It’s open enrollment season again and the Group Insurance Trust has taken the opportunity to strengthen its offerings with two new medical plans that give members even more flexibility in fine tuning their coverage through different levels of deductibles, co-pays, and premiums. Protect 40, a new co-pay plan, features a higher deductible and a higher $40 co-pay than the popular Protect 35 plan but lower than the Protect 45 copay plan. Protect HSA 3,500, a new HSA-eligible plan, features higher deductibles and lower member-paid coinsurance than the Protect 1500, 2500 and 2850 HSA plans with premiums approximating those of the Protect 45 copay plan.

As in previous years, the annual open enrollment period—continuing this year from November 1 through December 16—allows CalCPA-member firms a variety of options. Firms can offer employees the Trust medical, dental, and vision plans as a new benefit, while employees who had previously declined coverage can also enroll at this time. Current subscribers can take advantage of this opportunity to review their insurance needs, consider the new plans, and/or make any changes they have contemplated during the year. Finally, keep in mind that while most employers offer a single plan, your firm may elect to offer a combination of ProtectPlus co-pay, ProtectPlus HSA and Anthem Blue Cross HMO plans.

Choosing the Right Plan

While reviewing all the available choices might seem a daunting task, a new set of video presentations featured on the ProtectPlus website has just made it easier—even a little entertaining. Using the Video Toolbox feature on the homepage, you can get a video summary for each plan. The videos are segmented into topics such as coinsurance and deductibles so you don’t need to watch the whole presentation to get the information you are looking for. New videos are being added weekly, so be sure to check back frequently. Of course, you can still access plan information in written form. The 2012 EZ Guide is available online as an easy-to-read Summary Plan Benefits Comparison Chart. Once you’ve selected the plan or plans you’re interested in, you can get quotes based on the demographics of your firm using the Get a Quote Tool. If you have questions click on Ask the Expert and submit your query to the Trust staff. While they promise to get back to you within two days, you often receive an answer within the hour.

New Pharmacy Benefit Manager

Beginning January 1, 2012 ProtectPlus co-pay and HSA plan pharmacy benefits will be serviced by Medco rather than Express Scripts. (Please note that this change does not affect HMO participants.) Current subscribers who aren’t making any changes in their coverage should receive a welcome packet in the mail from Medco in the middle of December. Included in the mailing will be a welcome letter describing Medco services as well as your new pharmacy benefits ID card, which you will need to obtain your prescription drugs.

Between now and January 1, 2012 you can access the Medco open enrollment website to look up the cost of your prescription drugs pre- and post-deductible under the Medco pharmacy plan. After January 1, use your new Medco ID number to register at Medco.com to access the Medco mail order pharmacy and your personal prescription drug records. Although copays and coinsurance levels are not changing, differences between the old and new prescription drug formularies may result in an increase or decrease in your out-of-pocket costs.

Members who currently use specialty prescription medications for complex conditions will receive a letter introducing them to Accredo, Medco’s provider of specialty drugs. The letter will include information on contacting Accredo’s specialty pharmacists and nurses toll-free, 24 hours per day, 7 days a week. There is also an explanation of procedures for transitioning your specialty prescriptions and for scheduling regular deliveries.

Whether offered as an employee benefit through a group plan or purchased as an individual policy to help create a family safety net, long-term disability (LTD) insurance provides income when a policyholder suffers an injury or illness and can’t work. While most of us don’t believe, and can’t imagine, that we will ever need it, the value of such coverage is self-evident. Knowing it’s there certainly provides reassurance to policyholders and their families.

Like most things that seem self-evident, however, real life circumstances are often less than simple. If you’re in a coma, no one would suggest that you should come in to work anyway, but if you’re in pain, who decides if you’re in too much pain to work? Should your insurer take your word for it? Does it serve an insurance company to believe you, and if it disagrees, who is the final arbiter?

On September 9, the California state legislature unanimously passed SB 621 with the intent to take the ultimate decision-making authority for disability claims out of the hands of insurance companies and turn it over to the courts. The legislation is now awaiting the governor’s signature, which is considered almost certain. Originally authored by California’s new insurance commissioner Davey Jones when he was a state assemblyman, the bill continues many years of efforts to do away with “discretionary clauses” by which insurers reserve the right to make the final ruling on the legitimacy of disability claims.

For instance, you claim a back injury and your insurer decides that it is not disabling. At that point you appeal to your carrier. If they deny you again, and a discretionary clause is part of their policy, your options are extremely limited. Few courts would support your right to pursue a claim further.

