Broker Edge

December 2010, Vol. 9, No. 4
A newsletter dedicated to informing brokers affiliated with Fallon Community Health Plan

In this issue:

A message from Patrick Hughes

President & CEO, Fallon Community Health Plan

Pat Hughes Moving onward and upward
As I reflect on all that’s happened in 2010, I am first and foremost grateful for your support of and loyalty to Fallon Community Health Plan during a time of much uncertainty. On behalf of our employees, I thank you for your business and reassure you that we remain dedicated to delivering top-notch customer service and satisfaction.

In Massachusetts, our industry activities this year were driven in large part by turmoil in the merged markets. It’s a relief that the market feels different now, with a sense of stability and permanence in pricing taking hold. Local and national health care reform directives will continue to challenge us on most fronts. At FCHP, our response in 2011 will be to focus even more on delivering cost-competitive solutions to our customers. Our priority is to work diligently with our provider community to make low-cost, quality care an even broader reality.

FCHP has always been a forward-looking health plan, and this year is no exception. We are in a stronger position today than we were a year ago, and are having a positive fourth quarter—a trend we expect to continue in 2011. We have a three-year strategic plan in place and look forward to partnering with you for growth and profitability.

We also will continue to be a major player in the area of senior care services. In addition to nurturing Summit ElderCare®, the largest PACE program in New England, we launched this year a Medicare Advantage special needs plan (NaviCare® HMO SNP) and Medicare Supplement plans that complement our existing Medicare Advantage products.

FCHP was rewarded for its hard work with the distinction of having our commercial, Medicare Advantage and Medicaid plans all ranking in the top 10 nationally for the second consecutive year. No other health plan can say that.

As we focus on the business of health care, we remain steadfast in our mission of making our communities healthy. FCHP sustained its charitable giving and support throughout the year. I’m particularly proud of our Gather FORE a Goal event, in which many of you participated, that raised more than $173,000 for much-needed hunger relief throughout the Commonwealth. Once again, thank you!

I’m a big believer in what teamwork and discipline can achieve. I look forward to the road we’ll travel together in 2011.
Pat Hughes signature


FCHP plans rank among America’s top 10

Fallon Community Health Plan is the only health plan in the nation to receive a top 10 ranking in all three product categories of the National Committee for Quality Assurance’s Health Insurance Plan Rankings 2010-11. It was the second consecutive year in which FCHP received that distinction.

According to the national rankings, Fallon Community Health Plan is #1 for Medicaid out of 104 plans, #3 for Medicare out of 183 plans (and the top plan in Massachusetts) and #8 for its commercial HMO out of 227 plans.*

“What this means for our members is that whether they receive health care coverage through an employer, Medicare or Medicaid, they can rely on FCHP to deliver world-class care and service,” said Patrick Hughes, FCHP President and CEO. “Our consistently strong performance in the NCQA rankings validates our approach to taking care of each and every one of our members.”

* NCQA’s Health Insurance Plan Rankings 2010-11 – Medicaid; NCQA’s Health Insurance Plan Rankings 2010-11 – Medicare; and NCQA’s Health Insurance Plan Rankings 2010-11 – Private. NCQA is an independent, not-for-profit organization dedicated to measuring the quality of America’s health care.


New chief financial officer on board

Scott WalkerThere was a smooth transition in FCHP’s top financial position in mid October when R. Scott Walker replaced Charley Goheen as Executive Vice President and Chief Financial Officer. Charley, named Chief Financial Officer at Neighborhood Health Plan, worked with Scott and FCHP’s senior leadership team prior to his departure to ensure that we remain clearly focused on our business plans and priorities.

“I am confident that Scott’s accomplishments and deep experience in the financial and insurance industries will significantly contribute to the achievement of our business goals and solidly position FCHP for the future,” said Patrick Hughes, FCHP President and CEO.

