The Changing Landscape of Insurance Coverage

Transcription

1 The Changing Landscape of Insurance Coverage MARRCH Conference October 25, 2016

2 Presenters Karen D. Lloyd, PhD, LP Darrin Helt, LICSW Trevor B. Johnson, LICSW HealthPartners Blue Cross Blue Shield Medica Behavioral Health

3 Overview Over the past 5 years health insurance has been changing We will review: What has not changed What has changed Health plan drivers Areas for collaboration Questions and Comments

4 Health Insurance Fundamentals which has not changed Health insurance is a legal contract Health insurance is highly regulated

5 Example: Home Owner s Insurance Who When What Circumstances Private residence at 1234 Elm St., Our town, MN Oct. 1, 2015 through Sept. 30, 2016 Structural repair due to fire or storm damage up to $400K Contents covered up to $10K Alternative housing covered up to $5K Subject to $5K deductible Does not cover flood damage or mold damage Does not apply if the home is used as a rental property Any new construction requiring a permit must have documentation of permitting approval Does not apply if damage occurred during a criminal activity by the occupants

6 Example: Health Insurance Who When What Circumstances John X. Anyman plus spouse and children including adult children up to age 26 Oct. 1, 2015 through Sept. 30, 2016 Medical evaluation and treatment including inpatient in a hospital, outpatient in a clinic, intermediate care in a SNF, urgent care and emergency care in a hospital Durable medical equipment up to $20K Medical necessity criteria must be met Does not cover dental evaluation or treatment Does not apply to these elective procedures without prior auth see the list If Medicare is primary, all healthcare bills must be denied by CMS before consideration

7 Health Insurance is Highly Regulated Anti-Trust Requirements DHS Contract Requirements Accreditation Requirements NCQA URAC Audits every 1, 2 or 3 years, some planned and some not NCQA URAC CMS DHS Self-Insured Employers

8 Health Insurance Fundamentals which Haven t Changed Minnesotans are covered by many types of insurance State Public Programs Insurance from Minnesota based companies Fully insured Self insured Insurance from companies based in other states Implications of Minnesotans having many types of insurance Implications of high rates of people with insurance Implications of an aging population

9 Where MN Get Health Insurance (96% Insured) MN Council of Health Plans Note: military coverage not included in data

10 Health Plan Requirements Type of Product Scope Oversight Who defines benefit set? ERISA Federal US Dept. of Labor/ MN Commerce HMO State MN Dept. of Health Exchange Federal/ State MN Dept. of Health Self Insured Employer State law & Health Plan ACA State law Medicare Federal CMS Federal statute & CMS Portion of Pie Employer self insured Employer fully insured Individual Medicare PMAP/ MNCare/ MSHO/SNBC Federal/ State CMS/ MN DHS CMS with MN State Plan amendment MA/MNCare

11 Health Insurance Fundamentals which Have Changed Benefits within State Public Programs such as EIDBI or BHH The number of companies choosing to be selfinsured has increased Being self-insured provides more customized options Benefit set customization Network size and configuration Appeal process options

12 Health Plan Responsibilities in Administering Self-Insured Plans The Health Plan has the following responsibilities: To act on behalf of the participants in a group health plan and their beneficiaries to provide benefits to them; To follow the plan documents which are the foundation for plan operations; To pay only reasonable plan expenses; To carry out duties prudently. This includes things such as documenting decisions and the basis for these decisions; and Health plans are subject to following provisions in ERISA, which includes COBRA, HIPAA and other group health provisions in the law, as well as other regulations, such as the ACA.

13 Type of provider and impact on benefits Self-Insured Plans and Customization: Network Available to the Member Example where Member John Jones needs to seek Behavioral Health Services. John has a plan that is a self-insured plan with ACO Network, In Network and Out of Network benefits. Deductible Copay/ Coinsurance IP services Copay/ Coinsurance OP services ACO Provider $200 $200 $10 None In Network Provider not in ACO Out of Network Provider $1450 per individual/ $2900 per family $1450 per individual/ $2900 per family 10% after meeting deductible 40% after meeting deductible 10% after meeting deductible 40% after meeting deductible Out of Pocket Maximum $2500 per individual/ $5000 per family $4500 per individual/ $9000 per family

14 Self-Insured Plans and Customization: Network Available to the Member Example where Member John Jones sees an Outpatient Therapist. John has a plan that is a self-insured plan with both In Network and Out of Network benefits. Type of provider and impact on benefits Deductible Copay/ Coinsurance IP services Copay/ Coinsurance OP services Out of Pocket Maximum In Network Provider $200 per individual/$400 per family No copay or coinsurance after meeting deductible $40 copay $2500 per individual/ $4000 per family Out of Network Provider $600 per individual/ $1200 per family 30% coinsurance after meeting deductible 30% coinsurance after deductible $2500 per individual/ $4000 per family

