Health Insurance CO-OPs: Consumer Operated and Oriented Health Plans
University Health Plans, Inc. Student Health Insurance Plan Presented to:
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Transcript of University Health Plans, Inc. Student Health Insurance Plan Presented to:
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University Health Plans, Inc.
Student Health Insurance Plan Presented to:
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UNIVERSITY HEALTH PLANS
UHP’s Success
•20+ years experience
•Pioneered web-based enrollment/waiver system
•100% Student Health Programs
•60 College and University Clients
•Accountable Management/Decision Making
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UHP’s Client Services
•Represent the Client
•Competitive Premiums
•Enrollment/Waiver Billing
UNIVERSITY HEALTH PLANS
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UHP’s Client Services (continued)
•Customer Service
•Student/Client Advocate
•Secure Website
•Toll Free Number
•On-Site Training Available
UNIVERSITY HEALTH PLANS
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UHP’s Client Services (continued)
•Quarterly reviews/discussions
•Plan Evaluation/Plan Design
•Claim Reports
- detailed claims analysis
- claim run-out
- prescription drug detail
UNIVERSITY HEALTH PLANS
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UHP Client Services (continued)
•UHP claims audits
•UHP is the student/client advocate
•UHP’s complimentary products
•State Reports
UNIVERSITY HEALTH PLANS
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Customized On-Line ServicesUHP has developed several on-line resources to meet the needs of each school:
•Brochures and other forms on-line or downloadable
•On-Line Waiver and Enrollment
•On-Line Eligibility look-up
•On-Line Claims Status look-up
•On-Line ID Card request
•Preferred Provider and Member Pharmacy look-up
UNIVERSITY HEALTH PLANSwww.universityhealthplans.com
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BCBSMA PromiseTo Always Put Our Members’ Health First
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Blue Cross Blue Shield of Massachusetts
Your long-term partner should have a long-term vision
Our Mission…Our Philosophy
Blue Cross Blue Shield:
• Social Contract
• Long-term cost & quality focus
• 1% - 2% contribution to reserves
• Views healthcare delivery and administration as local with a national reach (one size does not fit all)
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Blue Cross Blue Shield of Massachusetts
Membership & Growth Year end 12/31/06
• Total Members 3,050,000• New members 128,800• Dominant market share 40%
Service ExcellenceYear end 12/31/06
• Strong Member Satisfaction 85%• Strong Provider Satisfaction 88%• Account Retention 95.8%
Financial StabilityYear end 12/31/06
• Earned Premiums $6.81B• Cash & Investments$2.6B• After Tax Net Income $122M• Statutory Reserves $1.6B
World Class Performance...Sustained Excellence
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Why Choose Blue?
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Blue Cross Blue Shield of Massachusetts
Brand Strength
• #1 market share in all 50 states
• Most recognized brand inhealthcare among consumers
• #1 in delivering the lowest overall costs (Fortune Magazine, Sept. 2005)
• 75% of Fortune 100 companies (9 of the top 10)
• 94 Million covered lives (1 in 3 Americans)
Unaided Brand Awareness
10%
18%
24%
CIGNA
United
Aetna
71%
Source: Brand Strength Measure Survey (2005)
The Blues are the Brand leaders among employers and consumers
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Network Access and Discounts
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Blue Cross Blue Shield of Massachusetts
*Includes Adult PCPs, Pediatricians, Ob/Gyns, Specialists
The Blue Cross Blue Shield Network Advantage
Local Networks• Over 15,000 providers*• 85 hospitals• Stable mature networks (consistent local benefit delivery)
Regional Networks• Over 32,000 providers*• 181 hospitals throughout New England• Stable mature networks (consistent regional benefit delivery)
National Networks• Over 1,000,000 providers*• Over 6,000 hospitals• Stable, mature networks (consistent national benefit delivery)• Only nationwide network with secondary and rural locations
More claims processed in-network provides savings; unsurpassed access to care allows consolidation ease
Benefit to Bentley College
Benefit to Bentley College
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Blue Cross Blue Shield of Massachusetts
The Blue Cross Blue Shield Network Advantage (cont.)
