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

Transcription

11.
11. 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.
11.1. Approval of the Action Minutes from the June 17,
2016 PEBP Board Meeting.
11.2. Receipt of quarterly staff reports for the period
ending March 31, 2016:
11.2.1. PEBP Chief Financial Officer Reports
11.2.1.1. Budget Report
11.2.1.2. Utilization Report
11.2.2 PEBP Operations Officer Report
11.1.
11.1. Approval of the Action Minutes from the June 17,
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
Video conferenced to:
University of Nevada Las Vegas
Systems Computing Services Building
4505 South Maryland Parkway Room 102
Las Vegas, Nevada 89154
--------------------------------------------------------------------------------------------------------------------ACTION MINUTES (Subject to Board Approval)
June 17, 2016
MEMBERS PRESENT
IN CARSON CITY:
MEMBERS PRESENT
IN LAS VEGAS:
Mr. Leo Drozdoff, Board Chair (joined at 9:17 a.m.)
Ms. Jacque Ewing-Taylor, Vice-Chair
Ms. Ana Andrews, Member
Mr. Don Bailey, Member
Mr. Tom Verducci, Member
Mr. James Wells, Member (joined at 9:31 a.m.)
Mr. Chris Cochran, Member (joined at 9:26 a.m.)
Ms. Rosalie Garcia, Member
Ms. Christine Zack, Member
MEMBERS EXCUSED:
Ms. Judy Saiz, 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. Nancy Spinelli, Public Information Officer
Ms. Kari Pedroza, Executive Assistant
1. Open Meeting; Roll Call
Vice-Chair Ewing-Taylor opened the meeting at 9:01 a.m. Vice-Chair Ewing-Taylor
outlined that Public Comment would be taken as indicated in the Agenda and another
opportunity for Public Comment would also be taken specifically about the HMO RFP,
Agenda Item 5 under that item.
2. Public Comment
Public Comment in Carson City:
 Peggy Lear Bowen- Retiree Participant (see attached for comments)
 Marlene Lockard- Retired Public Employees of Nevada (RPEN)
Public Employees’ Benefits Program Board
Friday, June 17, 2016
Minutes – Page 2
Public Comment in Las Vegas:
 Conrad Wilson- Past chair of the classified staff counsel in LV
3. Action ItemPublic Hearing to receive comment and take possible action on the proposed adoption,
amendment, and repeal of regulation (LCB File No. R028-16), including but not limited to,
revising the date that certain participants are eligible to participate in the Program.
Executive Officer Damon Haycock went over the proposed adoption, amendment and repeal
of regulation LCB File No. R028-16.
There were none.
Board ActionMOTION:
BY:
SECOND:
VOTE:
Move to approve the motion for the R028-16 to be approved by the
Board.
Member Bailey
Member Verducci
Unanimous; the motion carried.
4. Action ItemConsent Agenda
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 changes 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
Board Action on Items 4.1, 4.3.4 & 4.3.5.MOTION:
Move to approve Items 4.1, with the one-word change (board
members absent be changed to excused), 4.3.4 and 4.3.5.
BY:
Vice-Chair Ewing-Taylor
SECOND:
Member Bailey
VOTE:
Board Action on Item 4.2.MOTION:
Move to approve Item 4.2., with inclusion of the Center for Disease
Control guidelines in the definition for Reasonable and/or
Reasonableness as another entity that the plan administrator will
consider.
BY:
SECOND:
VOTE:
Minutes – Page 3
Member Andrews
Board Action on Item 4.3.1.MOTION:
Move to approve Item 4.3.1., with one change on plan year 2016 on
page 7.
BY:
Member Andrews
SECOND:
Member Garcia
VOTE:
Move to approve the report as provided with additional information
pending.
BY:
Member Cochran
SECOND:
Member Zack
VOTE:
Move to approve Item 4.3.3.
BY:
Member Andrews
SECOND:
Member Bailey
VOTE:
BOARD DIRECTION: The Board asked Pam Puckett of Carson Tahoe Health (CTH)
to provide an A1C progress break-down for each of the nine individuals who had an
average reduction of their A1C. The Board would like A1C information for each
individual showing where they were when they began the program and where they are
currently. CTH will provide the information to PEBP staff and PEBP staff will share
this information with the Board.
5. Action ItemHealth Claim Auditors, Inc. quarterly audit of HealthSCOPE Benefits (HSB) for the
timeframe January 1, 2016 – March 31, 2016.
5.1.
5.2.
5.3.
Report from Health Claim Auditors. (Robert Carr III, Health Claim Auditors)
HealthSCOPE Benefits response to audit report. (Mary Catherine Person, HSB)
Accept audit report findings and assess penalties, if applicable, in accordance with the
performance guarantees included in the contract pursuant to the recommendation of
Health Claim Auditors.
Board ActionMOTION:
BY:
SECOND:
VOTE:
Move to accept the audit report and access the penalties as outlined
in Health Claim Auditors’ report.
Member Wells
Member Verducci
6. Action ItemDiscussion and possible action regarding the following opportunities for Plan Year 2017
beginning July 1, 2016
Minutes – Page 4
6.1.
New reduced cost CDHP national network access for members living outside of
Nevada;
6.2
Utilizing existing Third Party Administrator (HealthSCOPE Benefits), contract with
a telemedicine vendor for virtual visits.
Move to allow Mary Catherine Person with HealthSCOPE Benefits
to make a selection relative to a network administrator for
participants residing outside of Nevada and allow her to make that
decision based on her analysis and taking into consideration Board
concerns about the sharing of protected information.
BY:
SECOND:
Member Bailey
VOTE:
Move that the Board authorize the third party administrator,
HealthSCOPE Benefits to contract with the telemedicine vendor for
virtual visits effective July 1, 2016.
BY:
SECOND:
Member Andrews
VOTE:
As Member Wells was not present at the meeting during the time that Item 3 was discussed, he
requested that the Board revisit the Item briefly.
3. Action ItemPublic Hearing to receive comment and take possible action on the proposed adoption,
amendment, and repeal of regulation (LCB File No. R028-16), including but not limited to,
revising the date that certain participants are eligible to participate in the Program.
Member Wells shared his concern that the proposed regulation language in Section 1,
subsection 3 (Page 2) in regards to when an employee who got approved leave without
pay, elected not to pay premium and then returns to work is eligible for coverage, is not
consistent with the other language in this regulation outlining eligible dates of
coverage.
Executive Officer Haycock agreed with Member Wells that the language is not
consistent and stated that the language would be changed to provide consistency.
Board ActionMOTION:
BY:
SECOND:
VOTE:
Move that we amend Regulation R028-16 to incorporate language in
to Section 1, subsection 3, regarding coverage being effective of the
1st of the month on or after the date that they come back from leave
without pay.
Member Wells
Member Andrews
The motion carried with Member Garcia opposed.
7. Action ItemDiscussion and possible action regarding Board approval of a PEBP sponsored Statewide
Survey to participants about Plan Year 2018 benefits.
Board ActionMOTION:
BY:
SECOND:
VOTE:
Minutes – Page 5
Move to proceed with the survey as presented with
suggested inclusions from the Board (identify what the
enhanced benefits are, add two questions regarding current
plan and premium and acceptable premium increase range,
add general health questions, and general demographic
questions).
Member Verducci
Member Garcia
Unanimous; the motion carried
8. Information/Discussion ItemDiscussion regarding the results of the PEBP Board survey provided to PEBP staff.
Vice-Chair Ewing-Taylor presented the PEBP Staff survey results to the Board. She
explained that it had been her intention to analyze all of the qualitative data that was
collected in the written comments so that the results would reflect general themes as
opposed to verbatim responses but she ran out of time.
The Board discussed the option of Vice-Chair Ewing-Taylor bringing the results of the
written comments after they were analyzed and summarized back to the Board. She
stated that she could do that but would have to bring back the results in August or
September. Board Chair Drozdoff offered to meet with any PEBP staff who wanted to
provide feedback or expand on their comments to the survey one-on-one.
9. Action ItemDiscussion and possible action including approval of the Draft Overview of the Scope of Work
and Scoring Criteria for Request for Proposals.
9.1. Health Maintenance Organization (HMO) services; and/or
9.2. Exclusive Provider Organization (EPO) services.
Board ActionMOTION:
BY:
SECOND:
VOTE:
Move that we accept the HMO RFP overview as outlined on slide ten,
the scope of work as outlined on slide 11, and the criteria as outlined
on slide 14 with the preferences for the meeting exceeding statewide,
open access, out of area services and that we continue to evaluate the
feasibility of an EPO option for some future date.
Member Wells
Member Verducci
10. Action ItemDiscussion and possible action for contracts terminating on June 30, 2017.
10.1. Ratification of a four year contract extension for Self-funded PPO Dental Network to
Diversified Dental Services Inc.;
10.2. Ratification of a five year contract extension for health plan auditing services to Health
Claim Auditors, Inc.; and
10.3. Ratification of a two year contract extension for voluntary home, auto, and property
insurance to Liberty Mutual Insurance.
Minutes – Page 6
Board Action on Items 10.1., 10.2. & 10.3.MOTION:
Motion that the state have the authority to go forward extending the
current contracts and the dental service, Liberty Mutual and Health
Claim Auditors for the time frames specified.
BY:
Member Bailey
SECOND:
Member Andrews
VOTE:
The motion carried with Member Cochran abstained.
11. Action ItemDiscussion and possible action regarding the portability of Health Reimbursement
Arrangement (HRA) Account authority from the Consumer Driven Health Plan to the
Medicare Exchange HRA.
Board ActionMOTION:
Move that the Board reject the Staff recommendation and move
forward with allowing portability of the HRAs for retiring people and
have HealthSCOPE work with Towers Watson to make that happen.
BY:
SECOND:
Member Garcia
Vice-Chair Ewing-Taylor and Member Garcia withdrew the motion.
MOTION:
BY:
SECOND:
VOTE:
Move that the Board ask staff to conduct financial analysis to include
OPEB liability, rates, the Medicare Exchange cost that is currently
absorbed by the CDHP and HMO participants and a formal position
from RPEN and bring this back to the next Board meeting.
Member Bailey
13. Information/Discussion ItemExecutive Officer Report.
Damon Haycock presented his report to the Board regarding the overall activities of PEBP.
12. Action ItemDiscussion and possible action regarding Towers Watson’s OneExchange’s Service
Improvement Plan.
Board ActionThere was no action taken on this Item. This Item will be added to the next Board meeting
agenda.
14. Public Comment
 Marlene Lockard- Retired Public Employees of Nevada (RPEN)
 There were none.
15. Adjournment
Chair Drozdoff adjourned the meeting at 3:29 p.m.
Public Comment under Item 2:
Peggy Lear Bowen: Good morning. My name and words for the record, P-e-g-g-y, space, L-e-ar, space, Bowen, space, B-o-w-e-n, Lear is L-e-a-r. I want to thank you very much for all the
work you're doing and how hard you are to protect the state insurance program for the present
day workers and for those who have retired and their spouses and significant others. I want to
thank you very much. I also want to thank you for the work you've done regarding those who I
nicknamed the orphans a few years ago during the legislative sessions who came from other
entities to become part of PEBP at that juncture.
And when we were brought forward, we were brought forward with the idea that if you have the
retirees from other agencies within the state government and things like that, such as teachers,
that you would maybe someday have your actives also in making a stronger program simply by
the numbers.
Well, at the end of last meeting -- I've learned a few lessons in the years that I've been around.
And the lesson that I've learned most recently is never make assumptions. Find out why people
have the passion they have and the direction they're going because it's based on their background
and never take anything personally.
Well, in the conversation with Mr. Wells after the last meeting, it was done in a public setting
with other people hearing, I understood why we worked so hard regarding those who were not
part of the state workers and such and related to the state workers as such, that Mr. Wells said
very clearly, and he has substantiated this year after year by his actions, that he never wanted the
retirees that were brought about in to the program because he felt, I'm going to say, and now I'm
making an assumption, it would harm the program, that it would take the program's financial
background down.
I want to suggest to you in the last motion that was passed for what you would be discussing and
working on maybe at this meeting, probably at this meeting, of the idea of bringing back that
legislative packet that failed in the legislature last legislature about sending the workers back to
where they came from, regardless of what that impact would be on those workers who joined the
