advantage
S P R I N G
HIPAA Is Here —
Are You Compliant?
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TA B L E O F C O N T E N T S
Voluntary Product Lines ..............2
The date to be fully compliant
with the privacy and security regulations within the federal Health
Insurance Portability and Accountability
Act (HIPAA) was April 14, 2003. All
health plans, provider groups, self-funded employer groups and business associates, including PacifiCare brokers,
should have implemented procedures
related to Protected Health Information
(PHI) of individuals. PHI includes not
only medical records, but also social
security numbers, employee ID numbers, or any information that identifies
an individual.
PacifiCare has been working for the
past two years to assure policies and
procedures related to PHI are in place
for the company, our brokers and our
other business associates. Brokers
were sent a new agreement that
addresses the use and disclosure of
PHI and the broker’s responsibility as
a PacifiCare business associate in soliciting new business and renewing existing business. The business associate
agreement will include guidelines for a
broker acting on behalf of a member.
The privacy regulations limit the release
of any information without the express
consent of the individual. Individuals
may have access to their own health
records and have the right to request
amendments and corrections. Under
the regulations, other parties have
access to information on an individual,
limited to the “minimum necessary” to
complete transactions on behalf of that
person. From a practical standpoint,
the privacy regulations mean any information that can identify an individual
must be secured or destroyed in an
appropriate manner, including locking
file cabinets, shredding documents, and
assuring faxes and e-mail messages
have compliance language. To ensure
that we all comply with the law, the
government has specified both criminal
and civil penalties for improper use
and disclosure of PHI.
The privacy regulations are the latest of
a number of HIPAA regulations to be
implemented since Congress passed the
act in 1996. Portability of health insurance, enhancements to COBRA benefits,
certificates of creditable coverage, and
modifications to pre-existing limitation
clauses are all changes that have been
2003 Bonus Programs.................4
Ancillary Coverage.......................6
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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Individual
Small Group
Mid-Market
part of the HIPAA regulations.
The final phase of HIPAA, the standardization of electronic health care transactions, becomes effective October 2003.
The automation of business processes,
such as enrollment and claims administration, is designed to reduce costs by
providing electronic transactions in place
of paper transactions. PacifiCare is also
working to meet this final phase of
HIPAA compliance, and we will keep our
employer groups and business associates
updated on the changes as they near.
For answers to questions about the
privacy regulations or other aspects of
HIPAA related to PacifiCare business,
contact your PacifiCare representative.
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Innovative Program Delivers
Voluntary Products to Employees
Traditional, paper-based communications don’t work
well to help employees understand their insurance
needs or how voluntary products work to meet their
needs. Many employees don’t read the materials so they
don’t know these products exist — or understand how
they work — and don’t enroll.
That’s why PacifiCare has launched an exciting new program
for delivering voluntary products to employees. The program,
“PacifiCare’s Employee Choice,” uses worksite marketing to
inform employees about voluntary products and help them
enroll in those products that fit their needs. It was introduced
April 1 in California.
“Voluntary products fill an important need because they supplement employees’ coverage without any added cost to the
employer,” explains Joe Smith, vice president of commercial
Product Development for PacifiCare. “Under this new program, we’ll be able to help many more consumers understand and take advantage of these products.”
be introduced in stages. On the basis of research detailing
employee and broker preferences, PacifiCare will initially offer
select, high-demand voluntary products in the first year, and
then progressively offer new products in subsequent years.
PacifiCare’s voluntary products can be a great
way to help employers bridge the gaps in the
benefits coverage they provide to employees.
In the first year, dental coverage, Healthy Renewal PassSM and
universal life insurance will be offered. In subsequent years,
the product offering may include vision, disability income, a
drug discount program, and critical illness coverage.
What Role Do Brokers Play?
You’ll receive commissions on everything sold through
PacifiCare’s Employee Choice. Your main role: Help us identify employer groups that are good prospects for the program,
and then introduce these groups to our sales force.
“Brokers play a critical role because they have the relationships with the employer groups and understand whether a
voluntary product offering fits within that employer’s benefits strategy,” Smith notes. “We need their help in finding
prospects. But the bulk of the work — the on-site
enrolling and seminars — will be handled by the enrollment specialists.”
PacifiCare is willing to partner with those brokers who have
their own worksite marketing force or current voluntary offerings that could be added to the portfolio, he adds.
How Does It Work?
Under PacifiCare’s Employee Choice, working with the broker
and employer, professional enrollment specialists will go into the
workplace to enroll individual employees into voluntary products. A suite of products will be offered on an “a la carte” basis.
The enrollment specialists introduce and explain the products to employees, and then work with employees one-onone to help determine what’s best for them and their families. They also help employees complete any paperwork
required in the enrollment process.
To avoid overwhelming employees with choices, products will
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Who is a good prospect for PacifiCare’s Employee Choice?
We’re looking for 51+ groups that do not have dental coverage or are looking to reduce or eliminate dental coverage.
“The brokers we’ve talked with are very excited about this
program,” Smith says. “They realized that this program not
only brings in additional income, but also helps them meet
their clients’ need to provide a comprehensive benefits program to their employees while managing costs.”
For more information, contact your PacifiCare sales representative, or visit our broker Web site at www.pacificare.com.
When Your Clients Ask for Self-Funded Products,
Do You Offer PacifiCare?
PacifiCare’s suite of self-funded products provides
one-stop shopping for brokers and clients.
site, Live Assist® and 24-Hour Health Information Audio
Library with Nurse Line)
If you’ve been looking for a new set of solutions to offer
your clients, look to PacifiCare. Our self-funded suite of
products offer a broad range of solutions: PPO, Indemnity,
Retiree, Self-Directed Health Plan (SDHP), and coming soon,
the Exclusive Provider Organization (EPO).
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Case Management
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Preauthorization
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PacifiCare PerksSM
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Women’s Health SolutionsSM
Through our Administrative Services Only (ASO) capabilities,
PacifiCare offers your clients the flexibility to self-fund their
benefits while PacifiCare administers the same level of service
they have come to expect from a leading health and consumer
services company. Our suite of ASO products is a one-stop
resource for administrative and medical management services,
provider networks, funding mechanisms and Stop-Loss coordination. Self-funded products from PacifiCare feature:
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Internet access
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Self-funded products from PacifiCare featuring buy-up
options so you can create a health plan as unique as the
people who work for you
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Health and Disease Management programs
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COBRA administration
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Personal AssistantSM for plan participants
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SignatureExpressSM, an internet-based benefits administration solution
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A Solution for Caregivers
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State of the art funding — through our partnership with
JP Morgan Chase Bank, we provide simple and efficient
funding through a streamlined daily billing and reconciliation process.
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Flexible Stop-Loss coordination — PacifiCare’s ASO is
able to provide a seamless interface between your medical
plan and Stop-Loss coverage.
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Enhanced customer service — for employers and plan
participants alike.
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Express Track® Installation — We are committed to
expediting the generation of proposals, the application
process and ID card issuance.
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Reporting information — offering the data clients need
to manage their cash.
For more information on PacifiCare’s self-funded products,
contact your PacifiCare representative.
PacifiCare self-funded products offer quality value programs
at no additional cost, including:
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24-Hour Health Information program (Interactive Web
Co-Brand Your Web Site With PacifiCare
Now you can offer your clients the convenience of
linking to the PacifiCare Web site for quotes, collateral
materials, and a host of information about our Small Group
and Individual plans. Clients simply surf over to our site
after clicking on a unique URL address posted on your Web
site. Or e-mail the URL to your clients and invite them to
take a look.
Creating the co-branded Web site is easy. Just log on to the
Small Group and Individual site at www.pacificare.com.
Click on “create my personalized Web site” and you’ll be
walked through the steps. It takes just a few minutes —
and there’s absolutely no cost involved.
If your clients appreciate self-service capabilities, they’ll
appreciate the PacifiCare link on your Web site. For more
information, visit www.pacificare.com, go to the broker
portal and register (if you haven’t already) at the Small
Group and/or Individual segment.
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Reap Rewards With 2003 Bonus Programs
Every year PacifiCare offers a variety of special bonus programs for its brokers, with rewards ranging from cash
bonuses to a resort getaway. It’s our way of saying “thank
you” to our brokers, who play a key role in our success.
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PPO Program — For each new group with 25 to 150
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+ employees.
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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+ medical members.
Pinnacle Club
This is our highest honor for brokers and consultants. Brokers
who earn a spot in the select Pinnacle Club group win a resort
getaway. The trip destination for 2003 winners is the Four
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Life & Disability Bonus Program
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 first enrolled member.
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Small Business Retention 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 percent 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.
Large Group
The following new group bonus programs offer quarterly
cash bonuses. The program runs from Jan. 1, 2003, through
June 30, 2003.
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With PacifiCare’s New Life & Disability Product Sale
Program, you can accumulate bonuses based on the
number of employees you enroll for each product line,
STD/LTD and Life/AD&D for the period of Jan. 1, 2003
through Dec. 31, 2003. Here’s what you’ll earn:
Employees Enrolled
Bonus
250- 500
$500
501-1,000
$1,250
1,001 – 2,000
$3,000
2,001+
$4,000
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
Bonus
Under 50
$50
50-99
$100
100-299
$150
300-699
700+
$300
$600
PPO Plans Now Offered for Individuals
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Looking for PPO options for Individual buyers?
PacifiCare now offers an array of PPO plans for
the Individual market.
Individual
The three low- to mid-range plans were introduced on
Jan. 1, 2003, and feature a range of premiums, deductibles
and benefits to choose from. “We used brokers’ input to
design these plans,” explains Shawn Veith, supervisor of
Individual Sales. “So they contain the features that brokers
and buyers want most.”
Each of the plans has a different deductible. The PPO 1000
plan is the most comprehensive option, with a deductible 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. It also includes prescription drug
coverage and maternity care.
The PPO 1500 plan includes prescription drug coverage
and has a deductible of $1,500 for individuals and $3,000
per family. It does not cover maternity care. The PPO 3000
is a low-range option and offers the most affordable premiums. It features a $3,000 deductible per individual and
$6,000 per family, and no coverage for prescription drugs
and maternity care.
The PPO 1500 and PPO 3000 plans both have increased
coinsurance maximums — $4,000 per individual and $8,000
per family — to help control premium costs.
All the PPO plans include a new, modified rating structure.
Under this structure, individuals who don’t qualify for the
standard rate can be placed at plus 20 percent, plus 50
percent or declined. In addition, PacifiCare now pays for
all medical record requests for the HMO and PPO plans.
For more information, contact our Individual Sales
representatives at (800) 411-0191. Or visit our new
broker Web site at www.pacificare.com. Select
Broker>California>Individual.
PacifiCare to Unveil New
Convenient, Consolidated Billing
We are always looking for ways to help you better
serve our mutual customer, the employer groups. To
that end, we’ve made several enhancements to our current
billing process.
Starting with June premium invoices, which mail in May, all
employer groups will notice our new, easy-to-read billing
format. This service will be especially beneficial to those
groups offering multiple products, including HMO, PPO,
life, dental and vision plans, where the new billing invoice
has been standardized across products. Employers also have
the option to consolidate all their bills into one.
By signing up for consolidated billing, employers will
receive one invoice for all their PacifiCare products,
instead of the separate bills they currently receive. There
is no additional cost for this format and you need do nothing more than remind your clients about this great new
feature and highlight it to prospective clients. We’ll take
care of the rest!
For more information about consolidated billing or any
of the other great new benefits in store for your customers with PacifiCare’s online services, contact your
Sales representative.
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One-Stop Shopping With Ancillary
Coverage Marketed Through PacifiCare
As PacifiCare expands its scope to become a consumer
services company — and not just a medical coverage
carrier — we encourage you to think of us as a single
source for benefits for your employer clients. The products
we make available now include dental plans (the number
two benefit requested by employer groups), vision plans,
and Life and Long-Term Disability coverage in all states
where PacifiCare offers medical coverage.
Offering ancillary products marketed by PacifiCare, alongside our medical coverage, provides an opportunity to
increase your level of business and commissions with us,
both with your existing book of PacifiCare business and with
new clients.
Since your PacifiCare sales team is now your single point of
contact, both for medical coverage and ancillary products,
you’ll find it easier to get information and answers about
ancillary products. Our sales executives have become
employee benefits experts, trained in the full line of products marketed by PacifiCare. This knowledge can bring
added value to you and your employer clients.
For employers, purchasing ancillary benefits through
PacifiCare can provide several advantages. Sourcing multiple
employee benefits from one vendor makes it easier for
employers to holistically analyze their entire benefits package. In addition, employers experience ease in administration, with uniform guidelines among products.
Another positive point — for you and your employer clients
— is that ancillary products marketed by PacifiCare are market-competitive. They come with quality provider networks,
service excellence and up-to-date plan designs that incorpo-
rate the features employers are looking for today. In short,
these ancillary plans are best-in-class products you can be
proud to market.
For Life and Long-Term Disability coverage, PacifiCare has
recently partnered with CNA®, a well-respected insurance
organization that has been in the group life benefits marketplace for nearly 60 years. Continental Casualty Company,
Continental Assurance Company and CNA Group Life
Assurance Company are the three CNA companies that
underwrite Group Life and Group Long-Term Disability from
CNA. CNA is a registered service trademark, trade name and
domain name of CNA Financial Corporation. CNA Group
Life and Group Long-Term Disability coverage are now available for Large Group employers and will be available to all
markets by third quarter 2003.
One-stop shopping with PacifiCare can be an advantage for
you and your employer clients. For more information about
ancillary products marketed by PacifiCare, contact your
PacifiCare account representative.
PacifiCare Ancillary Products
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Dental – HMO, PPO, Indemnity and Voluntary Plans
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Vision –PPO and Voluntary Plans
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Long-term Disability*
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Life Insurance*
*In partnership with CNA.
Broker Bonus ... (continued from Page 4)
Seasons Resort Maui at Wailea, April 21 – 25, 2004.
The program will run from Feb. 1, 2003, through Feb. 1,
2004. Here’s how you can qualify:
1. Number of new members — Top brokers from each
region with the most new members sold in their size market (Small Group or 51+) during the effective dates will
qualify. Small Group brokers must sell at least 300 new
members to qualify; Large Group brokers must sell at least
1,000 new members.
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2. Size of book of business — Top brokers from each
region with the largest book of business in their size market (Small Group or 51+) during the effective dates will
qualify. You must maintain at least an 85 percent retention
rate. Large Group brokers must also have a minimum of
1,250 members in the 51+ market.
For complete information on any of these bonus programs,
please contact your PacifiCare sales representative.
New Products Bear Brokers’ Mark
Brokers no doubt will be pleased with the new
PacifiCare products and improvements for small businesses since they had a part in creating them. The following
new products and benefit enhancements to PacifiCare’s
Small Business portfolio were designed based on feedback
from our brokers. The changes are effective Aug. 1, 2003.
Two new plans — Small businesses will have two more
plans from which to choose: a high-deductible PPO plan,
and a “self-directed” plan that will allow an insured to control their health care dollars and out of pocket costs.
Enhanced PPO plans — We are changing some of our
existing PPO plans (PPO 80/60-500 and PPO 70/50-1,000) by
removing the benefit maximum on the prescription drug
benefit and adding a copayment to the office visit. And as of
Aug. 1, all groups with a PPO plan will no longer have to
pay the additional deductible for Standard Participating
Hospitals, since this tiered hospital network feature will be
removed from all Small Group standard PPO plans.
Expanding Choice — PacifiCare’s Choice series will be
even more attractive with another plan available — the PPO
70/50-1000.
Combined HMO/PPO support — Striving to make administration easier for our employer groups and brokers, we
have combined our PPO and HMO support teams for those
accounts that offer both types of coverage. Group set-up,
plus enrollment and billing functions for these groups are
now managed by one unit. Brokers can call (800) 908-9056
for information on billing and eligibility.
The Small Group Broker Service Unit (BSU) will be supporting inquiries for HMO and PPO products. Small Group brokers can call (800) 947-1672 for information on claims status, enrollment status, premium status and account activity.
Please continue to call your PacifiCare account representative for claims payment exceptions, payment/collection
negotiations, rate quotes, appeals and grievances and broker commissions.
To learn more about the new products and enhancements
or PacifiCare’s other Small Business offerings, contact
your PacifiCare Small Business sales representative or
visit our Web site www.pacificare.com and select
Broker>California>Small Market.
Make Your Home a Safer — and Healthier — Place
Many people think their home is the safest possible place
for their family. But did you know that deaths caused by
accidents at home are on the rise? The National Safety Council
(NSC) reports a fatal injury occurs in the home every 18 minutes, and a disabling injury occurs every four minutes.
How do these accidents happen? According to the NSC, the
top four causes of deaths in the home are:
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solid and liquid poisonings
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falls
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fires and burns
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suffocation by ingested object
The good news? There are simple measures members can
take to avoid many of these accidents and safeguard their
homes. Since June is National Safety Month, it’s the perfect
time for members to do a home safety check, and PacifiCare
can help. With our newest PacifiCare PerksSM program —
Healthy Home & Child Safety — it’s easier than ever for
members to protect their homes.
Savings on Safety
PacifiCare PerksSM is a special, enrollees-only program that’s
part of our extensive Women’s Health SolutionsSM initiative.
With PacifiCare Perks, we offer our members discounts
through vendor arrangements on a wide variety of health
products and services. These discounts are separate from
members’ benefits plans and are offered at no charge — the
only cost is what members spend on the discounted products offered by the vendors.
The Healthy Home & Child Safety Perk helps PacifiCare
members save money on hundreds of safety products,
including:
Childproofing products — Members receive a 20 percent
discount on items from the Safe Beginnings® catalog and Web
site (www.safebeginnings.com), including safety gates, outlet
covers, door locks, window guards and cabinet latches.
Family safety items — Also through Safe Beginnings®,
members can receive discounts on such must-have items as
fire extinguishers, smoke detectors, carbon monoxide detec(continued on Page 8)
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Making Your Home a Safer —and Healthier — Place ... (continued from Page 7)
tors and first aid kits.
Emergency supplies — Part of having a safe home means
being prepared for an emergency or natural disaster.
Members save 10 percent on hand-generated flashlights,
waterproof matches, fuel bars, 72-hour kits and other items
from Emergency Essentials® (www.beprepared.com).
Healthy home products — Through our contract with
Allergy Buyers Club, members save 5 percent on such products as air purifiers, dehumidifiers, crib mattresses, water filters and non-toxic toys.
More Perks
PacifiCare offers several other Perks as well, including
Healthy Moms & Kids, Vision & Hearing, Fitness & Weight
Management, Pharmacy & Personal Care and
Complementary & Alternative Care.
Keeping Your Family Safe
The National Safety Council offers a library of home
safety information on its Web site, www.nsc.org. Here’s
a sample:
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The fire extinguisher in your kitchen should be rated
for grease fires and electrical fires.
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Place smoke detectors outside of sleeping areas and
on every level of your home.
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An unguarded window opened only five inches poses
a danger to children under 10.
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Even if your medicine cabinet is “high up,” a child may
still reach it.
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Besides cleaners and medicines, lock away such products as mouthwash, hair spray and perfumes.
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Store visitors’ coats and purses in a place where children cannot reach them.
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Women’s Health Solutions reflects PacifiCare’s commitment to improving the health and health care experience of
women and the people they care about. For more information on Perks and other programs, visit the Women’s Health
Solutions area at www.pacificare.com.
P.O. Box 6006
Cypress, CA 90630-6006
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Santa Ana, CA