State health benefit plan updater [Apr. 1, 1994]

New Numbers Signal Faster Service On Your Claim and Benefit Inquiries

Effective July 1, 1994, the telephone numbers that Health Plan members call to check on Plan claims and benefits will change for the first time in years-and the result should be faster answers to your questions.

Why? Because the HBP is contracting with its medical-claims administrator, Blue Cross and Blue Shield of Georgia. to handle members' telephone inquiries concerning specific claims and benefits.
(All member phone inquiries about other subjects, as well as written inquiries, will still be handled internally by members of the Merit System staff.)
Why the Change?
The switch is being made in an effort to improve response time and provide faster service for Plan members who call in with questions about claims or benefits. The number of calls was increasing steadily, and the system was becoming overloaded. A combination of additional staff and more telephone lines will help the Plan to maintain and improve service to its call-in customers.
More Lines, Longer Hours

How It Will Work
The expanded calling system will work, basically, just as the existing one does: You'll call one of the new numbers (all three appear in the box below). Then
TO INQUIRE ABOUT CLAIMS & BENEFITS
Beginning July 1, 1994
800-483-6983
TOLL-FREE
404-233-4479
ATLANTA AREA
404-842-8073
TDD (for the hearing-impaired)

The new arrangement will feature stateof-the-art telephone technology, and will have 33% more long-distance trunk lines to accommodate Plan members who call the toll-free 800 number. Those 16 lines, plus eight others to serve local callers, should speed response time noticeably.

HOURS ...
8:00 a.m. to 6:00 p.m. Monday through Friday

In addition, calling hours will be longer. On and after July 1, you'll be able to call from 8:00 a.m. until 6:00 p.m., Monday through Friday (the old hours were 8:30 to 4:30). That's ten extra hours a weeka 25% increase-and that additional time should make calling more convenient for many members.

you'll be asked to specify the general nature of your inquiry-a specific claim, a question about a benefit provision, or information on coordination of benefits. You'll speak with a Blue Cross and Blue Shield employee who has been specially trained to answer your questions.
(continued on page 4)

Preferred-Drug Set-Up Will Save HBP Money
Effective July 1, 1994, the Health Plan will institute a program that's designed to encourage members to save money on the per-day cost of prescription-drug therapy.
The campaign is based on the fact that various drug manufacturers have offered
See page 3 for questions and answers about the preferred-drug program ...
volume discounts and rebates for years to hospitals and other institutions which buy certain quantities of the products sold by those manufacturers. Now that policy has been extended to health-care plans, including the HBP, and the Plan intends to take advantage of the opportunity for increased savings on drug purchases by its members.
(continued on page 3)

Your Cost to Rise, But Ratio Stays 3: 1
Your share of the cost of your participation in the Health Plan will go up 10% for Fiscal Year 1994-but you will still pay just one-fourth of the actual cost of your coverage.
(That's for Standard Option coverage. High Option and HMO rates had not been set when UPDAIBR went to press, but were expected to rise by the same or a larger percentage. Your cost will appear on your Option Statement, or be given to you by your employer.)
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SEP. 2 3 1994

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Health-Care Reform...
WHAT'S GOING ON OUT THERE? AND HERE?

by Bobbie Jean Bennett, Commissioner of the State Merit System
You couldn't miss it if you wanted to--not if you read the papers and watch the tv news. There's a major reform movement going on in this country to change the very basis of the way health care is delivered to you and your family.

On the national front, the Clinton proposal (and the many alternatives to it) repeatedly appears as front-page news. The insurance industry, sales organizations, labor, trade associations, manufacturers-all are seeking input into the process of deciding the kind of coverage you'll have, bow it will be paid for, and bow it will be delivered. Why such overwhelming interest? Because the form which the final system takes will directly affect virtually all the working people-and a lot of non-working ones-in this country.
The Governor's Commission
On the state level, the Governor's Commission on Health Care bas spent many months studying various health-care systems and the reform initiatives that are being proposed. Last December, the Commission issued an interim report in which it reported on its progress in addressing these specific objectives:
1. Develop and coordinate a plan to respond to adoption of national healthcare reform.
2. Develop and coordinate a plan to reform health-care financing for nonfederal public employees and others covered by state-supported health care.
3. Evaluate the organization of statesupported programs in terms of their capacity to bring about reform while cutting administrative costs.
4. Coordinate efforts to enable both businesses and individuals to get access to health care at reasonable cost.
The Commission also recommended that immunizations should be an integral part of every health-care plan's array of preventive/diagnostic care.

