Kings County Office Kings County Office of Educationof Education

Judy FusselJudy Fussel, RHU, RHUPresident/COOPresident/COO

Buckman-Mitchell Buckman-Mitchell Financial & Insurance Financial & Insurance Services, Inc.Services, Inc.

Health Care ReformHealth Care Reform

Changes that must occur at renewal Changes that must occur at renewal 20102010– No lifetime benefit maximumsNo lifetime benefit maximums– Dependent coverage up to age 26Dependent coverage up to age 26– 100% coverage for preventive care100% coverage for preventive care

Mental Health ParityMental Health Parity

Effective October 1, 2010 new legislation requires Effective October 1, 2010 new legislation requires us to amend our benefits for Mental us to amend our benefits for Mental Health/Substance AbuseHealth/Substance Abuse

Coverage with PacifiCare Behavioral Health will be Coverage with PacifiCare Behavioral Health will be eliminatedeliminated

EAP Benefits provided through Anthem Blue CrossEAP Benefits provided through Anthem Blue Cross Benefits for Mental Health/Substance Abuse will be Benefits for Mental Health/Substance Abuse will be

included under the medical planincluded under the medical plan– Benefit structure still being evaluated by Anthem Blue Benefit structure still being evaluated by Anthem Blue

Cross to conform with the amended languageCross to conform with the amended language

Emergency Room Co Emergency Room Co PayPay 2009 24,107 ER visits with $22,273,465 in 2009 24,107 ER visits with $22,273,465 in

paid claimspaid claims Only 270 resulted in same day admits (1%) Only 270 resulted in same day admits (1%)

totaling $6,936,079 in paid claimstotaling $6,936,079 in paid claims Normal – 8% to 10% of ER visits would Normal – 8% to 10% of ER visits would

result in same day admit.result in same day admit.– Translation – SISC 3,000 ER visitsTranslation – SISC 3,000 ER visits– 21,000 ER visits unnecessary21,000 ER visits unnecessary

Members could have utilized Urgent Care Members could have utilized Urgent Care CentersCenters

Emergency Room Co Emergency Room Co PayPay SISC Goal SISC Goal

– Increase Urgent Care utilizationIncrease Urgent Care utilization– Increase member awarenessIncrease member awareness

How to get thereHow to get there– Provide County Specific member mailings Provide County Specific member mailings – Provide County Specific Urgent Care listingsProvide County Specific Urgent Care listings– Add ER Co Pays to all plansAdd ER Co Pays to all plans

Effective October 1, 2010 all plans will Effective October 1, 2010 all plans will have a $100 ER co pay. have a $100 ER co pay. – Co pay will be waived if admittedCo pay will be waived if admitted

Centers of Excellence Centers of Excellence (COE)(COE)

Focus on unique, high cost medical events that impact Focus on unique, high cost medical events that impact members & familiesmembers & families– Transplants & Bariatric proceduresTransplants & Bariatric procedures

Select and credential providers and provide specialized Select and credential providers and provide specialized case managementcase management

Covered TransplantsCovered Transplants– Heart, Lung, Liver, Kidney, Pancreas/Kidney, Bone MarrowHeart, Lung, Liver, Kidney, Pancreas/Kidney, Bone Marrow

Special programs to assure:Special programs to assure:– Quality of careQuality of care– Comprehensive care for patient with nurse managerComprehensive care for patient with nurse manager– Cost effective management of careCost effective management of care

Intent to assure great outcomes for membersIntent to assure great outcomes for members

Centers of ExcellenceCenters of Excellence

Two Parts – Network and Case Two Parts – Network and Case ManagementManagement– Facilities chosen based on:Facilities chosen based on:

Volume of proceduresVolume of procedures Readmission rateReadmission rate Post-operative complications & mortality ratePost-operative complications & mortality rate AccreditationAccreditation

– Case management includes:Case management includes: Member education and coaching on the benefits, the Member education and coaching on the benefits, the

procedure and aftercareprocedure and aftercare Post surgical monitoring of carePost surgical monitoring of care Coordination of other plan benefits, such as wellness Coordination of other plan benefits, such as wellness

and behavioral healthand behavioral health

Centers of ExcellenceCenters of Excellence

Benefit requirement includes:Benefit requirement includes:– Members must use a COE hospital to receive benefitsMembers must use a COE hospital to receive benefits– Members work with a nurse case managerMembers work with a nurse case manager– Utilization approval is requiredUtilization approval is required