state after being enticed to join the state who were not state workers. He felt it was -- it harms the
program, from his point of view, it makes other people in the program pay for people that didn't
pay in to the system when they were working as such as teachers in Clark County, teachers
across the state, and other entities that were brought in.
I'm going to suggest to you that this program as a whole made some commitments that I would
hope that you would not put in your RFP. The idea of bringing back the concepts of sending
people away and making the system stronger by, in fact, weakening it because you didn't keep
the promises that brought people in in the first place. And it is very important that the
privatization of your insurance company gets the State of the Nevada out of the retiree system.
All of those people who work for the State of Nevada, the A and B folk that were sent across the
lines to Utah, we heard were sold. And I made a comment last time of they were sold to a
company. And I made a comment last time, well, what about are the role that is going to be
there.
Mr. Wells' response to me quite some time ago was it depends on who the insurance company is,
which makes me believe that the monies that the State of Nevada through their PEBP program
provides to those people who work for the State of Nevada and earn this insurance as state
employees that that money has been convoluted or transferred and that you are only the conduit
of the money regarding your A and B Medicare folk. And you have other entities paying for their
insurance in terms of handling what their benefits are, who they can do, what they can see, and
how it's done. And it didn't come to light until we started looking at maybe not having
Hometown Health being your carrier.
You must, must realize that if you indeed fact quoting Senior Care Plus in talking about their
insurees with the state sold A and B Medicare folk, and that's beyond Hometown Health. I
believe you have other entities that are covered by those people, sold those people to a company,
and all you're doing is being a conduit. And the fact that the state provides other monies to help
assist, those people are dying in the Medicare hold because the state is unable to -After you've sold something I guess you can't affect the contract or maybe you can through
whatever you negotiate or do. But it's only fair to those thousands of people that you have on A
and B Medicare that the state has some responsibility for their insurance, for what their coverage
is, what their benefits are. And you don't have people dying because they can't afford their
medication, they can't afford -- And diabetic medication is the one that has hit the level. As soon
as something becomes very expensive, they cut the insurance coverage, but they get more
payback from the Medicare, from Medicare for how sick their people are. You cut their
medication, ability to pay for their medication, they get sicker, the insurance companies get more
money.
And so I need you to maybe look at it in a little different perspective about what your
responsibilities are for your A and B folk who other jobs are paying for their insurance basically
by virtue of their Medicare coverage which with you -- the state does not offer. And I got a little
wrapped up. But it is so important that you take back your folk either financially, fiscally,
covering the doughnut hole, however possible, that you -- you may have sold them but you didn't
sell the fact they worked for you for 27, 29, 35, 40 years. You didn't sell that. That commitment
was to the State of Nevada and that responsibility still stands. If you want to have coverage for
them through the A and B and the people you sold them to, fine. But you can't as an entity work
on a benefit for them from the State of Nevada for their service that covers what is killing them
right now.
Peggy Lear Bowen: My name and words for the record, P-e-g-g-y Lear, L-e-a-r, Bowen, B-o-we-n. And it's only that included under repeal sections under section four on page four, because it
was included as a person or critical labor shortage, are we -- do we have an addressed critical
labor shortage person coming back in after being retired and receiving both? Are we eliminating
whether a person with critical labor shortage needs to be defined, or is the fact that they're still
retired and receiving the other retirement. In other words, if I go back to work and in a critical
labor shortage area, will I still be able to be covered by insurance?
Executive Officer Haycock answered Ms. Bowen’s question.
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. A few things that came up today. The discussion you had about people who are
coming back from work after they were off work without pay. Much discussion in the lunch
room, the concern is that if they start up on the 14th of the month, they haven't paid the premium
from one to 13 of that month, and therefore they would be getting a gift, so to speak.
I would hope and pray that you would reconsider having an option available for them if they
want to pay the premium beginning that month of when they were brought back to work or when
they went back to work that they'd have the option for paying the premium that would have been
due had they been a working person at that time instead of out of work without pay, that sort of
thing. At least give them an option so that they have their insurance. That's number one.
Your telemed, I'm concerned that it is only for face time through technology with a doctor with
telemed. For those of us who are not going to get sick between eight to five on a weekday and
who are not -- who are not connected that they don't get a bonus for using telemed because that
would be a fine for others who don't telephonically or computer wise electronically connected,
that it's kept as an equal basis. It's just another option for people to get help with their doctors.
For a lot of people this is the situation. We call the nurse. The nurse says you got to go to urgent
care. You go to urgent care and they tell you have to go to the hospital. And you get to the
hospital and the hospital says, we don't have any reason to admit you. There are lots of bills that
have been incurred because you followed direction. And I don't want them ever to be deemed as
not payable and covered by our insurance because it wasn't determined as being urgent or an
emergency by when you finally got to the hospital.
And so we need to word craft and work with that situation so that nobody is penalized for
utilizing the options that they have available for them to use and not to assume that everybody is
going to get the smart phone and all of that other stuff. Okay. Cancel that one.
And I've heard a lot of things about the reserves being used up. But I remember Ms. Marlene's
comment a few meetings ago about, well, what about the new reserves. It's like the piggy bank is
empty but in fact from what I'm hearing that money is being built up in the accounts as we speak.
And you're saying no. If that's not the case, then we need to put it by this board on the record
what's happening with potential new reserves or any other reserves, not just the old ones.
Then the survey, again, pertaining to the technical part, I would hope that everyone would
receive a survey. And I want it in writing, in print, and electronically so that people can do them.
But I want – I would hope and pray -- God, that was rude. I apologize. I would hope and pray
that you would consider your survey so valuable that every single person receives it in a capacity
that they can fill it out and return it to you and have it set up so that if, oh, if you're on the HMO,
answer this part of the survey, and what if you're considering going to the high deductible. Well,
what would your answers be over there and vice versa. So that you get a whole picture of a
person who has options and that it is in writing and not just electronically done. Do both. Do a
blend. Because you truly want your survey back and not necessarily the means by which it was
sent.
And I love you all and I hope all is well. And I don't want anybody left behind. Everything is
done and thank you for all your hard work.
11.2.1.
11.2.1.1. Budget Report
11.2.1.1.
11.2.1.1.
Budget Report
STATE OF NEVADA
901 S. Stewart Street, Suite 1001
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
Date:
June 17, 2016
Item Number:
11.2.1.1
Title:
Chief Financial Officer Report
Summary
This report addresses the Operational Budget as of March 31, 2016 to include:
1. Budget Status
2. Budget Projections
3. Claims Summary
Budget Account 1338 – Operational Budget – Shown below is a summary of the
operational budget account status as of March 31, 2016 with comparisons to the same
period in FY 2015. The budget status is reported on a cash basis and does not include
incurred expenses and income owed to the fund.
The budget status report reflects actual income of $238.1 million as of March 31, 2016
compared to $231.8 million as of March 31, 2015 or an increase of 2.7%. Total expenses
for the period have increased $14.4 million or 5.9% for the same period.
The budget status report shows Realized Funding Available (cash) at $122.1 million.
This compares to $155.5 million for last year. After subtracting $31.1 million for
reserves for Incurred but not Reported (IBNR) claims, $23.7 million for the Catastrophic
Reserve and $31.3 million for the HRA Reserve, the remaining balance is $36.0 million
in Excess reserves. The table below reflects the actual revenue and expenditures for the
period. Although 75% of the fiscal year has elapsed total income is at 72% of budgeted,
total expenses are at 70% of budgeted and realized funding (Excess Reserves) is at 116%
of budgeted.
June 17, 2016
Page 2
Operational Budget 1338
Beginning Cash
FISCAL YEAR 2016
Actual as of
3/31/2016
Work Program
143,516,188
143,516,188
Premium Income
All Other Income
Total Income
236,684,386
1,416,556
238,100,942
328,625,786
1,413,838
330,039,624
72%
100%
72%
230,967,886
844,716
231,812,602
311,515,729
1,211,219
312,726,948
74%
70%
74%
Personnel Services
Operating - Other than Personnel
Insurance Program Expenses
All Other Expenses
Total Expenses
1,577,750
3,113,908
254,040,437
830,174
259,562,268
2,311,555
5,088,364
359,657,508
1,349,245
368,406,672
68%
61%
71%
62%
70%
1,513,615
4,674,229
238,257,623
701,770
245,147,238
2,096,382
5,306,381
329,625,600
1,010,542
338,038,904
72%
88%
72%
69%
73%
(21,461,327)
(38,367,048)
(13,334,635)
(25,311,956)
REALIZED FUNDING AVAILABLE
122,054,861
105,149,140
155,493,509
143,516,188
Incurred But Not Reported Liability
Catastrophic Reserve
HRA Reserve
(31,087,000)
(23,700,000)
(31,298,890)
(31,087,000)
(23,700,000)
(31,298,890)
(44,000,000)
(30,300,000)
(17,011,515)
(44,000,000)
(30,300,000)
(17,011,515)
NET REALIZED FUNDING
AVAILABLE
35,968,971
19,063,250
64,181,994
52,204,673
Change in Cash
Percent
100%
116%
FISCAL YEAR 2015
Actual as of
Fiscal Year
3/31/2015
2015 Close Percent
168,828,144 168,828,144
100%
108%
Current Budget Projections
The following table represents projections for FY16 based on data available as of March
31, 2016. The projection reflects total income to be more than budgeted by 3.1%, total
expenditures are more than budgeted by 3.8%, offset by total reserves that are also more
than budgeted by 27.3% (an increase in reserves is depicted by a negative number) when
adjusted for the work program (budget amendment) which reduced the budgeted excess
reserves by approximately $9.5 million. This reduction was a result of transferring those
funds to the IBNR reserve category and the HRA Contributions category.
June 17, 2016
Page 3
Budgeted and Projected Income (Budget Account 1338)
Description
Carryforward
State Subsidies
Contributions
All Other
Total
Budget
143,516,188
235,638,100
92,987,686
1,413,838
473,555,812
Actual 3/31/16
143,516,188
166,589,189
70,095,197
1,416,556
381,617,130
Projected
143,516,188
249,657,278
93,179,209
1,861,997
488,214,672
Difference
0
14,019,178
191,523
448,159
14,658,860
0.0%
5.9%
0.2%
31.7%
3.1%
Budgeted and Projected Expenses (Budget Account 1338)
Description
Operating
Self-Funded Admin
Self-Funded Claims
HSA/HRA Contributions
Fully Insured Products
Total Expenses
Restricted Reserves
Excess Reserves for Benefit
Enhancements
Total Reserves
Total of Expenses and
Reserves
Budget
8,749,164
9,008,385
171,289,083
59,566,411
119,793,629
368,406,672
Actual 3/31/16
5,521,832
6,615,682
119,782,650
44,494,523
83,147,581
259,562,268
Projected
8,800,763
8,828,372
171,289,083
53,873,903
111,599,001
354,391,123
Difference
(51,600)
180,013
0
5,692,508
8,194,628
14,015,549
-0.6%
2.0%
0.0%
9.6%
6.8%
3.8%
86,085,890
86,085,890
86,920,618
(834,728)
-1.0%
19,063,250
35,968,971
46,902,931
(27,839,681)
-146.0%
105,149,140
122,054,861
133,823,550
(28,674,410)
-27.3%
473,555,812
381,617,130
488,214,672
(14,658,861)
-3.1%
State subsidies are projected to be more than the budgeted amount by $14.0 million
(5.9%). Contributions are also projected to be higher than budgeted by $0.2 million
(0.2%). This is due to an increase in actual enrollment compared to the budgeted
enrollment (1.6%). When comparing actual enrollment as of March 1, 2016 to budgeted
enrollment the mix of participants reflect the following changes:






2.0% more state actives,
1.8% more state non-Medicare retirees,
0.3% fewer state Medicare retirees,
25.0% fewer non-state actives,
8.4% more non-state, non-Medicare retirees, and
1.0% fewer non-state Medicare retirees.
The HSA/HRA contributions are projected to be $5.7 million (9.6%) less than budgeted
when adjusted for the work program (budget amendment) which increased the HSA/HRA
funding availability from $25.3 million to $31.5 million. Fully Insured Products which
includes payments to the northern and southern HMOs as well as life insurance premiums
are projected to be $8.2 million (6.8%) less than budgeted.
Excess reserves will be adjusted to reflect shortfalls or surpluses in both the expenditure
and revenue categories. In addition, the PEBP Board approved utilizing approximately
$52 million for plan design enhancements in PY 2016 and 2017 at its meeting in March
2015.
June 17, 2016
Page 4
Claims Summary
Total self-funded paid medical claim dollars increased by $7.3 million or 9.2% from the
period ending March 31, 2015 to the period ending March 31, 2016. On a per participant
basis, medical claims paid increased 2.4%, dental increased 0.6% and prescription costs
decreased 2.5%.
Prescription costs do not include rebates from Catamaran RX or the Retiree Drug
Subsidy Program. Prescription rebates are received by PEBP approximately nine to
twelve months after they are earned.
Self-Funded Net Paid Claims - Total
Jul 2014 - Mar 2015 Jul 2015 - Mar 2016
Medical
Inpatient
Outpatient
Total Medical
Dental
Prescription
Total
$
$
$
$
$
$
30,366,479
49,190,053
79,556,532
16,773,323
17,279,508
113,609,363
$
$
$
$
$
$
31,159,066
55,705,485
86,864,551
17,413,103
17,967,564
122,245,218
% Change
2.6%
13.2%
9.2%
3.8%
4.0%
7.6%
Self-Funded Net Paid Claims - Per Participant Per Month
Jul 2014 - Mar 2015 Jul 2015 - Mar 2016
Medical
Dental
Prescription
Total
$
$
$
$
435.90
50.47
94.68
581.04
$
$
$
$
446.23
50.75
92.30
589.29
% Change
2.4%
0.6%
-2.5%
1.4%
Information obtained from HealthSCOPE Benefits and Catamaran quarterly reports.
June 17, 2016
Page 5
Contract Payments
The table below represents contract payments through March 31, 2016.
State of Nevada - Public Employees' Benefits Program
Payments for Contracts
as of March 31, 2016
FY 2015 Total
Amount
% of Total
Expenses
FY 2016 through March 31, 2016 (75.00%)
Amount
% of
Total
Expenses
% of Est'd % of Est'd
FY16
FY16
Contract
Budget
Contract
Term Date
Consulting / Auditing Services
AON Consulting
Casey, Neilon & Associates Inc.
Health Claim Auditors, Inc.
Sub-total
482,551
36,829
137,700
657,080
5.59%
0.43%
1.60%
7.61%
478,275
8.54%
8.54%
672,043
2.57%
11.85%
14.42%
232,174
0.00%
6.56%
45.36%
51.93%
440,878
34,457
125,800
638,532
6.08%
0.44%
1.60%
8.11%
49.26%
31.01%
25.91%
19.22%
59.64%
55.78%
64.38%
60.29%
6/30/2016
12/31/2015
9/30/2017
8.54%
8.54%
60.69%
60.69%
62.51%
62.51%
12/31/2021
2.95%
9.27%
12.22%
57.10%
61.29%
60.22%
78.68%
76.01%
76.64%
6/30/2017
6/30/2019
5.60%
5.86%
51.25%
62.70%
12.91%
113.97%
17.33%
19.26%
60.03%
95.08%
80.49%
79.22%
6/30/2016
6/30/2020
6/30/2020
112.25%
0.00%
112.25%
88.85%
0.00%
88.85%
6/30/2019
6/12/2015
Enrollment / Eligibility System
Morneau Shepell
Sub-total
737,394
737,394
672,043
PPO Network Fees
Diversified Dental Services
222,131
Hometown Health Partners
1,022,627
Sub-total
1,244,758
729,729
961,903
Third Party Administrator Services
Catamaran (Admin Only)
Extend Health
HealthSCOPE Benefits
Sub-total
566,622
3,916,088
4,482,710
461,119
4,034,494
4,936,490
Utilization Management / Wellness
989,241
US Preventive Medicine
521,399
663,623
1,510,639
11.46%
6.04%
17.50%
663,623
8.43%
0.00%
8.43%
8,632,581
100.00%
7,872,591
100.00%
24.42%
75.93%
44,305,659
27,721,709
57.23%
35.81%
93.04%
48,484,838
Health Plan of Nevada
58.31%
33.69%
92.00%
21.74%
27.31%
23.50%
63.98%
65.45%
64.51%
6/30/2016
6/30/2016
6.96%
6.96%
6,648,406
6,648,406
8.00%
8.00%
124.65%
124.65%
121.94%
121.94%
6/30/2018
5,387,572
77,414,940
100.00%
83,147,581
100.00%
25.13%
67.03%
15,995,974
16,800,278
16,170,018
11.71%
0.13%
11.83%
11.58%
0.00%
11.58%
12.91%
0.00%
12.77%
99.93%
0.00%
91.51%
120,488,483
120,488,483
88.17%
88.17%
102,982,373
16,742,735
6,982,886
17,447,502
41,173,123
12.25%
5.11%
12.77%
30.13%
17,900,698
44,494,523
12.34%
5.07%
13.26%
30.68%
136,658,501
100.00%
145,043,208
100.00%
Sub-total
Total Administrative Contracts
-
Health Maintenance Organizations
Sub-total
72,027,368
28,014,337
76,499,175
Life & LTD Insurance
The Standard Insurance
Sub-total
Total Fully Insured Products
5,387,572
Contracted Claims Expense
Catamaran
US Preventive Medicine
Sub-total
174,044
16,800,278
Non-Contracted Claims Expense
Medical Claims
Sub-total
102,982,373
71.00%
71.00%
HSA/HRA Expense
PPO HDHP HSA
PPO HDHP HRA
Medicare Exchange HRA
Sub-total
Total Claims
7,359,859
19,233,966
84.68%
6/30/2016
6/12/2015
June 17, 2016
Page 6
Recommendations
None.
11.2.1.2.
STATE OF NEVADA
Telephone (775) 684-7000 · (800) 326-5496
BRIAN SANDOVAL
Governor
Fax (775) 684-7028
DAMON HAYCOCK
Executive Officer
Board Chairman
AGENDA ITEM
X Action Item
Information Only
Date:
July 21, 2016
Item Number:
11.2.1.2
Title:
Self-Funded Plan Utilization Report for the period ending
March 31, 2016
This report addresses medical, dental, prescription drug and HSA/HRA utilization for the
period ending March 31, 2016. Included are:
 Executive Summary – provides a utilization overview.
 HealthSCOPE Utilization Report – provides graphical supporting details for the
information included in the Executive Summary.
 Catamaran Utilization Report – provides details supporting the prescription drug
information included in the Executive Summary.
Self-Funded Plan Utilization Report for the period ending March 31, 2016
July 21, 2016
Page 2
Executive Summary
Key Observations
During the period ending March 31, 2016:

Total medical spend was $86.9 million (9.2% more than in PY15 at $79.6 million), of which
68.7% was spent by the State Active population. The average plan cost was $446 PPPM,
2.4% more than the period ending March 31, 2015 at an average cost of $436 (see appendix
page 9).

The PY16 plan cost was $5,355 per member, up 2.4% from $5,231 for PY15 (see
appendix page 9).

Inpatient claims of $144 PPPM (1,610 admits * $17,386 ÷ 21,629 employees ÷ 9
months) were 2.0% lower than the $147 for PY15 (1,469 * $18,238 ÷ 20,279 ÷ 9) (See
appendix page 15, for number of admits and cost per admit, and page 4, for average
number of employees.)

The plan had more large cost claimants in PY16 with 122 claimants in excess of $100,000
compared to 115 claimants in PY15. Although representing 0.3% (122/38,758 members =
0.003) of the total membership, this segment accounted for 27.8% ($197,812 * 122 ÷
$86,864,551 = 27.8%) of dollars spent by the plan (see appendix page 9). Below is a chart
showing the high cost claimant amounts for the last five plan years.
PY
6/30/2011
6/30/2012
6/30/2013
6/30/2014
6/30/2015
3/31/2016
6/30/2016

Number of
High cost
Claimaints
55
157
167
139
157
122
163
Cost
Notes
$11,306,900
$36,772,529
$37,388,461
$31,345,612
$36,046,415
$24,133,064
Q3 PY16
$32,177,419 PY16 Annualized
The non-state retiree members of the CDHP are reflecting an increase in claims cost. For
this group, inpatient claims decreased by $0.4 million (12.5%) and outpatient claims
increased by $0.9 million (22.5%) when comparing PY16 to PY15. On a PMPM basis the
cost increased from $556 in PY15 compared to $644 for PY16 (15.9%). Overall medical
claims for non-state retirees continue to demonstrate the volatility caused by the size of the
non-state pool. (See appendix page 11 - 13).
July 21, 2016
Page 3
Medical–Cost Distribution
During the period ending March 31, 2016 the
largest group (89.6%) of members had claims
paid in the amount of less than $2,500. A little
less than a period of all CDHP participants
(22.4%) had no claims filed for the period. (See
appendix page 14.)
Q3 PY16 Member Distribution
0.30%
22.4%
10.3%
16.2%


The average medical claim for this period
was $305 which is virtually the same as the
period ending March 31, 2015 ($305).
($86,864,551 ÷ 284,738 claims = $305.07 vs
$79,556,532 ÷ 260,713 claims = $305.15).
(See appendix page 4)
51.0%
$100k +
>$2.5k
< $2.5k
0 Paid
No Claim
The average payment per claimant for a catastrophic claim was $197,812 (see appendix
page 9). For a summary of the high-cost claim categories, see appendix page 14.
Major Diagnostic
Musculoskeletal, Diseases of the Circulatory System and Neoplasms are the three most
expensive diagnostic categories, together accounting for 36.0% of total costs by the plan (see
appendix page 18). The costs associated with these three categories are:



Neoplasms at $11.5 million (See appendix page 19)
Musculoskeletal at $11.5 million (See appendix page 20)
Diseases of the Circulatory System at $8.3 million (See appendix page 21)
Dental
The average dental claim for the period ending March
31, 2016, was $162. This represents a 5.86% decrease
from the $172 average dental claim for the period
ending March 31, 2015. ($17,413,103 ÷ 107,373
claims = $162.17 vs. $16,773,323 ÷ 97,372 claims =
$172.26) (See appendix page 24)
% of Dollars Paid by Category
7%
23%
40%
30%
Preventative
Basic
Major
Periodontics
Of the $17.4 million in paid dental claims during the
period ending March 31, 2016, $7.2 million (41.1%) was for preventive services. (See appendix
page 24)
July 21, 2016
Page 4
Drug Utilization (See appendix pages 26-27)
Drug utilization (number of members utilizing the PEBP pharmacy benefit as a percentage of
all CDHP self-funded members) has decreased from 28.1% to 26.6% from the period ending
March 31, 2015 to period ending March 31, 2016.
Percent of total prescription costs paid by participants
during the ten quarters ending March 31, 2016.
Total prescription drug costs increased by $1.3 million (5.2%) from the period ending March
31, 2015, to the period ending March 31, 2016. Both the participant and the plan cost increased
when comparing the period ending March 31, 2015 with the period ending March 31, 2016.
The participant share increased by $0.6 million (7.6%) and the plan cost increased by $0.7
million (4.0%).
Generic drug utilization (generic scripts filled as a percent of all scripts) reflects an increase of
approximately 1.8% from 81.6% for the period ending March 31, 2015, compared to 83.4%
for the period ending March 31, 2016. The generic effective rate increased by 1.4% (97.5% in
March 2015 versus 98.9% in March 2016).
Mail order claims remained the same at 1.6% of total claims when comparing the period ending
March 31, 2015, to the period ending March 31, 2016.
July 21, 2016
Page 5
Enrollment
As of March 31, 2016, there were 42,188 participants enrolled in PEBP. This is 886 more than
the average budgeted enrollment for FY 2016 of 41,302, due primarily to an increase in State
Active Employees enrolled in the CDHP. Average enrollment in the self-funded plan
increased 5.8% from 20,182 in FY 2015 to 21,431 in FY 2016. Average enrollment in the
HMO plans decreased 7.8% from 10,285 to 9,545 during the same period. Average enrollment
in the Medicare Exchange decreased 0.6% from 11,042 in FY 2015 to 10,972 in FY 2016.
Below is a graphical representation of PEBP enrollment since July 2008.
July 21, 2016
Page 6
CDHP HSA/HRA Account Balances
HealthSCOPE Benefits administers approximately 9,747 CDHP Health Reimbursement
Arrangement (HRA) accounts with approximately $11.4 million in PEBP contributions for the
period ending March 31, 2016 compared to $12.9 million for the period ending March 31,
2015. The average contribution per account for the period ending March 31, 2016 is $1,165.
PEBP paid approximately $7.0 million in HRA claims. Assuming PEBP continues to pay HRA
claims at the current rate, it is expected that PEBP will pay approximately $9.4 million in HRA
claims during fiscal year 2016 leaving a liability of $13.9 million in unused HRA funds (which
includes rollover of $11.6 million from fiscal year 2015), or $1,423 per account.
July 21, 2016
Page 7
HealthSCOPE Benefits administers approximately 14,743 CDHP HSA accounts. PEBP
contributed approximately $18.4 million while employees contributed approximately $5.5
million for the period ending March 31, 2016. This compares to $17.1 million and $5.0 million
for the same period in PY15 when there were 14,633 accounts. The average employee
contribution increased from an average of $345 for the period ended March 31, 2015 to an
average of $376 for the period ended March 31, 2016.
For the period ending March 31, 2016, HealthSCOPE Benefits distributed approximately $17.9
million from participant accounts compared to approximately $16.7 million for the same period
in PY15. Since inception, HealthSCOPE Benefits has distributed approximately $83.5 million
from participant accounts. As of March 31, 2016, participants have cumulatively saved
approximately $28.2 million in their accounts, an average of $1,916 per account.
July 21, 2016
Page 8
July 21, 2016
Page 9
Exchange HRA Account Balances
Towers Watson administers approximately 10,959 Medicare Exchange HRA accounts, with
contributions of $22.3 million for the period ending March 31, 2016. These contributions
include a one-time contribution of $2 per month per year of service due to the Board actions
in March 2015 to reduce excess reserves. For the period ending March 31, 2016, PEBP paid
$12.0 million in Medicare Exchange HRA claims ($1,092 per retiree). Assuming PEBP
continues to pay Medicare Exchange HRA claims at the current rate, it is expected that PEBP
will pay approximately $16.0 million in HRA claims during fiscal year 2016 leaving a liability
of $18.0 million in unused Medicare Exchange HRA funds, or $1,641 per account, at the end
of the period.
(The following charts are based on Plan Year 2016 contributions and payments made
during the period ending March 31, 2016.)
July 21, 2016
Page 10
Recommendations
None.
July 21, 2016
Page 11
Appendix
Index of Tables
HealthSCOPE – Utilization Review for PEBP
July 1, 2015 – March 31, 2016
HEALTHSCOPE BENEFITS OVERVIEW.........................................................................3
MONTHLY COST SUMMARY ............................................................................................4
MEDICAL
Claims by Plan/Relationship ..........................................................................................6
Paid Claims by Age Group ............................................................................................7
Financial Summary ........................................................................................................9
Paid Claims by Claim Type .........................................................................................11
Cost Distribution – Medical Claims ............................................................................14
Utilization Summary ....................................................................................................15
Provider Network Summary ........................................................................................17
Agency for Healthcare Research (AHRQ) Summary ..................................................18
Neoplasms ....................................................................................................................19
Disorders of Musculoskeletal System ..........................................................................20
Disease of the Circulatory System ...............................................................................21
Emergency Room Summary ........................................................................................22
Savings Summary ........................................................................................................23
Dental
Claims Analysis ...........................................................................................................24
Savings Summary ........................................................................................................25
CATAMARAN RX UTILIZATION TABLES ...................................................................26
H S B D ATA S C O P E T M
1
Utilization Review
for
Nevada Public Employees’ Benefits Program
PEBP
July 1, 2015 – March 31, 2015
Jul 15 - Mar 16
TOTAL HEALTH MANAGEMENT by HEALTHSCOPE BENEFITS
2
Overview