The State Health Benefit Plan agrees, and has added specific immunizations to its preventive/diagnostic benefits, effective July 1, 1994 (see the story elsewhere in this issue of UPDATER).
Access, Cost, Efficiency
The bottom line on health-care reform can be summed up very simply: access, cost, and efficiency. That's what all of the proposals are aiming for. So when you're looking at a particular proposal, just ask yourself three questions: Does it offer adequate access to those who need it? Is the cost of the coverage at a reasonable level in today's environment? Is care delivered efficiently?
We ask you to listen, to read, and to evaluate. Watch what's happening in the continuing campaign for health-care reform, here as well as in Washington.
We, in turn, will monitor the operation of the Health Plan, as we have done for years-and will implement the best and the most effective of the new ideas that emerge, in our ongoing effort to deliver health care economically, fairly, and efficiently to Plan members and their eligible dependents.
Controlling the Costs
We in State government are striving constantly to maintain a workable system of quality health care at an affordable cost to members. We face every day the everrising cost of medical care, and we deal with it as best we can within the constraints of good management and sound, fair administrative policies. We continue to implement cost-management programs, and they are resulting in some substantial savings for the Plan. II

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Cost Rises, Ratio Remains...
(continuedfrom page 1)
Your employer--the State of Georgia, or the school system or agency for which you work--will continue to contribute the other three-fourths of actual cost. So it's
The rate increase was held to 10% partly through a $77-million saving under several cost-management measures. See the box on page 5.
still a 3: 1 ratio-about 75 cents on the dollar that comes from your employer, the other 25 cents from you. And that's for coverage on both you and all of your eligible dependents.
The 10% increase was the minimum that was necessary to maintain the 3: 1 ratio.
Your coverage under the Health Plan is an excellent bargain, all things considered -because it gives you and your family access to quality medical care at reasonable rates, and keeps the cost of prescription drugs in the affordable range. II

2

Preferred Drugs Will Save Money for Members, Plan...
(continuedfrom page I)

In practice, the program is simple-and calls for absolutely no effort on the part of Plan members.
The Plan has contracted with an outside firm, made up of physicians and pharmacists, to apply their clinical expertise in determining whether a specific drug is an acceptable substitute for other, similar drugs which are more highly priced. If Drug A is determined by the experts to be just as effective as is Drug B, and it also costs less, Drug A is then designated a "preferred drug."
Every physician who serves Health Plan members will be encouraged to select one of the preferred drugs when he or she prescribes medication for a member or a member's dependent(s). Pharmacists also are familiar with the preferred-drug concept; in fact, the master listing of preferred drugs is maintained electronically on the computer system through which our network pharmacists access INSURx, the Health Plan's claims administrator for prescription-drug claims.

Savings Will Add Up
The savings from the preferred-drug program will be two-fold:
First, you'll get an appropriate drug-one certified by the Plan's advisory panel of physicians and pharmacists-at the lowest available per-day cost.
Second, the manufacturer of every preferred drug will issue a rebate to the Plan. That rebate-although it will amount to less than a dollar per prescription-will add up to some $2.7 million in savings in Fiscal Year 1995, based on Fiscal Year 1994's utilization figures. And those savings, in the long run, will help to control the amount that you pay for your share of the cost of your Health Plan coverage in the future.
Benefits Will Not Change
Note: The introduction of the preferreddrug program will not cause any changes in the prescription-drug benefits paid by the Health Plan. II

Questions and Answers About Preferred Drugs
Here are some of the questions that Plan members have asked about the new preferred-drug program, and answers to those questions:
Q. What do I need to do?
A. For now, nothing. From time to time, your pharmacist may mention to you that there is a preferred substitution for a drug that you're taking. When and if that happens, ask your physician if the preferred drug will be as suitable for treating your condition as is the higherpriced drug.

PENALTIES FOR NON-COMPLIANCE
with MCP pre-certification rules (out-patient)
0 For failure to call the MCP at least two business days before procedure.........50% of professional fees*
to a maximum of $400
O For failure to abide by the MCP' s recommendation after a prompt call.........50% of professional fees*
to a maximum of $400
0 For failure to pre-certify procedure, even if it is retroactively approved...........$100 (minimum)
*"Professional fees" include: For MRls, charges by the imaging center (if one is used) and charges by a radiologist (regardless offacility used). For CAT scans, charges by the facility where the scan is performed and charges by a radiologist or physician. For both MRls and CAT scans, charges by a physician or surgeon for the "reading" or interpretation oftest results. For all surgical procedures, charges by any physician or any surgeon who performs a surgical procedure.
Note: These out-patient penalties will be assessed in addition to any penalties for non-compliance with MCP in-patient rules; they will be limited to $1,000 aggregate in a calendar year; and they will not count toward your stop-loss limit under the Health Plan.
Note also: These penalties apply only if the State Health Benefit Plan is your primary health-care coverage. This exempts retirees who have Medicare coverage, as well as other members who have any outside plan as their primary coverage.

