Group Benefits Administrative Update

Transcription

1 Q Group Benefits Administrative Update Claim verification processes Information for plan sponsors Manulife has a variety of processes in place to help ensure that only eligible claims expenses are reimbursed in accordance with the Group Benefits Policy. Our prepayment verification programs enlist the assistance of our plan members to help determine the accuracy and appropriateness of submitted claims. These are already in place for most clients, and other plan sponsors will begin benefiting from this approach in the coming months. There are now two new online reference documents available Hospital Audits - Nothing to Fear" and "Buying custom-made orthotics: What you need to know" for plan administrators and plan members who would like more information on Manulife s standardized control processes for managing plan member claims expenses. These new reference documents include tips for plan members and answers to frequently asked questions, and can be downloaded from under Fraud Prevention Services. The hospital claim verification program ensures that those hospital services that should have been provided at no cost to the plan member or the plan sponsor are not billed. To manage this risk, we periodically follow-up with plan members by sending them a questionnaire to confirm information related to their hospital stay. Once the questionnaire is received, a given claim is quickly assessed, and the appropriate reimbursement is made to the hospital. Approximately 1.5 percent of all hospital claims are verified in this manner, a process which helps to ensure plan members claims are appropriately billed to their group benefits plan. The prepayment verification program is similar to the hospital claim verification program in that it requests information from the plan member. This questionnaire is designed to help ensure that accurate and complete information about items like elastic stockings, orthotics and orthopaedic shoes has been provided before the claim is submitted for assessment, in order to confirm that the terms of the contract and administrative practices have been met. continued on next page... Inside this issue New materials available to promote e-booklets ClearSource TM Wellness Report: Reminder for plan members Medical Underwriting: Enhanced efficiency, greater consistency Updated PPR brochure and application form Proper claim forms and correct mailing address speed processing April is National Oral Health Awareness Month Dynamic Therapeutic Formulary (DTF) update

2 Because most medical suppliers don t require licensing or certification by provincial regulators, unlicensed suppliers don t have any industry-mandated standards of practice, nor does a governing body supervise them. This limits the recourse available to interested stakeholders when fraud or abuse is suspected. Approximately 5% of medical supply claims are subject to the prepayment verification, a process which determines the eligibility of the product submitted for reimbursement. Both of these verification programs focus on high-expense and high-risk areas to validate claims information prior to payment and to help ensure only eligible expenses are paid. Suppliers and service providers in turn are aware of these controls, and recognize that we will detect inaccurate, inappropriate or unethical billing practices and address these accordingly. We re able to manage the risk of inappropriate costs resulting from inaccurate or incomplete claim information being submitted, while at the same time minimizing the impact to our plan members and plan sponsors. New materials available to promote e-booklets One of the many value-added services Manulife Group Benefits offers is the ability for you and your plan members to view your booklets online, providing easy access to the most up-todate plan information. We recently developed an information flyer (form #GC2240E/F) that can be distributed to your plan members on its own, or as a payroll stuffer. These information sheets are now available through your regular materials ordering process. For more information, or to find out if your group is eligible for online booklets, please contact your Manulife Financial representative. ClearSource TM Canadian companies looking for group benefit solutions to offer their staff working in U.S. based operations now have the opportunity to consider ClearSource TM a group insurance product available to clients with less than 50 employees who live and work in the U.S. For more details, plan administrators are reminded that ClearSource TM information sheets (GC2219E/F) are available for order through your regular materials ordering process or by contacting your Manulife Financial representative. You can also get information by looking under the What's New section on the plan administrator site: blic/adm_welcome Wellness Report: Reminder for plan members This quarter s edition of Wellness Report looks at the subject of digestive health, including the disorder known as Irritable Bowel Syndrome (IBS). Please encourage your plan members to take part in the confidential online Digestive Health assessment survey on this important issue. The survey is being conducted by Connex Health, a workplace health and wellness consulting firm. When they complete the survey, participants will receive confidential, personalized feedback on their digestive health and, where appropriate, the survey will generate a letter of referral that can be taken to their family physician for further assessment. After the survey closes on April 30, 2007, Connex will share the aggregate results with Manulife Financial, and those results will be published in an upcoming edition of Employee Benefit News. Plan members can access Wellness Report on our website by going to and clicking on the Newsletters link found under the heading Group Benefits. Alternatively, plan administrators can send Wellness Report via your Intranet, or print and post it on your staff bulletin boards or as envelope stuffers.

