PERACARE PLAN DESIGN CONSIDERATIONS JANUARY 18, 2019 JESSICA LINART, DIRECTOR OF INSURANCE

Transcription

1 PERACARE PLAN DESIGN CONSIDERATIONS JANUARY 18, 2019 JESSICA LINART, DIRECTOR OF INSURANCE

2 Agenda» What is PERACare?» History of PERACare Plan Options» Guiding Principles Plan Design» Health Care Trends» Active PERACare» Pre-Medicare Program» Medicare Program» PERACare 18-month Plan 2

3 What is PERACare?» Overall name for PERA s health, dental, and vision insurance program Retiree program is available to retirees, benefit recipients, and their eligible dependents» Pre-Medicare and Medicare health plans» Dental plans» Vision plans Active PERACare is available to PERA-affiliated employers for their PERA members and their eligible dependents» 18 employers currently participating» Pre-Medicare health plans» Dental plans» Vision plans 3

4 History of PERACare» In 1985, Senate Bill (SB) created PERA s health care program for retirees Goal of eliminating differences among post-retirement coverage for retirees and offering savings to employers» Program was pre-funded for a year then began operations July 1986» Retirees were allowed to enroll at retirement or at other times as established within PERA Rules, and allowed to disenroll with 30-days advance notice 4

5 History of PERACare (continued) Provisions of SB became effective January 1, 2001» PERA s health care program was expanded Dental and vision coverage options were added PERA-affiliated employers were eligible to participate Program branded as PERACare Implementation philosophy» Managed competition model was introduced Multiple vendors/plan designs Similar plan designs among vendors Differentiation based on price, network, service area 5

6 History of PERACare (continued) Effective January 1, 2001» Five health carriers Cigna, Health Network, Kaiser, Rocky Mountain Health Plans, and Mutual of Omaha» Six pre-medicare plan designs: Three HMO, one POS, two PPO» Three Medicare plan designs: Two Medicare Supplement, one Medicare HMO» Caremark was Pharmacy Benefit Manager (PBM) for the Mutual of Omaha plans» Two dental carriers Cigna Dental HMO and United Concordia PPO» Two vision carriers Cole Managed Vision and Vision Service Plan (VSP)» Two similar plan designs 6

7 History of PERACare (continued) Effective January 1, 2007» Managed competition model and regional rating of health plans was abandoned» Pre-Medicare medical plans were consolidated with two vendors» Secure Horizons Medicare HMO was added» Dental and vision choices were simplified 7

8 History of PERACare (continued) Effective January 1, 2019» Two health carriers Anthem and Kaiser» Four pre-medicare plan designs: Two PPO, one Deductible HMO, one High Deductible Health Plan» Three Medicare Advantage plan designs: Two PPO, one HMO» CVS/Caremark is the PBM for the Anthem plans» Two dental carriers Cigna and Delta» One HMO, two PPO plan designs» One vision carrier VSP» Three plan designs 8

9 Guiding Principles Plan Design Considerations» PERA Law Provide a level of benefits consistent with prevailing community practices Provide enrollees protection from catastrophic financial loss Ensure the fiscal soundness of the trust fund» Triple aim of health care Improve the health of the retirees who participate Improve the quality of care received and/or satisfaction with the plan Reduce costs for participants or plan premiums» Industry trends and legislation 9

10 Health Care Trends» Marketplace consolidation CVS Caremark and Aetna Cigna and Express Scripts Anthem creating own PBM arm» IngenioRx» Payment based on Medicare Montana and North Carolina» Focus on primary care Direct/concierge models Onsite/near-site clinics Retail clinics Telemedicine» Pharmaceutical innovation Many new high-cost drugs coming into the market 10

11 Active PERACare» Active program was founded on the idea that bringing employers together could help reduce premiums While this has not materialized with small enrollment, there are still benefits to participating employers» Ability to offer two health plan choices to employees» PERA takes responsibility for contracting with carriers, processing enrollments and sending eligibility, COBRA administration» Multiple plan designs are offered to meet variety of employee needs HMO s with lower costs when seeking care High Deductible Health Plans with higher costs when seeking care, but lower premium and ability to participate in a Health Savings Account» All plans meet the requirements of the Affordable Care Act 11

12 Pre-Medicare Program» Since 2007, Anthem and Kaiser have been the only two health carriers Different models, provider networks, and service areas» Number of plans offered has shifted from seven to four plans Removing plans not currently offered in the marketplace (Kaiser HMO), with low participation (Anthem narrow network plan), or high costs (Anthem HDHP, Kaiser HMO), or regulatory limits (Anthem HDHP) Two plans offered still provide a high and low option» High out-of-pocket maximums in Anthem plans» PERACare QuitLine and Silver Sneakers offered to both Anthem and Kaiser participants 12

13 Anthem Pre-Medicare Program Triple Aim of Health Care» PERACare Select colonoscopy benefit Covered at 100 percent at in-network Ambulatory Surgical Center $300 copay if received at hospital» PERACare Select hip and knee replacement benefit Covered at 100 percent with participating surgeon and facility Deductible and coinsurance apply at other facilities» Encouraging use of Primary Care Physicians Physician visits have copay only, not deductible and coinsurance $0 copay for high performing Anthem Blue Priority physicians» Naturally Slim Weight loss and healthy lifestyle education program 13

14 Medicare Program Triple Aim of Health Care» Initially seen as continuation of pre-medicare benefits, however with Medicare expansion into drug coverage (Part D) and adoption of Medicare Advantage, now seen more as a separate program» Starting in 2019, two Medicare plan carriers: Offer different models of care and provider networks Highly rated carrier partners Medicare star ratings of quality of care and retiree satisfaction (out of 5)» Anthem 4.5 stars and SilverScript 4 stars» Kaiser 4 stars Medicare Advantage reduces costs for retirees while providing more coordinated care than Original Medicare plus additional benefits such as care management, home visits, nurse lines, and telehealth 14

15 PERACare 18-Month Plan Active PERACare Program» Employer survey/outreach for feedback» Reconsider how brokers can be paid through program if employers desire» Review number of plans offered and update benefit design 15

16 PERACare 18-Month Plan (continued) Pre-Medicare Program» Implement Pharmacy Audit vendor to monitor CVS Caremark performance» Review CVS Caremark contract pricing, potential RFP for PBM for 2021» Review of Anthem s performance reviewing several vendors Regenerative medicine for musculoskeletal injuries Genetic testing for drug effectiveness Programs to identify members who could enroll in Medicare under age 65 Care management programs for high-cost claimants» Implement CareMore program in Q2 or Q3» Analysis of upcoming Cadillac Tax 16

17 PERACare 18 Month Plan (continued) Medicare Program» Review SilverScript contract pricing, potential RFP for PBM for 2021» Consider using same vendor as Medicare Advantage plans if brings lower cost or improved retiree satisfaction 17