Total Medical Spend for 3Q PY16 was $86,864,551 of which 68.7% was spent in the State Active
population. When compared to 3Q PY15, there was a 9.2% increase in plan spending overall.

When compared to 3Q PY14, 3Q PY16 reflected an increase of 23.7% in plan spend, with State Actives
having an increase of 31.9%.

On a PEPY basis, the plan showed a slight increase of 2.4% when compared to 3Q PY15. The
largest group, State Actives, increased 2.0%.

When compared to 3Q PY14, 3Q PY16 reflected a 11.1% increase in plan spend, with State Actives
having an increase of 6.0%.





Jul 15 - Mar 16
89.6% of the Average Membership had paid Medical claims less than $2,500, with 22.4% of those
having no claims filed at all during the reporting period. This is on track with 3QPY15.
There are 122 High Cost Claimants (HCC’s) over $100K, that account for 27.8% of the total
spend. HCC’s accounted for 28.2% of total spend during 3Q PY15, with 115 members hitting the
$100K threshold. The largest claimant had total paid claims in the amount of $835,790 diagnosed
with ESRD.
IP Paid per Admit for the whole plan was $17,386, which is 4.7% lower than the 3Q PY15 IP Paid
per Admit of $18,238.
ER Paid per Visit is $1,886, which is 5.0% higher than 3Q PY15 ER Paid per Visit of $1,797.
95.9% of all Medical spend dollars were to In Network providers. The average In Network
discount is 61.5%, which is a 1.9% increase over the 3Q PY15 average of 59.6%.
3
M o n t h l y C o s t S u m m a r y – Ye a r o v e r Ye a r C o m p a r i s o n
PY16
Employees - Medical
Members - Medical
Employees - Dental
Members - Dental
Avg Member Age - Medical
Medical Claims Processed
Medical Claims Amount
Dental Claims Amount
All Claims Amount
PEPM - Medical
PEPM - Dental
Jul
21,096
37,694
37,522
62,395
37.5
30,832
$10,981,720
$2,290,415
$13,272,135
$521
$61
Aug
21,238
37,935
37,725
62,694
37.4
34,053
$8,333,254
$1,991,370
$10,324,624
$392
$53
Sep
21,540
38,455
38,082
63,285
37.4
34,234
$9,599,605
$1,830,220
$11,429,825
$446
$48
Oct
21,715
38,864
37,923
63,784
37.2
29,052
$7,355,382
$2,003,876
$9,359,258
$339
$53
Nov
21,786
39,028
38,324
63,945
37.1
28,586
$7,076,789
$1,721,922
$8,798,712
$325
$45
Dec
21,834
39,160
38,379
64,090
37.1
32,878
$9,592,579
$1,890,767
$11,483,347
$439
$49
Jan
21,772
39,164
38,322
64,059
37.1
28,873
$10,146,702
$1,791,801
$11,938,503
$466
$47
Feb
21,849
39,254
38,421
64,162
37.1
29,935
$11,396,840
$1,806,177
$13,203,017
$522
$47
Mar
21,828
39,267
38,398
64,234
37.1
36,295
$12,381,679
$2,086,553
$14,468,232
$567
$54
Avg/Total
21,629
38,758
38,122
63,628
37.22
284,738
$86,864,551
$17,413,103
$104,277,654
$446
$51
PY15
Employees - Medical
Members - Medical
Employees - Dental
Members - Dental
All Claims Amount
PEPM - Medical
PEPM - Dental
Jul
19,970
35,499
36,493
60,780
37.88
29,204
$9,725,546
$2,086,422
$11,811,968
$487
$57
Aug
20,156
35,779
36,749
61,131
37.81
28,439
$8,721,217
$2,000,244
$10,721,461
$433
$54
Sep
20,173
35,777
36,757
61,096
37.87
31,365
$7,972,088
$1,878,244
$9,850,332
$395
$51
Oct
20,216
35,885
36,847
61,259
37.94
30,687
$9,425,645
$1,986,922
$11,412,567
$466
$54
Nov
20,305
36,047
36,971
61,473
37.87
26,395
$7,486,810
$1,668,554
$9,155,364
$369
$45
Dec
20,436
36,231
37,114
61,684
37.77
22,844
$7,446,538
$1,630,849
$9,077,387
$364
$44
Jan
20,390
36,175
37,097
61,655
38.62
31,525
$10,034,003
$1,893,607
$11,927,610
$492
$51
Feb
20,437
36,250
37,181
61,757
38.53
28,445
$8,719,157
$1,704,157
$10,423,314
$427
$46
Mar
20,427
36,217
37,161
61,659
38.50
31,809
$10,025,529
$1,924,325
$11,949,854
$491
$52
Avg/Total
20,279
35,984
36,930
61,388
38.09
260,713
$79,556,533
$16,773,324
$96,329,856
$436
$50
Variance
Employees - Medical
Members - Medical
Employees - Dental
Members - Dental
All Claims Amount
PEPM - Medical
PEPM - Dental
Jul
5.6%
6.2%
2.8%
2.7%
-1.0%
5.6%
12.9%
9.8%
12.4%
6.9%
6.8%
Aug
5.4%
6.0%
2.7%
2.6%
-1.1%
19.7%
-4.4%
-0.4%
-3.7%
-9.3%
-3.0%
Sep
6.8%
7.5%
3.6%
3.6%
-1.2%
9.1%
20.4%
-2.6%
16.0%
12.8%
-5.9%
Oct
7.4%
8.3%
2.9%
4.1%
-2.0%
-5.3%
-22.0%
0.9%
-18.0%
-27.4%
-2.0%
Nov
7.3%
8.3%
3.7%
4.0%
-2.0%
8.3%
-5.5%
3.2%
-3.9%
-11.9%
-0.4%
Dec
6.8%
8.1%
3.4%
3.9%
-1.9%
43.9%
28.8%
15.9%
26.5%
20.6%
12.1%
Jan
6.8%
8.3%
3.3%
3.9%
-3.9%
-8.4%
1.1%
-5.4%
0.1%
-5.3%
-8.4%
Feb
6.9%
8.3%
3.3%
3.9%
-3.7%
5.2%
30.7%
6.0%
26.7%
22.3%
2.6%
Mar
6.9%
8.4%
3.3%
4.2%
-3.6%
14.1%
23.5%
8.4%
21.1%
15.6%
4.9%
Avg/Total
6.7%
7.7%
3.2%
3.6%
-2.3%
9.2%
9.2%
3.8%
8.3%
2.4%
0.6%
Jul 15 - Mar 16
4
P E P Y – Ye a r o v e r Ye a r Tr e n d
$6,500
$6,000
$5,709
$5,829
$5,535
$5,500
$5,355
$5,287
$5,000
$4,500
$4,000
$3,500
$3,000
PY16*
PY15
PY14
PY13
PY12
* Annualized
Jul 15 - Mar 16
5
Medical Claims by Plan / Relationship
Medical Claims by Plan - PY15
Total Costs
PMPM (Per Member per Month)
HRA
$42,073,998
$364
HSA
$44,790,553
$192
Medical Claims by Plan
Total
$86,864,551
$249
Total Medical Claims Paid / Relationship
1Q
2Q
3Q
Insured
$20,229,494 $16,773,111 $23,262,918
Spouse
$4,790,462
$4,126,003
$5,233,288
Child
$3,894,623
$3,125,637
$5,429,016
Total
$28,914,579 $24,024,750 $33,925,222
YTD
$60,265,523
$14,149,753
$12,449,276
$86,864,551
PMPM
$310
$322
$113
$249
Medical Claims by
Relationship
Child
14%
HSA
52%
Jul 15 - Mar 16
HRA
48%
Spouse
16%
Insured
70%
6
Paid Claims by Age Group (p. 1 of 2)
Paid Claims by Age Group
Age
Range
<1
1
2-4
5-9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65+
Total
Jul 15 - Mar 16
Med Net Pay
$
3,011,034
$
358,282
$
701,693
$
1,212,539
$
1,687,291
$
2,646,296
$
2,883,877
$
2,563,190
$
2,762,128
$
3,323,898
$
4,323,508
$
6,463,152
$
8,496,254
$ 14,553,156
$ 23,612,625
$
8,265,627
$ 86,864,551
Med
PMPM
$ 1,394
$
123
$
65
$
58
$
74
$
104
$
107
$
126
$
124
$
143
$
173
$
243
$
289
$
438
$
596
$
476
$
249
Rx Net Pay
$
38,906
$
5,399
$
20,471
$
116,228
$
188,693
$
343,663
$
418,679
$
288,541
$
419,202
$
604,567
$ 1,384,428
$ 1,403,362
$ 1,522,147
$ 2,678,840
$ 5,470,975
$ 3,078,463
$ 17,982,566
3Q PY16
Rx
Dental Net
PMPM
Pay
$
18 $
905
$
2 $
25,314
$
2 $
269,171
$
6 $
842,185
$
8 $
839,436
$
14 $ 1,082,388
$
16 $
714,455
$
14 $
666,852
$
19 $
791,219
$
26 $
855,908
$
56 $
991,877
$
53 $ 1,192,863
$
52 $ 1,420,826
$
81 $ 1,748,856
$
138 $ 2,171,301
$
177 $ 3,799,195
$
52 $ 17,412,751
Dental
PMPM
$
0
$
6
$
19
$
28
$
26
$
29
$
19
$
24
$
27
$
26
$
29
$
30
$
33
$
35
$
37
$
38
$
30
Net Pay
$
3,050,845
$
388,995
$
991,335
$
2,170,952
$
2,715,420
$
4,072,347
$
4,017,011
$
3,518,583
$
3,972,550
$
4,784,373
$
6,699,813
$
9,059,377
$ 11,439,227
$ 18,980,853
$ 31,254,901
$ 15,143,285
$ 122,259,867
PMPM
$ 1,412
$
131
$
85
$
91
$
109
$
147
$
141
$
165
$
169
$
196
$
257
$
326
$
374
$
553
$
771
$
692
$
331
7
Paid Claims by Age Group (p. 2 of 2)
Paid Claims by Age Group
Age
Range
<1
1
2-4
5-9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65+
Total
Jul 15 - Mar 16
Med Net Pay
$
1,830,903
$
282,299
$
806,977
$
1,916,122
$
1,189,713
$
2,032,231
$
2,394,561
$
2,607,780
$
2,598,876
$
3,355,934
$
4,323,738
$
4,433,944
$ 10,483,349
$ 11,439,027
$ 21,168,926
$
8,692,153
$ 79,556,532
Med
PMPM
$ 1,190
$
122
$
84
$
100
$
56
$
85
$
96
$
155
$
131
$
164
$
186
$
177
$
373
$
348
$
548
$
530
$
246
Rx Net Pay
$
14,987
$
48,982
$
22,892
$
99,252
$
132,309
$
400,409
$
371,196
$
305,036
$
313,098
$
562,901
$ 1,099,008
$ 1,101,136
$ 1,846,483
$ 2,949,172
$ 5,726,106
$ 2,086,957
$ 17,079,923
3Q PY15
Rx
Dental Net
PMPM
Pay
$
10 $
2,910
$
21 $
16,445
$
2 $
253,665
$
5 $
820,319
$
6 $
817,718
$
17 $ 1,026,331
$
15 $
697,406
$
18 $
593,907
$
16 $
772,457
$
27 $
796,905
$
47 $
967,320
$
44 $ 1,078,730
$
66 $ 1,405,060
$
90 $ 1,814,124
$
148 $ 2,210,854
$
127 $ 3,499,171
$
53 $ 16,773,323
% Change
Dental
PMPM
$
2
$
6
$
18
$
29
$
26
$
28
$
19
$
25
$
28
$
27
$
28
$
28
$
33
$
36
$
36
$
39
$
30
Net Pay
$
1,848,800
$
347,726
$
1,083,534
$
2,835,694
$
2,139,740
$
3,458,971
$
3,463,163
$
3,506,722
$
3,684,432
$
4,715,740
$
6,390,065
$
6,613,810
$ 13,734,892
$ 16,202,323
$ 29,105,886
$ 14,278,281
$ 113,409,778
PMPM
$ 1,201
$
148
$
104
$
134
$
88
$
130
$
130
$
198
$
175
$
218
$
261
$
249
$
472
$
474
$
732
$
696
$
329
Net Pay
65.0%
11.9%
-8.5%
-23.4%
26.9%
17.7%
16.0%
0.3%
7.8%
1.5%
4.8%
37.0%
-16.7%
17.1%
7.4%
6.1%
7.8%
PMPM
17.6%
-11.6%
-17.8%
-32.0%
22.9%
13.1%
8.4%
-16.7%
-3.6%
-10.1%
-1.5%
31.1%
-20.6%
16.7%
5.3%
-0.5%
0.7%
8
Cost
DistributionPMPY
High Cost
Claimants
Financial Summary
Financial Summary (p. 1 of 2)
Avg # Participants
Avg # Members
Mem / Part Ratio
Gross Cost
Plan Paid
Employee Paid
Client Paid-PEPY
Client Paid-PMPY
Client Paid-PEPM
Client Paid-PMPM
# of HCC's (>$100K)
HCC's / 1,000
Avg HCC Paid
HCC's % of Plan Paid
Facility Inpatient
Facility Outpatient
Physician
Other
Total
Jul 15 - Mar 16
All Combined
Groups
All Combined
Groups
All Combined
Groups
PY16 to
PY15
State Active
State Active
State Active
PY16 to
PY15
Non-State
Active
Non-State
Active
Non-State
Active
PY16 to
PY15
3Q PY16
21,629
38,758
1.79
$115,541,131
$86,864,551
$28,676,579
$5,355
$2,988
$446
$249
3Q PY15
20,279
35,985
1.77
$107,383,079
$79,556,532
$27,826,547
$5,231
$2,948
$436
$246
3Q PY14
19,420
33,927
1.75
$98,647,401
$70,204,066
$28,443,335
$4,820
$2,759
$402
$230
Variance
6.7 %
7.7 %
1.0 %
7.6 %
9.2 %
3.1 %
2.4 %
1.4 %
2.3 %
1.4 %
3Q PY16
17,389
33,064
1.90
$82,040,709
$59,632,795
$22,407,914
$4,573
$2,405
$381
$200
3Q PY15
16,089
30,428
1.89
$75,570,449
$54,102,853
$21,467,596
$4,484
$2,371
$374
$198
3Q PY14
14,949
28,059
1.88
$66,339,058
$45,209,352
$21,129,706
$4,032
$2,148
$336
$179
Variance
8.1 %
8.7 %
0.6 %
8.6 %
10.2 %
4.4 %
2.0 %
1.4 %
2.0 %
1.2 %
3Q PY16
5
7
1.36
$30,810
$22,019
$8,791
$5,872
$4,332
$489
$361
3Q PY15
5
8
1.56
$5,275
$1,525
$3,750
$407
$261
$34
$22
3Q PY14
6
12
2.00
$104,986
$94,365
$10,621
$20,970
$10,485
$1,748
$874
Variance
0.0 %
(12.9)%
(12.9)%
484.1 %
1,343.9 %
134.4 %
1,342.8 %
1,557.5 %
1,343.0 %
1,557.5 %
122
3.2
$197,812
27.8%
115
3.2
$207,728
28.2%
90
2.7
$205,564
26.4%
6.1 %
(1.4)%
(4.8)%
(1.4)%
77
2.3
$178,533
23.1%
67
2.2
$206,710
25.6%
49
1.7
$190,063
20.6%
14.9 %
5.9 %
(13.6)%
(9.8)%
0
0.0
$0
0.0%
0
0.0
$0
0.0%
0
0.0
$0
0.0%
$892
$971
$1,015
$110
$2,988
$966
$873
$1,002
$106
$2,948
$846
$816
$985
$111
$2,759
(7.7)%
11.2 %
1.3 %
3.8 %
1.4 %
$688
$733
$899
$85
$2,405
$720
$698
$861
$92
$2,371
$637
$611
$814
$87
$2,149
(4.4)%
5.0 %
4.4 %
(7.6)%
1.4 %
$0
$2,432
$1,740
$160
$4,332
$0
$35
$224
$3
$262
$8,407
$936
$1,200
$40
$10,583
annualized
annualized
annualized
annualized
annualized
annualized
annualized
annualized
annualized
0.0
0.0
