4. Consent Agenda (Leo Drozdoff, Chair) (All Items for Possible

Transcription

4.
4.
Consent Agenda (Leo Drozdoff, Chair)
(All Items for Possible Action)
Consent items will be considered together and acted on in one
motion unless an item is removed to be considered separately by
the Board.
4.1. Approval of the Action Minutes from the May 19, 2016
PEBP Board Meeting.
4.2. Approval of the changes as discussed at the May 19, 2016
PEBP Board Meeting to the PEBP Plan Year 2017 Master
Plan Documents.
4.3. Receipt of quarterly vendor reports for the period ending
March 31, 2016.
4.3.1.
HealthSCOPE Benefits – Obesity Care
Management Program
4.3.2.
Hometown Health Providers – Utilization and
Large Case Management
4.3.3.
Carson Tahoe Health – Diabetes Care
Management Program
4.3.4.
The Standard Insurance – Basic Life and Long
Term Disability Insurance
4.3.5.
Towers Watson’s One Exchange – Medicare
Exchange
4.1.
4.
the Board.
4.1. Approval of the Action Minutes from the May 19, 2016
PEBP Board Meeting.
STATE OF NEVADA
PUBLIC EMPLOYEES’ BENEFITS PROGRAM
BOARD MEETING AND PUBLIC HEARING
The Richard H. Bryan Building
901 South Stewart Street Suite 1002
Carson City, Nevada 89701
--------------------------------------------------------------------------------------------------------------------ACTION MINUTES (Subject to Board Approval)
May 19, 2016
MEMBERS PRESENT
IN CARSON CITY:
MEMBERS PRESENT
VIA TELEPHONE:
Mr. Leo Drozdoff, Board Chair
Ms. Jacque Ewing-Taylor, Vice-Chair
Ms. Ana Andrews, Member
Mr. Don Bailey, Member
Mr. James Wells, Member
Mr. Chris Cochran, Member
Ms. Rosalie Garcia, Member
Ms. Christine Zack, Member
MEMBERS ABSENT:
Ms. Judy Saiz, Member
Mr. Tom Verducci, Member
FOR THE BOARD:
Mr. Dennis Belcourt, Deputy Attorney General
FOR STAFF:
Mr. Damon Haycock, Executive Officer
Ms. Laura Rich, Operations Officer
Ms. Celestena Glover, Chief Financial Officer
Ms. Kari Pedroza, Executive Assistant
1. Open Meeting; Roll Call
Chair Drozdoff opened the meeting at 9:01 a.m.
2. Public Comment
 Peggy Lear Bowen- Retiree Participant (see attached for comments)
 Susan Dyke- Participant
3. Action ItemApproval of the Action Minutes from the April 21, 2016 PEBP Board Meeting.
Board ActionMOTION:
Move to approve the April 21st Board Meeting Action Minutes.
BY:
Member Wells
SECOND:
Member Bailey
VOTE:
The motion carried; Member Garcia abstained.
4. Action ItemApproval of the proposed changes to the Master Plan Documents for Plan Year 2017 (July 1,
2016 – June 30, 2017) to reflect previously approved plan design modifications, changes in
legislative or regulatory requirements; a change in the vision benefits, and technical
corrections or updates.
Public Employees’ Benefits Program Board
Thursday, May 19, 2016
4.1.
4.2.
4.3.
4.4.
Minutes – Page 2
Medical and Prescription Drug Master Plan Document
Dental, Life and Long Term Disability Master Plan Document
Enrollment and Eligibility Master Plan Document
HIPAA Privacy and Security Requirements Master Plan Document
PEBP Operations Officer Laura Rich presented the proposed changes to the Plan Documents
to the Board.
DISCUSSION ON ITEM 4.1: Vice Chair Ewing-Taylor had questions regarding revisions
listed in the Item 4 Report, specifically 4.1. Section B,
subsections m, q, r, t and u for HealthSCOPE Benefits
recommendations. Mary Catherine Person provided
clarification on the HealthSCOPE Benefits recommended
changes questioned by Vice Chair Ewing-Taylor.
There was discussion regarding tabling the change to the
Medical and Prescription Drug MPD identified as 4.1.
Section B, subsection n.
Member Cochran asked that 4.1. Section B, subsection f
proposed language be revised to provide further clarification
that it pertains to non-emergent ambulance and air
transportation services. It was decided that Member Cochran
would meet with Executive Officer Haycock and Mary
Catherine Person to work on the revised language to bring
back at the next board meeting.
Member Wells wanted to make sure that the word “not” was
placed before “reasonable” in 4.1., Section B, subsection t
and to clarify in 4.1., Section B, subsection g, add, “Not to
apply to Medicare primary”
Marlene Lockard from RPEN asked about 4.1. Section B,
subsection r in regards to the proposed documented
improvement timeframe of 2 weeks for chiropractic services.
Mary Catherine Person from HealthSCOPE Benefits
suggested that Section B, subsection r (3) language be
removed.
Board Action on Item 4.1.MOTION:
Move that the Board pull 4.1 B (f) (n), clarifying in 4.1. B (g) that it should
not apply to Medicare Primary, that 4.1 B r (3) be deleted and under 4.1.
B t, the word ‘not’, pending staff review, is added in advance of
‘considered not reasonable.’
BY:
Member Andrews
SECOND:
Vice Chair Ewing-Taylor
DISCUSSION: Chair Drozdoff would like staff to clear up the intent of 4.1. B, t, but the
core value of ‘it is not to be considered reasonable’ be included.
VOTE:
Unanimous; the motion carried.
Move that we approve Item 4.2. as outlined with one additional
clarification that staff capitalize the definitions as they did in the Medical
MPD.
BY:
Member Wells
SECOND:
VOTE:
Minutes – Page 3
Member Andrews
DISCUSSION ON ITEM 4.3: Vice Chair Ewing-Taylor had questions about proposed
revisions 4.3. Section B, subsections f and j. Operations
Officer Rich explained the reasons for these changes.
Member Wells had an issue with adding the proposed
language in 4.3 Section B, subsections k and l regarding the
update of qualifying events for participants who become
eligible for Medicaid or Nevada Check Up. He voiced his
concern about the primary participant being able to decline
coverage to enroll in Medicaid and/or Nevada Check Up
after receiving HSA contributions from PEBP. Vice Chair
Ewing-Taylor asked that a financial impact analysis of the
proposed changes be done by Aon.
Motion that the Board table k and l, and get further information
particularly in-depth information on the financial impact to the system and
the correct number of employees that this affects to re-discuss these two
changes and approve the balance of 4.3.
BY:
Member Bailey
SECOND:
Member Cochran
DISCUSSION: Member Wells asked that the maker of the motion add the provision for
capitalizing the definitions as was done in 4.2.
Members Baily and Cochran agreed to this addition to the motion.
DISCUSSION: Member Garcia asked if 4.3. Section B subsection h needs to be voted on
by the Board since it pertains to subsidy changes.
Chief Financial Officer Glover explained PEBP’s process for providing
subsidies to retirees when PEBP receives the Years of Service document
from Public Employees Retirement Services (PERS).
Member Wells was concerned that participants won’t receive their
subsidy prior to PERS submitting the Years of Service document to
PEBP.
Members Bailey and Cochran agreed to withdraw the motion.
Member Wells proposed the following revised language for 4.3. Section B, subsection h,
“Years of Service Premium Subsidy and Years of Service Exchange HRA
Contributions are effective upon the date of retirement based on the audit from either
the Public Employees’ Retirement System (PERS) or the Nevada System of Higher
Education (NSHE). Changes to the Years of Service Premium Subsidy and Years of
Service Exchange HRA Contribution resulting from a future audit will occur on the first
of day of the month concurrent with or following the date PEBP receives the audit results
from the PERS or the NSHE.
Motion that the Board approve 4.3., tabling k and l to be brought back at
a later date for additional discussion on the fiscal impact and potential
alternatives as well as the capitalization of the definitions throughout the
document and adding the language that we just described under h.
BY:
Member Wells
SECOND:
VOTE:
Minutes – Page 4
Member Bailey
Motion that the Board approve Item 4.4.
BY:
Member Andrews
SECOND:
Member Wells
DISCUSSION: Member Wells asked that the maker of the motion add the provision for
capitalizing the definitions as was done in the previous items.
Member Andrews agreed to the addition to the motion.
DISCUSSION: Vice Chair Ewing-Taylor voiced her concerns about Item 4.4, Section B,
subsection b, and suggested that the Board wait until the Quality Control
Officer position has been filled to have this discussion.
Member Garcia commented that she would find it difficult to make a
decision with regard to B, b, because she does not have the job
descriptions for either position to appropriately place the responsibility
and she would like to see those before making a decision.
Member Wells stated that the way he read this change was that it was
about appeals and requests for the review of appeals. His concern was that
when we move to a true Quality Control Officer role, the QC Officer
should not making operational decisions and then reviewing those same
operational decisions. It would be an operations person that would make
a decision and then the Quality Control Officer would confirm that that
operational decision was in accordance with laws and the plan documents.
If it is a true complaint then it should go to the Quality Control Officer
but if it is an appeal, that is an operational decision that the QC Officer
would be responsible for reviewing.
Executive Officer Haycock explained that this change was made so that
participants would know who to address their complaints to at PEBP
during this time.
AMENDED
MOTION:
Motion that the Board approve Item 4.4. with the removal of Item 4.4.
Section B, subsection b and the capitalizing the definitions as was done in
the previous items.
BY:
Member Andrews
SECOND:
Member Bailey
VOTE:
A fifteen minute break was taken. After the break, roll call was taken. All Members in Carson
City were present. Members Cochran and Garcia were present via telephone and Member Zack
was unable to return to meeting. Chair Drozdoff allowed a brief Public Comment period prior to
Agenda Item 5. Public Comment regarding Item 5:
5. Action ItemApproval of the federally mandated Summaries of Benefits and Coverage documents effective
July 1, 2016.
5.1. PEBP Consumer Driven Health Plan
5.1.1. Individual coverage effective July 1, 2016
5.1.2. Family coverage effective July 1, 2016
5.2.
5.3.
Minutes – Page 5
Health Plan of Nevada HMO effective July 1, 2016
Hometown Health Plans effective July 1, 2016
PEBP Operations Officer Laura Rich presented the proposed changes to the Summaries of
Benefits and Coverage documents to the Board.
Board Action on 5.1.MOTION:
Move for staff recommendation.
BY:
Member Wells
SECOND:
Member Andrews
VOTE:
Board Action was not taken on Items 5.2. and 5.3.
6. Action ItemDiscussion and possible action regarding the Board’s approval of the Master Plan Documents
and Summaries of Benefits and Coverage documents for future plan years.
Executive Officer Haycock explained that this item was included so that staff could get an
idea of which documents the Board would like to approve in the future.