Q. Is this program mandatory?
A. No-strictly voluntary. You don't have to change to a preferred drug-but you'll save money for yourself and for the Plan if you do.
Q. Is it safe to switch?
A. Definitely. No drug can be listed on the preferred-drug compendium unless it has been certified by both physicians and pharmacists as an appropriate substitute for a higher-priced medication.
Q. Will every prescription cost less?
A. In the final analysis, yes. But be sure to note that we're talking about per-day cost-the real cost of the therapy, not the cost of a specific unit of medication. On a per-day basis, the preferred drug will always cost less.
Q. How can I find preferred drugs?
A. You won't need to. If you are taking a non-preferred drug, and a preferred version becomes available, you'll be informed by means of a printed message on your explanation-of-benefits (EOB) form.

3

MCP Out-Patient Certification Changes...
Endoscopies In, Foot Surgeries Out
Since the last UPDATER was published in June 1993, some changes have been made in the pre-certification requirements for out-patient surgical procedures.
Specifically: Effective July 1, 1994, foot surgeries no longer have to be pre-certified. The CPT numbers for various kinds of foot surgery have been deleted from the list below. Endoscopies must be pre-certified by the MCP, beginning on July 1. There are three specific types which will be affected: CPT 43234: Upper gastrointestinal endoscopy (simple primary exam). CPT 43235: Upper gastrointestinal endoscopy-including esophagus, stomach, and duodenum and/or jejunum.
CPT 43239: Upper gastrointestinal endoscopy-with a biopsy (single
or multiple).
All the other CPT numbers shown below remain the same as before.
CPT Codes for Out-Patient Procedures
These are the five-digit codes used by medical professionals to file claims...
Arthroscopies (knee only): 29870 through 29889. CAT scans (except brain and spine): 70480 through 70492; 71250 through 71270; 72192 through 72194; 73200 through 73202; 73700 through 73702; 74150 through 74170; 76375. Colonoscopies: 45378 through 45385. Endoscopies:* 43234; 43235; 43239. MRis: 70336; 70540 through 70553; 71550; 72141 through 72158; 72196; 73220;73221;73720;73721;74181;75552;76400. Nasal Surgeries: 30130; 30140; 30400 through 30520; 30620; 30801; 30802; 30930. Tonsillectomies and/or adenoidectomies: 42820 through 42831; 42835; 42836.
*These are new requirements, effective July 1, 1994
Phone Inquiries...
(continuedfrom page I)
Remember, please: The new numbers are for questions about claims matters and benefits matters only. For any other kind of question-about eligibility, participation, or to call the MCPuse the same number that you have been using all along. Note: For your convenience, there are two listings of important Plan numbersincluding the new ones--on page two and here on page four. You may want to clip one of them and keep it handy for ready reference. II
4

Immunizations Added To Preventive Benefits
Effective July 1, 1994, five kinds of immunizations will be added to the list of allowable expenses in the Health Plan's preventive-care category:
-Haemophilus influenza (Hib) vaccine;
-Hepatitis B vaccine;
-Pneumococcal vaccine;
-Influenza vaccine; and
-Tetanus-diphtheria (ID) booster.

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NUMBERS

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Beginning July 1, 1994

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TO INQUIRE ABOUT

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CLAIMS & BENEFITS

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800-483-6983
TOLL-FREE

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404-233-4479

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ATI.ANTA AREA

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404-842-8073

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TO INQUIRE ABOUT

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ELIGIBILITY OR

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PARTICIPATION

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404-656-6322

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TO CALL THE MCP

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800-762-4535

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TOLL-FREE

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404-438-9770

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,ATI.ANTA AREA

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Cost-Management Programs Saved $77 Million Last Year
1hree major programs designed to conserve the health-care dollars of the HBP and its members helped the Plan save a total of $77.9 million during Fiscal Year 1993.
These are the savings realized by each of the programs:

The Prudent Buyer Program and Participating Physician Program The Medical Certification Program The Prescription-Drug Network

$53,000,000
16,100,000
8,800.000
$77,900,000

In addition, the contract signed on the Plan's behalf with the John Hancock National Transplant Network in March 1993 for the performance of transplants at various network centers resulted in a saving of approximately $48,000 on each of 25 transplants -an aggregate saving of roughly $1.2 million over a span of less than one year. That contract is expected to produce more savings in Fiscal Year 1994.

