State health benefit plan updater [June 1, 1996]

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Now-Paperless Claims, Faster Thrnaround

A Health Plan member can now buy his or her prescription drugs from a network pharmacy without having to file a paper claim-and get a check for reimbursement in roughly half the time as before-if that member's primary coverage is either the Standard Option or the High Option.

These two advantages are the result of a new contract with Systemed, the Health Plan's claims administrator for prescription-only drugs. The contract went into effect on March 1, 1996.
The arrangement was described in detail in a February memo to members. Here, as a reminder, are some facts about the contract and how its inception will make the filing of your drug claims faster, more convenient, andin many cases-Jess expensive...

not to continue participation under the new arrangement. Each pharmacy in the state has the right to opt in or out; and, while most chain pharmacies and many independents will continue to participate, the Plan cannot mandate participation. Be sure to ask if your

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Filing is totally electronic
Paperless claims are possible because of an electronic filing system, which utilizes computers to link pharmacies with Systemed-thus eliminating the need for paper forms.
In order for the paperless process to work, a purchase must be made at a participating network pharmacy on or after March 1, 1996-and the Health Plan must be the primary coverage.
TUrnaround is shorter
A major advantage of the electronic process-in addition to the convenience of paperless filing-will be the significantly shorter turnaround time for drug-claim reimbursement, which will range from two to three weeks.
1\\10 things to be aware of as the new Systemed network is phased in and the electronic claim-filing system is implemented:
-Some pharmacies which currently participate in the network may choose

pharmacist is a participant in the new Systemed network of the State Health Benefit Plan when you buy a drug.
The prices of many prescription drugs will be lower after March 1, 1996; the prices of others could rise slightly, or remain unchanged.
Benefits are unchanged
Otherwise, no changes were made in the prescription-drug program. Rate of payment remains the same: 80% for Standard Option, 90% for High Option. Any drug that was covered before March 1, 1996 continues to be covered; any drug that was excluded is still excluded now.

HMO Coverage to Expand
Health-maintenance organizations in four locales around the state will soon be opened to membership, thus expanding HMO coverage possibilities for active HBP members who live in the Atlanta, Savannah, Augusta, or Macon areas.
In the Atlanta area, both PruCare and Kaiser Permanente will remain available. Two other HMOs-Blue Cross/ Blue Shield of Georgia (BlueChoice) and U.S. Healthcare-will be opened to participation.
Elsewhere, these HMOs will become available to active members:
In the Savannah area: BlueChoice. In the Macon and Augusta areas: BlueChoice and U.S. Healthcare.
(continued on page 5)
Cost Management Saves $133 Million
There could be several reasons that your premium for Plan participation isn't going up in July, but one thing is for sure: The Plan's cost-management programs didn't hurt.
The amount of money saved last year totaled $133.7 million. Broken down by category...
-Prudent Buyer Program (hospital expenses)...$51.8 million.
-Medical Certification Program (medical expenses)...$36.9 million.
-Participating Physician Program (doctors' fees) ...$27.3 million.
-Pharmacy networklgeneric-drugincentive program...$15 million.
-Transplant contract...$3 million.

Here's how...
Filing a Paperless Claim for a Prescription Drug

If you buy a prescription drug at a participating network pharmacy-and if your primary coverage is the HBP's Standard or High Option-your drug claims can be conveniently "paperless," thanks to the Health Plan's electronic filing system.

It will work this way...