DISCUSSION ON ITEM 6: Member Cochran stated that he thought the current process was fine
and changes made to documents could be included in a consent
agenda item with a report outlining the changes.
Member Garcia commented that the current process works and she
doesn’t see any reason to change it.
Vice Chair Ewing-Taylor said that because the MPD is the
governing document it is critical that the Board understand the
proposed changes and suggested that any housekeeping items
changed in the documents could be kept on a log. She shared her
view that this discussion should include the new Board Members
and be their decision to weigh in on during a Strategic Planning
Session.
Member Wells agreed with Vice Chair Ewing-Taylor that this
discussion may be a little premature as new Board Members have
been appointed and that the MPD is the governing document for the
participants and the plan. Member Wells voiced his concern that if
the Board does not have a chance to see the proposed changes, some
changes could affect policy and benefits. He also stated that it would
be good to see the changes to the SBCs, but the Board does not need
to approve them as they are federally mandated.
7. Public Comment
 Judith Maus- Retiree Participant
8. Adjournment
Chair Drozdoff adjourned the meeting at 11:48 a.m.
Public Comment under Item 2:
Peggy Lear Bowen: Good morning. My name and my words for the record. P-e-g-g-y, L-e-a-r,
B-o-w-e-n. I speak quickly because of points of concern. Went to a Hometown, a Senior Care Plus
Meeting to discuss our insurance for this coming year, CJ was the representative at the Senior Care
Plus Meeting and explained to us very thoroughly that the A and B Medicare folk, through which
people are working and had been a part of the group was sent to Utah as an encapsulated group
had been sold to the Utah group. I thought slavery went out with Lincoln and the selling of human
beings was not something that we legally did anymore and that it made some sense when asked
years ago, Mr. Wells was asked that if this program of the exchange did not work out, could we
retrieve back those participants that had been put in this capsule lance and now I know the word
to use is sold, would they be retrievable and his answer was maybe, it was not a yes or a no, it was
maybe and maybe you can retrieve that which you’ve sold to somebody and do away with contracts
of that selling if in fact that’s what happened. The concern that we have here that those people
have hit a donut hole and it was explained to CJ at the Senior Care Plus Meeting that because of
the donut hole and the expense of diabetic medicines that are now being handled differently by
Senior Care Plus, at least and others that they would just simply have to go home and not have the
medicine because they couldn’t afford it and they could just die. I’m told that at an early meeting
on after these changes were made to our insurance program back in about 2011, that even in an
obituary and it was read here at this board, but probably not for the record, that the death was
hastened of that person who actually trusted and trusted within the State of Nevada and their
insurance benefits. That their death was hastened by the change in that program and that which
they could no longer afford to do. I am very concerned about that. I am concerned that the
hospitalists with Renown and the concept that you will not see or deal with any physicians or
people that were known to you unless they are, will not be known to you unless they are the actual
hospitalists in the hospital at the time extends to rehab and extended care. *Peggy then discussed
another person’s personal health information and poor medical care experienced at Renown.*
The hold that your insurance companies are having on your Southern HMOs down in Southern
Nevada. A type of, you can’t see our doctors if you don’t do this. Well let me tell you, you can’t
see your doctors on the high deductible plan or on other plans that are involved. It is a hold, strangle
hold, where they determine what they want to do with you. *Peggy then again discussed another
person’s personal health information and her poor medical care experienced at Renown.*
Thank you very much and I know that was a lot to cover. Don’t let people die because of following
the dollar and them getting paid what the insurance will pay and then kicking them out. It is so
important that you keep everyone on this Board working hard to save and protect the lives of the
state workers, non-workers and others. Please, please, please, be vigilant as you have and thank
you for all your hard work.
Peggy Lear Bowen: My name and words, for the record: Peggy, P-e-g-g-y, Lear, L-e-a-r, Bowen,
B-o-w-e-n. My concern regarding the benefits and coverage documents involved and for item
number five and the fact that we do not have two public access to make public comment
throughout. In the future, that it would behoove us for transparency purposes, not what’s
necessarily required by law, but what is the proper and appropriate thing when discussing any
benefits, whether they be, by the phone. Board meetings need to be how you have them, not
necessarily in any other way, but public access to make public comments for the record. In the
future I would hope that this Board, because this Board has in the past whenever it came to benefits
or whenever it came to evaluation of the Executive Director that the meetings were shut down and
comments were made, “if I could figure out how to shut them down more, I would” and that when
the last meeting of this nature was held in Las Vegas, Nevada, and Board vote was going to be
taken there and even the Governor couldn’t access the meeting because he couldn’t be present in
the room at the time, that they were called and it was suggested to the chair not to take a vote until
after it’s brought back to the Board where that accesses of public comment and other accesses were
available and we didn’t get it always in the rurals but we at least got it in the North and South and
we need that precedent to be re-established and kept in place as what you do and how you do so
that the members actually have that access. I am not asking for it to be today because I know of
the legal ramifications of if the documents are not, and it kills me to say this, because I was going
to ask for it for today that we will be out of compliance with what we have to do legally. I said it
would make us if I asked for a delay until the next Board meeting for this vote that it would get
you out of certain time structures that you have to have, so I am asking for future meetings that
it’s always available with placement so people can go to the table and make their public comment.
It’s not a legal requirement, it’s a moral requirement. Thank you very much.
Peggy Lear Bowen: My name and words, for the record: Peggy Lear Bowen, P-e-g-g-y, L-e-a-r,
B-o-w-e-n. Thank you and thank you Mr. Wells for eloquently stating why it needs to come back
before the Board and in public and especially with the Board being able to act and hear and being
directly involved in the master plan. Thank you very much. It was a well stated comment that you
made.
I would like to discuss one thing that has taken place and that is inequity of benefit. And that is
that I, as a member of the orphan group, do not hit a donut hole involved in my insurance for
paying for medical care or prescriptions or any of those things. It has now been very very made
apparent by those who are participants in the A and B Medicare Exchange that they hit the donut
hole and if they can’t afford their medications they literally don’t have the wherewithal to get a
specially and I don’t want to put one over the other because any medication that keeps you alive
is of equal value and diabetic benefits being provided by our group and when I was told that the
group had been sold to the Exchange and that Nevada actually benefited from the group that is
handling our A and B Medicare folk and that the umbrella of PEBP over the A and B Exchange
was merely that an umbrella to facilitate the handling of payments for process and the Nevada
money going into and being made to the company that is taking care of our A and B Medicare
people. That the PEBP umbrella is merely to facilitate payment and not to present anything with
benefit. If these people’s insurance is literally being maintained by jobs that they held other than
that for the state of Nevada and that their benefits are in reality not the benefits that PEBP is
offering to those who are still within the state and in particular the donut hole people, the orphan
people, that you have in reality an inequitable benefit. They aren’t receiving the benefits they
should have for working for the state of Nevada and that needs to be corrected and it’s not in
addition to their paycheck and it’s not an additional taxable thing and it should be, because they
worked for the state of Nevada and their lives and the extension of their lives and their comfort
through insurance benefits should be there and that’s important to me.
When I came and went to an urgent care and this is the second topic, for an injury that I received
and I went to the Reno Orthopedic Clinic which is part of the, our benefits in Reno that we can go
to for our doctors and things like that and it was a sense of urgency because of my pain. I am now
receiving letters from PEBP not from Medicare or anybody else, but from PEBP, denial of those
benefits for attending the Urgent Care and wanting more information and wanting medical
necessity for going to Urgent Care and everybody was perfectly fine with Medicare paying that
portion of the benefit, but when it came to the 20% for PEBP to pay all a sudden I’m getting a
denial of claim. When I came down and asked to speak to someone I was told there was no one
available, just call the insurance company and my point to you is, prior to this moment, that had
been a seamless situation and it has all handed from within house by the insurance company talking
to whomever and I am concerned that it is no longer that way. I would appreciate it and if it’s not
that way for me and I speak to you, think about how many people it’s not that way and they don’t
come and make the effort here and let you know. Thank you very much. One final comment, when
asked will the HRA or HSA money rollover, Mr. Wells within the 2011 to present day response
was it depends on who the insurance company is, so when you delve into the way things are set
up and whose handling the money and the appearance of the money and you can’t spend it if your
claim is over a year old, that we need to go back. If my money is in my account and I need my
money to spend, then I can’t. Thank you very much.
4.2.
4.
the Board.
4.2. Approval of the changes as discussed at the May 19, 2016
PEBP Board Meeting to the PEBP Plan Year 2017 Master
Plan Documents.
STATE OF NEVADA
PUBLIC EMPLOYEES’ BENEFITS PROGRAM
901 S. Stewart Street, Suite 1001
Carson City, Nevada 89701
Telephone (775) 684-7000 · (800) 326-5496
BRIAN SANDOVAL
Governor
Fax (775) 684-7028
www.pebp.state.nv.us
DAMON HAYCOCK
LEO M. DROZDOFF, P.E.
Executive Officer
Board Chairman
AGENDA ITEM
X Action Item
Information Only
June 17, 2016
Date:
Item Number: 4.2
Revisions to the Plan Year 2017 Master Plan Documents:
1. Self-funded Consumer Driven Health Plan (CDHP)
2. Self-funded PPO Dental Plan
3. Enrollment and Eligibility Requirements
4. HIPAA Privacy and Security Requirements
Title:
Summary
The purpose of this report is to provide amendments to the Plan Year 2017 Master Plan
Documents (MDPs) as recommended by the Board on May 19, 2016.
Report
1. Amendments to the 2017 Master Plan Document for the Consumer Driven Health
Plan (CDHP) Medical, Vision and Prescription Drug Plan:
A. Non-Emergent Air Transportation: Pre-certification is required to establish
Medical Necessity for all non-emergent care air transportation scheduled
between facilities. If the transportation between facilities is for emergent care,
no Pre-certification is required; however, all transportation costs will be
evaluated for Reasonableness.
B. Plan definition - Allowable Expenses: Allowable Expenses shall mean the
Maximum Allowable Charge for any Medically Necessary, eligible item of
expense, at least a portion of which is covered under the Plan. When some
other non-Medicare Plan pays first in accordance with the Application to
Benefit Determinations provision in the Coordination of Benefits section, this
Plan’s Allowable Expenses shall in no event exceed the other non-Medicare
Plan’s Allowable Expenses.
When some other non-Medicare Plan provides benefits in the form of services
rather than cash payments, the Plan Administrator shall assess the value of
said benefit(s) and determine the reasonable cash value of each service
rendered, by determining the amount that would be payable in accordance
with the terms of the Plan, shall be deemed to be the benefit. Benefits payable
under any other non-Medicare Plan include the benefits that would have been
payable had claim been duly made therefore, whether or not it is actually
made.
C. Plan definition – Chiropractic Services: PEBP considers Chiropractic Services
are Medically Necessary when all of the following criteria are met: 1) The
participant has a neuro-musculoskeletal disorder; and 2) The Medical
Necessity for treatment is clearly documented.