0.0
0.0
%
%
%
%
0.0 %
0.0 %
676.8 %
0.0 %
1,553.4 %
9
Cost
DistributionPMPY
High Cost
Claimants
Financial Summary
Financial Summary (p. 2 of 2)
Jul 15 - Mar 16
Avg # Participants
Avg # Members
Mem / Part Ratio
Gross Cost
Plan Paid
Employee Paid
Client Paid-PEPY
Client Paid-PMPY
Client Paid-PEPM
Client Paid-PMPM
# of HCC's (>$100K)
HCC's / 1,000
Avg HCC Paid
HCC's % of Plan Paid
Facility Inpatient
Facility Outpatient
Physician
Other
Total
State
Retirees
State
Retirees
State
Retirees
PY16 to
PY15
Non-State
Retirees
Non-State
Retirees
Non-State
Retirees
PY16 to
PY15
3Q PY16
3,066
4,417
1.44
$24,622,702
$19,860,635
$4,762,067
$8,637
$5,995
$720
$500
3Q PY15
2,925
4,184
1.43
$23,184,716
$18,623,745
$4,560,971
$8,491
$5,935
$707
$495
3Q PY14
2,856
4,045
1.42
$21,346,877
$16,593,864
$4,753,013
$7,747
$5,470
$646
$456
Variance
4.8 %
5.6 %
0.7 %
6.2 %
6.6 %
4.4 %
1.7 %
1.0 %
1.8 %
1.1 %
3Q PY16
1,169
1,271
1.09
$8,846,909
$7,349,102
$1,497,807
$8,382
$7,710
$699
$612
3Q PY15
1,260
1,365
1.08
$5,934,319
$6,828,409
$1,794,230
$7,226
$6,670
$602
$556
3Q PY14
1,609
1,811
1.13
$7,518,095
$8,306,485
$2,549,995
$6,883
$6,116
$574
$510
Variance
(7.2)%
(6.9)%
0.7 %
49.1 %
7.6 %
(16.5)%
16.0 %
15.6 %
16.1 %
10.1 %
39
8.8
$186,704
36.7%
38
9.1
$175,886
35.9%
25
6.2
$258,655
39.0%
2.6 %
(3.0)%
6.2 %
2.2 %
14
11.0
$221,754
42.2%
10
7.3
$190,140
27.8%
16
8.8
$162,761
31.4%
$2,022
$2,164
$1,534
$275
$5,995
$2,280
$1,854
$1,614
$188
$5,935
$1,689
$1,853
$1,700
$227
$5,470
(11.3)%
16.7 %
(5.0)%
46.3 %
1.0 %
$2,294
$3,004
$2,228
$184
$7,710
$2,440
$1,786
$2,280
$167
$6,670
$2,164
$1,681
$2,035
$231
$6,116
annualized
annualized
annualized
annualized
annualized
annualized
40.0
50.8
16.6
51.8
HSB
HSB
2010
Peer Index
$6,382
$3,436
$532
$286
%
%
%
%
(6.0)%
68.2 %
(2.3)%
10.2 %
15.6 %
$1,050
$1,122
$1,158
$106
$3,436
10
P a i d C l a i m s b y C l a i m Ty p e – S t a t e P a r t i c i p a n t s
Net Paid Claims - Total
State Participants
Actives
3Q PY16
Pre-Medicare
Medicare
Retirees
Retirees
Total
Actives
3Q PY15
Pre-Medicare
Medicare
Retirees
Retirees
Medical
Inpatient
Outpatient
Total - Medical
Dental
Total
$
$
$
$
$
Medical
Dental
Net Paid Claims - Per Participant per Month
3Q PY16
3Q PY15
Pre-Medicare
Medicare
Pre-Medicare
Medicare
Actives
Retirees
Retirees
Total
Actives
Retirees
Retirees
$
380 $
802 $
468 $
432 $
374 $
754 $
502 $
$
53 $
47 $
50 $
52 $
53 $
48 $
48 $
Jul 15 - Mar 16
21,208,214 $ 6,397,654 $
38,424,581 $ 10,909,813 $
59,632,795 $ 17,307,467 $
12,040,384 $ 1,431,608 $
71,673,179 $ 18,739,075 $
1,066,403 $
1,486,766 $
2,553,169 $
1,946,562 $
4,499,731 $
28,672,271
$19,560,822
50,821,159
$34,542,031
79,493,430 $ 54,102,853 $
15,418,554
$11,551,215
94,911,984 $ 65,654,068 $
$6,519,122
$9,668,975
16,188,097 $
$1,427,797
17,615,894 $
% Change
Total
Total
$1,444,535 $ 27,524,479
$991,114
$45,202,119
2,435,649 $ 72,726,599
$1,692,832
$14,671,845
4,128,481 $ 87,398,444
4.2%
12.4%
9.3%
5.1%
8.6%
% Change
Total
425
52
Total
1.6%
0.6%
11
P a i d C l a i m s b y C l a i m Ty p e – N o n - S t a t e P a r t i c i p a n t s
Non-State Participants
Actives
3Q PY16
Pre-Medicare
Medicare
Retirees
Retirees
Total
Actives
3Q PY15
Pre-Medicare
Medicare
Retirees
Retirees
% Change
Total
Medical
Inpatient
Outpatient
Total - Medical
Dental
Total
$
$
$
$
$
Medical
Dental
3Q PY16
3Q PY15
Pre-Medicare
Medicare
Pre-Medicare
Medicare
Actives
Retirees
Retirees
Total
Actives
Retirees
Retirees
$
489 $
756 $
449 $
698 $
34 $
629 $
463 $
$
42 $
39 $
42 $
41 $
29 $
38 $
44 $
Jul 15 - Mar 16
22,019
22,019
3,429
25,448
$
$
$
$
$
1,941,993
4,518,317
6,460,310
613,707
7,074,017
$
$
$
$
$
544,802
343,990
888,792
1,377,412
2,266,204
$
$
$
$
$
2,486,795
4,884,326
7,371,121
1,994,549
9,365,670
$
$
$
$
$
1,525
1,525
3,176
4,701
$
$
$
$
$
2,252,393
3,733,994
5,986,387
729,673
6,716,060
$
$
$
$
$
589,607
252,415
842,022
1,368,630
2,210,652
$
$
$
$
$
Total
2,842,000
3,987,934
6,829,934
2,101,479
8,931,413
-12.5%
22.5%
7.9%
-5.1%
4.9%
% Change
Total
600
42
Total
16.3%
-1.9%
12
P a i d C l a i m s b y C l a i m Ty p e – To t a l
Total Participants
Actives
3Q PY16
Pre-Medicare
Medicare
Retirees
Retirees
21,208,214
38,446,599
59,654,814
12,043,813
71,698,627
$ 8,339,647 $
$ 15,428,130 $
$ 23,767,776 $
$ 2,045,316 $
$ 25,813,092 $
Total
Actives
3Q PY15
Pre-Medicare
Medicare
Retirees
Retirees
Total
19,560,822
34,543,556
54,104,378
11,554,391
65,658,769
$
$
$
$
$
30,366,479
49,190,053
79,556,534
16,773,322
96,329,856
Medical
Inpatient
Outpatient
Total - Medical
Dental
Total
$
$
$
$
$
Medical
Dental
3Q PY16
3Q PY15
Pre-Medicare
Medicare
Pre-Medicare
Medicare
Actives
Retirees
Retirees
Total
Actives
Retirees
Retirees
$
380 $
789 $
463 $
446 $
374 $
715 $
491 $
$
53 $
44 $
46 $
51 $
53 $
44 $
46 $
1,611,205 $ 31,159,066
1,830,756 $ 55,705,485
3,441,961 $ 86,864,551
3,323,974 $ 17,413,103
6,765,935 $ 104,277,654
3Q PY15
$30,366,479
3Q PY16
$31,159,066
$
$
$
$
$
$49,190,053
$55,705,485
Inpatient
Jul 15 - Mar 16
Outpatient
8,771,515
13,402,969
22,174,484
2,157,470
24,331,953
$
$
$
$
$
2,034,142 $
1,243,529 $
3,277,672 $
3,061,462 $
6,339,133 $
% Change
Total
2.6%
13.2%
9.2%
3.8%
8.3%
% Change
Total
436
50
2.4%
0.5%
$16,773,322
$17,413,103
Dental
13
Cost Distribution – Medical Claims
3Q PY16 Cost Distribution
Avg # of
% of
% of
Total Paid
EE Paid
Members Members
Paid
% EE
Paid
Paid Claims Category
3Q PY15 Cost Distribution
Avg # of
% of
% of
Total Paid
EE Paid
Members Members
Paid
% EE
Paid
110
0.3%
$24,133,091
27.8%
$730,741
2.5%
$100,000.01 Plus
97
0.3%
$22,434,621
28.2%
$687,410
2.5%
178
0.5%
$13,297,052
15.3%
$1,057,421
3.7%
$50,000.01-$100,000.00
166
0.5%
$12,885,477
16.2%
$985,012
3.5%
309
0.8%
$11,970,901
13.8%
$1,750,908
6.1%
$25,000.01-$50,000.00
290
0.8%
$10,900,522
13.7%
$1,727,332
6.2%
811
2.1%
$13,247,247
15.3%
$3,644,247
12.7%
$10,000.01-$25,000.00
724
2.0%
$11,677,275
14.7%
$3,581,374
12.9%
1,156
3.0%
$8,685,689
10.0%
$3,959,247
13.8%
$5,000.01-$10,000.00
1,020
2.8%
$7,502,089
9.4%
$3,587,078
12.9%
1,507
3.9%
$5,771,720
6.6%
$3,443,398
12.0%
$2,500.01-$5,000.00
1,410
3.9%
$5,428,070
6.8%
$3,353,970
12.1%
19,753
51.0%
$9,758,851
11.2%
$11,566,531
40.4%
$0.01-$2,500.00
18,108
50.3%
$8,728,478
11.0%
$11,296,457
40.6%
6,260
16.2%
$0
0.0%
$2,524,086
8.8%
$0.00
6,113
17.0%
$0
0.0%
$2,607,910
9.4%
No Claims
8,674
22.4%
$0
0.0%
$0
0.0%
38,758
100.0%
$86,864,551
100.0%
$28,676,580
100.0%
8,056
22.4%
$0
0.0%
$0
0.0%
35,984
100.0%
$79,556,532
100.0%
$27,826,547
100.0%
HCC's by AHRQ Clinical Classifications Chapter
Distribution of HCC Medical Claims Paid
HCC
27.8%
Non-HCC
72.2%
HCC – High Cost Claimant over $100K
AHRQ Chapter
% Paid
Neoplasms
56
$5,920,579
24.5%
Diseases Of The Circulatory System
84
$2,526,626
10.5%
Injury And Poisoning
75
$2,140,466
8.9%
Diseases Of The Nervous System And Sense Organs
91
$1,781,274
7.4%
Diseases Of The Musculoskeletal System And Connective Tissue
79
$1,734,636
7.2%
Diseases Of The Genitourinary System
61
$1,629,054
6.8%
Certain Conditions Originating In The Perinatal Period
7
$1,489,263
6.2%
Endocrine; Nutritional; And Metabolic Diseases And Immunity Disorders
75
$1,165,204
4.8%
Infectious And Parasitic Diseases
63
$1,153,666
4.8%
Diseases Of The Respiratory System
98
$885,396
3.7%
120
$882,336
3.7%
Diseases Of The Digestive System
69
$832,776
3.5%
Diseases Of The Skin And Subcutaneous Tissue
49
$811,338
3.4%
Mental Illness
34
$382,419
1.6%
Residual Codes; Unclassified; All E Codes [259. And 260.]
77
$306,105
1.3%
Diseases Of The Blood And Blood-Forming Organs
42
$248,106
1.0%
Complications Of Pregnancy; Childbirth; And The Puerperium
3
$138,708
0.6%
Congenital Anomalies
9
$105,137
0.4%
122
$24,133,091
100.0%
Symptoms; Signs; & Ill-Defined Conditions & Factors Inf Health Status
Total
Jul 15 - Mar 16
#
Total Paid
Members
14
Inpatient Facility
# of Admits
# of Patient Days
Paid per Admit
Paid per Day
Admits / 1,000
Days / 1,000
Average LOS
Physician
Utilization Summary (p. 1 of 2)
Office Visit Utilization
Office Visit Paid / Visit
Office Visit Paid / Member
DX&L Utilization
DX&L Paid / Visit
DX&L Paid / Member
All Combined All Combined All Combined
Groups
Groups
Groups
3Q PY16
3Q PY15
3Q PY14
1,610
1,469
1,410
7,773
7,060
6,628
$17,386
$18,238
$13,169
$3,601
$3,795
$2,802
55
54
55
267
262
260
4.8
4.8
4.7
3.1
$34
$105
7.5
$62
$462
3.1
$31
$98
7.5
$59
$443
3.3
$28
$91
7.9
$53
$419
4,591
747
0.16
158
$1,886
0.16
4,008
656
0.15
149
$1,797
0.16
3,876
656
0.15
152
$1,479
0.17
annualized
annualized
annualized
PY16 to
PY15
Variance
9.6 %
10.1 %
(4.7)%
(5.1)%
1.9 %
1.9 %
0.5 %
0.0
9.7
7.1
0.0
5.1
4.3
%
%
%
%
%
%
State Active
3Q PY16
1,192
5,059
$15,597
$3,675
48
204
4.2
State Active
3Q PY15
1,039
4,617
$16,072
$3,617
46
202
4.4
State Active
3Q PY14
991
4,047
$11,724
$2,874
47
192
4.1
PY16 to
PY15
Variance
14.7 %
9.6 %
(3.0)%
1.6 %
4.3 %
1.0 %
(4.5)%
Non-State
Active
3Q PY16
0
0
$0
$0
0
0
0.0
Non-State
Active
3Q PY15
0
0
$0
$0
0
0
0.0
Non-State
Active
3Q PY14
1
2
$74,966
$37,483
112
224
2.0
PY16 to
PY15
Variance
0.0 %
0.0 %
0.0 %
0.0 %
0.0 %
0.0 %
0.0 %
2.8
$32
$88
6.8
$56
$381
2.8
$29
$82
6.7
$55
$369
2.9
$26
$74
6.8
$49
$334
0.0 %
10.3 %
7.3 %
1.5 %
1.8 %
3.3 %
4.5
$34
$156
12.2
$71
$867
2.9
$13
$39
0.0
$0
$0
5.4
$32
$171
4.8
$49
$235
55.2 %
161.5 %
300.0 %
0.0 %
0.0 %
0.0 %
3,709
516
0.15
150
$1,802
0.14
3,117
404
0.14
137
$1,794
0.13
2,903
424
0.14
138
$1,405
0.15
19.0 %
27.7 %
7.1 %
9.5 %
0.4 %
7.7 %
2
0
0.39
393
$2,140
0.00
0
0
0.00
0
$0
0.00
0
0
0.00
0
$0
0.00
annualized
annualized
annualized
annualized
annualized
annualized
Emergency
Room
*DX&L=Diagnostic, Xray, & Lab
Number of Visits
Number of Admits
Visits/Member
Visits / 1,000
Avg Paid per Visit
Admits per Visit
Jul 15 - Mar 16
14.5 %
13.9 %
6.7 %
6.0 %
5.0 %
1.7 %
0.0
0.0
0.0
0.0
0.0
0.0
%
%
%
%
%
%
15
Inpatient Facility
# of Admits
# of Patient Days
Paid per Admit
Paid per Day
Admits / 1,000
Days / 1,000
Average LOS
Physician
Utilization Summary (p. 2 of 2)
Office Visit Utilization
Office Visit Paid / Visit
Office Visit Paid / Member
DX&L Utilization
DX&L Paid / Visit
DX&L Paid / Member
State
Retirees
3Q PY16
302
1,895
$23,364
$3,723
91
572
6.3
State
Retirees
3Q PY15
320
1,802
$23,360
$4,148
102
574
5.6
State
Retirees
3Q PY14
264
1,549
$16,372
$2,790
87
511
5.9
PY16 to
PY15
Variance
(5.6)%
5.2 %
0.0 %
(10.2)%
(10.8)%
(0.3)%
12.5 %
Non-State
Retirees
3Q PY16
116
819
$20,208
$2,862
122
859
7.1
Non-State
Retirees
3Q PY15
110
641
$23,804
$4,085
107
626
5.8
Non-State
Retirees
3Q PY14
154
