WellCare Benefit Plan

Transcription

1 WellCare Benefit Plan Presented to: WellCare Advisory Committee 9/21/2006 Presented by: Tom Boyd, Executive Vice President Blue Cross & Blue Shield of RI

2 Agenda Review Recommendations from WellCare Advisory Committee Meeting Questionnaire Response Alternative Plan Design Other Options Available 2

3 WellCare Advisory Committee Meeting Recommendations for plan design: Focus on comprehensive coverage not catastrophic Drive toward primary care, disease/ case management and wellness programs Direct to high quality, cost effective settings Promote the use of generic drugs Design must be marketable and carriers must be able to administer 3

4 Plan A : Small Business Calendar year deductible (applies to services without a copayment) Plan coinsurance (applies to services without a copayment) Calendar year out of pocket maximum (deductible and copayments do not apply) Office visit: PCP Office visit specialist Urgent care copayment Emergency room Preventive testing (mammogram, pap smear, PSA, immunizations) $3000 / $ % $6000 / $12,000 $15 copayment $25 Copayment $50 copayment $200 copayment 100% 4

5 Plan A : Small Business (Cont.) Annual dental exam and cleaning Prescription retail 30 day supply Prescription mail order 90 day supply (2.5 copayments) Health Risk Assessment $50 copayment $500 deductible applies to tiers 2, 3, 4 Tier 1: $7 generic Tier 2: $30 preferred brand Tier 3: $50 non preferred brand Tier 4: $75 specialty drugs $500 deductible applies to tiers 2, 3, 4 Tier 1: $17.50 generic Tier 2: $75 preferred brand Tier 3: $125 non preferred brand Tier 4: $ specialty drugs Upon enrollment 5

6 Plan A : Small Business Alternative Proposal - Referral model Calendar year deductible (applies to services without a copayment) Plan coinsurance (applies to services without a copayment) Plan A Alternative $3,000 / $6,000 $1,500 / $3,000 20% 20% Calendar year out of pocket maximum (deductible and copayments do not apply) $6,000 / $12,000 $3,000 / $6,000 Office visit: PCP $15 copayment $20 copayment Office visit: PCP annual well visit N/A $0 copayment Office visit Specialist $25 Copayment $40 Copayment 6

7 Plan A : Small Business Alternative Proposal - Referral model (Cont.) Plan A Alternative Urgent care Copayment $50copayment $75 copayment Emergency room $200 copayment Preventive testing (mammogram, pap smear, PSA, immunizations) $250 copayment 100% 100% Annual dental exam and cleaning $50 copayment $50 copayment 7

8 Plan A : Small Business Alternative Proposal - Referral model (Cont.) Prescription retail 30 day supply Prescription mail order 90 day supply (2.5 copayments) Health Risk Assessment Plan A $500 deductible applies to tiers 2, 3, 4 Tier 1: $7 generic Tier 2: $30 preferred brand Tier 3: $50 non preferred brand Tier 4: $75 specialty drugs $500 deductible applies to tiers 2, 3, 4 Tier 1: $17.50 generic Tier 2: $75 preferred brand Tier 3: $125 non preferred brand Tier 4: $ specialty drugs Upon enrollment Alternative $1,000 deductible applies to tiers 2, 3, 4 Tier 1: $7 generic Tier 2: $30 preferred brand Tier 3: $50 non preferred brand Tier 4: $75 specialty drugs $1,000 deductible applies to tiers 2, 3, 4 Tier 1: $17.50 generic Tier 2: $75 preferred brand Tier 3: $125 non preferred brand Tier 4: $ specialty drugs Upon enrollment 8

9 Wellness Features Focus on primary care Lower copayment for Primary Care Physician Preventive testing and immunizations covered at 100% Completion of Health Risk Appraisal High risk with disease Enroll in disease management High risk without disease Receive outreach call Low risk Wellness programs recommended 9

10 Wellness Features Continue to actively manage the chronically ill Use of the most appropriate setting Copayment structure incents members to use Primary Care Physician or urgent care facilities Promote quality care BlueCross BlueShield Association Centers of Excellence Radiology privileging Preauthorization for high end radiology services Encourage use of generic drugs 10

11 Wellness Tools Array of Member Self-Service Tools Available On-Line via Provider finder search tool Links to pharmacy, medical & dental information Electronic EOB Hospital quality tool PLUS an Extensive Library of Educational Tools Mayo Clinic information Health trackers Online personal health assessment tools Health and wellness programs 11

12 Quality Initiatives Participant in BCBSA Quality and Cost Measurement initiative Quality based incentives Electronic health records 12

13 Other Options Available High Deductible Health Plans (HDHP) with Health Savings Accounts (HSA) Health Reimbursement Arrangements (HRA) with Flexible Spending Accounts (FSA) Change Legislation to allow: Exclusion of State Mandated Benefits Higher rates for smokers Allow Age/Gender and Morbidity Adjustments 13

14 Discussion/Questions? 14