D. Plan definition - Reasonable and/or Reasonableness: Reasonable and/or
Reasonableness means charges for services or supplies which are necessary
for the care and treatment of an Illness or Injury. The determination that
charges are Reasonable will be made by the Plan Administrator, taking into
consideration the following:
a. The facts and circumstances giving rise to the need for the service or
supply;
b. Industry standards and practices as they are related to similar scenarios;
and
c. The cause of the Injury or Illness necessitating the service or charge.
The Plan Administrator’s determination will consider, but will not be limited
to evidence-based guidelines, and the findings and assessments of the
following entities: (a) The National Medical Associations, Societies, and
Organizations; (b) The Centers for Medicare and Medicaid Services (CMS);
and (c) The Food and Drug Administration.
To be Reasonable, charges must be in compliance with generally accepted
billing practices for unbundling or multiple procedures. The Plan
Administrator retains discretionary authority to determine whether a charge is
Reasonable. The Plan reserves for itself and parties acting on its behalf the
right to review charges processed and/or paid by the Plan, to identify charges
that are not Reasonable and therefore not eligible for payment by the Plan.
E. Additional Exclusions and Plan Limitations: Provider Error and Negligence
Exclusions
a. Error: That are required to treat injuries that are sustained or an illness that
is contracted, including infections and complications, while the Plan
Participant was under, and due to, the care of a Provider wherein such
illness, injury, infection or complication is not reasonably expected to
occur. This exclusion will apply to expenses directly or indirectly resulting
from the circumstances of the course of treatment that, in the opinion of
the Plan Administrator, in its sole discretion, unreasonably gave rise to the
expense;
b. Negligence: For Injuries resulting from negligence, misfeasance,
malfeasance, nonfeasance or malpractice on the part of any licensed
Physician.
2. Amendments to the Plan Year 2017 Self-funded PPO Dental Plan and Summary
of Benefits for Life and Long Term Disability Insurance Master Plan Document:
A. Capitalized words that are defined in the Definitions Section throughout the
Plan Document for identification.
3. Amendments to the Plan Year 2017 Enrollment and Eligibility Master Plan
Document:
B. Years of service premium subsidy and years of service Exchange HRA
contribution are effective upon the date of retirement, based on the audit from
either the Public Employees’ Retirement System (PERS) or Nevada System of
Higher Education (NSHE). Changes to the years of service premium subsidy
and years of service Exchange HRA contribution resulting from a future audit
will occur on the 1st day of the month concurrent with or following the date
PEBP receives the audit results from the PERS or NSHE. (NAC 287.485).
4. Amendments to the Plan Year 2017 HIPAA Privacy and Security Requirements
Master Plan Document:
Recommendation
1. Approve the revisions to the Self-funded Consumer Driven Health Plan MPD
2. Approve the revisions to the Self-funded PPO Dental Plan MPD
3. Approve the revisions to the Enrollment and Eligibility Requirements MPD
4. Approve the revisions to the HIPAA Privacy and Security Requirements MPD
4.3.1.
4.
the Board.
March 31, 2016.
4.3.1.
HealthSCOPE Benefits – Obesity Care
Management Program
HealthSCOPE Benefits
Report on Obesity Care Management
OBESITY CARE MANAGEMENT PROGRAM
•
HealthSCOPE Benefits reviews the initial evaluation form submitted by the Obesity Care
Management (OCM) provider to make sure that the PEBP member meets the criteria for the weight
loss program.
•
HealthSCOPE Benefits notifies PEBP of the member’s enrollment in the OCM program.
•
HealthSCOPE Benefits tracks and monitors the monthly engagement forms and we work directly
with the providers regarding the compliance of the program.
•
HealthSCOPE Benefits works with the OCM providers on the appropriate billing for claims
reimbursement.
•
The Customer Care team at HealthSCOPE Benefits advises the PEBP members on how to enroll in
the program, as well as assisting them with locating providers who participate in PEBP’s Obesity
Care Management program.
TOTAL HEALTH MANAGEMENT
by HEALTHSCOPE BENEFITS
2
CRITERIA FOR THE PROGRAM
For adults 18 years and older:
The patient‘s BMI must be greater than 30 kg/m2, with or without any co-morbid conditions
present, or greater than 25 kg/m2 (or waist circumference greater than 35 inches in women, 40
inches in men) if one or more of the following co-morbid conditions are present:
•
•
•
•
•
•
Coronary artery disease;
Diabetes mellitus type 2;
Hypertension (Systolic Blood Pressure greater than or equal to 140 mm Hg or Diastolic
Blood Pressure greater than or equal to 90 mm Hg on more than one occasion)
Obesity-hypoventilation syndrome
Obstructive sleep apnea;
Cholesterol and fat levels measured (Dyslipidemia):
a. HDL cholesterol less than 35 mg/dL ; or
b. LDL cholesterol greater than or equal to 160 mg/dL; or
c. Serum triglyceride levels greater than or equal to 400 mg/dL.
For children 2 to 18 years:
• Services must be provided by an in-network provider who specializes in childhood obesity;
• Child must present a BMI ≥ 85th percentile for age and gender.
3
ONGOING REQUIREMENTS
In addition to meeting the requirements listed under the section titled “Criteria for Obesity/Overweight
weight loss benefits”, you must remain actively engaged in a medically supervised weight loss program.
Actively engaged is defined as:
•
Participation in the annual Health Assessment Questionnaire and biometric screenings for
participants and adult eligible dependents over 18 years of age.
•
Participation in regular office visits with the weight loss medical provider.
•
Consistently demonstrating a commitment to weight loss by adhering to the weight loss treatment
plan developed by your weight loss medical provider including but not limited to routine exercise,
proper nutrition and diet and pharmacotherapy if prescribed. Commitment to your weight loss
treatment will be measured by HealthSCOPE Benefits who will review monthly progress reports
submitted by the provider.
•
Losing weight at a rate determined by the weight loss medical provider.
4
MONITORING ENGAGEMENT
•
HealthSCOPE Benefits assists weight loss medical providers with completing monthly progress
reports.
•
The initial report should include your weight and BMI or waist circumferences, and a description of
your treatment plan to include weekly weight loss goals, final weight loss goal, exercise regimen,
diet and nutrition instructions.
•
Subsequent monthly reports should provide information regarding your weight loss progress and
adherence to the treatment plan. Submission of these reports will be a requirement for
payment under the enhanced wellness benefits.
•
If monthly weight loss reports are not received by HealthSCOPE Benefits, benefits under this
program end and coverage returns to the standard benefits.
5
HOW TO ENROLL
Step 1: Adults - age 18 years and older - Complete the Health and Wellness Health Assessment Questionnaire and
biometric screenings. The Health Assessment Questionnaire and biometric screenings is not required for children ages 2 to
18 years old.
Step 2: Find a provider from the list of participating weight loss providers by logging into www.healthscopebenefits.com
and click on “Obesity Care Management Program Providers.” You may also call 1-888-7NEVADA (1-888-763-8232) for
assistance in locating a participating weight loss provider. You may want to consider finding a provider that is close to your
home or work, or some other location that is convenient for you. HealthSCOPE Benefits can help you find a provider that
best meets your needs.
Step 3: Make an appointment with your participating weight loss provider.
Step 4: Before your appointment, print an Obesity and Overweight Care Management Program enrollment form. To get the
form, log in to www.healthscopebenefits.com and look under “forms”.
Step 5: Take the Obesity and Overweight Care Management Program enrollment form to your first appointment for
completion by your participating weight loss provider. Submit the completed form (by mail or fax) to HealthSCOPE Benefits.
The address and fax number are provided on the enrollment form.
Step 6: HealthSCOPE Benefits will review the information submitted by your provider. If you meet the criteria for the
weight loss program benefits, HealthSCOPE Benefits will enroll you in the program and notify PEBP and the Pharmacy
Benefits Manager of your enrollment. If you do not meet the criteria for weight loss benefits, HealthSCOPE Benefits will
notify you the enrollment in the Obesity and Overweight Care Management Program is denied.
Step 7: Engage in the Obesity and Overweight Care Management Program!
6
OBESITY CARE MANAGEMENT MEMBERSHIP
Weight Management Summary
# Mbrs Actively Engaged in Program
Average # Lbs. Lost
Total # Lbs. Lost
% Lbs. Lost
Average Cost/ Member (annualized)
# Mbrs Not Actively Engaged in Program
PEBP Q3 PY15
Females
333
16.7
5,576.6
7.41%
$4,614
37
Males
75
25.6
1,923.4
9.58%
$6,469
Total
408
18.4
7,500.0
7.87%
$4,955
11
48
* Analysis based on active members enrolled in the Weight Management Program; weight loss and costs are through March 2015.
7
PERCENT OF POUNDS LOST
% Lbs. Lost
12.00%
9.58%
10.00%
8.00%
7.87%
7.41%
6.00%
4.00%
2.00%
0.00%
Females
Males
Total
8
7,500 pounds lost!!
That is equal to this
pickup truck!
9
F I N AN C I AL S U M M ARY
Summary
*Non-Participant is defined as a member who has been diagnosed with obesity in the past 12 months, but is not enrolled in the
program; Analysis is based on members with >= 9 mos. of coverage
Avg # Employees
Avg # Members
Mem / EE Ratio
OCM
Members
401
447
1.11
NonParticipants
257
356
1.38
Variance
55.9 %
25.7 %
(19.4)%
Gross Cost
Gross Plan Cost
Gross Employee Cost
$2,138,988
$1,642,180
$496,808
$1,926,797
$1,412,624
$514,173
11.0 %
16.3 %
(3.4)%
$5,454
$1,650
$408
$123
$7,316
$2,663
$441
$161
(25.4)%
(38.0)%
(7.5)%
(23.2)%
# of High Cost Claimants (HCC's)
HCC's / 1,000
Avg HCC
HCC's % of Gross Dollars
1
2.2
$296,919
18.1%
1
2.8
$114,888
8.1%
0.0 %
(20.3)%
158.4 %
122.6 %
Threshold = $100K
Annualized
Annualized
High Cost
Claimants
PEPY Gross Plan Cost
PEPY Gross Employee Cost
PMPM Gross Plan Cost
PMPM Gross Employee Cost
10
COST DISTRIBUTION BY CLAIM TYPE
Cost
Distribution by
Claim Type
Hospital Inpatient
Facility Outpatient
Physician
Other
Total
OCM
Members
$880
$1,855
$2,054
$108
$4,897
NonParticipants
$2,069
$1,333
$1,799
$95
$5,296
Annualized
Annualized
Part
Variance
(57.5)%
39.2 %
14.2 %
13.7 %
(7.5)%
18.0%
Non-Part
37.9%
39.1%
Hospital Inpatient
41.9%
25.2%
Facility Outpatient
2.2%
34.0%
Physician
1.8%
Other
11
U T I L I Z AT I O N S U M M A R Y
Inpatient Facility
# of Admits
# of Patient Days
Paid per Admit
Paid per Day
Admits / 1,000
Days / 1,000
Average LOS
OCM
Members
20
83
$14,456
$3,483
60
247
4.2
NonParticipants
35
126
$15,435
$4,287
131
472
3.6
Variance
(42.9)%
(34.1)%
(6.3)%
(18.8)%
(54.2)%
(47.7)%
16.7 %
Office
OV / Member
OV Paid / Visit
OV Paid / Member
9.2
$74
$677
6.5
$32
$208
41.5 %
131.3 %
225.5 %
DX&L
DX&L / Member
DX&L Paid / Visit
DX&L Paid / Member
15.2
$52
$790
15.3
$46
$708
(0.7)%
13.0 %
11.6 %
Emergency Room
Number of Patients
Number of Visits
Number of Admits
Visits/Member
Visits / 1,000
Avg Paid per Visit
Admits per Visit
34
43
7
0.13
128
$1,819
0.16
44
62
12
0.23
232
$1,609
0.19
(22.7)%
(30.6)%
(41.7)%
(43.5)%
(44.8)%
13.1 %
(15.8)%
Annualized
Annualized
12
4.3.2.
