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HomeMy WebLinkAboutVI (D) Discussion/ Action re: Change from HMO to PPC Care Manager Policy AGENDA 2-0'1-97 Item VI D "CENTER OF GOOD LIVING- PRIDE OF WEST ORANGE" Ocoee )--a COMNISSIONLRS� �' RIISTYJOIINSON ►� CITY OF �COEEscorn ANDERSON v O150 N_LAKESHORE DRIVESCO'1'T A.GLASS 1�, OCOEE,FLORIDA 34761-2258 ]IMGLEASON 'Y�, (40�65G2322 ci6MANm i, �� �f G00� ELLIS SHAPIRO MEMORANDUM TO: THE HONORABLE MAYOR AND MEMBERS OF THE COMMISSION FR: PEGGY PSALEDAKIS, RISK MANAGEMENT DA: JANUARY 30, 1997 SU: CHANGE FROM HMO TO PPC CARE MANAGER POLICY First , let me thank you all for your patience during this negotiating process . BACKGROUND Our Health Insurance Carrier Blue Cross and Blue Shield HMO policy did not recognize Health Central as a service provider. Our commitment to each of you during the budgetary process of September, 1996 was to find a way to allow our City employee HMO participants to be able to utilize the services of Health Central . Each of the elected officials felt very strongly that Health Central be a part of any HMO contract we negotiate on behalf of our employees . PROCESS After many months of meetings and discussions we are able to provide the PPC Care Manager Policy to our HMO employee participants . The cost is the same as it is now, the benefits are the same however, the employees will receive an additional benefit unique to the PPC Care Manager Policy. These employees will also have the additional option of going out of the network. Under an HMO policy this is never allowed. It is always understood that going out of any network would result in additional costs . The example of this would be, the employee would be responsible for 30% of all charges . The $10 . 00 co-pay provision would not apply. ^/ ( 4 a. PAGE TWO CONCLUSION Once again, thank you for your patience through this long process . At this time we respectfully request that you approve the change from our Blue Cross and Blue Shield HMO plan to Blue Cross and Blue Shield PPC Care Manager Policy. Respectfully Submitted, Peggy Psaledakis Risk Management • WELCOME TO PPC CARE MANAGER 62,c) The Preferred Patient Caresn� Manager (PPCplan Care Care Manager) is the newest member of our Point of Service family of managed care plans. PPC Care Manager is designed to Blue Cross provide your enrolled employees and dependents with personalized comprehensive health Blue Shield care from the state's largest network of health care providers. With this plan,primary care ""ed"' physicians called Care Managers provide or coordinate care,helping to ensure consistency and continuity of medical care. Care Managers emphasize preventive care and promote early detection and treatment of diseases. Members are able to discuss all their medical needs with their Care Manager and have someone to call who knows their medical history. When care from a specialist is needed,the Care Manager will refer the member to a PPC specialist and coordinate inpatient or outpatient hospitalization. Why Did Blue Cross and Blue Shield of Florida Develop PPC Care Manager? • Point of Service plans are the fastest growing type of health care coverage in the United States. Over 300,000 members are already enrolled in POS in Florida. • In the late 1980s and 1990s employers observed: large annual premium increases in PPO and traditional plans; - relatively low increases in HMO plans. • While employers concluded they needed Primary Care Physician based health care plans,employees have shown varying levels of acceptance of regular HMO plans: some employees are already enrolled in HMOs and are happy with them; others may have misconceptions and a lack of confidence with the limitations of an HMO. They may accept an opt out POS plan "just in case"; some employees will never want an HMO. • Some employers want to maintain consistency with existing plans while moving toward the cost containment of a Primary Care Physician based plan. • Other employers wish to achieve greater cost containment through early intervention through preventive services. • Primary Care Physician based Point of Service plans enable a transition toward higher levels of health plan cost control while preserving flexibility in benefits and providers. Who Are Care Managers? Care Managers are primary care physicians who have successfully satisfied standards established and reviewed by BCBSF and are generally board eligible or board certified. These physicians practice Family Medicine, Internal Medicine, General Medicine and Pediatrics. Each member must select a Care