Formulary updates for prescription plans administered by Pharmacy Data Management, Inc. (PDMI) are now available at MedBen.com – simply click on “Plan Sponsors” (for employers) or “Plan Members” (for insureds) and select “Prescription Formularies” from the “Form” drop-down menu.
The new formularies become effective January 1, 2016. As always, plan administrators with questions can contact their Group Service Representative, while plan members can call MedBen Customer Service at (800) 686-8425.
Self-funded groups use either the Focus formulary or the Outcomes formulary. Focus offers the most cost-effective drug options, while Outcomes offers broader choice while still delivering significant cost savings. All fully-insured groups use the Focus formulary.
Should you still need a 2015 formulary, they will remain available on the MedBen website until the end of the year.
To determine if your group is fully insured or self-funded, check your MedBen ID card. If your account # is less than 10,000, your plan is fully insured; if it is more than 10,000, your plan is self-funded.
“The recommendation from this audit is that your certification continues.”
On September 16, 2015, a representative from SAI Global conducted a surveillance audit of MedBen to determine its management system’s compliance with ISO 9001 standards, and its effectiveness in achieving continual improvement. And based on the audit results, the company continues to demonstrate a commitment to quality service – a commitment that began when we first achieved ISO Certification in September of 2005.
In its written summary of the audit, SAI Global reported no findings or opportunities for improvement. Specific areas audited included:
The auditor also verified MedBen’s Quality Objectives and commitment to Continual Improvement, and reviewed its Quality Manual and other related documents.
Since achieving ISO 9001 Certification in 2005, MedBen has undergone voluntary semiannual audits to ensure that it has met and built upon established quality standards. The company has also been recertified every third year, most recently in 2014.
“For over a decade, MedBen has been an ISO Certified benefits manager,” said Chairman & CEO Doug Freeman. “To maintain that level of consistency and quality requires a companywide effort, so it’s a testament to the hard work of everyone here that these audits go so well.”
SAI Global is an internationally-recognized provider of standards compliance and risk management services.
We’re quickly approaching the holiday season and opportunities to celebrate with family and friends. As we observe Thanksgiving Day, our offices will be closed on Thursday, November 26 and Friday, November 27. MedBen will reopen on Monday, November 30.
Remember, however, that just because we’re closed doesn’t mean we’re not available to help you! Through our online services, you can get needed materials and answers to questions any time of the day or night.
And speaking of wellness, as many plan years end on December 31 – and incentives are often tied to completing these tests before year’s end – this is an opportune time for you to remind your employees that if they haven’t got their annual wellness exam, now’s the time to make an appointment!
Best wishes from everyone at MedBen for a safe and relaxing holiday!
At an employee appreciation event on Friday, October 23, MedBen honored employees who have reached anniversary benchmarks in 2015. The recognition presentation was co-hosted by MedBen Chairman & CEO Doug Freeman and President & COO Kurt Harden.
Receiving special congratulations were Andrea Corn, Director of Data Services and Special Investigation Unit (SIU) and Becky McCune, Senior Technical Software Specialist, both of whom are celebrating their 25th year with MedBen in 2015.
Corn started at MedBen in 1990 as a claims examiner trainee, eventually working her way up the ranks to management positions in the claims and information systems departments. She received her promotion to Director earlier this year.
Asked after the event what she enjoyed most about working at MedBen, Corn replied, “Besides the people that I work with which is a lot of the reason I like it here, I like working for a company that has a sense of humor and values the employees’ home life as much as work life.”
Corn added that the last 25 years “have flown by” and that she looks forward to MedBen continuing to lead in benefits management services during the coming years.
McCune first joined MedBen as a Computer Programmer Trainee, and her growth in the company has coincided with the computer revolution that has taken place in the past quarter-century. And as MedBen has expanded its technological presence, she has played a key role in many major projects, such as developing and maintaining the VisionPlus system, upgrading and enhancing the proposal quoting system from individual PCs to network-based, and creating an online customer service documentation system, to name just a few.
As for what she’s liked most about her quarter-century at MedBen, McCune cited the pleasant working environment and “opportunities to work on a variety of projects.” She also noted that one of her favorite memories is the expansion of the company to a two-story building (MedBen’s current home office) in 1991.