Coordination of benefits

1. Go to your network pharmacy and show your Plan ID card. The pharmacist will fill your prescription and file the claim for you electronically, using an on-line system that permits him or her to link up to Systemed's computer in a matter of seconds.
2. Pay for the prescription. (You'll pay a pre-negotiated price, based on network rates.)
3. And that's it. Within two to three weeks, you'll get a benefit payment (or a notice about your deductible) in the mail-directly from the HBP. (Turnaround time includes a built-in seven-day delay that's designed to give the pharmacist enough time to cancel charges for prescriptions that are ordered but are not picked up.)
Remember: This is how it works if you use a network pharmacy and if
the HBP is primary. But unless both of those requirements are met, the electronic filing process cannot be used. Here's what happens in other circumstances...
Outside the network...
If you're using a pharmacy that's not a part of the network: You must ask the pharmacist to complete a paper claim form (no information will be forwarded electronically). And you must file the form yourself, by mailas you have done in the past-using the address that's printed on the back of the claim form.
Two things to keep in mind if you use a non-network pharmacy...
-A non-network pharmacy will not stock the HBP's drug-claim form (the PDCF); be sure to take one with you and have the pharmacist fill it in. To get a PDCF, call the Blue Cross/Blue Shield customer service line.
-You are responsible for any charges that exceed the network rate.

If your Health Plan coverage is not the primary coverage for prescriptiononly drugs, you must file a claim in the manner prescribed by the primary plan-which could entail filling in a paper form. You file first with your primary insurer; wait until you receive an explanation-of-benefits form from that insurer; and then file your claim for secondary benefits (and be sure to attach the EOB) with the Health Plan.
(Note that the Health Plan's electronic filing process is never available when the HBP is secondary-whether your pharmacy is network or non-network.)
Report any change...
If you have a change in your primary coverage, update the Plan on a timely basis. You see, records on file with the Plan may show that a dependent has some other group health coveragewhen, in fact, that coverage has been cancelled. To notify the Plan in such a case, get a cancellation notice from the other insurer and mail it-along with a cover letter explaining the circumstances-to State Health Benefit Plan, Post Office Box 38151, Atlanta 30334. Include your Social Security number-and be sure to identify the covered person whose coverage was cancelled. Why do it? Because with no other coverage, you can file electronically since the HBP is primary!
Retired? Do read this...
Note for retirees: If you are enrolled in Medicare, and buy your prescription drugs from a network pharmacy, you can utilize the paperless claimfiling process-because the HBP is always primary for drugs bought by retirees with Medicare. But if your primary coverage is a plan other than the HBP or Medicare, you'll have to follow the rule that active employees follow: No electronic filing when the HBP is your secondary coverage.

How Are We Doing? Check the Numbers...
The Health Plan constantly monitors itself from a service standpoint: How many people are we covering? How well do we respond to their queries, their requests? Where is the Plan's money going? Here are some statistics to help you fill in a report card:
Plan enrollment
o Total number of people enrolled in
the State Health Benefit Plan as of the end of September 1995 was 517,407.
Of those, 241,859 were members; another 122,050 were spouses; and the remaining 153,498 were other enrolled dependents.
o HMO members accounted for
70,268 of the total enrollment, with 29,379 being Plan members and the remainder being dependents.
Plan volume
o Number of claims received in a
year: 5,769,000. That amounts to well over 100,000 claims in a week-or more than 22,000 every working day.
o Total amount of money paid out
in FY 95 as claims for benefits under the Standard Option and High Option: $747 million. Of that, $236 million (32%) was paid to physicians; $267 million (or 36%) went to hospitals;
Also see the pie chart on page 3...
$167 million (22%) went for outpatientllablX-ray charges; and $77 million (10%) for prescription-only drugs. In addition, more than $99 million was paid out as premiums for the Health Plan's HMO members.
o Telephone calls to customer ser-
vice lines (staffed by claims administrator Blue Cross and Blue Shield of Georgia employees) totaled 414,535. That's 34,545 a month, on averageor slightly more than 1,700 calls in every working day.
Plan response
o Out of all the calls, 93.8% were
responded to within 45 seconds (the Plan's goal is 90%). And only 2.6% were blocked by a busy signal (the Plan's goal is 5% or less).

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MCP Will Manage Care for Diabetics
Beginning this fall, the Health Plan will introduce a pilot program to help participants deal with the complications associated with Type I (insulin-dependent) diabetes mellitus.