4.
the Board.
March 31, 2016.
4.3.2.
Hometown Health Providers – Utilization and
Large Case Management
Quarterly
Update for
3Q FY 2016
(1/1/16 – 3/31/16)
Board Meeting 05/19/16 - Page 1
Report Table of Contents
Case Management Executive Summary……………………………………………….. 3 - 4
Case Management Reports………………………….………………………………….5 - 10
Utilization Management Executive Summary…….……………..………………….. 11 - 13
Utilization Management Reports……………………………………………………. 14 - 21
Appendix A: Medical Discharges by Facility………………………………...………22- 26
Performance Standards & Guarantees…………………………………………………….27
Case Management – Executive Summary
Case management (CM) is a voluntary process where the clinical professionals at the utilization management company work with patients
and their family members, caregivers and other health care providers to assist with coordination of various medical treatment needs of
patients. Case management services are particularly helpful when a plan participant (patient) needs complex, costly and/or hightechnology services such as those related to organ and tissue transplants, certain cancer treatments, serious head injuries, hospice care or
certain behavioral health issues.
Active Cases: This quarter 870 clients were screened. Of those 108 were enrolled in the Case Management (CM) program. That group
represents 12.4% of the cases screened. This is the baseline reporting period for Hometown Health. Cases are identified from precertifications as well as potential high cost and trigger diagnosis reports.
Screened
Enrolled
%
Current Quarter
01/01/2016 - 03/31/2016
870
108
12.4%
Previous Quarter s
07/01/2015 – 12/31/2015
1449
174
12%
Screened Plan Year 2016
2319
282
12.2%
For the current quarter, of the 870 clients screened:
• Of the 870 cases, 487 inpatients were managed and transitioned through case management to alternate
levels of care or discharged home on an independent basis, 108 cases were actually managed beyond the
hospital setting.
• 114 members were contacted for enrollment into CM. 108 members elected to participate in the CM
program.
Board Meeting 05/19/16- Page 3
Case Management – Executive Summary (continued)
The source of clients referred to CM continues to be from the Utilization Review nurses at time of referral, time of hospital
admission, or time of transition to an alternate level of care. These referrals make up 75% of the referrals to Case Management.
25% of the cases screened came from physicians, plan referrals, specialty clinics, and other health care facilities.
Case management cost savings for quarter three is $1,400,719 for the third quarter of FY 2016. Additional savings will be
realized under Healthscope for the early intervention and referrals/resources channeled to in-network provider services.
Conclusion
487 unique members were screened for possible case management intervention. Hometown Health was able to engage
and enroll 108 members for a 22.2% enrollment rate.
Case Management – Referral Reason Report
Quarterly
1/1/2016 to 3/31/2016
Year to Date
7/1/2015 to 3/31/2016
870
2319
High Dollar
Included in Trigger List
High Risk
870
2319
CM Trigger List
Other
Totals
Case Management – Referral Source Report
Quarterly
1/1/2016 to 3/31/2016
Screened
Open
Without
Full
Intervention Cases
Year to Date
7/1/2015 to 3/31/2016
Open Open
Benefit Other
Mgmt Cases
Claims Identification
Totals
Screened
Open Open Open
Without
Full Benefit Other
Intervention Cases Mgmt Cases
0
Totals
0
290
88
7
11
396
630
345
57
11
1043
Disease Mgmt
0
76
0
16
92
0
147
0
16
163
Family
0
0
0
0
0
0
0
0
0
0
34
34
34
34
CM-Medical
Home Health (picked up at time of hospital discharge)
Hospital
0
0
0
0
0
0
344
0
0
344
379
83
0
32
494
379
83
8
98
568
Physician
0
0
0
0
0
0
2
2
0
4
Plan Referral
0
0
7
0
7
0
3
11
0
14
Self Referral
0
0
0
0
0
0
0
0
0
0
Other
UR-concurrent/retrospective
Totals
0
669
247
14
93
1023
0
1009
924
78
159
2170
Case Management – Referral Source Report
Report Glossary:
Other Cases Screened (Without Intervention):
Number of cases screened by Case Management and not opened to Full or Benefit Management within the period.
Full Cases Opened:
Number of cases opened to Full (traditional) case management within the period.
Benefit Management Cases Opened:
Number of cases newly opened to Benefit Management (i.e., simple discharge planning, resource referral, extra-contractual agreements,
brief education) within the period.
Other Cases Opened:
Number of cases opened to Case Management and not opened to Full or Benefit Management within the period.
Case Management – Saving Detail for Open & Closed Cases
1/1/2016 to 3/31/2016
Case Type
Care Level
Vendor
Averted Adm Change in
Proposed
Total Savings
Status
Negotiations
Savings
Level of Care Alternative Plan
LCM
Active
$177,800
$177,800
LCM
Closed
$158,400
$158,400
LCM
Active
$158,250
$158,250
LCM
Active
$149,260
$149,260
LCM
Active
$108,810
$108,810
LCM
Active
$108,600
$108,600
LCM
Active
$81,200
$81,200
LCM
Active
$74,725
$74,725
LCM
Active
$50,400
$50,400
LCM
Closed
LCM
Active
$39,200
$39,200
LCM
Active
$32,200
$32,200
$45,950
$45,950
Case Management – Saving Detail for Open & Closed Cases – Cont’d
1/1/2016 to 3/31/2016
Case Type
Care Level
Vendor
Averted Adm Change in
Proposed
Total Savings
Status
Negotiations
Savings
Level of Care Alternative Plan
LCM
Active
$27,200
$
27,200
LCM
Active
$23,200
$
23,200
LCM
Active
$22,400
$
22,400
LCM
Active
$21,600
$
21,600
LCM
Active
$15,500
$
15,500
LCM
Active
$15,266
$
15,266
LCM
Closed
$12,800
$
12,800
LCM
Active
$11,000
$
11,000
LCM
Active
$
9,000
LCM
Active
$8,400
$
8,400
LCM
Closed
$8,400
$
8,400
LCM
Active
$8,200
$
8,200
$9,000
Case Management – Saving Detail for Open & Closed Cases – Cont’d
1/1/2016 to 3/31/2016
Case Type
Care
Level
Status
BH / CHEM
Closed
LCM
Active
$3,150
DIAB MGT
Active
$6,000
$6,000
DIAB MGT
Active
$6,000
$6,000
BH / CHEM
Active
$3,250
$3,250
LCM
Active
$2,200
$2,200
BH / CHEM
Closed
$286
$286
BH / CHEM
Closed
$286
$286
BH / CHEM
Closed
$286
$286
Quarterly Savings by Type
Vendor
Negotiations
Averted Adm
Savings
Change in
Level of
Care
$7,500
$8,358
Proposed
Alternative
Plan
Total Savings
$7,500
$961,986
$4,000
$7,150
$430,375
Total Quarterly Savings
$1,400,719
Q2 2016 Savings
$1,122,869
Q1 2016 Savings
$701,786
Year to Date ROI (Q1 + Q2 + Q3)
$3,225,374
Utilization Management – Executive Summary
The PEBP Consumer Driven Health Plan(CDHP) requires participants to obtain a pre-certification for certain medical services
such as inpatient hospital admissions, skilled nursing facility admissions and bariatric weight loss surgeries. This requirement is
also referred to as utilization management, utilization review, concurrent and retrospective review. The purpose of utilization
management is to evaluate the appropriateness, the medical need and efficiency of certain healthcare services and procedures.
Inpatient Utilization Overview:
Based on the third quarter, the PEBP population was 39,317 (average monthly lives for the quarter). Third quarter data shows
528 member admissions and 487 member discharges. Discharges for the third quarter were 12.47 members per thousand lives
managed. Discharges annualized were 49.84 members per thousand lives managed. Bed days for the third quarter were 92.59
members per thousand lives managed. Bed days annualized were 370.09 members per thousand lives managed. The average
length of stay was 7.43 days.
Inpatient Authorization and Denials:
The data show 487 authorized admissions were discharged in the quarter. General Med/Surg discharges composed the majority
of all discharges with 306 (62.8%), Mother and Newborn 90 (18.5%), Mental Health Acute 49 (10.1%), Skilled Nursing 13
(2.7%), Rehab 12 (2.5%), with ICU and NICU making up the remaining discharges. (12 for ICU and 5 for NICU representing
2.5% and 1%)
Quarter General
/Year Med/Surg
3Q 2016
306
(62.8%)
Mother &
Newborn
Mental Health
SNF
Rehab
ICU
NICU
90
(18.5%)
49
(10.1%)
13
(2.7%)
12
(2.5%)
12
(2.5%)
5
(1%)
Third quarter data shows 8 admission denials for a total of 11 days denied. 3 admits with 4 days were denied
as not covered by the plan. 3 admits with 5 days were denied as not medically necessary by the plan. 1 admit
with 1 day was denied due to insufficient medical information supplied. 1 admit with 1 day was denied as
service out of plan.
Utilization Management – Executive Summary (Continued)
Discharges by Specialty:

Reviewing each specialty for the third quarter, 306 med/surg discharges had 1468 authorized days with an average LOS of 4.8 days, bed days of
37.59 per thousand lives managed for the quarter (annualized 150.25 per thousand), and 7.83 members discharged per thousand of lives managed
for the quarter (annualized 31.31 per thousand).

For the quarter, ICU discharges were 12, with a total of 153 authorized days and an average LOS of 12.75 days. Bed days of 3.94 per thousand
lives managed for the quarter (annualized 15.74 per thousand) and .31 members were discharged per thousand lives managed for the quarter
(annualized 1.25 per thousand).