Manager but is not required to use a Care Manager. However,by using a Care Manager the member receives the higher level of benefits. Your employee and their covered dependents may choose his/her own Care Manager and may • change Care Managers at any time by calling the customer service number. PPC Care Manager Plan Design How Is The Plan Designed? • The plan is designed to provide the member with choices while still providing benefits for covered services. In most cases,the level of benefits received will be based on services being authorized vs. non-authorized as described below. ��Q q+ • Authorized services are provided when the Care Manager is used and PPC Care Manager guidelines are followed. Members will have a small copayment or Blue Cross coinsurance,no claims to file,and no balance billing for covered physician services. Blue Shield The deductible will apply to certain services as specified in this Plan Design section. of Florida • Non-Authorized services occur when the member chooses to see a provider on his or her own, without a referral from the Care Manager. These services are paid at the lower benefit level and the member is responsible for meeting any deductible or coinsurance requirements as specified in this Plan Design section. For certain services such as chiropractic,podiatry,mental and nervous disorders, alcohol and drug dependency, hospice,home health care, skilled nursing facility and certain therapies,the level of benefits the member receives is based on the provide's participation in the PPC network. In these cases,a Care Manager is not used. What is Blue Cross and Blue Shield of Florida's Experience in PPC Care Manager? • PPC Care Manager is the newest addition to Blue Cross and Blue Shield of Florida's family of Care Manager products. PPC Care Manager has been offered on a limited basis since January 1995. Currently, Publix Super Markets and Eckerd Drugs are enrolled in this plan. • HOI Care Manager. another member of the Care Manager family was first offered to employers in Florida in 1992. • PPC Care Manager Plan Design SUMMARY OF BENEFITS FOR CITY OF OCOEE - Based on • Plan Cl BENEFIT DESCRIPTION an p�Q Lifetime Maximum Benefit,Per Person $1,000,000 ® ` Calendar Year Deductible (CYD) Blue Cross • Individual $200 Blue Shield • FamilyAggregate $600 amnm The services listed below require authorization from a PPC Care Manager to be covered at the higher level. The calendar year deductible does not apply to services with a Copay or where indicated. Authorized Non-Authorized Hospital Per Admission Deductible $0 $500 Coinsurance Requirement Limit • Individual S1,000 $3,000 • Family Aggregate S3,000 $9,000 Physician Office Services • Routine Services SI0 Copay per visit 70% of Allowance • Preventive Care . • Specialty Care $10 Copay per visit Not Covered • Maternity Care $10 Copay per visit 70% of Allowance - First Office Visit • S I0 Copay per visit 70% of Allowance Total Maternity Care No Copayment 70% of Allowance • Well Child Care(deductible waived) S10 Copay per visit 70% of Allowance • Annual Gynecological Exam by a $I Copay per visit Not Covered PPC OB/GYN Physician up to$I i0 Per Calendar Year(does not require authorization by Care Manager) • Allergy or Immunization (without S1O Copay per visit 70% of Allowance office visit) Hospital Services* • Inpatient Care - Care manager 100% Not Applicable - Facility 100% of Allowance 70% of Allowance All Other Providers 100% of Allowance 70% of Allowance • Outpatient Hospital/Surgical Care - Care Manager 100% Not Applicable - Facility 100% of Allowance 70% of Allowance All Other Providers 100% of Allowance 70% of Allowance • Emergency Room Care Care Manager 100% Not Applicable - Facility 100% of Allowance 70% of Allowance All Other Providers 100% of Allowance 70% of Allowance • Non-Routine X-rays (inpatient 100% of Allowance 70% of Allowance or outpatient) • *The calendar year deductible will he waived for all authorized in-network services. =% PPC Care Manager Plan Design CI The services listed below do not require authorization from a PPC Care Manager: • BENEFIT DESCRIPTION Hospice Care 90% ofAllowance,subject to a anpv $5 200 lifetime maximum benefit Home Health Care 90% ofAllowance, subject to a Blue Cross $1,000 calendar year maximum benefit Blue Shield Skilled Nursing Care 90% of Allowance,limited to a nonce 120 days per calendar year Other Healthcare Providers (Ambulance, DME suppliers, prosthetic 90% of Allowance and onhotic suppliers) PPC Providers Non-PPC Providers Routine X-Rays,Routine and Non- 90% ofAllowance, no 70% of Allowance