The new program, to be known as the "diabetes-care-management project," will provide intensive case management, and will serve as an advocacy resource for people facing long-term treatment for the disease.
Services and education
The project will concentrate initially on diabetic patients who are hospitalized because of complications of the disease. Such patients will be offered case-management services, coordination of home care, and access to educational materials and information.
The new diabetes-care-management project will be provided through the MCP as a part of the Plan's overall effort to improve the nature and the scope of case-management services available to Plan members and their enrolled dependents.
The inception of the diabetes project was spurred by the seriousness of the disease and its mushrooming growth in recent years.
Unless it is detected and then treated, diabetes can result in serious health problems-blindness, kidney failure, and severe nerve damage. It is also a leading contributory factor in stroke and heart disease (see the sidebar at right for facts about the prevalence and the seriousness of diabetes).

Did You Know...?
-Diabetes is the major cause of new blindness in America, and more than 1,000 Georgians are thus affected.
-A diabetic is up to four times more likely to get heart disease than is a non-diabetic. For a stroke: the likelihood is up to six times greater.
-Diabetes causes a third of endstage renal diseases (more than 10,000 in the nation, nearly 400 in Georgia).
-The risk of leg amputation for diabetics runs 15 times greater; there are 1,350 such operations in Georgia each year.
-Nationwide, 14 million people suffer from diabetes; in Georgia, more than 334,000.
-The total cost of diabetes in Georgia in 1990 totaled $655 million--counting the direct (health-care) and the indirect (lost productivity) costs of the disease.
Sources: American Diabetes Association; Centers for Disease Control and Prevention; Division of Diabetes Treatment, National Center for Chronic Disease Prevention and Health Promotion.

Olympic Games Dictate Special Telephone Hours
The telephone numbers which HBP members call to ask about eligibility and benefits, or to check on specific claims, will be open for business during different hours while the Atlanta Olympic Games are going on.
The temporary hours will be from 7:00 a.m. through 3:30 p.m. Monday through Friday, from July 19 through August 4, 1996, inclusive.
There are two different sets of phone numbers, one for eligibility questions and one for inquiries about claims; all are listed here...
The main number for questions about claims is 404 233-4479; the toll-free number for use outside the Atlanta calling area is 800 483-6983; and the TDD line for the hearing-impaired (it is also toll free) is 800842-8073.
The main number for questions about eligibility is 404 656-6322, and the toll-free number for use outside the Atlanta calling area is 800 610-1863.
The reason for the changed hours is the expected crush of traffic in and around Atlanta during the Olympics. Some of the city's surface streets will be closed throughout the Games, and others will be open only on a limited basis. By arriving and leaving earlier, the employees (both Blue Cross/Blue Shield and Health Plan people) who staff the phones will be able to maintain contact with Plan members who have questions to ask them.

MEMBERS 241,859

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HOSPITALS $267 MILLION

TOTAL ENROLLMENT
517,407
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What's Happening in Health Care?
by Commissioner Bobbie Jean Bennett

From time to time, the UPDATER asks Commissioner Bennett to survey the health-care scene and tell us what she sees in the way ofnew developments, buzzwords, hot topics, and the like. This is one of those occasions.

Today, managed health care is a subject of interest to many employers and employees. More than half of all Americans who have health-care coverage are enrolled in some form of managed-care plan, and-while the plans are most prevalent in the far west, the upper midwest, and the northeast-they are rapidly expanding into the south.

Managed care is not a new concept; it has been around since 1929, when the first health-maintenance organization (HMO) was established in California.
What is it?
What is managed care? Simply stated, it is an attempt to contain the costs of health care through active management of the delivery of that care.
Typically, the providers (physicians) and the consumers (patients) of care are offered financial incentives in an effort to control costs.
Managed health care focuses on the prevention of disease; on early detection and intervention when an illness occurs; on the promotion of healthful lifestyles; and on providing medically necessary services in a cost-effective setting. For example, a person with an upset stomach would be encouraged to see a primary-care physician in his or her office, rather than going to a hospital's emergency room.
In theory, everybody wins in managed care. The members of managed-care plans enjoy both lower premiums and healthier lives, while the plans' sponsors (employers) control costs. What, then, are the potential drawbacks? Of the most concern are these two: That the financial arrangements with providers might discourage necessary medical care, and that the management process itself might interfere with the delivery of urgently needed care and treatment.
Managed-care health plans are found on a continuum, ranging from HMOs at the more aggressively managed end to "managed-indemnity" plans at the other end. The Health Plan's Standard and High Options are examples of the managed-indemnity approach.

