Employer Bulletin
State Employers
Vol. 20, State E
October 20, 2003
Bulletin Provides State Maintenance Plan and Uniform Benefits
Comparative Information
This bulletin article provides a comparison of the 2004 Uniform
Benefits (UB) to the State Maintenance Plan (SMP) and the Standard
Plan. Employees affected by the withdrawal of CompcareBlue North
and its replacement with SMP in those counties where no qualified
Tier 1 Health Maintenance Organization (HMO) is available in 2004
have raised questions regarding the two plans. Please distribute
the following to employees who have questions regarding SMP during
the Dual Choice enrollment period.
Why is SMP being offered and why did CompcareBlue North
withdraw from the plan?
The Group Insurance Board's new 3-Tier employee contribution
structure provides the lowest employee contributions for health
plans in Tier 1. In response to concerns that all employees have
access to a Tier 1 plan, the Board determined that SMP would fill
that role. For more than 20 years, SMP has filled that role in the
State employee's program under the 105% formula.
Some of the major providers in the northern part of the state are
among those with the highest cost. CompcareBlue North decided it
could not offer its plan at a premium rate low enough to be in Tier
1, and withdrew because officials there felt it would not be competitive.
Had the plan remained in the program, it would have been at a Tier
2 or Tier 3 level, and the Department of Employee Trust Funds (DETF)
would have placed SMP in these counties to offer a Tier 1 plan.
Over the past several years, other plans in these northern counties
have made similar decisions to withdraw.
The Board is concerned that lack of competition among providers
is causing fewer choices of health plans for members. Since we have
no relationship with physicians and hospital groups, we must rely
on our health plans' abilities to contract with providers to
create additional offerings.
Is Uniform Benefits a better plan than SMP?
That depends on each individual's personal situation. While
there are differences between UB and SMP, the value of the benefit
package is substantially equivalent. Although SMP has an up-front
$100 deductible, a change from UB to SMP may result in lower out-of-pocket
costs for some members. For example, SMP has higher benefits than
those of UB in the following areas:
- UB has a $40 emergency room (ER) copayment every time the ER
is used unless the individual is admitted to the hospital. SMP
has no ER copay.
- SMP offers preventative dental care for children under 12. Dental
coverage is not available under UB, though some plans offer it
as an option.
- SMP has a better benefit for:
- home health care;
- physical, speech and occupational therapy;
- durable medical equipment;
- inpatient mental health coverage up to 120 days;
- and oral surgery.
While we recognize that SMP has lesser coverage in other areas,
such as hearing aids (one every third year) and no copays for outpatient
treatment of mental health/alcohol and drug abuse, the overall value
of SMP is fundamentally the same as UB.
Is there a profit margin on the SMP plan?
This is a self-funded plan so there is no margin for profit. All
premiums go to pay claims with a small fixed fee paid to Blue Cross
& Blue Shield United of Wisconsin (BCBSUW) for administration
services.
Why did the Group Insurance Board (GIB) make changes to
the current SMP plan?
The Board approved the redesign of SMP effective January 1, 2004
to make the plan design:
- More closely aligned with other plans in Tier 1;
- Easier to understand and use;
- More cost effective.
1. Why was SMP given Tier 1 status and how was it made
to more closely align with other Tier 1 plans?
In response to concerns that all employees have access to a Tier
1 plan, the Board determined that SMP would fill that role. However,
SMP's current structure does not meet the criteria of a Tier
1 plan based upon its efficiency, provider discounts, and other
criteria. In fact, the Board's actuary originally recommended
that SMP benefits be subject to significantly greater deductibles
in order to make it a true Tier 1 plan. This was due to the substantially
higher cost of many of the providers that are covered under this
plan. The SMP plan design was modified by adding an up-front deductible
and a specialty care and hospital network to bring it closer to
the level of efficiency of a Tier 1 plan. While the changes adopted
still do not result in the classification of a true Tier 1 plan,
they do bring the plan closer to that tier. In any other area, SMP
would cost employees more in monthly premium than it does now.
2. How is SMP easier to understand and use? SMP's
current plan design includes a deductible and coinsurance that applies
only to major medical services. It does not apply to hospital or
professional charges. This type of plan was common in the 1970s.
Health insurance has changed dramatically since that time, and SMP
has become one of the few of its type remaining in the marketplace.
With this change to an up-front deductible along with no coinsurance
on all services (except for nervous and mental/drug and alcohol
treatment), we hope our plan will become easier for members and
providers to understand and use.
3. How do these changes make the plan more cost effective
and affordable? Nationally, health insurance costs have
been rising at double-digit rates for the last four years and this
trend is expected to continue for several years to come. Over a
year ago, the GIB, which manages the state employee health insurance
program in conjunction with DETF, studied ways to hold down the
rapid increases in health insurance costs for state employees. The
referral and network changes made to the SMP plan will result in
a plan more comparable to an HMO, and should result in a more efficient
plan with better provider discounts. The change to an up-front deductible
and no coinsurance helps to keep the cost of administration down.
As the plan saves money, future increases would reflect the savings.
Please contact Bill Kox, Division of Insurance Services, at (608)
266-0211 if you have questions comparing the SMP with other plans.
COMPARISON OF STATE PLAN TYPES FOR 2004
The Chart below is designed to help you compare benefit between
Uniform Benefits, SMP, and the Standard Plan.
