New diabetes-related claims enhancements with more improvements coming soon
In 2018, coverage for continuous glucose monitors and flash glucose monitors (collectively referred to as glucose monitoring systems or GMS) was added to benefit plans as a Green Shield Canada (GSC) standard medical device, unless an opt-out request was received from a client. At that time, plan member reimbursement of GMS was subject to an approved authorization form, a diagnosis of type one diabetes, and a minimum requirement for blood-glucose testing frequency.
To better support plan members and their access to health care, we’ve made some changes by removing unnecessary red tape from the process (all while remaining cost neutral for plan sponsors).
- Effective immediately, this benefit will no longer be subject to a prior
- Instead, we will leverage our real-time claims history data to determine if the plan member is using short-acting insulin, an insulin pump, or insulin pump supplies and therefore is insulin-dependent. If present, the GMS claim will be automatically approved if coverage is included in the benefits plan.
- If short-acting insulin, an insulin pump, or insulin pump supplies are not on file for the previous 90 days, the plan member will be required to submit a prescription with their claim stating they are insulin-dependent.
These changes will improve the plan member experience while still ensuring these devices are approved only for those plan members who truly need them. While the coverage process will change, the reasonable and customary fees and administrative guidelines – such as frequency limitations and test-strip policies – will all remain the same.
Impact to pharmacies
To date, GMS have been managed in our adjudication system (Advantage) in a way that limited pharmacies from submitting claims electronically through their software at point of sale, even though these devices and associated supplies are primarily dispensed at a pharmacy. This means that plan members have been paying out-of-pocket and submitting their claims for reimbursement themselves. While direct claim submission has been possible by the pharmacy via our online provider portal, providerConnect®, the volume of claims received has been extremely low.
As a result, we’ve updated Advantage so pharmacies can now submit these devices and supplies through their electronic software using product identification numbers (PINs). These PINs will also provide us with an opportunity to offer better direction when it comes to these devices, supplies, and provincial plans. We shared this update with pharmacies in mid-November to ensure a smooth transition and an enhanced plan member experience.
Insulin infusion pumps
As you may know, some provinces provide grant dollars towards insulin infusion pumps. In the past, applying those grant dollars has been complicated and time-consuming for an insurer. To simplify and streamline the process, we will be moving to a standard deductible process in Q1 of 2022. Depending on the grant the plan member is accessing, the deductible will be applied quarterly or biannually for the same value as the grant.
Targeted communication will be issued to impacted plan members – sharing the good news that claim processing will be easier and explaining the overall process.
Our cost containment and claims management strategies for these quickly evolving benefits is not negatively impacted by the above enhancements. We continue to manage access and are using our system capability in a better, more efficient manner to ensure we’re not creating unnecessary barriers to care.
We are committed to improved diabetes management for both plan members and plan sponsors and are confident these enhancements will result in less cumbersome claiming processes and greater access for plan members living with diabetes.
Biosimilar transitioning – Quebec update and what it means for your plan members
On May 18, the Government of Quebec announced the province’s intention to implement a biosimilar switching policy under its public prescription drug insurance plan. The new Quebec policy is expected to generate annual savings of $100 million as of 2022, which is promised to be reinvested into the health care system and improve access to innovative drug therapies.
Under Quebec’s biosimilar switching policy, patients will transition to a biosimilar under the supervision of their treating physician by April 12, 2022. The biologic originator drugs that are being phased out are as follows:
Biosimilar transitioning for Quebec groups coming in May
Prior to the announcement, we were not able to offer our Biosimilar Transition Program for groups in Quebec due to regulations that require all private insurance plans to offer basic medication insurance coverage which must, at the very minimum, include the medications covered by the public plan, i.e., those appearing on the Régie de l’assurance maladie du Québec (RAMQ) “List of medications.”
Consistent with this provincial policy change, GSC is implementing biosimilar transitioning as a standard for all groups with plan members residing in Quebec effective May 1, 2022.
Biosimilar drugs cost 15 to 50 per cent less than originator drugs. Savings realized as a result of biosimilar transitioning will flow through a plan sponsor’s drug experience and any impacts to premiums will be applied at the next renewal. Similarly, we expect that cost reductions for high-cost biologic originator claims will also be reflected in the pooled experience for plans with stop-loss insurance.
Impact to plan members
We will be notifying plan members the week of January 31, 2022, that they will need to transition to a biosimilar alternative by May 1, 2022.
Letters will be mailed to plan members who are currently taking one of the above listed targeted biologic originator drugs. We will also recommend they consult with their prescriber to change their prescription to the applicable biosimilar drug and for other transitioning support.
In accordance with RAMQ criteria, exemptions will apply to:
- Individuals who are pregnant will need to transition within 12 months after childbirth.
- Pediatric patients must transition within 12 months after their 18th birthday.
- Patients with chronic illnesses who have experienced failure to two or more biologic therapies used to treat the same condition.