You can expect more managed care in the future, both in and out of the State Health Benefit Plan. Employers face increasing pressure to control costs. The population is aging, resulting in higher health-care costs. Both of these factors will influence the rate and the scope of the growth of managed care.
We're managing care...
The Health Plan already has in place a number of measures for managing health care. Among them...
-The Medical Certification Program, for pre-certification and case management of medical hospital admissions and certain out-patient procedures.
-The Behavioral Health Services program, for pre-authorization and referral of treatment for mental-health conditions and substance abuse.
-The Prescription Drug Network, for assurance of reasonable prescriptiondrug prices and encouragement of the use of cost-effective generic drugs.
-The Transplant Network, for highquality organ transplants and tissue transplants on a cost-effective basis.
-The Participating Physician Program, for maintaining reasonable levels in physicians' charges to members.
What's ahead?
The Plan will implement the diabetescare-management project this fall. We are also exploring benefit changes that would increase the appropriate use of primary-care physicians' services, and curtail unnecessary use of emergency rooms and of specialists' services. Our focus will be a dual one: improvement in the Plan's cost-effectiveness, with a continuing commitment to quality as the number-one priority for your and your family's health care.
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Physical Therapy...
DON'T BE SURPRISED
Many members have reported some unpleasant surprises when they used the services of a physical therapistparticularly in the out-patient department of a hospital.
The members expected that the providers would accept the Health Plan's reasonable charge for such services, but things didn't work out that-way. Instead, members were charged fees far higher than the Plan's limits, and "balance billed" for the excess.
You should be aware that many physical therapists aren't governed by the HBP's Participating Physician Program (PPP), and that balance billing is a real possibility.
What can you do to avoid a situation like this? Check out your provider in advance. It's possible to get physical therapy from various sources-from individual practitioners, hospital outpatient departments, specialty rehabilitation facilities, and possibly others.
Whichever you use, find out up front if that provider (or the entity which employs that provider) is a member of
the PPP. If not, ask if the provider will
s accept the RBP allowances as full
payment for his or her services. If the answer is no, get a fee quote. And do remember: The Health Plan pays a fixed amountfor each therapy visit, regardless of how many services are performed during that visit.
Then call the HBP's customer-service representatives at 800 483-6983-and ask them if the fees you were quoted exceed the Health Plan's allowances for those specific services. If they do, you'll be responsible for any excess (as well as for your regular deductible and co-payment share). Depending on the answer you get, you may want to explore other provider possibilities.
Of course, if the therapist works for a PPP physician and the physician is going to file your claim, there's not a problem; you won't be balance billed.
To be a good health-care consumer, avoid billing surprises, and possibly save some money, ask your physician for a referral to a physical therapist who will accept the Plan's allowances.

A Special Note...
Retirees on Medicare
If you're enrolled in Medicare, then that federal program is your primary coverage. But because Medicare does not cover prescription-only drugs, the HBP is considered your primary coverage for the purpose of purchasing drugs. Thus you're allowed to utilize the new electronic filing system to have your prescription-drug claims filed on a paperless basis (see story on page 1). But note....
This applies to Medicare only. If your primary coverage is any other group health-care plan, then the basic principles apply: no paperless claims unless the HBP is your primary coverage.
No Changes This Year In Certification Listing
Most years, the Plan publishes a notice of changes in the list of outpatient surgical/diagnostic procedures that require certification by the MCP (the listing appears on page 89 of your "State Health Benefit Plan" booklet dated November 1, 1995).
This year? Not a single change. So you may rely on the booklet list until you receive notification of a change.