Other MedBen employees honored at the event include:
Just a reminder that there's still time to register for the 10th Annual Granville Turkey Trot (GTT)!
For the third consecutive year, MedBen serves as a premier sponsor for this 5K fun run/walk, which will be held on Thanksgiving morning, November 26 in Granville, Ohio starting at 9:30am. Kids as young as 6 years old can participate... and you can even sign up your dog as a workout buddy!
The event benefits the Food Pantry Network of Licking County, whose mission is to acquire, store, and distribute nutritious food to the financially deprived and otherwise needy in Licking County. In 2014, the GTT raised $100,000 for this worthy cause -- and we hope to do even better this year!
Online registration has ended, but you can still sign up at the pre-race "Wing Ding," taking place at the Farmer's Market in Granville on Saturday, November 21 from 8:30am-12:30pm. (You can also pick up your race packet at this event.) If you can't make it then, just download a form from the GTT website and drop it off on Wednesday, November 25th, 9:00am–6:00pm at St. Luke's Church Parish House on 118 South Main Street in Granville.
Registration costs are $35 for adults ($40 on race day), $12 for ages 6-13 ($15 on race day), and $5 for dogs. This is a non-timed event.
If you can't make it but would still like to donate, or even participate as a "virtual runner," visit the GTT website for additional details. You can also find information there if you're interesting in volunteering to help on race day.
We hope to see you bright and early on November 26!
Etta Short, MS, writing in Employee Benefit News:
"Unhealthy behaviors can prevent employers from meeting business objectives and employees from performing optimally in the workplace.”
Through effective workplace wellness programs, Short says, employers help to "meet employee benefit and health objectives, reduce health care claims and increase employee job satisfaction, recruitment and retention." She also highlights three "best practices" that fuel participation in these programs:
Workplace wellness works best when employer and employee alike are invested in its long-term success. That's why MedBen WellLiving works with employers to put a program in place that promotes healthy lifestyle changes for plan participants, backed by ongoing support from management.
From day one, MedBen WellLiving has essential components in place to encourage better health, such as individualized coaching for participants at risk for chronic disease. And as the program progresses, we'll provide you with charts, reports and other materials to show participants how the focus on wellness has affected the overall health of the company as well as the corresponding costs from reduced illness.
Focusing on the long-term objectives of a wellness program -- and having the tools to achieve those objectives -- increases its chance of success. Learn more about how MedBen WellLiving can help you achieve your company's health goals by contact Vice President of Sales & Marketing Brian Fargus at email@example.com.
MedBen helped current and prospective clients gain a better understanding of how to comply with a critical health care reform mandate at two workshops on November 16 and 17.
Mike Ankrum, Sr. Healthcare Reform Consultant for Five Points ICT, and Caroline Fraker, Vice President of Compliance for MedBen, headed the workshop, which provided employers with in-depth, line-by-line advice on completing forms required under the Affordable Care Act.
In order to properly complete the reports in 2016, Applicable Large Employers (those with 50 or more employees) must have an accurate employment and coverage tracking system going back to the beginning of 2015. Hoping for further delays is not a wise option, Ankrum cautioned: "It's game on... penalties have begun as of January 1."
Two forms must be completed and sent by early 2016: 1095-C to employees by February 1, and 1094-C to the IRS no later than February 29. Failure to complete these forms in a timely and accurate manner will result in fines of $250 per return -- and that's on top of what Ankrum called the "sledgehammer" penalty if you're not offering adequate coverage to full-time employees, or offering unaffordable coverage.
A large portion of the workshop focused on the 1095-C forms and how employers should enter the applicable codes for the offer of coverage for each calendar month. "Employers must enter the correct code, either one for all 12 months, or separate codes for each individual month," Fraker said, adding that the offer of coverage codes "get to the heart of affordability."
And that's not all: In addition to offer of coverage codes, employers must also provide Safe Harbor codes, which identify employee status for a given month as it relates to coverage offered or applied. "These codes show the IRS why you shouldn't have to pay a penalty," Fraker noted.