1,030
$16,578
$2,479
113
758
6.7
PY16 to
PY15
Variance
5.5 %
27.8 %
(15.1)%
(29.9)%
14.0 %
37.2 %
22.4 %
4.7
$42
$198
10.9
$79
$859
4.5
$39
$178
10.8
$73
$791
4.8
$34
$164
11.7
$64
$755
4.4 %
7.7 %
11.2 %
0.9 %
8.2 %
8.6 %
5.8
$34
$199
14.1
$83
$1,171
5.8
$34
$198
14.6
$71
$1,035
6.0
$30
$181
16.5
$59
$967
0.0 %
0.0 %
0.5 %
(3.4)%
16.9 %
13.1 %
3.4
$52
$177
8.6
$66
$568
681
180
0.21
206
$2,418
0.26
658
193
0.21
210
$1,804
0.29
665
155
0.22
219
$1,560
0.23
3.5 %
(6.7)%
0.0 %
(1.9)%
34.0 %
(10.3)%
199
51
0.21
209
$1,646
0.26
233
59
0.23
228
$1,820
0.25
308
77
0.23
227
$2,001
0.25
(14.6)%
(13.6)%
(8.7)%
(8.3)%
(9.6)%
4.0 %
0.18
181
$1,514
0.16
annualized
annualized
annualized
annualized
annualized
annualized
HSB
Peer Index
$17,993
$3,960
60
273
4.5
Emergency
Room
*DX&L=Diagnostic, Xray, & Lab
Number of Visits
Number of Admits
Visits/Member
Visits / 1,000
Avg Paid per Visit
Admits per Visit
Jul 15 - Mar 16
16
Provider Network Summary
In Network Discounts
61.5%
•Average in Network
Discount
3Q PY16
67.0%
66.7%
3Q PY15
3Q PY14
62.7%
•In Network Utilization
61.5%
60.8%
95.9%
59.1% 59.0%
61.3%
59.6%
59.2%
57.4%
56.8%
Network Utilization
100%
4.1%
6.2%
7.4%
95.9%
93.8%
92.6%
Inpatient Facility
Outpatient Facility
Physician
Combined
80%
60%
40%
PEBP PY16 Additional Savings Total
Savings Description
20%
Non-Network Negotiations
Subrogation
0%
3Q PY16
3Q PY15
In Network
Jul 15 - Mar 16
OON
3Q PY14
Transplant Savings
Total Savings
1Q
2Q
3Q
PY16
$1,038,054
$638,577
$926,568
$2,603,198
$95,509
$124,174
$114,860
$334,542
$548,032
$1,681,595
$13,367
$776,118
$4,337
$565,737
$1,045,765 $3,503,478
17
AHRQ* Clinical Classifications Summary
AHRQ Clinical Classifications Chapter
*Developed at the Agency for
Healthcare Research and
Quality (AHRQ), the Clinical
Classifications Software
(CCS) is a tool for clustering
patient diagnoses and
procedures into a
manageable number of
clinically meaningful
categories.
Total Paid
% Paid
Neoplasms
$11,542,255
$11,462,254
$8,260,269
$8,053,330
Symptoms; Signs; And Ill-Defined Conditions And Factors Influencing Health Status
$7,935,045
$6,915,183
$5,193,772
$5,172,557
$3,976,448
$3,594,180
Infectious And Parasitic Diseases
$2,914,127
Mental Illness
$2,900,742
Complications Of Pregnancy; Childbirth; And The Puerperium
$2,660,004
Certain Conditions Originating In The Perinatal Period
$2,197,805
Diseases Of The Skin And Subcutaneous Tissue
$1,526,711
Residual Codes; Unclassified; All E Codes [259. And 260.]
$1,355,795
Diseases Of The Blood And Blood-Forming Organs
$661,905
Congenital Anomalies
$542,169
Total
$86,864,551
13.3%
13.2%
9.5%
9.3%
9.1%
8.0%
6.0%
6.0%
4.6%
4.1%
3.4%
3.3%
3.1%
2.5%
1.8%
1.6%
0.8%
0.6%
100.0%
Insured
Spouse
Child
$9,555,081 $1,528,349
$458,826
$8,306,683 $2,494,066
$661,506
$6,852,471 $1,274,241
$133,558
$5,622,919 $1,278,190 $1,152,221
$5,304,074 $1,195,139 $1,435,831
$4,461,153
$969,716
$1,484,314
$3,675,158
$761,998
$756,616
$3,976,156
$822,993
$373,407
$2,734,075
$506,651
$735,722
$2,775,661
$542,249
$276,269
$1,655,563
$383,800
$874,764
$1,404,406
$408,640
$1,087,696
$1,407,953 $1,077,890
$174,161
$3,369
$2,808
$2,191,627
$1,140,084
$288,349
$98,278
$909,931
$376,592
$69,272
$396,979
$124,747
$140,179
$83,807
$113,333
$345,029
$60,265,523 $14,149,752 $12,449,276
Male
Female
$4,424,660 $7,117,595
$3,976,863 $7,485,392
$5,537,244 $2,723,026
$3,378,252 $4,675,078
$2,855,851 $5,079,194
$2,865,206 $4,049,976
$2,421,039 $2,772,733
$2,905,268 $2,267,289
$1,812,847 $2,163,602
$1,875,670 $1,718,510
$1,538,222 $1,375,905
$1,471,229 $1,429,513
$24,130
$2,635,875
$811,519
$1,386,285
$457,825
$1,068,886
$800,900
$554,896
$241,126
$420,779
$354,199
$187,969
$37,752,048 $49,112,503
Top 10 Categories by Claim Type
18.80%
34.80%
17.30%
12.10%
39.90%
Jul 15 - Mar 16
40.90%
17.30%
OP as % of CCS
Physician as % of CCS
13.50%
33.10%
34.60%
34.50%
4.30%
10.40%
36.20%
41.40%
IP as % of CCS
4.00%
7.70%
3.80%
2.30%
34.80%
Neoplasms
5.00%
62.50%
31.30%
6.80%
27.60%
13.30%
Symptoms; Signs; And Ill-Defined Conditions And Factors Influencing Health Status
20.50%
27.50%
42.10%
4.80%
3.20%
3.40%
1.40%
7.80%
5.90% 4.50%
14.00%
15.60%
1.80%
0.80%
Other as % of CCS
18
AHRQ Category – Neoplasms
Diagnosis Category
Maintenance Chemotherapy; Radiotherapy
Cancer Of Breast
Benign Neoplasms
Secondary Malignancies
Cancer; Other Primary
Other Gastrointestinal Cancer
Colorectal Cancer
Cancer Of Bronchus; Lung
Cancer Of Lymphatic And Hematopoietic Tissue
Cancer Of Skin
Cancer Of Male Genital Organs
Neoplasms Of Unspecified Nature Or Uncertain Behavior
Cancer Of Urinary Organs
Cancer Of Uterus And Cervix
Malignant Neoplasm Without Specification Of Site
Cancer Of Ovary And Other Female Genital Organs
Overall
Patients
85
285
1,980
79
180
42
74
41
101
552
154
1,548
65
256
29
43
5,514
% of
Patients
1.54%
5.17%
35.91%
1.43%
3.26%
0.76%
1.34%
0.74%
1.83%
10.01%
2.79%
28.07%
1.18%
4.64%
0.53%
0.78%
----
Claims % Claims Total Paid
% Paid
481
2,996
4,064
581
1,173
743
1,023
705
1,162
1,702
1,145
2,956
506
777
149
305
20,468
17.9%
16.9%
9.4%
7.1%
6.6%
6.0%
5.7%
5.7%
5.7%
5.4%
5.4%
2.8%
2.1%
1.5%
1.0%
0.8%
100.0%
Relationship
Insured
0-17
2.9%
18-26
4.6%
75.5%
50-59
14.4%
27.9%
6.1%
60+
Jul 15 - Mar 16
11.4%
18.4%
40-49
Child
$2,066,873
$1,954,986
$1,080,303
$814,089
$766,447
$695,878
$659,131
$655,372
$652,743
$624,946
$619,955
$325,930
$241,375
$174,184
$112,444
$97,600
$11,542,255
Age Range
27-39
Spouse
2.35%
14.64%
19.86%
2.84%
5.73%
3.63%
5.00%
3.44%
5.68%
8.32%
5.59%
14.44%
2.47%
3.80%
0.73%
1.49%
----
38.9%
19
AHRQ Category – Disease of the Musculoskeletal
System/Connective Tissue
Diagnosis Category
Spondylosis; Intervertebral Disc Disorders; Other Back Problems
Non-Traumatic Joint Disorders
Osteoarthritis
Other Connective Tissue Disease
Other Back Problems
Intervertebral Disc Disorders
Other Bone Disease And Musculoskeletal Deformities
Other Non-Traumatic Joint Disorders
Spondylosis And Allied Disorders
Infective Arthritis & Osteomyelitis (Except That Caused By Tb Or Std)
Acquired Deformities
Other Acquired Deformities
Systemic Lupus Erythematosus And Connective Tissue Disorders
Rheumatoid Arthritis And Related Disease
Acquired Foot Deformities
Pathological Fracture
Osteoporosis
Overall
Patients
2,274
2,169
646
3,424
1,905
652
1,985
1,799
350
49
328
109
99
136
173
53
225
16,376
% of
Patients
13.89%
13.24%
3.94%
20.91%
11.63%
3.98%
12.12%
10.99%
2.14%
0.30%
2.00%
0.67%
0.60%
0.83%
1.06%
0.32%
1.37%
----
Relationship
Insured
69.0%
17.6%
0-17
27-39
40-49
Child
13.4%
50-59
60+
Jul 15 - Mar 16
% Paid
10,705
9,639
1,983
10,866
8,099
2,094
9,301
7,873
1,005
442
764
272
405
393
400
128
439
64,808
19.5%
18.1%
12.8%
11.3%
9.2%
7.9%
5.8%
3.6%
3.1%
2.5%
2.0%
1.2%
0.8%
0.7%
0.7%
0.5%
0.3%
100.0%
16.52%
14.87%
3.06%
16.77%
12.50%
3.23%
14.35%
12.15%
1.55%
0.68%
1.18%
0.42%
0.62%
0.61%
0.62%
0.20%
0.68%
----
$2,239,841
$2,076,723
$1,465,575
$1,291,931
$1,059,679
$901,921
$660,849
$410,523
$355,368
$284,132
$231,109
$140,010
$97,251
$75,929
$75,140
$59,714
$36,557
$11,462,254
Age Range
18-26
Spouse
Claims % Claims Total Paid
8.1%
6.9%
12.9%
16.8%
24.8%
30.6%
20
AHRQ Category – Diseases of the Circulatory System
Diagnosis Category
Diseases Of The Heart
Cardiac Dysrhythmias
Coronary Atherosclerosis And Other Heart Disease
Nonspecific Chest Pain
Aortic; Peripheral; And Visceral Artery Aneurysms
Acute Myocardial Infarction
Cerebrovascular Disease
Congestive Heart Failure; Nonhypertensive
Hypertension
Diseases Of Arteries; Arterioles; And Capillaries
Diseases Of Veins And Lymphatics
Acute Cerebrovascular Disease
Heart Valve Disorders
Peri-; Endo-; And Myocarditis; Cardiomyopathy (Except Caused By Tb/Std)
Pulmonary Heart Disease
Peripheral And Visceral Atherosclerosis
Essential Hypertension
Other Circulatory Disease
Conduction Disorders
Other Diseases Of Veins And Lymphatics
Other And Ill-Defined Cerebrovascular Disease
Varicose Veins Of Lower Extremity
Hypertension With Complications And Secondary Hypertension
Occlusion Or Stenosis Of Precerebral Arteries
Phlebitis; Thrombophlebitis And Thromboembolism
Hemorrhoids
Cardiac Arrest And Ventricular Fibrillation
Transient Cerebral Ischemia
Other And Ill-Defined Heart Disease
Late Effects Of Cerebrovascular Disease
Aortic And Peripheral Arterial Embolism Or Thrombosis
Overall
Jul 15 - Mar 16
Patients
1,866
563
293
740
40
28
205
75
2,130
386
321
80
305
67
72
76
1,766
360
112
63
32
64
92
82
102
82
16
42
103
26
9
10,198
% of
Patients
18.30%
5.52%
2.87%
7.26%
0.39%
0.27%
2.01%
0.74%
20.89%
3.79%
3.15%
0.78%
2.99%
0.66%
0.71%
0.75%
17.32%
3.53%
1.10%
0.62%
0.31%
0.63%
0.90%
0.80%
1.00%
0.80%
0.16%
0.41%
1.01%
0.25%
0.09%
----
Claims % Claims Total Paid % Paid
6,653
1,778
834
1,760
106
138
630
310
3,819
695
842
382
554
166
386
179
3,168
606
223
155
67
168
214
139
371
134
45
85
133
73
26
24,839
26.78%
7.16%
3.36%
7.09%
0.43%
0.56%
2.54%
1.25%
15.38%
2.80%
3.39%
1.54%
2.23%
0.67%
1.55%
0.72%
12.75%
2.44%
0.90%
0.62%
0.27%
0.68%
0.86%
0.56%
1.49%
0.54%
0.18%
0.34%
0.54%
0.29%
0.10%
----
$2,719,235
$874,258
$739,045
$574,558
$457,309
$448,031
$276,009
$268,059
$226,425
$183,379
$159,087
$157,826
$151,601
$147,771
$143,382
$112,404
$104,683
$89,609
$77,336
$48,979
$47,028
$46,660
$37,787
$35,547
$31,059
$25,047
$21,534
$21,378
$20,744
$11,242
$3,258
$8,260,269
32.9%
10.6%
8.9%
7.0%
5.5%
5.4%
3.3%
3.2%
2.7%
2.2%
1.9%
1.9%
1.8%
1.8%
1.7%
1.4%
1.3%
1.1%
0.9%
0.6%
0.6%
0.6%
0.5%
0.4%
0.4%
0.3%
0.3%
0.3%
0.3%
0.1%
0.0%
100.0%
Relationship
Insured
Spouse
Child
75.1%
19.2%
5.7%
Age Range
0-17
3.1%
18-26
3.6%
27-39
8.2%
40-49
50-59
14.4%
27.2%
60+
43.6%
21
Emergency Room / Urgent Care Summary
2Q PY16
2Q PY15
HSB Peer Index
ER/Hospital
ER/Hospital
ER/Hospital
Physician UC
Physician UC
Physician UC
UC
UC
UC
ER/Urgent Care
Number of Visits
4,591
7,377
4,008
5,836
Number of Admits
747
0
656
0
Visits Per Member
0.16
0.25
0.15
0.22
Visits/1000 Members
Avg Paid Per Visit
0.18
0.20
158
254
149
216
181
200
$1,886
$44
$1,796
$29
$1,514
$73
0.16
0.00
Admits per Visit
0.16
0.00
0.16
0.00
Total Plan Paid
$8,658,685
$327,209
$7,197,365
$167,989
annualized
annualized
annualized
annualized
ER / UC Visits by Relationship
ER / Hospital
Urgent Care
Per
1,000
Physician
Urgent Care
Per
1,000
Total
Per
1,000
Insured
2,602
120
4,261
197
6,863
317
Spouse
680
139
902
185
1,582
324
1,309
4,591
107
118
2,214
7,377
181
190
3,523
11,968
288
309
Relationship
% of Paid
Insured,
61.0%
Spouse,
Child, 18.5%
20.5%
Child
Total
Visits by Day of Week