According to Jones, such clauses “give insurance companies the freedom to easily justify coverage denials when a policyholder takes a carrier to court over denied benefits and claims. This bill levels the playing field for consumers so they can have their day in court and get the benefits they paid for with their premiums.”

While the passage of SB 621 marks a step forward for policyholders, it won’t by itself put an end to discretionary clauses. Group LTD insurance is governed by federal ERISA rules, which specifically allow the inclusion of discretionary clauses in policies. Nevertheless, in practice their use is significantly diminishing, if a carrier wishes to have full discretionary powers, highly specific language will need to be in disability plan’s Summary Plan Description..

During his tenure as Insurance Commissioner, John Garamendi was successful in getting a number of group disability insurance carriers to remove such language from their policies. Also, in recent years courts have asserted the right to review disputed claims and substitute their judgments for that of insurance administrators.

On their part, many insurance companies have recognized the ill-will generated by putting their policyholders in a compromised position and are voluntarily making changes. These changes certainly signal the future direction of LTD insurance. Moreover, because the same or similar practices appear in life insurance and long-term care policies, consumers can expect to see parallel changes in plan design over time.

The CalCPA ProtectPlus group LTD plans with Lincoln Financial do not give the insurance carrier discretionary power to solely determine whether a claim should be paid or not. Instead, Lincoln’s contract provides a process where a claimant can request a review by the California Department of Insurance. For more information on the CalCPA group LTD plans, visit www.cpaprotectplus.com or call Hover Insurance Services, Inc. (800) 805-9480. Groups with 2-9 employees contact Banyan Administrators, LLC (877) 480-7923.

Doug Hessel is Program Director, CalCPA ProtectPlus Ancillary Products at Hover Insurance Services. You can contact him at dhessel@hoverinsurance.com

Fortunately for consumers, the cost of prescription drugs still accounts for only 10 percent of healthcare spending nationwide. This is only good news because increases in the cost of hospital care and physician services have grown even faster, exceeding 5 percent annually.

Generic Counterparts

Nevertheless, several important factors have helped keep prescription costs in check. First and foremost, has been the introduction of generic alternatives when brand-name pharmaceuticals lose patent protection.

A report by the Kaiser Family Foundation points out that, “almost 80 percent of FDA-approved drugs have generic counterparts,” and explains that when there are two generic alternatives on the market, the generic price is usually about half the original price of the brand name drug. Moreover, when several competing generics are available, prices often plummet to 20 percent or less of the original brand cost.

The Value of a Formulary

In conjunction with cost-sharing techniques such as deductibles, copayments and co-insurance, another tool used by health insurers to keep prescription expenses down is the use of a formulary. Comprising a list of approved prescription drugs, formularies encourage the use of generics and lower-priced alternatives among their subscribers by creating a differentiated copayment schedule. Under such an arrangement, if you elect a brand-name drug when a generic equivalent is available, you will be responsible for a greater share of the cost.

Formulary lists are typically assembled by teams of doctors and pharmacists who evaluate drugs on the basis of safety and effectiveness in the treatment of diseases. Lists are updated regularly and will usually contain both brand name and generic drugs. When a generic is available for a brand-name product, the brand-name product is generally considered non-formulary. Typically only the generic equivalent will be on the formulary list, a practice endorsed by the FDA. In this way a formulary decreases the total prescription costs for a medical plan by steering subscribers to lower cost alternatives that fully meet their needs.

Other “utilization management strategies,” as they are known in the healthcare industry, include the requirement for prior authorization in the case of certain drugs and/or greater patient cost-sharing for new, bio-tech, and specialty pharmaceuticals. Such measures aid in controlling the cost of premiums for all plan participants.

ProtectPlus Formulary

Beginning January 1, 2011, ProtectPlus adopted use of the same formulary utilized by the Anthem Blue Cross HMO plans. The formulary is updated quarterly and can be found online at the ProtectPlus website under “Anthem Blue Cross Formulary List.”

 The copayment structure for ProtectPlus copay plans and Anthem Blue Cross HMO plans is the same for a 30-day supply bought through an in-network retail pharmacy and a 60-day supply when ordered through Anthem’s Express Scripts mail order pharmacy.

• generics = $10 copayment              

• brand-name = $150 annual deductible per member

• brand-name/formulary = $25 copayment

• brand-name/non-formulary = $45 copayment

• self-injectables (excluding insulin) = 30 percent of prescription drug maximum amount

One way to keep your prescription drug costs down is to provide a copy of the Anthem formulary list to your doctor. He or she can then use it to help select the best medication for you while still being mindful of your out-of-pocket costs. Another good strategy is to let your pharmacist know that you prefer to use generics when possible. Many pharmacies will substitute a generic when available unless the prescribing physician specifies a brand-name with the phrase “dispense as written,” but you can’t assume it. Ultimately, what matters is taking the appropriate medication for your condition. However, if an equivalent drug is available that will safely and effectively treat the condition and save you money, where is the downside?