3 Enhanced efficiency, greater consistency We ve streamlined our Medical Underwriting practices to serve you better. Effective January 1, 2007, Manulife Financial implemented a variety of changes designed to streamline the medical underwriting practices used to administer all group benefits plans. This streamlined approach enables us to deliver increased efficiency, enhanced service, and more consistency for both you and your plan members. The move consolidates medical underwriting activities, selecting and applying the best practices for use with all plans. Medical Underwriting Practice Here s what you can expect New salary corridors for coverage increases Evidence of insurability will be required the first time a request to increase a plan member s coverage exceeds the non-evidence limit for your plan. Once approved, Manulife Financial will allow up to and including a 10% salary increase for the next 5 years. After 5 years, the plan member would be required to submit new evidence of insurability. For salary increases greater than 10%, the full amount will be underwritten and evidence of insurability must be provided. Late applicants for Extended Health Care (EHC) coverage in Quebec (RAMQ) Manulife Financial will automatically provide Extended Health Care (EHC) benefits, without evidence of insurability, for late applicants in the province of Quebec. Under RAMQ (Bill 33), Manulife Financial is required to provide drug coverage to all Quebec plan members. The move to extend the full EHC benefit will enhance coverage for plan members in Quebec. Correspondence to plan administrators and plan members For greater speed and efficiency, Medical Underwriting will send correspondence to plan administrators by whenever possible. For added privacy, correspondence to plan members will be mailed to the plan member s home address using Canada Post. Files closed after 90-days Medical Underwriting currently provides plan members with 90-days to respond to requests for information. If no response has been received, the file will automatically be closed until the plan member contacts us. Manulife will discontinue sending follow-up letters after 90-days. To hear more details regarding what you can expect from our new Medical Underwriting standards practices, please contact your Manulife Financial representative.

4 Updated PPR brochure and application form Provincial Plan Replacement (PPR) coverage is a product that duplicates the health insurance coverage available through provincial plans. It s available for plan members (and their dependants) who live in Canada, but for a variety of reasons are not covered by their provincial plan, and PPR is able to bridge the waiting period gap. We now have an updated PPR brochure and application form that you can order through your regular materials ordering process. The updated PPR brochure includes: additional information to let plan members better understand the PPR product, the required plan member/dependant information, a revised authorization section, and a new section on choosing the type and length of coverage, and an explanation of the total cost. Proper claim form and correct mailing address speed processing (former Liberty Health (LH) groups only) Sometimes it takes a while to change old habits. That s why we re reminding plan administrators of former LH groups of the correct mailing address to use for submitting claim forms. If mail is sent to the previous address in Markham, rest assured that these claims will be re-directed to the proper address; however, processing of the claim will be delayed as a result. Plan members can select the claim form they require directly from the Plan Member Secure Site. As an additional reminder, it s also beneficial to submit completed claim forms as the claims are incurred, rather than submitting them at a later date. This ensures that no claims go astray. April is National Oral Health Awareness Month Oral Health Awareness Month is a chance to promote the importance of good oral health, and its connection to your plan members overall health. You may also want to take this opportunity to encourage plan members: to have an open dialogue with their dental providers to ensure they understand their treatment recommendations, and the options available to them; to seek alternate opinions if they re not certain, or feel uncomfortable with the suggested course of treatment; to ask for a statement describing the precise nature of the dental work completed, and to carefully review this statement prior to paying and leaving the office. It s important that plan members know that they must take on this responsibility to ensure they are receiving the care they have paid for; to consider signing up for automatic bank deposits, which typically allows reimbursement within 24 hours; and finally Old Address Suite Steeles Ave Markham, ON L3R 0X4 Addressed to either: Manulife Financial or Liberty Health (LH) New Address Manulife Financial PO Box 400 Waterloo, ON N2J 4A9 to review their booklet wording to ensure they understand their benefit and what, if any, out-of-pocket expenses they are responsible for.

