into effect in 2016
Health plans will collect data for administering the value based benefitdesign
Employees/retirees and covered spouses will need to designate aprimary care physician (PCP) through their health plan and reviewhealth risk assessment with PCP
2016: Participants complete recommended healthy activities and participate
in disease management program if appropriate
PCP copays waived if employee & covered spouse completed healthrisk assessment in 2015; surcharge if no PCP selection and/or healthrisk assessment not completed in 2015
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Healthy Activity Requirements
Participants with a Chronic Condition & Eligible for
the Disease Management Program
Participants not Eligible fo r the Disease Management
Program
Year 2015: Health Activity Requirements No
Surcharge
Year 2015: Healthy Acti vity Requirements No
Surcharge
Employees and covered spouses required to designate a PCP
Complete carrier health risk assessment; review with PCP.
PCP sign-off confirming review
Employees and covered spouses required to designate a PCP
Complete carrier health risk assessment; review with PCP. PCP
sign-off confirming review
Year 2016: Healthy Acti vity Requirements Surcharge
Appl ies
Year 2016: Healthy Activity Requirements Surcharge
Appl ies
Actively participate in the disease management (D/M) program
& follow disease management call-in & treatment guidelines of
the care manager, or complete/graduate from the D/M program
Complete a Nutrition Education or Weight Management program
sponsored by your health plan (i.e. online or class setting)
Complete carrier health risk assessment; review with PCP.PCP sign-off confirming review
Complete carrier health risk assessment; review with PCP. PCPsign-off confirming review
Complete all recommended age/gender specific biometric
screenings & discuss the results with your PCP
Complete all recommended age/gender specific biometric
screenings & discuss the results with your PCP
Year 2017: Healthy Acti vity Requirements
Surcharge Applies
Year 2017: Healthy Activity Requirements Surcharge
Appl ies
Actively participate in the disease management (D/M) program
& follow disease management call-in & treatment guidelines ofthe care manager, or complete/graduate from the D/M program
Complete all recommended age/gender specific biometric
screenings and discuss results with your physician
Complete all recommended age/gender specific biometric
screening & discuss with your PCP
Complete carrier health risk assessment; review with PCP. PCP
sign-off confirming review
Complete carrier health risk assessment; review with PCP.
PCP sign-off confirming review
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Healthy Activity Requirements
Participants with a Chronic Condition & Eligible for
the Disease Management Program
Participants not Eligible for the Disease Management
Program
Year 2020: Healthy Activi ty Requirements Surcharge Applies
Year 2020: Healthy Activity Requirements SurchargeAppl ies
Actively participate in the disease management (D/M)
program & follow disease management call-in &
treatment guidelines of the care manager, or
complete/graduate from the D/M program
Complete carrier health risk assessment; review with
PCP. PCP sign-off confirming review
Complete all recommended age/gender specific
biometric screening, maintain blood pressure and
cholesterol in the normal ranges, & discuss with yourPCP
Complete all recommended age/gender specific
biometric screening & complete a physical exam
showing blood pressure, and cholesterol in the normalrange, & discuss with your PCP
Complete the online Personal Health Assessment
(PHA), including your current blood pressure, BMI,
cholesterol levels and take a copy of the PHA to
your physician & discuss results with your PCP
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You have time to get your activities done!
2015: Complete your healthy activities between Jan 1 and Sep 30 to avoid surcharge
in 2016.
2016: Complete your healthy activities between Oct 1 2015and Sep 30 2016
After 2016: Oct 1 through Sep 30
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Non-Compliance Surcharges
Participant penalties
$50 per year premium surcharge for healthy individuals who fail to
complete healthy activity requirements
Begins in 2016, increases to $75 in 2017
Applies individually to employee/retiree and spouse
$250 per year premium surcharge for individuals identified for diseasemanagement who fail/refuse to engage in treatment
recommendations and healthy activity requirements
Begins in 2017; increases to $375 in 2018
Alternative activities available to individuals unable to complete
required activities due to medical reasons Appeals process
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Wellness Program Beyond Employees andRetirees
Delivery System ReformsIntegrate community health workers into the
overall health management of members
In consultation with the State, identify high value
medical services and offer recommendations foradministering incentives that reward these high
value services
Provide reporting and data to the State and itsvendors to support plan management and the
development of additional strategic initiatives
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Carrier Performance Measures
Increasing the percentage of eligible members who receive
preventive care, including cancer screenings
Increase treatment compliance by participants with diabetes,
hypertension, and hyperlipidemia
Increase number of participants with diabetes, hypertension,
and hyperlipidemia with key numbers in the normal range
(e.g. blood pressure, HbA1c, etc.)
Reducing hospital readmission rates within 30 days of
discharge
Reducing emergency room visits by participants with asthma,
COPD, and diabetes
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Dental Plans
DPPO UCCI Annual maximum increased to $2,500 from
$1,500
DHMO Delta Dental National network
Enrollees in UCCI DHMO MUSTselect a new
dental plan Must also select primary dental office (PDO)
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SLEOLA Bargaining Unit I
Separate RFP for Medical Plans Still have PPO, POS, and EPO
Only one carrier: CareFirst
Separate contract from Program medical plans
No wellness
Subgroup on enrollment forms
Carve-Out Prescription Still under Express Scripts
Sub-group to Program
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Open Enrollment
October 15 November 14
NO IVR paper only
Be sure to print summary statements every day!
Many participants must make new elections
All POS participants (except SLEOLA)
All DHMO participants
All Aetna EPO participants
Everyone will get new cards
Domestic partner coverage ends 12/31/14
Rates not available yet Stay Tuned!
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Open Enrollment New Packet DistributionPolicy
Lost or misplaced OE packets are considered aHIPAA improper disclosure
To avoid HIPAA jail ABCs MUST:
Send a confirmation of receipt of all expected
boxes and the condition of the boxes to
[email protected] on the date of receipt
Distribute packets within 5 business days and
email [email protected] date
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mailto:[email protected]:[email protected]:[email protected]:[email protected] -
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HIPAA Reminders
DO NOT put employee names in email subject line
ALWAYSproperly secure printed material containing
PHI
ALWAYSencrypt email containing PHI or
attachments containing PHI NEVERdiscuss individual cases using a speaker
phone
NEVERdiscuss/disclose PHI without executed HIPAArelease
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