Scott Walker comes to FCHP from ComplexCare Solutions, Inc., a specialized, community-based care management organization, where he served as Chief Financial Officer. Prior to that, he was a CFO of National Accounts and also of Business Alliances at Aetna, and the Controller and Chief Accounting Officer for Uniprise (a UnitedHealth Group Company). Scott has a bachelor of science degree in accounting from Saint Michael’s College in Colchester, VT, and is a member of The American Institute of Certified Public Accountants and The Connecticut Society of Certified Public Accountants.


Benefit changes for 2011

As a result of the following benefit changes, Fallon Community Health Plan’s fully insured plans will not be grandfathered under national health care reform.

♦ Dental coverage no longer offered

As previously communicated, Fallon Community Health Plan will no longeroffer dental benefits and discounts for the entire family as part of our commercial products, effective upon anniversary dates beginning January 1, 2011.

This was a difficult business decision for us. However, by eliminating this underutilized coverage, we’ll be able to shift our efforts and resources to other services that are more sought after by our customers.

If you have any questions about these benefit changes, please contact your FCHP sales executive through our dedicated broker line, 1-888-746-4823.

♦ DME and prosthetic/orthotic benefit changes

Our coverage for durable medical equipment (DME) and prosthetic/orthotic devices has changed for our commercial plans—and is slightly different than what we communicated to you earlier. Durable medical equipment and prosthetic/orthotic devices includes, for example, oxygen, walkers, wheelchairs, breast pumps and blood glucose monitors for diabetes.

FCHP has removed the $1,500 DME limit previously in place on all of our standard commercial offerings, effective on enrollment anniversary dates on or after September 23, 2010. This benefit now is unlimited. However, a coinsurance will apply on all policies, beginning on enrollment anniversary dates on or after January 1, 2011.

The coinsurance amounts have changed from our previous notice to you.

For HMO plans, the DME coinsurance generally will be 30%, with a 20% coinsurance for prosthetic limbs. However, when a plan has other coinsurance, the DME and the prosthetic coinsurances will match the coinsurance amount on other benefits. For example, if a plan has a coinsurance of 35%, the DME coinsurance would be 35% vs. 30%, and the prosthetic coinsurance would be 35% vs. 20%.

For PPO plans, the DME coinsurance generally will be 30% for the in-network and out-of-network benefit. The prosthetic limbs coinsurance will be 20% in-network and 40% out-of-network. In both cases, however, when a plan has other, higher coinsurance, the DME and prosthetic coinsurances will be the higher amount.

For example, if a plan has a coinsurance of 20% in-network and 40% out-of-network, the DME coinsurance would remain 30% in-network and rise to 40% out-of-network; the prosthetic coinsurance would remain 20% in-network and remain 40% out-of-network.

Coinsurance applies after the deductible on all deductible plans. Large employer groups should contact their account manager if they have questions concerning benefit offerings.


Coverage ended for prescription non-sedating antihistamines

As of January 1, 2011, Fallon Community Health Plan will no longer include non-sedating antihistamines on its three-tier commercial plan formulary (list of covered medications). A non-sedating antihistamine is a medication that relieves allergy symptoms without causing drowsiness.

Many of the non-sedating antihistamines are now available as over-the-counter (OTC) products in the same strength as the more expensive prescription alternatives—and they’ve been proven to be as safe and effective. Most of these antihistamines were Tier-3 prescription drugs with the highest copayments.

The non-sedating antihistamines to be removed from the commercial plan formulary are: Allegra® and Allegra-D®; cetirizine (brand name Zyrtec®); Clarinex® and Clarinex-D®; fexofenadine and fexofenadine PSE; and Xyzal®.


FCHP adds Medicare Supplement product

Fallon Community Health Plan began marketing last fall Medicare Supplement (Medigap) insurance options for individual consumers living across Massachusetts. Our Medicare Supplement plans further diversify our non-group senior-product portfolio. These plans may be of interest to FCHP Direct Care, FCHP Select Care or Fallon Preferred Care members who are soon to be Medicare eligible and want greater access to benefits and providers.