Member's Idea Adopted
Lieutenant Colonel (Ret.) A.T. Wilson of Columbus, a 31-year veteran of the U.S. Army and a member of the HBP since 1982, had a good idea. So good, in fact, that we're putting it to work.
After reading his Plan booklet when it came out in November 1995, Wilson wrote to us and called the 104-page publication "...a fine piece of work." Thank you, sir.
But, he continued, "many acronyms/ abbreviations are used repeatedly," and it is difficult to recall them after seeing them 10 pages or so before.
He's right, of course. We use all the shortened forms (terms like COBRA and MCP and BHS) because use of the full version would render your booklet virtually unreadable-and considerably longer.
Colonel Wilson didn't object to the abbreviations; he just wanted them where the reader could refer to them more comfortably. So, he suggested, why not prepare a short list of oftenused terms, print it in the UPDATER, and invite other members to cut it out and use it as a booklet bookmark?
We did, and we do. It appears at left. Thanks again, sir.

HMO Expansion... (continuedfrom page 1)
Each HMO has an individual "service area," composed of counties in which it can operate. For details about each HMO's service area, see the booklet titled "Comparison of Coverage Options;" it is a part of the comparison-of-benefits package, and is available at your personnel/payroll office for the asking if you live in a county where an HMO(s) operates.
(Coverage under the Standard Option or the High Option will remain open to all eligible employees and teachers throughout the state.)
There are several kinds of HMOs, including independent-practice-association, or IPA, models, as well as staff/group models. The major difference between these two is the way in which treatment is delivered: The IPA models provide care from the offices of individual physicians, while staff/group models utilize central facilities where a number of providers practice under one roof. Kaiser and PruCare are basically staff/group models, with some care provided by affiliated community physicians; the others are IPA models.
Each HMO sets its own rules for the kind and amount of coverage it will provide for a covered person outside its service area-a college student who lives away from home, for example. Generally, an HMO will provide no routine care outside its service area-but it will provide ''urgent'' or emergency care for any covered family members at other locations. Ask your HMO for specifics.
HMO enrollment for eligible active employees is available during open enrollment periods.
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Ql. What kind of claim(s) can I file with the paperless electronic process?
AI. Claims for prescription drugs, if (a) you bought the drugs on or after March 1, 1996 (b) from a networkaffiliated pharmacy-and (c) the HBP is your primary coverage.
Q2. What about Medicare claims?
A2. If you're a retiree whose primary coverage is Medicare and secondary coverage is the Health Plan, you may use the electronic filing system for all your drug claims.
Q3. What if some other plan is my
primary coverage-not the REP?
A3. The exception just described in Q2 applies only to Medicare; if your primary plan is any other group plan, and the HBP is secondary, you cannot utilize paperless claim filing. You'll file first with your primary plan, in the manner prescribed by that insurer, and then file with the HBP.

PAPERLESS CLAIM FILING
Q4. What if I use a pharmacy that's
not in the network?
A4. You cannot use the Health Plan's electronic filing system. You must ask the pharmacist to fill in a paper claim for you, just as in the past; and you must file that claim yourself, by mail, just as you have done in the past. No data will be forwarded electronically in such a case. And be sure to take a PDCF (HBP drug-claim form) with you; non-network pharmacies don't stock them, and you'll need a PDCF which has been filled in by the pharmacist for filing your claim with the Health Plan.

Q5. What do I have to do in order to have my claims filed electronically?
A5. Just visit a participating pharmacy and show your Health Plan ill card. Pay the pharmacist, who will file your claim electronically, using the on-line system to link up with the Systemed computer. Within three weeks or less, you'll receive either a check for reimbursement or a notice about your deductible, sent to you directly from the Health Plan.
Q6. Will my drugs cost more?
A6. Some drugs will cost less, others more, and some the same as before. But the electronic filing system won't have any effect on drug prices. That's because the prices you pay at a network pharmacy are pre-negotiated; and, since Systemed re-negotiated its prices with many of the pharmacies in Georgia before the new contract went into effect on March 1, you'll pay the current members-only rate-alwaysno matter how claims are filed.

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State Health Benefit Plan State Merit System P.O. Box 38342 Atlanta, Georgia 30334

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ATLANTA, GEORGIA 30334
PERMIT NO. 1334

IMPORTANT BENEFIT INFORMATION