Exh 4DAgenda Item: D
Date: Z - / - Q
CITY OF ATLANTIC BEACH
CITY COMMISSIONER MEETING
STAFF REPORT
ITEM:
SUBMITTED BY:
DATE:
Changes to City's Health Insurance Health Maintenance
Organization (HMO)
George Foster, Human Resource Manager
February 9, 2000
BACKGROUND: We have been advised by American Heritage Life (AHL) that
effective April 1, 2000, the City's HMO will be replaced b..y a Select
Exclusive Provider Organization (EPO). Employees currently
within the AHL HMO will be automatically converted to the AHL
EPO. An EPO is very similar to an HMO, with the following
enhancements that will benefit our employees:
Benefits provided: Avery similar plan of benefits.
Physicians: All of the physicians as currently selected by City
employees are in the EPO network.
Primary Care Physician: Employees no longer required to select
a Primary Care Physician (Gatekeeper). They may go directly to
any physician, or specialist, listed in the directory of providers.
Prescriptions: The EPO plan does not contain a closed formulary
- which currently restricts the prescriptions that an employee may
obtain. The EPO also contains a greater number of participating
pharmacy as all PAID Prescription pharmacies are included..
Well Care: Still provided.
FUNDING: Funding is currently within the budget as there are no changes to
current premium rates.
REQUESTED ACTION: None. This Staff Report is for information only.
ATTACHMENT: AHL EPO Highlights and Summary and Questions & Answers
CITY MANAGER:
~/ Highlights of the AHL Select Exclusive Provider
Organization (EPO)
AHL Select EPO
• Basically, the EPO is very similar to an HMO, but with enhancements that you will find
-- : favorable.
• You will have a very similar plan of benefits to your current HMO plan (please refer to
your benefit schedule for applicable co-pays).
Basic Differences From Your Current HMO Plan:
• You are not required to choose a specific Primary Care Physician.
• You do not need a referral to a Specialist; However, you must use a Network Provider.
You may see a Network Specialist as needed without approval from a Primary Care
Physician.
• No longer do you need to choose between the two HMO Networks of Intecare and
Baptist St. Vincent's (formerly Mission Health). There will be one complete Network
and almost the entire list of Doctors from the two HMO Networks plus additional
Doctors are in the AHL Select EPO Network. You may freely go between the hospital
systems as long as the provider is in the Network. Your Network of providers has
increased.
• Those who are currently with the Baptist/St. Vincent's HMO will be under a new
prescription card program through PAID Prescriptions. You will only be receiving a new
drug card if you are with the Baptist St.Vincent's HMO. The new prescription plan is not
a closed formulary as you are currently under. You will now be able to obtain many of
the prescription drugs that were previously non-formulary without having to obtain
-- formulary exceptions. This will make obtaining your prescriptions much easier. Those
who chose Intecare are already under the PAID Prescription plan and can continue to
use their prescription card.
• With the PAID Prescription Card, you are no longer restricted to Eckerd's, Winn Dixie
and Pavilion Pharmacies to fill prescriptions. You may go to any PAID participating
pharmacy (over 98% of all pharmacies in Jacksonville are PAID Pharmacies).
• If you are out of the area, only emergencies will be covered.
You must always use a Network Provider
Be sure to always refer to your directory when seeking a~
medical care. You are ultimately responsible for making sure
that you use Network Providers.
American .Heritage Life
Exclusive Provider Organization (EPO) Network
. Questions & Answers
1. What is an EPO?
An EPO is an abbreviation for the term Exclusive Provider Organization. An Exclusive
Provider Organization provides benefits when a specific group of medical providers is
used. There are no benefits provided for the purchase of medical services and supplies
from anyone not in the group, except for Emergency Benefit Situations shown in item
#10 in this outline and for medically necessary services that are not available from an
EPO provider.
2. What providers can the employee choose from if he selects one of the AHL EPO
Networks?
AHL Select EPO
If the employee selects the AHL Select EPO, in Jacksonville he may use Baptist Medical
Center, Baptist Medical Center-Beaches, BMC-Nassau, Memorial Hospital Jacksonville,
Orange Park Medical Center, St. Vincent's Medical Center, Shands Jacksonville or
Wolfson Children's Hospital, as well as any of the physicians listed in the AHL Select
EPO physician directory.
There will be no benefits available for services and supplies received from any medical
providers not fisted in the specific directory of the network chosen by the employee,
except for Emergency Benefit situations shown in item #10 in this outline and far
services not available from an EPO provider.
~. Does the employee need to choose a Primary Care Physician, and are referrals
required?
It is not necessary for the employee to select a Primary Care Physician in the AHL
Select EPO. The employee is required, however to use one of the EPO physicians listed
in the network's directory.
He may select the Physician of his choice at the time of service. Referrals are not
re uired.
