Lipitor Gone Generic

Lipitor generic, Atorvastatin, has been added to the drug list with Anthem as of November 30, 2011.  This generic is tier 1 and will be a significant savings for members if they choose to take the generic. The tier 1 with Anthem is the lowest co-pay for members.  As always, members would want to consult with their Physicians if the generic would be suitable for them to switch to.

Also, Anthem announced the name brand, Lipitor, as of December 5, 2011, has moved to tier 3. Depending on the plan members are enrolled in, the full cost of the name brand could be the member's cost. Members are advised to check on the particular drug benefit they have to determine how this will impact them.

If you have any questions or need more information on this the Anthem website is a great tool to utilize for any drug changes with Express Scripts or you can always contact Customer Care with McGohan Brabender and we’ll be happy to assist.

Healthcare Reform Preventive List

New guidelines with Healthcare Reform now provide some preventive services to be paid by your carrier at 100%.  We have posted the general list from the healthcare.gov  website below.  With any health insurance carrier, services are only processed as preventive if coded as such by your doctor.

            Preventive care is usually precautionary.  An example would be if your doctor orders a colonoscopy because of your age and codes the claim as preventive, this would process under the preventive benefit.  But, if your doctor recommends a colonoscopy to investigate symptoms, and codes the claim as diagnostic, this would not be considered preventive.

Healthcare Reform Preventive List

Meet the Customer Care Team: Johanna!

       We are going to introduce a member of our Customer Care Team each week.  We hope this helps you to get to know us better.  Along with putting a face to a name or voice on the phone.  This week we are introducing: Johanna.

       Johanna has been with the team since June of 2007.  She has become one of our team's greatest assets.  She is currently our Senior Customer Care Representative and handles more of the complicated or escalated issues we receive.  Her wealth of knowledge and expertise in resolving tough claim issues is invaluable to our clients and to McGohan Brabender.  Johanna's passion allows her to really think outside the box and look at claim issues from all angles in order to truly help our members. She resides in Centerville, OH with her husband and son.  Johanna is very active in her church and enjoys spending time with her family.  The Customer Care Team is very lucky to have her.  Say Hello to Johanna!

Help with Reading your Explanation of Benefits

Have you ever received claim information from your insurance company and was so confused you didn’t know what to do?  Well, help is here!

Reading any Explanation of Benefits (EOB) can be challenging for members trying to figure out what is meant and what you actually owe on a claim. Below are three examples from Anthem, United Healthcare and Humana with an easy to understand breakdown on an EOB.  Your days of not understanding your claims can hopefully be behind you!  Of course if you have any questions, you can always call member services on the back of your ID card.  If you are still unsure, McGohan Brabender Customer Care is always here to help!

Guide to Anthem's Explanation of Benefits

Guide to United Healthcare's Explanation of Benefits

Guide to Humana's Explanation of Benefits

Find help with the cost of Medicine

Our team received a “tip” on this site and it was too good not to share!  In our opinion this is one of the best sites found so far!  Below is link to a source of discounts, coupons, and so much more for prescription medication.  This site can help with all ages and even someone without insurance benefits.  We are very excited about finding this website and it is truly worth a look!

NeedyMeds.org

HSA Contribution Limits for 2012

Please see updates for increases in HSA contribution limits for 2012. Remember these amounts include any contribution employees may receive through employer contributions.

New Contribution limits for 2012 with HSA – Health Savings Account 

Individual:  $3,150.00

Family:  $6,250.00

Catch-up Contribution $1,000.00 – 55 years of age and older for 2012.

HSA Qualified Expenses IRS List

Walgreens and Express Scripts Negotiation Update

The negotiations for Walgreens and Express Scripts for their contract renewal continues, however both sides are losing optimism for a favorable outcome as the January 1, 2012 deadline nears.

