Improving the Medicare Market Adding Choice and Protections (1996) / Chapter Skim
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L What Should Be the Basic Ground Rules for Plans Being Able to Participate in the Medicare Managed Care Market? Case Study: The California Public Employees' Retirement System
L What Should Be the Basic Ground Rules for Plans Being Able to Participate in the Medicare Managed Care Market? Case Study: The California Public Employees' Retirement System
Pages 338-352
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From page 338... ...
Elkin* INTRODUCTION As an increasing number of Medicare-eligible individuals enroll in managed care health plans, there is a growing concern about how health plans will be held accountable for providing Medicare patients with affordable, quality care.
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From page 339... ...
Many clinicians, purchasers, and consumers have expressed concern that the economic and utilization incentives of capitated, managed care plans may result in the underutilization of care and the erosion of customer service. To ensure the success of managed care as a viable health delivery system for the future, the needs of the members of health plans must be balanced with the need to reduce the cost and make more efficient use of our health resources.
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From page 340... ...
The primary goal of the CalPERS Health Benefits Program is to provide access to quality health care for its members. To achieve this goal the CalPERS Board of Administration has put into place various requirements to hold health plans accountable to the terms and conditions of their contracts.
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From page 341... ...
More than 75 percent of the participating employers employ less than 100 workers. In recent years there has been a dramatic increase in the number of public employers joining the CalPERS Health Benefits Program because of the success in cost containment and improvements in service and quality standards (California Public Employees' Retirement System, 1994, pp.
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From page 342... ...
These requirements fall into five major categories: statutory and regulatory compliance, provider access, quality and cost data, uniform benefit design, and customer service. These major categories encompass contractual requirements, conditions of participation, monitoring systems, and internal procedures and policies that enable the staff to monitor the performance of the health plans and hold them accountable.
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From page 343... ...
In reviewing a proposal from a new plan or a proposed expansion of an existing plan into a new geographic area in California, CalPERS staff perform a careful analysis of provider access. Even though DOC examines network coverage as part of its licensure review, CalPERS staff verify the actual network coverage in detail to determine whether adequate primary care physicians, clinics, specialists, and hospitals are available to serve the enrollees.
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From page 344... ...
Many members switched to other HMOs. To minimize disruption to members who have selected a particular HMO and primary care physician, CalPERS requires health plans to inform members at least 60 days prior to any contract termination with a medical group and encourages health plans to minimize these contractual disputes during the contract year.
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From page 345... ...
Standardizing the Medicare Supplemental and Managed Risk Plan benefits simplified the health plan selection process and assured Medicare-eligible CalPERS members that they would receive affordable, comprehensive services, regardless of the plan that they selected. The CalPERS Board believes that requiring HMOs to follow a standard benefit design has improved CalPERS' ability to hold its plans accountable, negotiate lower premiums, and simplify the plan selection process for its members (California Public Employees' Retirement System, 1995a, p.
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From page 346... ...
In order to become a more informed purchaser and to hold health plans more accountable for the $1.5 billion annual premiums paid for care, CalPERS requires HMOs to provide basic cost and performance information on an annual basis. Initially, HMOs were required to submit data on cost, rating methodology, and basic performance in an attempt to compare the cost of care provided by the health plans.
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From page 347... ...
In 1994 CalPERS notified its health plans that it intended to provide its members with a Quality of Care Report Card in the spring of 1995 to assist them in making more informed choices. This marked the beginning of a major effort to independently collect and publish information by using 11 Health Plan Employer Data and Information Set (HEDIS, version 2.0)
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From page 348... ...
The combination of the standard benefit design and the report card have greatly enhanced the consumer's ability to make an informed decision when choosing a health plan. They have also been instrumental in helping CalPERS reduce the cost of care and enable members to continue to receive comprehensive services at affordable prices.
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From page 349... ...
In past years some health plans were less than accurate when portraying themselves to CalPERS members during open enrollment. In response to these problems, CalPERS now requires its HMOs to submit their advertising text to CalPERS staff for review and approval.
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From page 350... ...
A major strength of the CalPERS Health Benefits Program is that members can appeal directly to the Board for review of their complaints once they have exhausted their appeal rights with their health plan. Members are informed of this option annually during the open enrollment period and are given the address and telephone number of the Member Service Unit, which is staffed by CalPERS Health Benefits Program employees.
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From page 351... ...
The Health Plan Guide that is mailed to every member's home is prepared by CalPERS staff and clearly describes the process for making plan changes and enrollment changes as well the benefits, copayment charges, and deductibles for both HMO and PPO plans. Written text prepared by the health plans is reviewed and edited before it is inserted into the booklets so it complies with the Board's policy regarding the content of written material distributed to CalPERS members.
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From page 352... ...
1995a. Health Plan Guide: Combined Information On: Basic, Supplement to Medicare and Managed Medicare Health Plans.
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