TML MultiState Intergovernmental Employee Benefits Pool

Transcription

TML MultiState Intergovernmental
Employee Benefits Pool
Innovative | MemberCentric | Competitive | Dedicated to Service | NCQA Accredited
MultiState
TML
Intergovernmental Employee Benefits Pool
Champion the Integrity of the Healthcare Dollar by Optimized Efficient Performance Based Outcome
CON TE N TS
From the Chairman
1
What is the TML MultiState Intergovernmental Employee
Benefits Pool?
4
Member Equity Management
5
Available Benefits
7
Retiree Benefits
9
A Wellness Plan that Works!
10
Medical Intelligence
11
Medical Intelligence Sample Reports
14
Public/Private Network Alliance
16
External Clinical Specialty Independent Review
Organization (IRO) | Evidence Based Medicine
17
Provider Network Transparency Sophistication Options
18
Telehealth | Healthiest You
19
Managed Care | Cost Efficiency
20
Health Information Technology (HITECH)
22
Regulatory Compliance and Reporting
26
Customer Care & Communication Tools
27
TML MultiState IEBP Milestones
28
From the Chairman
TML MultiState Intergovernmental Employee Benefits Pool will champion the management of the integrity of the healthcare dollar
by performance based outcome provider network service opportunities during the 2015-2016 Plan Year. The Texas and Oklahoma
Political Subdivision Synergistic teamwork continues to be the most effective step in achieving the mission statement of the IEBP
membership:
“To provide excellent service offering competitive health benefits and administrative
services to eligible municipalities and other governmental entities in Texas and other states by utilizing
innovative, viable, affordable alternatives while maintaining financial integrity.”
Claim Dollar Per Employee Per Year
PY03-04
PY04-05
PY05-06
PY06-07
PY07-08
PY08-09
PY09-10
10,475
6,517
PY11-12
PY12-13
6,956
9,064
9,064
PY10-11
6,460
9,821
5,995
9,028
6,070
8,449
5,837
7,970
5,421
7,516
5,048
7,140
5,026
6,616
5,126
4,843
6,059
PPRPY
12,716
Industry Standard
12,118
11,786
11,961
Pool
12,829
Per Employee Per Year Claim Dollar
PY13-14
Rolling 12
The Board of Trustees continues to be sensitive to the management of member equity within the benefit expansion of the Patient
Protection Affordable Care Act (PPACA).
1
Dedicated to Service for Over 30 Years
Investment
Earnings, Rate Increase, and Equity Offset
Membership Equity Return
Reserve booked adjustment
Investment Income
Net Income from prior Plan Year
Average Rate Increase
Projected Claim Utilization
Administrative Cost
Administrative Cost with fees
Medical Trend
Prescription Trend
Stop Loss Trend
PPACA Administrative Fee
2015-2016
$0
$2,495,194
$2,123,457
($6,564,952)
5.6%
$165,630,978
10.02%
15.45%
6%
12%
8%
2014-2015
$806,891
$2,000,000
$2,235,939*
$806,891
6.8%
$146,241,900
10.65%
16.74%
6%
8%
30%
2013-2014
$5,288,203
$2,066,042
$3,183,804
$7,347,292
4.5%
$134,028,025
10.41%
16.89%
7%
9%
30%
4.7%
$120,872,471
10.52%
17.28%
7%
10%
30%
Federal Liaison:
$60,000
1.4% plus Federal
Liaison: $175,000
1.88% plus Federal
Liaison: $175,000
n/a
*Budgeted
1
2012-2013
$3,055,684
$2,247,466
$2,974,554
$3,055,684
From the Chairman (continued)
Pool Membership Rate Overview
TML MultiState IEBP understands the impact of today’s economy and the challenges confronting our Membership. The IEBP
Board strives to maintain the stability of healthcare rates as a primary deliverable to the Pool membership. With a 7.52% PPACA
administrative cost increase, the Board was able to maintain healthcare increase in the single digits. Without the PPACA increase,
rates would have decreased by 0.72% or remained flat. The Board appreciates the engagement of the Pool membership in
maintaining the integrity of healthcare costs.
2015-2016
2014-2015
2013-2014
2012-2013
Average Rate Increase 5.6%
4% of Members did NOT
get a rate increase
15% of Members received
a decrease in rates
39% of Members had
an increase under 5%
18% of Members had
an increase between 5-10%
8% of Members had
16% of Members had
an increase over 15%
IEBP Equity Return $806,891
get a rate increase
a decrease in rates
38% of Members had
28% of Members had
5% of Members had
20% of Members had
IEBP Equity Return $5,288,203
get a rate increase
a decrease in rates
19% of Members had
9% of Members had
4% of Members had
14% of Members had an
increase over 15%
3.4 million IEBP investment income
offset the cost YOUR healthcare
get a rate increase
a decrease in rates
16% of Members had
29% of Members had
9% of Members had
13% of Members had
During the 2014-2015 plan year, TML MultiState IEBP obtained Interim NCQA Accreditation has been extended. NCQA
consistently raises the bar of health plans today by a rigorous set of more than sixty (60) standards in more than forty (40) areas
in order to earn a NCQA seal of approval. The IEBP will continue to deliver and promote services in the following qualitative
NCQA categories.
Access and Services
Access to care and services needed
Qualified Health Providers
Access to performance based providers with covered individual satisfaction survey interface
Staying Healthy
Focus on detection of illness early and promotion of good health
Getting Better
Health plan services to provide resources for Membership to recover from illness
Living with Illness
Health Plan resources to assist covered individual in the management of a chronic disease state
2
From the Chairman (continued)
Solution to Managing the Integrity of the Healthcare Dollar
EcoSystem Interoperability is an ongoing focus for IEBP to ensure the electronic interchange between the delivery participants is
updated and improved within the Health Information Technology endeavors. In addition, due to the regulatory administrative
fees and regulatory reporting requirements, IEBP has recalibrated the organization to support the ongoing Affordable Care Act
revisions.
Administrative Strengths
Public Employee Benefits
Alliance (PEBA)
 The Standard: Life, LTD,
STD, ADD
 Pre/Post Sixty-five Retiree
Benefits
 Healthy Initiatives:
Telehealth
 Deer Oaks: Employee
Assistant Program
 Medical Home Model of
Care
Regulatory
Compliance
 Standard Benefit
Language
 Benefit Expansion
 Administrative Fees
and Penalties
 Regulatory
Reporting
 HIPAA Bill
 State Waiver
HITECH/Ease of Access
 MyBenefits on Demand
 MyIEBP Mobile App
 Online Enrollment (OES)
 Online Enrollment
Custom (OES Custom)
 Explanation of Benefits
 Customer Care
 Provider Network Look
Up
 ICD-10 Compliant
Protected Health
Information
 External Security
Administrative Audit
 Security Officer
 Reprint Requirements
 Covered Individual
Authorization Approval
Eligible Covered Individual
 Definition of eligible employee and dependent
 Supporting Documentation: Birth Certificate(s),
Marriage certificates(s), Divorce Decrees(s), Adoption
Placement, Foster Care Document(s), Legal
Conservatorship/Guardianship, Incapacitated Child, Tax
Records for Grandchild coverage, Death Certificate (s),
Common Law Certificate(s), Loss of Coverage, Spouse
Changes: Termination of Spouse’s, Spouse changes
from full-time to part-time employment, Spouse takes
an unpaid leave of absence, Significant Change (10% or
more) in benefit coverage of Spouse’s plan
MemberCentric/Engagement
Medication Therapy Management Program
 Retail/Mail
 Generic
 Formulary
 Non-Formulary
 Cost Share
 Biosimilar
 Biotech/SpecialtyRx
 Step Therapy
 Prior Authorization
Healthy Initiative Healthy Living
 Calendar Year Biometric Screenings
 Health Power Assessment
 Increase Awareness of Healthy Living
Resources
 Data Analytic Gap in Care Reminder
Correspondence
Consumer Centered Pool Plan
 Section 125: Premium Only Plan, Grace
Period 2 months and 15 days, $500
maximum unreimbursed medical carry
over, annual unreimbursed amount 2015
$2,550.00
 Health Reimbursement Arrangement
 Retiree Reimbursement Arrangement
 Health Savings Account
 GAP Benefit Plans
 Pre/Post Tax Employee Awareness
Performance-Based Outcome
Evidence Based Medicine
 Clinical Protocol Requirements
 NCI, NCCN Guidelines
 Premium Network/Tier 1
 Experimental/Unproven
 Medically Justified
Performance-Based Provider Network
 Premium Network/Tier 1
 Preferred Provider Network
 Out of Network
 Secondary Network
 Professional Negotiation
 Reference-Based Pricing
 Patient Advocacy
 No Cost Share Benefits
 Preferred Lab
Patient Protection and Affordable Care Act (PPACA)
 Data Analytics
 Provider Pricing Transparency
 Intake
 Notification Utilization Review
 Utilization Management
 Intensive Care Management
 HEDIS Category of Disease State
 Gaps in Care Management
 Professional Health Coaching
IEBP will be working with the Political Subdivision Risk and Non Risk Membership in ongoing PPACA and Regulatory
Reporting Compliance. The Board of Trustees continues to support the Political Subdivision pooling concept and now the synergy
is more important due to the PPACA mandates and Regulatory Reporting requirements. Your trustees work diligently to ensure
employees, dependents and retirees have access to affordable, minimum essential compliant benefits.
Respectfully,
James Stokes, Board Chairman
3
What is the TML MultiState Intergovernmental Employee Benefits Pool?
Member Dedication
Premium Only Plan, Standard Plan, Two month fifteen day
Grace Period Plan, Maximum Unreimbursed Carry Over Plan,
Health Reimbursement Arrangement (HRA), and Health Savings
Account (HSA); and pre and post sixty-five retiree benefit plan
options.
The Pool consists of political subdivisions that join together
through an Interlocal Agreement to provide health benefits to
eligible employees, officials, retirees, and dependents. The longterm commitment of IEBP’s Members makes the organization
successful. In 2014, the Pool serviced over 890 Member Employers.
IEBP continues to focus on performance based medicine,
membership growth, and the management of healthcare cost
integrity. IEBP promotes active benefit plan engagement from the
covered individual to achieve successful healthy lifestyles and
health managed outcomes and a cost affordable rate.
In the Summer of 2013, IEBP participated and received interim
accreditation from the National Committee Of Quality Assurance
(NCQA), a non-profit organization dedicated to improving health
care quality by certifying healthcare organizations. NCQA is
a nationally recognized evaluation that purchasers, regulators
and consumers can use to assess health plans. The accreditation
process evaluates how well a health plan manages all parts of
the delivery system: physicians, hospitals, other providers and
administrative services in order to improve and consistently
provide the quality of benefit and services to their membership.
From inception, the Pool’s purpose was to provide Texas political
subdivisions with an alternative to the commercial insurance
marketplace. Availability of healthcare benefits at a competitive
price, coupled with excellent service is the main component of the
Pool’s mission. As a result, the Board of Trustees closely reviews
administrative costs and takes a very aggressive position towards
cost management, Healthy Initiatives services, and effective
managed care strategies.
Healthcare is changing and IEBP continues to expand the focus on
qualitative performance based healthcare benefits and outcomes
to the membership.
Board of Trustees
History
The Board is composed of up to twenty-four Trustees. Fifteen
voting Trustees are elected to designated places corresponding
to the separate Texas Municipal League Regions 2-16. Up to six
additional voting Trustees at Large shall be appointed by the
Chairman of the Board of Trustees, with the approval of the Board
of Trustees. The Board of Trustees also includes three non-voting
Ex-officio Trustees.
The Pool operates under the authority of the Interlocal
Cooperation Act and Chapter 172 of the Local Government
Code, which established the Texas Political Subdivision
Uniform Group Benefits Program. The Pool, through Interlocal
Agreements, is able to provide health; dental; vision; life; long
term and short term disability; Consumer Centered Benefit
Plan Options: Section 125 (Flexible Spending Account) Options:
Board
Boardof
of Trustees
Trustees
Trustees at Large
Appointed by Chair
Bill Storey
Dr. Lew White
Mike Slye
Glen Metcalf
Richard Browning
Larry Fields
Eddie Edwards
City of Borger
Michael Smith
City of Jacksboro
Leah Gore
City of Gainesville
David Riley
City of Idalou
Gayle Sims
City of Waxahachie
Brenda Samford
City of Carthage
Connie Standridge
City of Corsicana
Dru Gravens
City of Crane
Vice Chairman
Stephen Haynes
City of Brownwood
Glenn Johnson
City of Port Neches
Vic Barnett
City of Caldwell
Chairman
James Stokes
City of Deer Park
Joe Cardenas
City of Uvalde
Joe Hermes
City of Edna
Jorge Arcaute
City of Alton
1
4
Ex-officio Trustees
Bennett Sandlin
Terry Henley
Andres Garza
Member Equity Management
Rate Stability Due to IEBP’s Integrity of Healthcare Dollar Management
Plan Year
Equity at Plan Year End
2015-2016
2014-2015
2013-2014
2012-2013
2011-2012
2010-2011
2009-2010
2008-2009
2007-2008
2006-2007
2005-2006
2004-2005
2003-2004
$51,370
$51,340
$59,390,300
$58,144,870
$57,337,979
$54,559,496
$51,645,531
$55,634,126
$55,672,248
$62,523,386
$57,937,730
$51,573,649
$45,719,571
Cost Projection
Average Rate Increase
5.6%
6.8%
4.5%
4.7%
3.4%
8.7%
1.6%
4.7%
4.7%
3.6%
16.1%
1.6%
8.5%
Total over last 13 Plan Years:
Annual Average:
Equity Offset
$0
$806,891
$5,288,202
$3,055,684
$1,469,346
$4,167,860
$3,988,595
$3,562,346
$3,613,745
$2,907,344
$0
$7,154,307
$6,879,523
$42,893,843
$3,299,526
Investment Revenue
Earned FY
IEBP Fund
Stability Fund
Total
Annual Net Income
2012-2013
2011-2012
2010-2011
2009-2010
2008-2009
2007-2008
2006-2007
2005-2006
2004-2005
2003-2004
$1,686,225
$5,061,169
$2,393,314
$3,589,147
$4,750,958
($630,745)
$4,321,698
$2,517,803
$2,188,777
$2,305,243
$1,288,329
$2,286,123
$662,370
$953,559
$794,322
($1,163,091)
$1,245,089
$718,310
$751,395
$752,439
$2,974,554
$7,347,292
$3,055,684
$4,542,706
$5,545,280
($1,793,836)
$5,566,787
$3,236,113
$2,940,172
$3,057,682
$806,891
$2,778,483
$2,913,965
($3,988,595)
($38,122)
($6,851,138)
$4,585,656
$6,364,081
$5,854,078
$3,174,180
Integrity
Integrity of the Healthcare
Dollar of
and Healthcare
Member Equity (inDollar
millions)
and Member Equity
62.50
58.00
55.70 55.60
51.60
42.50
51.60
54.60
57.50 58.10
51.34
45.70
45.23
37.40
33.50
10/0009/01
10/0109/02
10/0209/03
10/0309/04
10/0409/05
10/0509/06
10/0609/07
10/0709/08
5
Competitive | MemberCentric | Affordable | Innovative
1
10/0809/09
10/0909/10
10/1009/11
10/119/12
10/129/13
10/139/14
10/148/15
Member Equity Management (continued)
High Dollar Claim Review
$10,200,000 (10.2%) in Expanded Benefit Risk with discounts of about 6.12%. Total Patient Protection Affordable Care Act
administrative and benefit costs increase healthcare contribution costs by an additional 7.52%.