1290
1400
1131
1200
1000
800
1084
1063
1032
929
848
680
721
Sunday
Monday
625
672
607
614
672
600
400
200
0
Tuesday
Wednesday
ER / Hospital UC
Jul 15 - Mar 16
Thursday
Friday
Saturday
Physician UC
22
Savings Summary – Medical Claims
Dollars
PPPM
% of
Eligible
$309,818,366
$1,592
100.0%
COB
$7,299,211
$37
2.4%
Medicare
$17,512,985
$90
5.7%
Excess/Maximums
$3,795,589
$19
1.2%
$165,669,451
$851
53.5%
$19,609,437
$101
6.3%
Description
Eligible Charges
PPO Discount
Deductible
Coinsurance
$9,067,143
$47
2.9%
Total Participant Paid
$28,676,579
$147
9.3%
Total Plan Paid
$86,864,551
$446
28.0%
Total Participant Paid - PY15
Total Plan Paid - PY15
2.4%
$154
$476
5.7%
1.2%
28.0%
2.9%
6.3%
COB
Excess/Maximums
Deductible
Total Plan Paid
Jul 15 - Mar 16
24.8%
53.5%
Medicare
PPO Discount
Coinsurance
75.2%
Total Plan Paid
23
Dental Claims Analysis
Cost Distribution
Paid Claims Category
Avg # of
Members
% of
Members
Total Paid
% of Paid
Total EE Paid
% of EE
Paid
$1,000.01 Plus
4,587
7.2%
$6,787,216
39.0%
$4,367,946
51.6%
$750.01-$1,000.00
2,058
3.2%
$1,834,134
10.5%
$1,025,911
12.1%
$500.01-$750.00
3,410
5.4%
$2,153,998
12.4%
$1,158,281
13.7%
$250.01-$500.00
9,900
15.6%
$3,447,862
19.8%
$1,022,452
12.1%
$0.01-$250.00
20,900
32.8%
$3,189,894
18.3%
$869,119
10.3%
$0.00
452
0.7%
$0
0.0%
$28,104
0.3%
No Claims
22,323
35.1%
$0
0.0%
$0
0.0%
TOTAL
63,629
100.0%
$17,413,103
100.0%
$8,471,813
100.0%
Total Paid
$7,154,675
$5,186,585
$3,840,689
$1,231,154
$17,413,103
% of Paid
41.1%
29.8%
22.1%
7.1%
100.0%
Category
Preventive
Basic
Major
Periodontal
Total
Network Performance
100%
80%
6.0%
6.3%
22.9%
7.1%
20.5%
19.0%
60%
40%
25.0%
20.0%
15.0%
94.0%
93.7%
92.9%
20%
10.0%
5.0%
0%
29.8%
41.1%
22.1%
7.1%
0.0%
3Q PY16
3Q PY15
In Network
OON
3Q PY14
Avg Discount
Total Number of Claims = 107,373
Jul 15 - Mar 16
% of Paid
0%
20%
Preventive
40%
Basic
60%
Major
80%
100%
Periodontal
24
Savings Summary – Dental Claims
Dollars
PPPM
% of
Eligible
$36,207,640
$63
100.0%
$115,896
$0
0.3%
Excess/Maximums
$2,843,532
$5
7.9%
PPO Discount
$7,363,296
$13
20.3%
Deductible
$2,322,983
$4
6.4%
Coinsurance
$6,148,830
$11
17.0%
$8,471,813
$15
23.4%
Total Plan Paid
$17,413,103
$30
48.1%
Description
Eligible Charges
COB
Total Participant Paid - PY15
Total Plan Paid - PY15
0.3%
$22
$44
7.9%
20.3%
32.7%
48.1%
67.3%
6.4%
17.0%
COB
PPO Discount
Coinsurance
Jul 15 - Mar 16
Excess/Maximums
Deductible
Total Plan Paid
Total Plan Paid
25
Prescription Drug Utilization
PY 2016 Compared to PY2015
PY 2016
PY 2015
7/1/2015 - 3/1/2016
7/1/2014 - 3/1/2015
Membership Summary
Member Count
46,418
43,221
Utilizing Member Count
12,326
12,137
Percent Utilizing
26.6%
28.1%
265,848
255,583
0.64
0.66
4,611
4,639
221,807
208,542
2,539
5,288
83.4%
98.87%
81.6%
97.53%
Mail Order Claims
4,127
4,018
Mail Order % of Total Claims
1.6%
1.6%
Claims Cost Summary
Total Prescription Cost
$27,134,407.56
$25,802,839.86
Total Ingredient Cost
$26,735,482.66
$25,375,391.66
Total Dispensing Fee
$301,165.80
$322,102.12
Total Other (e.g. tax)
$4,304.35
$2,781.29
Total Incentive Fee
$86,275.98
$102,564.79
Avg Total Cost per Claim
$102.07
$100.96
Avg Total Cost for Brand
$486.36
$461.00
Avg Total Cost for Generic
$29.93
$31.00
Claim Summary
Net Claims (Mail/Retail)
Claims per Elig Member per Month
Total Claims for Brand
Total Claims for Generic
Total Claims for Brand w/Gen Equiv
Generic % of Total Claims
Generic Effective Rate
26
26
Prescription Drug Utilization
PY 2016 Compared to PY2015
PY 2016
PY 2015
7/1/2015 - 3/1/2016
7/1/2014 - 3/1/2015
Member Cost Summary
Total Copay
Avg Copay per Claim
$9,166,843.86
$8,523,332.15
$34.48
$33.35
Avg Copay for Brand
$132.31
$112.00
Avg Copay for Generic
$16.97
$18.00
Avg Copay for Brand w/Gen Equiv
$34.33
$72.00
Copay % of Total Prescription Cost
33.8%
33.0%
$17,967,563.60
$17,279,507.59
$9,908,955.41
$9,437,592.31
$8,058,608.19
$7,841,915.28
Avg Plan Cost per Claim
$67.59
$67.61
Avg Plan Cost for Brand
$354.05
$349.00
Avg Plan Cost for Generic
$12.96
$13.00
Net PMPM
PMPM for Specialty Only
$43.01
$44.42
$23.72
$24.26
PMPM without Specialty
$19.29
$20.16
Plan Cost Summary
Total Plan Cost
Total Specialty Drug Cost
Total Non-Speciality Cost
27
26
11.2.2.
11.2.2. PEBP Operations Officer Report
STATE OF NEVADA
Telephone (775) 684-7000 · (800) 326-5496
BRIAN SANDOVAL
Governor
Fax (775) 684-7028
DAMON HAYCOCK
Executive Officer
Board Chairman
AGENDA ITEM
X Action Item
Information Only
Date:
July 21, 2016
Item Number:
11.2.2.
Title:
Operations Report for period ending March 31, 2016
SUMMARY
This report provides a summary of PEBP operations through the period ending March 31, 2016.
REPORT
PROGRAM UPDATES
Towers Watson OneExchange: Due to the disproportionate percentage of participant issues and
complaints, PEBP took a more active role in the complaint and resolution process with our
Medicare Exchange participants. Traditionally, participants who called PEBP were immediately
referred to Towers Watson and only escalated issues were assigned to and researched by PEBP
staff. This led to a rather high amount of issues on the Issue Log. In an effort to mitigate some of
these issues, the Member Services Unit (MSU) began assisting participants at the front end by
providing those with known issues an additional level of customer service by coordinating with
the participant and Towers Watson to ensure swift resolution. The added time spent by PEBP
MSU staff did affect the overall call statistics, however, the added value in customer service
resulted in a fewer number of issues that had to be researched by other staff, therefore reducing
the resolution time for the participant.
In March, Board Chair, Leo Drozdoff, Executive Officer, Damon Haycock and Operations
Officer, Laura Rich traveled to Sandy, Utah and met with Towers Watson One Exchange staff to
discuss and develop possible strategies for improvement. Towers Watson agreed to develop a
plan of action and present this plan to the Board.
Operations Officer Report
July 21, 2016
Page 2
Wellness: PEBP reached out to both the UNR and UNLV Schools of Medicine to propose a
pilot program where we can leverage resources and provide an opportunity to push a no cost
wellness incentive surrounding the registered dietician programs and nutrition counseling. The
program is still in the early planning stages, and we have had very successful discussions with
UNR. UNR is eager to explore these opportunities and will be coming back to PEBP with initial
findings so we can proceed.
Additionally, we have assigned a staff member to enhance our wellness program as a whole.
With the launch of our new website, he will be adding a robust wellness piece. He will be
augmenting the calendar to include wellness events and coordinating with other agencies and
organizations to ensure we can bring a focus back to current wellness benefits and opportunities
with PEBP.
ELIGIBILITY
In February, PEBP implemented an upgrade to the eligibility system and successfully
transitioned onto a new platform. All PEBP staff received extensive training over a 3-day
period. As is common in all IT projects, there were some bumps along the way which did
temporarily affect operations in both Eligibility and MSU, however the majority of the issues
were able to be resolved timely. The Eligibility Unit was the most affected by these changes,
therefore the staff in that unit endured the additional burden of the issues and process changes
resulting from the new system. The staff coordinated heavily with the vendor to ensure most
fixes were in place prior to the beginning of open enrollment.
MEMBER SERVICES UNIT (MSU)
MSU experienced significant turnover at the end of 2015. Three of the nine staff were promoted
within or to other agencies, which left MSU short staffed for several months until MSU was able
to hire and train staff. By the time MSU was again fully staffed and properly trained, PEBP
transitioned to an upgraded eligibility system which required all staff to re-learn the end-user
interface.
As mentioned above, the volume of complaints and issues stemming from our Medicare
Exchange participants prompted PEBP to re-evaluate how MSU addressed customer service for
Exchange participants. In general, PEBP has received positive feedback from participants on the
advocacy provided by both MSU and Complaints and Appeals staff.
MSU has also experienced a surge of email and walk-ins. Typically MSU staff has been able to
accommodate walk-ins and respond to emails in a timely matter, however, given the rise in both,
PEBP has pulled staff from other units to provide additional support. If these trends continue,
MSU will have to reassess staffing, processes and scheduling to ensure the needs of participants
are being appropriately met.
The table below reflects PY 15 and PY 16 MSU call center activities:
Operations Officer Report
July 21, 2016
Page 3
PLAN YEAR 15
PLAN YEAR 16
JulSep
2014
OctDec
2014
JanMar
2015
AprJun
2015
JulSep
2015
OctDec
2015
JanMar
2016
AprJun
2016
62
85
396
74
179
422
398
81
71
64
18
99
21
69
52
72
9,967
8,506
12,193
11,062
9,790
9,253
10,038
11,155
1,322
N/A
N/A
4,983
1,421
N/A
N/A
3,139
11,422
8,655
12,607
16,218
11,411
9,744
10,488
14,447
PEBP Average # of
Calls Answered Per
Day
112
96
140
125
111
108
117
126
PEBP Abandonment
Rate
0.61%
0.98%
3.14%
0.66%
1.79%
4.33%
3.79%
0.72%
PEBP Average Call
Duration (minutes)
0:04:38 0:05:12 0:04:33 0:04:56 0:04:24 0:04:10 0:04:20 0:04:27
PEBP Abandoned
Calls
PEBP Voice Mail
Calls
PEBP Answered
Calls
Morneau Total
Rollover Calls
PEBP Total
Incoming Calls
PEBP Average Speed
to Answer (seconds)
PEBP Total Walk-ins
PEBP Average # of
Walk-ins Per Day
PEBP Total Emails
0:00:13 0:00:16 0:00:30 0:00:12 0:00:20 0:00:43 0:00:39 0:00:13
404
383
124
146
164
419
427
467
4.5
N/A
4.3
N/A
1.4
985
1.6
1,144
1.8
871
4.7
2,027
4.7
2,057
5.2
3,521
CONCLUSION
PEBP is constantly assessing the operational component of programs, eligibility, enrollment, and
customer service. As participants utilize different methods to seek help, we adjust as timely and
appropriately as possible to provide the highest level of service. Challenges exist with our
Medicare Exchange vendor, a new system upgrade, and periodic turnover, however PEBP will
continue to meet these challenges head on and create dynamic solutions moving forward.

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

Transcription

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