Recently, Anthem has released the following letters and frequently asked questions regarding what will happen next for their clients who currently use Walgreens Pharmacies:

Anthem Letter to Employers

Anthem Letter to Employees

Anthem FAQ for Walgreens Customers

Your Right To Appeal

Health care and the processing of claim is not a perfected science. Claims get coded incorrectly by providers’ offices, sent with incorrect ID information, or processed incorrectly through benefit plans. For health care consumers, it can take some digging and effort in order to get these matters corrected. Sometimes, it even takes an appeal (or multiple appeals).

Based on a recent article by Money Magazine:

·         15% of health claims are denied

·         14% of denied claims are appealed

·         50% of appeals are successful

As patient advocates for our clients, the McGohan Brabender Customer Care Team acts as the patient advocate – mentioned in section 4 – to help identify errors, craft appeals, and escalate the battle when necessary.

Make sure to check out Money Magazine’s article for more information on your right to appeal!

Update: Express Scripts/Walgreens Negotiations

Express Scripts, the company that administers [Anthem/Empire/UniCare]’s prescription drug Plan has been notified by Walgreens of their intention to leave the network when the contract expires on December 31, 2011.  The parties are still in negotiations and Anthem hopes to have this signed by the end of the year.

We have heard that Walgreens is informing customers of their intention to terminate the relationship at the end of the year with letters.  

Below you will find a Q/A sheet that Anthem has distributed.  Please feel free to use this information as warranted.  As we have more information to share, we will continue to update this blog.

Thank you

Anthem FAQ

Anthem's Radiology Shopper Program

Recently, Anthem launched a new Radiology Imaging Shopper Program for the following counties in Ohio:

Belmont, Butler, Carroll, Clark, Clermont, Clinton, Columbiana, Cuyahoga, Delaware, Erie, Fairfield, Franklin, Fulton, Geaga, Greene, Hamilton, Hancock, Holmes, Huron, Jefferson, Lake, Licking, Lorain, Lucas, Madiosn, Mahoning, Medina, Miami, Montgomery, Muskingum, Pickaway, Portage, Richland, Ross, Stark, Summit, Trumbull, Tuscarawas, Union, Warren, and Wood.

With this tool, members can compare costs for the same procedure at multiple locations in their area. For more information on this program and how if can help to keep your health costs down, check out this flier from Anthem!

Top 5: Causes of Changing Prescription Costs #1

1. How often your prescription plan carrier reviews the pricing of medications

The price of prescription medications is constantly changing based on a variety of factors. Anthem has compared the rise and fall of prices to gas or hotel rooms. The frequency that your insurance carrier audits the cost of prescriptions can mean significant impact for you.

For instance, some carriers only check the price of medications on a bi-annual basis while others check on a monthly basis. As a member, this can impact the total out of pocket throughout the year.

	Prescription Cost	Price to Member with bi-annual review	Price to member with monthly review
January	50	50	50
February	75	50	75
March	100	50	100
April	100	50	100
May	100	50	100
June	100	50	100
July *biannual review month	100	100	100
August	75	100	75
September	25	100	25
October	25	100	25
November	25	100	25
December	25	100	25
Total Cost		950	800

In this example, the member on the bi-annual plan has more consistency in their cost, but their final year out of pocket is $950. The member on the monthly review plan has costs all over the place, but their final year out of pocket is only $800. This can go either way for the member, but the frequency that the plan reviews this cost can impact the consistency of the prescription pricing as well as the out of pocket cost to the member.

For more examples of the causes of changing prescription costs, check out our Top 5: Causes of Changing Prescription Costs and check back often for articles explaining further each of these examples.

Top 5: Causes of Changing Prescription Costs

One of the more common questions that our team receives from our clients is: I just went to the pharmacy, and the cost of my medication nearly doubled from last month; what is going on?

Many factors can play into the cost of a prescription, but over the next few weeks, our team will be looking into what we see as the Top 5 Causes of Changing Prescription Costs. Keep checking in over the next few weeks for articles elaborating on the following causes:

1. How often your prescription plan carrier reviews the pricing of medications

2. Patents on medications and patent extensions

3. The availability of and introduction of generic medications

4. FDA approved uses of prescriptions

5. Manufacturer rebates and the net cost of a prescription to your plan

In the meantime, you can also check out the nice article that Anthem put together explaining some of these causes.

