The Value of Medicare Advantage for the City & County of San Francisco and your retirees

Transcription

1 The Value of Medicare Advantage for the City & County of San Francisco and your retirees March 12, 2015

2 Medicare Advantage plans 2

3 How is the Medicare Advantage program funded? Employee/Employer Medicare Payroll Taxes Part B Premium Medicare Beneficiary General Federal Revenues Centers for Medicare and Medicaid Services (CMS) Employer/Retiree Medicare Advantage Plan Premium UnitedHealthcare 3 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

4 What is Group Medicare Advantage NPPO? Geographic availability Individual Medicare Advantage Historical Group Medicare Advantage Limited to areas with viable contracted networks Group Medicare Advantage NPPO National Value to employers Significantly reduced benefit costs Little to no retiree disruption Plan type Provider access Primarily HMO Contracted providers only Non-differential PPO All willing Medicare providers Value to retirees Equivalent benefits Financial value proposition Sustainability Typically higher retiree out of pocket costs Actuarial equivalent benefits at lower cost Significant market disruption followed Balance Budget Act of 1998 Actuarial equivalent benefits at lower cost Nearly a decade of price stability and significant plan sponsor savings Reduced premiums One ID card for medical (and prescription) Broad provider access 4

5 UnitedHealthcare Medicare Advantage PPO How it works National PPO solution covers all Medicare retirees regardless of where they live in United States - including U.S. territories Customized plan design ensures your retirees receive the same or better benefits Non-differential passive PPO benefits mean that retirees pay the same cost-sharing when accessing care in or out-of-network No PCP selection is required; no referrals are needed to see a specialist Value added benefits for retirees include: Chiropractic, Silver Sneakers, hihealth Innovations hearing aids, Solution for Caregivers Dedicated Group Medicare Advantage Service Model offers a single national network platform, single national plan design, single ID card for medical/pharmacy, and single claims and administrative platform 5

6 UnitedHealthcare offers program stability Optimizing reimbursement Risk adjustment accuracy Star ratings Sustainable, affordable Medicare plans Improving member health HouseCalls Wellness/Prevention Designated employer team Retiree experience and services Medicare-dedicated customer service Ongoing advocacy and support Reducing overall costs Network efficiency Innovative contracting Active clinical management 6

7 Helping retirees with value-added programs, education and services Stay healthy Return to health Living with illness End of life Prevention and Wellness Programs Utilization Management Programs Group Retiree Case Management Programs Specialty Programs HouseCalls Health Risk Assessment Preventive Care Reminders/Member Rewards Program 24/7 Nurseline Access Support SilverSneakers Solutions For Caregivers hi HealthInnovations hearing aid discounts Clinical Intake: Inpatient/ Outpatient Services Post-Acute Transition Secondary Level of Care Prior Authorization MedAssist Medication Therapy Management (MTM) Clinically Integrated Delivery Model (CIDM) includes transitional care management, diabetes, heart disease, and multi-morbidity Advanced Illness (AI) Case Management for those with life-limiting illnesses including referrals to hospice and palliative care. End Stage Renal Disease (ESRD) Transplant Resources and Care Management Specialized Quality Provider Network 7

8 Access to any willing provider backed by a large national network Guaranteed access to our national network of nearly 500,000 contracted health care providers A history of acceptance by providers not in our network May see providers who do not accept the plan and submit a claim for reimbursement* Our contracted provider network includes hospitals, physicians, and ancillary health care professionals in all 50 states Includes access for mental health services, transplant care, physical therapy, speech therapy, occupational therapy and chiropractic care We contact non-network providers to smooth the way for retirees to receive services Our hospital advocate program lends a personal touch The plan protects members from balance billing 8 * for providers who participate in Original Medicare. Does not apply to the <1% of doctors who do not participate in Original Medicare. Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

9 Access to any willing provider Backed by our large national network Retirees in our Medicare Advantage National PPO can see any willing provider (contracted with UnitedHealthcare or not) at no incremental cost In Network 62% of claims Out of Network 38% of claims Member submitted claims (out of network) 0.1% of claims Access to our national network of 500,000 contracted providers Access to providers not in the UnitedHealthcare Medicare Advantage network Access to providers not in the network will not bill UnitedHealthcare Note: Claim percentages shown are actual City and County of San Francisco claims 9

10 HouseCalls Uniquely impactful An innovative home assessment program available to qualified members of select UnitedHealthcare Medicare Advantage plans Most beneficial for the most vulnerable Medicare Advantage members who: Are chronically ill Find it hard to access the care they need Want to take a more active role in their health but need support Benefits Prevents complications by identifying gaps in care Increases adherence to care plan More timely, comprehensive and accurate data Increases care coordination and collaboration with member s Primary Care Physician This program is currently in development in California 10

