Week 1: General Information and Cost Containment Systems

General Information (15 minutes)

  1. Identify the number, as of June 30, 2009, of total covered persons and Massachusetts-residing covered persons for whom you administer benefits under the following plans:
    1. Insured Plans
      1. Medium-Large Group (Employers with over 50 employees)
      2. Municipal/State/Federal Groups
      3. Small Group/Individual (Employers with fewer than 50 employees/Individuals)
    2. Self-Funded Plans
      1. Medium-Large Group (Employers with over 50 employees)
      2. Municipal/State/Federal Employees
      3. Small Group/Individual (Employers with fewer than 50 employees/Individuals)
    3. Government Programs
      1. Medicare
      2. Medicaid
      3. Other

  2. Identify the revenue generated between July 1, 2008 and June 30, 2009 for the following:
    1. Insured Plans
      1. Medium-Large Group (Employers with over 50 employees)
      2. Municipal/State/Federal Groups
      3. Small Group/Individual (Employers with fewer than 50 employees/Individuals)
    2. Self-Funded Plans
      1. Medium-Large Group (Employers with over 50 employees)
      2. Municipal/State/Federal Employees
      3. Small Group/Individual (Employers with fewer than 50 employees/Individuals)
    3. Government Programs
      1. Medicare
      2. Medicaid
      3. Other
  3. Identify the service area of your offered health plan's provider network (if your company offers more than one network, please provide information separately for each network).

  4. Identify the number, as of June 30, 2009, of the following types of providers that are contractually part of the network offered by your company to small employers (if your company offers more than one network, please provide information separately for each network):
    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  5. Briefly describe the history and operational structure of your health plan.

Cost Containment (25 minutes)

  1. Who is responsible for evaluating cost containment initiatives considered by your company?

  2. Describe the process and management resources within your company involved in evaluating existing systems to identify cost savings opportunities. Please describe the timing and frequency of these reviews.

  3. Highlight the systems in your company that perform the following cost containment activities, explaining the purpose of the activity, staff involved, and relative cost and savings associated with these systems:
    1. Utilization Review
    2. Case or Disease Management
    3. Health Promotion/Education
    4. Investigation of Fraud
    5. Coordination of Benefits
    6. Provider Reimbursement Systems
  4. Highlight the cost containment initiatives that your company has implemented over the past decade identifying:
    1. How the cost containment opportunity was identified
    2. The solutions that were considered to address the problem
    3. The non-cost criteria (e.g., improved quality, effect on members) used when considering initiatives
    4. The reasons that the initiative was chosen
    5. The upfront cost in staff and financial resources to implement the initiative
    6. The annual savings realized or anticipated from implementing the initiative

  5. Highlight the cost containment initiatives that your company investigated but did not implement over the past decade identifying:
    1. The reasons that the initiative was not taken or an alternate approach was chosen
    2. The upfront cost in staff and financial resources to implement the initiative

  6. What additional cost containment initiatives have you researched or evaluated that cannot be put into place due to existing laws, regulations or other administrative barriers, identifying:
    1. The upfront cost in staff and financial resources to implement the initiative
    2. The annual savings anticipated from implementing the initiative

Follow-up Questions