Plan Year 2014-15
Oct-Nov
Number of Potential Covered Individuals
Oct-Feb
Oct-March
Oct-Apr
Oct-July
$2.0
2
$2.0
2
$2.0
2
$2.0
2
$2.0
2
$2.05
1
$2.05
1
$2.05
1
$2.05
1
$2.05
1
$2.25
1
$2.25
1
$2.25
1
$2.25
1
$2.25
1
$2.5
1
$2.5
2
$2.5
2
$2.5
2
$2.5
3
$ Amount (in Millions)
$2.55 $2.75 $3.0
$3.5
1
0
0
$2.55 $2.75 $3.0
$3.5
1
1
0
1
2.55 $2.75 $4.5
$5.0
1
1
3
1
2.55 $2.75 $4.5
$5.0
1
1
3
1
2.55 $2.75 $4.5 $4.75
1
1
3
1
$4.5
1
$4.5
2
$5.5
1
$5.5
1
$5.0
1
$5.0
1
$5.0
1
$5.5
1
$5.5
1
$7.50
1
$5.5
1
Satisfaction Survey
Annually, IEBP respectfully requests the Membership to provide feedback regarding the services accessed. Membership feedback
is extremely important to ensure IEBP staff maintains the focus of the Members they serve.
Receptionist
Billing & Eligibility
Benefit Service Specialist
04-05
97.34%
97.51%
96.75%
05-06
99.28%
98.75%
97.77%
06-07
07-08
08-09
97.83% 98.62% 99.47%
97.12% 98.22% 98.98%
97.55% 97.34% 97.81%
09-10
10-11
11-12
12-13
98.38% 99.25% 99.55% 99.88%
97.96% 98.55% 97.59% 98.96%
97.14% 96.82% 97.77% 97.71%
13-14
14-15
99.57% 98.22%
98.84% 97.77%
98.25% 96.84%
Phones
86.28%
92.86%
89.11% 91.24% 93.88%
93.14% 93.27% 94.29% 94.11%
92.05% 90.73%
Website
General
97.87%
86.32%
93.26%
92.93%
90.70% 90.26% 90.45%
88.17% 90.56% 92.12%
91.05% 90.40% 89.33% 88.36%
90.06% 92.18% 91.17% 93.00%
84.87% 75.42%
87.68% 90.80%
Service Improvement
Overall
95.88%
92.45%
97.61%
98.45%
95.67% 96.62% 96.65% 95.01% 97.79% 95.21% 96.10%
93.11% 96.52% 98.46% 97.93% 95.88% 96.85% 97.63%
95.13% 96.25%
97.67% 96.45%
Overall Satisfaction Survey Results
98.45%
97.93%
96.52%
95.88%
96.85%
97.67%
12-13
13-14
96.45%
93.11%
92.45%
04-05
98.46%
97.63%
05-06
06-07
07-08
08-09
09-10
6
10-11
11-12
14-15
Available Benefits
Comprehensive Major Medical Plans
Telehealth Services
Comprehensive Major Medical and Consumer Centered Preferred Provider Network (PPN) Plans with a number of deductible, copayment, benefit percentage, and out of pocket options.
Telehealth medical consultation services is expanding in the
United States, servicing approximately 3 million consumers.
Access to care 24/7/365 on consumer demand via phone and
online video consultations is delivered to the Pool membership
by the value added
addition
of the telehealth
benefit.
Reduce
Health
Plan Claims
Consumer Driven Healthcare Plans
Defined benefit plans versus traditional plans focus on the
development of a healthier employee population, which creates a healthier and more productive workforce. This program
incorporates the following:
¾
¾
¾
¾
¾
Section 125 Flexible Spending Arrangement (FSA)
• Grace Period - 2 month and fifteen day extension
• $500 Unreimbursed Healthcare Maximum Carry Over
• Premium Only Plan
• Prohibition of FSA Stand Alone Plans
• Qualifying Event $500 Unreimbursed Healthcare
Maximum Carry Over
Health Reimbursement Arrangement (HRA)
• Prohibition of HRA Stand Alone Plans
Retiree Reimbursement Arrangement (RRA)
Health Savings Account (HSA)/High Deductible Plans
• Prohibition of HRA Stand Alone Plans
Consumer Centered Pool Plan Options
Improve Ease of Access
to Healthcare!
866-703-1259
www.healthiestyou.com
The telehealth doctors are U.S. board certified providers in the
field of Internal Medicine, Family Practice, Emergency Medicine, and Pediatrics. They average 15 years practice experience
and are licensed in the state they provide services.
1
Telehealth services do not replace your primary care physician,
but can be used when you need immediate physician care for nonemergent medical issues. The telehealth level of care is an affordable, more convenient alternative to urgent care and ER visits.
Section 125 (Flexible Spending Arrangement)
IEBP offers HIPAA Title II compliant paper and/or debit
Section 125 administration services for premium only plans,
dependent childcare and unreimbursed healthcare expenses.
Effective Plan Years January 1, 2015 and thereafter, a cap on unreimbursed healthcare expenses of $2,550 was implemented per
the regulatory mandate. The Employer Member has the option
of a, the Section 125 Premium Only Plan; a two month, fifteen
day Section 125 Grace Period Plan; or the $500 maximum unreimbursed medical only Section 125 Carry Over Plan. Discrimination Testing is also available.
The covered individual will be responsible for completing a
health history overview prior to receiving medical telehealth
services. The doctors do not write orders for laboratory services, but will prescribe appropriate medications except for mental
illness and narcotic medications. Consultations can be conducted in English or Spanish and are available to children and
adults who are covered individuals under IEBP’s benefit plan.
Alternate Medical Plans
IEBP requires 100% employee participation for healthcare benefits except for employees who have health coverage through
a spouse, the military, or through a retirement plan. This plan
is for the employees only and not for their dependents. IEBP
offers four Alternate Plan options. The Alternate Plan must
coordinate with the employee’s core benefit plan. Council is
required to meet the 100% participation requirement.
Medication Therapy Management Program
IEBP, Pharmacy Benefit Manager, Attending Physician, IEBP
Medical Management Team, community Pharmacist, and the
covered individual will work together to provide a progressive
Medication Therapy Management Program for political subdivisions. IEBP’s Medication Therapy Management Program will
enhance the covered individual’s ability as an educated consumer regarding evidence based prescription utilization. IEBP
works closely with evidence based medicine subject matter experts to ensure the Medication Therapy Management Program
is clinically supported by pharmaceutical alternatives based on
the covered individual’s choice.
7
Available Benefits (continued)
Three Dental Plans with Voluntary Options
Coverage for prescriptions and biotech/biosimilar prescriptions that are available through the Pharmacy Benefit Manager
will be paid per the prescription Summary of Benefits and Coverage. Eligible biotech/biosimilar prescriptions may be purchased from network providers per the prescription Summary
of Benefits and Coverage. For eligible prescriptions purchased
outside of the Pharmacy Benefit Manager or the network providers, the plan will pay at the out of network benefit percentage and will not, at any time, pay at 100% for any prescription
services under the out of pocket provision of the Plan. The plan
includes several copay options to allow the educated consumer
to manage their out of pocket expense.
The Dental 2 Plan is a scheduled benefit plan with no deductible for preventive services and a $50 accumulated calendar
year deductible for basic and major services. The maximum
benefit is $1,200 per covered individual per calendar year. Mandatory and voluntary benefit options are available.
The Dental 3 Plan includes coverage for preventive services at
100% with no deductible. Basic services are paid at 80% and
major services at 50%, subject to a $50 calendar year deductible and a $2,000 per year maximum. Orthodontic coverage
is included for dependents under the age of 19 with a $3,000
lifetime maximum.
Pharmacy Benefit Manager Administrative Services
¾
The Dental 4 Plan includes coverage for preventive services at
100% with no deductible. Basic services are paid at 80% and
major services at 50%, subject to a $50 calendar year deductible
and a $1,500 per year maximum. Mandatory and voluntary
benefit options are available.
Effective Cost Management Pricing
• Maximum Allowable Cost (MAC)
• Average Wholesale Pricing (AWP)
• Average Sales Pricing (ASP)
• Reference Pricing
Two Vision Plans with Voluntary Options
Involves designs where plans pay a fixed price for a
particular procedure which certain providers will accept
as payment in full. The goal is to negotiate cost effective
arrangements with high quality providers. Plans may have
a reference based pricing program where they do not count
amounts above the reference price paid by participants
toward the out-of-pocket limit. Plans would treat providers
who accept the reference amount as the plans’ only in
network providers and would have to use a reasonable
method to ensure that it provides adequate access to high
quality providers.
¾
¾
¾
¾
Vision Plan A provides up to $65 for an annual eye examination and a scheduled amount for frames, lenses or contact
lenses. Vision Plan B provides up to $85 for an annual eye
examination and a scheduled amount for frames, lenses or
contact lenses. Mandatory and voluntary benefit options are
available for both Vision plans.
Group Term Life, AD&D and Voluntary AD&D
Group Term Life and Accidental Death and Dismemberment
coverage for employees and their dependents is available to
IEBP Members. Basic Life includes an Accelerated Death Benefit. Optional Life Benefits include additional life, dependent
life, and retiree life benefits.
MAC A Plan
If a brand name drug is dispensed and a generic alternate
drug exists, the covered individual pays the difference
between the brand name and generic price in addition to
the appropriate copayment for the brand name. The cost
difference between the brand name and generic price does
not apply to any individual deductibles or out of pocket
amounts. The MAC differential applies to all prescriptions
purchased through this program when a generic alternate
is available.
Long Term and Short Term Disability
IEBP offers long term and short term disability benefits that
provide protection from loss of income when an employee can
no longer work.
Voluntary and Supplemental Benefit Options
¾
MAC C Plan
Covered individual will pay the appropriate copayment
amount of the prescription.
Voluntary benefit options:
• Cancer Supplemental Policy
• Accidental Supplemental Benefits
• Critical Care Supplemental Policy
¾
Prior Authorization, Step Therapy, and Cost Share Evidence Based Management Services are provided.
Supplemental benefit option:
• Employee Assistance Program
COBRA Continuation of Coverage Administration
IEBP offers COBRA Continuation of Coverage administration
and will mail notification letters, provide participant direct
billing services, maintain records, and monitor and implement
regulatory changes. COBRA Continuation of Coverage is a
temporary extension of coverage under the Plan, as well as
other health coverage alternatives that may be available to you
through the Health Insurance Marketplace.
Tiered Copay Options enhance the management of the
covered individual’s out of pocket expenses.
• Over the Counter (OTC)
• Retail Network Options
• Generic - Retail and Mail
• Best Brand Price Drug List (Formulary) - Retail and Mail
• Non Best Brand Price List (Non Formulary) - Retail and Mail
• Cost Share Copay - Retail and Mail
• Biotech/Biosimilar - Mail 34 day dispensement
8
Retiree Benefits
Pre Sixty-five Retiree Benefit Program
Post Sixty-five Retiree Plans
The IEBP Pre Sixty-five Retiree Pool and the IEBP active
employee Pool that services some pre sixty-five retirees are
considered an “employment-based health plan” that is certified
for participation in the Early Retiree Reinsurance Program. The
Early Pre Sixty-five retiree must meet the definition of a retiree
from the prior political subdivision employer.
IEBP offers two plan options for post sixty-five retirees who are
Medicare A and B eligible.
¾
¾
Medicare Advantage Plan
Medicare Supplemental Plan that may be expanded to
include a Medicare Part D prescription plan
Retiree Benefit Plan Options
Personal
Profile: Pre
and Post 65
Retiree
Pre 65 Retirees
Needs
Assessment:
Post 65
Retiree
Plan Type
Education
Post 65 Retirees
Employer Plan
Extend Health
Plan
Presentation
Wrap-up &
Expectation
Setting
Enrollment
Insuraprise
Employer Plan
Pre 65 Pool:
Platinum
Gold
Silver
Bronze
Medicare A:
Hospital Insurance
Medicare B:
Medical Insurance
HMO Advantage Plans
Medicare C:
Choice Plus/Medicare Advantage Plan
Medicare Supplemental Plans
Medicare D:
Prescription Benefit
Medicare Exchange Plans
Medicare Advantage with Part D Plan 2016
HMO Service Areas and Monthly Rates
Rates Include HMO Advantage and Part D Plans

Medicare Supplemental 2016
HMO Option 1: Full Gap Coverage - Formulary H
Austin, TX:
$391.12
Counties: Bell, Travis, Williamson
Houston, TX:
$351.33
Counties: Austin, Brazoria, Fort Bend, Hardin, Harris,
Jefferson, Liberty, Montgomery
Other (TX):
$295.82
Counties: Corpus Christi: Nueces, San Patricio;
Dallas/Fort Worth: Collin, Dallas, Denton, Ellis, Johnson,
Kaufman, Rockwall, Tarrant counties; San Antonio:
Atascosa, Bexar, Comal, Guadalupe, Kendall, Wilson
Oklahoma (OK): Census Required for Underwriting
Counties: Canadian, Cleveland, Oklahoma,
Pottawatomie

HMO Option 2: Tier 1 Generic Gap Coverage Formulary G
Austin, TX:
$279.66
Counties: Bell, Travis, Williamson
Houston, TX:
$232.58
Counties: Austin, Brazoria, Fort Bend, Hardin, Harris,
Jefferson, Liberty, Montgomery
Other (TX):
HMO Option 2 Not Available
Oklahoma (OK): Census Required for Underwriting
Counties: Canadian, Cleveland, Oklahoma,
Pottawatomie
Part D Options 2016
Deductible
Copay
Retail Mail Service
Initial Coverage Limit
TrOOP Threshold
Catastrophic Coverage over TrOOP
Benefits "Plan Pays"
Part A and Part B Calendar Year Plan
Deductible
Part A and Part B MOOP Annual Limit
(Medicare copayments, coinsurance and
deductibles)
Lifetime Policy Maximum
Part A - Hospital (Part A Deductible) - Days
1 - 60
Part B - Durable Medical Equipment
Part B - Medicare Part B Deductible
(Applicable to Part B DME)
Part B - DME Remainder of Medicare
Approved Amounts (After Part B
Deductible Has Been Met)
Part B - Medicare Part B Deductible
(Applicable to Part B Medical Services)
Part B - Medical Services Remainder of
Medicare Approved Amounts (After Part B
Deductible Has Been Met)
Part B Excess Charges - (the difference
between Medicare allowable amount and up
to 115% of Medicare allowable amount)
Foreign Travel
Supplement Plan: Plan F
Monthly Rate* $225.68
Prescription Plan: Not included in price
Service Area: National
Rate: Composite
Employer Funding Requirement: None
Supplement Plan: Plan K
Monthly Rate* $128.95
Prescription Plan: Not included in price
Service Area: National
Rate: Composite
Employer Funding Requirement: None
Plan F
Plan K
N/A
N/A
N/A
N/A
$4620 per year (2010 amount shown)
N/A
Covered 100% by Plan
Covered 50% by Plan
Not Covered
Remainder After Medicare Payment
Covered 100% by Plan.
Not Covered
Not Covered
Medically Necessary Emergency Care Services, applicable only during the first six
months of each trip outside of the United States.