Most Anesthesiologists Have Joined the PPP

A year ago, UPDATER reported that the Participating Physician Program (PPP) was succeeding overall-with more than 90% of the physicians in the state of Georgia enrolled in it.

The problem, we said, was with certain specialists, particularly anesthesiologists, whose participation rate was barely 70%.
That picture now has changed. As this UPDATER went to press, all but two of the anesthesiology groups in the state had responded to the urging of the Health Plan and joined in partnership with the PPP.
The two organizations which are still nonPPP participants are West Paces Ferry Anesthesia, which provides anesthetic services for West Paces Ferry Hospital in Atlanta, and Anesthesia Associates of Macon/Pain Care Inc., which serves HCA Coliseum Medical Center in Macon.
The Rationale for PPP
Membership in the PPP is so important because all PPP physicians agree by contract to abide by the Health Plan's billing guidelines; non-PPP physicians don't agree to do that.
This can lead to over-billing by non-PPP practitioners-in amounts higher than the Plan will pay. The over-charge can then be "balance-billed" to an individual Plan member, who generally has no recourse after the fact but to pay it.
The key: Check first to see if the anesthesiologist(s) at the hospital chosen by your doctor is a PPP participant. If not, consider making some other arrangement. (For

details, see the article on balance-billing in the June 1, 1993 UPDA1ER.)
Be aware: The PPP status of any physician can change in a hurry. If you don't know, be safe: Ask your physician-and do so before surgery is performed. II
HOW BIG IS IT?
Did you ever wonder just how big it really is-this State Health Benefit Plan that you belong to? Here's an idea...
-The total number of people enrolled in the HBP was 483,284 on June 30, 1993, the end of FY 93. Of the total, 222,562 were State employees and teachers; the other 2f/J,722 were eligible dependents.
-In 1993, the HBP processed just over six million claims-6,039,000, to be precise. That's 23,775 claims every working day, counting both the prescription-drug and medicalservices varieties.
-Of the medical-services claims, which totaled almost three million, more than 79% were processed within 15 calendar days.

Uncle Sam Wants Dependents' Data
When this open enrollment period rolls around, watch for a "special miscellaneous update form" from the State Health Benefit Plan.
It will ask you for some information about the dependents you have covered under the HBP. Here's why:
In 1993, the Congress passed a wideranging piece of legislation called the Omnibus Budget Reconciliation Act, or "OBRA 93." One of its provisions mandated the gathering of information about health-care-plan members and their enrolled dependents for inclusion in the federal "Medicare and Medicaid Coverage Data Bank."
Your employer is required by federal law to send this information to the data bank-at the same time it sends in your W-2 tax information. And, because the Health Plan maintains records on Plan members and dependents, the Plan is assisting your employer in meeting its obligation by distributing the special update form to all of its members.
What to Do
What do you do when you get your form? First, don't be alarmed; providing the information is mandatory, and the Plan is simply giving employers a helping hand with the data-gathering process.
Second, please review the information shown on your form, and correct it if necessary. The information you see will be that which is current in Health Plan records as of April 1, 1994.
It's Basic Information
This is the information you'll be asked to provide or update, as OBRA 93 requires:
-Your name (as a participant in a health-care plan); your taxpayer ID number, or TIN (usually the same as your Social Security number).
-The name and TIN of any dependent who is also covered by the I-IBP.
-The type of coverage elected by you and by your eligible dependent(s).
Again: It's routine, and it's mandated by federal law. Your employer and the Health Plan need your assistance, and will appreciate your cooperation. II

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HIGHLIGHTS
of this issue of UPDATER...
PAGE 0 FASIBR SERVICE on phone inquiries about claims and benefits
should result from additional trunk lines and longer calling hours ................................................. 1 0 NEW PREFERRED-DRUG PROGRAM saves money two ways ................................................. 1 0 COST OF PARTICIPATION to rise 10% for Fiscal Year 1994,
but you'll still pay about 25 cents on the dollar for your coverage ............................................... 1
0 HEALTI-I-CARE REFORM: A messa2e from the Commissioner ................................................ 2 0 COST-MANAGEMENT MEASURES saved the Plan $77 million .............................................. 5 0 REQUIREMENTS CHANGED for MCP out-patient pre-certification ........................................ .4 0 MOST OF THE STAIB'S ANESTHESIOLOGISTS now in PPP ................................................ 5 0 REMINDER: You'll pay a penalty if you don't follow MCP rules .............................................. 3 0 IMPORTANT NEW PHONE NUMBERS for you to clip and save ..............................................4
State Health Benefit Plan Georgia State Merit System Post Office Box 38342 Atlanta, Georgia 30334-0342
Important Benefit Information