Additional benefits include:Additional benefits include:– Travel reimbursement if member lives 50 or more Travel reimbursement if member lives 50 or more

miles from a COE facilitymiles from a COE facility Reimbursement of medically necessary trips based on Reimbursement of medically necessary trips based on

IRS mileage. Reimbursement for Air if member lives IRS mileage. Reimbursement for Air if member lives 300 miles or more. Air requires pre-approval and is at 300 miles or more. Air requires pre-approval and is at coach level.coach level.

Hotel accommodations (actual charge or $174, lesser Hotel accommodations (actual charge or $174, lesser of)of)

Maximum total travel benefit:Maximum total travel benefit: $5,000$5,000

90-Day Prescription 90-Day Prescription OptionOption

Effective October 1, 2010Effective October 1, 2010– Member will be able to receive a 90-day Member will be able to receive a 90-day

supply of medications at a retail pharmacysupply of medications at a retail pharmacy– Must have a prescription for a 90-day Must have a prescription for a 90-day

supplysupply– Co pay will be a 3 times the 30-day supply Co pay will be a 3 times the 30-day supply

co payco pay– Can use all pharmacies except CVS for the Can use all pharmacies except CVS for the

90-day supply90-day supply Mail Order option with informedMail still Mail Order option with informedMail still

available with discounted co paysavailable with discounted co pays

RX PlansRX Plans

Effective October 1, 2010 Implementing Step Effective October 1, 2010 Implementing Step Therapy for ARB’sTherapy for ARB’s– ACEI’s are considered first line agent for prevention, ACEI’s are considered first line agent for prevention,

detection, evaluation and treatment of High Blood detection, evaluation and treatment of High Blood Pressure.Pressure.

i.e. lisinoprili.e. lisinopril

– Following medications require use or trial of ACEI Following medications require use or trial of ACEI before being approved under the planbefore being approved under the plan

Atacand, Teveten, Avapro, Micardis, Diovan, Cozaar, Atacand, Teveten, Avapro, Micardis, Diovan, Cozaar, BenicarBenicar

RX PlansRX Plans

Generics are free at CostcoGenerics are free at Costco OTC products for PPI’s and Allergy meds OTC products for PPI’s and Allergy meds

are free with doctor’s prescription and are free with doctor’s prescription and must be tried firstmust be tried first

Step Therapy in effect forStep Therapy in effect for::– Allergy MedsAllergy Meds– MigraineMigraine– OsteoporosisOsteoporosis– Non-Sedating AntihistaminesNon-Sedating Antihistamines– Depression MedDepression Med– Sleep AidesSleep Aides– Proton Pump InhibitorsProton Pump Inhibitors

RX PlansRX Plans

Allergy MedicationsAllergy Medications – $0 Co Pay for Zyrtec OTC, Claritin OTC, $0 Co Pay for Zyrtec OTC, Claritin OTC,

Zyrtec-D OTC & Claritin-D OTCZyrtec-D OTC & Claritin-D OTC– Includes the generic OTC equivalentsIncludes the generic OTC equivalents– Requires prescription from your physicianRequires prescription from your physician– No other allergy medications are coveredNo other allergy medications are covered

Migraine MedicationsMigraine Medications– Must try sumatriptan (generic Imitrex) or Must try sumatriptan (generic Imitrex) or

Relpax FirstRelpax First– If not effective, Physician can work with If not effective, Physician can work with

AHC for authorization of another AHC for authorization of another medicationmedication

RX PlansRX Plans

Osteoporosis MedicationsOsteoporosis Medications– Must try alendronate (generic Fosamax) Must try alendronate (generic Fosamax)

firstfirst– If not effective, Physician can work with If not effective, Physician can work with

AHC for authorization of another AHC for authorization of another medicationmedication

Non-sedating Antihistamine MedicationsNon-sedating Antihistamine Medications– Must try Fluticasone (generic) or Nasonex Must try Fluticasone (generic) or Nasonex

firstfirst– If not effective, Physician can work with If not effective, Physician can work with

AHC for authorization of another AHC for authorization of another medicationmedication