Following is an outline of the most important plan modifications subscribers will see this year. Some are in response to health care reform but not all.

Health Care Reform Mandates

Beginning January 1, every health plan must comply with the following provisions:

• All dependents up to age 26 are eligible for coverage
• No cost-sharing for in-network preventive services
• No pre-existing limitations for children under 19
• Prior authorization or higher cost-sharing disallowed for out-of-network emergency services
• New rules for appeals process
• Removal of lifetime maximum limits (copay and HSA plans)
• Removal of lifetime limits for hospice care (copay and HSA plans)
• Removal of annual limits on durable medical equipment (HMO plans)

Premium Rates

Naturally, all these mandated changes come at a price. Over the past seven years, the Group Insurance Trust has delivered single digit increases that were well below national and regional trends. However, a thorough analysis of the costs associated with these mandated benefits, plus unusually high claims experience in 2009, resulted in an increase to CalCPA ProtectPlus medical plan rates that is significantly higher than that of previous years.

Because each firm’s rates are based on a combination of factors, each firm’s increase is unique. Renewal packets, including rate information specific to each firm, were mailed to participating firms on November 1. If you did not receive your renewal package please contact Banyan Administrators, LLC at (877) 480-7923 immediately.

Plan Design Changes

In addition to the mandated changes described above, for the 2011 calendar year the Trust is implementing changes specific to the ProtectPlus program. There are also changes specific to Anthem HMO plans.

Prescription Drug Formulary

A significant change to be implemented in the ProtectPlus copay and Anthem Blue Cross HMO plans in the coming year is the introduction of the Anthem Blue Cross formulary (preferred list of drugs). This list is updated quarterly by a committee of doctors and pharmacists who evaluate drugs on the basis of safety and effectiveness in the treatment of diseases. To view the list on www.cpaprotectplus.com, click on Forms/Prescription and select Anthem Blue Cross Formulary List.

The formulary list contains both brand name and generic drugs. In many cases when a generic is available for a brand name product, the brand name product will be considered non-formulary and only the generic equivalent will be on the formulary list, a practice endorsed by the FDA.

Beginning January 1, the copayment structure for ProtectPlus copay plans and Anthem Blue Cross HMO plans will be the same for a 30-day supply bought through an in-network retail pharmacy and a 60-day supply when ordered through Anthem’s Express Scripts mail order pharmacy.

• generics = $10 co-payment
• brand-name = $150 deductible per member
• brand-name/formulary = $25 co-payment
• brand-name/non-formulary = $45 co-payment
• self-injectables (excluding insulin) = 30 percent of prescription drug maximum amount

Administrative Updates

In addition to these rather significant changes in Trust plans, there are a couple of administrative issues that are important to note.

Anthem will be issuing new ID cards for all subscribers, regardless of whether they make an open enrollment change. This change is required by the National Blue Cross and Blue Shield Association, which is trying to standardize ID cards across all Blue plans. Please alert your employees to watch for an envelope from Anthem.

The Anthem Blue Cross HMO customer service phone number is now (888) 209-7847. This is the same customer service number that PPO and HSA subscribers currently use.

In addition to the quality medical care and competitive prices members have come to expect, when you subscribe to a CalCPA-endorsed ProtectPlus health plan, you get the added benefit of an administrative support team whose sole purpose is to make your insurance dealings clear, easy, and responsive. This is never more critical than when you find yourself facing a denied claim. If this should happen, here are the steps you can take to get an explanation and, at least sometimes, a decision reversed.

Begin by calling the Anthem member service phone number on the back of your medical ID card. You should have your EOB (explanation of benefits) in hand so that you can ask why a particular treatment was either denied or only partially paid. If the answer isn’t clear, or you feel the claim wasn’t handled properly, your next step should be to call the ProtectPlus service representatives at Banyan Administrators at (877) 480-7923. Every member of the Banyan team is a licensed agent and is there to serve you. Moreover, they are your advocates. Their job is to make sure you get the care you need as smoothly as possible, so you shouldn’t feel shy about asking. This is what your insurance plan is all about.

If the Banyan agent doesn’t solve the problem to your satisfaction, Banyan can walk you through the Anthem appeals process. Appeals are handled slightly differently depending on whether they concern completed care, treatments in progress, or future procedures. Anthem will provide a written response within 30 business days with the results of its decision.