The monthly rate is per Retiree. The Retiree needs to be entitled to Medicare Parts A & B, and continue to pay the Part B premium.
Option 1 | Formulary H
Monthly Rate: $206.34
$0
Full Gap Coverage: Member pays same copays for all Rx
through the coverage gap.
31 day supply: $5/$25/$60/33%
90 day supply: $10/$50/$120/33%
$3,310
$4,850
Generics $2.95 or 5% / all other drugs $7.40 or 5% (greater amount of)
9
Option 2 | Formulary G
Monthly Rate: $78.02
$0
Tier 1 Gap Coverage: Member pays same copays for Tier 1 Generic
Rx through the coverage gap. Member pays discounted cost for Rx.
31 day supply: $5/$25/$60/33%
90 day supply: $10/$50/$120/33%
$3,310
$4,850
Generics $2.95 or 5% / all other drugs $7.40 or 5% (greater amount of)
A Wellness Plan that Works!
Healthy Initiatives HealthPlan
The Healthy Initiatives HealthPlan encompasses wellness,
medical management, chronic care management, and
professional health coaching services to provide resources for
the covered individual who is personally health engaged. Many
of the leading causes of death and illness can be effectively
managed through early detection, proper medical treatment,
pharmacological management, and behavioral intervention
and support.
Year
Healthy IniƟaƟves HealthPlan • Calendar
2016
Access your Health Power Assessment by signing in at
www.iebp.org and selecting Healthy Initiatives and then
Health Power Assessment.
Personal Health Record
For Covered Individual’s Personal File
NAME
Male
Female
Date of Birth
Access your Personal Health Record and Health Power Assessment by logging in at www.iebp.org
1.
When did you have your blood work done?
mm/dd/yy Normal Heart Rate 60-80 beats/min
2.
What is your height?
feet
inches
3.
What is your weight?
pounds
Normal Body Mass
Index (BMI) 19-24%
4.
What is your waist measurement?
inches
5.
What is your blood glucose?
Less than 100 mg/dL
100-125 mg/dL
126 mg/dL or higher
Normal
Impaired/Pre-diabetes
Diabetes
6.
What is your blood pressure?
Less than 120/80
120-139
140 or higher
Optimal
Pre-hypertension
High Blood Pressure
7.
What is your total cholesterol?
Less than 200 mg/dL
200-239 mg/dL
240 mg/dL or higher
Optimal
Borderline High
High Cholesterol
8.
What is your LDL (bad) cholesterol?
Less than 115 mg/dL
115-159 mg/dL
160 mg/dL or higher
Optimal
Borderline High
High
What is your HDL (good) cholesterol?
Less than 40 mg/dL for men and 50 mg/dL for
women increases the risk of heart disease.
9.
Less than 150 mg/dL
150-199 mg/dL
200 mg/dL or higher
10. What is your triglyceride level?
The interface of medical, prescription, lab and health risk
assessment information is critical to IEBP’s ability to provide
the Membership with appropriate professional healthcare
support. The Healthy Initiatives HealthPlan works with
the covered individual to identify solutions to healthcare
concerns. IEBP’s Healthy Initiatives HealthPlan should assist
in patient care compliance and the promotion of healthy living
guidelines for the employee and dependent population. IEBP
will implement integrated data and reporting along with
customized supportive services that help covered individuals
achieve behavior changes and long-term healthy lifestyles.
If you are 18 years of age or older, upon completion of your
calendar year biometrics and Health Power Assessment, you
will receive a $150.00 Healthy Initiatives incentive check, a
Healthy Initiatives confirmation letter, and a personal health
profile.
Normal
Borderline High
High
Calendar Year Benets Effec�ve January 1, 2016 for Plan Year 2015-16
AGE & GENDER BIOMETRIC SCREENINGS
Health Power Assessment Questionnaire
Preventive Office Visit | CPT 99385-99397
Lipid Panel | CPT 80061
Comprehensive Metabolic Blood Panel
CPT 80053
TSH | CPT 84443
PSA | CPT 84152-84154
Fecal Occult (including colonoscopy and
sigmoidoscopy as a qualifer) | CPT 82270
Mammogram (*one (1) per calendar year for
Female Female Female Female Female Female Female Male Male Male Male
18-29 30-35 36-39 40-49
50
51-73
74+ 18-39 40-50 51-70 71+
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
females ages 40-49; **one every two (2) calendar
years for females ages 50-73) | CPT 77052, 77057
PAP (every three (3) calendar years for
females ages 30-50) | CPT 88141; 88155,
88142-88154; 88164-88167, 88174-88175
X
X
X
X
X
X
X
X
X
X
X*
X**
X**
X
X
X
X
The TML MultiState Intergovernmental Employee Benefits Plan is a non-Federal governmental health plan that has elected to be exempted from the
HIPAA Title I prohibitions against discriminating against individual participants and beneficiaries based on health status. Therefore, the rules regarding
Nondiscrimination and Wellness Programs in Health Coverage in the Group Market do not apply to this plan.
The program includes age and gender based biometric
screenings, a Health Power Assessment, a Personal Health
Record, and an incentive program for Healthy Initiatives
calendar year compliance. The biometric screenings will be
paid at 100% of the network fee or at the usual and reasonable
rate for non network providers. Upon completion of your
calendar year biometric screenings and Health Power
Assessment, a personal health profile will be provided to the
covered individual to assist them in their ongoing engagement
to a healthy lifestyle.
10
Intake Personnel
Non-licensed personnel who receive all medical management
incoming calls regarding notifications, pre-determination,
concurrent review, and retrospective review inquiries. The event
is assigned to a Nurse and entered into the medical management
operating system. The Intake staff retrieve and mail all outgoing
letters. They also are responsible for sending declination letters
on new inpatient/outpatient requests, within established NCQA
guidelines, that do not have the clinical information for review.
Utilization Review LVN
Responsible for accurate and timely processing requests for
Imaging, Durable Medical Equipment, and Ancillary Services
(Home Health, Physical Therapy, Occupational Therapy, Speech
Therapy, etc.). This position also provides back-up for the Intake
Staff. They utilize Interqual (National Evidence Based Medicine
Guidelines) for evidence based medicine review of requested
services. They interact with the Medical Director and IROs as
necessary to process requested services; when Interqual’s evidence
based medicine criteria is not met. Their main point of contact is
Practitioners and Facilities. Refers covered individuals to Case
Management or Healthcare Coaching for assistance with personal
management of health and wellbeing.
Utilization Review RN
Responsible for accurate and timely processing requests, to
include pre-service, retrospective review, and concurrent review,
for Inpatient and Outpatient events. They utilize Interqual
(National Evidence Based Medicine Guidelines) for evidence
based medicine review of requested services. They interact with
the Medical Director and IROs as necessary to process requested
services; when Interqual’s evidence based medicine criteria is not
met. Their main point of contact is Practitioners and Facilities.
Refers covered individuals to Case Management or Healthcare
Coaching for assistance with personal management of health and
wellbeing.
Utilization Management RN – Catastrophic Care
Responsible for managing catastrophic cases (Chemotherapy,
Radiation Therapy, Transplants, NICU Babies, Brain Injuries,
Multiple Trauma, etc.) that require intensive management.
Responsible for accurate and timely processing of requests for all
events/services. They utilize National Evidence Based Medicine
Guidelines, i.e., Interqual, NCI (National Cancer Institute),
NCCN (National Comprehensive Cancer Network), etc. for
evidence based medicine review of requested events/services.
They interact with the Medical Director and IROs as necessary to
process requested services; when evidence based medicine criteria
from national criteria guidelines is not met. They are responsible
for educating the Practitioners regarding the oncology review
process. These Nurses work with Patients, Families, Practitioners,
Facilities, Employers, Stop Loss, Partners, and Vendors to facilitate
patient care. Refers covered individuals to Case Management or
Healthcare Coaching for assistance with personal management
of health and wellbeing.
Medical Review/Appeals Nurse
Responsible for reviewing all Pre-Determinations and
Retrospective Reviews (that have never been assigned to a
UR LVN/RN). Investigates Genetic Testing and questionable
requests for evidence based medicine status i.e., experimental/
investigational. A letter will be sent to the individual requesting
the review; if the inquiry is related to a medical necessity issue.
Provides support for coding (ICD-9, ICD-10, CPT, HCPCs)
questions, upgrades, changes, etc. Refers covered individuals to
Case Management or Healthcare Coaching for assistance with
personal management of health and wellbeing.
Definitions
Notification
Telephone call to Medical Management Intake Personnel to
request review of a pre-admission/pre-service event. The request
is entered into the Medical Management operating system and
assigned to a Nurse for evidence based medicine review. The
determination will be communicated via telephone/fax to the
requesting practitioner or facility. A letter will be sent to the
Practitioner, Facility, and Covered Individual.
Retrospective Review
Review of an admission/outpatient/service/durable medical
equipment/ancillary event, when notification was not obtained
prior to the event. The review is assigned to a Nurse for evidence
based medicine review. The determination will be communicated
via a letter to Practitioner, Facility, and Covered Individual.
Concurrent Review
On-going review of services provided during an inpatient
admission, after the initial admission has been approved, for
medical necessity and level of care determinations. Services may
be provided in an inpatient healthcare facility, i.e., hospital, skilled
nursing facility, long term acute care, rehabilitation facility, etc.
The determination will be communicated via telephone/fax to
the facility and via a letter to Practitioner, Facility, and Covered
Individual.
Case Management
IEBP offers our covered individuals and their family access to
a case manager. Case Management is designed to coordinate
care and services for those who have experienced a critical event
or diagnosis. The goal of case management is to help covered
individuals regain their optimum health or improve their
functional ability.
Case Management is an Opt In program. Covered individuals,
their family, a practitioner, and/or a facility may refer by calling
a case manager at 1-888-818-2821 Option #10. Enrollment can also
be done online. A case manager may reach out to individuals
who have been identified by our utilization review nurses, claims,
practitioners, etc.
A nurse case manager will assess, plan, implement, coordinate,
monitor and evaluate options and services required to meet
individual needs. Assistance will be provided with obtaining
resources and facilitating communication between providers.
Support is also provided to the patient and family.
11
Medical Intelligence (continued)
The Intensive Care Management staff consists of Licensed
Professional Nurses. The nurses have years of experience in
healthcare and know the importance of not intruding in the
doctor/patient relationship. By promoting healthcare alternatives
that are acceptable to the covered individual, their doctors and
employer, Intensive Care Management helps to control healthcare
costs and use benefits wisely.
¾
Heart Rate/Pulse: The number of heart beats per minute. A
lower heart rate suggests better cardiovascular fitness and
more efficient heart function.
¾
Blood Pressure: The force of blood pushing against the
walls of the arteries as the heart pumps blood. If this pressure rises and stays high over time, it can damage the body
in many ways. High blood pressure is a serious condition that can lead to coronary heart disease, heart failure,
stroke, kidney failure and other health problems.
¾
Total Cholesterol: A waxy substance that is produced in the
liver or may be consumed in food. The body produces the
necessary amount of cholesterol to make hormones, vitamin D, and digestive substances. When excess amounts of
cholesterol are present in the blood stream, it begins to be
deposited on the artery walls resulting in the narrowing of
the arteries and decreasing blood supply to the heart. Often,
an individual with high cholesterol does not have any signs
or symptoms; it may result in raising your blood pressure.
¾
LDL Cholesterol: Referred to as “bad or lousy” cholesterol as
excess amounts leads to plaque growth and atherosclerosis.
Higher levels of LDL cholesterol increase your chance of a
heart attack. Eating a diet lower in saturated fat and cholesterol and high in fiber and plant based (vegetables/fruits/
beans/legumes) can lower help lower LDL level. Aerobic
physical activity also lowers LDL and increases HDL.
¾
HDL Cholesterol: Referred to as “healthy or good” cholesterol. HDL cholesterol acts to remove bad cholesterol
from the blood stream. A high HDL level reduces your risk
of heart disease; low levels of HDL increases your risk of
heart disease. HDL levels can be raised by aerobic physical
activity, becoming tobacco free and maintaining a healthy
weight.
Telephonic Outreach Program
Based on clinical stratification, covered individuals will be
identified as potential high risk per the predictive risk scores per
the HEDIS categories of disease states.
Educational Mailings
IEBP’s cover letter includes the name and number of their
Professional Health Coach and the invitation for members to call
if they would like additional information.
Population Health Coaching Engagement
Population Health Engagement supports members in all stages
of health. This program provides information to the covered
individual regarding healthy lifestyle choices and management
of chronic disease states. The program offers personalized
professional coaching to support the healthy lifestyle of change
and plan of action. Online tools and educational materials
are available to covered individuals. The population health
engagement team consists of a multidisciplinary team of licensed
professional nurses, counselors, registered dietitians and certified
diabetes educators.
Heart Health Biometrics
Heart disease remains the number one cause of death in the United
States for both men and women. Living a healthy life may reduce
your risk of heart disease (which includes coronary artery disease,
hyperlipidemia, and high blood pressure). Commonly ordered
provider services monitor the health of your heart include:
12
Medical Intelligence (continued)
¾
Triglycerides: Another type of fat in your blood. High
levels can raise your risk of heart disease and maybe a sign
of metabolic syndrome. Triglycerides are usually caused
by: obesity, poorly controlled diabetes, hypothyroidism,
kidney disease, and alcohol. Certain medications may also
raise triglycerides.
agement Service Team can effectively identify the covered
individuals that could benefit from a personal health coach.
The program provides resources that support the covered
individual’s healthy lifestyle choices in areas of nutritional,
emotional, social, intellectual, financial and spiritual wellbeing.
Comprehensive Metabolic Profile Biometrics
¾
This blood test measures: glucose, electrolytes (sodium,
potassium, chloride, calcium, carbon dioxide), kidney function
(BUN, creatinine, eGFR) and liver function [albumin, total protein,
AST (SGOT), ALT (SGPT)].
¾
Kidney Health: The kidneys filter water and waste products from the blood to form urine. Commonly ordered labs
that monitor kidney function are part of the comprehensive
metabolic profile, specifically sodium, potassium, blood
urea nitrogen (BUN), serum creatinine, and calcium. It is
important to talk to your attending physician about your
results.
¾
Endocrine Health: The endocrine system is made up of
eight major glands in the body. The glands produce hormones which help regulate body functions such as digestion, breathing, body temperature, reproduction, elimination, blood circulation, sexual function, mood and growth
and development. Diabetes is one of the most common
diseases of the endocrine system. Commonly ordered labs
that monitor endocrine health are glucose, hemoglobin
A1C, thyroid-stimulating hormone (TSH) and prostate specific antigen (PSA). It is important to talk to your attending
physician about your results.
¾
Glucose, serum (blood): This measures the amount of sugar
or glucose in your blood. It is a test that can diagnose diabetes or determine how well diabetes is controlled.
¾
Liver Health: The liver is an organ that has many functions
including: metabolizing the food, beverages, medications,
over the counter medications and supplements that we
ingest, makes proteins, excretes bile and stores glycogen/
Vitamins D, A, B12 and trace elements. Commonly ordered
labs that monitor liver function are part of the comprehensive metabolic profile, specifically albumin, total protein,
ALT (SGPT), and AST (SGOT). It is important to talk to
your attending physician about your results.