Fallon Senior Plan’s two Medicare Supplement plans, “Core” and “1”, effective for January 1, 2011, have different levels of coverage and premiums. There are no networks, members don’t have to designate a PCP and can see any Medicare provider without referrals. Because of this flexibility, members pay higher premiums than most Medicare Advantage plans. However, they pay little to nothing for health care expenses such as deductibles, coinsurance and other services that are not covered after Medicare has covered its portion of the costs.

If you’d like more details about these Medicare Supplement product and prescription drug plan (PDP) options, please contact your FCHP sales executive through our dedicated broker line, 1-888-746-4823.


Massachusetts health care updates

♦ “Small business” health care law signed in August

Gov. Patrick last August signed S. 2585, an act to promote cost containment, transparency and efficiency in the provision of quality health insurance for individuals and small businesses.

On October 15, Gov. Patrick signed legislation making “technical corrections” to the original bill, which primarily involved changes to effective dates. Most merged market changes became effective October 1, 2010. Now many provisions of the bill require further guidance from state agencies before implementation can begin.

Below are a few provisions of the 63-page bill.

  • Limited and tiered networks. One of the most talked about sections of the law is the requirement that insurers offer limited or tiered network plans in the merged market with at least a 12% price differential compared to the base premium for a full-network product. This provision goes into effect January 1, 2011.

    FCHP helped to pioneer this approach, introducing FCHP Direct Care back in 2002 as an innovative limited network solution for customers looking to save without sacrificing access to high quality health care. The FCHP Direct Care network consists of more than 13,000 providers and the service area covers two-thirds of the state population. For more information, see our FCHP Direct Care flyer or call your FCHP sales executive through our dedicated broker line, 1-888-746-4823.
  • On-and-off loophole closed. Consumers can no longer buy nongroup insurance shortly before a pricey medical procedure then drop it afterwards—a practice that drove up the costs for everyone. Now insurers will have open enrollment periods twice a year in 2011 and once a year thereafter.
  • Changes in rating factors. Changes are made to certain rating factors for merged market business. One change requires insurers to use 1-year bands for age rating, for example, as opposed to the current 5-year bands.
  • Increased DOI oversight of rates. Establishes temporary standards for the presumptive disapproval of merged market rates by the Division of Insurance. These standards will be in place for the next two years.
  • Group Purchasing Cooperatives. Small businesses may group together to purchase health care plans.
  • Wellness programs. Offers technical assistance and subsidies to small businesses that initiate employee wellness programs and purchase these programs through the Connector. Group Purchasing Cooperatives also will be required to offer wellness programs.
  • Contract prohibitions. Bans anti-competitive contract provisions between insurance carriers and health providers that restrict product innovation or tie reimbursement rates to those received by other providers.
  • Data collection. Adds several new requirements for providers and insurers to collect and submit standardized data that state regulators will analyze and review.
  • A mandate on mandates. Requires the Division of Health Care Finance and Policy to do a comprehensive review every four years on the cost and public health impact of existing mandates. [An earlier-proposed moratorium on new mandates was not included.]

♦ Infertility coverage mandate expanded

The health care cost-control law included a provision that expanded the definition of, and coverage for, infertility. The law redefines fertility to mean the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger, or during a period of 6 months if the female is over the age of 35.

Massachusetts was the first state in the nation in 1987 to enact a mandate to cover fertility treatments and procedures and has the most comprehensive coverage of the 15 states that now mandate it. It covers IVF, IUI, GIFT, ZIFT, and sperm and egg retrieval, but does not include experimental procedures or the cryopreservation of eggs.

♦ New law requires autism coverage

Gov. Patrick signed a new law in August that mandates insurers to offer coverage for an expanded range of autism services, at coverage limits that are equal to those for physical conditions, and with no limits to the number of visits to an autism services provider. The law is effective on policy anniversary dates on or after January 1, 2011. Self-insured plans are exempt.

The law mandates that insurers cover the cost of diagnosis and treatment of certain autism spectrum disorders. Treatments include rehabilitative, psychiatric and therapeutic care, assessments and evaluations, applied behavioral analysis and pharmacy care.

