THE DUST HAS FINALLY SETTLED

The Dust Has Finally Settled

Now that the dust has finally settled and the full implementation of Trustee Modifications to the Medical Plan come into full effect on July 1, 2006 with the 1% premium to the active members. Lets look at what we really got.

I agree that drastic changes were necessary to get the Plan on sound footing to insure its longevity and reserve stability. We have gotten in return higher co-pays linked to lower percentage coverage that end up with the participant paying 45% + or - of an routine visit expense. If your visit is $60 dollars and your co-pay is $20 dollars then the Plan pays 80% of $40 dollars or $32 dollars. The Plan has paid 54% of the bill. So for routine visits the Plan has basically cut it’s burden in half.This is where the Plan will make it's most savings.

Now lets look at Blue Shield as an Administrator of the Plan.

When you present your Insurance Card to your Provider for coverage do you know what happens after that? The claim goes to a regional Blue Shield address for direct forwarding to a Blue Shield Center for processing and not to MEBA. The Plans office does not see it until it is all over and done with. Then they get basically the same Explanation of Benefits that we receive in the mail and then process a check to the Provider and a bill for the remainder to you.

Each State has their own Regional Center, some have two. California for instance has one in Los Angeles for the southern half of the state and another in Red Bluff for the northern half. Now the kink in the system is that if you use a Provider that is not in any PPO or HMO system but is a cash only Provider you would naturally think to just get the bill and send it to MEBA Plans in Baltimore.
Don’t do it. Call the Plans Office and talk to Judy, Janice or Susan and get the Blue Shield mailing center closest to you and mail the bill along with an enlarged copy of both sides of the Medical Card along with the entire Card ID number written on the bill. If you just send it to the Plans office they have to submit it to Blue Shield in Maryland.

The difficulty arises in that the Plans office does not know anything about your claim until Blue Shield is done with it and sends the results to them. This is accomplished by snail mail. When they get the results in the mail then it is entered into the MEBA System. Then and only then can the ladies like Judy, Janice or Susan check if your claim is in the system. The Plans Office has no direct data link to Blue Shield.

How do I know all this? Judy , Janice and Susan have been working diligently for two months for me to get a claim settled from April 6, 2006 that I mistakenly sent directly to MEBA because I was not aware of the State mailing list.

This is a far cry from the days when it was done in house with an Explanation of Benefits and reimbursement within 2 weeks and when the Plan had triple the number of participants and Medical billing Personel.