***Educational Post – Self-funded, Consumer-driven*** The State Health Benefit Plan (SHBP) is a “self-funded, consumer-driven” medical plan. While this is a long post, everyone needs to understand this and how it impacts all of us as we gear up for the upcoming legislative session! SELF-FUNDED Our SHBP is not a typical insurance plan as we, not the insurance companies, are the funding source for our medical bills; hence the name “self-funded.” As a state employee, we all pay a premium for our healthcare. This money is placed in a special fund set aside by the state government. Most teachers and state employees also receive contributions from their districts or their agencies as part of their compensation package. We had the choice this year of three insurance carriers as follows: Blue Cross/Blue Shield of Georgia (BCBSGA) United Health Care (UHC) Kaiser Permanente (KP) within the Metro-Atlanta area only. The policy of our State Health Benefit Plan (SHBP) is written and governed by the Department of Community Health (DCH). It is NOT written by the insurance carrier you selected. The DCH contracts with each carrier to manage our plan. The carrier does not set what is or is not covered, and coverage for each carrier is set according to the mandates of the DCH. Each carrier also supplies the list of providers with whom they already have medical reimbursement contracts. The SHBP pays the price negotiated between the carrier and the providers according to each carrier’s contract. This is why, even though the Department of Insurance has no jurisdiction over the SHBP, decisions about provider reimbursements do affect the SHBP. For example, any medical services provided by Grady Memorial Hospital will be now charged as out-of-network by BCBS. CONSUMER-DRIVEN For our SHBP, this definition is slightly different from most. It basically means you are responsible for making sure everything is in network. You, as the consumer of healthcare, are responsible for shopping around to find the best deal for your healthcare needs. You have to ask if any procedure or lab work is covered under your co-pay or if the procedure or lab work is in network. This also applies to all personnel that you come in contact with for procedures or lab work. This can be a problem if you ensure your doctor and hospital are in-network and they bring in an out-of-network assistant while you are in surgery. The DCH used to protect the member when this happened and paid the bills for the assistant as in-network. Around 2011, however, they changed their policy and will now no longer pay those out-of-network assistants bills. This is the source of the dispute between UHC and the DCH. The DCH changed these policies and then retroactively audited UHC and withheld millions in payments. The DCH is currently stonewalling attempts by The Atlanta Journal-Constitution (AJC) to obtain records through an Open Records request in regards to this matter. Each carrier has different contracts for different facilities, so if you need services such as an MRI, CT Scan, or minor surgery, it would be highly recommended to shop around for medical services. Our members have found extreme price differences between medical services. The Health Reimbursement Account (HRA) plans are set up with the idea that each member will compare medical services and find the best rates. Unfortunately, it is hard to shop for rates when you are in need of medical care! It used to be the insurance carriers job to provide the best rates for their members, but they are now shifting this burden to us, the insured. MEDICAL PLAN As stated above, the SHBP is not an insurance plan and we are not placed in an insurance pool of insured patients where the insurance company is taking a risk of whether or not you will need costly medical attention. The risk in the SHBP is assumed by the state and surplus funds can also be used by the state (as they were in 2008-2009). The for-profit insurance companies are contracted to manage the plan, and since the state assumes the risk with our SHBP, the insurance companies will make a profit. There is much about the DCH that concerns TRAGIC. We question whether a consumer-driven policy is a right choice for state employees, as many work long hours that do not allow for personal phone calls during times when medical offices are open. We question how the DCH determines which services are covered and what avenues are available for members to challenge decisions made about our coverage. We constantly question the DCH about the lack of transparency about our SHBP. Most of all, we question how our rates are set and how the state sees our policy as affordable for state employees. When a powerful organization such as The Atlanta Journal and Constitution cannot even get the DCH to turn over documents through Open Records requests, what will it take for teachers, state employees, and retirees to find answers to our questions? What will it take to refocus the DCH to providing the services for the citizens it is charged with serving?
Posted on: Wed, 10 Dec 2014 11:45:49 +0000
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