5 Dynamic Therapeutic Formulary (DTF) update The list of drugs covered on the DTF undergoes a continuous review by a team of health care professionals at ESI Canada, Manulife s Pharmacy Benefit Manager. Drugs covered on the DTF may periodically change to ensure the most effective and affordable drugs used to treat most medical conditions are included. Twice a year ESI Canada reviews commonly-used drug classes in light of new medical research. This may result in certain drugs being removed from Tier 1 of the DTF. When a drug is scheduled for removal, you will be given advance notice in Administrative Update, so that you can communicate the information to your plan members. Listed below are the therapy classes that have recently been reviewed, and the outcome of each review. Drugs that are being removed may be covered, as determined by the plan sponsor, on the second tier of your plan. Please make note of the following changes that will take effect as of September 5, 2007, as well as a reminder of those changes taking place effective March 15, Drug or Drug Class reviewed Drug(s) to be removed from DTF-Tier 1* Drug(s) remaining/added Reason for recommendation Effective September 5, 2007 Hormonal contraceptives for prevention of pregnancy Plan B to be removed effective September 5, 2007 Oral contraceptives, Mirena IUS, Evra Patch, NuvaRing All drugs covered/added have similar effect and have similar costs. Plan B (emergency oral contraceptive) no longer requires a prescription. - Some non prescription drugs for specific diseases are covered, e.g., Aspirin for stroke prevention Fibric acid derivatives for treating high cholesterol Generic Lipidil (fenofibrate) regular to be removed effective September 5, 2007 Generic and brand Lipidil Micro, generic Lipidil Supra, Lipidil EZ, generic Lopid (gemfibrozil), Bezalip SR Each drug in this drug category is covered on the DTF as they do not have the same clinical effect. Exception, generic Lipidil regular is not as costeffective as the other formulations of Lipidil, so it will be removed from the DTF. Reminder - Effective March 15, 2007 Reminder: Paxil CR Paxil CR (all strengths) to be removed effective March 15, 2007 Paxil (regular formulation) and its generics Paxil CR has similar effects as Paxil but is not considered interchangeable with generic Paxil Coverage of Paxil (regular formulation) only will encourage use of the generic Other drugs in this drug class are still covered, so provide many options for patients (e.g., Prozac, Celexa, Zoloft, etc.). Reminder: Bisphosphonates for osteoporosis and Paget s disease Brand Fosamax (all strengths and formulations) to be removed effective March 15, 2007 Generic Fosamax (alendronate) Fosamax is not considered interchangeable with its generic counterparts in some of the major provinces Removal of brand Fosamax will encourage use of the generic Other drugs in this drug class are also still covered so provide many options for patients (e.g., Actonel, Aclasta, Aredia and generics, Didrocal, Didronel and generics, etc.). Reminder: Combination estrogens/ progestins for hormone replacement therapy femhrt, Activelle, and Premelle to be removed effective March 15, 2007 Premplus The non-covered drugs are combination drugs which are not as cost effective as Premplus. Please note: Drugs that are being removed from DTF-Tier 1 may be covered, as deemed appropriate by the plan sponsor, on the second tier of the plan

6 Q Updated plan member materials with the September 5th changes will be available as of August 1st for distribution, including: Letter for affected plan members: To assist you in communicating these changes to plan members, a letter outlining this information is available for you to print and distribute, as required: DTF Pocket Guide: This guide (GC2158E/F) will be updated to reflect the new information, providing your plan members with a list of drug coverage for the most commonly prescribed drugs and therapeutic alternatives for drugs not covered by the DTF. Plan member Feature Sheet: The DTF Pocket Guide can be attached to the Feature Sheet (GC2162E/F) that provides new plan members with an overview of the DTF. It also includes DTF stickers for their doctor s files. Ordering a new supply of DTF plan member materials 1. Go to and login to the appropriate public site. 2. Select the Forms hyperlink/button to open the Materials Reorder form (GL0006E/F). 3. Print off and complete this form, and fax it to Manulife Financial c/o Relizon Canada ( ). If you have any questions regarding the DTF or any of these upcoming changes, please contact your Manulife Financial representative. Group Benefit products are offered through Manulife Financial (The Manufacturers Life Insurance Company). Manulife Financial and the block design are registered service marks and trademarks of The Manufacturers Life Insurance Company and are used by it and its affiliates including Manulife Financial Corporation.