15 State Public Health Insurance and Special Needs Basic Care Programs The core components are the same across health plans Each health plan has the option to add additional benefits or services Improve the health of the member Improve access to care Anticipate lower medical costs

16 State Public Health Insurance and Special Needs Basic Care Programs Product Eligible Prepaid Medical Assistance Program (PMAP) Pregnant women, parents, caretakers, children under age 21, adults without children Income Range Benefits Parents, Caretaker Relative, Children 19-20, Adults w/o children up to 133% FPG Pregnant women up to 278% FPG Children 2-18 up to 275% FPG Infants <2 up to 283% FPG Medical Assistance Basic Care Expanded coverage for pregnant women, children $3 non-preventive visit copay (no copay for mental health visits) $1/$3 drug copays ($12/mo. max) MinnesotaCare Child, MinnesotaCare (MNCare) Children under 21, Adults Without Children Up to 200% FPG Medical Assistance Basic Care (expanded benefits for MNCare Child) $15 non-preventive visit copay $50 ER/$150 inpatient hospital $6/$20 drug copay ($60/mo. max)

17 State Public Health Insurance and Special Needs Basic Care Programs (cont.) Product Eligible Minnesota Senior Health Options (MSHO) Adults over age 65 (dual) Income Range Benefits MA - up to 100% FPG (75% FPG w/spend down) $3,000/person asset limit Medicare Parts C & D (medical and drugs) Medical Assistance Basic Care Elderly Waiver (Nursing Home frailty) Care Coordination Part D cost sharing only Special Needs Basic Care (SNBC) Adults age with certified disability (dual and non-dual) MA - up to 100% FPG (75% FPG w/spend down) $3,000/person asset limit MA-EPD cert disability, monthly income >$65K Medical Assistance Basic Care PCA, Waiver carved out Care Coordination Cost Sharing waived

18 PMAP and MnCare vs MA Transportation to health services (PMAP) Dental Care Nurse Line (24/7) Other potential benefits (may vary by plan) Incentives for health screening and/or preventive health visits Car seats Community Education programs Health club membership Health/Lifestyle coaching

19 MSHO vs MA Care Coordination Transportation to medical appointments Dental Other potential benefits (may vary by plan) Health Club Strength and balance kits Safety devices

20 SNBC vs MA No Copays on Prescription Car Seats Program (S.E.A.T.S.) Quit Smoking Program Care Navigation & Coordination 24/7 Nurse Line Disease Management Other potential benefits (may vary by plan) Fitness Club Membership Incentives for health screening and/or preventive health visits (e.g. mammogram incentive program)

21 Health Plan Drivers Health Care Triple Aim: (Institute for Healthcare Improvement) Improving the patient s experience of care Improving the health of populations Reducing the per capita cost of health care Behavioral/ Medical Integration: year life expectancy reduction for people with serious mental illness (WHO) Double to quadruple medical costs when behavioral condition co-occurs (Milliman American Psychiatric Report, April 2014)

22 Health Plan Drivers (cont.) Affordability: (Health Affairs Blog February 2016) The most serious health care problem in America is affordability In 2014, CMS estimated $9,695 avg. spent on every man, woman, child

23 Functions Provided by Health Plans 1 Benefit structure development, implementation and education 2 Ensure access to high quality providers through contracting, credentialing, and complaint management 3 Care Coordination, case management for complex & co-occurring conditions, transportation, interpreter services, timely access 4 Health promotion services such as healthy pregnancy, tobacco cessation, disease management, reduced stigma 5 Utilization management to assure that the service is part of the benefit set, medically necessary and delivered at the least restrictive level of care 23

24 How Do We Support Your Work? Provide historical treatment perspective Education about and facilitation to services and supports available through their health plan

25 Opportunities for Collaboration: Categories and Examples On the Individual Member Level Timely access to treatment (e.g. facilitate access to a Rule 25 assessor and SUD treatment placement) On the Community or County Level East Metro Crisis Alliance On the State Level DHS Workgroups i.e. Case Management Administrative Uniformity Committee new codes On the National Level America s Health Insurance Plans (AHIP) & National Council for Behavioral Health Outlier Practices and Medical Tourism

26 Fundamentals of Utilization Review Questions asked as a request or claim is processed: Member eligibility is this a current member? Covered benefits is this a covered service in the benefit set? Network provider is this provider a contracted network provider? Medical necessity is this the least restrictive level or intensity of care available to meet the member s clinical needs? Member liability how much does the member pay?

27 Online Resources MNHealthplans.org Bluecrossmn.com Healthpartners.com Medica.com Ucare.org HennepinHealth.org MakeItOK.org

28 Questions and Comments? Thank you!