For the quarter, Mental Health discharges were 49, with a total of 387 authorized days and an average LOS of 7.9 days. Bed days of 10.03 per
thousand lives managed for the quarter (annualized 40.12 per thousand) and 1.26 members were discharged per thousand lives managed for the
quarter (annualized 5.03 per thousand).

For the quarter, Mother & Newborn discharges were 90, with a total of 239 authorized days and an average LOS of 2.66 days. Bed days of 6.11 per
thousand lives managed for the quarter (annualized 24.43 per thousand) and 2.3 members were discharged per thousand lives managed for the

For the quarter, NICU discharges were 5, with a total of 79 authorized days and an average LOS of 15.8 days. Bed days of 2.06 per thousand lives
managed for the quarter (annualized 8.25 per thousand) and .13 members were discharged per thousand lives managed for the quarter (annualized
.51 per thousand).

For the quarter, Rehab discharges were 12, with a total of 210 authorized days and an average LOS of 17.5 days. Bed days of 5.45 per thousand
lives managed for the quarter (annualized 21.8 per thousand) and .31 members were discharged per thousand lives managed for the quarter
(annualized 1.25 per thousand).

For the quarter, Skilled Nursing discharges were 13, with a total of 226 authorized days and an average LOS of 17.38 days. Bed days of 5.72 per
thousand lives managed for the quarter (annualized 22.85 per thousand) and .33 members were discharged per thousand lives managed for the

For the quarter, Transplant discharges were 0, with a total of 0 authorized days and an average LOS of 0 days. Bed days of 0 per thousand lives
managed for the quarter (annualized 0 per thousand) and 0 members were discharged per thousand lives managed for the quarter (annualized 0 per
thousand).
Utilization Management – Executive Summary (Continued)
Age and Gender Distribution:
Third quarter discharges show 38% of the members discharged fall in the age bracket of 50-64. Overall women make-up
59% of all discharges in quarter three.
Out Patient Utilization and Denials (Services Include: Medical Office Visits, Durable Medical Equipment ,
Outpatient Surgery, Ambulatory Services, Home Health, Infusion, Transportation, Mental Health Outpatient,
Dialysis, Outpatient Therapies , Partial Hospitalization and Prenatal Care) :
Third quarter outpatient utilization consisted of 928 requests for services authorized. Authorizations for services are as
follows: Medical Office visits composed 39.0% of total requests. Durable Medical Equipment requests composed 33.6% of
total requests. Outpatient Surgery composed 16.4% of total requests. Ambulatory Services composed 4.7% of total requests.
The remaining requests composed 6.3% of total requests and include Home Health, Infusion, Transportation, Mental Health
Outpatient, Dialysis, Outpatient Therapies, Partial Hospitalization and Prenatal Care. (1.6%, 1.5%, 1.2%, .9%, .8%, .1%,
.1% and .1% respectively)
There were 19 requests for services denied during third quarter of FY 2016. The requests included 10 for Medical Office
Visits. 4 were denied as not covered by plan with 3 denied as not medically necessary and 3 denied for insufficient medical
information to authorize. In addition there were 4 requests for Durable Medical Equipment. 3 were denied as not medically
necessary with the other denied for insufficient medical information. There was two requests for Outpatient Mental Health
services, both denied as not medically necessary. Three requests for Ambulatory Services, two denied as not covered by
plan and one denied as not medically necessary.
Estimated savings provided do not include denials of coverage for services designated as non covered in the PEBP Master
Plan document or potential savings from Letters of Agreement negotiated by Hometown health, but administered by PEBP
and Healthscope.
Inpatient Utilization
3rd Quarter Plan Year 2016
1/1/2016 - 3/31/2016
Average Population
39,317
Quarterly Discharges Per Thousand
12.47
Total Discharges
487
Quarterly Bed Days Per Thousand
92.59
Days Approved
2,762
Total Reviews Performed
Admissions
528
Concurrent
457
Retrospective
71
*The above table provides an overview of inpatient pre-certification/authorizations.
Inpatient Authorizations & Denials
1/1/2016 - 3/31/2016
Admissions
Total
Med/Surg
Maternity
Mental Hlth
ICU
Rehab
Transplant
NICU
SNF
# of Discharges
487
306
90
49
12
12
0
5
13
Quarterly Discharges per 1000
12.47
7.83
2.3
1.26
0.32
0.31
0
0.13
0.33
Total Denied
Denials
Total
Medical
Obstetrical
Mental Hlth
Surgical
8
3
2
1
2
Denied, not covered by plan
4
1
2
1
0
Denied, not medically necessary
3
1
0
0
2
Denied, Insufficent Medical Information
1
1
0
0
0
Total Number of Denied Requests
*The above tables provide an overview of inpatient authorization by utilization data. Total denied days are derived from
prospective and concurrent reviews.
Inpatient Discharge Information
1/1/2016 - 3/31/2016
Average LOS
Quarterly Bed
Days per 1,000
Quarterly
Discharges per
1,000
1,468
4.8
37.59
7.83
12
153
12.75
3.94
0.32
Mental Health
49
387
7.9
10.03
1.26
Mother & Newborn
90
239
2.65
6.11
2.3
NICU
5
79
15.8
2.06
0.13
Rehab
12
210
17.5
5.45
0.31
Skilled Nursing
13
226
17.38
5.72
0.33
Transplants
0
0
0
0
0
487
2,762
5.67
92.59
12.47
Discharges by
Specialty
Total Auths
Total Days
General Med/Surg
306
ICU
Total
*The above tables provide an overview of discharges by category and as a whole, in addition the table provides a further
breakout of the medical category. Graphic representation of Discharges by specialty is located on pages 16 through 18 of
this report.
Total Authorizations by Specialty
350
300
250
200
150
100
50
0
Total Days by Specialty
306
90
49
12
12
5
13
0
1600
1400
1200
1000
800
600
400
200
0
1468
387
General
Med/Surg
Authorizations
239
153
210
226
79
ICU
Mental
Health
Mother &
Newborn
NICU
0
Rehab
Skilled Transplants
Nursing
Total Days
Average LOS by Specialty
20.00
18.00
16.00
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
17.50
17.38
15.80
Average Bed Days per Thousand
12.75
7.90
4.80
2.66
0.00
ALOS
40.00
35.00
30.00
25.00
20.00
15.00
10.00
5.00
0.00
37.59
10.03
3.94
6.11
5.45
2.06
5.72
0.00
Discharges per Thousand
9.00
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
7.83
Bed Days per 1000
2.30
1.26
0.31
0.13
0.31
0.33
0.00
Discharges per 1000
General Med/Surg Discharges
1600
1400
1200
1000
800
600
400
200
0
Mother & Newborn Discharges
300
1468
239
200
100
90
306
4.80
37.59
7.83
Average LOS
Bed Days per
1000
Discharges per
1000
2.66
0
Total Auths
Total Auths
Total Days
General Med/Surg
Total Days
ICU Discharges
6.11
Average LOS
Bed Days per
1000
Mother & Newborn
2.30
Discharges per
1000
NICU Discharges
200
100
79
153
80
150
60
100
40
50
12.75
12
3.94
0.31
15.80
20
5
Total Auths
Total Days
Average LOS
ICU
Bed Days per
1000
Total Auths
Discharges per
1000
0.13
Total Days
Average LOS
Bed Days per
1000
Discharges per
1000
5.45
0.31
Bed Days per
1000
Discharges per
1000
NICU
Rehab Discharges
Mental Health Discharges
450
400
350
300
250
200
150
100
50
0
2.06
0
0
250
387
210
200
150
100
49
7.90
Total Auths
Total Days
Average LOS
Mental Health
10.03
Bed Days per
1000
1.26
Discharges per
1000
50
17.50
12
0
Total Auths
Total Days
Average LOS
Rehab
Skilled Nursing Discharges
226
250
200
150
100
50
13
17.38
5.72
0.33
Average LOS
Bed Days per
1000
Discharges per
1000
0
Total Auths
Total Days
Skilled Nursing
Transplant Discharges
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0
0
0.00
0.00
0.00
Total Auths
Total Days
Average LOS
Bed Days per
1000
Discharges per
1000
Transplants
Age & Gender Distribution
1/1/2016 - 3/31/2016
Male
Female
Total
Age Categories
19 - 29
30 - 49
50 - 64
13
31
98
34
85
89
47
116
187
0 - 18
24
38
62
65+
32
43
75
Total
198
289
487
Gender Comparison by Age
120
100
89
85
98
80
60
40
38
24
34
43
31
32
Discharges
13
20
0
0-18
0-18
19-29
19-29
30-49
30-49
50-64
50-64
65+
65+
F
M
F
M
F
M
F
M
F
M
*The above table provides a breakout of discharged members by age categories, the above graph provides a comparison of male to female
discharges in the same age categories.
