The Local Choice Health Benefits Program

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The Local Choice Health Benefits Program

2005 Regional Meetings

March 2005

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What’s New?

• CommonHealth Programs

• New Plan Designs

• Broader Plan Choices

• Funding Requirements

• Financial Overview

• Renewal Requirements

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What Else is New?

• COBRA/USERRA/HIPAA Updates

• Dependent Definitions

• GASB 45

• Medicare D

• Alternate ID #s

• General Housekeeping

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CommonHealth

Linda Sweeney

Rose O’Toole

Stacey Dorton

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Continental Health Promotion804 Moorefield Park Drive, Suite 304

Richmond, VA 23236(804) 560-4500

www.chp-online.com/tlc

The Local ChoiceCommonHealth

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Our Vision StatementFor CommonHealth is that:

State and Local Choice employees in Virginiawill be the healthiest in the nation

The CommonHealth Mission:

To make a difference in the health of theemployee and the workplace by:

Integrating health into the work culture,

Building trustworthy partnerships,

Changing individual behavior.

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What does CommonHealth include?

On-site Health Check Screening Total Cholesterol HDL Cholesterol Blood Glucose Blood Pressure Comprehensive Health Questionnaire Participant Incentive New Incentive for CommonHealth Administrators

achieving a 35% participation rate

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Annual Health Education Program Small Steps, Big Rewards Minutes Matter Have a Ball with Fitness (Available July 2005)

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Baby Benefits

This free program is designed to promote a healthy pregnancy and prevent premature birth.

New Child Safety Seat Program offers a $30 reimbursement for the purchase and safe installment of a child safety seat.

1-800-828-5891

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Breaking Free from Tobacco

This program offers the support needed to quit and stay quit. Participants can receive an eight-week supply of nicotine patch or gum at no cost.

1-800-394-6380

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The Compass Quarterly Newsletter

Annual Health Improvement Challenge

Fitness Center Discounts

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National Employee Health & Fitness Day

May 18, 2005

Promote the event at your location Sign up interested employees Choose a one-mile (about 15 minutes) walking course Contact your CommonHealth Regional Coordinator to order

step counters provided through The Governor’s Healthy Virginian’s Initiative

Goal = 50 or more groups participate!

Be on the lookout for information in the mail and on the CommonHealth Web site.

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Questions?

Eastern Region – Tammy Glotz1-804-379-8568 [email protected]

Central Region – Rose O’Toole1-804-378-9914 or [email protected]

Western Region – Stacey Dorton1-276-739-9961 [email protected]

CommonHealth Manager – Linda Sweeney1-804-560-4500 [email protected]

Visit us at www.chp-online.com/tlc

Thank you for supporting CommonHealth!

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Anthem Blue Cross and Blue Shield

Amy Feinman

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Anthem Cross and Blue Shield

The Local Choice 2005/2006

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• Look Back at 2004/2005

• 2005/2006 Changes

• 2005/2006 Plans

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The Local Choice 2005/2006• Look Back at 2004/2005

– 10 new groups joined TLC– 1 group left TLC– Membership increased 4%– Maintained a 13% trend factor– Benefit analysis and plan changes

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The Local Choice 2005/2006• 2005/2006 Medical Plan Changes

– New four plan design

– No lifetime benefit maximum on any product

– All plans have the same coverage and exclusion base

– All plans have BlueCard

– All plans will have out of network coverage

– Copayments do not count towards the out of pocket calculation

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The Local Choice 2005/2006• 2005/2006 Medical Plan Changes

– Key Advantage Expanded is the only plan with vision coverage. (Vision benefits will continue to be on a 24 month basis. The 24 months begins the month you have your eye exam, or purchase frames, lens, or contact lenses.)

– This year only, because of the elimination of 4 plans, 4th quarter deductible carryover will apply for all plan changes.

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• Really Good News– New member handbooks will be published this

year.– They will have a standard format with inserts

for plan specific coverage amounts.

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• 2005/2006 Plans– Please refer to your comparison charts.

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• Questions?

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ValueOptions

Nathan Coley

Joseph E. Chodkiewicz

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March 7, 2005

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ValueOptions

• Founded by a psychiatrist• Clinically focused delivery system• Over 25 years of EAP experience• 84,000 provider locations- 23 million

covered lives for managed care• Virginia based employer

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ValueOptions

• Mental Illness/Substance Abuse and EAP Benefits

• Dedicated toll free number: 866-725-0602

• Website: www.achievesolutions.net/tlc

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ValueOptions

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ValueOptions

Employee Assistance Program Benefits

• Four sessions per problem per year with no cost to the member

• Everyone in the household is eligible• Provides confidential, professional counseling,

education and referral services

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ValueOptions

EAP Offers help with a variety of issues:

• Marital and family problems• Alcohol and /or drug abuse assessment• Balancing work and family• Work-related concerns• Financial or legal issues (including mediation

services)• Grief and loss• Personal growth and development

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ValueOptions

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ValueOptions

Mental Illness/Substance Abuse

• Call 866-725-0602 for pre-certification• Certification is based on medical necessity• Benefit coverage is based on provider status• Out of Network benefit, when available,

provides lower coverage and providers may balance bill the member

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ValueOptions

Medical Necessity

• The service must be appropriate and essential for the evaluation and/or treatment of a mental disorder.

