Oregon Legislative Session Update

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1 for Producers and Consultants Oregon Legislative Session Update... 1 Oregon Health Insurance Exchange... 2 A Message from John Mychalishyn, Director of Individual Sales: Kelly Jones Joins Individual Sales Team... 3 Updated Individual Plan Underwriting and Administration Guide... 3 The Leaders Program for Medical Policy Updates... 4 Medication Safety: Controlled Substance Utilization Service... 5 Pharmacy Discount Program Offers Solution for ACA- Required Drug Coverage... 6 USAble Life Update... 6 Service Excellence: 2013 Year-End Results... 6 Upcoming Industry Events... 6 Oregon Legislative Session Update The Oregon State Legislature convened on February 4, 2013 and is scheduled to adjourn at the end of June. LifeWise is tracking the following bills: HB 2181 Trauma System Hospitals. This bill would require an insurer to have an adequate network of trauma system hospitals in its provider network. It would require an insurer to reimburse for services provided by out-of- network trauma system hospitals at a specified rate and require providers to accept reimbursement as payment in full and not balance bill the patient. LifeWise has concerns with the bill as currently drafted. HB 2240 ACA Conformance. This bill would make changes to Oregon health insurance law to align with changes from the Affordable Care Act. It would abolish the Oregon Medical Insurance Pool on June 30, HB 2902 Nurse Practitioner Payment Parity. This bill would require insurers to reimburse physician assistants and nurse practitioners in independent practices at the same rate as physicians for the same services. LifeWise is opposed to this bill that would require payment parity. HB 2969 Ambulance Care Reimbursement. This bill would require that insurers that provide coverage for ambulance care and transportation to reimburse the provider directly. HB 3458 State Supplemental Reinsurance Program. This bill would establish a state supplemental reinsurance program to help mitigate premium increases in 2014 by supplementing the federal temporary reinsurance program in the Affordable Care Act. It would mirror the current structure of the Oregon Medical Insurance Pool (OMIP) assessment and would apply the assessment to the same populations through The assessment amount would be limited to $4 per member per month in LifeWise is supporting this bill. SB 122 Health Evidence Review Commission. This bill would authorize the Department of Consumer and Business Services (DCBS) to adopt rules prohibiting or limiting coverage by health benefit plans of items, services or medical technologies pursuant to guidance by Health Evidence Review Commission. LifeWise is opposed to this bill. SB 372 Pharmacy Benefit Managers (PBMs). This bill would require DCBS to adopt rules related to the following activities by PBMs: claims processing, retail pharmacy network management, clinical formulary development and management services and the establishment of pharmacy reimbursement pricing and methodologies, including maximum allowable cost. LifeWise is evaluating this bill. (more next page) ( )

2 continued: Oregon Legislative Session Update SB 365 Autism. This bill would establish requirements for coverage of autism spectrum disorders by health benefit plans, the Public Employees Benefit Board, and the Oregon Educators Benefit Board. It would require the Oregon Health Licensing Agency to establish licensing procedures for providers of applied behavior analysis. LifeWise is evaluating this bill. SB 402 Reimbursement of Covered Drugs by PBMs. This bill would specify the reimbursement of covered drugs by PBMs and require PBMs in contracts with a pharmacy, to specify the methodology and sources used to determine the maximum allowable costs, set forth appeals procedures, and specify the process for making changes to the list or the maximum allowable cost for any drug on the list. LifeWise is evaluating this bill. SB 413 Notice of Proposed Rate. This bill would require insurers to notify all policyholders affected by the rate filing within 3 business days of the filing if there is an average premium rate increase of 7% or more and affects 1,000 or more enrollees in the individual and small employer markets. The notice must include instructions on accessing the DCBS website about the rate increase. LifeWise has concerns with the bill as drafted and is drafting amendments. SB 460 Biosimilar Drugs. This bill would restrict the substitution of a biosimilar product for a prescribed biological product. LifeWise is opposed to this bill. SB 539 Wellness Demonstration Project. This bill would require DCBS to apply to the U.S. Department of Health and Human Services to participate in an individual market wellness demonstration project under the Affordable Care Act. LifeWise is supporting this bill. SB 608 Enrollee Reimbursement for Out-of-Network Charges. This bill would require DCBS to adopt a form and standards for an enrollee to submit a claim to the insurer to request reimbursement for the charges of an out-of-network provider that were paid by an enrollee. LifeWise is evaluating this bill. We will continue to follow the session and provide an update in the next LifeWise CONNECTIONS. Oregon Health Insurance Exchange Cover Oregon, the Oregon Health Insurance Exchange, continues to meet on a monthly basis. More information and agendas for upcoming meetings can be found at: 2