Suffice it to say, completing these forms can be a complicated and time-consuming process. So to assist, MedBen has partnered with Five Points to offer several service options to help ALEs create and distribute Form 1095-C to employees and prepare and file Form 1094-C with the IRS. But whether you use these services or go a different route, it is imperative to start now -- after all, 2016 is just around the corner!
We will post portions of the workshop on our YouTube page soon -- we'll let you know here when they're available. In the meantime, if you would like more information about data reporting services available through MedBen, please contact Fraker at 800-851-0907 or firstname.lastname@example.org.
Kurt Harden, President and Chief Operating Officer of MedBen, chaired the 2015 Healthcare Bundled Payments Conference held November 12 and 13 in Scottsdale, Arizona.
The conference featured speakers from The Cleveland Clinic, Johns Hopkins Healthcare, and The University of Texas MD Anderson Cancer Center, discussing successful strategies for the Medicare Bundled Payments Care Initiative (BPCI), the new Comprehensive Care for Joint Replacement (CCJR) mandate, and commercial bundled payment initiatives.
"With bundled payments it is not a matter of if they spread, but how fast,” Harden said in his opening remarks to conference attendees. “The key is to understand all of the new information that accompanies the bundles.”
Harden added that through the initiatives, organizations that had previously only seen their own claim information will now have access to a rich new stream of claim data to help them improve their efficiency and quality. “Interpreting this new information is where we come in." he said.
MedBen formed its MedBen Analytics subsidiary earlier this year, developing a proprietary analytics software which takes the numerous and disparate Medicare files available to bundled payment initiative hospitals, health systems and physician practice participants and creates actionable insights for success with bundled payments.
"Our analytics tool was developed in cooperation with The Camden Group, a leading national bundled payments expert, and has made use of valuable feedback from clients in both retrospective and prospective bundles. These are reports to help organizations succeed at bundled payments," Harden said.
Harden attended the conference with Wendell Crain, Director of Security, Infrastructure and Web Development for MedBen Analytics.
Last month on this blog, we posted that the Department of Justice (DOJ) has been investigating the inappropriate placement of implantable cardiac devices (ICDs) in Medicare patients. The DOJ recently provided additional details about the results of its nearly five-year inquiry.
According to a DOJ press release, 457 hospitals, including many of the country's largest hospital systems, have settled with the government for more than $250 million. “While recognizing and respecting physician judgment, the department will hold accountable hospitals and health systems for procedures performed by physicians at their facilities that fail to comply with Medicare billing rules,” said Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the Justice Department’s Civil Division.
(You can see which hospitals are paying and how much at the Modern Healthcare website. Free registration may be required.)
Under research-based clinical criteria, ICDs should not be placed within 40 days of the patient suffering a heart attack or significant cardiac event, or within 90 days of the patient undergoing angioplasty or bypass surgery. A number of studies have suggested that the costly devices were frequently being placed outside of these and other medical criteria. Some critics have even referred to the ICDs, which need to be replaced every five years, as an annuity for the health care providers who place the devices.
As we noted in the earlier post, while the DOJ has been investigating the placement of these devices since 2010, MedBen started performing clinical reviews of ICDs in 2007, using board-certified cardiologists to ensure that the devices met criteria for placement. This clinical review process, performed by only a handful of third party administrators (TPAs) or carriers, has saved MedBen clients nearly $2.5 million in claim costs, by denying the inappropriate ICDs and protecting the patient from liability for the costs.
Clinical reviews are different from standard claim or coding reviews conducted by most claim-paying organizations. MedBen works with a team of over 125 board-certified physicians to quickly scan claims before they are paid.
When it comes to benefits incentives that help to recruit and retain employees, health care coverage leads the way by a sizable margin, a recent survey reveals.
Overall, 38% of respondents to the 2015 Strategic Benefits Survey said that they used benefits as a recruiting tool, and within that group, 80% cited health care coverage as an effective means of luring talent -- significantly greater than such other benefits as retirement plans and vacation time. The survey of more than 460 randomly selected HR professionals was conducted by the Society for Human Resource Management (SHRM).
Additionally, a greater emphasis on a healthy workplace is increasingly finding favor with companies as a means of attracting and keeping employees. About two-thirds (69%) of respondents indicated their organization offered some type of wellness program, resource or service to employees, and over half of that group reported that employee participation increased in last year compared with 2013.