¾
Opt In: Enrollment method by which members call the professional health coaching line and request a professional
healthcare coach or agree to coaching upon receiving an
outreach call or letter. Healthcare providers may refer their
patient to a professional health coach or they can call in a
referral to (888) 818-2822.
¾
Case Findings: Case Findings are currently done monthly
for each program. A Case Finding identifies members for
each disease management program based on medical,
prescription and/or lab value claim data information. The
information is stratified into risk index. Once the information is stratified, the Multidisciplinary Medical Care Man-
Modules of Care: Modules provide an organized collection
of information needed by members to help them achieve
a desired health goal. Modules ensure that material is
presented completely and in a coherent fashion to help
members understand their disease(s) process(es). Modules
provide evidence based guidance for coaching sessions
thus aiding coaches in focusing on the member’s educational needs and stated goal.
Modules/practice guidelines arose from frequently stated health
goals such as quitting smoking, losing weight, or managing
diabetes as well as the medical conditions reflected in the IEBP
demographics. At present time, modules include: Asthma, COPD,
Depression, Diabetes, High Cholesterol, High Blood Pressure, Risk
of Alcohol Use, Tobacco Cessation, and Weight Loss.
13
TARGET OF HEALTH
Medical Intelligence Sample Reports
HEALTHCARE TARGET OF SUCCESS MEASUREMENT - HEDIS REPORTS
HEDIS
| Sample
Pool HEDIS:
June Report
2012-July 2013
Group
Name
POOL
Asthma
Mbr
Count
664
Asthma
% of Total
Mbrs
3.2%
Breast
Cancer
Member
Count
62
Breast
Cancer %
of Total
Mbrs
0.3%
CV
Mbr
Count
4,108
CV %
of Total
Mbrs
19.9%
Colorectal
Cancer
Member
Count
41
Colorectal
Cancer %
of Total
Members
0.2%
COPD
% of
Total
Mbrs
1.1%
COPD
Mbr
Count
218
Depression
Member
Count
644
Depression
% of Total
Mbrs
3.1%
Diabetes
Member
Count
1,592
Diabetes
% of Total
Members
7.7%
Female
Female
Organ Cancer Organ Cancer Mbrs in
Member
% of Total
Eligibility
Count
Members
Period
27
0.1%
20,632
BODY
MASSHEDIS:
INDEX
Mini-Pool
June(BMI)
2012-July
2013
BIOMETRICS
SUMMARY
REPORTS
Breast
Breast
Colorectal
Biometrics
Summary
| Sample
Report
Number
of
Members
and
%
of
Total
Members
tested Colorectal
broken downCOPD
by Body Mass Index (BMI) and GroupFemale
Pool:
June
2012-July
2013
Asthma
Asthma
Cancer Cancer %
CV
CV %
Cancer
Cancer % COPD % of Depression Depression Diabetes Diabetes Organ Cancer
Group
Name.
Name
MINI
Group
Mbr
% of Total
CountScreening
Mbrs
552 Result 3.7%
Member
BMI of Total
Count % ofMbrs
Total
0.4%
# of66
Mbrs
Mbr
of Total Member
of Total sugar
Mbr
CHOLESTEROL
Glucose/Blood
Count
Mbrs
Count
Members
Count
% of Total
% of Total
2,358
# of 15.8%Mbrs 25 # of 0.2% Mbrs117
Total
Mbrs
0.8%
# of
Female
Organ Cancer Mbrs in
Member
% of Total HgbA1c
Member % of Total
Member
% of
Total
Eligibility
HDL
LDL
TRIGLYCERIDES
Count
Count
Members
Count
% of Total Mbrs
% of Total
%
of Total Members % ofPeriod
Total
493
3.3%
937
16
14,944
Mbrs
# of
Mbrs 6.3%# of
Mbrs
#0.1%
of
Mbrs
The
filter keeps
the Subscriber
Status
keepsTested
Active, COC,
Retired
NameLab Result
NormalStatusMbrs
Tested Current
Mbrs andTested
Mbrs
Tested Filter
Mbrs
Mbrs andTested
Mbrs
Tested
Mbrs
Tested
Pre65E HEDIS:
2013
POOL
Normal June 2012-July
270
17.72%
1,716
66.64%
1,876
64.89%
1,562
60.97%
128
17.80%
1,084
42.48%
1,671
65.22%
Colorectal Colorectal
COPD
Female
Female
Body MassOutside
Indexof(BMI)Breast Breast
Asthma
Asthma 1,254
Cancer 82.28%
Cancer %
CV
Cancer %
COPD %
of Depression
Cancer Organ
Mbrs in
Normal
859 CV %
33.36%Cancer 1,015
35.11%
1,000
39.03% Depression
591 Diabetes
82.20%Diabetes
1,469Organ57.56%
891Cancer 34.78%
Below
Group 18.5:
MbrLimits
% of Underweight
Total Member of Total
Mbr of Total Member
of Total
Mbr
Total
Member
% of Total Member % of Total
Member
% of Total
Eligibility
Name Total
Count
Mbrs
Count 100.00%
Mbrs
Count
Count 2,891
Members
Count Mbrs
Count
Period
Grand
1,524
2,575 Mbrs
100.00%
100.00%
2,562 Count
100.00% Mbrs
719
100.00%Members
2,552 Count
100.00% Members
2,562
100.00%
18.5
- 24.9:
Normal
P65E
1
1.1%
1
1.1%
0 Normal
0.0%
3370
0.0%
19.96%
36
40.4%
1
1.1%
66.7%
66.27%
0
2,060
4
4.5%
3
3.4%
14
15.7%
0
0.0%
89.00
0.0%
68.60% 0
0.0%
1,699
063.44%
0.0%
116
0
20.49%
0.0%
1,119
0
41.85%
0.0%
1,828
3.00
68.13%
50.00%
12
50.00%
1
9.09%
11
45.83%
14
58.33%
50.00%
12
50.00%
10
90.91%
13
54.17%
10
41.67%
100.00%
24
100.00%
11
100.00%
24
100.00%
24
100.00%
25.0 - 29.9:
Overweight
Mini-Pool: June 2012-July 2013
30.0
- 39.9:
Obese
Pre65I
HEDIS: June
2012-July 2013
BMI
CHOLESTEROL
Glucose/Blood sugar
HDL
HgbA1c
LDL
TRIGLYCERIDES
Body
Mass Index
(BMI)
| Sample
Report Colorectal
Breast
Breast
Colorectal
COPD
Female
Female
40.0 - above:
Morbid
Obesity
Screening
% of Total
%CVof%Total Cancer
% of Total
% of Total
% of Total
% of Total
% of Total
Asthma
Asthma
Cancer Cancer %
CV
Cancer % COPD % of Depression Depression Diabetes Diabetes Organ Cancer Organ Cancer Mbrs in
of
Mbrs
#Mbr
ofMembers
Mbrs Member
# of broken
Mbrs down
#by
of Body
Mbrs
# of (BMI).
Mbrs The
#Lab
of Result
Mbrs Status
# of
Mbrs
Number
ofResult
Members
and
%
Total
Tested
Mass
Index
filter Eligibility
keeps
Group
Mbr
% of Total #
Member
ofof
Total
of Total
of Total
Mbr
Total
Member
% of
Total
Member
% of Total
Member
% of
Total
Group
Name
Normal
Mbrs
Tested
Mbrs
Tested Count
Mbrs Members
TestedCount Mbrs
Mbrs
Tested Mbrs
Mbrs Count
Tested Members
Mbrs
Tested
Mbrs
Tested
Name
Count
Mbrs
Count
Mbrs
Count
Mbrs
Count
Count
Members
Period
Pool: JuneThe
2012-July
2013Status filter keeps Active, COC, and Retired.
Current.
Subscriber
P65I
MINI
2
1,780
BMI Drill-down for POOL
Body Mass Index (BMI)
2013
June
2012--July
July
201333.73%
1,351 June
80.04%
9062014
943
31.40%
979
36.56%
450 18.5
79.51% Underweight
1,557
58.23%
855
31.87%
Below
Body Mass Index
Number of
% of Total
18.5 - 24.9
Normal
1,688 100.00%
100.00%
100.00%
566
100.00%
2,674
100.00%
2,683
100.00%
(BMI)2,686 100.00%
Members3,003 Members
Tested 2,678
25.0 - 29.9
Overweight
POOL
Underweight
14
0.9%
30.0 - 39.9
Obese
Pre 65: June 2012-July 2013 Normal
270
17.7%
40.0 & Over
Morbid Obesity
BMI
sugar
HDL
HgbA1c
LDL
TRIGLYCERIDES
Overweight CHOLESTEROL497 Glucose/Blood
32.6%
TML Intergovernmental Employee Benefits Pool
Page 3 of 57
Screening
% Board
of Total
%under
of Total
of Total
% ofother
Total
% of Total
% or
ofConsultant,
Total or TML IEBP staff%without
of Total
The information
provided to you as a TML IEBP
Member is confidential
federal
Divulging
this information to any person
than another Board Member,
the Board’s General Counsel
Obese
584 law and regulations.%38.3%
proper
written
authorization
from
the
covered
person
is
a
violation
of
those
regulations.
You
should
also
consult
with
either
the
General
Counsel
or
the
TML
IEBP
Executive
Director
before
releasing
this
information
to
anyone.
Group
Result
# of Morbid
Mbrs Obesity
# of
Mbrs159 # of
Mbrs
# of
Mbrs
# of
Mbrs
# of
Mbrs
# of
Mbrs
10.4%
Name
Normal
Mbrs
Tested
Mbrs
Tested
Mbrs
Tested
Mbrs
Tested
Mbrs
Tested
Mbrs
Tested
Mbrs
Tested
Grand Total
1,524
100.0%
Outside of
Normal
Group Name Limits
Grand Total
P65E
Normal
2
14.29%
13
54.17%
14
Outside of
Normal
12
85.71%
11
45.83%
14
Mini-Pool:
June 2012-July
2013
Limits
Gaps
in Care
Letter Campaign
|
Sample
Report
Plan Year
2011-2012
BMI
Drill-down
for MINI
Grand Total
14
100.00%
24
100.00%
28
June 2012 - July
CV 2013 Preventive Care
Asthma
Group Name
Body Mass
Index
of 2012
Mar
2012 Number
June
Nov 2013
2012
2014
2014 % of Total
(BMI) 304
Members729 Members Tested
Pool
11
MINI
Underweight158
12 369
0.7%
Mini-Pool
12
Normal
337
20.0%
Pre 65
1
2
Overweight
576
34.1%
ASOs
Obese
617
36.6%
HEALTH
Brenham COACHING SURVEY
4
1
Morbid Obesity
146 13
8.6%
Health
Coach
| Sample
Report
Brownsville
65
1
Grand
Total
1,688 121
100.0%
Annual
Survey:Survey
June 2012-July
2013
COPD
Nov 2013
2012
15
3
Diabetes
Dec 2013
2012
708
392
6
21
185
4 of 57
Carrollton
15
58
43the Board’s General Counsel or Consultant, or TML Page
The
information
provided to you as a TML
IEBP Board Member
is confidential
under federal
law and regulations.
Divulging this information to any person other than another Board Member,
IEBP staff without
Surveys
Returned
Outcome
Survey
Annual
Survey
proper written authorization from the covered person is a violation of those regulations. You should also consult with either the General Counsel or the TML IEBP Executive Director before releasing this information to anyone.
Cuerro
Community
Hosp
0
18
Sent
232
435
Pre
65: June
2012-July
2013
Del Rio
7
21
41
Returned
96
179
BMI Drill-down for P65E
Fredericksburg
6 2013
15
8
June 2012 - July
Huntsville
2
6
6
Group
Name
Body
Index
Number
of Identified
% of Total
Lifestyle
Choices made as a Result
ofMass
Coaching
Activities
to Incorporate into Lifestyle
Health Coaching has Helped Subscribers to:
Liberty
3
7
9
(BMI)9
Members
Members
Updated Vaccines
Change eating
habitsTested
209
Prepare for MD Visit
31
Lufkin
0
31
MINI
Underweight
2
14.3%
Made MD Appointment
20
Increase physical activity
225
Obtain proper health/meds
27
Normal
2
14.3%
Mesquite
58
Lower
B/P
206
Lose Weight
193
Manage Stress better
36
Overweight 15
3
Midland
65 as Rx21.4%
2
3
Lower
Blood Sugar
13
Take Meds
121
Set82
& meet health goals
69
Obese
7
50.0%
Port Lavaca
6
10 health (b/p, blood sugar)
Manage
Stress Better
331
Better stress
management
124
Monitor
36
Grand Total
14
100.0%
Totals
587
1,519
24
1,511
Change Smoking/Alcohol
19
Lower
b/p or blood sugar27
128
Be
health engaged3,668
63
Lost Weight
Found an MD
Taking Meds as Rx
Began Regular Exercise
Managed Pain
Eating Habit Changes
43
8
35
48
5
74
Improve overall health
Reduce/stop tobacco/alcohol
Keep health care appts
14
3
165
57
91
Mindful of lifestyle choices
Page 5 of 57
The information provided to you as a TML IEBP Board Member is confidential under federal law and regulations. Divulging this information to any person other than another Board Member, the
Board’s General Counsel or Consultant, or TML IEBP staff without proper written authorization from the covered person is a violation of those regulations. You should also consult with either the
General Counsel or the TML IEBP Executive Director before releasing this information to anyone.
90
Medical Intelligence Sample Reports (continued)
POPULATION MANAGEMENT REPORT and GAPS IN CARE
Gaps
in Care
| Sample
Report
Pool Gaps
in Care:
June 2012-July
2013 (Established Treatment Standards)
Report Case
Description - Short
Asthma (NS)
Report Rule Description
Patient(s) with presumed persistent asthma using an inhaled corticosteroid or
acceptable alternative.
Breast CA Scrn (NS)
Patient(s) 42 - 69 years of age that had a screening mammogram in last 24
reported months.
CAD
Patient(s) currently taking an ACE-inhibitor or angiotensin II receptor
antagonist.
Pre 65 Gaps in Care: Patient(s)
June 2012-July
2013 (Established Treatment Standards)
currently taking a statin.
Patient(s) compliant with prescribed ACE-inhibitor-containing medication
Report Case
(minimum compliance 80%).
Description
Report
Rule
Description
CAD (NS) - Short
Patient(s)
prescribed
lipid-lowering therapy during the measurement year.
Breast
Patient(s)
of agecancer
that had
a screening
mammogram
in last
24
CervicalCACAScrn
Scrn(NS)
(NS)
Patient(s) 42
that- 69
hadyears
a cervical
screening
test in
last 36 reported
months.
Colorectal CA Scrn (NS) reported
Patient(s)months.
50 - 75 years of age that had appropriate screening for colorectal
CAD
Patient(s)
cancer. currently taking an ACE-inhibitor or angiotensin II receptor
antagonist.
COPD (NS)
Patient(s) that had appropriate spirometry testing to confirm COPD diagnosis.
Patient(s)
taking
a statin.
Depression
Patient(s) currently
18 years of
age or
older taking a medication for depression
CAD (NS)
Patient(s)
therapy
treatmentprescribed
that had anlipid-lowering
annual provider
visit. during the measurement year.
Colorectal CA Scrn (NS) Patient(s)
- 75 yearsfor
of age
that hadthat
appropriate
screening
colorectal
Patient(s) 50
hospitalized
depression
had a mental
healthfor
evaluation
cancer.
within 7 days after discharge.
