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the Advantage August 2019

August 26, 2019

Cuts to Ontario’s provincial travel coverage

The Ontario government recently confirmed that the Ontario Health Insurance Plan’s (OHIP’s) limited coverage of emergency out-of-country medical costs will end effective January 1, 2020. Currently OHIP covers out-of-country inpatient services to a maximum of $400 per day for a higher level of care, such as intensive care, and up to $50 per day for emergency outpatient care and physician services. With the elimination of this coverage, the Ontario Renal Network within Cancer Care Ontario will be administering a program to help Ontario renal dialysis patients with financial aid for dialysis services when travelling abroad as of January 1.

OHIP will continue to reimburse eligible emergency out-of-country claims incurred up to and including December 31, 2019. The timeframe to submit eligible claims has not changed and is still 12 months from the date of service. Therefore, eligible claims can be submitted up to December 31, 2020.  

Note that this change will not impact the coverage provided under GSC’s travel plans – your plan members will not see any difference in their benefits or our claims adjudication process for out-of-country emergency medical claims. Updated booklet wording will be incorporated at the next reprint/repost after January 1, but wording modifications will be minimal. 

It is worth noting that GSC offers a single-trip, emergency medical travel product for individuals under 65 years of age – our SureAway™ product. SureAway is a stand-alone travel plan, not a top-up travel product, meaning it’s not intended to supplement an existing travel benefit that a plan member may already have through another health plan (through a group plan or GSC’s SureHealth product). If any of your plan members are interested in stand-alone single-trip travel coverage, information is available on the SureHealth website at surehealth.ca. From there, they can get a quote and/or apply online. They can also speak with an agent or apply over the phone at 1.866.617.4582.

Change4Life® gets a new look… part two, plus our grand prize draw

Good news – we are continuing to refresh our Change4Life portal. Part one was revealed in April of this year with a new look for the home page, log-in screen, health risk assessment, and rewards page. Part two is coming later this year bringing a refresh to all the rest of the Change4Life pages. With a clean new look and easier navigation, we are making it easier than ever to take small steps toward a healthier lifestyle and to have fun – and earn points – while doing it!

We will be running our final contest of the year in the form of a grand prize draw to encourage plan members to check out the refreshed site once it is ready… so stay tuned for more information.

 

Coming this fall… enhancements to GSC’s administrative guidelines for hearing aid claims

At GSC, we’re focused on helping our plan sponsors provide their plan members with the health coverage they need, while also ensuring the long-term sustainability of benefit plans and preventing benefits fraud and abuse. With these goals in mind, we continually look at our claims data to identify areas where guidelines and procedures can be improved. As a result of a recent deep dive into how claims for hearing aids are currently being processed and reimbursed, we will be implementing enhancements to our administrative guidelines effective October 1, 2019.

What’s changing? Updates to our claim form include removing information we no longer require and requesting additional information related to the details of the prescriber and dispenser – including their credentials. Once we implement the enhancements, we’re confident this will result in efficiencies for both GSC and providers, and will offer a much better plan member experience – a win-win!

And while the enhanced administrative guidelines are effective October 1, we will be reviewing the current reasonable and customary (R&C) fees for hearing aids as part of our standard annual review of all extended health benefits later this year. Any changes will be effective December 1, 2019, but would not factor into the reimbursement of claims for plans that include a dollar maximum for the audio benefit, as that maximum is usually less than what the R&C fee allows.

What’s being communicated? Our call data shows us that over 90 per cent of plan members contact us to verify benefit eligibility prior to ordering hearing aids, and as such, we aren’t planning to issue a communication directly to plan members. We recently communicated our updated claim submission requirements to hearing aid providers and will issue a reminder email closer to October 1. At the same time we’ve taken the opportunity to remind them of GSC’s Incentives Policy – one that applies to all health professionals, and we encouraged them to continue to contact us to verify coverage details.

If you have any questions about these updates, contact your account team.

