Gregory Nickell: Some answers for Shirlee Zerkel

From Shirlee Zerkel, December 13, 2006

Subject: Re: Questions about preventive services in Basic Plan for 2007

Dear Mr. Nickell:

Thank you for the promised response. I still do have questions and the main one is this:
Since a colonoscopy is an unusual test in that during the preventative test, work to remove polyps can actually be done. Why don't you, Medical Mutual and Aetna work on a solution as to how this test is to be paid. Why can't STRS/MM or Aetna require that the physician bill the test and the actual removal of polyps as separate parts on the same bill. The additional amount that it would cost for the removal of the polyps could then have the medical code for treatment and the test could have the preventive code.
Also when you mention 100% preventive tests, do you mean just the administering of the test, such as the surgeon in a colonoscopy or is the facility, anesthetist, etc. also covered?

Thank you again,

Shirlee Zerkel

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From Gregory R. Nickell, December 13, 2006

Subject: Re: Questions about preventive services in Basic Plan for 2007

Dear Ms. Zerkel

I am responding on behalf of Sandy Knoesel to your December 11, 2006 email request for clarification regarding the 2007 Basic Plan's Preventive Benefits.

First, I want to apologize for any confusion that has been created through your review of written material and your conversations with Medical Mutual. I understand the importance of retirees knowing and understanding their health benefits and how to best utilize them. Let's see if we can clear up your concerns.

I will try and address each of your issues.

1. Some preventive tests and services that STRS says are covered are not on the printed list from Medical Mutual. You are correct. The Medical Mutual list I believe you reference was an outline of 2007 benefits for the Plus, Basic and Indemnity Plans. It was not designed to be a complete listing of benefits. While there was a notation at the bottom of the first page that stated in part, "This document is only a partial listing of benefits", I realize based on the concerns you raise that there should have been more emphasis on subsequent pages restating that the lists were not complete.

2. About a month ago I spoke with Medical Mutual and was told that only one routine visit a year was allowed; now I am told that I can go to a GP for a routine physical and then also to a gyn for a female exam and both would be covered by the 100%. Both statements are correct assuming the claims are submitted by a network provider with either a preventive diagnosis and/or procedure code. The routine physical exam and the gynecological exam are processed as distinctly different services and therefore, both would be allowed under the 100% preventive network coverage. However, if you had a second claim submitted by the general practitioner (GP) for a routine visit, this would not be covered under the 100% preventive coverage just like the Medical Mutual individual indicated.

3. Today, I spoke with Medical Mutual about the differences in the lists and was told that STRS was to get information out to the members on the basic policy that could be taken to our doctors so they would know what is covered as routine. STRS Ohio is finalizing this document and it will be sent to 2007 Basic Plan participants soon.

4. I was also told today by Medical Mutual that the Colonoscopy is routine until they find polyps that have to be removed during the procedure. Then it becomes a medical situation, subject to the deductible in our insurance policy. Yet the retiree does not know which it will be until the test is over. Will it be no cost or will the retiree have to pay for the entire test? That is a very expensive test and the retiree's budget may not allow for such an expense. Is this a way to keep us from using the 100% routine preventive services? Let me answer the last part of your question first. I assure you there is no intent to discourage retirees from utilizing preventive services. The primary purpose of adding this benefit is to assist retirees with maintaining their health.

The 100% routine preventive services are limited to screenings, tests and immunizations. Removal of polyps is not considered to be a part of a screening/test procedure. In this specific situation, as you state, the test can transition into treatment during the screening and is billed by the provider with a code that is diagnostic rather than preventive.

I realize the treatment is expensive and it could place the individual in a difficult financial position. But, when compared to other situations where a condition is discovered as a result of a preventive test/screening it is quite similar. For example, if it was determined from a preventive EKG that you had a heart condition and later you had surgery to treat the situation, the EKG would be covered at 100% but the heart surgery would be subject to deductible and coinsurance. In both cases, you would be subject to the deductible and coinsurance for the treatment of the condition and you would not have any out-of-pocket expenses for a screening/test.

We are continuing to explore whether there are any other options to address this issue with Aetna and Medical Mutual.

5. Is this same feature also true for other preventive tests-that if an illness is uncovered by the test, then the test will not be covered 100% because it is now a health condition? Other tests are performed separately from any treatment and therefore, they would be covered at 100% assuming they are billed by a network provider with a preventive diagnosis and/or procedure code.

6. Sandy, you stated in an email to me that you were working closely with Aetna and MM concerning the coverage. I do not see that STRS and the insurance company are on the same page. STRS Ohio staff conducted multiple meetings along with joint conference calls with Aetna and Medical Mutual to ensure this benefit is processed the same between both administrators and that all parties have the same understanding. The STRS Ohio program utilized what many believe to be the best point of reference for preventive services, the U.S Preventive Services Task Force. STRS Ohio's coverage is based upon the U.S. Preventive Services Task Force's list of recommended services and is designed to cover what most physicians would see as preventive services.

7. I am not the only confused retiree, and the person at MM also has received many calls with these same questions. Again, I extend my apologies for any confusion caused by the introduction of the 100% preventive service coverage. As indicated in the answer to your first question, there is room for improvement. We constantly review our communications and will keep your concerns in mind as new materials are developed. STRS Ohio staff also contacted Medical Mutual to stress the importance of clear communications regarding the Basic Plan's preventive services.

Ms. Zerkel, I hope the information provided above answers your questions. If you still have concerns regarding the 2007 Basic Plan Preventive coverage, please contact me.

Sincerely,

Gregory R Nickell

Director, Health Care Services

nickellg@strsoh.org