Depression
Patient(s)
years
of age or
taking
a medication
for depression
Diabetes
Patient(s) 18
with
a diagnosis
ofolder
diabetic
nephropathy,
proteinuria,
or chronic
treatment
that
had antaking
annualan
provider
visit. or angiotensin II receptor
renal failure
currently
ACE-inhibitor
Diabetes
Patient(s)
antagonist.with a diagnosis of diabetic nephropathy, proteinuria, or chronic
renal
failure
taking
an ACE-inhibitor
angiotensin
II receptor
Adult(s)
that currently
had a serum
creatinine
in last 12 or
reported
months.
antagonist.
Diabetes Care (NS)
Patient(s) 18 - 75 years of age that had a HbA1c test in last 12 reported
Adult(s)
months. that had a serum creatinine in last 12 reported months.
Diabetes Care (NS)
Patient(s)
of age
age with
that had
a HbA1c
test in
Patient(s) 18
18 -- 75
75 years
years of
a LDL
cholesterol
in last
last 12
12 reported
months.
months.
Patient(s) 18 - 75 years of age that had an annual screening test for diabetic
Patient(s)
18 - 75 years of age with a LDL cholesterol in last 12 months.
retinopathy.
Patient(s)
of age
age that
that had
had annual
an annual
screening
for diabetic
Patient(s) 18
18 -- 75
75 years
years of
screening
for test
nephropathy
or
retinopathy.
evidence of nephropathy.
Patient(s)
of agephysician
that had annual
HTN
Patient(s) 18
that- 75
hadyears
an annual
visit. screening for nephropathy or
evidence
nephropathy.
Hyperlipidemia
Patient(s)of
with
a LDL cholesterol test in last 12 reported months.
HTN
Patient(s)
an profile
annualtest
physician
IVD (NS)
Patient(s) that
with had
a lipid
duringvisit.
the report period.
Hyperlipidemia
Patient(s) with a LDL cholesterol test in last 12 reported months.
IVD (NS)
Patient(s) with a lipid profile test during the report period.
Eligible
Eligible &
Eligible but
Members Compliant Non-Compliant
Number of Eligible
Compliance
and Compliant
Rate
Members in Coaching
142
123
19
86.6%
27
2,868
1,837
1,031
64.1%
287
297
191
106
64.3%
36
303
219
84
72.3%
38
Number of Eligible
148
135
13
91.2%
24
Eligible
Eligible &
Eligible but
Compliance
and Compliant
Members
Compliant
Non-Compliant
Rate
Members 29
in Coaching
434
113
321
26.0%
3,185
2,062
1,123
64.7%
245
15
10
5
66.7%
2
4,305
1
53
1
127
3
1,661
0
20
1
126
2
2,644
1
33
0
11
38.6%
0.0%
37.7%
100.0%
99.2%
66.7%
329
37
5
11
2
26
3
29.7%
40.0%
2
2
51
2
43
0
8
100.0%
84.3%
2
13
1
1,181
1
929
0
252
100.0%
78.7%
212
1,192
10
872
9
320
1
73.2%
90.0%
197
2
1,192
10
863
9
329
1
72.4%
90.0%
199
2
1,192
10
279
9
913
1
23.4%
90.0%
66
2
10
1,192
1
964
9
228
10.0%
80.9%
1
216
2,924
10
921
23
210
6
1
2,157
10
798
17
154
6
0
767
0
123
6
56
0
1
73.8%
100.0%
86.6%
73.9%
73.3%
100.0%
0.0%
334
3
153
3
30
2
7
20
2
PROCHASKA SUMMARY REPORTS
Prochaska
Summary
Sample Report
POOL - ALL: June
2012-July| 2013
Page 8 of 57
Grand Total Active
POOL
The information provided to you as a TML IEBP Board Member is confidential under federal law and regulations. Divulging this information to any person other than another Board Member, the Board’s General Counsel or Consultant, or TML IEBP staff without
Pre-Contemplative
Contemplative
Preparation
Maintenance
Termination
Members
proper written authorization from the covered
person is a violation of those regulations.
You should also consult with
either the General Counsel or theAction
TML IEBP Executive Director
before releasing this information
to anyone.
% of Total
Mbrs along
Prochaska
Stage
% of Total
Mbrs along
Prochaska
Stage
% of Total
% of Total
% of Total
% of Total
% of Total
Mbrs along
Mbrs along
Mbrs along
Mbrs along
Mbrs along
# of
# of
# of
# of
# of
# of
# of
Prochaska
Prochaska
Prochaska
Prochaska
Prochaska
Condition Description
Mbrs
Mbrs
Mbrs
Stage
Mbrs
Stage
Mbrs
Stage
Mbrs
Stage
Mbrs
Stage
POOL
Hypertension, Hyperlipidemia,
Grand
Active
36
6.1%
49
8.4%
162
27.6%
329
56.1%
8
1.4%
3
0.5%
586 Total
100.0%
Coronary Artery Disease (CAD)
Pre-Contemplative
Contemplative
Preparation
Action
Maintenance
Termination
Members
Diabetes
23
7.4%
14
4.5%
91
179
1
0.3%
1
0.3%
309
% of
Total
% of
Total
% 29.4%
of Total
% 57.9%
of Total
% of
Total
% of
Total
%100.0%
of Total
Asthma
1
7.1%
9
64.3%
4
28.6%
14
100.0%
Mbrs along
Mbrs
along
Mbrs
along
Mbrs
along
Mbrs along
Mbrs along
Mbrs
along
Obesity
28.6%
35.7%
35.7%
100.0%
# of
Prochaska
#4of
Prochaska
#5of
Prochaska
#5of
Prochaska
# of
Prochaska
# of
Prochaska
#14
of
Prochaska
Depression
1
9.1%
1
9.1%
4
36.4%
5
45.5%
11
100.0%
Mbrs
Stage
Mbrs
Stage
Mbrs
Stage
Mbrs
Stage
Mbrs
Stage
Mbrs
Stage
Mbrs
Stage
Unknown
2
28.6%
5
71.4%
7 Page100.0%
TML
10 of 57
The
information provided to you as a TML IEBP
is confidential1under federal
law and regulations. Divulging this information to
other than another Board Member, the Board’s General Counsel or Consultant, or 4TML IEBP staff
without
Osteoarthritis
1 Board Member
25.0%
25.0%
2 any person50.0%
100.0%
proper written authorization from the covered person is a violation of those regulations. You should also consult with either the General Counsel or the TML IEBP Executive Director before releasing this information to anyone.
Chronic Fatigue Syndrome
1
50.0%
1
50.0%
2
100.0%
Rheumatoid Arthritis
1
50.0%
1
50.0%
2
100.0%
Chronic Hepatitis
1
100.0%
1
100.0%
Chronic Obstructive Pulmonary
1
100.0%
1
100.0%
Disease (COPD)
Graves Disease
1
100.0%
1
100.0%
Guillain-Barre Syndrome
1
100.0%
1
100.0%
Leukemia
1
100.0%
1
100.0%
Multiple Sclerosis
1
100.0%
1
100.0%
Osteoporosis
1
100.0%
1
100.0%
Prostate Cancer
1
100.0%
1
100.0%
Skin Cancer
1
100.0%
1
100.0%
Systemic Lupus Erythematosus
1
100.0%
1
100.0%
Pre-Contemplative
% of Total
Mbrs along
# of
Prochaska
Mbrs
Stage
Contemplative
% of Total
Mbrs along
# of
Prochaska
Mbrs
Stage
MINI - ALL: June 2012-July 2013
MINI
Preparation
% of Total
Mbrs along
# of
Prochaska
Mbrs
Stage
15
Action
% of Total
Mbrs along
# of
Prochaska
Mbrs
Stage
Maintenance
% of Total
Mbrs along
# of
Prochaska
Mbrs
Stage
Termination
% of Total
Mbrs along
# of
Prochaska
Mbrs
Stage
Grand Total Active
Members
% of Total
Mbrs along
# of
Prochaska
Mbrs
Stage
Public/Private Network Alliance
MultiState
TML
• Direct Interface with Political
Subdivision
• Risk and Non-Risk Benefit
and Claim Adjudication
Services
• Plan Management
Administrative Services
• Customer Services: Phone,
E-Mail, Patient Advocacy
• Prompt Pay Proactive
Correspondence
• Benefit Plan Set-Up
• NCQA Accreditation Quality
Management
• HealthX Relationship: Online
Claim Look Up/Electronic
EOB/ID Card, Electronic
Fund Transfers Pay Plus:
ACH/Virtual Card
• OptumInsight Clinical Data
Analytics/Provider Cost
Transparency possibly UMR
Cost Estimator
• OptumRx Pharmacy Benefit
Manager
• Medical Intelligence
• Underwriting
• Medication Therapy
Management Program
(MTMP) delegate to
OptumRx, Restat/
Catamaran and RxResults/
Rx Reportal
• ID Card/Electronic EOB/
EOP Vendor Interface
• Internal Audits and
Education Program
• Legal/Legislative/
Regulatory Support
• Internet Services
• Consumer Driven Debit
Card Relationship; Tiered
Card Access/Alegeus/
WealthCare
• Reinsurance Interface
• Right of Recovery Services
• Electronic Data Interface
(EDI) Services: Mail,
Scan, Pre/Post Duplicate
Audit, OnBase/Electronic
Workflow Management
• Public Employees Benefit
Alliance Services (PEBA)/
Benefit Purchasing
Cooperative
• IEBP Business Continuity
Plan
• MyBenefits on Demand
• MyIEBP Mobile App
• Delegate Telehealth Service
to Healthiest You
• Implement Reference Based
Pricing for Out of Network
Services
• TELA/HOV Data Entry
Relationship
• AS400 and CPS
Eligibility and Claim
Processing System
• Audit of Eligibility
Audit
• Repricing transmission
to United Healthcare
• SAS 70/SOC Service
Organization Control
Audit
• Medical and Dental
Claim Adjudication
Platforms
• iCES Contract Audits
• Claim Check’s claim
audit
• Marketing Synergy
• Claim Adjudication
Business Continuity
Support
• Health Information
Technology
• UMR Business
Continuity
• Security Guidelines
• Provider/Member
Appeals
• Call Trak
• Network Hierarchy
• Billing Duplication
Audit
• Organizational Plan
Indicator (OPI) Network
Hierarchy
Options PPO Network
• Options PPO Primary Network
• Centers of Excellence Designated
Provider Transplant and Obesity
Treatment Centers
• Three Tiered Secondary Network/
Professional Negotiations
• IEBP Provider Network Wrap
• IEBP Patient Advocacy Services
• Premium Network Identification
• Repricing Software
• System Audit/iCES
• Provider Network Disruption
Review
• Provider Credentialing
• Provider Network Website
• Public/Private Sector Marketing
Synergy
Choice Plus Network
• Choice Plus Primary Network
• Centers of Excellence Designated
Treatment Centers
• Three Tiered Secondary Network
• Premium Network Identification
• IEBP Direct Covered Individual
Provider Case Rate
• Provider Network Disruption
Review
• Public and Private Sector Marketing
Synergy
• ICD-9 to ICD-10 mapping
•
•
•
•
•
•
•
•
•
•
•
•
•
Choice Plus Network IEBP Pool
Option October 2015
Choice Plus Primary Provider
Network
Centers of Excellence Designated
Treatment Centers
Premium Network Identification
IEBP Direct Covered Individual
Provider Case Rate
Patient Advocacy
Out of Network Reference Based
Pricing
Repricing Software
System Audit/iCES
Provider Network Disruption
Review
Provider Credentialing
Provider Network Website
Marketing Synergy
ICD-9 to ICD-10 mapping
16
Tier 1 Premium Choice Plus
Network
• Tier 1 (Premium
Practitioner Performance
Based) Network
• Choice Plus Provider
Network
• Centers of Excellence
Designated Provider
Transplant and Obesity
Treatment Centers
• Three Tiered Secondary
Network and Professional
Negotiations
• IEBP Direct Covered
Individual Provider Case
Rate
• Patient Advocacy
• Out of Network Reference
Based Pricing
• Provider Network
Disruption Review
• Provider Benefit
Information Portal
• Marketing Synergy
Accountable Care Network
• Accountable Care
Organization Network
• Centers of Excellence
Designated Provider
Transplant and Obesity
Treatment Centers
• Three Tiered Secondary
Network and Professional
Negotiations
• IEBP Direct Covered
Individual Provider Case
Rate
• Patient Advocacy Services
• Out of Network Reference
Based Pricing
• Provider Network
Disruption Review
• Provider Benefit
Information Portal
• Public/Private Sector
Marketing Synergy
External Clinical Specialty Independent Review Organization (IRO)
Evidence Based Medicine (EBM) aims to apply the best available
evidence gained from the scientific method to medical decision
making. It seeks to assess the quality of evidence of the risks and
benefits of treatments (including lack of treatment). EBM recognizes that many aspects of medical care depend on individual
factors such as quality and value of life judgments, which are
only partially subject to scientific methods. EBM, however, seeks
to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure
the best prediction of outcomes in medical treatment, even as
debate continues about which outcomes are desirable.
Medically Justified External Specialty Review
Medically Justified Non-Evidence Based Medicine treatment
plans are also reviewed. Due to the challenge of evidence based
medicine with rare diagnosis, the External Medical Specialist
and the attending physician may agree that the most effective treatment plan is a medically justified non-evidence based
medical approach. Samples of Medically Justified approvals
include:
¾
Rare Diagnosis
¾
No other treatment available due to co-morbidities
¾
Concern for Complications due to treatment area
¾
Co-morbid Disease State Risk
¾
Treatment Consistencies for Continuum of Care
¾
Repeat of prior successful treatment intervention and disease state; disease state put in remission
¾
Treatment dose should be in compliance for best outcome
¾
Severity of illness defined as ongoing intensity and complication of disease state with lab value concerns
¾
Atypical progression of disease state
IEBP will review the medically justified non-evidenced based
medical treatment plan to verify benefit plan coverage eligibility.
To manage this process effectively, IEBP contracts with a multitude of Specialty Review Medical Consultants to achieve the
most effective treatment outcome using evidence based medicine
approaches for benefit plan coverage.
Unproven Medical Procedures/Treatment
Experimental/Investigational/Unproven Services: medical,
surgical, diagnostic, mental health, substance use disorder, or
other healthcare services, technologies, supplies, treatments,
procedures, drug therapies, medications or devices that, at the
time IEBP makes a determination regarding coverage in a particular case, are determined to be any of the following:
¾
Any drug not approved by the U.S. Food and Drug Administration (FDA) for marketing; any drug that is classified as IND
(Investigational new drug) by the FDA;
¾
Determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on health
outcomes due to insufficient and inadequate clinical evidence
from well conducted randomized controlled trials;
¾
Not consistent with the standards of good medical practice
in the United States as evidenced by endorsement by national
guidelines;
¾
Exceeds (in scope, duration, or intensity) that level of care
which is needed - Given primarily for the personal comfort or
convenience of the patient, family member(s) or the provider;
¾
Subject to review and approval by any institutional review
board for the proposed use. (Devices which are FDA approved under the Humanitarian Use Device exemption are
not considered Experimental or Investigational.); or
¾
The subject of an ongoing clinical trial that meets the definition of a Phase 1 or 2 clinical trial, or is the experimental arm
of a Phase 3 or 4 clinical trial as set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA
oversight.