Outpatient Authorizations & Denials
3rd Quarte r Plan Ye ar 2016
1/1/2016 - 3/31/2016
Authorizations
Medical Office Visits
Durable Medical Equipment
Outpatient Surgery
Ambulatory Services
Infusion
Home Health
Mental Health Outpatient
Dialysis
Transportation
Transplant Outpatient
Prenatal Care
Outpatient Therapies
Partial Hospitalization
Totals
362
312
152
44
14
15
8
7
11
0
1
1
1
928
Me d
Me ntal Home
Off
OP He alth He alt Partial
Total
De nials
Visit DME Surg
OP
h
Hosp
Total Number of Denied Requests
19
10
4
0
2
0
0
Denied, Not Medically Necessary
9
3
3
0
2
0
0
Denied, not covered by plan
6
4
0
0
0
0
0
Denied, Insufficient Medical Info
4
3
1
0
0
0
0
Amb
Svcs
3
1
2
0
Appendix A
Medical Discharges by Facility and Level of Care
Facility
ALEGENT HEALTH IMMANUEL MED CTR
ALLINA HEALTH EMS
AURORA BAYCARE MEDICAL CENTER
AVALON WEST HEALTH AND REHAB
BANNER CHURCHILL COMMUNITY HOSPITAL
BARTON MEMORIAL HOSPITAL
CAROLINAS HEALTHCARESYSTEM UNION
CARSON NURSING &REHAB C
CARSON TAHOE BEHAVIORAL HLTH SVCS
CARSON TAHOE REGIONAL MEDICAL CENTER
CARSON TAHOE REGIONAL MEDICAL CENTER
CARSON TAHOE SIERRASURGERY
CARSON VALLEY MEDICAL CENTER
CEDARS SINAI MEDICALCENTER
CENTENNIAL HILLS HOSP MED CTR
CHILDREN'S HOSPITALOAKLAND
CHRISTUS SPOHN HOSPITAL SHORELINE
COMANCHE CO MEMORIALHOSPITAL
CONTINUECARE HOSP OFCARSON TAHOE
DESERT PARKWAY BEHAVIORAL HEALTH
DESERT REG MED CTR
DESERT SPRINGS HOSPITAL
EISENHOWER MEDICAL CENTER
EL CAMINO HOSPITAL
EMORY UNIVERSITY HOSPITAL
FLORIDA HOSPITAL
HAVASU REGIONAL MEDCTR
HEALTHSOUTH HOSPITAL
HEALTHSOUTH REHAB HOSP DESERT CANYON
HEALTHSOUTH SUNRISEREHAB HOSPITAL
HUMBOLDT GENERAL HOSPITAL
HUNTINGTON MEMORIAL
KINDRED HOSPITAL LASVEGAS
Total Admits
Total Days
1
2
3
1
1
3
2
4
3
59
7
1
2
1
21
3
1
2
1
5
1
5
2
1
2
1
1
2
1
1
1
1
4
Level Of Care
1
4
8
20
4
5
13
39
30
556
35
3
3
2
70
15
3
11
21
56
1
44
6
6
12
1
3
46
14
14
5
3
71
Acute
Acute
Acute
SNF
Acute
Acute
Mental Health
SNF
Mental Health
Acute
Mental Health
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Mental Health
Acute
Acute
Acute
Mental Health
Acute
Acute
Acute
Rehab
Rehab
Rehab
Acute
Acute
Acute
ALOS by Level of Care
1.00
2.00
2.67
20.00
4.00
1.67
6.50
9.75
10.00
9.42
5.00
3.00
1.50
2.00
3.33
5.00
3.00
5.50
21.00
11.20
1.00
8.80
3.00
6.00
6.00
1.00
3.00
23.00
14.00
14.00
5.00
3.00
17.75
Facility
LAS VEGAS RECOVERY CENTER
LEGACY VILLAGE REHABILITATION
LIFE CARE CENTER OFPARADISE VALLEY
LIFE CARE CENTER OFRENO
MAMMOTH HOSPITAL
MANOR CARE HEALTH SERVICES-WINGFIELD
MARY GREELEY MEDICALCENTER
MAYO CLINIC HOSPITAL
MAYO CLINIC HOSPITALROCHESTER
MD ANDERSON CANCER CENTR LYMPHOMA
MEDICAL CENTER OF ARLINGTON
MISCELLANEOUS VENDOR
MONTEVISTA HOSPITAL
MOUNTAIN VIEW HOSPITAL
MOUNTAIN VIEW HOSPITAL
NEW FRONTIER TREATMENT CENTER
NORTH AUSTIN MEDICALCENTER
NORTH AUSTIN MEDICALCENTER
NORTH VISTA HOSPITAL
NORTHEASTERN NEV R/H
NORTHERN NV MEDICAL
NORTHWEST MEDICAL CENTER
PONCA CITY MEDICAL CENTER
PRAIRIECARE
PROVIDENCE OF ST JOSEPH
PROVIDENCE PORTLAND
PROVIDENCE PORTLAND
PROVIDENCE WILLAMETTE FALLS MED CTR
RAPID CITY REGIONALHOSPITAL
RENOWN REGIONAL MEDICAL CENTER
RENOWN SOUTH MEADOWS
RONALD REAGAN UCLA MEDICAL CENTER
Total Admits
Total Days
1
2
1
4
1
1
2
1
1
2
1
1
1
22
1
1
1
1
3
5
4
1
1
1
1
1
1
1
1
85
10
1
Level Of Care
7
20
28
43
1
12
9
8
4
18
13
2
5
93
15
12
10
8
10
12
5
1
2
6
1
5
14
10
1
349
18
16
Mental Health
SNF
SNF
SNF
Acute
SNF
Acute
Acute
Acute
Acute
Acute
Acute
Mental Health
Acute
Rehab
Mental Health
Acute
Rehab
Acute
Acute
Acute
Acute
Acute
Mental Health
Acute
Acute
Rehab
Acute
Acute
Acute
Acute
Acute
7.00
10.00
28.00
10.75
1.00
12.00
4.50
8.00
4.00
9.00
13.00
2.00
5.00
4.23
15.00
12.00
10.00
8.00
3.33
2.40
1.25
1.00
2.00
6.00
1.00
5.00
14.00
10.00
1.00
4.11
1.80
16.00
Facility
ROSEWOOD CTR FOR EATING DISORDERS
SALT LAKE REGIONAL MED CTR
SANTA MONICA - UCLAMEDICAL
SENIOR BRIDGES
SEVEN HILLS BEHAVIORAL INSTITUTE
SHRINERS HOSPITALS FOR CHILDREN
SO NV ADULT MENTAL HEALTH SERVICES
SOUTHERN HILLS HOSPITAL
SPRING MOUNTAIN TREATMENT CENTER
SPRING VALLEY HOSP MED CTR
ST MARKS HOSPITAL
ST MARKS HOSPITAL
ST MARYS HOSP & MEDCTR - CO
ST MARYS REGIONAL MED CTR
ST ROSE DOMINICAN HOSPITAL - DELIMA
ST ROSE DOMINICAN HOSPITAL - DELIMA
ST ROSE DOMINICAN SAN MARTIN CAMPUS
ST ROSE DOMINICAN SIENA
SUMMERLIN HOSPITAL MEDICAL CENTER
SUNRISE HOSPITAL & MEDICAL CTR
SUNRISE HOSPITAL & MEDICAL CTR
SUTTER GENERAL HOSPITAL (SAC)
TREASURE VALLEY HOSPITAL
U OF U HOSPITAL CLINICS
Total Admits
Total Days
1
1
1
1
3
1
1
8
4
6
1
1
1
1
5
1
10
33
21
20
1
1
1
9
1
1
3
1
2
13
23
7
46
23
25
16
15
10
1
2
19
27
32
126
102
165
18
6
1
46
5
28
Level Of Care
Mental Health
Acute
Acute
Mental Health
Mental Health
Acute
Mental Health
Acute
Mental Health
Acute
Acute
Rehab
Acute
Acute
Acute
Rehab
Acute
Acute
Acute
Acute
Rehab
Acute
Acute
Acute
Mental Health
Rehab
3.00
1.00
2.00
13.00
7.67
7.00
46.00
2.88
6.25
2.67
15.00
10.00
1.00
2.00
3.80
27.00
3.20
3.82
4.86
8.25
18.00
6.00
1.00
5.11
5.00
28.00
Facility
UCLA CPN SANTA MONICA BAY PHYSICIANS
UCSF MEDICAL CENTER
UHS OF DENVER
UNIVERSITY MEDICAL CENTER-LV
UNIVERSITY OF MIAM HOSP
VA SAN FRANCISCO MEDICAL CENTER
VALLEY HOSPITAL MEDICAL CENTER
WASHINGTON HOSPITAL
WEST HILLS HOSPITAL-NV
WEST HILLS HOSPITAL-NV
WESTERN REGIONAL MEDICAL CENTER
Total Admits
Total Days
1
2
1
10
1
1
3
1
1
15
1
Level Of Care
17
6
17
54
18
2
11
3
15
62
6
Acute
Acute
Mental Health
Acute
Acute
Acute
Acute
Acute
Acute
Mental Health
Acute
17.00
3.00
17.00
5.40
18.00
2.00
3.67
3.00
15.00
4.13
6.00
Performance Standards & Guarantees – Self Reported
1/1/2016 – 3/31/2016
Service Performance Standard
(Metric)
Guarantee Measurement
Pass/Fail
I. Quarterly and annual
management reports
100% - Delivery of Quarterly reports within 45
days of end of reporting period as established by
PEBP.
Pass
II. Notification of potential
high expense cases*
95.0% - Designated PEBP staff will be notified
within 5 business days of the UM vendors initial
notification of requested service.
III. Pre-certification
information shall be provided
to PEBP’s third party
administrator
98% - Pre-certification requests from healthcare
providers shall be communicated to PEBP’s
third party administrator using an approved
method e.g. electronically, within 5 business
days of UM completing pre-certification
determination.
IV. Concurrent hospital
review
98% - Concurrent hospital reviews shall be
completed and communicated using an approved
method e.g. electronically within 5 business
days of determination decision.
Pass
Pass
Pass
*High expense case is defined as a single-claim or treatment plan expected to exceed $1,000,000.
4.3.3.
4.
the Board.
March 31, 2016.
4.3.3.
Carson Tahoe Health – Diabetes Care
Management Program
Carson Tahoe Health
Diabetes Care Management Pilot Program
Quarterly Report for
1/1/16 – 3/31/16
Program Participation Summary
Participation
Quarter
1/1/16 - 3/31/16
Eligible Participants Based on PEBP Criteria
53
Participants Enrolled in Program
Participants Disenrolled from Program
Appointments with Care Manager
28
1
31
Baseline Screening Exams & Tests
n=28
30
25
25
20
19
16
15
12
10
5
0
12
10
8
8
11
12
11
Compliance to Standards of Care
Participants >9 months
n=9
9
Baseline
8
7
7
6
6
5
5
Performance
7
6
6
5
5
4
4
4
1
0
4
3
3
2
5 5
5
2
2
1
2 2
2
2
Average A1c
Participants >9 months
n=9
8.0
7.8
7.6
7.5
7.4
7.2
7.0
6.8
6.8
6.6
6.4
6.2
6.0
Baseline
Performance
Status of Behavior Goals
Behavior
Goals
Action Plan
Goal Description
Pre-Program
Behavior
Current
Behavior
Has action plan & is
following 2 points of
plan
7
26
Blood Sugar
Monitoring
Knows & follows
frequency & target
goals for monitoring
13
25
Diet
Portion control &
carb counting at least
75% of meals
6
26
Behavior
Goals
Exercise
Tobacco
Medications
Goal Description
Exercises minimum of 45xs per wk for 30 minutes;
if exercise restriction more
than before
Taking tobacco cessation
class, medication or
actually quit
Takes consistently, knows
reasons, routes & timing
Pre-Program
Behavior
Current
Behavior
10
17
1
1
21
23
Behavior
Goals
Weight Loss
Problem
Solving
Goal Description
Loses at least 5% of
body weight unless
contraindicated
Able to problem solve
scenarios related to
disease process &
management
Pre-Program
Behavior
Current
Behavior
4
10
10
28
Participant Story
• Has type 2 diabetes
• Currently taking 5 medications
• History of hypertension, high cholesterol &
acid reflux
Participant Progress
– Exercising 5-7 days per wk; 8k-10k
steps per day
– Lost 12 lbs
– A1c down to 6.1%; was 6.9%
– Made large diet changes
– Reports feeling much better
PEBP
Diabetes Care Management Pilot Program
Quarterly Report for
January 1, 2016 – March 31, 2016
CTH Diabetes Care Management Pilot Program
Quarterly Report: 1/1/16 – 3/31/16
Program Overview
State of Nevada Public Employees’ Benefits Program (PEBP) and Carson Tahoe Health
System (CTH) and its provider group, Carson Tahoe Physicians Clinic (CTPC) entered
into a two-year agreement on November 1, 2014 to provide a Diabetes Care
Management Program on a pilot program basis.