At this point most disputes are resolved, but if you are still not satisfied you have the final option of filing for an Independent Medical Review (IMR). The IMR is provided by the California Department of Insurance (DOI). There is no charge to you for this service and the DOI’s decision is binding. Simply complete and submit the one-page application to request a review. Anthem will provide the applicable medical records and claims documentation required by the DOI and you can add any pertinent information in support of your claim. The Department will inform you of its determination in approximately 30 business days following submission of the IMR request.           

Because the ProtectPlus program is a Multiple Employer Welfare Arrangement (MEWA), ProtectPlus plan participants must submit their IMR application to the Department of Insurance which oversees MEWAs. IMR requests for many other healthcare plans in California are reviewed by the Department of Managed Care.  You can download the IMR application at http://www.insurance.ca.gov/0100-consumers/0020-health-related.

You can access these new tools by logging onto the Anthem Blue Cross website directly (www.anthem.com) or you can click through from the ProtectPlus site (www.cpaprotectplus.com). If you take the latter route, choose “Plan Members” then go to “My Plans” and click on “ProtectPlus (Anthem Blue Cross).” Please note that Anthem recently completed a major re-design of its website and you will be instructed to register, or re-register if you had an account on the earlier website, before accessing your account information. Once on your Anthem personal Account Summary page you will find several icons that you can click and drag onto your personal menu to customize your page.

Click on the “Facility Cost and Quality” icon to open the Anthem Care Comparison page. Once there click on “find a facility for a procedure or condition.” A drop-down list provides categories of treatment (e.g. cancer, lungs, orthopedic, or pediatric conditions). When you have chosen a category you can then choose from another list of procedures and diagnoses. You then put in your city or zip and the distance you are willing to travel.

The site will return a list of facilities that provide the procedure in question, typical minimum costs, typical maximum costs, and the average number of times this particular service was provided by the facility in a year. You may be shocked to discover that the average fee at some facilities is several times higher than the average fee charged by others. You may also find that one facility performs the procedure on a regular basis and another conducts it rarely.

To illustrate how significantly the negotiated fee can impact out-of-pocket costs, we searched facilities that perform standard colonoscopy screenings within a 20 mile radius. The results were surprising. For the 16 facilities within the search area, the typical maximum cost ranged from $996 to $4,982 for the same procedure. If the medical plan pays 70% of the negotiated rate, the member’s out-of-pocket costs at 30% could be as little as $299, or as much as $1,495.

If you want still more information, the Facility Cost and Quality tool can also display a customized graphic comparison much like those featured in Consumer Reports with rankings on various scales for factors such as complications, average length of stay, hospital safety, and patient satisfaction ratings.

Another useful tool that you can add to your personal menu is the “Treatment Cost Advisor.” This tool graphically illustrates the cost difference between in-network and out-of-network service providers for specific services.

If you are one of those who tends to say, “wake me when it’s over,” these tools may not be for you. But for those who want to take an active role in their care, the ability to compare medical costs and outcomes represents a major advance.

Boasting an impressive reach, this coverage extends to all 50 states and Puerto Rico, plus more than 200 countries and territories worldwide. So, you can enjoy your vacation at ease knowing that covered healthcare is within easy reach. Here are a few guidelines for making use of your coverage with the least hassle.

Always carry your ID card wherever you are traveling, and in any emergency go to the nearest hospital. If you don’t need emergency care but do need to see a doctor or visit a hospital before you return home, call the “Coverage while traveling” number on the back of your Anthem Blue Cross ID card for help in locating the provider nearest to you, or referral authorization. For travel in the US, Puerto Rico and US Virgin Islands, you can also find participating provider information online (provider.bcbs.com).

Once at the hospital or doctor’s office, present your Anthem Blue Cross card. For services provided in the US, you shouldn’t have to complete claims forms or pay up-front for medical care other than your usual out-of-pocket expenses such as deductibles and copays. Anthem will send you a complete explanation of benefits.

If you are traveling out of the country and need emergency medical care, call, or have a family member or friend call the BlueCard Worldwide Service Center collect (1-804-673-1177) as soon as you are admitted to a hospital. If you need nonemergency care, the service center will help you make an appointment with a doctor or facilitate your hospitalization at a network hospital. The center can help obtain cash-less access for inpatient care except for your usual out-of-pocket expenses. For outpatient care and/or services from a non-network hospital you may have to pay the provider and submit a claim form.