Expert External Specialty Review
IEBP Medical Benefit Plan’s Interface Expert External Specialty
Review organizations supporting the benefit plan document to
enhance the qualitative accurate Claim Adjudication process.
Evidence-based medicine is a process of external expert medical
evaluation to ensure clinical protocol compliance in the delivery
of healthcare services. Comprehensive current clinical protocols
and the latest medical standards, advancements and pharmaceutical interventions available to effectively treat the patient are
utilized. The process of Evidence Based Medicine includes:
¾
Establishing a clear knowledge of the patient’s history,
medical condition, and treatment plan.
¾
Comprehension of current clinical protocols and the latest
medical standards, advancements and pharmaceutical
interventions available to effectively treat the patient.
¾
Review of recommended treatment plans to ensure that
it is the precise care that is needed to ensure a positive
outcome
¾
Peer to Peer review with the attending physician.
¾
Consideration of whether treatment options are FDA approved, medically justified, experimental and/or unproven.
17
Provider Network Transparency Sophistication Options
Provider Care Path Pricing Transparency
Provider Care Path Pricing Transparency identifies a list of providers and facilities that offer the most cost effective services with
an estimate of the cost for a clinical care path procedure, using historical claims data from a large database. The program accesses
396 care paths within the UnitedHealthcare Choice Plus network repricing engine. IEBP accesses 21 care paths and 52 procedures.
Care Path Geographic Area
Texas is regionalized into fifteen distinct markets. Each market represents a geographic area and is relatively homogenous in terms
of pricing.
Market ID Market Name
42576
Victoria (Beeville, Cuero, Port Lavaca)
42577
Dallas (Ft Worth, Plano, Arlington, Irving)
42578
Amarillo (Canyon, Childress, Borger)
42579
El Paso (Alpine, Fort Stockton)
42580
East TX (Tyler, Longview, Texarkana, Nacogdoches, Palestine)
42581
West Central (San Angelo, Abilene, Brownwood)
42582
Waco (Groesbeck, Gatesville)
42583
San Antonio (New Braunfels, Kerrville Schertz, Sequin)
42584
Austin (Temple, Georgetown, San Marcos, Bastrop)
42585
North Central (Wichita Falls, Graham, Vernon, Bowie)
42586
Houston (Sugarland, Conroe, Galveston, Baytown)
42587
Beaumont (Port Arthur, Orange, Nederland)
42589
Corpus Christi (Alice, Portland, Rockport, Kingsville)
42628
West TX (Lubbock, Midland/Odessa)
42629
Rio Grande Valley (McAllen, Laredo, Brownsville, Harlingen)
Care Paths and Procedures
Care Paths may have up to fifteen distinct services (initial office visit, x-rays, surgeon costs, hospital cost, anesthesia, etc.). Care
Paths identified are non-emergent by design. Variation may occur within the provider’s care path due to a provider changing billing and treatment behaviors.
Sample Average Network Pricing by Geographic Area
Market
Care Path Name
Austin
Total Hip Replacement
Dallas
Houston
San Antonio
West Texas
East Texas
Service Name
Major Joint Replacement
Total HIp Replacement (THR)
Physical Therapy Visit Charge
Physical Therapy
18
No. of Providers/
Facilities
14
50
30
61
110
79
42
82
55
20
35
23
8
12
14
11
29
24
Min
$10,792
$1,127
$280
$7,466
$1,446
$260
$9,796
$1,169
$138
$9,740
$1,123
$310
$16,580
$1,955
$600
$6,400
$1,333
$290
Median
$15,850
$2,327
$1,720
$25,576
$1,735
$1,640
$20,654
$1,408
$630
$19,931
$1,504
$1,280
$21,864
$2,000
$1,040
$15,582
$2,408
$1,140
90th
Percentile
$22,819
$2,779
$2,220
$40,099
$2,331
$2,250
$27,868
$2,042
$1,698
$21,799
$2,821
$2,050
$23,131
$2,140
$2,060
$30,612
$3,171
$2,220
Max
$22,819
$2,779
$3,700
$42,319
$3,634
$3,650
$49,878
$3,263
$1,890
$25,280
$3,750
$2,230
$23,131
$2,666
$2,550
$98,319
$3,171
$3,990
Telehealth | Healthiest You
What is Healthiest You?
als specializing in telehealth. These organizations have established a rigorous screening and credential verification process
for each and every physician applicant, ensuring they meet the
highest standards of qualification. All network doctors are U.S.based and fully licensed.
Healthiest You is an affordable option to the challenge of
healthcare access. Healthiest You provides users with 24/7
access to licensed physicians. Regardless of your location, this
service enables you to connect with a doctor in real time for the
treatment or diagnosis of common conditions.
Can I get a prescription?
Who is it for?
It is for you! Whether you are single, married, military, working, retired, have medical coverage, cobra, Medicare, Healthiest
You is for everyone, regardless of age or pre-existing conditions. However, a parent or legal guardian must consult with a
network doctor on behalf of a child under the age of 18.
What do you treat?
In some cases, a visit to the doctor’s office can be avoided,
saving time and money. As a complement to primary care, the
goal is to make sure you’re equipped with all the tools and resources you need to reduce the cost and frequency of in-person
consultations. Part of that effort involves the delivery of care
for a comprehensive list of common conditions by qualified
physicians over the phone.
Is this Insurance?
No. Healthiest You is a cutting edge technology platform that
connects you with expert telehealth physicians who can diagnose, treat, and prescribe on a wide variety of common medical
and health conditions.
Return to Work MD Statements
When should I use it?
Doctors can be hard to reach, illnesses can occur in the middle
of the night, and sometimes you just have a question that
doesn’t require an in-person consultation. In all of those circumstances, Healthiest You is a convenient solution. This telehealth service is an always-accessible complement to primary
care. Studies have shown that more than 70% of in-person
consultations could have been effectively diagnosed over the
phone. Use of this service is designed to reduce unnecessary
face-to-face consultations, saving you time and money. Network physicians are standing by to consult with you day or
night, 24/7. The goal is to make sure you never go without care
when you need it.
How do I pay for Healthiest You?
You may pay with a credit card, debit card or an ACH transfer
from your checking account. The IEBP plan will pay $30.00 and
the covered individual will be responsible for a $10.00 copay
unless you are accessing a high deductible plan.
Covered individuals on a high deductible plan will be required
to pay $40.00. Once the high deductible is met, the covered individual will receive a reimbursement of $30.00 from the IEBP
plan.
Member Engagement and Responsibilities
A Health History is required prior to telehealth services. On
line access is available via [email protected]
or a covered individual may complete their health history over
the phone with a customer service representative. All you need
to do to access the service is call 866-703-1259.
The goal is to make sure all your health needs are met. If you
consult with a network doctor who determines that a prescription medication will be a necessary part of your treatment,
they’ll promptly call in your prescription to the pharmacy of
your choice. All you have to do is stop by and pick it up. There
are, of course, some restrictions. All prescription medication
will be limited in accordance with your state’s regulations.
Network physicians will not issue prescriptions for drugs on
the DEA controlled substances list.
Return to Work documents may be available dependent on the
telehealth service provided.
How does Healthiest You work with my medical coverage?
Healthiest You is not insurance and insurance coverage is not
required to participate or access the system. However, if you
are insured, prescriptions ordered as a result of your telehealth
consultation may be covered depending on your specific coverage.
Once the member receives their card and welcome letter, their
account is already active and there is no need to register or
activate anything. Remember to put the Healthiest You number in your phone. The card serves as a reminder to the service but is not required to use it. All you need to do to access
the service is call 866-703-1259. Members will be required to
provide their name, date of birth and zip code to access the
physicians network. Be sure to visit the website and download
the Healthiest You app
to make sure you are
getting the most out of
the service. Their team
will work relentlessly
to make sure they are
constantly educating
and enlightening both
members and administrators of this benefit.
Who are the doctors?
Healthiest You is committed to providing you with quality
care. This commitment applies to all aspects of your member
experience, but it begins with whom they select as caregivers.
They utilize cutting edge organizations of medical profession-
19
Managed Care | Cost Efficiency
Self-Audit Reimbursement
measurements is conducted. The multi-page objective clinical
review form has been designed to document inconsistencies in
records and treatment protocols. Each physician and hospital bill
is subjected to our Claims Edit System for unbundling and upcoding determination during the claim process.
Any covered individual who reviews eligible medical expenses
and discovers an overcharge made by the medical facility or
practitioner may provide IEBP/Group Benefits Administrator with a copy of the original billing, corrected billing, and an
explanation. The covered individual will be reimbursed 30% of
the amount of savings generated. The reimbursement may not
exceed the covered individual’s calendar year deductible and
out of pocket amount. To assist the covered individual with
claim cost management, a Claim Audit Tool may be found in
the Member Rights & Responsibilities Guide.
Internal High Dollar Claim Audit
IEBP audits all claims in excess of $30,000.
External Claim Audit
An external claim audit is conducted on non network per diem
hospital claims in excess of $20,000 paid and all network noncase rate outpatient surgery claims in excess of $15,000 paid.
Secondary Network claims in excess of $15,000 paid will be
referred for external audit.
Patient Advocacy Program
IEBP’s Patient Advocacy Program is available to assist covered
individuals in managing their out of pocket expenses.
Pre/Post Duplicate Claim Audit
Electronic Audit
IEBP has a software program that identifies duplicate billings at
the line level of a claim. This automated process occurs before
an analyst receives the claim. Therefore, a provider-billing
duplicate is identified electronically and the error rate is decreased. Manual post duplicate audits are conducted to ensure
duplicate payments are minimized.
Claim Liaison Audit
Claim audits are conducted when claim costs are considered
to be in excess of usual and customary for the same services, in
the same locality, under similar conditions. The Claim Liaison
Audit is designed to verify the legitimacy of charges, treatments,
procedures, and confinements on any and all claims. The audit
identifies documentation discrepancies and provides an extensive analysis and documentation of the quantity, nature and
intensity of services billed, severity of illness, and unidentified
and experimental therapies. An extensive clinical review using
Interqual criteria to document quantity and quality of service
IEBP maintains software programs that pre-screen network
claims and pre/post screen out of network claims. The electronic
screening audit assists in identifying provider billing procedures.
Claims that pass the audits are sent for adjudication; claims that
are identified as problematic are sent for review and adjudication.
Usual, Reasonable & Customary
A usual, reasonable and customary charge is deemed to be
110% of the amount prescribed by the Centers for Medicare
and Medicaid Services (CMS), RBRVS, other specialty CMS fee
schedules, and the Ingenix Essential RBRVS Fee Schedule.
Reference Based Pricing
Employee Benefit Research Institute: A New Twist on the Defined
Contribution Concept in Employment-Based Health Benefits.
This analysis examines reference pricing, a form of defined contribution health benefits, where plan sponsors pay a fixed amount
or limit their contributions toward the cost of a specific healthcare
20
Managed Care | Cost Efficiency (continued)
service, and health plan Members must pay the difference in price
if a more costly healthcare provider or service is selected.
¾
Prompt Pay Provider Claims Tracking and Handling
The PPN plan has physicians and facilities outside of Texas
through the UnitedHealthcare Choice Plus Network. If
a covered individual requires immediate care at a non
network provider, the Plan will pay eligible benefits at the
benefit percentage referenced on the Medical Summary of
Benefits and Coverage subject to the network deductible
and network out of pocket. Treatment or services provided
outside the United States or its territories, unless required
for immediate care, are excluded.
A Prompt Pay Tracking report tracks claims and related documentation belonging to the Prompt Pay provider. This tracking
report is programmed utilizing the Tax ID numbers associated
with that provider and accounts for non-completed claims
processing activity, as well as claims denied for additional
information. Claims denied for additional information may
require different tracking rules depending upon from whom
the additional information is being requested.
Management or designated staff are responsible to review the
report daily for claims or claim referrals. Customer Care staff
will focus on claims denied for additional information and will
pro-actively contact covered individuals and providers to expedite receipt of the requested additional information.
¾
On October 1, 2006, IEBP changed the provider network to
UnitedHealthcare Options PPO. The purpose of this change
was to achieve more cost-effective healthcare treatment. IEBP’s
Board of Trustees made the decision to enter into a long-term
agreement with United Medical Resources (UMR), a wholly
owned subsidiary of UnitedHealthcare.
Designated Centers of Excellence
The Morbid Obesity treatment must be performed at a PlanDesignated Morbid Obesity Treatment Center. The transplant
must be performed at a hospital or facility designated by the
Plan as a Transplant Center. A list of designated Centers of Excellence may be obtained from Multidisciplinary Medical Care
Management. Center of Excellence providers must be network
providers with UnitedHealthcare Choice Plus network.
On September 1, 2011, IEBP transitioned from the UnitedHealthcare Options PPO network to the UnitedHealthcare
Choice Plus Network, except for select Employer Members in
East Texas. In January 2013, IEBP transitioned all Pool Members to the Choice Plus Network. Effective January 1, 2016,
IEBP will upgrade the Choice Plus Network with Premium
Tier 1 performance based outcome providers with appropriate
network steerage plan design.
Provider Billing Cost Management Services
The Alliance will promote comprehensive and cost-efficient health
benefit programs for political subdivisions in the state of Texas
and other states. The management support and systems flexibility provided by UMR will allow for UnitedHealthcare owned
systems to manage the network and claims adjudication process
efficiently.
Out of Network Providers
Services provided by a non network provider are paid at the
lower benefit percentage level and are subject to a separate
calendar year deductible. Reasonable and customary limits
are utilized in determining maximum allowable charges. If the
provider is billing in excess of the designated reasonable and
customary limit, the covered employee or dependent will be
responsible to pay the amount over the usual and customary
amount. The covered individual will always be responsible for
a portion of the bill. The network and non network deductibles
do not accumulate toward each other.
Emergency Care
What if I need emergency care and the nearest hospital or
doctor is out of network?
The IEBP medical plan provides for emergency and immediate care situations. Eligible charges that are medically
considered emergent or immediate care will be subject to
the network deductible and reimbursed at the network
benefit percentage up to the usual, reasonable and customary amount for the emergent or immediate eligible services.
TML MultiState IEBP Provider Network
In addition, the UnitedHealthcare Choice Plus premium doctor
identification provides monetized value driver performance
based outcome information.
Out of Area
What if I am on vacation and out of state?
Out of network claims are repriced if out of network providers
participate in the Multi-Plan Supplemental Network. The discount amount will not be balance billed to the covered individual and the claim will be adjudicated at the out of network benefit
percentage. The secondary network option has increased to the
provision of two secondary networks, professional negotiations
and patient advocacy services, and a billing audit function.
Stop Loss/Reinsurance Interface
IEBP is an experienced administrator managing stop loss and
is pre-approved with most major stop loss carriers. Monthly
tracking reports are generated from the integrated billing, eligibility, and claims administration system.
Public Employee Benefits Alliance (PEBA)
IEBP provides administrative support services to PEBA. Due
to this administrative extension, IEBP’s Membership is not
required to pay the PEBA participation or proposal fees, but
maintains access to PEBA benefits.
21
TML MultiState IEBP
droid™ andHealth
iPhone™
Information Technology (HITECH)
P Mobile
MyBenefits on Demand
MyBenefits on Demand is a quick and simple way to get to
your benefit books, enrollment and other forms, reference
material, documents, and guides on the IEBP website. There
is a concise list of categories, each with its own sub-categories,
that makes navigation to retrieve specific documents very easy.