GSC’s updated administrative guideline for non-emergency claims incurred outside of Canada

Effective January 1, 2020, non-emergency claims (such as planned dental work and professional services) incurred outside of Canada will no longer be covered by benefit plans. Emergency travel claims will continue to be assessed according to your plan’s travel benefit parameters. Plans with contract language that specifically includes these types of claims (noting this isn’t common practice), plan members whose country of residence is outside Canada, and plan members on work assignments outside of Canada, will not be affected by this update.

Why are we making this change?

Non-emergency out-of-country claims represent a very low percentage of our overall claims experience, but we have seen significant growth of these claims due to the emergence of medical tourism as a multi-billion-dollar industry. Although we have been routinely adjudicating these non-emergency claims, we didn’t see a high volume of these types of claims in the past, and they were typically for services that tended to be less expensive in foreign countries, such as major dental services. This trend, however, has shifted strongly upwards in recent years which has prompted us to look further into our data.

For example, for dental services alone, the three-year trend on our book of business shows increasing growth year over year in non-emergency paid claims incurred outside of Canada:

Year

Increase

2016 to 2017

1.8%

2017 to 2018

7.45%

2018 to 2019

15.5%

 Behind this growth is the emergence over the past 20 years of medical tourism that mainly involves individuals from high-income countries seeking treatment in low-income countries – typically to save on costs, especially if they do not have a benefits plan. Medical tourists seem to fall into one of two groups: those who go to a foreign country for treatment either for the sole purpose of treatment or as part of a holiday package, and those on holiday or visiting relatives abroad who then access treatment during their visit.

What types of claims do we see? Many are dental claims, yet most dental problems are not critical. If a person doesn’t receive a dental service immediately, it’s not likely to lead to catastrophic consequences. Most people should be able to wait until they get back to Canada to receive dental services. The majority of the extended health types of claims we see are spa-like massage treatments.

Our most prominent concern regarding these claims is that foreign providers are not listed on our provider registry. This means we can’t easily perform audits on services performed, and we are already seeing an increase in fraudulent claims activity outside of Canada. Unlike emergency travel claims where we may have the ability to negotiate pricing and to access preferred providers, these non-emergency claims present difficulties in obtaining provider credentials and qualifications for the charges incurred. We also lack insight into the quality of care, safety requirements, and disciplinary protocols of the provider’s governing body (if one exists) in the country the claim is incurred. And last but not least, the plan member’s continuity of care is disrupted.

What’s next?

Starting January 1, we will be advising plan members of this updated administrative guideline on benefit statements while allowing payment for the first non-emergency out-of-Canada claim. Subsequent claims will not be reimbursed, and plan members will be advised as such.

We will be updating our contract and booklet language to support this administrative update. The new wording will be incorporated at the next reprint/repost after January 1. For plan sponsors that want to continue to cover these types of claims on an ongoing basis, we recommend doing so via a health care spending account. Contact your account team for more information.

Recent paper describes positive outcomes for BEACON

Since August 1, 2018, GSC has been offering the BEACON digital mental health therapy program as a standard benefit within our extended health plans for plan members and their eligible dependents (age 16 and over) who are covered for mental health/counselling benefits. Using the evidence-based cognitive behavioural therapy (CBT) form of psychotherapy, BEACON can help bridge the gap in delivering effective, affordable, and accessible mental health treatment options. We first introduced BEACON in the July 2018 issue of The advantage.

Measureable outcomes are key

Measuring patient outcomes is an integral part of offering access to evidence-based psychotherapy treatment through online delivery such as BEACON. Sharing these outcomes allows GSC’s plan sponsors to fully understand the services being delivered and whether they are effective. This type of transparency allows you to consider the value BEACON provides to your plan.