Tax Excise Chart

As a follow up to our last article regarding COBRA/FMLA compliance, today we are sharing a great excise tax chart created by Christine Roberts of Mullen & Henzell. Ms. Roberts has a fantastic blog, E is for ERISA, that I encourage you to reference for employee benefits update information.

The chart created by Ms. Roberts explains how failure to comply with COBRA, HIPAA, GINA, Mental health parity, Insured plan nondiscrimination rules, internal claims and appeal requirements, and/or external review procedure can result in excise taxes for the employer, insurer, HMO, and/or TPA. You can check it out here for a better understanding of what non compliance could mean for your group.

COBRA/FMLA Compliance

Recently, a court case ruled on the how FMLA, STD, and COBRA work.

The Family and Medical Leave Act (FMLA) ‘provides certain employees with up to 12 weeks of unpaid, job-protected leave per year. It also requires that their group health benefits be maintained during the leave.’ This act ‘applies to all public agencies, all public and private elementary and secondary schools, and companies with 50 or more employees. These employers must provide an eligible employee with up to 12 weeks of unpaid leave each year for any of the following reasons:

·         for the birth and care of the newborn child of an employee;

·         for placement with the employee of a child for adoption or foster care;

·         to care for an immediate family member (spouse, child, or parent) with a serious health condition; or

·         to take medical leave when the employee is unable to work because of a serious health condition.

Employees are eligible for leave if they have worked for their employer at least 12 months, at least 1,250 hours over the past 12 months, and work at a location where the company employs 50 or more employees within 75 miles. Whether an employee has worked the minimum 1,250 hours of service is determined according to FLSA principles for determining compensable hours or work.’

In the court case, an employee went on FMLA. Once FMLA had run out, their employer put them on STD without offering them COBRA coverage. At the end of STD, the employer offered the employee COBRA coverage. However, the carrier refused to reimburse the employer for medical expenses incurred during the employee’s STD coverage. The employer argued that the requirement to be on FMLA, work 40 hours a week, or be on COBRA was only a condition for initial eligibility, but the court ruled in favor of the carrier, and the carrier was not responsible for reimbursing the employer for the employee’s medical expenses incurred while on STD.

For more information on this case, check out Plan Sponsor. For more information of FMLA, check out the United States Department of Labor.

Get to Know Your Anthem Plan

Just getting started with a new Anthem plan - or want to know more about your existing plan? Then Anthem's interactive video tutorial is a great resource for you! Here you can get a deeper understanding of your plan based on the type of benefits (HSA, HRA, PPO, HMO, EPO)and coverage (individual or family) you have elected!

You can find this video tutorial by going to www.anthem.com/basics, or it can always be accessed on our Video Tutorial page. Make sure to check out our other videos while you are there, too! From e-service tutorials to McGohan Brabender made Anthem application step by step videos to help your new hires or open enrollment employees, we try to ensure that you have the links to everything in one place.

Want to see more of the videos produced by the McGohan Brabender team? Check out the MB Studio page to see some of our team's projects!

New Women's Preventive Services

Recently it was announced that the Affordable Care Act has been expanded to include additional prevention coverage for women's health and well being. Under the act, originally signed into law in March 2010, it is required that health plans cover preventive services without cost share, such as copays or coinsurance, when going to an in network provider. Coverage included preventive services like mammograms, colonoscopies, and immunizations.

On August 1, 2011, the Affordable Care Act was expanded to include well-woman visits, screening for gestational daibetes, HPV testing, counseling for STIs, counseling and screening for HIV, contraceptive methods and counseling (except when group exclusions apply), breast feeding support/counseling and supplies, and screening and counseling for interpersonal and domestic violence. For an outline of the guidelines, check out the US Department of Health and Human Services site.