The overall goals of the program are:
1.
2.
3.
4.
Improve patient and physician compliance with diabetes standards of care,
Improve patient diabetes self-management,
Improve medication management; and
Reduce the overall medical and pharmacy claims spend for the identified diabetic
population.
Program Participation Summary
During the quarter, 4 new participants enrolled in the CTH Diabetes Care Management
Program for a total enrollment of 28 participants, which represents a 53% participation
rate.
For the quarter, participants had a total of 31 in-person and telephonic 1:1 diabetes
education appointments with the Care Manager with overall program appointments
totaling 123.
Table 1: Program Participation Summary
Participation
Eligible Participants Based on PEBP Criteria
Participants Enrolled in Program
Participants Disenrolled from Program
Appointments with Care Manager
2
Quarter
1/1/16-3/31/16
53
28
1
31
Baseline for Standards of Care
One of the overall program goals is to improve patient and physician compliance with
the standards of care. Baseline data is collected when a participant enrolls in the
program in order to track improvements throughout program.
Patients and physicians are evaluated for compliance with the standards of care after a
minimum of nine months of program participation, which allows for time to implement
lifestyle changes and measure changes at appropriate intervals. Improvement was
demonstrated in 8 of 11 measures with performance maintaining for 2 measures and
decreasing for 1 measure.
Notably, the average hemoglobin A1c decreased 0.7%. An A1c is a blood test that
measures a person’s average blood glucose level over a few months. A1c is the gold
standard measure of long-term glucose control for diabetic patients and a 1% drop in
A1c can reduce long-term complications by 40%.
Figure 1: All active participants’ baseline screening exams & tests (prior to enrollment
in program), if screening performed
Baseline Exams & Tests
n=28
30
25
25
19
20
16
15
10
12
8
10
8
5
0
3
12
11
12
11
Figure 2: Baseline screening exams & tests compared to performance period for
patients who have participated for greater than nine months
Performance - Participating >9 months
n=9
9
Baseline
8
7
7
6
6
5
5
Performance
7
6
6
5
5
5
4
4
4
1
4
3
3
2
5 5
2
2
2 2
1
0
4
2
2
Figure 3: Baseline A1c compared to performance period A1c for patients who have
participated for greater than nine months
Average A1c - Participating >9 Months
n=9
8.0
7.8
7.6
7.5
7.4
7.2
7.0
6.8
6.8
6.6
6.4
6.2
6.0
Baseline
Performance
5
Behavior Goals
People with diabetes can achieve and maintain optimal health by following lifestyle and
behavior changes. Goals and any barriers in achieving them are reviewed at each
appointment. As goals are met and maintained, new ones are set.
Table 2: Active participants’ (n=28) baseline behaviors (prior to program enrollment)
and current behaviors
Behavioral Goals
Action Plan
Blood Sugar
Monitoring
Diet
Exercise
Tobacco
Medications
Weight Loss
Problem Solving
Has action plan & following at
least 2 points of the plan (i.e.
exercise, carb counting,
medication, checking sugars).
Knowledgeable & adheres to
frequency & target goals for blood
sugar monitoring.
Knowledgeable about portion
control & carb counting at least
75% of meals.
Understands importance of &
exercises minimum of 4-5xs per
wk for 30 minutes; if exercise
restriction, patient does more
than pre-program level.
Knows importance of tobacco
cessation, taking cessation class,
medication or actually quit.
Taking medications consistently &
knowledgeable about reasons,
routes & timing.
Loses at least 5% of body weight
unless contraindicated.
Able to problem solve scenarios
related to disease process &
management.
6
Pre-Program
Behavior
Current
Behavior
7
26
13
25
6
26
10
17
1
1
21
23
4
10
10
28
Participant Progress Story
The CTH Diabetes Care Management Program is completely individualized to the
participant based on medical history and current status. Participants set goals and the
Care Manager is there to coach and empower them to take charge of their diabetes
through self-management.
Participant Story
This participant has type 2 diabetes and currently takes 5 medications. Participant has
a history of diabetes, hypertension, high cholesterol and acid reflux.
Pre Program
•
•
•
•
•
Blood sugars were going up
A1c was 6.9%
Was not exercising
Increased cholesterol levels
Not checking blood sugars
Current Program Status
•
•
•
•
•
•
Exercising 5-7 days per week; walking 8,000-10,000 steps per day
Lost 12 pounds
A1c down to 6.1%
Monitoring blood sugars
Made large diet changes
o Increased healthy monounsaturated fats
o Portion size & carb counting
o Changed to whole grains
o Stopped all sugar drinks
o Eating less meats & increased fish intake
o Increased fiber intake
o Increase vegetable intake
Reports feeling much better
7
4.3.4.
4.
the Board.
March 31, 2016.
4.3.4.
The Standard Insurance – Basic Life and Long
Term Disability Insurance
Quarterly Update for
January 01, 2016 to
March 31, 2016 for Plan
Year July 2015 through
June 2016
The Standard
Board Meeting Date: May 19, 2016
Page: 1
Report Table of Contents
Life Insurance & Long-Term Disability Executive Summary
Life Insurance Claims
Life Insurance Earned Premiums & Paid Claims - Active Employees
Life Insurance Earned Premiums & Paid Claims - Retirees
Long-Term Disability Claims
Long-Term Disability Earned Premiums & Paid Claims - Active Employees
Long-Term Disability Claims Diagnoses
Customer Service
Appeals and Complaints
Page: 2
Page 3
Page 4
Page 5
Page 6
Page 7
Page 8
Page 9
Page 10
Page 11
Life Insurance & Long-Term Disability Executive Summary
Quarterly Update for January 01, 2016 to March 31, 2016
Basic Life Insurance Incurred After July 1, 2008 - the Incurred Loss Ratio (ILR) since July 1, 2008 through March
31, 2016 for the Basic Life is 86%. The plan is in a deficit of ($349,749). When analyzing the data by member
category for the same time period and coverages, the ILR is:
— State Actives = 35%
— State Retirees = 315%
— Non-State Actives = 43%
— Non-State Retirees = 194%
Long Term Disability Incurred After July 1, 2008 - The Incurred Loss Ratio (ILR) July 1, 2008 through March 31,
2016 is 105% and the plan is in a deficit of ($8,403,233). The ILR by member category is:
— State Actives = 105%
— Non-State Actives = 104%
Page: 3
1st Month
2nd Month
3rd Month
Jan-16
Feb-16
Mar-16
Quarter
Total
YTD Total
Jul-15 through Jun-16
Active Employees
Basic Life
State Employees
Non-State Employees
Totals
Retirees
Basic Life
State Retirees
Non-State Retirees
Totals
1
0
1
2
0
2
0
0
0
3
0
3
44
0
44
12
4
16
8
1
9
0
0
0
20
5
25
101
44
145
Total Claims
17
11
0
28
189
Page: 4
Life Insurance Earned Premiums & Paid Claims - Active Employees
Quarterly Update for Plan Year to Date July 01, 2015 to March 31, 2016
$3,500,000
$1,200
$3,000,000
$1,000
$2,500,000
$800
$2,000,000
$600
$1,500,000
$400
$1,000,000
$200
$500,000
$0
Q1
Earned Premium $1,041,242
Paid Claims
$225,000
$0
Q2
Q3
Q4
$2,097,101
$3,170,350
$0
Earned Premium
$0
Paid Claims
$547,500
$672,500
Q1
Q2
Q3
Q4
$355
$722
$1,104
$0
$0
$0
$0
$0
State Active Employees
Non-State Active Employees
Reported cumulatively for current plan year, beginning 7/1
Claims figures do not include Active Claim or IBNR Reserves
Page: 5
Life Insurance Earned Premiums & Paid Claims - Retirees
$2,000,000
$900,000
$1,800,000
$800,000
$1,600,000
$700,000
$1,400,000
$600,000
$1,200,000
$500,000
$1,000,000
$400,000
$800,000
$300,000
$600,000
$400,000
$200,000
$200,000
$100,000
$0
Earned Premium
Paid Claims
Q1
Q2
Q3
Q4
$209,950
$419,923
$628,508
$0
$0
$607,917
$1,146,667
$1,759,792
$0
Q1
Q2
Q3
Q4
Earned Premium
$110,137
$218,094
$324,049
$0
Paid Claims
$259,667
$480,917
$797,167
$0
State Retirees
Non-State Retirees
Page: 6
State Employees
Non-State Employees
Totals
1st Month
2nd Month
3rd Month
Jan-16
Feb-16
Mar-16
0
0
0
0
0
0
0
0
0
Page: 7
Quarter
Total
0
0
0
YTD Total
4
0
4
Long-Term Disability Earned Premiums & Paid Claims - Active Employees
$4,000,000
$45,000
$3,500,000
$40,000
$3,000,000
$35,000
$30,000
$2,500,000
$25,000
$2,000,000
$20,000
$1,500,000
$15,000
$1,000,000
$10,000
$500,000
$5,000
$0
Q1
Earned Premium $1,109,203
Paid Claims
$538,264
Q2
Q3
Q4
$2,234,459
$3,378,246
$0
$0
$1,067,667
$1,814,557
$0
Q1
Q2
Q3
Q4
Earned Premium
$381
$773
$1,180
$0
Paid Claims
$866
$20,159
$40,537
$0
State Active Employees
Non-State Active Employees
Page: 8
Long-Term Disability Claims by Diagnosis - Active Employees
25%
18%
16%
20%
14%
12%
15%
10%
8%
10%
6%
4%
5%
2%
0%
%
Back
Bone/ Joint/
Muscle
Heart/ Circ
Cancer
Mental
Disorders
20%
17%
13%
12%
9%
0%
%
Heart/ Circ
Back
Nervous
Bone/ Joint/
Muscle
Cancer
16%
16%
14%
12%
10%
Top 5 by Incidence
Top 5 by Liability
Rolling Five Years April 01, 2011 to March 31, 2016
Rolling Five Years April 01, 2011 to March 31, 2016
Page: 9
Customer Service
1st Month
2nd Month
3rd Month
Mar-16
Quarter
Total
Jan-16
Feb-16
121
55
19
66
261
128
42
11
96
277
Year to Date
232
50
30
100
412
481
147
60
262
950
1,669
546
206
893
3,314
Customer Service
Enrollment Calls
Life/Disability Benefits Calls
Coverage Continuation Calls
Other Calls
Total Calls Received
Page: 10
Appeals and Complaints
1st Month
2nd Month
3rd Month
Mar-16
Quarter
Total
Jan-16
Feb-16
0
0
0
0
1
1
Year to Date
0
0
0
0
1
1
0
5
5
Appeals and Complains
Total Appeals
Page: 11
4.3.5.