3 A Message from John Mychalishyn, DIRECTOR of Individual Sales Kelly Jones Joins Individual Sales Team The Individual Sales Team is pleased to welcome Kelly Jones as the Regional Sales Manager. As we enter the execution phase of healthcare reform, I am pleased to announce that Kelly Jones has joined the Individual sales team as the Regional Sales Manager. Kelly s past experience with producer relations and her understanding of market needs will ensure we deliver our objectives positively and effectively. Kelly has been with the LifeWise family of companies since 1986, starting in the Finance department and then moving to the community-rated sales team. She took a short five-year break working with Providence Health Plan in Washington, but returned to our organization to take on the challenge of creating a corporate-wide Producer Relations program. Kelly s responsibilities have evolved over time, and she has spent the last several years serving as the Senior Manager for Producer Relations and Distribution Marketing. Kelly has established great relationships with many of you that will allow her to hit the ground running. I am confident that she has the right leadership and strategic skills to lead our producer distribution channel in the individual market. The Individual Sales Executives Marcy Klippenes and Shelly Solorzano will report to Kelly. Kelly will report to me. Kelly can be reached at (425) in the office, (206) via cell, and by at [email protected]. Please join me in congratulating Kelly on her new role. Updated Individual Plan Underwriting & Administration Guide LifeWise Health Plan of Oregon has updated its Underwriting and Administration Guide for Individual & Family Plans (.pdf). The new guide is available today on Updates include additional helpful information regarding incomplete applications and the follow-up process. You ll find this information on page 4. Download your new guide today or ask your LifeWise Sales Executive, Shelly Solorzano or Marcy Klippenes, to provide a copy for you. 3

4 The Leaders Program for 2013 LifeWise Health Plan of Oregon once again brings you The Leaders Program for Individual & Family plan sales and renewals. In 2013, you have an opportunity to earn a quarterly bonus for new sales. Bring in a minimum of five new Individual and Family plan members in a quarter and you ll earn $30 per each medical member added and $10 for each new dental member. The quarterly membership bonus which rewards new sales and retention has been improved. See the details in The Leaders Program (.pdf) flyer on the Producer Resources section of The Leaders Program is effective from January 1, 2013 through December 31, All new sales and renewals processed during Q will be applied. For more details, talk to your LifeWise Sales Executive. Medical Policy Updates At LifeWise Health Plan of Oregon, our Medical Services and Quality staff develop and adopt medical policies that support safe and quality medical care and treatments for our members while reducing the waste and harm of unnecessary treatments. All of our policies are based on the most recent peer-reviewed scientific literature and formed by national professional society guidelines and best standards of practice. To view our policies, click on the Medical Policies link at the bottom of the homepage at Here are some recent medical policy updates: Sleep Studies In 2011, LifeWise implemented a Sleep Studies initiative to give our members more access to home testing technology to diagnose sleep related disorders. There are two common options when testing for sleep related disorders: home-based and facility-based. This medical policy requires a review for medical necessity for all facility-based sleep testing and allows for the use of home-based sleep testing devices without medical necessity review. Home-based testing is an alternative that can improve the member experience in a comfortable and convenient setting while helping to control costs at the same time. In the first four months after this policy was implemented, utilization of home sleep testing increased 280% while utilization of facility-based testing decreased 37%. Members were not notified directly regarding this change in policy. (more next page) 4