Other SHRM survey findings:
Last year, the Supreme Court narrowly ruled that certain businesses could request a religious exemption from covering women's contraceptives under their health plans. But today, the court accepted an additional challenge to the birth control mandate:
"The Supreme Court on Friday agreed to hear another challenge to the Affordable Care Act, this time to decide whether religiously affiliated organizations such as universities, hospitals and charities should be free from playing any role in providing employees with contraceptive coverage.
"The Obama administration says it has provided the organizations with an easy way to opt out of the legal requirement that employers include contraceptives as part of health insurance coverage. Employers who object must file their religious objections and let insurance companies and the government take over from there.
"But the groups say even that step would implicate them in what they sincerely believe to be a sin, adding that they face ruinous fines if they refuse to comply. They want to be included under the blanket exclusion from providing the coverage that the government has already extended to churches and solely religious groups."
It’s no secret that diet plays a huge role in health. That’s why this holiday season, we caution you to think before scarfing down those seasonal goodies – especially if you’ve not received an annual wellness exam yet.
Those who wait to get their annual checkup until after the holiday feasts put themselves at risk for overstated results. So it’s a smart idea to schedule a visit before making the rounds of parties and get-togethers.
MedBen WellLiving reminds you that there are great benefits that come with receiving an annual exam, including building a doctor-patient relationship and receiving lifestyle guidance. Your doctor may even detect a serious disease at its earliest stages giving you a better prognosis and saving money. Not to mention, some employers offer incentives for those who receive the exam prior to the conclusion of the year.
Be sure to eat a balanced diet and limit your intake on salt, fats, and sugary foods. Try substituting typical desserts like cookies and pie with festively-shaped fruits or vegetables. And stay active, getting regular exercise and adequate sleep.
For more information on your annual wellness exam or screenings you may need, please visit MedBen.com, click on “MedBen Access,” and once logged in, select the “MedBen WellLiving” link.
Pharmaceutical use shows no sign of slowing, with nearly 60% of Americans using prescription drugs in 2011, new research finds.
According to Reuters Health, a multi-year study revealed that prescription drug users rose from 51% of U.S. adults in 1999 to 59% of adults in 2011. Lead author Elizabeth D. Kantor of Memorial Sloan Kettering Cancer Center in New York told Reuters that “something beyond the aging of the U.S. population appears to be driving the increase in prescription drug use,” such as more lower-cost drugs, scientific advances and increased marketing.
Whatever the reason for the growth, it's clear that prescription drug costs are consuming an ever-larger chunk of the health care dollar -- so it's more important that ever for self-funded health plans to have a savings strategy in place.
For years, MedBen has been an industry leader in pharmacy benefits management. We find intelligent ways to reduce drug spending while ensuring that patients have access to needed medications.
Key to the MedBen Rx savings strategy is delivering 100% of all paid discounts and rebates back to the employer. In 2014, our clients saved an additional 9.3% from pharmacy benefits management compared to national Rx programs.
For the third year in a row, MedBen is pleased to promote healthier lifestyles while supporting a worthy cause through its sponsorship of the Granville Turkey Trot (GTT), a 5K fun run/walk.
Taking place in Granville, Ohio on Thanksgiving morning (November 26th, 2015) at 9:30am, the 10th annual GTT offers a great opportunity to get in a refreshing workout before settling in for the holiday's other activities (i.e., eating). The cost is just $35 for adults and $12 for ages 6-13.
MedBen will serve as co-premier sponsor of the GTT. Funds raised by the event will benefit the Food Pantry Network of Licking County, whose mission is to acquire, store, and distribute nutritious food to financially deprived members of the community.
Registrants may pick up packets for themselves as well as friends and family at a special pre-race "Wing Ding" in downtown Granville on Saturday, November 21 from 8:30am to 12:30pm. Or if you have not yet registered, you can do so and receive your packet then.
And there's more! Whether you participate in the GTT or not, you're welcome to attend the Turkey Waddle on November 21. Area bands will entertain at the Broadway Pub and Day Y Noche in Granville, and a $10 admission gets you access to both locations! All proceeds go to the Food Pantry.