• The service must expect to improve a patient’s condition or level of functioning, and/or prevent regression.

• The service must meet national standard of practice.

Medical Necessity Criteria can be found at our website: www.valueoptions.com

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ValueOptions

As of June 30, 2005,

The following plans are no longer offered:

• Cost Alliance• Value Alliance

• KeyShare

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ValueOptions

Beginning July 1, 2005

The TLC Program will offer 4 new plans:

Key Advantage ExpandedKey Advantage 200Key Advantage 300Key Advantage 500

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ValueOptions

Questions???

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Thank you!www.valueoptions.com

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Medco

Derek Fredenburg

Robin Nieman

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The Local Choice Rx Benefit

administered by Medco

Presenter: Derek Fredenburg

George Bognar

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New Copay Information

Effective upon group renewal date (July or Oct)

Retail

(per 34 day supply)

Mail

(34 day supply or less charges retail copay, 35 to

90 charges mail copay)

Tier 1

(Typically Generics)

$15 $30

Tier 2

(Typically lower cost brand-name drugs)

$20 $40

Tier 3

(Typically higher cost brand-name drugs)

$35 $70

If a brand name drug has a generic equivalent, the member pays the difference between the two if the brand name drug is requested.

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Medco Customer Service for TLC 1-800-355-8279

Accessible 24 hours a day, seven days a week (except for Thanksgiving and Christmas)

How can this help me?1. Ask a pharmacist….2. Refill a prescription3. Order new mail order forms4. Locate a retail pharmacy5. Get a copay quoteThese are only some of things we can assist you with.

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Retail Pharmacy

1. When you need a drug on a short term basis

2. Over 50,000 stores in the network nationwide

3. All major chains are in the network

4. A retail copay is applied per 34 day supply of medication, up to a 102 day supply (3 month) with one prescription

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medco.com secure and convenient prescription

management for membersAward winning member website• Verified Internet Pharmacy Practice

Sites (VIPPS™) A Program of the National Association of Boards of Pharmacy

What can I do?1. Refill medications by mail on line2. Get the status of a Mail Rx Order3. Copay quotes4. Ask a pharmacist5. Find a retail pharmacy6. Is my medication covered?

http://www.nabp.net/

http://www.nabp.net/

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Medco by Mail1. For prescription medications you use on a regular

basis2. Dedicated primary mail pharmacy just for TLC

and State employees – located on Richmond VAPO Box 35030Richmond VA 23235-0030

3. Wilson Rx Award - Medco has re-earned the distinction of being named the nation's top-rated PBM and mail order pharmacy in the WilsonRx Pharmacy Benefit Satisfaction Report 2004.

4. Safe, convenient, cost effective, and it is quick.

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Delta Dental of Virginia

Duncan Sheils

Matt Macdonald

Terri Green

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Dental Benefit Solutions

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Discussion Points

• History of Dental Benefits

• Dental Plan Enrollment

• Costs and Trends

• Plan Changes for 2005

• The Delta Difference

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Discussion Points






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History of Dental Service Plans

• 1954– International Longshoreman’s Union and dental professionals create dental care

program for Union’s children – First not-for-profit dental service plan created, (Washington State Dental Service -

now Delta Dental of Washington). • 1955

– Similar organizations created by dental societies in CA and OR.• 1963

– Aerojet-General Corp first large company to buy a dental program. • 1966

– ADA established the National Association of Dental Service Plans - forerunner of Delta Dental Plans Association.

– Organization’s main purpose to increase the availability of dental services to the public

• 1970s– Commercial insurers enter dental marketplace

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Discussion Points






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Current Dental Marketplace

IBIS Study, 2000-2004

National Dental Plan Enrollment

144.0

153.7156.2 156.5 156.6

130

140

150

160

170

1999 2000 2001 2002 2003

En

rolle

es

(M

illio

ns

)

55% of the US population has group dental insurance

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Delta Dental National Enrollment

IBIS Study, 2000-2004

Delta Dental Plan Enrollment

14.620

28.6

35.739.8 42.2 43.5 45.4

0

10

20

30

40

50

1984 1989 1994 1999 2000 2001 2002 2003

Enr

olle

es (M

illio

ns)

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Competitive LandscapeNational Market Share

National Market Share (In-force dental premium)

12%

14%7%

9%

4%

4%

1%

15%

30% Delta Dental

2%

1%

1%

Delta Dental

BC/BS

MetLife

Aetna

CIGNA

Guardian

UCCI

Fortis

United healthcare

Ameritas

Humana

Others

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Discussion Points






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Current Dental MarketplaceTransition to PPO products

• PPO products are continuing to capture more than 50% of new covered lives

• DMO business continues to lag with a continued negative outlook for future sales

shcampbell

this slide can be removed if we use the next two slides. dotpoint versions vs text/sentence versions

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Premium Trends

Historic Premium Trends

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

1999 2000 2001 2002 2003 2004

medical dental (ind.)

dental ppo dhmo

Medical trends continue to outpace dental trends.

