MARSP News & Announcements

Putting the focus on the patient: Medical home defined

Submitted by Blue Cross Blue Shield of Michigan

The Patient-Centered Medical Home (PCMH) places the patient and primary care practice at the center of care and creates a healthcare setting that is a collaborative partnership between the patient and their personal physician.Blue Cross Blue Shield of Michigan’s patient-centered medical home program is transforming primary care across Michigan. The PCMH model was developed to strengthen the doctor-patient relationship and improve health care quality by helping primary care doctors and their health care teams more effectively manage their patients’ care.

To accomplish this goal, PCMH practices use such features as e-prescribing, chronic disease management, 24-hour access to a clinical decision-maker and patient registries to track and monitor care. Health care teams also work closely with patients to help them set individualized health goals and encourage them to take a more active role in their own health management.

In July 2012, Blue Cross Blue Shield of Michigan designated 994 primary care practices — representing 3,017 primary care doctors across the state — as PCMH practices.

What is the PCMH?

The PCMH is a model of healthcare based on an ongoing, personal relationship between a patient, doctor and the patient’s care team.  Whatever the medical needs – primary or secondary, preventive care, acute care, chronic care, or end-of-life care – the patient has a medical “home”; a single, trusted doctor and care team, through which continuous, comprehensive and integrated care is provided.

The PCMH model includes a personal doctor and care team that will provide medical care.  When specialty care is needed, at the patient’s request, the doctor and care team will personally manage, facilitate and coordinate the care with appropriate qualified professionals, such as hospitals, nursing homes, pharmacies and related community resources.

The PCMH model proposes to improve primary care by focusing on the patient-doctor relationship and to strengthen this dynamic through a more comprehensive approach to patient care and more active patient involvement.

What the Blues are Doing

Participating Blue Cross and Blue Shield companies are working with doctors, healthcare quality advocates, governmental entities, consumer advocate groups and employers to develop and test the PCMH model.

BCBS companies have PCMH initiatives in 40 states across the country and Washington, DC that explore effective means of provider reimbursement and integrate quality improvement, care management and patient educational tools into primary care practices.  More than 5 million members are currently benefitting from care delivered through a BCBS PCMH initiative.

BCBSA works with outside quality and research organizations to ensure the effectiveness of PCMH pilots to enhance the primary care practice infrastructure and improve clinical quality, outcomes, affordability, and physician and patient satisfaction. Additionally, BCBSA serves as conduit for patient advocacy groups, employers, business coalitions, physician professional societies, government officials and other interested stakeholders wanting to partner with BCBS companies to further the PCMH model of care.

Patient satisfaction, delivered in accordance with an agreed care plan, is the hallmark of the PCMH.  Patients who receive care through the PCMH model will benefit from the following:

• Access to doctors that utilize improved technologies to stay better connected with the medical community and manage care more efficiently.
• Improved access to care through easier scheduling of appointments and extended office hours.
• More focused, personal interaction with doctors and care teams that will help navigate through the complex healthcare system.
• A more comprehensive delivery of primary care through the improved coordination of care, managed by the patient’s personal doctor and their care team.

To find a physician with the PCMH designation, go to www.bcbsm.com and do the following:

• Click on “Advanced Search”.
• Select how many miles you are willing to drive to receive care and enter your zip code.
• Select “MPSERS” as your health plan
• Select “MPSERS Blue Preferred (PPO)” if you are non-Medicare or “MPSERS Medicare Plus Blue” if you are Medicare.
• Enter the 3-letter prefix from your Blue Cross card if it is different than what is listed on the screen.
• Select “Doctor, specialist, and medical professional” in the Step 3 box for “What are you looking for?”
• Select “Patient-Centered Medical Home” in the Step 4 box and click on “Go”.
• This will generate a list of providers in your area.
  • If there are no providers in your area, you may need to expand the number of miles you are willing to travel.

Click here to view the screenshots of this written procedure.

The Senate Government Operations Committee just now voted to move three bills to the Senate floor related to Medicaid expansion in Michigan.  The Senate Healthy Michigan workgroup developed a substitute for HB 4714 that builds upon the Medicaid expansion and reforms developed by the House, and passed the bill on a 4-0 vote.  The version of HB 4714 passed by the committee today is supported by Governor Snyder and Senate Majority Leader Randy Richardville.
 
Additionally, on 3-2 party-line votes, the Committee passed Senate Bill 422, sponsored by Senator Bruce Caswell (R-Hillsdale), and Senate Bills459 and 460, sponsored by Senator Patrick Colbeck (R-Canton Twp.). Senate Bill 322 would provide for state health care coverage to individuals under 100% of the Federal Poverty Level who do not otherwise currenty qualify for health insurance under existing programs, while Senate Bills 459-460 seek to create a free market, high deductible, private sector alternative to the Medicaid expansion.
 