All plans listed below are substantially equivalent in the value
of their benefits.
- Plan benefits vary and in places any one plan may contain a
benefit that is better than that of a different plan.
- Although HMOs offering Uniform Benefits may appear in either
Tier 1, 2 or 3, plans in Tier 1 have the most cost-effective contracts
with their providers. Plans with less cost effective contracts
fall into other tiers.
- SMP is designated as a Tier 1 plan in counties where no qualified
Tier 1 plan is available.
This outline is not intended to be a complete description
of coverage. For details, see specific language in Uniform Benefits
and the SMP and Standard Plan booklets. Wherever percentage of payment
is listed, it means percent of charges. Out-of-network charges may
be subject to Usual, Customary and Reasonable (UCR) determination.
All services subject to medical necessity.
| BENEFIT |
UNIFORM BENEFITS |
SMP |
STANDARD PLAN |
| In Network |
Out of Network |
| Annual Deductible1
(ded) |
No deductible |
$100 individual /
$200 family
|
$100 individual /
$200 family
|
$500 individual /
$1,000 family
|
| Annual
Co-insurance2 (coins)
|
As described below |
None |
None |
80% / 20%
Annual OOP maximum (includes deductible):
$2,000 individual /
$4,000 family
|
| Lifetime Maximum |
$2 Million |
$2 Million |
$2 Million |
$2 Million |
| Hospital Days |
No day limit |
365 per admission |
365 per admission |
365 per admission |
| Emergency Room |
$40 copay per visit |
100%, no copay |
100%, no copay |
80%, no copay |
| Ambulance Service |
100% |
100% |
100% |
80% |
| Transplants
(May cover these and others listed)
|
Lifetime benefit of $500,000
Bone marrow, musculoskeletal, corneal, kidney, heart,
liver, kidney/pancreas, heart/lung, and lung
|
100%
Bone marrow, musculoskeletal, corneal, and kidney
|
100%
Bone marrow, musculoskeletal, corneal, and kidney
|
80%
Bone marrow, musculoskeletal, corneal, and kidney
|
| Mental Health3 |
Inpatient 30 days
Outpatient 100%
Transitional 100%
|
Inpatient 120 days
Outpatient 90%
Transitional 90%
|
Inpatient 120 days
Outpatient 90%
Transitional 90%
|
Inpatient 120 days
Outpatient 90%
Transitional 90%
|
| Alcohol, & Drug Abuse3 |
Inpatient 100% to $6,300
Outpatient 100% to $1,800
Transitional 100% to $2,700
|
Inpatient 90% to $6,300
Outpatient 90% to $1,800
Transitional 90% to $2,700
|
Inpatient 90% to $6,300
Outpatient 90% to $1,800
Transitional 90% to $2,700
|
Inpatient 90% to $6,300
Outpatient 90% to $1,800
Transitional 90% to $2,700
|
| Hearing Exam |
100% |
Benefit for illness or disease, 100% |
Benefit for illness or disease, 100% |
Benefit for illness or disease, 80% |
| Hearing Aid |
80% up to $1,000 per ear, every 3 years |
No benefit |
No benefit |
No benefit |
| Routine Vision Exam |
One per year |
One per year for children under 18, 100% |
No benefit for routine |
No benefit for routine |
| Skilled Nursing Facility
(non custodial care)
|
120 days per benefit period |
100% for 730 days per admission less hospital
days used |
100% for 730 days per admission less hospital
days used |
80% for 730 days per admission less hospital
days used |
| Home Health
(non custodial care)
|
50 per year; Plan may approve an additional 50 |
100% for 365 days less hospital days used |
100% for 365 days less hospital days used |
80% for 365 days less hospital days used |
| Physical / Speech / Occupational Therapy |
50 per year; Plan may approve an additional 50 |
100%, no limit on visits or days |
100%, no limit on visits or days |
80%, no limit on visits or days |
| Durable Medical Equipment |
20% co-insurance, $500 OOP maximum |
100% |
100% |
80% |
| Hospital Pre-Certification |
Varies by plan |
Advantage Program for inpatient stays. Voluntary
2nd surgical opinion |
Advantage Program for inpatient stays. Voluntary
2nd surgical opinion |
Advantage Program for inpatient stays. Voluntary
2nd surgical opinion |
| Referrals |
In network varies by plan. Out of network required. |
In network not required. Out of network required. |
Not required |
Not required |
| Primary Care Provider |
Varies by plan |
Primary care clinic required |
Not required |
Not required |
| Treatment for Morbid Obesity |
No benefit |
No benefit |
100% |
80% |
| Oral Surgery |
11 procedures |
23 procedures. 100% |
23 procedures. 100% |
23 procedures. 80% |
| Dental Care |
Varies by plan |
Preventative up to age 12, 100% |
No benefit |
No benefit |
| Prescription Out-of Pocket Maximum4 |
$300 individual /
$600 family
|
$300 individual /
$600 family
|
$1,000 individual /
$2,000 family
|
$1,000 individual /
$2,000 family
|
1 Deductible applies to all services
except mental health
2 Coinsurance applies to all services
up to the listed out-of-pocket maximum, then 100%
3 Any benefits paid for mental health
during the year will be applied toward the alcohol and drug abuse
maximums.
4 Separate from other out-of-pocket
maximums, such as the medical
|