5 continued: Medical Policy Updates Continuous Positive Airway Pressure (CPAP) This month, LifeWise changed the way Continuous Positive Airway Pressure (CPAP) devices are covered. CPAP machines are used for treating obstructive sleep apnea, which can lead to more serious health complications if left untreated, such as hypertension and heart problems. Our claims data show that the prescribed devices often go unused; nearly 40% of LifeWise s members who are prescribed CPAP devices are not compliant. The CPAP medical policy is designed to help members adhere to their treatment for obstructive sleep apnea and reduce the cost of unused equipment. The key points to the policy are: The member will be required to rent the CPAP machine for three months prior to purchase. The CPAP machine provider (usually a durable medical equipment DME supplier) must submit a billing modifier that indicates the member has been using the machine. If approved for coverage, the rental costs will be applied toward the purchase of the CPAP device. When CPAP treatment does not meet the new guidelines, either the supplier or the member may be responsible for the cost of the CPAP machine. If a member rents a CPAP machine from an in-network healthcare provider in Oregon or Washington and the usage does not meet the new guidelines, then the healthcare provider must cover the cost of the CPAP machine. If the member rents a CPAP machine from an out-of-network healthcare provider and the usage does not meet the new guidelines, the member may be responsible for the full cost of the machine. LifeWise has notified our in-network doctors of this policy. Members who rented, but did not purchase, equipment between October and December of 2012, received a letter in late March explaining these guidelines and are encouraged to discuss them with their doctor. Employers received a letter explaining these guidelines in March as well. A copy of the member letter is attached with this bulletin. Vitamin D Testing In February, a policy was implemented that defines when Vitamin D testing is medically necessary. Vitamin D is a nutrient critical to human health, and levels are influenced by exposure to sunlight, diet, and some disease processes. Most people need vitamin D supplements, and professional medical societies advise that physicians recommend vitamin supplements without ordering blood tests. According to this policy, LifeWise will cover vitamin D testing only when it is medically necessary, such as in the following scenarios on the next page: (more next page) 5

6 continued: Medical Policy Updates Patients who have a diagnosis of reduced bone density, or a disease specifically associated with vitamin D overproduction and toxicity. Patients who have a clinically documented disease or condition that is specifically associated with vitamin D deficiency. Patients who are being evaluated or treated for a known condition associated with defects in vitamin D metabolism. This policy impacts both individual and group membership. There was no direct communication to members about this policy. Please note, these medical policies do not apply to LifeWise Medicare Supplement policies. If you have questions about these medical policies, please talk with your LifeWise Sales Representative. Medication Safety: Controlled Substance Utilization Service Controlled substances are drugs regulated by the Drug Enforcement Agency that have higher abuse potential than typical prescription drugs. Controlled substances, including narcotics, stimulants, and anti-anxiety drugs, can be an effective form of treatment when prescribed and used correctly. Rising opioid abuse means that drug overdoses are now the single largest cause of accidental death in America. - The Wall Street Journal Controlled substance abuse and, more specifically, prescription drug abuse, is a growing epidemic. According to Prescription for Addiction in the Wall Street Journal, Rising opioid abuse means that drug overdoses are now the single largest cause of accidental death in America. They surpassed traffic accidents in 2009, the most recent Centers for Disease Control and Prevention (CDC) data available. LifeWise Health Plan of Oregon will implement a Controlled Substance Utilization service effective April 5, This service is offered at no cost to our members. The main objective is to ensure the safe and appropriate utilization of controlled substances by providing case management services to the members identified as at-risk. Beginning in April, members that are identified will receive a letter and phone call from a LifeWise Case Manager. The case manager will utilize engagement and coaching techniques to uncover and address the participant s barriers to optimal health as well as coordinate services among healthcare providers. Please contact your LifeWise Sales Representative if you have any questions. 6

7 Pharmacy Discount Program Offers Solution for ACA-Required Drug Coverage Under the Affordable Care Act, LifeWise Health Plan of Oregon is required to provide members with coverage for certain drugs when prescribed for preventive reasons by their provider. These over-the-counter-drugs, when prescribed by a physician, include: Iron Aspirin Smoking cessation Folic acid Fluoride Birth control. LifeWise members who do not have pharmacy benefits included with their medical plan have access to the Pharmacy Discount Program to provide coverage for these drugs. With the Pharmacy Discount Program, members simply show their LifeWise ID card at the pharmacy counter in order to have qualifying prescriptions covered in full. If a member forgets to present their ID card at the pharmacy, they can fill out the Discount Card Reimbursement Form (.pdf) to be reimbursed for these drugs. To use this form, a member will need to print it out, then mail the completed form back to the address listed on the form. This form will be processed directly by LifeWise. This form is available on the Forms page at Remind your clients that they can get answers to health questions free and quickly from experienced registered nurses by calling the LifeWise Health Plan of Oregon 24-Hour NurseLine at