Assessing network value:
• Low unit cost (per claim discounts)
• Care Management (utilization controls)
• Depth & Breadth of networks (access to care)
Blue Cross Blue Shield is the recognized industry leader in network value
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Blue Cross Blue Shield of Massachusetts
Healthy Member Interventions
Prevention and wellness communications and programs
• Healthy Blue Programs
• Worksite Wellness Programs
Comprehensive e-health and communication strategies to address a large population with non-complex health issues
• www.ahealthyme.com
• www.bluecrossma.com Award Winning Web Sites
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Blue Cross Blue Shield of Massachusetts
Healthy Blue Programs
Support: • LIVING HEALTHY Babies• Living Healthy Smoke-Free• Blue Care Line – 24/7; (888) 247-BLUE• DecisionCare Guide
Campus Wellness• Healthy Blue at School• Personal Edge (fee for service)
Incentives: • Fitness Benefit - $150 per yr.• Weight Loss Benefit - $150 per yr.• Discounts (bike helmets, safety products)• Living Healthy Naturally:
— 20% discount on acupuncture, massage therapy, nutrition counseling
• Living Healthy Vision:— Up to 25% discount (frames, lenses,
contacts)
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Blue Cross Blue Shield of Massachusetts
Care Management
Program Goals
• improve health status, quality of life, lower rates of complication and inpatient admissions
Member Identification
• claims data, PHRAs, episodes of care, physician referral, member referral
Specialized Programs
• transplants
• outpatient therapies
• pediatric focus
• rare diseases – multiple sclerosis, cystic fibrosis, Parkinson's
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Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield’s View of the Future…
Old Thinking: Quality is a given. So, contain costs.
• Gaps in care
• Unsustainable rise in costs
• Think once, Order twice
• Pay for metrics (HEDIS based)
New Thinking: Promote quality and costs will be contained.
• Fewer adverse events
• Reduced waste
• Think twice, order once
• Pay for performance (evidence based)
© 2006 Blue Cross Blue Shield Association. All Rights Reserved.
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Blue Cross Blue Shield of Massachusetts
Claims Processing
• Average turnaround time – 3.6 days (year end 2006)
• Auto adjudication rate – 91.2% (year end 2006)
• Claim payment accuracy – 99.7% (year end 2006)
• Financial accuracy – 99.9% (year end 2006)
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Blue Cross Blue Shield of Massachusetts
BCBSMA Student Business
• History— Harvard University
— Massachusetts Institute of Technology
— Northeastern University
— UMass Dartmouth
— UMass Worcester
— Berklee College of Music
• Underwriting Rationale
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Blue Cross Blue Shield of Massachusetts
Bentley College Student Plans
• PPO Benefit Plan
— Referrals not required
— 100% in-network nationally
— 80% out-of-network nationally
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Blue Cross Blue Shield of Massachusetts
PPO Benefits (option 1 – 100/80)Benefit In-Network Out-of-Network
Maximum Unlimited Unlimited
Deductible None $250 per member
Office Visits $15 Co-Pay then 100% 20%*
Emergency Room $50 Co-Pay then 100% $50 Co-Pay the 100%
Maternity Care (inpatient) No charge 20%*
Vision Exam Co-Pay then 100% 20%*
(1 per 24 mos.)
Prescription Drugs (ESI) $10/$25/$45Co-Pay ** Not Covered
*Deductible applies
**No annual maximum
Option 1 = $984.00 annual student rate (add $5.00 for on-call travel assist and $3.00 for $10,000 AD&D coverage)
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Blue Cross Blue Shield of Massachusetts
PPO Benefits (option 2 – 90/70)Benefit In-Network Out-of-Network
Maximum Unlimited Unlimited
Deductible $250 per member*** $250 per member***
Office Visits $15 Co-Pay then 100% 20%*
Emergency Room $100 Co-Pay then 100% $100 Co-Pay then 100%
Maternity Care (inpatient) 10%* 30%*
Vision Exam $15 Co-Pay then 100% 20%*
(1 per 24 mos.)
Prescription Drugs (ESI) $10/$25?$45 Co-Pay ** Not Covered
*Deductible applies
**No annual maximum
***In and out-of-network combined
Option 1 = $891.00 annual student rate (add $5.00 for on-call travel assist and $3.00 for $10,000 AD&D coverage)
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Blue Cross Blue Shield of Massachusetts
PPO Benefits (option 3 – 80/60)Benefit In-Network Out-of-Network
Maximum Unlimited Unlimited
Deductible $250 per member*** $250 per member***
Office Visits $20 Co-Pay then 100% 20%*
Emergency Room $100 Co-Pay then 100% $100 Co-Pay then 100%
Maternity Care (inpatient) 20%* 40%*
Vision Exam $20 Co-Pay then 100% 20%*
(1 per 24 mos.)