Specifically, there are categories and subcategories for the following:
¾
Benefits – Medical, Dental, Vision, Prescription, Consumer
Driven, Retiree
¾
Eligibility and Enrollment – Requirements, Forms, Open
Enrollment
¾
Fund Contact – Agreements and Guides
¾
Health
and Wellness
Healthy
Living
Guides and
Fact
Introducing
the –New
TML
MultiState
IEBP
Sheets
¾
Helpful Guides – Various Employee, Fund Contact and
Provider Guides
Mobile App for Android™ and iPhone™
ICD-10 Compliance
IEBP is ICD-10 compliant ready. The current systems have been
upgraded to be prepared for the three to seven character expanded field requirement, and the increased number of injury
and AMA professional procedure codes, which total over 70,000
codes. IEBP has also confirmed that their third-party vendors,
with whom claim and diagnosis data is exchanged, are ready and
compliant with the ICD-10 coding structure.
MyIEBP Mobile
JAMES SMITH
1234567890
Cutting Edge Technology
1234567890
As an industry leader, IEBP provides its Membership with the
sophistication of cutting edge technology to maximize accuracy
in claims adjudication and claim cost management services.
IEBP and the United Medical Resource Alliance (UMR) currently use the Trizetto QicLink claim adjudication system. The
QicLink software includes the full range of claims administration functions consisting of enrollment and eligibility, group
and individual billing, plan setup, provider demographic and
network information, claims adjudication, reinsurance, utilization management and reporting. The adjudication component
includes the ability to auto adjudicate claims by submitted
batches.
and your family’s health information anytime, anywhere.
he status of a claim or email a copy of your ID card to a
ything related to your health.
1234567890
1234567890
1234567890
The MyIEBP Mobile app provides instant access to you and your family’s health information anytime, anywhere.
Whether you want to find| physicians
check the status of a claim or email a copy of your ID card to a
MyIEBPMobile
Ease near
ofyou,
Access
online
services:
provider, MyIEBP Mobile is the go-to resource for everything related to your health.
IEBP
has a mobile phone application available for its Members
REGISTER
Provider
Search
Register
first at www.iebp.org
to access these mobile and online services:
to satisfy
a variety of
requests:
My Eligibility
Provider Search
Find
network
providers
Access your eligibility information and deductible
Find network providers
¾
¾
¾
¾
¾
¾
¾
and out of pocket
met year-to-date
Eligibility
and
benefit accumulator
status
My Claims
View your claims
My
My IDClaims
Card
Claims
claims
View andstatus
Email your IDon
Card paid and pending
My Messages
View
your
claims
View Customer Care messages
My Debit
Card balances for Flex, HRA
Debit
card
and
HSA accounts
Check balances and account activity on Flex, HRA,
Customer Care
and HSA
accounts
Contact Customer Care 24/7
My
Messages
Viewing
and emailing the benefits
ID Card
DOWNLOAD
NOWCustomer
View
Careproviders
messages
Searching
for network
The MyIEBP Mobile app is available from the Apple App Store as a
free
download
for iPhone,
iPod Touch and iPad.
It is also 24/7
available asusing a secure email portal
Accessing
Customer
Care
a freeCustomer
download in the Android
marketplace for Android devices.
Care
Accessing
full IEBP
website
Contactthe
Customer
Care
24/7
The application is available for both Apple iPhone and Android
MultiState
TML
devices.
1821 Rutherford Ln, Ste 300, Austin Texas 78754
www.iebp.org
800-348-7879
Store as a
ailable as
vices.
Austin Texas 78754
The Qiclink system interfaces to claim screening software for
out of network claims. Interfacing for screening of in network
claims is done via the repricing process with UnitedHealthcare.
The system was upgraded in March 2014 for acceptance of the
diagnosis code conversion from ICD-9 to ICD-10. Additionally,
the system was converted from legacy character-based screens
to Windows GUI screen technology and the database infrastructure was converted to Microsoft SQL.
IEBP is currently in the process of migrating to UMR’s CPS
claim adjudication system. This system offers additional benefits and features and will allow for increased efficiencies in
claim administration functions. The migration will be completed for a 10/1/2015 cutover.
www.iebp.org
800-348-7879
IEBP continues to face the pressures of mounting health costs,
lingering economic uncertainties and increasingly complex
reimbursement rules. IEBP will continue to stay focused on
managing the administrative costs of the plan. The Health
Information Technology Act assists IEBP in managing adminis-
22
Health Information Technology (HITECH) (continued)
with a CCD+ addenda record containing the re-association
number to the Explanation of Payment. In addition to delivering a fast and secure payment, VRA also provides features that
streamline data processing and payment reconciliation to help
Providers work more efficiently.
trative costs by beginning the conversion from a paper process
to electronic communication.
IEBP has developed and made available to all its groups an
on-line enrollment system with the value added benefit calculator. Per membership request, IEBP upgraded their Internet,
mobile devices, on-line access to prescription and medical pricing transparency, electronic claim look-up and explanation of
benefits and the production of Electronic Fund Transfers (EFT)
with the Electronic Payment Option.
Claim Processing
Electronic Payment
IEBP utilizes two forms of electronic payment to its providers – ACH and virtual debit cards. ACH is the traditional
fund transfer mechanism between the payer’s bank and the
provider’s bank. The virtual debit card solution to the provider
network optimizes the adoption of electronic claim reimbursement. ACH and virtual card transactions are a convenient way
for payers to leverage a trusted technology infrastructure into a
healthcare payment system. The provider one-time-use payment card number will allow the payment transaction via the
provider’s point-of-service terminal. Payment is then electronically routed to the provider’s existing bank account per their
merchant acquirer agreement. Virtual payments also incorporate fraud prevention mechanisms common to traditional credit
cards, making them safer than the traditional paper check. In
addition, providers may also receive the electronic HIPAA 835
Electronic Remittance Advice (ERA).
Recently, IEBP’s ePayment vendor released its Virtual Reimbursement Account (VRA) process, which delivers hands-free
ACA-compliant payments. VRA is specifically designed for
healthcare providers as it solves many of the problems of
traditional electronic payments. The VRA process not only
automates payments from issuance to final settlement, but it
also allows for a flexible credit card fee schedule for the Providers to accommodate small and large payments. Payments are
delivered directly to the Provider’s desired account as an ACH
Besides the Trizetto QicLink software, IEBP utilizes a front-end
“claim scrubbing” system called QicLink Front End Preprocessing System (QLFEPPS) that verifies eligibility, providers, and
networks. It also checks for non network claims and automatically
sends them via electronic data interchange (EDI) to our national
network for potential discounts. QLFEPPS also screens up front for
potential accident diagnoses. UMR has the ability to build specific
business rules and modifications into this system down to the client level.
The result is extremely clean claim data going into our claim
paying system for faster, more accurate processing. QLFEPPS
performs routing of the claims for repricing for networks allowing access to their fee schedules, and the repriced claims are then
routed for loading into QicLink.
With the migration to the CPS claims adjudication platform
planned for October 2015, a different but functionally equivalent
front-end claims preprocessing and “scrubbing” system will be
implemented. In addition, out of network claims will be routed for
repricing to a Medicare-based Reference Based Pricing system to
help reduce the cost of health claims for the subscribers and payers.
IEBP utilizes the on-site OnBase document imaging system to scan
claims and all related correspondence for storing of the electronic
images in the OnBase system. The OnBase system interfaces the
scanned pended claim letters, Explanation of Benefits, appeals, and
other claim-specific correspondence with the incurred claim. The
combination of claim document scanning and a sophisticated frontend claim scrubbing system reduces the average time required to
adjudicate claims.
23
Data Warehouse and Reporting
Your Membership Information is Protected
IEBP maintains a complete SQL data warehouse of all claims
and related information for the purpose of reporting and
generating statistical information. Extensive claims reporting is run monthly and on request. A comprehensive package
of month-end reports is posted to our secured website for
retrieval by each ASO, including claims paid and utilization
summaries, plan analysis, Rx utilization summaries, claims
paid detail, claims pended or suspended, eligibility reports,
medical management detail and summary reports, refund
requests, and a number of other reports. Special custom reports are available for a fee. IEBP maintains a full seven years
plus the current year of all claims and related data in the data
warehouse.
Protecting the privacy and confidentiality of your personal information is a priority for IEBP. We are committed to maintaining the highest level of security for your personal information,
including any information received from the IEBP MyHealth
web portal. To achieve this, IEBP has adopted and adheres
to security standards designed to protect your information
against accidental or unauthorized access or disclosure. IEBP
has implemented appropriate security measures to protect
your information against loss, misuse or alteration. Among the
safeguards that IEBP developed for this website are administrative, physical and technical barriers that, together, protect any
information stored on the IEBP MyHealth web portal.
Electronic Communication with IEBP
IEBP also has a data warehouse for reporting on a wide array
of data analytics related to disease state, disease management, claims analyses by a variety of criteria, and gaps in care
reporting and notification.
www.iebp.org
IEBP maintains a comprehensive website which provides access to a wide variety of information and services to covered
individuals and employer groups. Available reference information includes claim status, eligibility, dynamic provider
searches, online customer service, and numerous documents
such as plan benefit books, Summaries of Benefits and Coverage, and forms and publications. In addition, the website provides for online completion and submission of other coverage
information, appeals, and right of recovery documentation. The
website is constantly updated with the latest information by an
in-house webmaster and support staff.
¾
Accident/Injury Questionnaire
• Fax: 512-719-6539 (OnBase Right Fax for Claims)
• Online: www.iebp.org/survey
¾
Pre-Existing Prohibited Jan 2014 (some run-out)
• Fax: 512-719-6539
• Call: 800-282-5385
• E-mail: www.iebp.org > Login > My Tools > Online
Customer Care > Send a Secure Email
• Español: 800-385-9952
¾
New Hire
• Fax: 512-719-6565 (OnBase Right Fax for B&E)
• Call: 800-282-5385
• Español: 800-385-9952
¾
Terminations
• Fax: 512-719-6565
• Call: 800-282-5385
• Español: 800-385-9952
¾
Qualifying Event Additions or Terminations
• Fax: 512-719-6565
• Call: 800-282-5385
• Español: 800-385-9952
Business Continuity and Disaster Protection/Recovery
IEBP performs daily backups and data replication to a disaster
recovery site as part of a comprehensive Business Continuity Plan for continued operations in the event of a disaster. A
hot site is maintained at SunGard Availability Services which
includes a series of application and database servers as well
as a Storage Area Network (SAN) for continual replication of
all production data. The Business Continuity Plan is subjected
to a comprehensive test of all data and voice communication systems twice per year. The SunGard facility is located in
Scottsdale, AZ with additional arrangements with the SunGard
facility in Austin, TX for staff workspace.
Data Backup
IEBP does daily backups of all systems to tape. The usual best
practices for IT data backups are followed, which includes doing daily incremental backups and periodic, typically weekly,
full backups. The latest technology backup software is utilized
to ensure complete and accurate backups with comprehensive
tracking in the associated backup database. The backup tapes
are stored internally in a fireproof safe until the next day’s pick
up by Iron Mountain off-site storage.
24
EcoSystem Interoperability
Your IEBP Board is extremely proud of providing services to the Political Subdivision membership and hope together we can continue
to have a strong voice for cost effective performance based healthcare benefits for our employees, dependents, and retiree population.
Together we will continue to make a positive impact in each of your communities.
CPS System Interoperability
HOV vs. TELA India/China 
Claim Network Hierarchy 
Duplicate Billing Audit 
CPS Claim Adjudication System 
Billing and Eligibility AS400 
CallTrak: Medical and Dental Separate Platform 
Policy and Procedure Management (PPM) 
Treasury Data Warehouse 
CallTrak 
OPI Network Hierarchy: Primary, 
Tier 1 Network, Reduction Savings (CRS),
Professional Negotiations, OON: RBRVS, MDR
InfoPort 
Stop Loss Reporting 
Ease of Access
 Remote/Partial Remote/Onsite Workforce
 MyBenefits on Demand
 MyIEBP Mobile App
 IEBP’s Member Database
 Member Identification Number
 Member Identification Numbers plus two person
codes
IEBP System Interoperability
EcoSystem
Interoperability
24/7/365
 MultiState
 NCQA Accreditation
 IEBP’s OnBase
 Optum’s Right of Recovery Diagnosis List
 IEBP’s ODS Data Warehouse
 Custom Online Enrollment System and Online
Enrollment System
 OptumMedical ROR Diagnosis
 Strategic Engagement Distribution Model
 Medical Intelligence: Intake, Utilization Review,
Utilization Management: Catastrophic Care, Case
Management, Professional Health Coaching, Appeal
Review Nurse, Succession Planning
 Security/Business Continuity Plan
 Stop Loss Clinical/Cost Management
External Vendor Interoperability
HealthX 
TML vs. Paychex Payroll System 
RedCard Explanation of Benefit 
CMS/Interqual/Truven/OptumInsight/ 
Provider Transparency, Cost Estimator vs.
HealthEdge/Interqual/Truven/OptumInsight/
Provider Transparency/Cost Estimator
RedCard 
PayPlus Explanation of Payment 
Out of Network Reference Based Pricing 
25
Regulatory Compliance and Reporting
PPACA Administrative Fees | Register in pay.gov
Ten Year Document Retention Plan
Patient Centered Outcome Research Institute (PCORI)
¾ 2012 - $1.00 per participant
¾ Fee is based on increases in the projected per capita amount
of National Health Expenditures, lasting through 2019
¾ Form of Payment is 720
¾ Collection of Overpayment Form 720X
¾ Payment Date is July
Enter payment information (electronic only)
¾ Ensure bank does not have ACH transaction blocked
¾ U.S. Government IDs are referred to as the Agency Location Code or ALC +2 value
• For the reinsurance contribution submission process the
ALC +2 is 7505008015
Census Calculation
¾ Actual count
• Census Per Month/Days in month
¾ Snapshot Factor Method
• March 5, 2014
• June 5, 2014
• September 5, 2014
¾ 5500
• Census will reflect the census on most recent 5500
Reinsurance Trust Fund Overview
¾ 2014 January-September Per Participant Per Year Census
Calculation
• $63.00 two installments
• 1st-$52.50; 2nd-$10.50
¾ Eligibility Enrollment 11/15/2014 delayed to 12/5/2014
¾ Remit 1st contribution amount no later than 1/15/2015;
remit 2nd contribution amount no later than 11/15/2015
¾ 2015
• 1st-$33.00; 2nd-$11.00 nine months later
• Risk Adjustment Allowance $70,000 attachment
point $45,000, a $250,000 reinsurance cap and a 50%
coinsurance rate
¾ 2016
• 1st-$21.60; 2nd-$5.40 nine months later
• Risk Adjustment Allowance $90,000 attachment point, a
$250,000 reinsurance cap and a 50% coinsurance rate
Administrative Penalty Fees
40% Excise Tax Taxable Years beginning after December
2017 [40% x (coverage divided by threshold)] = amount of
applicable tax liability
• Individual $10,200
• Family $27,500
• High Risk Professions and older population (attained
age 55) additional $1,650 = $11,850 and $3,450 = $30,950;
discussion of age and gender adjustments
Comment in regards to EAP >10 visit inclusion, Onsite Clinic,
Dental and Vision benefits included within Medical Plan: awaiting comments—discussing benefits that COBRA participants.