The Senate will consider all three bills when it returns to session on August 27. 

Please click here to view the comparison summary between the Master Health Care Plan vs. HMOs offered by MPSERS.

Please click here for the 2012 insurance rates for MPSERS health insurance.

Blue Cross Blue Shield of Michigan/Catalyst Rx 2012 Updates

There are several changes to the Blue Cross Blue Shield Master Health Care Plan effective January 1, 2012. Here is a summary of those changes:

Completing the Living Well Assessment will save $100 on both the coinsurance maximum and deductible. The Living Well Assessment was mailed on October 14thto non-Medicare members and will be mailed the week of October 31st for Medicare members.

New Health Care Coverage Cards
Members will be receiving two cards for 2012 – one from Blue Cross Blue Shield for your Medicare Advantage Plus Blue Group PPO and one from Catalyst Rx for your prescription benefit. You will receive the new cards before January 1, 2012.

Prescription Drug Updates for 2012
Michigan Public School Employees Retirement System and Catalyst Rx, your pharmacy benefit manager, will be updating member coverage for the 2012 plan year for three drug classes: Proton Pump Inhibitors (PPIs), Non Sedating Antihistimines (NSAs), and Erectile Dysfunction (ED) drugs. Effective 1/1/12, these medications will no longer be covered through your prescription drug plan. However, Medicare will continue to offer coverage on some PPIs and NSAs for Medicare members. You should check the formulary for 2012 if you have questions about whether or not a PPI or NSA drug you are currently taking will continue to be covered in 2012. This formulary will be coming in the mail in the next few weeks for Medicare members.

PPIs are drugs used to treat conditions like Gastroesophogeal Reflux disease (GERD), heartburn, and ulcers. NSAs are drugs that treat seasonal allergies. Over the past several years, most of the drugs previously available only by prescription are now readily available over the counter (OTC), in both their brand and generic forms.

Lifestyle drugs are not covered under your plan. In 2012, this will include ED medications. ED medications, which are currently only available by prescription, will be available to MPSERS members at a 100% cost share of Catalyst Rx’s negotiated discounted price. For members who wish to obtain these drugs, present your prescription and prescription drug ID card to obtain this discount.

Medicare Prescription Drug Plan in 2012
Medicare-eligible members will be returning to a Medicare Part D Prescription Drug Plan (PDP) plan in 2012. You will not need to do anything to be a part of the 2012 PDP, your enrollment will be handled by the Retirement System. Many of you will remember the PDP from as recently as 2009 and know that it works very much like the plan today. Information about the 2012 PDP will be sent out to the Medicare membership in early November, so please be on the lookout!

Many members have questions regarding Part D Vaccine Coverage.Except for vaccines covered under Part B, Medicare drug plans must cover all commercially-available vaccines (like the shingles vaccine) when medically necessary to prevent illness.

Spectrum Health
Spectrum Health recently sent a letter out to all MPSERS members regarding which Medicare Advantage plans they will accept in 2012. In addition to those listed, Spectrum will also accept the MPSERS Medicare Advantage Plus Blue Group PPO in 2012. If you have additional questions, please contact Spectrum’s Patient Relations Department at 616-391-2624.

Please click here to view the schedule of upcoming regional seminars hosted by Blue Cross Blue Shield and Catalyst Rx.

Here is an update MARSP received from Blue Cross/Blue Shield regarding some issues that many of you are having with the VOC form:

UPDATE
Verification of Coverage Form
Due to BCBSM on July 29th

Several members have reported receiving a phone confirmation that they have returned their VOC form when they haven’t sent it back or called/went online to complete it. The situation is that some members received calls due to the computer system picking up the 2010 file, when it should have been the 2011 response file. Members received the call in error and must respond for 2011.

Medicare-eligible members have called to say that Blue Cross Customer Service stated that not everyone would receive the VOC form so not to worry about it. The VOC forms were sent to the contract holder, not each member on the contract. A member on the spouse’s contract will not receive the form. The subscriber must respond for him/herself and the spouse or other dependents that may be on the contract.

Original article published June 21, 2011:
Starting May 31, 2011, BCBSM began mailing the 2011 Verification of Coverage (VOC) form. The deadline to complete and return the form for you and your dependents is July 29, 2011. If you have not received your VOC form by June 15th, contact BCBSM to obtain the form for completion. You can also complete the form over the phone by calling 1-888-231-0382 or online at www.MPSERS.coverageupdatecenter.com.

