ANNUAL E NROL L ME NT
Impor tant Date s Annual Enrollment Period October 1 – November 15, 2019 Effective date of coverage January 1, 2020 Questions and completed forms should be directed to: nohrmbenefits@lsuhsc.edu
Pr e miums 5% increase for all health plans
Offic e of Gr oup Be ne fits For OGB information: Website: info.groupbenefits.org Phone: 225-925-6625 For BCBS information: Website: www.bcbsla.com/ogb Phone: 1-800-392-4089 For Vantage information: Website: employees.vhp-stategroup.com Phone: 1-888-823-1910
LSU First & WebTPA: Working Together
How We Support Members Proprietary & Confidential – not to be reproduced or distributed without permission.
Paperless EOBs Now members can receive an email notification that their EOB is available to view online! Selecting the “paperless” option will stop EOB statements from being mailed to the member. The EOB will be provided in electronic format that is available via the WebTPA Member Portal. Electronic EOBs are print-ready, so if a member needs the paper copy, they will be able to print it on the website. Paperless EOBs will only be available to members who are registered on the WebTPA portal. Sign up on the portal and opt into paperless EOBS by November 15 to be entered to win a Google Home! | 7 Proprietary & Confidential – not to be reproduced or distributed without permission.
User-Friendly Member Portal | 8 Proprietary & Confidential – not to be reproduced or distributed without permission.
View, Download & Print ID Cards | 9 Proprietary & Confidential – not to be reproduced or distributed without permission.
View Deductible Balances Proprietary & Confidential – not to be reproduced or distributed without permission. | 10
Integration with Calorie Counter Integration with Apple Watch, Fitbit, Garmin, Jawbone, Misfit, Runkeeper, Google Fit Meal Plans Advice From Experts Personalized Fitness Plan & Exercise Demos Member-Created Goal Teams / Employer-Based Fitness Competitions Recipes, Articles, Tips and More! Active Support Free at no additional cost to the plan or the member! Message Boards Proprietary & Confidential – not to be reproduced or distributed without permission. | 11
Mobile App WebTPA On-the-go functionality to view ID cards, check eligibility, review claims, and more! Available for Android, iPhone, iPad Proprietary & Confidential – not to be reproduced or distributed without permission. | 12
LSU First Health Plan Perks Cleveland Clinic Center of Excellence Program Cardiac Orthopedic and Spine Reminder: EAP is now online. Members can visit www.mylifevalues.com for more information. It includes a discounted gym membership, fitness products and more! Proprietary & Confidential – not to be reproduced or distributed without permission. | 13 13
2020 LSU First Health Plan Changes Proprietary & Confidential – not to be reproduced or distributed without permission.
2020 LSU First Health Plan Changes • 5% Premium Increase • Pre-Authorization for Cancer Services 2020 Plan Changes What You Need to Know Proprietary & Confidential – not to be reproduced or distributed without permission. | 15 15
Question & Answer Session Proprietary & Confidential – not to be reproduced or distributed without permission.
Utilization Management Services
What Is Utilization Management? • I t is a se rvic e tha t a ssure s the me mb e r re c e ive s the hig he st q ua lity o f c a re , in the mo st a ppro pria te d se tting , a nd fro m the mo st a ppro pria te pro vide r • We se e k to a vo id o ve r-use a nd unde r-use o f me dic a l se rvic e s b y ma king c linic a l c o ve ra g e de c isio ns b a se d o n a va ila b le e vide nc e - b a se d g uide line s
What Services are Being Offered? • Re vie w me dic a l se rvic e s a nd me dic a tio ns tha t re q uire pre - a utho riza tio n Pre - se rvic e MRI s, PT / OT / ST , o utpa tie nt surg e ry Re vie ws • E nsure ho spita l sta y is pro vide d in a c c o rda nc e with e vide nc e - b a se d g uide line s a nd to pro mo te the tra nsitio n o f c a re fro m the ho spita l to ho me o r a no the r he a lth c a re se tting Conc urre nt Inpa tie nt a nd lo ng -te rm c a re Re vie ws • Re vie w o c c urs a fte r me dic a l c a re ha s b e e n re c e ive d Pro c e dure s a nd ho spita liza tio ns up to 14 da ys a fte r the da te Post- se rvic e o f se rvic e Re vie ws