The federal Centers for Disease Control and Prevention estimate one out of every 110 children has an autism spectrum disorder.


National health care reform update

♦ FCHP fully insured groups not grandfathered

The national reform law exempts (grandfathers) health plans that existed on March 23, 2010, from some new coverage requirements—if they do not make certain “significant changes” compared to their polices in effect on that date.

As a result of benefit changes for 2011, Fallon Community Health Plan’s fully insured plans will not be grandfathered under national health care reform. Self-funded groups must evaluate whether any desired benefit changes affect their grandfather status.

It is difficult to remain a grandfathered plan given the list of prohibited changes in the law—and most benefits of being grandfathered have been trumped by Massachusetts health care reform.

Under national reform, grandfathered plans still have to comply with many key provisions, such as no lifetime limits on coverage and no restricted annual limits, no rescission of coverage when people get sick, no coverage exclusions for children with pre-existing conditions and extension of parent’s coverage for young adults up to age 26 in certain circumstances.

For more information, go to fchp.org/news/health-care-reform/grandfathered-plans or www.healthcare.gov/law/features/rights/grandfathered-plans/index.html.

♦ New coverage for preventive services

Group health plans and health insurers are required to cover certain preventive services without any cost-sharing for the enrollee when delivered by in-network providers. Most FCHP members will see little difference under the law. FCHP pioneered $0 wellness copayments and is aligning any benefits as necessary to comply with the law. Prescribed over-the-counter preventive medication does not fall under this requirement.

The recommended services are effective on enrollment anniversary dates on or after September 23, 2010. The regulations apply to both fully insured and self-insured plans. For examples of covered preventive services, see healthcare.gov/center/regulations/prevention/taskforce.html.

♦ Lifetime and annual limits prohibited for essential benefits

The new law prohibits group health plans and health insurers from imposing lifetime or annual limits on the dollar value of “essential” health benefits. Additional federal guidance will be forthcoming on the services and items that are to be covered as “essential benefits.” The annual limits are phased in, allowing a defined aggregate dollar cap each year until January 1, 2014.

The regulations are effective for plan years beginning on or after September 23, 2010, and apply to fully insured, self-insured and grandfathered health plans. FCHP has worked with self-insured employer groups directly impacted by this requirement, and we also have updated our plan designs accordingly.

♦ Tax changes for HSAs

Reminder: There are two tax changes being implemented on January 1, 2011, under health care reform:

  • The costs for over-the-counter drugs not prescribed by a doctor are no longer reimbursable through an HRA or FSA, and also are excluded from being reimbursed on a tax-free basis through a HSA. Please note that FCHP partners with UltraBenefits to offer HRA and high-deductible administration as well as stand-alone FSA administration.
  • The tax on distributions from a health savings account that are not used for qualified medical expenses will be increased to 20% of the disbursed amount.

Wherever, whenever coverage from FCHP

People unfamiliar with Fallon Community Health Plan sometimes question how widely we cover emergency situations. The answer is simple: FCHP covers emergency and urgent care worldwide.

Emergency services do not require referral or authorization. When members have an emergency medical condition, they should call 911 or its equivalent, or go to the nearest medical facility for care—wherever they are. Afterwards, the member or someone on his/her behalf should notify FCHP Customer Service and the primary care doctor within 48 hours or as soon a medically possible.

FCHP also has an extensive pharmacy network, allowing members to fill prescriptions at thousands of pharmacies across the nation including, for example, CVS/Caremark, Brooks/Rite Aid, Walgreens, Target, Kmart, Wal-Mart, Price Chopper, Shaw’s/Osco and Stop & Shop. In addition, FCHP offers a mail-order prescription service through CVS/Caremark that allows members to conveniently order prescription refills from any location either online or by phone, fax or mail—and save money.

And, now, for even greater convenience, CVS/pharmacy recently introduced a mobile application for customers using the iPhone® and other Apple mobile devices. It is available as a free download from iTunes and the Apple App Store. With the app, customers may find nearby CVS/pharmacy locations using the GPS-based store locator, refill prescriptions from a personalized prescription history for pickup at any CVS/pharmacy, transfer prescriptions from another pharmacy to CVS/pharmacy, and more.