Finally, if you want to help the cause but can't make it to Granville, consider becoming a Virtual Runner. For a $35 donation, you get all the racer perks without having to leave home!
Visit the Granville Turkey Trot website to register or get more information. We hope to see you there!
However obvious it may seem, it bears repeating that the most effective wellness is frequently also the most basic. Case in post: newly released research pitting healthy lifestyles vs. medicine.
According to Reuters Health, a 15-year diabetes study found that in a head-to-head comparison, diet and exercise outperformed the drug metformin in preventing high-risk individuals from developing the disease. “The lifestyle intervention was more powerful in preventing or delaying diabetes development during the original three-year Diabetes Prevention Program and remains more powerful over the entire 15-year study,” said professor and paper coauthor David M. Nathan of the Massachusetts General Hospital.
“However, there are specific subgroups in which the lifestyle intervention had an even more powerful effect – specifically, those older than age 60,” Nathan told Reuters Health by email. Metformin was relatively more effective in people younger than 60 and those who were more obese, he said.
As Ben Franklin so eloquently put it, “An ounce of prevention is worth a pound of cure.” At MedBen WellLiving, we subscribe to this way of thinking, as our program is designed to put prevention at the forefront.
In addition to encouraging proper diet and exercise, Primary Prevention encourages regular checkups and recommended care, thereby improving the chances of catching diabetes and other chronic conditions in their earliest stages. Moreover, seeing a family doctor regularly provides an added incentive to maintain a healthy lifestyle.
Got more information about Primary Prevention through MedBen WellLiving by contacting Vice President of Sales & Marketing Brian Fargus at email@example.com.
In the months -- more precisely, years -- leading up to the October 1 implementation of the ICD-10 medical coding system, there was no small amount of concern as to whether the massive increase in codes would create claims inaccuracies and turnaround delays. And while it's still early, the initial prognosis is... so far, so good.
Emdeon, a major claims clearinghouse with which MedBen worked throughout the transition, reported in an e-mail that the implementation on their end has been even smoother than expected:
"ICD-10 volume continues to ramp at forecasted rates with over 70% of medical and hospital claims submitted coded in ICD-10. 99.8% of the claims that should be coded ICD-10, providers are coding ICD-10.
"So far in the month of October, Emdeon has received and processed millions of ICD-10 coded claims delivered to thousands of health plans!"
As for MedBen, because we have been preparing for the ICD-10 transition since 2013, internal claims processing has been virtually unaffected. “Any isolated issues have been quickly addressed, and we have remain comfortably above our benchmark turnaround time of 95% of claims examined and paid within 15 calendar days,” said MedBen Director of Data Processing and Technical Compliance Wayne Millard.
For our clients, our goal was to make the transition as seamless as possible. And these initial reports would seem to indicate that the many hours of system coding and testing has been time well-spent.
MedBen clients with questions regarding the ICD-10 coding system are welcome to contact Millard at firstname.lastname@example.org.
Several clients have brought to our attention recent attempts by non-MedBen-affiliated brokers to generate business through the use of scare tactics. Specifically, they are using the looming threat of the “Cadillac” tax and other Affordable Care Act (ACA) requirements to coerce employers into signing them on as their agent of record.
The “Cadillac” tax – so-called because it penalizes health care plans deemed too benefit-rich by the federal government starting in 2018 – has been a particularly useful come-on for brokers to prey on employers. It bears emphasizing that as new health care rules have been introduced, MedBen and its brokers have been advising clients all along on the best ways to proceed – and that will continue to be the case.
At several MedBen University sessions this year, our Vice President of Compliance Caroline Fraker offered a detailed explanation of how the tax works and strategies to avoid it. And as 2018 draws closer, we'll consult clients and brokers individually about recommended plan changes.
Bottom line, always be cautious of anyone who tries to sell you into buying a service through scare tactics. If you are being pressured by a broker into signing an agent of record, please note his or her name and contact MedBen Vice President of Sales & Marketing Brian Fargus at email@example.com.
Lastly, if at any time you have questions about any state and federal regulations and how they affect your health care plan, do not hesitate to contact Caroline Fraker at firstname.lastname@example.org.