11 Pharmacy Saver Program Pharmacy Saver reduces costs for retirees and employers at nearly 20,000 of America s most popular pharmacy locations nationwide Retirees pay a small copayment (as low as $2). The program features contracted rates at select pharmacies that are lower than the plan sponsor copays. The prices are on specific lists of drugs which vary by participating pharmacy The program features contracted rates at select pharmacies that are lower than the plan copay. The prices are on specific lists of drugs which vary by participating pharmacy. Members are automatically eligible, no other paperwork required 10 of our top 10 most utilized generics are included in the program Website: UnitedHealthcare s Member Savings Promise UnitedHealthcare is committed to providing you affordable prescription drugs. As a member of our Medicare prescription drug plans, you have our Savings Promise that you will get the lowest price available. That low price may be your plan copay, the pharmacy s retail price or our contracted price with the pharmacy 11 11Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

12 One stop shopping for education and customer service The simplicity and convenience of ONE Nationwide benefit plan regardless of where you live One ID card One claims process One customer service support team 95% of our customers get what they need in ONE call 12

13 High risk medications There are certain drugs that are not recommended for use by those 65 years of age or older. These drugs are considered High Risk Medications (HRMs) because of the increased risk of potential side effects or safety concerns, e.g. falls and fractures For the health and safety of our members, we will be removing from MAPD coverage certain High Risk Medications (HRMs) on January 1, In addition, utilization management controls (e.g., prior authorization, quantity limits) will be in place for those HRMs still covered on the formulary CMS guidelines require that MAPD plans include programs to review drugs that could have significant negative side effects for seniors. These may be approved through a formulary exception process. Preliminary HRM impact for CCSF is 905 unique members Based on 2015 MAPD formulary (2016 formulary not yet filed with CMS). We will rerun analysis once formulary has been approved We will coordinate an outreach campaign in the fall to inform and assist the member during this transition Transition supply may be applicable in certain situations 13

14 A single plan solution Integrated Medicare Advantage with Part D Advantages Formulary tiering structure will continue to follow the standard commercial Traditional formulary within the parameters of CMS guidance. Plan design copay structure will remain the same, with the exception of diabetic test strips and lancets Diabetic test strips and lancets will be covered at $0 copay under the Medicare Advantage portion of the plan. Members may still use their ID card at pharmacies to receive these products Integrated customer service experience; single ID card Addition of clinical programs for conditions such as diabetes, hypertension, and osteoporosis to close gaps in care Common retiree communications Considerations Addition management for High Risk Medications. This may include additional prior authorizations, additional quantity limits applied and certain HRMs will not be covered (i.e., Ambien). Retirees will be enrolled into the new MAPD plan and technically termed from the current standalone Part D plan in the eyes of CMS this will require additional communication and a new ID card Seamless coordination of Part B and D medications for optimal retiree experience 14

15 Promoting the optimal use of medical resources UnitedHealthcare Medicare Advantage Utilization vs. Medicare Fee-For-Service ER visits Inpatient acute admissions Re-admissions Outpatient Observations -22% -5% -24% +9% Medicare Fee-For- Service UnitedHealthcare MA = 2013 CY cost and utilization based on claims Medicare FFS = 2012 CMS 5% sample, risk adjusted and trended to ! Hospital admissions and re-admissions are the largest drivers of avoidable costs

16 Driving consistent improvement in quality Centers for Medicare & Medicaid Services (CMS) Star Ratings Quality bonus paid to only 4 star plans Medicare Advantage Payments 2013 Performance 2014 Data Collection 2015 Star Ratings 2016 Over 94% of UnitedHealthcare group MA members, and over 99% of group MA NPPO members are in 4 Star or better plans We continue to invest significant resources on our member, provider, pharmacy, operational and advocacy initiatives to increase star ratings Member engagement to encourage screenings, vaccines, prescriptions Working with providers to ensure right care, right time, right place Timely and accurate responses to appeals Robust analytics and real time monitoring to understand effectiveness Passing all CMS audits Partnering with CMS to recommend improvements to rating methodology ¹2015 Projection 16

17 Ensuring precise records for claim codes Accurate CMS reimbursements on your behalf Accurate claim documentation and coding initiatives Case study of why it s important: Diabetes coding Revenue impact can be large if a member is missing a condition in their coding For example, we measure: Patient assessment forms Insulin prescription without Diabetes code Members without visits Low income members to get support Chart reviews Suspect based on member history Prospect based on literature prevalence rates Average CMS revenue for retirees = $790 PMPM. Coding accuracy for this would be: Disease load for diabetes = without complications Disease load for diabetes = with complications Coding difference = 0.22 $2,085 annual revenue lost due to absence of coding for complications As your trusted administrator, UnitedHeatlhcare strives for precise third party reimbursements which ensures long term sustainability for your program 17