Routine Lab Services deductible (Performed in location other than the physician's office) Alcohol and Drug Dependency 90% of Allowance 70% of Allowance ( Subject to a lifetime maximum benefit of $2,000 per person for inpatient,outpatient or any combination of services) • Mental and Nervous Conditions 90% of Allowance 70% of Allowance (Subject to a limit of 31 inpatient days and $1,000 outpatient benefits per calendar year) Chiropractic Office Services 90% of Allowance 70% of Allowance Podiatric Office Services 90% of Allowance 70% of Allowance DEPENDENT CHILDREN: • Covered through the end of the calendar year in which age 19 is attained;or through the end of the calendar year in which age 25 is attained, if I)dependent upon the covered employee for support and living in the covered employee's household,or 2) dependent upon the covered employee for support and a full-time or pan-time student. PRE-EXISTING CONDITIONS: • There is a 12 month waiting period for pre-existing conditions for members not covered under the prior carrier plan. IMPORTANT • To receive maximum benefits,health care services must be provided or authorized by your PPC Care Manager. • This is a Summary of Benefits and not a contract. All benefits are subject to the provisions,exclusions and limitations set forth in the master contract. • int PPC Care Manager Plan Design CI • BLUESCRIPT PHARMACY PROGRAM Your employees may also take advantage of our BlueScript Pharmacy Program with over �p�an ® 2,400 participating pharmacies all over Florida, including major pharmacies like Eckerds • and Walgreens. These pharmacies agree to: Blue Cross • File claims for the member; Blue Shield ofb°° • Accept payment directly from Blue Cross and Blue Shield of Florida for covered prescriptions; and • Collect only the appropriate copay from the member at the time the prescription is purchased. Benefits are as follows: • Copay Amount Per Prescription Generic $5 Name Brand $10 • Participating Pharmacy 100% of the Allowance • Non-Participating Pharmacy 80% of the Allowance • Oral contraceptives are included. • The following are limitations which are placed on prescription drugs: • a maximum of 31 day supply for each covered drug. (A 31 day supply is the prescribed daily dosage times 31 days); authorized refills will be covered only up to one year from the original prescription date; disposable syringes when prescribed with a supply of insulin, limited to a 31 day supply, per prescription;and Imitrex-a monthly supply of two packages (2 doses each) or fraction thereof; and anaphylactic kits - one kit. • :% PPC Care Manager Plan Design with BlueScript • Utilization Management Programs Utilization Management is a key component in the authorization,coordination and monitoring of members' medical care under the plan. � ��Q® • Referral Authorization/Admission Certification Blue Cross These programs are designed to review and record all hospital admissions,emergency Blue Shield room visits,outpatient procedures and out-of-office referrals. In conjunction with the °mama member's Care Manager,utilization management staff will direct referrals and all hospital care to cost-effective participating providers when appropriate. Additionally, the member's current eligibility status and contract benefits will be verified. Admission certification includes criteria which addresses the medical necessity of the admission in terms of the severity of the member's condition and the intensity of treatment provided to the member. • Focused Concurrent Review Program By design, Blue Cross and Blue Shield of Florida's unique DRG hospital inpatient reimbursement provides appropriate incentives for the hospital itself to conduct concurrent review and thereby lessen such direct intervention by Blue Cross and Blue Shield of Florida- However,concurrent review of an inpatient admission may be initiated by Blue Cross and Blue Shield of Florida to monitor the appropriateness of selected hospitalizations. Review of a hospital stay may occur at appropriate intervals. Blue Cross and Blue Shield of Florida will provide notification when our criteria for payment is no longer met. • For hospital days which arc not certified, the member or patient may continue with the hospital stay, however, payment will be denied for those days determined to he not medically necessary. The member or patient may also elect outpatient treatment; contract benefits for necessary outpatient care will then be provided. • Discharge Planning Discharge planning identifies the need for treatment following hospitalization. Blue