On our team

♦ Team leader updates

We wish the best of luck to Jack Hyland, Senior Director of Retention Sales, who left FCHP in November to join Kaiser Permanente in Atlanta, Georgia.

At the same time, we promoted two key team leaders. Jen Lavigne has been named Director of Retention Sales. She has been overseeing FCHP’s small business and Western Mass. team and has handled a diverse book of business with us.

Andre Gabryjelski is now Director of Medicare and Consumer Sales. He has been overseeing several lines of business at FCHP and is an experienced manager who is dedicated to helping businesses successfully manage their health care benefits.

♦ Welcome new account managers

In our Retention and Consumer Sales area, we were pleased to recently welcome Kristen Pietrewicz and Karrie Loiselle to our account management team.

Kristen Pietrewicz Kristen joined FCHP with responsibility for managing our national accounts. Most recently, Kristen has worked as senior manger of product development at BC/BS of Massachusetts. Previously, she was Manager of MA Market Performance at Harvard Pilgrim Health Plan and a manager in Strategy and Product Development at Tufts Health Plan. Kristen works directly with Vice President of Retention and Consumer Sales Beth Helenius.

Karrie Loiselle

Karrie joined our team to serve as Account Manager for our Western Massachusetts territory. Karrie previously worked as a Senior Sales Executive in our Consumer Sales Department, working primarily with intermediary and small groups, as well as supporting our Medicare Advantage product. She reports into our Director of Retention Sales, Jennifer Lavigne.


fchp.org redesigned inside and out

We hope you like the fresh new design of our Web site, with improved navigation and page layouts, which we launched in late October. All your favorite tools and content are still available—it’s just easier to find and read what you want!

Our “old” Web content management system was outdated and limited, restricting our ability to respond to our customers and business/
regulatory needs. We switched to a more dynamic and flexible software program, which presented the perfect opportunity to also implement a much-needed design refresh. The new design and layout are a result of hundreds of hours of user testing, research and analysis of our Web usage statistics.

We love the greater operational efficiency of the site, and believe you’ll have a more positive user experience, too. Let us know!


FCHP corner

♦ FCHP “Gather FORE a Goal” raises $173,000 for hunger relief

FCHP held its annual fundraising event in September and raised more than $173,000 for food pantries and hunger relief programs throughout our service area in Massachusetts. This initiative strongly supports our mission of making our communities healthy.

On behalf of more than 85 food pantry/hunger relief program recipients and the people they serve, FCHP would like to thank all of its Gather FORE a Goal sponsors. In particular, we’d like to acknowledge the amazing generosity of our top “Facilitators of the Feast” donors: Booz & Company, CVS Caremark and The Revere Group.

♦ Supporting innovative community programs

Fallon Community Health Plan last fall awarded more than $95,000 in Community Benefits Grants to innovative programs that support children, seniors and improved access to good nutrition.

The 2010 grant recipients were:

  • Partners for a Healthier Community, Inc. and Square One (Springfield)—for Square One’s Launching Healthy Habits program and to support the expansion of Partners for a Healthier Community’s Farm to Preschool and Families program.
  • Regional Environmental Council, Inc. (Worcester)—to help sustain the expansion of the organization’s Food Justice Program.
  • Franklin County Home Care Corporation (Turners Falls)—to support its Sustaining Meals on Wheels for Homebound Elders program.
  • Brain Injury Association of Massachusetts (Westborough)—to support its Falls Prevention Program focused on educating and empowering older adults.
  • Massachusetts Audubon Society (Worcester)—for its “Let’s Go!” program for middle school students that promotes fitness through participation in outdoor exploration activities.

FCHP’s dedicated broker line: 1-888-746-4823

Broker Edge is published quarterly to provide the broker community with the latest Fallon Community Health Plan news and product facts, health care trends and marketplace information. fchp.org/brokers