18 Actuarial equivalence of the UnitedHealthcare MA NPPO vs current plan Plan designs will not be identical The Medicare Advantage (MA) plan designs must comply with CMS regulations, which create deviations from the current plan design However, UnitedHealthcare MA plan design is set up to be actuarially equivalent to the current plan Plans cannot be an exact match as the current plan is a Medicare Coordination plan, but Medicare Advantage is a Medicare Replacement plan UnitedHealthcare Medicare Advantage plans use copays instead of coinsurance Actuarial equivalent plan designs mean that retirees, on average, spend the same amount for out of pocket expenses in each of the two plans Copays provide more predictable cost sharing expenses for retirees, regardless of the cost of the service Copays provide for higher satisfaction for retirees 18

19 Actuarial equivalence of the UnitedHealthcare MA NPPO vs current plan Payments using current plan features Medicare Pays (~80%) Plan Pays (~85% after M care) Member Pays (~15% after M care) Payments using MA plan features Member has $100 office visit Member has $233 office visit $80.00 $ $17.00 $39.60 Average cost $3.00 $7.00 $5.00 Member has $100 office visit Member has $233 office visit MA Plan Pays $95.00 $ Average cost Member Pays $5.00 $5.00 $5.00 Members under the current plan pay varying amounts depending on the cost of the service. However, under Medicare Advantage, the member knows their portion of the cost, regardless of cost of the service. On average, they pay the same amount as in the current plan. 19 Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

20 Group Medicare Advantage vs. Secondary to Medicare Administrative Services Only (ASO) Coverage Group Medicare Advantage A D V A N T A G E S Significant Savings Opportunity Maintain current level of benefits through a simplified actuarial equivalent benefit design Minimal retiree disruption near universal provider access Single ID card easy to understand copayment based plan Integrated Clinical and Wellness Programs as well as value added services (e.g., Silver Sneakers) Secondary ASO Coordination Plan A D V A N T A G E S Maintain current level of benefits No retiree disruption Option to provide some coverage for the roughly 1% of providers who have opted out of Medicare altogether Flexibility in communications and plan design Broader pharmacy benefits C O N S I D E R A T I O N S Comparable, but not exact benefits Nominal provider access issues - <1% No coverage for Opt. Out providers CMS oversight of enrollment, communications, etc. Potential variation in long-term CMS funding C O N S I D E R A T I O N S Cost Neutral No Savings Opportunity Requires two medical ID cards confusing Medicare COB methodology No Integrated Clinical and Wellness Programs or value added services (e.g., Silver Sneakers) Potential variation in cost and premium 20

21 Appendix: Transitioning to a Medicare Advantage plan

22 Click to edit Master title style The retiree experience UnitedHealthcare will help retirees every step of the way Click to edit Master text styles Medicare Advantage Announcement Enrollment Materials Second level Third level Announcement Fourth Letter level Fifth level Enrollment Guide Education Meetings Meeting Invitation Missing Information letter Welcome Guide Confirmation of Enrollment & Member ID card Retiree Education (multi-touch) Education Communication Tips for Out-of-Network Doctor Communication Call Center Support Online Resources 22

23 Pre-enrollment group retiree call center Click to edit Master title style Average speed of answer 5 seconds Click to edit Master text styles Second level Call Center open 8 am 8 pm local time, seven days a week, 365 days per year Third level Fourth level Licensed advisors will answer call referencing CCSF Fifth during levelenrollment process All call center advisors will be educated on CCSF culture Senior sensitivity and CCSF specific benefits training Average tenure: 6.5 years More than 300 pre-enrollment advisors available Green Bay, WI Concord, NC Charlotte, NC Member Satisfaction: 93% are completely or very satisfied 23

24 Click to edit Master title style Post-enrollment group retiree call center Average speed of answer 22 seconds Click to edit Master text styles Call Center open 8 am 8 pm local time, Monday-Friday Second level Third level Fourth level No call prompting to reach an advisor. Retirees simply remain on the line and are connected with the next Fifth available level advisor. All call center advisors will be educated on City and County of San Francisco culture Senior sensitivity and City and County of San Francisco specific benefits training Average tenure: 3.5 years Green Bay, WI Greensboro, NC Sunrise, FL Harlingen, TX 330 group customer service advisors Member Satisfaction: 96% are completely or very satisfied 24