Please note that these guideline are effective August 1, 2011, but non-grandfathered plan and issuers are not required to provider coverage without cost sharing consistent with the guidelines of the act until the first plan year that begins on or after August 1, 2012. As always, it is beneficial to contact your member services line with your insurance carrier to verify what all is covered (and how it will pay!) under your benefit plan.

Controlling the Cost of Healthcare – for the Employer

The cost of healthcare seems to always be on the rise, both for employees and their employers. Various plans have been introduced throughout the years to help control these costs – from front end deductibles to high deductible/HSA plans. Recently, United Healthcare and McGohan Brabender partnered to launch a new, innovative program and product to help employers earn significant trend and rate adjustments for their renewals call Bend the Trend.

The easiest way to understand how the program works is to break the program down into Years 1 and 2.

Year 1 establishes the foundation for the Bend the Trend Program at the employer level. To "get on the field to play," employers agree to some basic strategic commitments in the following categories: wellness, optimal plan components, outcomes-based plan design, diabetes prevention/control. Don't worry, it sounds a lot more complicated than it actually is -- and chances are good that you're probably already doing some of it or all of it already. If you are an existing UHC customer, you can go ahead and start at year 2.

For meeting each employer strategic commitment, points are awarded Click Here to Download PDF Chart . The more commitments you meet, the more points you earn. Thus, the greater the premium discounts.

Beginning with your Year 1 start date, the Year 2 clock begins ticking. Now we need your employees to get involved. Do you remember those four strategic buckets we started with at the employer level? Well, we take those same four buckets and add some employee activities to them. Some are very simple, and others may require a little more effort – but that's ok. Our goal is to get your employees to own their health care plan…not rent it!

Just as with the employer commitment, employees earn points. Some of the points are awarded for participation while others are based on outcomes.

At the end of Year 1, your Year 2 rate adjustments are determined. This is done by adding up your earned Year 1 and Year 2 points. The greater your points, the greater your rate adjustment.

Want to know more about this program? Check out the Bend the Trend website for a potential financial impact calculator, wellVibe trailer, and a contact form!

Top 5: Ways to Control the Cost of Healthcare #5

5. Get pre-authorizations or predeterminations of

benefits done when necessary

Pre-authorizations are prior approval from an insurance carrier for a procedure. These are not guarantees that the claim that comes in will be covered, but it is a statement that the insurer intends to cover the service. Many non-emergency medical procedures and services require a pre-authorization, and it is important to ask your physician if a prior-authorization is needed before a procedure. Most physicians will be generally aware of procedures requiring a pre-authorization, and they will call into the insurance carrier for review. Without a pre-authorization, some claims that might have been covered will be denied. If you want to be certain that a procedure does or does not require a pre-authorization, you can always get the procedure coding from your provider and call them in to your insurance carrier to verify.

Predeterminations of benefits are similar to pre-authorizations, but they are not required. Often, they are done for procedures in which a provider must prove that a patient meets medical criteria for a procedure before it can be performed. For instance, treatment of varicose veins is often denied as not medically necessary. However, if a physician does a predetermination of benefits with the insurance carrier and can provide documentation proving that the member meets the medical criteria, the procedure could be covered.

While it is always important to consider your health and the advice of your physician first, you can also help to control the cost of your healthcare by ensuring that the necessary steps (such as getting a pre-authorization or predetermination of benefits) are taken before any major procedure.

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.

Top 5: Ways to Control the Cost of Healthcare #4

4. Ensure that your lab work is being completed by an in-network/participating lab

Just like in network providers, it is important to utilize in network (or participating) labs in order to receive the highest benefit from your medical coverage. Just like going to an out of network provider, using an out of network lab can result in higher costs, balance billing, and claims going towards a higher, out of network deductible.

For instance, let’s say that you have the following benefits and have already met your in network deductible for the year.