Many people covered under the health insurance marketplaces will find themselves with fewer plan options in 2016, as nearly a third of health insurance plans created under the Affordable Care Act have closed or are closing soon.
According to The Washington Post, four co-ops, as the nonprofit plans are known, have decided or been ordered to shut down in the past week alone. In total, eight of the 23 co-ops in existence a year ago will be unavailable to consumers in 2016.
A common reason for the shutdowns pertains to funding promised under the ACA which was intended to help cushion insurers who experience higher-than-anticipated claims due to sicker customers. Earlier this month, the Department of Health and Human Services (HHS) announced that it could afford to pay insurers participating in the marketplaces just 12.6% of nearly $3 billion they were owed under the provision, known as risk corridors.
In related news, the Obama administration announced last week that it expects only a small bump in marketplace plan enrollment in 2016. The Associated Press reports that HHS has set a target of 10 million people enrolled and paying their premiums by the end of next year -- about the same number of individual covered now under the plans.
“If enrollment plateaus, we may see growing discussion of whether the law is fulfilling expectations in covering the uninsured, and whether the subsidies for low- and middle-income people are sufficient to make coverage truly affordable,” said Larry Levitt, an expert on the law with the nonpartisan Kaiser Family Foundation.
Experts cite high turnover, costs and complexity as reasons for the slow enrollment growth.
November means autumn leaves, turkey, football – and of course, Transitional Reinsurance (TR) reporting to the Centers for Medicare and Medicaid Services (CMS). During November, self-funded plan sponsors must provide their TR report to CMS and, in turn, let CMS know when payment will be made.
By way of reminder, the TR program was designed to reduce the uncertainty of insurance risk in the individual market by making payments to establish a pool of funds from which individual health insurance carriers can request reimbursement for their unanticipated high claims costs resulting from health care reform’s expanded coverage. While the majority of the contributions to the program will go to reimburse carriers, a portion will go to the United States Treasury’s general fund.
This year, the amount due per each covered life (i.e., each employee, spouse and dependent on your plan) is $44.00. Generally, that includes all medical benefit plans and policies, including catastrophic coverage. Not subject to the TR payment rules are those plans and policies considered “excepted benefits” under the Affordable Care Act, including hospital indemnification policies, stand-alone dental or vision plans, integrated HRAs, HSAs, FSAs, EAPs, disease management and wellness plans that don’t provide medical benefits, as well as stop-loss policies.
Again this year, a plan sponsor can remit payment in two installments – January and November of 2016. To begin the process, a Contributing Entity (or their TPA) must submit the entity’s enrollment count to the U.S. Department of Health and Human Services by November 16, 2015. MedBen is again offering reporting and filing services for its clients. If you have not already signed up for this service, you can request a description of our service offering and fees be contacting your MedBen group service representative (GSR).
Clients who would like more about the process and rules surrounding the TR Program Fees can request a more detailed summary from their GSR. And if you have any general questions about the TR reporting process, contact MedBen Vice President of Compliance Caroline Fraker at email@example.com.
The rising price of prescription drugs is a frequently-covered topic in the media, but recent events have shown the spotlight that much brighter. Even so, comparatively little has been written about when patients can do to keep their medication costs in check.
Noting that about one-third of Americans have been hit by an unexpected price increase in their medications during the past year, Consumer Reports (via the Fiscal Times) offers strategies that individuals can try to battle rising drug costs. Tips that benefit patients with pharmacy coverage include:
Not included in the list, but a good strategy nonetheless, is for patients with recurring prescriptions to take advantage of mail order pharmacy services if offered under their plan. Depending on your benefits, you may realize additional savings.
Employers can also help their employees to keep prescription drug costs down, by providing a group pharmacy plan that offers additional savings. Under the MedBen approach for pharmacy plans, member receive superior rates on retail and mail order medications, including some of the deepest generic discounts available. Additionally, we can integrate over-the-counter drugs into your prescription plan design... another avenue for member savings.
Finally, MedBen delivers 100% of paid rebates back to the client... which helps to keep pharmacy plan costs down for employer and employee alike.
If you would like to learn more about the MedBen approach to pharmacy plans, we invite you to contact Vice President of Sales & Marketing Brian Fargus at firstname.lastname@example.org.