4.
the Board.
March 31, 2016.
4.3.5.
Towers Watson’s One Exchange – Medicare
Exchange
The Public Employees’ Benefits Program
Quarterly Update – 3rd Quarter Plan Year 2016
Presented By: Willis Towers Watson’s OneExchange
Date: May 19th, 2016
willistowerswatson.com
The Public Employees’ Benefits Program | 2
Executive Summary
At the end of Q3 2016, PEBP’s total enrollment into Medicare policies through Willis Towers Watson’s
OneExchange slightly decreased to 12,557. Since inception, 85 plans across carriers have been selected
by PEBP’s retirees. Medicare Supplement (MS) plan selection remains at 74% of the total population
with the majority of participants selecting AARP and Anthem BCBS of Nevada as their insurer; each
carrier holds plans for 5,590 and 2,280 enrollees respectively. The average monthly cost for MS plans
decreased slightly from last quarter to $149. The percentage of Medicare Advantage (MA or MAPD)
plans selected remains constant at 26%, which is slightly above the average for OneExchange’s Book of
Business (BOB). OneExchange believes this is a result of our high-quality offering of MA plans to State
of Nevada retirees. Top MA carriers include Health Plan of Nevada with 1,267 individual plan selections
and Hometown Health Plan with 1,056 individual plan selections. The average premium cost to PEBP
retirees is $24, which is consistent with the prior quarter.
PEBP participant satisfaction with Enrollment increased slightly from the previous quarter. Enrollment
satisfaction results increased from 4.2 for Q2 to 4.5 for Q3 with 63 Enrollment surveys submitted. The
Service satisfaction score results remained at a 3.9 when compared to the prior quarter with 593
survey submissions (compared to 553 surveys for Q2). The combined score for Enrollment and Service
decreased slightly last quarter by one point from 4.0 to 3.9.
There were 10,932 Health Reimbursement Arrangement (HRA) accounts established by PEBP
participants at the end of Q3. There were 118,508 claims submitted against the HRA for
reimbursement in Q3, with a total reimbursement amount of $11,370,958.20.
The “Office Hours” pilot program that was kicked off in September, 2015 continued into the first part
of 2016 with two days of meetings in Carson City at the end of January. A new approach was taken in
Carson City with a larger HRA focused presentation in the morning followed by individual
appointments.
In March, OneExchange held Retiree Meetings in Winnemucca, Elko, and Ely with presentations for
those who will become Medicare eligible in the coming months as well as those who are already
Medicare eligible with a focus on the HRA. While the attendance was not as high as anticipated at
these meetings the participants gained knowledge regarding Medicare Enrollment and how to
effectively use the HRA.
On March 24th, 2016, representatives of PEBP meet with OneExchange in Salt Lake City where it was
agreed that the pilot program would continue for another 3 – 4 months. A meeting for April 19th was
created for Las Vegas with the larger meeting in morning and individual appointments in the
afternoon. Attendance for the April 19th meeting was over 120 people.
OneExchange attended a RPEN sponsored Retiree meeting in Las Vegas on April 20 th with a
presentation that focused on the HRA. Representatives from UNLV attended the meeting to also gain
additional knowledge about OneExchange and the HRA.
CONTENTS
Executive Summary
2
Summary of Retiree Decisions and Costs
5
Summary of Retiree Carrier Choice
6
State of Nevada Post-65 Market Summary
7
Customer Service – Voice of the Customer (VoC)
8
Customer Service – Issues Log Resolution
9
Health Reimbursement Account (HRA)
10
Performance Guarantees
11
Summary of Retiree Decisions and Costs
RETIREE PLAN SELECTION THROUGH 03/31/2016
PREVIOUS QTR
Total Enrolled Through OneExchange
12,557
12,572
Number Of Carriers**
85
85
Number Of Plans**
859
859
PLAN TYPE SELECTION THROUGH 03/31/2016
PREVIOUS QTR
Medicare Advantage (MA, MAPD)
3,280 (26%)
3,308 (26%)
Medicare Supplement (MS)
9,293 (74%)
9,289 (74%)
Medicare Advantage
Medicare Supplement
26%
“The percentage of Medicare Advantage plans selected
by PEBP’s retiree population is slightly above the average
for OneExchange’s BOB. TWOE believes this is a result of
the high-quality offering of Medicare Advantage plans to
State of Nevada retirees through OneExchange.”
74%
PLAN TYPE
NUMBER ENROLLED
AVERAGE PREMIUM
Medicare Supplement
9,293
$149
Medicare Advantage
3,280
$ 24
Part D Drug Coverage
8,024
$ 29
Dental Coverage
1,279
$ 32
Vision Coverage
1,340
$ 14
** Reflects total carriers and plans that PEBP retirees have enrolled in nationwide, since inception.
Summary of Retiree Carrier Choice
TOP MEDICARE SUPPLEMENT PLANS
TOTAL
AARP
Anthem BCBS of NV
United of Omaha
Humana
Aetna
5,590
2,280
573
308
141
COST DATA FOR MS PLANS
COST
Minimum
Average
Median
Maximum
$ 22
$ 149
$ 144
$ 339
TOP MEDICARE ADVANTAGE PLANS
Health Plan of NV
Hometown Health Plan
Humana
Aetna
United Healthcare
TOTAL
1,267
1,056
441
163
79
COST DATA FOR MA PLANS
Minimum
Average
Median
Maximum
COST
$ 0
$ 23
$ 0
$ 208
TOP MEDICARE PART D (RX)
Humana
AARP Part D from United Healthcare
SilverScript
Coventry Health
Cigna Health Spring
TOTAL
3,574
2,409
703
510
244
COST DATA FOR PART D
Minimum
Average
Median
Maximum
COST
$ 13
$ 28
$ 26
$ 134
Medicare Supplement Plan Choice
3% 2%
5%
AARP
6%
Anthem
United of Omaha
24%
60%
Humana
Aetna
All Others
Medicare Advantage Carrier Decisions
5%
2%
7%
40%
14%
Health Plan of
NV
Hometown
Health
Humana
Aetna
United
Healthcare
33%
Medicare Part D (RX)
Humana
3%
8%
5%
AARP from UH
9%
45%
SilverScript
Coventry Health
32%
Cigna
HealthSpring
State of Nevada Post-65 Market Summary
STATE OF NEVADA MEDICARE ADVANTAGE PLANS
Reno: Sparks and
Washoe County
Carson City
Las Vegas: Clark County
Plan Options
Carriers
Price Range
Plan Options
Carriers
Price Range
Plan Options
Carriers
Price Range
STATE OF NEVADA MEDICARE SUPPLEMENT PLANS
Reno: Sparks and
Washoe County
Carson City
Plan Options
Carriers
Price Range
Plan Options
Carriers
Price Range
Plan Options
Carriers
Price Range
STATE OF NEVADA MEDICARE PART D (RX)
Reno: Sparks and
Washoe County
Carson City
Plan Options
Carriers
Price Range
Plan Options
Carriers
Price Range
Plan Options
Carriers
Price Range
NOTE: Plan availability reflect 2016 options as of 1/1/2016 for a 65 year old male.
PLAN TOTAL
9
3
$0 - $245
4
1
$24 - $185
10
5
$0 - $126
PLAN TOTAL
20
4
$77 - $310
20
4
$77 - $310
20
4
$90 - $348
PLAN TOTAL
23
9
$16-$127
23
10
$0 - $127
23
9
$16 - $127
Customer Service – Voice of the Customer (VoC)
OneExchange conducts phone and email surveys of all participant transactions. Each survey contains
approximately 12-16 questions. Responses are scanned by IBM Mindshare Analytics which expose
trends within an hour, alerting OneExchange of issues and allowing for real-time feedback and
adjustments.
Q3 ENROLLMENT SATISFACTION
CSAT SCORE
COUNT
%
5
41
65%
4
18
28%
3
1
2%
2
0
0%
1
3
5%
63
100%
5
4
4.5
4.2
4.5
3
2
1
Q1
Q2
Q3
4.0
3.9
3.9
Q1
Q2
Q3
4.1
4.0
3.9
Q1
Q2
Q3
Q4
Q3 SERVICE SATISFACTION
COUNT
%
5
5
285
48%
4
4
130
21%
3
72
12%
2
40
7%
2
1
71
12%
1
598
100%
CSAT SCORE
3
Q4
Q3 ENROLLMENT & SERVICE COMBINED
COUNT
%
5
5
326
50%
4
4
148
22%
3
73
11%
2
40
6%
2
1
74
11%
1
661
100%
CSAT SCORE
3
Q4
Customer Service – Issues Log Resolution
Each quarter a certain number of participant inquiries are received by both PEBP and OneExchange
that require escalation to OneExchange’s Issues Log. Items on the Issues Log are carefully evaluated
and continuously monitored by seasoned OneExchange staff until resolution is reached. The total
number of inquiries reviewed during Q3-PY16 is 204 and are associated with the following categories:
Customer Experience
Enrollment Request
13
8
Enrollment Status
Automatic Reimbursement
39
11
HRA
49
Reimbursement/Claims
84
Enrollment
Status
20%
Enrollment
Request
4%
Reimbursement
/ Claims
44%
HRA
26%
Automatic
Reimbursement
6%
Health Reimbursement Arrangement (HRA) Account
CLAIM ACTIVITY FOR THE QTR
TOTAL
HRA Accounts
10,932
Number of Claims Paid
77,142
Accounts with no Balance
4,911
Claims Paid Amount
$11,370,958.20
CLAIMS BY SOURCE
TOTAL
A/R File
67,797
Mail
48,169
Web
2,542
CALL CATEGORY
General / Instructional
TOTAL
2,319
Denial Reason Explanation
627
Other
561
Form Requests
280
Was Fax Received
190
Performance Guarantees
CATEGORY
COMMITMENT
OUTCOME
PG MET
Claims Turnaround Time
≤ 2 days
1.78 days
Yes
Claim Financial Accuracy
≥ 98%
99.57%
Yes
Claim Processing Financial Accuracy
≥ 98%
99.43%
Yes
HRA Call Center Abandon Rate
≤ 5%
6.16%
No*
HRA Customer Service - Avg Speed To Answer
≤ 30 sec
192 sec
No*
Reports
≤ 10 Business days
As Scheduled
Yes
HRA Web Services
≥ 99%
Uptime > 99%
Yes
Benefits Admin Customer Service Avg Speed to
Answer Q3 (1/1 – 3/31)
≤ 5 Q1
2.60 minutes
Yes
*Call volumes to the HRA Customer Service Center in Q3 2016 were larger than anticipated. Additional staffing was trained
and added to the center but the results were not able to be corrected enough to meet the measures.

4. Consent Agenda (Leo Drozdoff, Chair) (All Items for Possible

Transcription

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