Covered Benefits	Network	Non-Network
Deductible (single/family)	$500/$1000	$1000/$2000
Out of Pocket Limit (single/family)	$3000/$6000	$6000/$12000
Preventive Care Services Services include but are not limited to: Routine exams, pelvic exams, pap testing, PSA tests, immunizations, annual diabetic, eye exam, vision and hearing screenings ·         Physician Home and Office Visits (PCP/SCP) ·         Other Outpatient services @ Hospital/Alternative care facility	$25/$50 20%	40% 40%

You go to your physician for your annual preventative visit. You have run a check on your insurance carrier’s website, and you confirm that your physician is in network. During your annual preventative exam, your physician runs some bloodwork and sends it off to their lab. Your physician’s bill processes through insurance, and since you have already met your in network deductible, you only owe a $25 copay.

However, your lab work was sent to an out of network lab. They bill $100. The contracted rate for these services is $50, and your insurance carrier applies this to your out of network deductible, which you have not yet met. Since the lab is not contracted, they are able to balance bill, and you are responsible for $100.

Had you requested that your physician send your lab work to an in network lab (which you can find a listing by doing an search on your insurance carrier’s site), then the lab work would have been adjusted to the contracted rate of $50, of which you would have only been responsible for 20% (or $10 – a difference of $100 for you).

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.

Top 5: Ways to Control the Cost of Healthcare #3

3. Opt for generic or lower cost drug alternatives when available

Many factors play into the costs of prescription medications: cost of ingredients, costs of research and development, patents, etc. Often, brand name prescriptions have an initial higher cost for healthcare consumers to offset the cost of developing the medications during the window of time when their patent allows for the company to have control over the distribution of the medication. After this time, other companies can create generic alternatives to the brand names.

As the US Food and Drug Administration states:

Generic drugs are important options that allow greater access to health care for all Americans. They are copies of brand-name drugs and are the same as those brand name drugs in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use.

Health care professionals and consumers can be assured that FDA approved generic drug products have met the same rigid standards as the innovator drug. All generic drugs approved by FDA have the same high quality, strength, purity and stability as brand-name drugs. And, the generic manufacturing, packaging, and testing sites must pass the same quality standards as those of brand name drugs.

Since the companies creating the generic medications do not have to invest as significantly in the research and development of the medication, they can sometimes offer it at a discount rate.
While your primary decision on medications should be the advice of your physician, opting for generic or lower cost drug alternatives is another way to control the cost of your healthcare, and you can ask your provider about your options.

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.

Top 5: Ways to Control the Cost of Healthcare #2

2. Choose the right care facility (Primary Care Physician vs. Urgent Care vs. Emergency Room)

There are lots of options when it comes to where you go to receive health care services, and those options have different purposes as well as different financial implications.

Duke Health offers the following explanation of when to use each type of health care service:

Primary Care Provider

Unless you are experiencing a life-threatening emergency, primary care centers are the best places to start. Primary care providers are physicians who deliver basic care for common illnesses. They are your first stop for most undiagnosed health concerns.

You should visit a primary care center for illnesses such as colds, flu, and sore throats; minor injuries, aches, and pains; or routine health exams. You can schedule appointments with primary care providers during the week, and they are available by phone anytime for advice about health problems.

Urgent Care Center

If your primary care physician is not available and you need quick medical attention for a non-life-threatening problem, visit an urgent care center. Urgent care centers have similar resources to primary care facilities, but they provide comprehensive quality care on a walk-in basis with extended hours.

Go to an urgent care center when you need immediate medical attention or have non-emergency health concerns after hours. Examples include ear infections, sprains, simple cuts and burns, and eye injuries.

Emergency Department

Life-threatening emergencies and late-night trauma require an immediate visit to the hospital. Emergency rooms offer inpatient care, emergency services, trauma services, and more. Emergency clinicians are able to recognize, diagnose, and make recommendations for a wide array of medical issues.

Call 911 or drive to the emergency department at your nearest hospital whenever conditions cause severe symptoms and/or put your health at serious risk. Examples include heart attacks, poisoning, severe bleeding, and broken bones.

While life threatening emergencies require a visit to the emergency room, other illnesses or injuries do not and can offer significantly lower cost options for care.

For instance, let’s say that your benefits are as follows and you have already met your deductible year to date: