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Managed Care Round Table

Managed Care Round Table. Beth Spoto, Spoto & Associate Mike Scribner, SHP Savannah. Spoto. & Associates, LLC. shpllc.com. Medicare 13% Medicaid 16% State Health Benefit 7% Commercial 46% (52% 4 years ago) Uninsured 18% Georgia’s Current Population is 9.6 million. Spoto.

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Managed Care Round Table

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  1. Managed Care Round Table Beth Spoto, Spoto & Associate Mike Scribner, SHP Savannah Spoto & Associates, LLC shpllc.com

  2. Medicare 13% • Medicaid 16% • State Health Benefit 7% • Commercial 46% • (52% 4 years ago) • Uninsured 18% Georgia’s Current Population is 9.6 million Spoto Georgia’s Payer Mix & Associates, LLC shpllc.com

  3. State Retirees • Retirees moving to be under either Cigna (2) or UHC (2) Medicare Advantage PFFS Plans effective 1/1/10 • Plans must move from PFFS to MA PPO/HMO for 2011 Active State Employees • All new employees must be enrolled in HRA or HSA high deductible plan • United PPO no longer offered to state employees State Health Benefit Plan Spoto & Associates, LLC shpllc.com

  4. CMO Update Spoto & Associates, LLC • WellCare • Small impact of HB 1234 • Aggressive stance to avoid cost increases • Peach State • Outsourcing therapy network to TRS with caps on daily rates • Requesting take-backs based on adjusted CCR or pricing increases (assumed or actual). • Need to check your letter/computed amounts. • Increasing triage rate shpllc.com

  5. PFFS plans must be contracted by 2011 to continue • Coventry and Wellcare discontinuing PFFS plans effective 12/31/2009 (they will still have MA PPO/HMO plans • Clients received solicitations from many plans recently: Humana Aetna United (Secure Horizons) Cigna Sterling Amerigroup Wellcare • Many solicitations will attempt to add PPO/HMO as well. • SHBP moving retirees to Cigna/UHC MA Plans • Cigna – No action required, providers will be “deemed” into PFFS • UHC – Opt In for PFFS and Opt Out for PPO/HMO Medicare Advantage Spoto & Associates, LLC shpllc.com

  6. Losing market share in rural areas • Overtaken by UHC in several markets • Still retained Board of Regents / University System • Big push to complete Open Access products statewide and MA in targeted areas • Moving business to POS product Spoto Blue Cross Blue Shield of GA & Associates, LLC shpllc.com

  7. 3 Major Initiatives Ongoing • Move to OOPS • Moving to Medicare rates/methodology for PPS hospital • CAH move to Medicare rates/methodology • 12/01/09 • Selected as program administrator • United awarded contract from Humana – effective 4/1/09 • Humana appealed award –final decision 12/31/2009 • Humana will now administer at least through 9/30/2009 TRICARE Spoto & Associates, LLC shpllc.com

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