8 USAble Life Update USAble Life Bonus Program Learn more about the Broker Bonus program from USAble Life in the flyer attached with this bulletin. USAble Life hosts a Broker Bonus program for sales and renewals of its Life and Disability Insurance products. If you sell USAble Life, or have transitioned your clients to USAble Life, you are eligible to participate in this program. Please see the flyer from USAble Life describing the bonus program, attached with this bulletin. As we have been transitioning the Life and Disability business from LifeWise Assurance Company to USAble Life, you should know that the persistency premium bonus they describe is based on the snapshot of your combined LifeWise Assurance and USAble Life business on December 31, 2012 (does not include Stop Loss). Please note, USAble Life is solely responsible for their products and their producer compensation programs. Renewal Transition Continues Thank you for your support as we continue to transition Life and Disability products to our vendor partner, USAble Life. Currently, renewals are being released days prior to their effective date. As the transition continues, please keep in mind that we are accelerating some renewals to ensure that all remaining group plans are transitioned to their new USAble Life products by July, 2013, with some renewals released off anniversary. Those groups will receive an extended rate guarantee on their plan to carry them into next year. Your clients current anniversary dates will not change. More Information Please contact Lori Bryant if you have questions about any of your transitioning groups or the new USAble Life bonus program. You can reach Lori at or [email protected]. Get the details about USAble Life and the array of products, services, features and benefits they offer by visiting USAbleLife.com/LessComplicated. You ll find an interactive website that details all that USAble Life brings to the table and it s suitable for sharing with employers as well. Also, for the latest USAble Life information, please check out the latest edition of their producer newsletter, USAble Life Elements. 8

9 Service Excellence: 2012 Year-End Results During Q4, our claim accuracy exceeded our goal, demonstrating our commitment to quality. By processing claims correctly the first time, our customers are satisfied and the waste of rework and adjustments are eliminated. Providing peace of mind to our members about their LifeWise Health Plan of Oregon healthcare coverage requires a commitment to service excellence. To deliver excellence, we manage and report our performance on many key service metrics. These metrics monitor our ability to serve our customers in an accurate, efficient and timely manner. We are pleased with our performance for answering the phones and for our low abandonment rate when customers call for service. Our claim accuracy exceeded our goal, demonstrating our commitment to quality. By processing claims correctly the first time, our customers are satisfied and the waste of rework and adjustments are eliminated. Our claims turnaround ended just below goal due to a higher than normal volume of inventory in the first part of the year. Several process improvements were implemented in 2012 to address the inventory and by the end of the year the turnaround times were at or exceeding our goal of 98%. Below are a few of the key metrics that we tracked regularly to ensure we meet our industry-leading service goals for our customers. Definitions for each of the metrics are noted after the chart. Year-End Year-End Results 2012 Target 2012 Year-End* CUSTOMER SERVICE Service Level 76% 75% 75.4% Abandonment Rate 2.3% 5% 2.3% CLAIMS Claims Financial Accuracy 99.6% 99% 99.6% Claims 30 Day Turnaround 98% 98% 97.7% Claims Auto-Adjudication 84% 84% 84.8% *Updated quarterly NOTE: These results are an aggregate of LifeWise Health Plan of Oregon and our affiliates in Washington and Alaska. Claim results exclude claims processed by our Pharmacy Benefit Manager. DEFINITIONS Service Level: Percent of calls answered within 30 seconds. Abandonment Rate: Percent of incoming calls that disconnect before being answered. Claims Financial Accuracy: Percent of claim dollars paid without a financial error. Claims 30-Day Turnaround: Percent of claims paid within 30 calendar days. Claims Auto-Adjudication: Percent of claims paid by the system. 9

10 Upcoming Industry Events TCAHU Employer Invitational Event Understanding the NEW Tax Considerations of Choosing the Right Benefits Package Date: April 9, 2013 Time: 9:00 10:00 a.m. Registration & breakfast 10:00-11:00 a.m. Program Location: Club Green Meadows 7703 NE 72nd Avenue, Vancouver, WA Speaker: Cost: Tom Kramer, tax attorney from Bullard Law $30 for TCAHU members, $35 for non-members, $120 for a table of six Register: Online at Info: Find out what happens to employers when they make benefit plan decisions, related to taxes and distributions (both now and during the Exchange era). This is an event to invite your employer clients (incumbent business only, no prospective clients allowed). PAHU Spring Forum LifeWise is proud to sponsor PAHU s annual Spring Forum. Getting in SHAPE for 2014 and Beyond Date: April 27, 2013 Time: 7:00 a.m. - 4:30 p.m. Location: Embassy Suites, Portland Airport 7900 NE 82nd Avenue, Portland Cost: $125 for PAHU members, $175 for non-members Register: Online at Info: OAHU Day at the Leg Date: April 24, 2013 Location: Oregon State Capitol 900 Court Street NE, Salem Info: 10