4. What if the participating medical centers and the list of physicians do not provide
a particular medical service that the employee needs?
If the employee or a covered family member has the AHL Select EPO plan and requires
the services of a medical specialty that is not represented in the selected EPO directory,
the employee or his covered dependent must contact the AHL Managed Care
Department prior to obtaining that service, and obtain their approval of the specialty
care.
Questions.8~ Answers (cont'd)
5. Do hospital admissions have to be pre-certified?
Yes. Most hospital admissions under the AHL EPO network plan require pre-admission
certification. Please refer to your benefit booklet for maternity. provisions. IT IS THE
EMPLOYEE'S RESPONSIBILITY TO MAKE SURE .THIS IS DONE PRIOR TO
ADMISSION.' IF NOT, THERE WILL BE A SUBSTANTIAL REDUCTION IN THE
- . BENEFITS OTHERWISE PAYABLE. For pre-admission certification, please telephone
the AHL Managed Care Department between -the hours of 8:OOA.M. to 5:00 P.M.
Eastern Standard Time, Monday through Friday, except holidays. Their telephone
numbers are:
In Jacksonville, FL: (904) 992-2653
Outside of Jacksonville, FL: 1-800-821-2775
6. Are there any other medical services or supplies that require pre-authorization?
Yes. Other medical services include but are not limited to Hospice Care; Skilled Nursing
Facilities; Home Health Care; Speech, Occupational and Physical Therapies; as well as
the purchase or rental of Oxygen Equipment and other Durable Medical Equipment and
all services that are not available from an EPO provider.
7. What is the procedure to schedule an annual exam with pap smear and
mammogram?
Under the EPO plan, all one has to do is simply make an appointment with any EPO
OB/GYN physician or the family care physician within the network and state that she
would like to schedule an appointment for her annual examination. This plan contains a
"wellness" benefit, after the co-payment, which covers an exam, pap smear and any
other tests or immunizations ordered by the physician. In addition to this benefit, women
are eligible to receive one routine mammogram between the ages of 35 and 39. Women
between the ages of 40 and 49 may receive one such screening every two years. After
_ age 50, the plan provides for one such screening every year.
8. Is there a wellness benefit for male enrollees?
Yes. The plan provides a wellness benefit at 100% after the co-payment. This includes
any tests or immunizations ordered by the physician.
9. How does the Prescription Drug Benefit work?
The employee will be issued a Prescription Drug Card from PAID Prescriptions that
includes a mail order program for maintenance drugs for the AHL Select EPO. Refer to
your benefit schedule for the drug card co-pays. Prescriptions must be filled at
participating pharmacies.
Questions & Answers (cont'd)
90. What are in-network~and out-of-network EPO Emergency Benefits?
Our EPO network plan requires a co-payment if covered employee or dependent visits
the Emergency Room at one of the EPO hospitals within that network. This co-payment
will be waived if he is admitted. The out-of-network EMERGENCY benefit includes the
same co-payment amount at any hospital, anywhere. Jf the- employee or covered
dependent is admitted to a non-EPO hospital, the AHL Managed Care Department will
arrange for the patient to be transferred to an EPO facility as soon as the patient is
stabilized.
REMEMBER, THE INSURED OR HIS/HER REPRESENTATIVE MUST TELEPHONE
THE AHL MANAGED CARE DEPARTMENT WITHIN 2 WORKING DAYS FOLLOWING
AN URGENT OR EMERGENCY ADMISSION. FAILURE TO CONTACT THE
MANAGED CARE DEPARTMENT WITHIN THE TIME REQUIRED WILL SERIOUSLY
JEOPARDIZE THE BENEFITS. Please refer to the Schedule of Benefits for the specific
co-pay amount.
11. What is considered Emergency Care?
If you go to an Out-of-Network provider for emergency care, it will only be considered as
eligible for Network benefits if it meets the. following criteria:
Emergency Care means medical services provided after the sudden or
unexpected onset of a medical condition manifesting itself by acute symptoms,
including injury caused by an accident, which are severe enough that the
absence of immediate medical attention could reasonably be expected to result
in any of the following:
(1) Placing the patients life or health in serious jeopardy;
(2) Serious impairment to vital bodily functions; or
(3) Serious and permanent dysfunction of any bodily organ or
part.
~`**If you are admitted to the hospital you must contact our Managed Care Department
within two (2) working days.***
1~. - What if the employee has dependents living outside the EPO area? Will they be
covered?
EPO benefits are not available to individuals residing outside of the EPO area. Some of
these situations might be students, natural children residing in another geographic
location, or employees residing outside the EPO area.
13. Where should one mail any claim correspondence?
EPO providers will file all claims for employees and covered dependents. If the
employee should receive a bill or balance due statement for any reason, please send
them to:
Group Claim Department
American Heritage Life Insurance Company
9776 American Heritage Life Drive
Jacksonville, FL 32224