advantage
Dental and Vision Products — A Good
Strategy for You and Your Clients
Adding PacifiCare Dental and
Vision plans to the mix of products that you offer your clients can be
a good strategy — both to meet the
needs of employers and to add to your
own bottom line.
In these times of rapidly escalating
premiums, employers of all sizes
must be mindful of managing costs,
yet at the same time effectively meet
the needs of their employees as they
develop benefit strategies. The addition of dental and vision benefits can
help mitigate employee concerns
about medical benefits that may be
reduced — or copayments and
deductibles that have to be raised —
for employers to manage costs. These
plans add a fraction of the cost of
medical plan premiums, yet provide a
richer, more complete benefits package that’s attractive to employees
By offering dental and vision plans on
a voluntary basis, along with medical
coverage that’s employer-paid, companies can gain additional advantages
both in maximizing benefit dollars
and in maintaining employee satisfaction. (See the sidebar for more information about PacifiCare Dental and
Vision Voluntary Dental Plans.)
When you offer PacifiCare Dental and
Vision plans alongside PacifiCare medical
coverage, you can help your clients in
many ways, including:
■ reduction
of administrative costs
■ elimination
of redundant administra-
tive and service-related processes
■ simplification
of the tasks for the
benefit administrator
of redundancy of benefits
between two plans (for example,
with complementary medical and
vision coverage)
W I N T E R ■
2 0 0 3
TA B L E O F C O N T E N T S
I-Plans Add Value .........................2
Small Group Choice....................4
PacifiCare and Costco ...................5
■ prevention
Employers want and need value for
the benefits dollars they spend.
Cross-selling PacifiCare’s dental and
vision products alongside medical
coverage can satisfy their needs —
and count toward Pinnacle Club
qualification for you. For more information about PacifiCare Dental and
Vision products, call your PacifiCare
account representative.
Find News You
Can Use — Faster
We know your time is limited. That’s
why we include these eye-catching
icons near stories of particular interest to you and your specific market
segment. Look for them in this and
future editions of Advantage.
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SG
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Individual
Small Group
Mid-Market
Voluntary Dental Plans Now Available
From PacifiCare Dental and Vision
PacifiCare Dental and Vision
recently introduced Voluntary
Dental PPO Plans — for all sizes of
employer groups. These plans, also
known as employer-endorsed
plans, let businesses offer dental
benefits to employees without
incurring premium costs.
Key features of the Voluntary PPO
plans include:
■ incentives
that encourage in-network use of provider services
■ specialty
■a
very competitive fee schedule as
the basis for payment
“As employers feel the squeeze on
benefits dollars, these new plans
allow them to expand their coverage
alternatives,” says Scott Rinefort,
PacifiCare Dental and Vision manager of Product Development. “The
plans not only ease the burden of
rising costs for employers, but also
satisfy the needs of employees, who
participate at a 55 percent rate.”
care without referrals
CA
New PPO Individual Plans Offer Value, Affordability
More cost-sharing to hold down premiums, plus
Disease Management programs to increase value, are
Individual hallmarks of PacifiCare’s first-ever PPO products for
Individual buyers.
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The three new low- to mid-range plans have been launched
for a Jan. 1, 2003 effective date.
Your input has helped shape these plans, which provide a
range of premiums, deductibles and benefits to choose from.
For example, the most comprehensive plan offers low-cost
hospitalization, prescription drug coverage and maternity care,
while other plans offer higher deductibles and increased coinsurance maximums, which help to control premium costs.
“We’ve built our new Individual PPO plans to avoid complications and to deliver the features you and buyers are asking for,” said Kim Simco, PacifiCare’s director of Product
Management, Small Group and Individual Sales.
Among the features of the PPO 1000 plan are deductibles
of $1,000 per individual and $2,000 per family, coinsurance
maximums (participating providers) of $3,000 per individual and $6,000 per family, and a $30 copay for office visits
with a participating physician. (See chart below.)
Both the PPO 1000 and PPO 1500 plans include prescription drug coverage. The PPO 3000 is a low-range option,
offering the most affordable premiums.
For all three PPO plans, we are also introducing a modified rating
structure in which applicants can be placed at the standard rate,
+20 percent, +50 percent or declined. In addition, PacifiCare
will pay for all medical record requests effective Jan. 1, 2003.
In the meantime, if you have questions or comments, our
Individual Sales representatives are available at (800) 411-0191.
Or visit our new broker Web site at pacificare.com and
select Broker>California>Individual.
PPO* Plan Highlights
Calendar Year Deductible
Individual
Family
Coinsurance Maximum
– Participating Providers
Individual
Family
Office Visits
Participating
Non-Participating
Hospital
Participating**
Non-Participating
Rx
Participating – 100% after
Non-Participating – 50% after
Deductible (brand)
Maximum Benefit (brand)
Maternity Care
Participating
Non-Participating
PPO 1000
PPO 1500
PPO 3000
$1,000
$2,000
$1,500
$3,000
$3,000
$6,000
$3,000
$6,000
$4,000
$8,000
$4,000
$8,000
$30 copay
70% after deductible
50% of limited
fee schedule
after deductible
$30 copay (maximum 4
Office Visits per year)
50% of limited
fee schedule
after deductible
70% after deductible
50% after deductible
up to $1,000 maximum
per day
80% after deductible
50% after deductible
up to $500 maximum
per day
70% after deductible
50% after deductible
up to $500 maximum
per day
$10 generic/$35 brand
$10 generic/$35 brand
$100
$20 generic/$35 brand
$20 generic/$35 brand
$100
$1,000
Not covered
Not covered
Not covered
70% after deductible(s)
50% of limited fee
schedule after
deductible(s)
Not covered
Not covered
Not covered
Not covered
CHART
50% of limited
fee schedule
after deductible
*PPO plans are underwritten by PacifiCare Life and Health Insurance Company.
**An additional $500 applies for standard participating hospitals.
CA
2
Reap Rewards With 2003 Bonus Programs
PacifiCare is proud to announce its special bonus program for 2003. It’s our way of saying “thank you” to our
brokers, who play a key role in our success.
Large Group
The following new group bonus programs offer quarterly
cash bonuses. The program runs from Jan. 1, 2003, through
June 30, 2003.
PPO Program — For each new group with 25 to150
employees, you’ll receive a $2,000 bonus. New groups with
151 to 350 employees result in a $7,000 bonus. The top
bonus is $10,000 for groups with 351-plus employees.
HMO Program — For each new group with 100 to 299 medical
members, brokers will receive a $1,000 bonus. Groups with 300
to 699 medical members represent a $2,000 bonus. The top
bonus is $4,000, for groups with 700-plus medical members.
Here’s a look at PacifiCare’s Broker Bonus programs for 2003:
Small Group
New Group Bonus Program — As in 2002, Small Group
brokers who enroll a minimum of 50 new medical members
with effective dates of Jan. 1, 2003, through June 30, 2003,
will receive a quarterly bonus. The bonus is $30 per new
medical member for PPO sales and $15 per new medical
member for HMO/POS sales. Bonus is paid retroactive from
the first enrolled member.
Small Business Retention Bonus Program — This program runs from Jan. 1, 2003, through Dec. 31, 2003, and
rewards high retention rates. For example, brokers with 400
to 499 members and a retention rate of 95 to 109 percent
will receive a $1,000 bonus for the quarter. Brokers with the
same number of members and a 110 percent or higher
retention rate will earn a $1,500 bonus.
The more members you have, the higher the bonus.
Brokers who reach 1,000 or more members with 90 percent to 99 percent retention will attain “Signature Club”
status and receive a $6,500 bonus. Those with Signature
Club status who have a 100 percent or greater retention
rate will receive an $8,000 bonus.
Dental & Vision Bonus Program
Bonus programs for small and large brokers for Dental or
Vision product sales based on case size, with effective dates
of Jan. 1, 2003 through Dec. 31, 2003. What you’ll earn:
Case Size Members
Under 50
Bonus
$50
50-99
$100
100-299
$150
300-699
$300
700+
$600
For complete information on any of these bonus programs,
please contact your PacifiCare sales representative.
CA
3
Small Groups Enjoying Wider Range of Choices
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Small Group
When you encouraged PacifiCare to expand our
health coverage options, not only did we listen,
we responded.
And now our new Choice Series is meeting the needs of
small groups with 10 or more enrollees. What’s more, our
HMO/PPO Dual Option product is extending the level of
choice we offer groups with at least two enrollees.
Our Choice Series plans, launched last year, offer the flexibility and wider options you and your clients are looking for
in Small Group coverage. Small groups with 10 or more
enrollees can select any combination of four plans from a
menu of seven plan options — four HMO and three PPO.
Our Indemnity plan is also available for those outside of the
national PPO service area and is not included in the fourplan maximum. The specific plans to choose from are the
HMO 10, HMO 15, HMO 20 and HMO 30, as well as the
PPO 80/60-250, PPO 70/50-250 and PPO 80/60-500.
Employers with at least two enrollees can select the
HMO/PPO Dual Option product and choose one HMO and
one PPO plan from the same list of seven plan options.
“Our broader choice of plans distinguishes us from our
competition,” says Kim Simco, PacifiCare’s director of
Product Management, Small Group and Individual Sales.
“We’re confident that our portfolio of products meets the
varied needs of small business owners, and we anticipate
great success in 2003.”
To learn more about the Choice Series or Dual Option products,
contact your PacifiCare Small Group sales representative or go to
pacificare.com and select Broker>California>Small Market.
Revised Prescription Drug Benefit for Small
Business and Individual HMO and POS Plans
Effective Jan. 1, 2003, all forms of medications
prescribed for the treatment of sexual dysfuncIndividual Small Group tion, which includes, but is not limited to,
erectile dysfunction, impotence and anorgasmy or hyporgas-
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SG
my, will be excluded from all Small Group and Individual
HMO and POS prescription drug benefits. An example of such
medications would include Viagra. For more information,
please contact your PacifiCare account representative.
New ID Cards for PPO Enrollees
Just so you know … keeping personal information secure
and protecting our enrollees’ privacy rights are important
— and these issues are among our top priorities. In
response to state and federal regulations, we will be changing the PacifiCare identification number for all PPO
enrollees this spring. PacifiCare will be replacing existing
PacifiCare ID cards and changing the identification numbers
from enrollees’ Social Security numbers to a new number.
For more details, see the related story “Simple Steps Help
Meet Privacy Mandates” on Page 6.
CA
4
A ‘Perk’ for Every New Year’s Resolution
It’s a new year, and you know what that means:
New Year’s resolutions. At PacifiCare, our resolutions
haven’t changed. We’re still committed to providing our
members with even more value for their health care dollar.
That’s why we would like to remind you about PacifiCare
PerksSM*, a special members-only program that’s part of
Women’s Health Solutions. Under the PacifiCare Perks program, we contract with outside vendors to help members save
on a broad array of health-related products and services.
These “Perks” are separate from benefit plans and are available
to all commercial members at no additional plan premium.
And speaking of resolutions, our Perks program can help
members meet a wide range of New Year’s goals. Here’s a
brief look at what we offer:
Fitness & Weight Management — Members determined to
shed extra pounds in 2003 can use this Perk to get discounts on Weight Watchers® fees (in Ariz., Calif., Colo. and
Nevada only), health club memberships, and on DietMate®
handheld computerized weight-management tool.
Healthy Moms & Kids — This Perk gives new and expectant
parents discounts on a host of items, including Clear Plan
Easy™ fertility monitors, breastfeeding accessories, infant
carriers, Safe Beginnings® family safety products and more.
In addition, moms (and others) who have resolved to kick
the smoking habit in 2003 can take advantage of discounted
LifeSign® smoking cessation products.
Complementary & Alternative Care — Those who resolve
to cut back on the stress in their lives can get special discounts on Spa Wish gift certificates and vitamins, as well as
audio and video tapes on yoga, Tai Chi and massage.
Healthy Home — The new year is the perfect time to do a
home safety check. Using this new Perk, members save on
such items as fire extinguishers, air purifiers, water filters
and carbon monoxide detectors.
how childproof your home is. Parents will save on such
important items as crib mattresses, safety gates, outlet covers, smoke detectors, door locks and more.
Pharmacy & Personal Care — This year, don’t make so
many trips to the pharmacy. Instead, members can save time
and money by ordering over-the-counter medicines and
cold remedies through the mail.
Vision & Hearing — Many people neglect hearing and eye
exams. With our Perks program, members receive 35 percent off of hearing aids and can get a comprehensive hearing exam for only $25 through Newport Audiology Centers.
Discounts also are available on eye exams, LASIK eye
surgery (in some states), glasses and contact lenses.
The PacifiCare Perks discounts vary from vendor to vendor
and are subject to change. In most cases, members access
the discounts by simply contacting the vendor directly. For
more information, contact your PacifiCare sales representative or visit pacificare.com.
*If your current PacifiCare coverage includes benefits for products or services
described herein, these discounts do not apply. Discounts described herein are
only for enrollees who do not have a covered benefit or have exhausted their
benefits. Enrollees would not receive an additional discount over and above
the covered benefit that their employer has purchased for them. Vendor participation and actual, usual and customary charges may vary on a location-bylocation basis. Discount does not apply to sales tax or shipping charges, and
cannot be combined with any other discounts. Certain items may be excluded from discount. PacifiCare does not endorse or guarantee products noted.
If you are hearing impaired, please call one of the
following numbers as appropriate:
California: (800) 442-8833; Colorado: (800) 659-2656;
Arizona and Nevada: (800) 360-1797; Texas and
Oklahoma: (800) 557-7595; Oregon and Washington:
(800) 786-7387
Child Safety — The new year is also a good time to assess
Brokers Benefit from PacifiCare
Partnership with Costco
PacifiCare recently entered into an agreement with
Costco to offer low cost PPO plans to their Executive
Small Group Small Business members. The California Department
of Insurance approved Costco as a purchasing alliance and
PacifiCare’s PPO plans were chosen as the benefit plans for
the program in selected counties in Southern California.
SG
If you have Small Group clients (50 or fewer employees)
who have Costco Executive memberships, you can offer
them this program. PacifiCare worked in partnership with
Costco to develop two PPO options. You are an important
part of this sales process, and will receive a 5 percent flat
commission on every new group you bring into the program. Business written through this program is eligible for
PacifiCare’s Small Business new group and retention bonus
programs. Plus PacifiCare will continue to pay you 7 percent
on any of your in-force PacifiCare Small Group businesses
electing this program.
Currently available in Los Angeles, Orange, Riverside, San
Bernardino, Ventura, San Diego and Santa Barbara counties,
(continued on Page 6)
CA
5
Simple Steps Help Meet Privacy Mandates
Protecting the privacy of our members is a priority
at PacifiCare. These protections are not only a matter
of ethics, but also of law, and we need your help to
ensure compliance.
You’re probably well aware that the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) mandates
protection of individually-identifiable health information
which relates to an individual’s physical or mental health,
health care treatment or payment for health care treatment.
Anyone who comes in contact with member Protected
Health Information (PHI) is affected.
It’s important to know that member-specific information
covered by HIPAA’s privacy provision doesn’t just include
diagnoses and conditions. Protected Health Information
includes, but is not limited to, the following identifiers:
■
■
■
■
■
Member name
Address
Social Security number
Member ID number
Phone number
The Privacy Ruling becomes effective April 14, 2003, and we
want to make you aware of some specific ways HIPAA will
impact your handling of PacifiCare member information
which can be linked to an individual.
Currently, brokers contact PacifiCare on behalf of the enrolled
members in order to assist with customer service issues such as
claims resolution, enrollment and eligibility. Although these services are part of health care operations, when HIPAA becomes
effective, the broker will be required to obtain an authorization
from the member before PacifiCare will be able to release PHI.
If you perform business functions on behalf of PacifiCare,
you will be asked to sign a Business Associate agreement as
an addendum to your existing contract with PacifiCare.
The HIPAA Privacy Rule requires everyone who has contact
with Protected Health Information to use appropriate
administrative, technical and physical safeguards. Safeguards
may include, but are not limited to:
■
■
■
■
■
Locked file cabinets
Restricted access to electronic information
Locked storage/microfilm/scanning rooms
Shred bins
Limited facility access
Reasonable efforts should be made to limit PHI to the minimal amount of information necessary to accomplish your
business. For more information on HIPAA’s privacy rules and
government guidance on specific requirements, go to
www.hhs.gov/ocr/hipaa. For further assistance or questions,
please contact your PacifiCare representative.
PacifiCare Partnership with Costco ... (continued from Page 5)
the PPOs have the same underwriting guidelines as our
other Small Group products. The only requirement is that
clients must be Costco Executive members.
Please contact your local PacifiCare Small Group representative for more information or visit the Costco Web site
(www.costco.com).
P.O. Box 6006
Cypress, CA 90630-6006
To find it:
■ Click on “Services”
■ Scroll down to “Services for Your Business”
■ Click on “Health Insurance”
■ Select “California”
To sign a client up for one of the Costco PacifiCare PPOs,
call the Costco Call Center at (866) 235-5300.
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