RxPortalRxPortal

www.americanhealthcare.com– Follow the RxPortal link under the Follow the RxPortal link under the

Members tab to reach the RxPortal Members tab to reach the RxPortal homepagehomepage

– You will need to register. Do not use the You will need to register. Do not use the first 3 letters of your ID cardfirst 3 letters of your ID card

Can check your prescription historyCan check your prescription history Covered drugsCovered drugs Mail Order RefillsMail Order Refills And do a trial claim on your medicationAnd do a trial claim on your medication

RenewalRenewal

Medical Plans – 9.5% OverallMedical Plans – 9.5% Overall– Range 8.4% to 12.2%Range 8.4% to 12.2%

RX Plans – 5.6% OverallRX Plans – 5.6% Overall– Range 2.8% to 14.8%Range 2.8% to 14.8%

Dental – Dental – – Incentive Plan No IncreaseIncentive Plan No Increase– PPO Plan 10.8% PPO Plan 10.8%

Vision – 5.8%Vision – 5.8%

Medical OptionsMedical OptionsCSEA MembersCSEA Members

Option #1 Option #2 Option # 3

Deductible $200/$500 $500/$1,000 $500/$1,000

Coinsurance

90% 80% 80%

OOP Max $300 Ind/$900 Fam

$1,000 Ind/$3000 Fam

$1,000 Ind/$3000 Fam

Office Visit $10 $20 $30

RXRetail $3 G - $15

BMail $3 G - $35 B

Consumer ShareRetail $5 – $15 - $35Mail $10 - $35 - $80

Consumer ShareRetail $5 – $15 - $35Mail $10 - $35 - $80

Open enrollment October 1, 2010Open enrollment October 1, 2010

Medical OptionsMedical OptionsUnrepresented MembersUnrepresented Members

Option #1 Option #2 Option # 3 *

Deductible $200/$500 $500/$1,000 $500/$1,000

Coinsurance 90% 80% 80%

OOP Max $300 Ind/$900 Fam

$1,000 Ind/$3000 Fam

$1,000 Ind/$3000 Fam

Office Visit $10 $20 $30

RXRetail $3 G - $15 BMail $3 G - $35 B

Consumer ShareRetail $5 – $15 - $35Mail $10 - $35 - $80

$200 Ind/$500 Fam DedRetail $10 G - $35 BMail $25 G -$90 B

Option 3 – Power Select NetworkOption 3 – Power Select Network Open enrollment October 1, 2009Open enrollment October 1, 2009

Medical OptionsMedical OptionsKTA MembersKTA Members

Option #1

Deductible $200/$500

Coinsurance 90%

OOP Max $300 Ind/$900 Fam

Office Visit $10

RXRetail $3 G - $15 BMail $3 G - $35 B

Open enrollment October 1, 2009Open enrollment October 1, 2009

Dental OptionsDental OptionsIncentive Plan Delta Preferred Option

In-Network

Out of Network

In-Network Out of Network

Deductible None None $25/$75

Diagnostic, Preventive, Basic, Crowns

70%-80%-90% 100%

70%-80%-90% 100%

UCR

100% 50% UCR

Prosthodontics 50% 50% UCR 50% 50% UCR

Annual Max $1,500 $2,000 $1,000

Orthodontics 50% to $1,000 Lifetime 100% to $2,000 Lifetime

If using a PPO dentist under the Incentive Option, benefits increased by $200 per If using a PPO dentist under the Incentive Option, benefits increased by $200 per yearyear

Open Enrollment October 1, 2010Open Enrollment October 1, 2010 Moving from Incentive Plan to DPO & Back again, start at 70%Moving from Incentive Plan to DPO & Back again, start at 70%

Vision PlanVision Plan

Vision Service PlanVision Service Plan– Exam & Lenses Every 12 monthsExam & Lenses Every 12 months– Frames Every 24 monthFrames Every 24 month– $5 Co Pay Exam$5 Co Pay Exam– $25 Co Pay Materials$25 Co Pay Materials

Kings County Office Kings County Office of Educationof Education

Judy Fussel, RHUJudy Fussel, RHUPresident/COOPresident/COOBuckman-Mitchell Financial & Buckman-Mitchell Financial & Insurance Services, Inc.Insurance Services, Inc.