Dear MARSP member:

We have a little more specific information for members on the MPSERS insurance coverage through Blue Cross Blue Shield of Michigan. Most of this has been stated in the past, but we continue to receive questions about these issues.

1)     HAVE NOT RECEIVED 2011 INSURANCE CARD

If you have not yet received your new MPSERS/BCBSM Medicare Advantage (MA)Medicare PLUS Blue Group PPO card, call BCBSM at 1-800-422-9146.

2)     REIMBURSEMENT LEVEL

The MPSERS MA Medicare PLUS Blue Group PPO reimburses all providers at the “Original Medicare-approved” rates, and includes the MPSERS portion in the same check. The member is still responsible ONLY for the deductible and coinsurance.

3)     SPECTRUM HEALTH

We just learned this morning that “technically MPSERS is the only group of the Medicare Advantage PPO with which Spectrum Health participates,”but it apparently has not reached all of the providers in that system yet. One of our members spent all day yesterday with all of his providers asking why not; in the end that was what he was told. THEREFORE, when members call to ask if providers participate, they should stipulate that this is the MPSERS MA PPO plan. Our member will be able to have his scheduled surgery without issue.

Asking for clarification from BCBSM, this is the response I received: “Spectrum has indicated that they will accept and bill for the MAPPO product from BCBSM, they were not specific that it only applies to MPSERS. I agree that members should indicate that this is a MPSERS group product.”

4)     NON-PARTICIPATING PROVIDERS

If a provider participates with Original Medicare anywhere in the 50 United States but not BCBSM, MPSERS retirees can use that provider and hopefully they will send the bill to BCBSM for the member. BCBSM will reimburse them according to the Original Medicare-approved rates, regardless whether they participate in the MPSERS MA PPO or not.

Are there providers who do not participate with Original Medicare? We are toldthat to the best of our knowledge, Mayo Clinic Jacksonville and Scottsdale never have and never will participate with ANY insurance.

Can our members use those providers? Yes, if the provider will see them.

5)     IF NON-PAR PROVIDERS WILL NOT SUBMIT THE BILL TO BCBSM

The members can get an itemized bill from the provider and submit it themselves to BCBSM. BCBSM will then reimburse the provider directly at the Original Medicare-approved rates plus the MPSERS portion. The members are responsible only for the deductible and coinsurance and the clinics cannot “balance bill.” A response to the balance bill question came from BCBSM that “it is against the law to balance bill under the MA PPO plan.”

This is true as well for any other providers who may not accept Original Medicare. We received a call yesterday that a member’s appointment was canceled at the Jacksonville Mayo Clinic when they learned that he has the MPSERS/BCBSM MA PPO. So, if they won’t see them, it appears that they will need to find a new provider.

6)     OPT-OUT

The other option would be to opt-out, but remind members that if they opt-outthey will be 100% responsible for all Medicare premiums, deductible, copays and other expenses. There will be no MPSERS supplemental (subsidy) if they opt-out of the MPSERS MA PPO. If someone opted-out it included medical and prescription if s/he used the Catalyst Rx prescription plan. If s/he discovers it was a mistake, there is a 6-month waiting period to get back into the MPSERS plan.

7)     REQUIRES PAYMENT UP FRONT

If a non-par provider will see the member but requires payment up front, it is up to the member if s/he continues to see this provider. The member can ask for and send an itemized statement to BCBSM for reimbursement, but it must state that the bill was paid and how it was paid – cash, credit card, etc. – and the full amount paid in U.S. Dollars, of course. The caution here would be to be sure that the amount paid is not more than the Original Medicare-approved amount – not sure how the member would know that.

8)     HEARING AID BENEFIT

Several callers/writers stated, “I didn’t know that MPSERS included a hearing benefit; send me the information.” The explanation of the benefit is on pages 59-61 of the MPSERS 2001 benefit booklet on the www.bcbsm.com/mpsers website. It has been a benefit since 1992.

9)     VERFICATION OF COVERAGE

About 2,700 MPSERS retirees did not return the annually required Verification of Coverage form in 2010 – therefore, their MPSERS medical and prescription coverage was canceled. Be sure to be watching for that form in your mailbox this spring or summer; MPSERS has not set a 2011 due date yet. Watch the MARSP VANGUARD and website for information as soon as we have it, www.marsp.org.

PLEASE be sure to let us know if you have any other questions or concerns. All of the MARSP staff is as up-to-date as possible on these issues and can usually help. Thank you for your support of MARSP. Enjoy a healthy and happy 2011.