[Image Source]

The fact that the new employee was related had, in fact, no bearing on how the matter was handled. What was relevant, however, was the firm’s written policy, clearly spelled out in its benefit plan subscription agreement (an employer’s master application and agreement with the Group Insurance Trust or other carrier), that new employees had to complete a two-month waiting period before being eligible for benefits. Naturally, the firm’s owner was disappointed that his relative would have to wait the same as any other new hire. Nevertheless, he was also appreciative that Banyan had helped him keep his firm in compliance with both HIPAA and ERISA rules. The Department of Labor (DOL) is concerned about fair treatment of employees and issues of discrimination immediately arise if employees are not treated equally.

Because Banyan service center representatives had the information at their fingertips in their computer system, they were able to provide an explanation to the firm’s owner on the phone. Even if the owner had not contacted Banyan proactively, Banyan would have flagged the employee’s enrollment form when it came in because it did not meet the employer’s established policy. An important feature of Banyan’s computerized recordkeeping is to help member firms prevent unintended regulatory violations.

At the same time, the Trust provides flexibility by offering member firms a broad range of options in setting their own policies. A firm can choose to add new hires to their existing plans on the first of the month following the day of hire or up to six months after, provided they are consistent. Existing rules are subject to change as the Patient Protection and Health Care Affordability Act (health care reform) is implemented and the specifics of the law are ironed out. The Trust and Banyan will continue to monitor evolving regulations and keep you informed as health care reforms solidify.

Generally, employers may change their benefit waiting period and other employee eligibility policies during the annual open enrollment period. It makes sense to review these policies each year to ensure that they are consistent with your firm’s hiring practices. If you are not sure about your company’s benefits eligibility policy as stated in your ProtectPlus Subscription Agreement, or if you are not sure whether the subscription agreement is consistent with your employee handbooks or other new-hire materials, call the Banyan Service Center at (877) 480-7923 or email cpaprotectplus@banyan-llc.com. A Banyan member service representative will be happy to answer your questions.

Over the last few weeks the Group Insurance Trust has received a number of phone calls in response to headlines about significant premium increases recently proposed by Anthem Blue Cross. In fact, it turns out that Blue Cross is just one of many major insurers in California and throughout the nation who are contemplating big rate hikes. The good news, which Trust staff has repeated to these callers, is that ProtectPlus subscribers are not subject to the threatened rate increases that are so much in the news.

Since being licensed by the State of California as a Multiple Employer Welfare Arrangement (MEWA) in 1997, the Trust has acted as the insurer for the entire ProtectPlus medical, dental and vision plans, designing benefits to meet the needs of CalCPA members and setting its own rates.

The Trust’s executive director, Susan Young, notes, “The confusion may have arisen because the Trust contracts with Anthem Blue Cross for use of its Prudent Buyer Network and to adjudicate claims. The Trust has an administrative-services-only agreement for which it pays Anthem a negotiated fee per member, per month, for the services it provides.”  Young adds, “Although ProtectPlus members get the advantage of Anthem’s deep provider discounts, members should understand that it is the Trust that is responsible for setting ProtectPlus premium rates and benefits, which are based on our group’s claims experience. This is why the recent threatened increases by Anthem and others do not directly affect ProtectPlus members.”

For CalCPA members who are not yet taking advantage of the remarkable benefits found in the Trust program, this is an excellent time to see how their present plan stacks up against the ProtectPlus plans. Solo practitioners and members with small group plans who are facing big increases may well find that ProtectPlus offers them superior coverage at significantly lower rates.

While for many years premium rates for the ProtectPlus copay and HSA-eligible plans have been consistently competitive, now members can also appreciate the remarkable stability of these plans. Over the last six years, participating firms with two or more members have experienced an average annual premium increase of 7.42 percent, well below industry averages every year. The following chart tells the story.

Year Rate Action
2005        8.7 %
2006        6.3 %
2007        6.2 %
2008        6.9 %
2009        6.9 %
2010        9.5 %

For a quick look at the range of plans available to your firm, take a look at the CPA ProtectPlus web site (http://www.cpaprotectplus.com). For help in identifying plans that best suit your firm’s needs, try the new “Plan Selector” located on the home page (http://cpaprotectplus.com/main/plan_selector.php). Through a few simple questions, this tool can streamline your choices. You can also contact Tom Kowalski, sales manager for the Group Insurance Trust, who can answer your questions and walk you though the application process. You can call him at (650) 802-2406 or email tom.kowalski@calcpa.org.  Alternatively, you can use the “Ask Our Sales Manager” feature (http://cpaprotectplus.com/landing_pages/HomePage/index.html) from the Web site home page. Tom or another staff member will reply to your question personally.

[Image Source]