BEACON recently published a blog article (https://www.mindbeacon.com/insights-for-leaders/how-beacon-digital-therapy-delivers) that highlights the results of its recent Outcomes Overview paper. Written by Dr. Peter Farvolden, Ph.D., C.Psych., BEACON clinical lead, this paper presents outcomes based on a recent sample of 1,006 participants who accessed the BEACON program.

Updated communication materials

Just a reminder that BEACON’s Communication Success Guide is a convenient resource that can help you ensure your plan members are aware of the program and the support it provides. Available at , the guide is now refreshed with new and improved content; this includes a “What to Expect with BEACON” two-minute video that shows how BEACON works from beginning to end. Click to access the guide.

GSC has also updated our plan member communications that support the BEACON program. You can find the poster, fact sheet, and “Did you know” communication at greenshield.ca/en-ca/sponsors-advisors/benefits-of-gsc/smartspend. Be sure to check them out. And if you have any questions about BEACON or need more information, contact your account team.

Coming soon…

 In addition to addressing depression, anxiety, and post-traumatic stress disorder (PTSD), BEACON will be adding the capability to address insomnia later this year.

 Insomnia is a persistent and growing concern in our society and often occurs alongside other mental health problems. About 13 per cent of Canadian adults suffer from insomnia.

 CBT for insomnia (sometimes called CBT-I) is often recommended as a first-line treatment as it helps people reset thinking and behavioural patterns that contribute to poor sleep. BEACON provides personalized therapy to every user, so along with sleep, underlying issues (such as related depression or anxiety) can be addressed as part of therapy to help achieve optimal mental well-being.

Pharmacist Deprescribing Program coming Oct. 1 

As introduced in May 2019 issue of The advantage, GSC will be launching the Pharmacist Deprescribing Program effective October 1, 2019.  

Here’s what you need to know…

Deprescribing – and the goal of GSC’s program – is the planned and supervised process of reducing or stopping a medication that is no longer helping the individual or is doing harm, while maintaining or improving the person’s quality of life.

The Pharmacist Deprescribing Program focuses on two drug categories: proton pump inhibitors (PPIs), which treat stomach acid problems such as GERD (gastroesophageal reflux disease), and benzodiazepines and z-drugs (BZRAs), which are commonly used for sleep.

Under the program, in a collaborative decision-making process with both patients and their physicians, pharmacists will identify suitable patients and offer them the opportunity to reduce or stop the applicable drugs with pharmacist support and counselling through one-on-one sessions.

Please click here to view a fact sheet that can be shared with your plan members to let them know about this innovative program.

If you don’t want this program to be included in your benefits plan, contact your GSC account team by September 8, 2019. If your opt-out request isn’t received by this date, the Deprescribing Program will be added effective October 1, 2019. Similar to other pharmacist-delivered programs, this program isn’t available in Quebec due to its regulatory environment.  

UPDATES TO GSC’S NARCOTIC PAIN MEDICATION STRATEGY

In the May 2019 issue of The advantage, we told you that GSC is making some enhancements to the way we handle narcotic pain medications. We can now confirm that the enhancements will be effective October 1, 2019. With the ongoing opioid crisis in Canada top of mind, GSC is committed to developing policies and strategies that are based on the most recent research and guidelines. As these drugs present a high safety risk to both plan members and others in the community, the changes to our Narcotic Pain Medication Strategy are designed to minimize the risk of long-term use and addiction, and to reduce the availability of opioids which have the potential for diversion.

Please click here to view the Plan Member Update that can be shared with your plan members to let them know about the changes that may impact their drug claims.

INTRODUCTION TO THE SMARTSPEND™ FORMULARY

The summer 2019 issue of Follow the Script® featured a review of the types of drug formularies offered by GSC as well as introducing our new managed formulary, the SMARTspend Formulary, which is designed to ensure plan members have access to appropriate drug treatment while maintaining the sustainability of your plan. Offering two levels of formulary management – lite and enhanced – the SMARTspend formulary will be launched October 1, 2019; contact your account team with any questions.

Click here to read the feature article in Follow the Script.