TITLE
Title
2017 HEALTH PLAN UPDATES
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SPONSOR
Sponsor
John Dean (Carol Campbell)
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BACKGROUND
Background
While there are no significant proposed plan changes for 2017, and no medical or dental rate increases for employees or pre-65 retirees are recommended, there are a few changes made necessary due to statutory and plan issues that may affect a very limited number of employees that need to be addressed, including the following:
1. Currently, treatment of Autism Spectrum Disorder is specifically excluded in the Guilford County health plan. Last year NCGS 2015-271 set forth the requirement that such exclusions be removed and that Adaptive Behavior Treatment for Autism Spectrum Disorder be a covered benefit for plan years beginning on or after July 1, 2016. According to the statute, the same deductible, copayment and coinsurance percentages should apply as those currently in place for mental and physical health services for in and out of network services, but may be limited to $40,000 per year (to be indexed in future years). The statute allows for coverage of these services to be discontinued when the person reaches age 18.
2. Discrimination in certain health programs or activities on the basis of race, color, national origin, sex, age or disability has long been prohibited by federal law. Section 1557 of the Affordable Care Act sets forth that the application of long-standing civil rights nondiscrimination laws applies to health plans and extends to gender transition services. The Guilford County plan currently excludes coverage for these services. It is recommended that this exclusion be removed and replaced with notification and pre-authorization criteria as set forth in the attached.
3. Diseases that require treatment with specialty medications are particularly difficult to manage. Specialty pharmacy costs continue to rise, with some medications costing as much as $100,000 for a 3-month course of treatment. United Healthcare (UHC) has a Specialty Pharmacy Program that will assign a case manager to each person taking these medications to serve as a resource for questions and concerns related to side effects and medication management, provide a single source for purchase, deliver medications directly to the employee at home or an alternate address, help participants manage their diseases more effectively, and protect these fragile medications from damage during shipping. By limiting the supply to thirty (30) days, the program helps the plan limit waste when a medication regimen is modified or discontinued. It is recommended that Guilford County enroll in this program. UHC projects that savings from this program will be approximately $300,000 per year.
4. Periodically UHC makes changes to its formulary. The tier changes (for instance, when a drug is going from a Tier 1 to a Tier 3 medication) are automatic. However, as a self-funded health plan sponsor, the County can choose whether or not to follow the recommendation to exclude prescriptions as UHC suggests. There is a full list of the exclusions and tier changes in the attachments, but only the following medications scheduled for exclusion are currently being taken by participants:
(a) Diabetes drugs Lantus and Lantus Solostar are scheduled for exclusion, but not until April 1, 2017, to allow adequate transition time. Forty-one (41) plan participants are currently using these medications. These Lantus products will be replaced by Basaglar, which is a follow-on biologic for Lantus.with the same active ingredient. It will be available to participants with a cheaper copay ($7 vs. $50). Moving forward with this exclusion will result in a projected annual savings to the plan of $20,500.
(b) Pain medications OxyContin and Butrans are scheduled for exclusion effective January 1, 2017. Both medications have several lower cost options available. Seven (7) plan participants are affected by the exclusion, which is projected to save the plan $12,600 annually.
(c) Prescription emolients that are mixed by a pharmacist to treat skin conditions are scheduled for exclusion January 1, 2017. There are lower cost over-the-counter products available. Three (3) plan participants will be affected by this exclusion, with an estimated annual plan savings of $12,100.
5. The statutory limit for the medical flexible spending plan has increased from $2,550 to $2,600.
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BUDGET IMPACT
...Budget Impact
NO ADDITIONAL COUNTY FUNDS REQUIRED
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REQUESTED ACTION
Requested Action
Approve the following: 1.) Remove exclusions for Adaptive Behavior Treatment for Autism Spectrum Disorder and mirror copayments, deductibles and coinsurance for this treatment with those that apply to other physical and mental health services. Provide coverage up to a $40,000 annual maximum to age 18; 2.) Remove the exclusion for gender transition services and replace with compliant language that sets forth limits and exclusions related to these services; 3.) Enroll the County's health plan in UHC's specialty pharmacy program; 4.) Accept pharmacy formulary changes recommended by UHC; and 5.) Amend the medical flexible spending plan maximum to reflect an increase from $2,550 to $2,600.
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