¾
Minimum Essential Coverage Reporting, Calendar Year 2015
Calendar Year 2015: <250 Paper File by February 28, 2016 or Electronic File March 31, 2016. Excess of 250 must file electronically.
95% accuracy delayed 70% covered - Excess of 13/26 week break in employment new hire.
Small Employers (<50 EEs, 30 hour a week a 130 hours a month, Applicable Large Employers ALE (>50 2015 reporting
1560 hours a year for the census ALE/NON-ALE FTE count)
6055
must file/individual
mandate
IRS form
B=Issuer/Carrier
Group Health, Self Insured, Association,
Multi-Employer Plans, GovernmentSponsored Programs: Medicare Part A,
Medicaid, CHIP, TRICARE, CHAMPVA
1094-B
Aggregate
Transmittal
1095-B Taxpayer
Return by insurers/benefit plans
 Each EE
 Certificate of Coverage by 2.1.16
 Last four digits of SS#
 Waiting period
 Initial Measurement Period
 COBRA
 Retirees
 Non/Active EE’s Board/Council
compliance > 100 employees compliance with FTE (30 hour a week a 130 hours a
month, 1560 hours a year ) access to benefit compliance
6056
do not file/eligibility for
tax credit
6055
must file/individual mandate
IRS form
C=Combined
SF Plan = Sponsor/Carrier
1094-C
Aggregate
Transmittal
For Section 6055:
 Reporting required by anyone that provides minimum
essential coverage.
 This report is used to determine months in which an
individual is covered by minimum essential coverage. (Section
5000A)
1095-C
Each EE
Certificate of
Coverage by
2.1.16
Last four digits of
SS#
IRS form
B=Issuer/Carrier:
Plans
1094-B
Aggregate
Transmittal
6056
must file/elig. for tax credit (Pay or Play)
Affordable not more than 9.5% of Box 1 W-2
form & minimum essential cvrg 60% ntwk benefit
IRS form
C = Combined
SF Plan = Sponsor/Carrier
1095-B
Each EE Certificate of
Coverage by 2.1.16
Last four digits of SS#
Coverage for NonEmployees: COBRA,
Shareholders, NonEmployee Directors,
and Retirees
1094-C
Aggregate
Transmittal
1095-C
Each EE Certificate of
Coverage by 2.1.16
Last four digits of SS#
Part I, II, and III ALE
Self-Insured
Part I, II Insured Plans
For Section 6056:
 Information about the employer offering coverage (including contact information and the number of fulltime employees).
 For each full-time EE, information about the coverage (if any) offered to the EE, by month, including the
lowest EE cost of self-only coverage offered.
 This report is used to determine an employee’s eligibility for premium tax credit. (Section 4980H)
File: Department of Treasury, IRS Center, Austin, TX 73301 - Penalties Reported on IRS Form 8928. Reporting penalties under sections 6721 and 6722. Penalty Relieve 2015 if good
faith effort is documented. File Deadline 2.28.16 <250 paper forms or Electronic filing March 31, 2016, Covered Participants February 1, 2016
26
1
Customer Care & Communication Tools
Healthy Living Guides
Customer Care Team
The Customer Care team strives to assist the covered individual in understanding their healthcare plan. Customer Care
provides friendly, bilingual benefit information and educates
covered individuals regarding medical and prescription benefit
plans, benefit plan exclusions, limitations, notification requirements, out of pocket expenses, notification penalties, the appeal
process, network variations, and Explanation of Benefits (EOB)
information or Explanation of Payment (EOP) to support electronic fund transfer payments. Customer Care communication
options include phone, e-mail, fax and patient advocacy services. IEBP utilizes a server-based call center phone system that
offers the latest in call, email, fax, and data integration, ACD
call routing and distribution, call recording, and reporting.
Benefit Books
COBRA Continuation of Coverage Billing
IEBP may direct bill COBRA Continuation of Coverage participants.
Employee On Site Education Meetings
On site Benefit Education Meetings are provided to Membership. 100% employee participation in the Education meeting is
requested. Meetings for spouse education are recommended.
ID Card Development
IEBP will provide a standard ID card.
Member Rights and Responsibilities Guide
IEBP is committed to respecting the right of the covered individuals and ensuring the Membership is aware of their rights
and responsibilities.
Political Subdivision MemberCentric Guide
IEBP provides a guide to review the differences in Section 125,
Health Reimbursement and Health Saving Accounts.
Provider Coding Guidelines
Provider Network Directory
Provider information is available online or in a directory format. Provider directories are distributed to the Membership
annually, but access to daily updated provider information is
available at www.iebp.org.
Retiree Billing
Gaps in Care Campaign Letters
IEBP can direct bill retirees and will notify all participants of
rate and plan changes.
Cardiovascular (February), Preventive Care (June), Asthma
(September), Diabetes (November).
Asthma
Breast Cancer
Colon Cancer
COPD
Dental Health
Diabetes
Eat Right & Exercise
Healthy Eyes
Irritable Bowel Syndrome
Ischemic Heart Disease
Men’s Health
Mental Health
Migraine Headaches
Multiple Sclerosis
Neuropathy
Osteoarthritis
Osteoporosis
Physical Activity
Rheumatoid Arthritis
Skin Cancer Prevention
Sleep
Sleep Apnea
Smoking Cessation
Stress Management
Suicide Prevention
Type 2 Diabetes
Weight Management
The Provider Coding Guidelines booklet is provided, upon request, to providers requesting information about IEBP’s claims
adjudication process. The Provider Coding Guidelines booklet
is also located at www.iebp.org.
Benefit Books are written annually and mailed to the Member
Employer prior to the beginning of the Plan Year.
Healthy Living Fact Sheets
Alcoholism
Asthma
Back Pain
Bariatric Surgery
Celiac Disease
Chronic Fatigue Syndrome (CFS)
Chronic Obstructive
Pulmonary Disease (COPD)
Chronic Pain
Coronary Artery Disease (CAD)
Depression
Financial Health
Gout
Grief and Grieving
Healthy Eating
Healthy Eyes
Healthy Pregnancy
Hyperlipidemia
Hypertension
Summary of Benefits and Coverage
Heart Disease
Hypertension
Immunizations
Managing Holiday Stress
Men’s Health
Skin Cancer Prevention
Smoking & Tobacco Cessation
Mailed to the Member Employer prior to the beginning of the
Plan Year. English and Spanish versions are available.
Supplemental Benefits Option Guide
An overview of The Standard Insurance Life products will assist
the Member Employer and covered individual in understanding
the eligibility benefits and treatment criteria of the benefit.
Transparency to Healthcare Benefits Guide
The Transparency to Healthcare Benefits Guide assists employees in understanding their healthcare benefits.
27
TML MultiState IEBP Milestones
In 1979, when it became clear that Texas cities found it increasingly difficult to find health insurance at competitive prices, TML
created a health insurance trust fund. In the intervening thirty-three years, that trust fund has undergone numerous changes
(including two name changes), but the goal has remained the same — to constantly improve the provision of employee benefits to
Texas cities. The key milestones in that continuous progress are illustrated below.
2016
Political Subdivisions and UnitedHealthcare continues to evolve in developing custom Transparent Provider
Network access with customization to the Political Subdivision arena and the management of the taxpayer dollar.
The Provider Network Options include (1) Options PPO Primary Network, Secondary Network, Professional
Negotiations, IEBP Provider Wrap Network, Out of Network Reference Based Pricing Options and Patient
Advocacy Services (2) Choice Plus Primary Network, Secondary Network, Professional Negotiation Service, IEBP
Direct Covered Individual Case Rate, Out of Network Reference Based Pricing options and Patient Advocacy
Services (3) Choice Plus Primary Network, IEBP Direct Covered Individual Provider Case Rate Network, Out of
Network Reference Based pricing options and Patient Advocacy Services (4) Tier 1 (performance based outcome
providers), Choice Plus Primary Network, Secondary Network, Professional Negotiations, IEBP Direct Covered
Individual Provider Case Rate, Out of Network Reference Based Pricing options and Patient Advocacy Services
(5) Tier 1 (performance based outcome providers), Choice Plus Primary Network, IEBP Direct Covered Individual
Provider Case Rate Network, Out of Network Reference Based Pricing options and Patient Advocacy Services,
(6) Accountable Care Organization (ACO), Secondary Network, Professional Negotiations, IEBP Direct Covered
Individual Provider Case Rate Network, Out of Network Reference Based Pricing options and Patient Advocacy
Services, (7) Accountable Care Organization (ACO), IEBP Direct Covered Individual Provider Case Rate, Out of
Network Reference Based Pricing options and Patient Advocacy Services.
2015
Regulatory Reporting and PPACA benefit expansion and services compliance, UnitedHealthcare and Political
subdivision network development to include Options PPO, Choice PPO, Premium Network/Tier I performance
based network, out of network reference based pricing initiative, interface with providers regarding gaps in care
data analytics, generic prescription fixed fee schedule. Infomart development for political subdivision reporting
dashboard. Sophistication in telehealth opportunities with Healthiest You.
2014
ICD-9 conversion to ICD-10 computer conversion, Section 1332 of ACA state waiver in support of the HR 1076.
Section 1332 current law is effective 2017 but a bill is present to move it to 2014. Carry over not in excess of $500 for
Section 125. Development of Provider transparency and promotion of performance based outcome. February 1, 2014
TML IEBP Trust Document Merge into MultiState TML IEBP assumed name certificate February 10, 2014 to TML
MultiState IEBP. Approval from Department of Insurance in Oklahoma that TML MultiState IEBP would fall within
the Oklahoma Interlocal Statute.
2013
TML IEBP moves forward with Health Information Technology (Online Enrollment), implements Summary of
Benefits and Coverage, offers Biosimilar prescriptions as an alternative to Biotech/Specialty prescriptions, NCQA
Accreditation, Telemedicine services, Integrated MemberCentric Medical Home Model of Care, Comprehensive
Eligibility Management and Personal Health Profile, include Interstate Trust, UnitedHealthcare Distribution Model,
Texas Essential Benefits Benchmark. IRS Tax Exempt Correspondence stating expansion of Pools.
2012
Added Data Analytics for Medical Intelligence Program, converted East Texas members to the Choice Plus Network
(Public/Private Sector), prohibition of HIPAA Title II: Discrimination, Pre-existing look back period and Special
Enrollment.
2011
Healthcare Reform in action/National Legislative Liaison Representative, implemented Choice Plus Network
(Public/Private Sector), received recognition as a qualified health plan by national HHS (if compliant with essential
benefits) and tax credit for tax exempt employers who have <50 lives salaries averaging less than designated
amount and employer subsidy for premium/contributions, electronic option for member EOB, electronic provider
payment.
2010
Implemented compliance with the Patient Protection Affordable Care Act (PPACA). Added Defined Contribution,
Consumer Centered Pool plans, with HRA and/or HSA support progressive Medication Therapy Management
Program (MTMP), developed Pre Sixty five Retiree Pool, Healthcare Reform Review, converted ODS ASP to TML
IEBP Host, and converted Member Database from COBAL to SQL, HealthX expansion and Online Enrollment
report improvement.
28
TML MultiState IEBP Milestones (continued)
2009
During Texas Legislative Session, Senate Bill 654 amended Chapter 172 of the Local Government Code by expanding the
definition of “political subdivision” to include a political subdivision of another state. Developed Business Continuity
Plan, Value Tiered Prescription Access, Medically Justified, Non-Evidence Based Medicine and accessed external Online
Enrollment System.
2008
Member Equity Stabilization Fund formula, Evidence Based Medicine (EBM), Milliman Datawarehouse, Creditable
Coverage recognized to offset pre-existing limitation. Service improvements included: clinical stratification/
adjusted risk index, Healthy Initiatives HealthPlan: Community Based Biometric Screenings/Health Risk
Appraisals/Incentive plan, Multidisciplinary Professional Coaches, Navigating GASB Liability Risk transition,
OON RBRVS U&C and 100% participation requirement updated.
2007
Service improvements included: addition of Section 125 Debit Card, HealthX, BeWellatTMLIEBP, Exante
relationship, D2 claim stratification and Ernst & Young as Underwriting Consultant. PEBA benefits include Disease
Management, EAP, Cancer, Critical Care and Accidental Supplemental, Life/LTD/STD, Wellness and Health Power
Assessment.
2006
Developed an alliance with UMR accessing the UnitedHealthcare Options PPO Network (Private/Public Sector)
2005
Developed an alliance with and assumed administrative services for Public Employee Benefits Alliance (PEBA).
Service improvements included: Online Claims look-up, Onsite Wellness with external vendor, secondary repricing
network and addition of the Patient Advocacy Program.
2004
Service improvements included: Onsite Wellness with local providers, expansion of Consumer Driven Plans and both
contributory & non-contributory Medicare supplements.
2003
Service improvements included: In-house Professional Negotiations, automated pre/post duplicate identifier,
implementation of a Wellness Program, HIPAA Title II compliance, Out of Network Hospital U&C fee schedules,
and Chapter 172 Trustee training for self-funded members.
2002
Service improvements included: addition of Claim Cost Management, Disease Management, three-tier prescription
drug copay plan and PHCS out of state network access.
2001
Service improvements included: addition of a Collection Specialist, Part-time Medical Director, increased electronic
claim adjudication process, Online Enrollment services and updated website with benefits online.
2000
TML GBRP assigned and transferred all of its rights and obligations under contract to TML Intergovernmental
Employee Benefits Pool (TML IEBP).
1999
Service improvements included: In House Right of Recovery, website enhancements and continued relationship
development with Reinsurance carriers.
1998
Expansion of TML IEBP’s Provider Network, Out of State Network, expanded administrative services to self-funded
Independent School Districts.
1993-95
Trust terms were incorporated into the Interlocal Agreement. Service improvements included: purchasing the
Texas Municipal Center building, improved technology with imaging/OCR and electronic claims, the addition of
URN/TML Transplant Centers and transitioned the leased Preferred Provider (PPN) Network into the TML IEBP
Statewide PPN.
The Pool became partially self-funded which allowed more political subdivision flexibility. In house services
1989-91 included: Marketing, Underwriting, Claims Adjudication, Utilization Management and Large Case Management.
Service improvements included adding two Vision plans.
1989
The Pool (TML GBRP) became a partially self-funded pool under Texas Political Subdivision Employees Uniform Group
Benefits Act, Texas Local Government Code Chapter 172. The Act called for the Pool to be governed by a Board of
Trustees (§172.006) and gave them investment authority under the Public Funds Investment Act and Texas Trust Code
(§172.009). The Pool purchased both individual and aggregate stop loss and all claims processing and administration was
done utilizing Pool staff.
Service improvements included hiring Billing & Eligibility staff and purchasing computers. Operational Guidelines:
1984-86 separated Risk Pool Boards between TML, TML GBRP and TML IRP.
1979
Health Benefits Trust (TML Group Benefits Risk Pool), under Texas Municipal League (TML) Insurance Trust was
created and accepted by the Board of Trustees.
29
TML MultiState IEBP
1821 Rutherford Lane, Suite 300
Austin, TX 78754
Toll-Free: 800-348-7879
Phone: 512-719-6500
Fax: 512-719-6509
www.iebp.org
Revised September 2015

TML MultiState Intergovernmental Employee Benefits Pool

Transcription

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