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& you!Provider Summit
Today’s Discussion
• Welcome – Dr. Ron Paulus, CEO
• Introductions
• Mission’s strategic health benefits goals
• Why we went through a due-diligence process
• What’s changing (and what is staying the same)
• Our new health plan administrator – HealthSCOPE Benefits
• How HealthSCOPE’s plan administration works
• Tools and resources you can use
• Where to go/who to call
• Question/answer session
• Significantly improve plan administration and service to employees and providers
• Engage our people in a meaningful and sustained approach to total health management
• Make measurable contributions to improving the health and wellness of our plan members
• Reposition the value proposition of our benefits
• Manage total cost at the most efficient level possible while supporting a highly competitive health plan
• Partner with Corporate Wellness to promote preventive health, disease management and wellness initiatives
Our Strategic Goals
Why We Selected HealthSCOPE
• Commitment to work with our unique client-specific networks and approaches
– Crescent PPO, direct contracts, and Employee Assistance Network [EAN]
– Mission’s internal disease management programs (MyHealthyLife)
• Experience with hospital systems and consumer-directed health plans
• A top-notch account management and implementation team
• A dedicated customer care team for Mission
Benefit/Service/Coverage 2010 2011Medical CIGNA HealthSCOPE
PPO Network Custom network comprised of Crescent PPO, Employee Assistance Network (EAN) behavioral health providers, and directly-contracted providers.
No change
Rx Benefit Manager (complete carve-out)
American Health Care No change
Dental CIGNA HealthSCOPE
HRA (Health Reimbursement Account)
CIGNA HealthSCOPE
FSA (Flexible Spending Account)
CIGNA HealthSCOPE
HSA Debit Card None HealthSCOPECOBRA Ceridian HealthSCOPE
Transplant network CIGNA LifeSOURCE Network Multiple – coordinated through HealthSCOPE
Disease management Mission No change
Wellness Program Mission No change
What’s Changing – and What’s Not
Continued Focus on Chronic Disease
Management
MyHealthyLifeHEALTH ENHANCEMENT & DISEASE MANAGEMENT
Classes:
• Diabetes classes: series of 5 classes
• High blood pressure: series of 3 classes
•Asthma & COPD: individual education sessions with an educator
• Depression: No classes
Care Manager:
• In MOST cases, the care manager is a Mission employee . May also be a community pharmacist.
• Participant must meet with care manager at least quarterly (with a commitment to meet as frequently as once a month if requested by their case manager)
• Missed visits are cause for disenrollment in the program
PLEASE REMIND PATIENTS ABOUT MISSION’S MY HEALTHY LIFE PROGRAMS
Programs cover diabetes, high blood pressure, high cholesterol, asthma/COPD, and depression. Once enrolled, the participant receives enhanced benefits (for both Rx plan and the health plan) for certain Rx and medical services related to the underlying condition(s)
7
Mission Basic - 114 enrollees
7
Out of Pocket Maximum$4,000 Single$8,000 Family
Deductible
$1,200Single
$2,400 Employee + One
Family
100% Coverage
Out-of-Pocket
Maximum
includes
coinsurance but
does NOT include
the deductible
Preventive Care:100%, no deductible(70% non-network)
Note: Rx will now be
handled by American
Health Care
Coinsurance70% coverage for any provider
Up to Coinsurance Limit(Including Rx)
New for 2011
8
Mission HSA – 59 Enrollees
Mission
80%
$1,200 Single$2,400 Employee + One
$2,400 Family
100% Coverage
Network
70%
Deductible
Out-of-Pocket Maximum
Mission & In-Network$4,000 Single$8,000 Family
Non-Network
Unlimited
Non-Network
50%
Out-of-Pocket
Maximum
includes
coinsurance and
deductible
Health Savings Account
Accessed via HealthSCOPE HSA card (at employee’s discretion)
2011 Annual Contribution $500 Single
$1,000 Family
Coinsurance
Mission & In-Network Preventive Care:
100%, no deductible
Note: Rx will now be
handled by American
Health Care
New for 2011
9
Mission PPO – 1,050 Enrollees
Mission
80%
Mission$500Single
$1,000 EE + One
orFamily
100% Coverage
Mission & In-Network
Co-pays
$30 PCP$30 Behavioral Health
$45 Specialist
Note: Rx will continue
to be handled by
American Health Care
Network
70%
Network$500Single
$1,000EE + One
or Family
Non-Network$750Single
$1,500 EE + One
or Family
Deductible
Out of Pocket Maximum
Mission$2,000 Single$4,000 Family
Network$4,000Single
$8,000 Family
Non-Network
Unlimited
Non-Network
50%
Out of Pocket
maximum
includes both the
deductible and
coinsurance
CoinsuranceMission & In-Network
Preventive Care:100%, no deductible
10
Mission CDH – 5,077 Enrollees
Mission
80%
$2,000 Single$3,000 Employee + One
$4,000 Family
100% Coverage
Note: Rx will continue
to be handled by
American Health Care
Network
70%
Deductible
Out-of-Pocket Maximum
Mission$2,000 Single$4,000 Family
Network$2,000Single
$4,000 Family
Non-Network
Unlimited
Non-Network
50%
Out-of-Pocket
Maximum
includes
coinsurance but
does NOT include
the deductible
Health Reimbursement Account
Automatically offsets member’s responsibility when the claim is adjudicated
(no debit card required)
2011 Annual Contribution (added to any applicable
2010 Rollover)$1,000 Single
$1,500 Employee + One$2,000 Family
2010 Balance Rollover to 2011 Capped at:$1,000 Single
$1,500 Employee + One$2,000 Family
Coinsurance
Mission & In-Network Preventive Care:
100%, no deductible
HealthSCOPE BenefitsThe
Total Health Management Company
Creating
Healthy People. Healthy Business. Healthy Futures.