Prescription Drugs (ESI) $10/$25/$45 Co-Pay ** Not Covered
*Deductible applies
**No annual maximum
***In and out-of-network combined
Option 1 = $802.00 annual student rate (add $5.00 for on-call travel assist and $3.00 for $10,000 AD&D coverage)
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Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield
Member Services
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Blue Cross Blue Shield of Massachusetts
Why Choose Blue?
• Brand strength and value
• Network access and discounts
• Innovative products and health care solutions
• World class concierge service
Uniquely positioned to be Bentley College’s long-term partner
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Nationwide Life Insurance Company
Nationwide Facts:
•Rated A+ by A.M. Best
•Insuring student plans for over 6 years
•$100 Million in student insurance premium
•$30 Million in UHP/Nationwide premium
•Access PPO’s for best possible discounts, including
Multi-Plan/PHCS and FirstHealth (HCVM, CCN)
•ExpressScripts Rx Plan
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Consolidated Health Plans (CHP)Claims Administration Services
CHP Facts:
•Headquartered in Springfield, MA
•Providing claims payments services for over 10 years
•Over 100 College and University clients
•$40 Million in paid claims
•Flexible Benefits
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Consolidated Health Plans (CHP)Claims Administration Services
CHP Claims Payment Statistics:
•Average turn around time 5-7 business days on “clean”
claims
•Payment at 99% accuracy
•Random audits performed to ensure consistent accuracy
•Utilization review on claims over $10,000
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Consolidated Health Plans (CHP)Claims Administration Services
CHP Customer Service Statistics:
•Same day response for calls received before 2:00 pm
•24 hour response time for all email inquiries
•Continual customer service training to ensure accuracy of
responses
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Consolidated Health Plans (CHP)Claims Administration Services
CHP On-Line Services:
•Available 24/7
•Eligibility status look-up
•Claims status inquiry
•On-Line “EOB”, including date of service, payment date,
PPO savings, patient responsibility, etc.
•Preferred provider look-up
•On-line/printable brochure
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Nationwide Life Insurance Company
Option 1Benefits
Aggregate Maximum $50,000 Per Condition per Policy Year
Physician's Office Visit 100% after $15 Copay In-network or $25 Copay Out-of-Network
Emergency Room 80%
Inpatient Hospitalization 80%
Surgical Charges 80%
Lab and X-Ray 80% (100% for labs when samples are taken or drawn at Health Services)
Prescription Drugs 100% after $10 copay for generic or $15 copay for brand name $500 maximum per Policy Year
Premiums
Student Only $828.00
Spouse Only $1,800.00
Child Only $1,325.00
2nd Year Cap of no more than 14%
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Nationwide Life Insurance Company
Option 2
Premiums
Student Only $814.00
Spouse Only $1,790.00
Child Only $1,300.00
2nd Year Cap of no more than 14%
Benefits
In-Network Out-of-Network
Aggregate Maximum $50,000 per condition per policy year $50,000 per condition per policy year
Physician's Office Visit 80% after $15 copay 70% after $15 copay
Emergency Room 80% 70%
Inpatient Hospitalization 80% 70%
Surgical Charges 80% 70%
Lab and X-Ray 80% (100% for labs when samples are taken or drawn at Health Services)
70% (100% for labs when samples are taken or drawn at Health Services)
Prescription Drugs($500 max per policy year)
100% after a copay of $10 generic or $15 for brand name
100% after a copay of $10 generic or $15 for brand name
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Nationwide Life Insurance Company
Option 3
Premiums
Student Only $915.00
Spouse Only $2,000.00
Child Only $1,450.00
2nd Year Cap of no more than 14%
Benefits
In-Network Out-of-Network
Aggregate Maximum $50,000 per condition per policy year $50,000 per condition per policy year
Physician's Office Visit 100% after $15 copay 80% after $15 copay
Emergency Room 100% 80%
Inpatient Hospitalization 100% 80%
Surgical Charges 100% 80%
Lab and X-Ray 100% 80% (100% for labs when samples are taken or drawn at Health Services)
Prescription Drugs($500 max per policy year)
100% after a copay of $10 generic or $15 for brand name
100% after a copay of $10 generic or $15 for brand name
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Nationwide Life Insurance Company
Benefit Modifications
Benefit Modification Student Only Rate (Dependents will be proportional)
1.) Increase maximum prescription drug coverage to $750 $18
2.) Immunizations (all combined) $11
3.) Routine physicals (up to $100 per year) $12
4.) STD screening package (all combined) $10