Cross and Blue Shield of Florida uses established criteria to identify potential need for services or supplies following discharge from the hospital. A treatment plan is determined from the onset of care. The discharge planner maintains contact with the treating physician as often as needed. Blue Cross and Blue Shield of Florida also assists by identifying alternative services within the community which provide home health care services or supplies. This assures that care required upon discharge is arranged in a timely,cost-effective manner and and services will continue after release from the facility. • Case Management Program This program is an additional service provided for members who have a catastrophic or chronic condition. Our goal is to assure that potentially high-cost patients are placed in the most cost-effective setting without compromising quality of care. Our Individual Benefits Coordinators (Case Managers)are located throughout the • state. They are experienced registered nurses who routinely review- hospital admissions to identify those cases which may benefit from an alternative setting. �•� PPC Care Manager Plan Designs When the patient's case has been identified for consideration,a Benefits Coordinator will visit with the patient and,when appropriate, with his or her family,the attending • physician,and other health care professionals involved in the patient's care. Blue Cross and Blue Shield of Florida assists by discussing with the physician the patient n prescribed treatment and choices for alternative settings. However,the patient and Qa�Q physician together decide the appropriate seeing. • Following a medical assessment of these patients and a determination of their benefit Blue Cross eligibility,a proposed treatment plan, including alternatives to inpatient acute care, is Blue Shield developed. d Ronda This treatment plan is reviewed by the patient,the patient's family,and the attending physician for approval. Blue Cross and Blue Shield of Florida's Case Management professionals then coordinate the implementation and monitoring of the treatment plan. Management Reports Blue Cross and Blue Shield of Florida will provide the following reports: • Periodic Utilization Reports • Annual Account Specific Report • • :% PPC Care Manager Plan Designs PP()Plan Design • CHOICES ARE THE KEY TO POINT OF SERVICE PPO (roc) a s BlueCross Shield Blue Cross and Blue Shield of Florida's Point of Service PPO Plan is a unique combination te. of traditional indemnity insurance and PPO coverage. It offers traditional deductible and coinsurance based benefits with incentives to use the Preferred Patient Cares"' (PPC) network. Point of Service PPO was developed in response to employers' requests for a plan that would combine the managed care features of a PPO with the flexibility to go out of the network and still receive benefits. Many employers want to offer their employees: • A PPO plan with the option of knowing you can go outside the PPO network if you choose; and • An excellent product design as an introduction to managed care. With Blue Cross and Blue Shield of Florida's Point of Service PPO Plan.you get the added value of our Traditional provider programs. If your employees use the PPC network,they receive a higher level of benefits. They can elect to go outside the PPC network and still receive benefits,but at a reduced level. In either case,they may take advantage of our agreements with PPC and Traditional providers to: • Accept prenegotiated allowances; • • File all claims directly with Blue Cross and Blue Shield of Florida; and • Not balance bill for the difference in the prenegotiated allowance and the provider's charge. The provider will bill only for any deductibles,coinsurance and non-covered services. Your employees may also take advantage of our BlueScript Pharmacy Program with over 2,400 participating pharmacies all over Florida, including major pharmacies like Eckerds and Walgreens. These pharmacies agree to: • File claims for the member; • Accept payment directly from Blue Cross and Blue Shield of Florida for covered prescriptions;and • Collect only the appropriate copay from the member at the time the prescription is purchased. • PPO Plan Design With BlueScript SUMMARY OF BENEFITS FOR THE CITY OF OCOEE - Based • on Plan 20 with BlueScript RX __ LIFETIME MAXIMUM BENEFIT PER MEMBER: $1,000,000 Op�m + ® HOSPITAL INPATIENT DAYS PER CALENDAR YEAR: Unlimited BlueDEDUCTIBLE AMOUNTS PER CALENDAR YEAR: Cross Blue Shield • Individual Maximum $200 a gam • Family Aggregate Maximum $600 PER ADMISSION DEDUCTIBLE AMOUNT: (Non-PPC Hospitals Only) $100 COINSURANCE PERCENTAGE PAYABLE FOR: • Preferred Patient Care (PPC) Providers 90% of PPC Schedule • MI Other Providers 80% of Allowance MAXIMUM OUT-OF-POCKET COINSURANCE EXPENSE AMOUNT PER CALENDAR YEAR: • Individual Maximum *$1,000 • Aggregate Family Maximum *$3,000 • Maximum out-of-pocket coinsurance expenses do not include the calendar year deductible amount, the per admission deductible amount,any benefit penalty reduction, non-covered charges or any charges in excess of the allowance. • UTILIZATION MANAGEMENT PROGRAMS: • Admission Certification - PPC Providers: Admission certification is required for all admissions. Penalty for non-certified admissions is the responsibility of the PPC provider. - Non-PPC Providers: Admission certification is required for all admissions. The penalty for non-certified admissions is a 25% reduction in the maximum plan allowance for the admission and is the responsibility of the member. • Second Surgical Opinion - PPC Physicians: Not required - Non-PPC Physicians: Required. Benefits for certain surgical procedures will be reduced by 25%of the surgeon's allowance,if a confirming opinion is not obtained. • Individual Case Management Individual Case Management is available as described in the Utilization Management Programs portion of this Plan Design section. • PPO Plan Design With BlueScript ACCIDENT CARE- ALL PROVIDERS: • 100% of the allowance up to a maximum of$500 within 90 days of the accident.• Covered services in excess of the $500,whether rendered during or after the 90 days, are subject to the calendar year deductible and paid at the coinsurance percentage. w 5 Note: The per admission deductible will apply to accident related admissions to non- %CI PPC hospitals. Blue Cross ADULT ROUTINE EXAMS- PPC PROVIDERS ONLY: Blue Shield • 100%of PPC Schedule,Not Subject to the Calendar Year Deductible, Not to Exceed ol Florida $200 Per Calendar Year SKILLED NURSING FACILITY - BENEFIT MAXIMUM PER CALENDAR YEAR: • 80% of Allowance, Not to Exceed 60 Days Per Calendar Year HOME HEALTH CARE- BENEFIT MAXIMUM PER CALENDAR YEAR: • 80% of Allowance, Not to Exceed $1,000 Per Calendar Year HOSPICE CARE- BENEFIT MAXIMUM PER LIFETIME: • 80% of Allowance, Not to Exceed $5,200 Per Lifetime MENTAL AND NERVOUS DISORDERS - BENEFIT MAXIMUMS: • Inpatient Care: Paid subject to the deductible and coinsurance not to exceed 31 inpatient days and 31 inpatient visits per calendar year. • Outpatient Care: Paid subject to the deductible and coinsurance not to exceed $1,000 per person per calendar year.• Hospitalization or Combination of Inpatient and Partial Hospitalization: Paid subject to the deductible and coinsurance not to exceed the cost of 31 inpatient psychiatric hospitalization days/visits per calendar year, including physician fees. ALCOHOL ANI) DRUG DEPENDENCY - BENEFIT MAXIMUMS: • Lifetime Maximum Per Member $2,000 (Inpatient,outpatient,or any combination of services) • Inpatient Care: Paid subject to the deductible and coinsurance. • Outpatient Care: Paid subject to the deductible and coinsurance not to exceed an allowance of$35 per visit or a maximum of 44 lifetime visits for treatment provided by a physician or psychologist. MATERNITY BENEFITS: • Maternity benefits are provided for the covered employee or the covered employee's spouse. Maternity benefits are not provided for a dependent daughter. • PPO Plan Design With BlueScript MAMMOGRAM SCREENING SERVICES: • • Benefits are provided for mammogram screening services for female members as follows: One baseline mammogram while the member is 35 years of age or older,but p�Q younger than 40 years of age; • • - A mammogram every two years,inclusive,or more frequently,based on the Blue Cross patient's physician's recommendation while the member is age 40 or older, but Blue Shield younger than age 50; GI ram. - Age 50 and over,one mammogram every year; One or more mammograms per year,based on the patient's physician's recommendation,for women at risk for breast cancer based on personal or family history. WELL CHILD CARE: • Benefits are provided for well child care services, which arc physician-delivered or physician-supervised, for the covered dependent child of a covered family member for the following: newborn's first examination in the hospital. The examination must be provided and billed by a physician other than the delivering obstetrician or anesthesiologist; periodic examinations, which include a history,physical examination, developmental assessment and anticipated guidance necessary to monitor the • normal growth and development of a child; oral and/or intramuscular injections for the purpose of immunization; and - laboratory tests. • These services must conform with prevailing medical standards and will be limited to I8 visits during a 16 year period at approximately the following age intervals: Age Intervals birth 15 months 6 years 2 months 18 months 8 years 4 months 2 years 10 years 6 months 3 years 12 years 9 months 4 years 14 years 12 months 5 years 16 years • These benefits will not be subject to the calendar year deductible,but will be paid a1 the coinsurance percentages applicable based on the type provider used, PPC or non- PPC. These benefits will be limited to one visit per age interval and will cease on the day before the date of the dependent child's 17th binhdate. TRANSPLANT SERVICES: • Benefits are provided for medically necessary services for the following transplants: • heart,heart-lung combination,liver, kidney, cornea and bone marrow. PPO Plan Design With BlueScript BLUESCRIPT PHARMACY PROGRAM: • • Copay Amount Per Prescription Generic S5 anov - Name Brand $Ip • � Oral contraceptives are covered. Blue Cross • Participating Pharmacy 100% of the Allowance Blue Shield of Roma • Non-Participating Pharmacy 80% of the Allowance • The following are limitations which are placed on prescription drugs: a maximum of 31 day supply for each covered drug. (A 31 day supply is the prescribed daily dosage times 31 days); authorized refills will be covered only up to one year from the original prescription date; disposable syringes when prescribed with a supply of insulin, limited to a 31 day supply,per prescription;and Imitrex -a monthly supply of two packages (2 doses each)or fraction thereof; and anaphylactic kits -one kit. DEPENDENT CHILDREN: • Covered through the end of the calendar year in which age 19 is attained;or through • the end of the calendar year in which age 25 is attained, if 1)dependent upon the covered employee for support and living in the covered employee's household,or 2) dependent upon the covered employee for support and a full-time or part-time student. PRE-EXISTING CONDITIONS: • This plan does not provide benefits for the treatment of a pre-existing condition, for any member,until the member has been continuously covered under the plan for a 12 month period. A pre-existing condition is any condition which manifested itself,or of which there were symptoms which would cause a prudent person to seek diagnosis or treatment,or which was the subject of medical advice or treatment by a provider during the 6 month period immediately preceding the effective date of the member's coverage. The waiting period for pre-existing is waived for initial enrollees who were covered under the prior group plan. This is a summary of benefits and not a contract All benefits are subject to the provisions, exclusions and limitations set forth in the master contract. • C. PPO Plan Design With BlueScript Utilization Management Programs • • Admission Certification Program an The Admission Certification Program is designed to review all inpatient hospital stays, pp0 including elective, planned,emergency and maternity admissions. This program helps determine if appropriate care is being received in the most appropriate setting. The BltECrosS program is not designed to change or override medical decisions made by the BlueShield physician and the patient. The program merely determines the level of payment, if of Florida any,under the benefit plan. PPC providers are responsible for obtaining admission certification for any inpatient admission. Additionally, the member is not responsible for any reduction in benefits due to non-certification. If the member elects to go to a non-PPC provider, the member is responsible for obtaining admission certification and is responsible for any benefit reductions resulting from a non-certified admission. If the patient or the physician does not agree with the admission certification decision, an appeal can be made, in writing, within 90 days of receipt of the decision. The Utilization Management department will review the appeal to determine if the admission meets the objective criteria. If the criteria are met,the admission will be certified. If there is no additional information which would allow the admission to be certified, the initial decision will be upheld. • Focused Concurrent Review Program• By design, Blue Cross and Blue Shield of Florida's unique DRG hospital inpatient reimbursement provides appropriate incentives for the hospital itself to conduct concurrent review and thereby lessen such direct intervention by Blue Cross and Blue Shield of Florida. However,concurrent review of an inpatient admission may be initiated by Blue Cross and Blue Shield of Florida to monitor the appropriateness of selected hospitalizations. Review of a hospital stay may occur at appropriate intervals. Blue Cross and Blue Shield of Florida will provide notification when our criteria for payment is no longer met. For hospital days which are not certified,the member or patient may continue with the hospital stay,however, payment will be denied for those days determined to be not medically necessary. The member or patient may also elect outpatient treatment; contract benefits for necessary outpatient care will then be provided. • Mandatory Second Surgical Opinion (MSSO) Program Under this program,each member is required to obtain a confirming surgical opinion from a physician who is participating in this Second Surgical Opinion program when a non-PPC physician intends to perform any of the planned (i.e.,surgery that is not an emergency or urgent) surgical procedures that require a confirming opinion. There is no coinsurance or deductible responsibility for members when receiving covered consultations under this program. If a member does not obtain a confirming opinion, the benefit allowance will he reduced by 25%. This penalty is the member's responsibility and is in addition to all applicable obligations and limitations under the • PPO Plan Design With BlueScript benefit plan. The benefit reduction amount will not be applied towards the out-of- pocket maximum. • • Discharge Planning Program an y Discharge planning identifies the need for treatment following hospitalization. Blue ��Q Cross and Blue Shield of Florida uses established criteria to identify potential need for • services or supplies following discharge from the hospital. Blue CrossBlue A treatment plan is determined from the onset of care. The discharge planner of month d maintains contact with the treating physician as often as needed. Blue Cross and Blue Shield of Florida also assists by identifying alternative services within the community which provide home health care services or supplies. This assures that care required upon discharge is arranged in a timely,cost-effective manner and and services will continue after release from the facility. • Case Management Program This program is a voluntary benefit provided for members who have a catastrophic or chronic condition. Our goal is to assure that potentially high-cost patients are placed in the most cost-effective setting without compromising quality of care. Our Individual Benefits Coordinators (Case Managers) are located throughout the state. They are experienced registered nurses who routinely review hospital admissions to identify those cases which may benefit from an alternative setting. When the patient's case has been identified for consideration,a Benefits Coordinator will visit with the patient and,when appropriate,with his or her family,the attending • physician,and other health care professionals involved in the patient's care. Blue Cross and Blue Shield of Florida assists by discussing with the physician the patient's prescribed treatment and choices for alternative settings. However,the patient and physician together decide the appropriate setting. Following a medical assessment of these patients and a determination of their benefit eligibility,a proposed treatment plan, including alternatives to inpatient acute care, is developed. This treatment plan is reviewed by the patient,the patient's family,and the attending physician for approval. Blue Cross and Blue Shield of Florida's case management professionals then coordinate the implementation and monitoring of the treatment plan. • .: PPO Plan Design With BlueScript Management Reports • Blue Cross and Blue Shield of Florida will provide the following reports: an Network Utilization Reports ��� This reports the savings incurred through the use of our PPO and Traditional networks. Blue CrOSS •Blue Shield Paid Claims Report amm. This report shows claims by employee and dependent and is further broken down by hospital and doctor claims. Line items include the patient's name,date of service,date the claim was paid,amount paid and amount billed. In addition,this report includes a summary by type of service with information such as cost per case,length of stay, and a breakout between inpatient and outpatient claims. This report will be provided on an annual basis. • • PPO Plan Design With BlueScript