Inkblot’s Access offering
With the pandemic nudging plan members towards “care that comes to them,” the situation calls for mental health services that are digital and available anytime, anywhere. As we shared in a recent GSC Update, we’re excited to lead the charge with fresh ideas and support plan sponsors in delivering robust, accessible mental health services to plan members (and their dependents).
Following is a recap of our Inkblot offerings, including the newest layer of our digital mental health strategy, called Access.
- Inkblot Direct to Consumer (DTC): Part of our Digital Clinic, GSC plan members can connect directly with an Inkblot professional via video counselling and online chat/email support. Existing benefits plan reimbursement limitations apply.
- Inkblot Employee Assistance Program (EAP): As GSC’s preferred EAP provider, Inkblot delivers the most tailored EAP experience in the marketplace, headlined by digital mental health care (including 24/7/365 crisis support) and backed by valuable additional services.
- NEW! Inkblot Access: Access is a low-cost option for plan sponsors that provides plan members with a mental health hub for rapid counselling support, plus reduced rates to stretch their benefit maximums across more sessions.
So, where do you go from here? And how do you decide which offering is the best fit for your organization? The handy chart below captures the all-important details, helping you compare the key features:
Contact your GSC account team to learn more about Access today.
Lower-cost virtual physiotherapy with Phzio Canada
In our May 2021 issue of The advantage, we shared details about a pilot with Phzio Canada to provide a digital solution to treat acute and chronic conditions while eliminating barriers associated with traditional physiotherapy care, such as time and transportation. Phzio was able to demonstrate decreased self-reported post-treatment pain levels and positive experience ratings among plan member participants.
As part of our Digital Clinic – a carefully vetted suite of virtual health services – Phzio offers preferred pricing to all GSC plan members seeking treatment with registered physiotherapists. Available across Canada in both English and French, Phzio’s pricing is much lower than a traditional treatment, at $59 for an initial visit and $49 for a follow-up visit. Better yet, all claims will be billed via providerConnect®, so plan members only need to pay out-of-pocket for the amount their plan won’t reimburse – noting all claim payments will flow through the traditional claims experience and are subject to the existing physiotherapy limitations within a benefits plan.
And don’t forget about Phzio’s MSK360 product: a self-serve resource portal – free for GSC plan members – that can be used to address and prevent musculoskeletal and ergonomic issues via videos that demonstrate stretches and best practices, like creating an ergonomically correct workspace.
You can promote Phzio to your plan members by directing them to the Phzio page on GSC’s Digital Clinic, or you can leverage it as a preferred solution to maximize existing limitations on your benefits plan – such as waiving or reducing a co-payment when accessing Phzio’s digital platform. You can also share this handy fact sheet with your plan members. Contact your account team for more information.
The new Change4Life® is here
In October we shared a GSC Update about forthcoming enhancements to Change4Life and the upcoming contest. The updated site, with new features and a fresh new look, is now live.
As a reminder, we’re encouraging plan members to check out the new Change4Life with a contest. Plan members who log in to Change4Life and earn points from November 1 to December 31, 2021, will automatically be entered (maximum one entry per day) into a draw for one of three grand prize packages valued up to $1,000 each.
There’s still a few weeks left to participate, so be sure to promote Change4Life to your plan members with this promo package, which includes materials such as a poster, a screen saver, and more.
Watch for more Change4Life updates in 2022.
Digital Clinic additions
A few weeks ago, we shared a GSC Update about exciting new additions to our Digital Clinic. GSC plan members and their dependents now have access to even more Digital Clinic solutions – and more exclusive discounts – making it easier to access safe, reliable digital health options they can count on, wherever they are.
Cross the Line – Active (CTL) – Provides virtual one-to-one personal training with diverse coaches who create tailor-made activity plans designed to help plan members achieve impressive and sustainable results. The discounted monthly fee is $40 plus applicable taxes and includes a free nutrition plan for the first month.
Daily Burn – Offers thousands of on-demand workout videos, personal fitness guidance, encouragement, and motivation. Following sign up, the first 30 days are free, and GSC plan members get a 25 per cent discount on the monthly subscription.
Manage My Pain – Is a simple and effective app used to track, analyze, and share chronic pain details so plan members can get the support they need. Downloading the app is free, and GSC plan members receive five comprehensive reports at no cost.
These new additions do not require you to add anything to your plan design – applicable fees are payable by the plan member and are not covered by a traditional benefits plan.
Bill 64 reforms privacy laws in Quebec
Quebec’s Bill 64, Act to Modernize Legislative Provisions respecting the Protection of Personal Information, received royal assent on September 22, 2021. The purpose of the bill was to reform current legal requirements in Quebec around the protection of personal data and information in both the private and public sectors. Bill 64 not only updates the current legal framework for users’ personal data and privacy rights, but also harmonizes Quebec’s privacy laws with those of other jurisdictions. Provisions under the act take effect over a period of three years that started on September 22, 2021.
Details about Bill 64 can be found on the Government of Quebec’s website.
GSC is currently assessing these changes to Quebec’s privacy laws and the impact they might have on our practices. Be assured we will make any necessary changes to meet these requirements in a timely manner.