Utilization Management Process Re vie w Me mbe r Pr ovide r Conta c ts UM the se e s or de r s for Prior r e que st Pr ovide r se r vic e s Authoriza tion for se r vic e s
Medical Necessity Determination • Benefits are verified to confirm plan allowance for certain diagnosis and requests • A medical necessity approval determination does Verification not guarantee payment or verification of benefit. It is a verification that the request meets medical necessity •Approval received •An adverse determination for medical necessity is made after review has determined it does not meet guidelines Determination •An adverse determination based on of lack of information is made for a requested service with no information provided for review •If you receive an adverse determination, your provider can conduct a physician to physician review & /or provide additional information to the request Rights within 14 days •Also a formal appeal can be completed within 180 days of the notification of adverse determination
What Are The Benefits of Utilization Management? Prevent unnecessary tests and costs to member Enhance provider and member relationship Prioritize outpatient and home-based care for faster recovery Ensure members have appropriate care and are provided all required services to maintain their health Careful monitoring of inpatient procedures to provide better outcomes
Care Coordination Services
What Is Care Coordination? • F RE E se rvic e o ffe re d to a ll me mb e rs o f the he a lth pla n • Ca re c o o rdina tio n se rvic e b e ne fits inc lude : Individualize d appr oac h to e nsur e that e ac h me mbe r r e c e ive s the appr opr iate me dic al c ar e , se r vic e s, and c ommunity r e sour c e suppor t De signate d Nur se Car e Coor dinator that assists with managing e ve r yday c ar e ne e ds and addr e sse s ac ute and c hr onic c onditions Coor dination ac r oss your he althc ar e te am that le ads to lasting r e sults so that you c an ac hie ve and maintain your be st he alth Car e Coor dinator is available by phone or in pe r son *L o uisia na Ope ra tio ns Site
What Is Our Care Coordination Model? • Co mmunity-b a se d Ca re Co o rdina tio n se rvic e mo de l with c a re c o o rdina to rs tha t a re e mb e dde d in the c o mmunity a nd a ssig ne d to spe c ific me mb e rs fo r o utre a c h Understands the culture and Understands the drivers community relationships to behind individual members effectively engage the member and affect behavior Patient change Local Physician Payer Community Office Care Provider Coordinator Hospital Builds relationships with Front line driver for value physicians/providers to and quality improvement enhance behavior change programs
What Is The Role of The Care Coordinator? • Pa rtic ipa te s in Me mb e r/ Pro vide r e ng a g e me nt a nd c o lla b o ra tio n Ca re Co o rd ina to r a c ts a s a sing le po int o f Me d ic a l c o nta c t with a c c e ss to Do c to r the e ntire c a re te a m. • Sup p o rts c a re c o o rd ina tio n So c ia l in b e ha vio ra l he a lth ne e d s • C o o rd ina tio n in o the r Wo rke r re so urc e ne e d s • Pro vide s g uida nc e in Pa tie nt/ me dic a tio n a dhe re nc e • Po ly-pha rma c y issue s Pha rma c ist Me mb e r • Drug -drug inte ra c tio ns Othe r Pro vid e rs & • C o o rd ina te s with me mb e r’ s Re so urc e s e ntire c a re te a m • • Advo c a te s fo r the me mb e r Assists with lo c a ting a nd He a lth He a lthc a re • Assists in na vig a ting the c o nne c ting with a va ila b le Pla n Syste m he a lth pla n a nd the c o mmunity re so urc e s he a lthc a re syste m
Example of Care Coordination • Co o rd ina te c a re with pro vid e rs a nd c a re te a m Diabe tic Me mbe r • Id e ntify c urre nt und e rsta nd ing Ne e ds Assistanc e o f c o nd itio n • Id e ntify re so urc e ne e d s With Managing T he ir • Me e t 1:1 to d isc uss Co nditio n ind ivid ua lize d tre a tme nt pla n a nd he a lth g o a ls • Pro vid e ta ilo re d d ise a se spe c ific e d uc a tio n Shor t- T e r m • Re vie w me d ic a tio ns • Assist with o b ta ining a g luc o me te r/ te st strips o r o the r re so urc e s • Ong o ing c o nta c t with Ca re Co o rd ina to r • Assist me mb e r in me e ting L ong- T e r m lo ng -te rm g o a ls • Impro ve d he a lth a nd se lf- ma na g e me nt o f c hro nic d ise a se
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