HealthSCOPE Benefits
• Susan Johnson – Regional VP,
Account Management
HealthSCOPE Benefits Overview
• Currently Ranked as the 5th Largest Third-Party Administrator in the United States by Business Insurance Magazine
7 Locations
200+ Clients Representing Over 350,000 Covered Participants
• Independent and Privately Held
• Significant Experience with Consumer Driven Plans
• Data-Oriented Partnership
• Highly Flexible
• Over 300 Employees Nationally
• Dedicated Mission Team
Customer Care Contacts
WEB SELF-SERVICE
(24 HOUR/365 DAY
ACCESS TO CLAIMS
STATUS & HISTORY,
FORMS, PLAN DOCUMENT,
ID CARD ORDERING,
FSA/HRA BALANCES,
HEALTH & RX INFORMATION )
CUSTOMER CARE
REPRESENTATIVES
Dedicated Team
M-F 8:00 a.m. – 5:00 p.m.877-226-2058
INTERACTIVE VOICE
RESPONSE SYSTEM
24 HOUR/365 DAY
ACCESS TO CLAIMS
STATUS
Service MetricsMetric Industry Standard 2009 Results
Claims Turnaround Time 90.0% within 20 Business Days94.50% in 10 Calendar Days
99.10% in 20 Calendar Days
Claims Financial Accuracy 99.0% 99.9%
Claims Processing Accuracy 95.0% 99.5%
Claims Coding Accuracy 96.0% 99.25%
Customer Service Average
Speed of Answer< 35 Seconds 17 Seconds
Customer Service
Abandonment Rate 4.00% 0.76%
HealthSCOPE Benefits Service Subject to Performance Guarantees
ID Card Sample
01/01/2011
Provider EOB Sample
Provider Customer Care Web Tools
Click on Provider to check on:
• Claim Status
• Eligibility
• Benefit Information
• Precert Information
• Copies of EOBs
www.healthscopebenefits.com
Provider Customer Care Tools
Do you have a User ID & password?
• If not, Register
• If so, continue to login.
www.healthscopebenefits.com
Provider Customer Care Tools
Login to check:
• Claim Status
• Eligibility
• Benefit Information
• Copies of EOBs
www.healthscopebenefits.com
Providers’ View of Accumulators
Jane Doe
23 Main Street
Anytown,
ST
12345
7890
Self
12345
67890
ABC Company
Precertification
• Hines and Associates Providing Precertification and
Case Management
• Nationwide & URAC Accredited
• Providers can complete Precertification online at
www.healthscopebenefits.com
• Precertification is required for:
• Non-emergency inpatient admissions
• Outpatient surgical procedures
• MRI & CT Scans
• PT, OT, ST – After 12th Visit
• Infusion Services/Injectables
• Chemotherapy
New for 2011
Precertification
Select the Utilization Review
Interactive Form
Click on the on-line referral tab
Precertification
• Secure https://www.hinesassoc.com/form_utilization_review.html
• Type in known information
Interactive UR Form
PrecertificationContinuation of UR Form
• After form is complete with known information and any attachments are attached – click submit.
Attachments can be attached here
Click Submit when done
PrecertificationConclusion of On-line Submission
• Once “Submit” button is clicked, a “Successful Form Submission” appears
Precertification
What Else Happens?
• The insured, a family member, hospital representative or the doctor can precertify via either method (phone or on-line)
.• If notified of the confinement by a provider, Hines will contact the insured and/or family
• Letters are sent to the insured, facility, and physician
• Denials are handled according to DOL timelines and URAC standards
• While doing this, Hines…– answers all questions
– channels to PPO providers
– anticipates discharge planning needs
– prescreens for case management
• Biologics’ patient centric, comprehensive payor programs start at the
point of diagnosis and continue to survivorship or end of life care
including the following:
• Patient Advocacy / Intense Care Management
• Plan of Treatment Review
• Mission programs for Cancer Management including Cancer Navigators
will be involved in patient care
• Precertification of Chemotherapy is required
Cancer Management
Benefits Administration
• Flexible Spending Account
Administration
• COBRA/HIPAA Administration
• HSA Administration through
Healthcare Bank
HSA vs. HRA
Health Savings
Accounts (HSA)
Health Reimbursement Arrangement
(HRA)
Who owns the funds in these accounts? Employee Employer
Who funds it? Employer and / or Employee Employer
Is it portable? Yes Generally not
Can it rollover? Yes Yes (Employer sets rules)
Employee federal tax advantages? • Employer contributions are not taxable to
the employee
• Employee contributions are tax free
• Earnings are tax free
• Qualified withdrawals are tax free
• Employer payments for reimbursements
are not taxable income to the employee
• Employee claims against the account are
tax free
Are there health plan requirements? Must be accompanied by an HSA-qualified
high-deductible health plan (HDHP)
No requirements, but generally accompanied
by a high-deductible health plan (HDHP)
When are funds available? Immediately upon deposit At discretion of employer
Can interest accrue? Yes No
HSA Debit Card Sample
My Healthy Life Integration
• HealthSCOPE Benefits will be reaching out to members to
encourage participation
• Only members participating will received the improved
benefits
• HSB will track all of the requirements in our system
Submit Medical and Dental Claims to:
HealthSCOPE Benefits
P. O. Box 99005
Lubbock, TX 79490-9005
EDI payer ID: 71063
877-226-2058
www.healthscopebenefits.com
Thank you!
We appreciate you and look forward to working with you in 2011–
and so do our employees!
Directly-
contracted
providers
E A Nemployee assistance network