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Benefit Trends

• Composite fillings on posterior teeth

• Invisalign braces

• TMJ

• Cleanings-four/year (periodontal cleanings)

• Implants

• Consumer directed healthcare

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Discussion Points






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The Local Choice Dental PlansEffective 7/1/05 and 10/1/05

Key Advantage Expanded Key Advantage 200, 300, 500

Deductible

Major Services

Basic Services

Maximums

Deductibles

Orthodontia

Major Services

Basic Service

Diagnostic & Preventive Services

$1,500 annual$1,500 lifetime ortho

$25 ind. / $75 family

50% Premier Allowance




$1,200 annual$1,200 lifetime ortho

$25 ind. / $75 family





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Discussion Points






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Who Is Delta Dental?

• The largest and most experienced provider of group dental benefits nationally

• Delta Dental Plans Association– 38 plans with a common mission & focus

– Shared national provider networks

– National Provider File

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Superior Networks and Access

DeltaPremier

• Largest Network

Available Anywhere!

• 136,500 dental offices

• 2675 Participating Premier Providers in Virginia (79% of all providers statewide)

• 29 million members

• 82% of TLC/School groups using a Premier provider

• 77% of TLC Government groups using a Premier provider

• 210 New Premier Providers since 4/1/04

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National Networks…With Local Control

• Seamless network of Delta Dental Plans across the country

• Recruitment and management of provider networks performed by local representatives

• Professional Relations staffs are well versed on concerns with specific offices or local dental societies - part of the community

• Delta Dental offers the best of both worlds– Ability to offer national networks, while providing local support for providers

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State-of-the-Art Technology

DCS2000® Claims System• Single site for claims processing and customer

service• Designed specifically for dental claims• Server-based, Windows technology• Paperless processing

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Superior Performance

Our service and administration are consistently ranked among the best in the industry.

Superior Performance

0

10

20

30

40

50

60

70

80

90

100

ClaimsTurnaround

within 15 days

ClaimsTurnaround

within 30 days

ProcessingAccuracy

FinancialAccuracy

98.6% 100% 99.8% 99.8%

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Internet Website: www.deltadentalva.com

•Find Participating Dentists•Check Benefit Design •Check Claims

•Annual Maximum Status•Real Time/On-line Enrollment•Deductible Status

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Making a Difference in the Community

Fulfilling our mission of providing affordable oral healthcare to all Virginians

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The Delta Difference!

• Total Focus on Dental Benefits• Largest, Most Experienced Dental Benefits Carrier

in the Nation • Aggressive Cost Management• Superior Network Access• Proprietary DCS2000® Dental Claims System• Community Involvement • Satisfied Customers!

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Broader Plan Choices

• 25 or fewer - any one plan.

• 26 to 100 - any two plans, one of which may be the Regional HMO, if available

• 100+ - any two self funded plans plus the Regional HMO, if available

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Funding Requirements

• Full Time 80% of average single rate20% of average dependent rate if less than 75%

participation.

• Part Time40% of average single rate10% of average dependent rate if less than 75%

participation

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TLC/DHRMFinancial Overview

T.J. Clayton

George Gibbs

Walt Norman

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Renewal Requirements

• Data Sheet

• Memo of Understanding

• Group Profile Sheet

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COBRA Update

• Regulations finally final• New Requirements

– Q/Bs to provide certain notices to plan (divorce, etc.)– Notice of Unavailability– Termination Notice

• Changes to Initial Notice, Election Notice – Recommend sending new initial notice to all

• TLC will send materials prior to July 1, 2005– Our forms must be used

• TLC will allow 45-day grace period on COBRA premiums

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USERRA

• Uniformed Services Employment and Re-employment Relief Act requires all groups regardless of size to offer 24 months of Extended Coverage for Active Duty Military call ups.

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HIPAA

• All groups regardless of size must send certificates of creditable coverage to terminating participants

• MOU required

• With QME, TLC will allow Plan Change effective 7/1/2005 or later.

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Dependent Definition under WFTRA

• Spouse – Legally recognized in VA

• Children – To end of year turning age 23 regardless of

student status– Lives at home or away at school– Unmarried – Receives over ½ of support from either or both

parents (To be effective later in the year)

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GASB 45

• Federal requirement that cost of retiree coverage be funded or carried as liability on books.

• Private sector requirement since early 1990s as FASB

• TLC will provide guidance and data but each group will be responsible for any required actuarial certification and/or filings

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Medicare D

• Still unclear

• Requires certification of creditable coverage

• TLC will initially let you know if creditable

• Awaiting further CMS guidance

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Alternate ID #s

• Effective 10/1/2005 TLC will issue alternate ID numbers to all covered employees

• Still 4 ID cards

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General Housekeeping

• Life Evac Air Ambulance now in network

• Reporting Medicare eligibility required

• New email and web addresses:

www.thelocalchoice.virginia.gov

[email protected]

http://www.thelocalchoice.virginia.gov/

Documents

The Local Choice Health Benefits Program