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Public Employees Benefits Board Meeting. July 18, 2000 Medical Benefit Decisions for 2001. Overview. Medical Procurement Process, Planning Decisions Needed Today Final benefit changes for 2001 Employee contributions Retiree subsidy. Prep for Procurement.
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Public Employees Benefits Board Meeting July 18, 2000 Medical Benefit Decisions for 2001 Washington State Health Care Authority/PEBB
Overview • Medical Procurement Process, Planning • Decisions Needed Today • Final benefit changes for 2001 • Employee contributions • Retiree subsidy Washington State Health Care Authority/PEBB
Prep for Procurement • Multiple plan and provider meetings - administrative efficiencies, streamlined approaches • Advisory Task Force meetings - purchasing approach, employee cost-sharing • Research, review of other experiences Washington State Health Care Authority/PEBB
Experience in Other States for 2001 • CalPERS • approved 9.2% premium increase for HMOs • 2 PPO plans will increase 18% and 22% • Minnesota announced 19% increase in premiums Washington State Health Care Authority/PEBB
Procurement results • Bids from all current medical plans • Expanded service areas - managed care plan in every county • 2 plans expanding to serve 4 more counties • only 5 counties with one managed care plan - down from 6 in 2000 • only 4 counties with two managed care plans - down from 6 in 2000 • only 1 plan with a net reduction in service area, dropping 1 county Washington State Health Care Authority/PEBB
Procurement results, cont. • Overall, appears to be adequate access to providers (PCPs within 25 miles or less) • Other changes: • Aetna’s national withdrawal from Medicare+Choice plans - Aetna will still offer a PEBB retiree plan, but not Medicare+Choice Washington State Health Care Authority/PEBB
Benefit Changes • Pharmacy Benefit Streamlining-Package • eliminate requirement for over the counter drugs • clarify expectation for retail dispense of 3 month supply, with 3 copays • formulary insulin at $10 copay • mail order clean up: 90 days vs. 100 (MCOs and UMP) • UMP Pharmacy change Washington State Health Care Authority/PEBB
Benefit Changes, cont. • Modification of exclusion language: clarify refractive surgery not covered • (Exclusion #19 Orthoptic therapy (eye training) and vision services including refractive surgery, except as specified for vision care.) • Expansion of contraceptive benefits (Legislative Budget - all FDA approved drugs and devices) • (Modify exclusion #22 in MCOs regarding implants; #21 in UMP regarding devices and implants) Washington State Health Care Authority/PEBB
Benefit Changes, cont. • Coverage criteria related to transplants (replacing reference to “experimental or investigational”) Washington State Health Care Authority/PEBB
Background on UMP Pharmacy Change • Simplifies claims adjudication for retail pharmacies; members won’t have to pay full cost and wait for reimbursement • Cost-sharing impact of changes: • Approximately half of UMP members will have slight decrease or no change in overall cost-sharing • Others have slight increase in cost-sharing (averages $5 per month for non-Medicare) • Reduces premium $4 for first tier rate Washington State Health Care Authority/PEBB
Background on UMP Pharmacy, cont. • Separate deductibles: • $200 per member/$600 per family for medical • $100 per member/$300 per family for retail and mail order Rx • Out-of-pocket costs limited to: • $1,125 per member/$2,250 per family for medical services from preferred providers (or out-of-area) • Maximum of $75 per script Washington State Health Care Authority/PEBB
CY 2000 Enrollment 91.7% of employees have access to $0-$5 plan 8.3% have access to $6-$20 plan CY 2001 Projection 93.5% of employees with access to $0-$5 plan 2.9% with access to $6-$20 plan 3.7% with access to $20-$25 plan Employee Contributions Washington State Health Care Authority/PEBB
Employee Contributions CY01 Washington State Health Care Authority/PEBB
Employee Contributions CY00 Washington State Health Care Authority/PEBB
Medicare Retiree Subsidy - CY01 • Medicare retiree explicit subsidy $69.98 per member per month • Established in Legislative Budget, ESSB 5180, Laws of 1999, Section 719 • CY 00 subsidy is $62.48 per member per month • RCW 41.05.085 established subsidy, limits subsidy to no more than 50% of the premium; Board authority to establish amount of any subsidy for spouses and dependents. Washington State Health Care Authority/PEBB
Medicare Retiree Contributions(after subsidy) Washington State Health Care Authority/PEBB
Non-Medicare retiree subsidy • Non-Medicare retirees subsidized through pooling mechanism established in RCW 41.05.022 (single community-rated risk pool) • Implicit subsidy estimated at $143.77 per member per month for CY01 • CY00 subsidy estimated at $134.37 per member per month Washington State Health Care Authority/PEBB
Summary - Voting • Pharmacy Benefit Streamlining Package • Exclusion modification • Contraceptive Benefits • Coverage Criteria • Employee Contributions • Retiree Subsidy Washington State Health Care Authority/PEBB