~ CANCER PREVENTION information inside ~
quently asked questions frequently asked questions frequently asked questions frequen
F.A.Q. ons frequently asked questions frequently asked questions frequently asked questions ... from our Health Advantage members Q: How do I select a primary care physician (PCP)? A: When you enroll with Health Advantage, you will be provided a listing of primary care physicians from which to choose. (You also may access our Web site at www.healthadvantage-hmo.com.) The listing will note any restrictions based on age or other factors. You should list that PCP on your enrollment form. Primary care physicians generally include general practitioners, family practitioners, internists and pediatricians.
Q: What is the age limit for dependent coverage? A: Dependent age limits are provided for the following: 1. A child less than age 19 and living in the home. 2. A child who is enrolled and regularly attending on-campus classes as a full-time student at an accredited college, university or vocational training school, usually under age 21 and who is financially dependent on the employee. (Check your Health Advantage Evidence of Coverage, as this age limit may vary.) 3. Refer to your Health Advantage Evidence of Coverage for additional dependent coverage.
Q: What should I do if my PCP is out of the office and I need immediate medical care? A: Your PCPâ€™s contract requires him/her to have someone available to take calls 24 hours a day, seven days a week. There should never be a time that you cannot reach your PCP or a covering physician who can direct you to the proper level of care.
Q: Does Health Advantage coordinate benefits? A: Yes. If you or your dependents have other insurance coverage, which provides benefits for hospital, medical or other expenses, your benefit payments may be subject to coordination of benefits. Even if Health Advantage is not the primary carrier, you still must follow the plan policies in order for Health Advantage to coordinate benefits. It is the memberâ€™s responsibility to provide Health Advantage a copy of the primary carrierâ€™s Explanation of Benefits (EOB) and inform Health Advantage of all changes in other insurance coverage immediately.
Q: Will my new baby be covered as soon as it is born? A: A newborn is eligible for coverage from the date of birth, provided the child is enrolled within 90 days. To avoid a delay in claims being paid, you should complete an enrollment form, have your group administrator sign it and submit it to Health Advantage as soon as possible. Your employer may require that this be done within 30 days, so we recommend that you check with your personnel office.
Q: If my PCP refers me to a specialist, should I verify with Health Advantage that this provider is innetwork?
A: Yes, it is a good idea to contact Health Advantage Customer Service or check the Health Advantage Web site to verify that a specialist is participating with Health Advantage. As a member, it is your responsibility to ensure that any provider that you see is participating.
Customer Service Numbers Little Rock Toll-free Number (501) Number
State/Public School Employees 378-2437 1-800-482-8416 e-mail: email@example.com firstname.lastname@example.org Medi-Pak (Medicare supplement)
Medicare (for beneficiaries only): Part A (hospital benefits) Part B (physician benefits)
378-3151 1-877-356-2368 378-2320 1-800-482-5525
UniqueCare, UniqueCare Blue, Blue Select®, BlueCare PPO & PPO Plus (individual products) 378-2010 1-800-238-8379 Group Services
Federal Employee Program (FEP)
Medi-Pak HMO (Health Advantage) 954-5200 1-800-354-9904 USAble Administrators
For information about obtaining coverage, call: Category
Little Rock Toll-free Number (501) Number
Medi-Pak (Medicare supplement)
UniqueCare Blue, Blue Select®, BlueCare PPO & PPO Plus (individual products) 378-2937 1-800-392-2583
Regional Office locations: Central Northeast Northwest South Central Southeast Southwest West Central
Little Rock Jonesboro Fayetteville Hot Springs Pine Bluff Texarkana Fort Smith
Customers who live in these regions may contact the regional offices or call the appropriate toll-free telephone numbers above.
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is published four times a year by the Arkansas Blue Cross and Blue Shield Advertising and Communications Division for the company’s members, health care professionals and other persons interested in health care and wellness.
INSIDE THIS ISSUE
What is cancer? ........................................... 4 Depression & cancer, Cancer statistics ...... 5 Watching for skin cancer ............................. 6 Reducing prostate cancer risk ..................... 7 Who’s at risk for breast cancer .................... 8 Smoking: #1 cause of lung cancer ............... 9 Cigarettes: the “cancer stick” .................... 9 Lowering cancer risk: a doctor’s view ....... 10 Focus on Health – Preventing Cancer ........ 11 Why health care costs are so high ........ 12-13 Pre-certification changed; Prenatal benefit .. 14 Survey says – Health Advantage is A-OK .... 15 Supporting JDRF ........................................ 15 Group or individual health plan? ........... 16-17 How coverage decisions are made ............ 18 The pharmacist is in .................................. 19 Race for the Cure; More member discounts ..... 19 Financial information privacy notice ......... 20 BlueAnn Club Update ................................. 21 ASE/PSE customer info .............................. 22 Women’s Health and Cancer Rights Act ..... 22 Blue & Your Community ............................. 23 Blue Online ................................................ 24 Vice President of Advertising and Communications Patrick O’Sullivan Editor Kelly Whitehorn — BNYou-Ed@arkbluecross.com Designer Gio Bruno
Contributors Mark Carter, Janice Drennan, Damona Fisher and Kathy Luzietti
What is Cancer? Cancer
is the word for a group of more than 100 diseases in which abnormal cells grow and divide rapidly. These cells crowd out and destroy the normal ones. They also can spread to other parts of the body via the bloodstream and lymphatic system. This process is known as metastasis.
Types of Cancer Although cancer can begin in almost any part of the body, there are four basic types: • Carcinomas: The most common types of cancers, which arise from cells that cover external and internal body surfaces. Examples are lung, breast and colon cancer; • Sarcomas: Cancers arising from cells found in the supporting tissues of the body, such as bone, cartilage, fat, connective tissue and muscle; • Lymphomas: Cancers that originate in the lymph nodes and tissues of the body’s immune system; • Leukemias: Cancers of the immature blood cells that grow in the bone marrow and tend to accumulate in large numbers in the bloodstream.
How Tumors Form No one knows exactly why cancer happens, but several causal factors have been identified. Each cell in the body has a specific function. Normally cells do their job and either divide to form new cells or die. There is a continuous balance of new and dying cells in
normal tissue. In cancer, normal growth control is lost. Sometimes a cell changes or mutates and doesn’t do the job it is supposed to do. Its DNA (genetic code) is damaged. When that cell divides, it makes more abnormal cells. The grouping of abnormal cells in a specific area of the body is called a tumor. Some tumors are benign, meaning that they do not spread. They can often be removed and, in most cases, they do not come back. Those that spread are called malignant tumors. Only malignant tumors are considered cancerous. Cancer spreads in two ways. Cancer cells can invade adjacent healthy tissue by migration or penetration, or the tumor cells can break away and travel to other parts of the body, where they form new tumors.
Tumor Grades For most cancers, a biopsy, which is the surgical removal of a sample of the affected tissue, reveals information about the status of the cancer. The tissue is examined under a microscope and assigned a grade. A low grade (I or II) refers to tumors with fewer cell abnormalities. A high grade (III or IV) indicates highly abnormal cell appearance and large numbers of dividing cells.
Cancer Stages Tumors also are classified according to the stage of the cancer. These stages are based on the size of the tumor and whether it has spread. In general, these stages are: I. A small, localized tumor; II. A larger tumor that is beginning to spread into other organs and cavities;
III. Cancer cells have spread to regional lymph nodes; IV. Cancer has metastasized to other parts of the body, often to multiple organs and tissues.
Causes of Cancer Cancer develops over time. Cancer results from a complex mix of factors related to lifestyle, heredity and environment. Medical researchers have found substances that cause cells to mutate, including chemicals, radiation, viruses and bacteria. By far, the largest exposure of humans to chemicals comes from smoking. Most cancers (80 to 90 percent) occur in people with no family history of the disease. Some types of cancer do occur more frequently in families. Whether that occurrence is because of lifestyle, environment or heredity is unknown.
Risk Factors Studies over the years have shown that certain risk factors are associated with cancer, but not everyone with these risk factors will develop cancer. In turn, not everyone who has cancer has evidence of these risk factors. Risk factors include: tobacco; diet (high-fat, possibly low-fiber); ultraviolet radiation (from the sun and tanning booths); alcohol (heavy drinking); ionizing radiation (from X-rays, atomic explosions, outer space, radioactive substances); chemicals and other substances (i.e., pesticides, cigarette smoke, asbestos, uranium, benzene); hormone replacement therapy (estrogen alone); diethylstilbestrol (DES) (synthetic estrogen); and heredity. — Source: National Cancer Institute (For more information, visit http://www.nci.nih.gov.)
diagnosis of cancer is often unexpected and alarming, causing emotional upset and anxiety for the person with cancer. More often than not, the emotional turmoil subsides within a few weeks, but if it doesn’t, the patient should be evaluated for depression. Depression occurs in about 10 percent of the general adult population, but it occurs in approximately 25 percent of adults with cancer. Symptoms include: • Persistent sad mood • Loss of interest in normal activities • Fatigue or lack of energy • Inability to sleep or sleeping too much • Loss of appetite or weight gain • Difficulty concentrating or remembering • Feelings of guilt and worthlessness • Thoughts of suicide or suicide attempts
• Irritability or excessive crying • Chronic aches and pains that don’t respond to treatment. Many times, depression in cancer patients goes undiagnosed because it is thought to be a reaction to the diagnosis. Treating cancer patients with depression improves the mental condition of the patient, reduces suffering and enhances the quality of life. Depression has been shown to cause immune suppression, which can affect the body’s ability to fight cancerous cells. Studies show that the more severe the medical condition, the more likely the person will be clinically depressed. With treatment, 80 percent of all depressed people can improve, usually within weeks. Treatment options include medication, psychotherapy or a combination of both. If you think you may be suffering from depression, please consult your physician.
Depression & Cancer
— Source: National Institute of Mental Health
• This year, more than 552,200 Americans are expected to die of cancer, more than 1,500 people per day. • Cancer is the second leading cause of death in the U.S., exceeded only by heart disease. • Skin cancers are more common than cancers of any other organ, and more than 1.3 million cases of basal cell and squamous cell cancer are expected to be diagnosed this year. • The five-year relative survival rate for all cancers combined is 60 percent. • The National Institutes of Health estimate overall costs for cancer in the year 2000 were $180.2 billion: $60 billion for direct medical costs (total of all health expenditures); $15 billion for indirect morbidity costs (cost of low productivity due to illness); and, $105.2 billion for indirect mortality costs (cost of lost productivity due to premature death). • Approximately 1,268,000 new cancer cases are expected to be diagnosed in the U.S. in 2001. • Anyone can get cancer. Most cases affect adults beginning in middle age. Nearly 80 percent of all cancers are diagnosed at ages 55 and older. • In the U.S., men have about a 1 in 2 lifetime risk of developing cancer, and for women the risk is about 1 in 3.
Mirror, mirror on the wall The mirror is your best friend when it comes to detecting skin cancer
Skin cancer affects approximately the same number of patients as all other cancers combined, according to the American Cancer Society. In 2001 alone, there will be more than 51,000 cases diagnosed in the United States. Early detection and treatment are crucial. The most common types of skin cancer, squamous cell and basal cell carcinoma, are curable when detected early. Melanoma skin cancer is more serious because it often spreads to other parts of the body. Squamous cell and basal cell carcinoma — nonmelanoma skin cancer Approximately 75 percent of all skin cancers are basal cell carcinomas. They usually are found on areas exposed to the sun such as the head and neck. It is a slow-growing cancer, and it is unusual for it to spread to other parts of the body. Squamous cell carcinoma accounts for approximately 20 percent of all cancers. They usually appear on the face, ear, neck, lips and backs of hands (areas exposed to the sun). Very few squamous cell skin cancers spread to other parts of the body.
Melanoma skin cancer Melanoma skin cancer is most often seen on the torso of fairskinned men and on the lower legs of fair-skinned women. Having dark-pigmented skin lowers the risk of melanoma, but it does not mean that a person with dark skin cannot get melanoma. Risk factors for mela-
noma skin cancer include: • Moles — A mole is a benign skin tumor. Moles are not usually present at birth but begin to appear in children and teenagers. Having certain types of moles (such as dysplastic nevus or an atypical mole) increases the risk for melanoma. They are often larger than other moles. • Fair skin — Caucasians with red or blond hair and fair skin that freckles or burns easily are at an especially high risk for melanoma cancer. • Family history — The risk is greater if a close relative (mother, father, sibling or child) have been diagnosed with melanoma. • Immune suppression — People who have been treated with medicines that suppress the immune system, such as organ transplant patients, have an increased risk of developing melanoma. • Too much sun — People with too much exposure to light from the sun or tanning beds and lamps, are at a greater risk. • Age — Approximately 50 percent of melanomas occur in people age 50 and older. However, melanoma is the most common cancer in people age 30 and younger. Melanoma skin cancer can be detected early; and you, along with your physician, play an important role in detection. Part of a routine checkup should include a skin examination. It’s also important to check your own skin about once a month. You should know the pattern of moles, freckles and other marks on your skin so you will notice any changes. Self-examination is best done in front of a full-length mirror. A hand-held mirror may be used for areas that are hard to see. Spots on the skin that change in size, color or shape should be seen by a physician right away. Following are the differences between normal moles and melanoma. Watch for signs of possible melanoma. • One half of the mole does not match the other. • Edges of the mole are ragged or notched. • Color of the mole is not the same all over. • The mole is wider than about 1/4 inch. After melanoma is found, your physician will determine what treatment plan is best for you. Treatment options may include surgery, chemotherapy and radiation therapy. If you have questions about melanoma, please consult your physician.
Live Long and Prostate: Reducing your chances of cancer
rostate cancer has a specific target — men over the age of 40. While it remains rare for men under 50 to contract the disease, almost half of American men under 70 have at least microscopic prostate tumors, studies reveal. By the time a man reaches his 80s, that percentage rises to 70 to 90 percent. So, chances are most men will have to deal with prostate cancer in one form or another. The lifetime probability for contracting prostate cancer for an American man is 8 percent. But prostate cancer is a slow-developing disease and, if detected early, is manageable and even curable. Prostate cancer is the most common form of cancer contracted in American men, in whom it is the second leading cause of cancer death, behind lung cancer. Prostate cancer is a malignant tumor that develops in the prostate gland (found in men only) that can spread through the blood and lymph fluid to other organs, bones and tissues. Compared to other cancers, prostate cancer is slow-growing — as many as 90 percent of all prostate cancers remain dormant and not clinically important for decades. Symptoms usually are not noticeable in early stages of the disease, which makes early screening via a physician’s examination all the more important. But once symptoms do occur, they include a slowing or weakening of the urinary stream, frequent urination, blood in the urine, swollen lymph nodes in the groin area, impotence, and/or pain in the hips, ribs, pelvis or spine. Early detection and more accurate screening tests have led to a decrease in the number of diagnosed cases in recent years. Men with a history of the disease in their family should be aware that genetics plays a significant role in the development of the disease. The risk for prostate cancer also has been found to be greater in men whose mother or sister had breast or ovarian cancer. Lifestyle factors such as diet and exercise have been found to reduce the risks of contracting prostate cancer. Treatment for prostate cancer today is highly successful and includes surgery to remove the prostate gland, radiation, various medications that slow the growth of the cancerous cells, and sometimes chemotherapy. The important thing is to be aware of the risk factors and to remember that the symptoms don’t have to obvious for prostate cancer to exist. Regular exams with your personal doctor are the key to early detection and prevention. Your doctor can test your prostate-specific antigen (PSA) levels to determine if the prostate is enlarged due to infection or cancer. For more information on prostate cancer, its causes, associated risks, symptoms and treatment, visit the American Cancer Society on-line at www.cancer.org or WebMD at www.WebMD.com. — Sources: WebMD and the American Cancer Society
Breast Cancer: Who’s at risk?
reast cancer is not fruit from the family tree. In other words, a family history of the disease is no guarantee a person will or will not develop breast cancer. The causes of breast cancer are not fully known, however, health and medical researchers have identified a number of risk factors that increase a woman’s chances of getting breast cancer. Risk factors are not necessarily causes of breast cancer but are associated with an increased risk of getting breast cancer. It is important to note that some women have many risk factors, but never get breast cancer. Some women have few or no risk factors but do get the disease. Being a woman is the number-one risk factor for breast cancer. Getting older is a risk factor that runs a close second. There are some risk factors that can be controlled and others that cannot. Remember, even if these risk factors are not present, you still can develop breast cancer. Factors that may increase your risk of breast cancer include:
Factors you cannot control • • • • •
Getting older — the older you get, the greater your risk of breast cancer. Having a mother, daughter or sister who has had breast cancer. Having the mutated breast cancer genes BRCA1 or BRCA2. Having had breast cancer. Being young (<12 years) at the time of your first period, starting menopause later (>55), never being pregnant, or having your first child after age 30.
Factors you can control • • • •
Having more than one drink of alcohol per day. Taking birth control pills for five years or longer can slightly increase your risk for breast cancer. Not getting regular exercise. Currently or recently using some forms of hormone replacement therapy (HRT) for 10 years or longer, which may slightly increase risk. Being overweight or gaining weight as an adult. Being exposed to a large amount of radiation, such as having very frequent spine X-rays during scoliosis treatment.
— Sources: Susan G. Komen Breast Cancer Foundation, National Cancer Institute
Breast Cancer Resources To find out more about breast health or breast cancer, check out the following organizations: Susan G. Komen Breast Cancer Foundation 1-800-462-9273 www.komen.org American Cancer Society 1-800-227-2345 www.cancer.org National Cancer Institute 1-800-422-6237 www.cis.nci.nih.gov
Any Arkansas public library — books, video and audio tapes have been made available for check-out at more than 200 Arkansas public libraries by the Komen Foundation.
Smoking takes your breath away It’s the No. 1 cause of lung cancer
ore people die of lung cancer than of colon, breast M and prostate cancers combined. It is the number-one cause of cancer death for both men and women. It is most often found in people 40 and older. And there’s no doubt about it. Smoking cigarettes is the leading risk factor for cancer. Researchers estimate that smoking causes 8 out of 10 lung cancers. The more cigarettes smoked and the higher the number of years a person has smoked, the greater the risk for lung cancer. If you are a non-smoker but breathe the smoke of others, you have a greater risk of developing lung cancer. For example, if your husband smokes, you have a 30 percent greater chance of developing lung cancer than a spouse of a non-smoker. Smoking cigars or pipe does not help. They are almost as likely to cause lung cancer as cigarette smoking. Also, smoking low-tar cigarettes does not reduce
your risk for lung cancer. Are there other risk factors besides smoking for lung cancer? Yes. For example: • Working with asbestos; • Lung-scarring from some types of pneumonia; • Previous history of lung cancer; • Age. However, sometimes people get lung cancer who have never smoked and have no known risk factors. Researchers do not know why this happens; and, at this time, it can not be explained. Signs and symptoms of lung cancer include: a cough that won’t go away; chest pain; hoarseness; weight loss and loss of appetite; bloody or rustcolored spit or phlegm; shortness of breath; fever without a known cause; recurring infections such as bronchitis; and wheezing. Treatments for lung cancer include surgery, chemotherapy and radiation therapy. If you have any questions about lung cancer, please consult your physician.
It’s called “the cancer stick” for a reason S
uppose that on each day of your life, on the news every single night, the lead story was that three — not one, but three — passenger jet airplanes had crashed, killing all aboard? The news would be overwhelming and heartbreaking. Now imagine that it wasn’t an airplane crash that killed all those people, but cigarettes. The truth is that you don’t have to imagine that cigarette smoking kills a large number of people each day because it is a reality. And the hardest reality to accept is that smoking is the number-one preventable cause of death. Smoking causes lung cancer and is a risk factor for other types of cancer including mouth, larynx, bladder, kidney, pancreas, cervix, stomach and even leukemia. Tobacco smoke contains at least 43 carcinogenic (cancer-causing) substances. Tobacco use accounts for one in every three of all cancer deaths in the United States. It is responsible for 90 percent of lung cancers among men, and 70 percent among women. Approximately 180,000 Americans die each year from cardio-
vascular disease caused by smoking. If you quit smoking, the benefits are immediate. 20 minutes after quitting — Blood pressure drops. 8 hours after quitting — Carbon monoxide level in blood drops to normal. 24 hours after quitting — Risk of heart attack decreases. 2 weeks to 3 months after quitting — Circulation improves; lung function increases. 1 to 9 months after quitting — Coughing, sinus congestion and shortness of breath decrease. 1 year after quitting — Excess risk of heart disease is half that of a smoker’s. 5-15 years after quitting — Stroke risk is reduced to that of a non-smoker. 10 years after quitting — Lung cancer death rate decreases to almost half that of a continuing smoker’s; risk of developing cancer of the mouth, throat, esophagus, bladder, kidney and pancreas decreases. 15 years after quitting — Risk of coronary heart disease is that of a non-smoker’s.
Eat right. Exercise.
Don’t smoke. You hear that advice over and over again … on television, in magazines and from your doctor. Following a healthy regimen decreases your risk for illness and increases energy and quality of life. So, does that advice work when it comes to helping the people of Arkansas lower their risk of developing cancer? Yes, according to Bill Tranum, M.D., a Little Rock oncologist with the Arkansas Oncology Clinic, P.A. “It’s boring and it’s not what people want to hear. It’s public health, which means what the public can do for themselves without a doctor. Don’t smoke. Eat right. Maintain a healthy weight. Exercise. Avoid the sun. All of these would have immensely more effect than anything else, but this advice takes time and it is boring to most people,” said Dr. Tranum. ”There’s no miracle, and all the herbs and vitamins out there won’t help as much as just living healthy.” Arkansas Blue Cross and Blue Shield and its family of companies have many outstanding oncologists as part of our physician networks. Recently, we interviewed one of those physicians, Dr. Tranum (who is certified in both hematology and oncology by the American Board of Internal Medicine) to hear his personal thoughts on cancer prevention and other related issues. As an oncologist, most of Dr. Tranum’s patients usually have a suspicion, if not a diagnosis, of cancer before they enter his office. Most of his patients are referred to him by family practice physicians or surgeons who have discovered cancer through a biopsy. What he sees in his patients follows the national trend — a majority of his patients have been diagnosed with lung cancer. “There’s not even a close second. Many of my patients have been diagnosed with lung cancer, usually caused by smoking,” said Dr. Tranum. After Dr. Tranum’s initial evaluation of his patients, he visits with them to recommend a treatment plan. “The first thing I do is educate them about the type
of cancer they have. I tell them what they have and what stage the cancer is in. I then tell them the best treatment options for them and the probability of cure,” said Dr. Tranum. With his patients, he chooses to focus on the treatment plan and how to overcome their cancer. He doesn’t like the negative aspects of cancer, and he is amazed at the unfeeling behavior of family members at times. Sometimes people forget that cancer is not an automatic death sentence. “They want to know how long the cancer patient has to live. I am shocked by the insensitivity to ask this in front of the patient, and I won’t answer that question. If the patient wants to know, I will discuss it. However, I like to focus on the probability for survival,” said Dr. Tranum. It’s not surprising that most patients are nervous or upset to discover they have cancer, Dr. Tranum pointed out. However, he feels they are nervous because they do not know what to expect. After he has the opportunity to explain their cancer to them and put forth a timeline for treatment, patients usually become less apprehensive about their diagnosis. During his 23 years as a private practice physician, there have been Little Rock many advances in treatment options for Oncologist Bill Tranum cancer patients. Dr. Tranum notes those offers some he considers his top three advancehelpful advice ments in cancer treatment as: 1) Development of new medications. 2) Statistical analysis of the effect of treatment options. 3) The control of nausea and vomiting (brought on by treatment) for the patient. “We are just beginning to see strides with cancer. We need more help in developing cures and treatment options. People still die from cancer every day,” said Dr. Tranum. While there is no definite cure for cancer and no complete assurance that a person will never develop it, there are very successful treatment plans that put cancer in remission and extend life for decades. And there’s no substitute for taking good care of yourself to reduce your chances of developing cancer. Many, many people live long, prosperous quality lives after a cancer diagnosis.
Can you lower yours?
P reventing Cancer
Testicular cancer is curable The most common type of cancer in men between the ages of 18 and 34 is testicular cancer. However, when detected early, it also is one of the easiest to cure. If testicular cancer goes undetected at its earliest stages, it may spread throughout the lymph node system into the lungs and other parts of the body. Testicular cancer is particularly dangerous because there are usually no symptoms associated with it. However, several predisposing factors may place some men at higher risk: past medical history of undescended testicle, mumps orchitis, inguinal hernia during childhood, or previous testicular cancer. All men should perform monthly testicular self-examinations (TSE). The optimal time to perform the examination is in the shower. Both hands should be used to examine each testicle with the thumbs in front and the first two fingers behind the testicle. The testicle should be rolled between the fingers and the thumb, feeling for any lumps or bumps. Testicular cancer usually starts as a small pea-sized lump within the testicle. It probably would not be noticed unless self-exams are routinely performed. And, finding a lump is no reason to panic (lumps or bumps in the testicle are not always cancer), but it is a reason to see your physician for an examination. Treatment of testicular cancer includes surgery (removal of the testicle and associated lymph nodes), radiation therapy and chemotherapy.
What you should know about colon and rectal cancer Colon and rectal cancer or colorectal cancer begins in either the colon or rectum. The colon has four sections, and cancer can start in any of the four sections. Since colon and rectal cancer share many of the same features, they are usually discussed together. While researchers do not know the exact cause of colorectal cancer, risk factors include: family or personal history of colorectal cancer; personal history of polyps or inflammatory bowel disease; aging; diet and obesity; and lack of exercise. Symptoms include: a change in bowel habits such as diarrhea or constipation; a feeling that you need to have a bowel movement that doesn’t go away; bleeding from the rectum or blood in the stool; cramping or steady stomach pain; decreased appetite; weakness or fatigue; and jaundice (yellow-green color of the skin and in the white part of the eye). Screening tests include a sigmoidoscopy (a slender tube is placed in the rectum to allow the doctor to look at the inside of the rectum and part of the colon for cancer or polyps) and a fecal blood occult test (sample of the stool is tested for blood). Health Advantage recommends that adults age 50 and above receive a sigmoidoscopy every four years. Health Advantage also recommends that those 50 and above have a fecal blood occult test annually. The treatment of colorectal cancer includes surgery, radiation therapy and chemotherapy.
11 Information about Hodgkin’s Disease Hodgkin’s Disease (also known as Hodgkin’s lymphoma) is cancer that begins in lymphatic tissue — which includes the lymph nodes and other organs that are part of the body’s system that forms blood and protects against germs. Because lymphatic tissue is found throughout the body, Hodgkin’s Disease can start almost anywhere. If it spreads through the lymphatic vessels and into the blood stream, it may then spread to almost any other place in the body. Both children and adults may get Hodgkin’s Disease but it is most common in two groups: early adulthood (ages 15-40) and late adulthood (after age 55). For the most part, there are no major risk factors for Hodgkin’s Disease. Some people with the disease may have no symptoms. Others may have symptoms such as enlarged lymph nodes, coughing or shortness of breath, fever, night sweats, itching, fatigue and loss of appetite. Treatment for the disease usually is effective and includes chemotherapy and radiation therapy.
Why Are Health Care
s a physician in Arkansas, I’m acutely aware of the rapidly rising cost of health care. And you, as a person with health insurance, no doubt are feeling the direct effects of these rising costs. When the cost of medical care goes up, so does the cost of health insurance. But why is this happening? What is causing medical costs to rise rapidly, which in turn causes the cost of health insurance to increase? Here are 12 major drivers of higher health care costs in Arkansas:
Changing Demographics — As a nation, our work force is getting older. As we age, we consume a greater amount of health care. In Arkansas, our median age increased from 33.8 years in 1990 to 36.0 years in 2000, both of which are higher than the national average.
New Technologies — Today we are able to provide incredible new treatments such as organ transplants, which were not available just a few years ago. While these advances have improved our quality of life, they have come at significant costs. Take the example of pharmaceutical advances. In 2000, a new drug was approved for people with rheumatoid arthritis. Some experts now believe that this drug should be used for almost everyone with this illness. It improves the quality of life for many people with this crippling disease. However, this drug costs $1,000 per month. To provide this drug for the approximately 4,800 of our insured members who may need it, would result in a 6 percent premium increase for all 480,000 members who are fully insured through Arkansas Blue Cross and Blue Shield and Health Advantage. That’s right — one drug for 1 percent of our members could raise premiums by 6 percent for everyone. And … there are several other $1,000-per-month drugs for other illnesses available or in development. Patient Demand — Americans are heavy consumers of medical services and demand choices in health care. They want access to heavily advertised drugs and services and want more choice of providers.
Increasing Litigation/Regulations — Both the federal and state governments periodically develop new rules and regulations that apply to insurers. Each of these mandates results in premium increases. In addition, fear
12 Factors Driving Up Information in this article was compiled and provided by Raymond Bredfeldt, M.D., medical director for Arkansas Blue Cross and Blue Shield’s Northwest Region, headquartered in Fayetteville. Dr. Bredfeldt is a board-certified family practice physician. He served for 10 years as director of the UAMSAHEC Family Practice Residency Program at Fayetteville.
of litigation has caused many of the restrictions of managed care to be lifted in the past few years. With the reduction in these cost-containment efforts have come increases in medical services and costs.
Increasing Supply of Physicians — During the past 10 years, the number of physicians has grown at a rate that is 28 percent higher than the overall population. Studies show that as the supply of physicians increases, so does the number of services people receive from physicians. People see doctors more frequently for more minor problems today than ever before. (While the number of physicians is increasing nationally, there is still an unequal distribution of physicians, with many rural areas having too few physicians and many urban areas having too many.)
Shortage of Non-Physician Professionals — Arkansas and the nation are experiencing a shortage of nurses. This is causing hospitals to compete for these health care professionals with higher salaries, thus driving up employment costs. There is a similar, but less acute, shortage of physical therapy and occupational therapy health care professionals.
The Consumer Is Not the Direct Payer for Health Care — Few people realize that the drug for which they paid a $15 or $20 co-payment actually costs $150 or more. People are not aware that the few minutes they spend seeing a doctor for a common cold results in an average total cost of $200 or more (doctor’s fees, lab/X-rays, pharmacy). Co-payments and deductibles have not kept up with medical cost inflation, making the consumer less aware of actual costs. While most forms of property and
Costs So High? Medical Costs in Arkansas casualty insurance cover catastrophic events (floods, fires, accidents), health insurance generally covers many common, everyday medical services, in addition to catastrophic services.
Health Status of the Population — The health status of the Arkansas population is poor, ranking 46th in the nation. We have high rates of obesity, smoking, cancer and heart disease.
Emerging Diseases — The emergence of new diseases, or re-emergence of old, such as AIDS, Hepatitis C and tuberculosis, are driving up medical costs, as are such factors as environmental pollution and resistance to antibiotics.
Increasing Number of Uninsured — As health insurance premiums increase, so does the number of people who decide to drop their insurance. This raises costs in two ways. First, the people most likely to drop their insurance tend to be those who are healthy and believe that they can get along without insurance. As healthy people leave the insurance pool, the people left with insurance tend to be those with more health problems. This causes overall premiums to increase for those left behind in the insurance pool. Second, uninsured people tend to utilize higher-cost care in emergency rooms for routine problems since emergency rooms cannot turn anyone away. Often these services go unpaid. This raises the cost of health care for everyone else, because these costs are passed on to others.
Variability in Physician Practice Patterns — No two doctors handle the same problems exactly alike. For example, in Arkansas the average cost to treat a common cold in 1999 was $178 (it is closer to $225 in 2001). One doctor averaged $728 for every person he saw with a cold in 1999. He ordered much more lab than the average physician. Similar degrees of variability occur with every type of illness. There is probably no other industry in which that kind of variability exists in the delivery of a service.
Excess Use of Avoidable Care — People tend to go to doctors for more minor problems today than they did 10 years ago. They also get many more medical services. People have assumed that more is always better in regard
13 Did You Know? With rising medical costs causing health insurance premiums to increase, it’s important to understand that Arkansas Blue Cross and Blue Shield is a not-for-profit, mutual insurance company. That means that we are owned by our policyholders, not by stockholders. All revenues earned by Arkansas Blue Cross are utilized in only two ways: — To pay providers and members for covered benefits; — To pay associated administrative expense. Any revenues received that are greater than these two categories of expense are held as unassigned funds (surplus) for future payment of claims and expenses for the benefit of our members. Health insurance is historically a cyclical business, and in those years when claims and expenses exceed revenues, surplus is used to meet those obligations to our members. And while Arkansas Blue Cross is not-for-profit, it is not exempt from taxes. The company pays state premium and federal income taxes like any other health insurer. In 2000, this tax liability amounted to more than $7.6 million. Another important point is that Arkansas Blue Cross is better able to serve its members because it maintains low operating costs. In 2000, our administrative costs were approximately 12.5 percent of premiums, which is lower than the industry average. This means that more than 87 cents of every premium dollar in 2000 was used to pay for actual medical care received by our members. to medical treatment. For example, it has been estimated by the American Academy of Family Physicians that Americans receive 50 million unnecessary prescriptions every year for antibiotics. These unnecessary prescriptions cause side effects and are the reason that so many bacteria now are resistant to antibiotics.
eased for physicians, hospitals and members
eginning Aug. 13, 2001, Arkansas Blue Cross and B Blue Shield eliminated hospital admission pre-certification requirements for members who have insurance with Arkansas Blue Cross and Blue Shield and Health Advantage HMO. What does this mean for you as a member covered by Health Advantage HMO or Arkansas Blue Cross? It means that you or your physician are no longer required to call for precertification (or approval) when you are admitted to an in-network hospital. Your physician will continue to make all decisions regarding your admission and stay in the hospital. Admission precertification will no longer be required for routine hospital admissions, which includes hospitalization, surgery and diagnostic testing performed at in-network facilities. However, if services are performed at an out-ofnetwork facility or outside the state of Arkansas, it will continue to be your responsibility to notify our utilization management company by calling the pre-certification number on your ID card. Hospital admission pre-certification will continue to be required for members in the following group
Hospital admission pre-certification no longer required insurance plans: • Federal Employee Program (FEP) — ID cards feature a number that begins with an “R” • Access Only — ID cards feature a toll-free telephone number for pre-certification and Arkansas’ FirstSource logo (not an Arkansas Blue Cross and Blue Shield logo) • USAble Administrators — All USAble members with a pre-certification number noted on their ID card should be pre-certified prior to an admission. “This change will reduce the administrative burden on members, physicians and hospitals. Yet at the same time, through a cooperative arrangement with our hospitals, we will have the ability to monitor and offer case management services and care coordination,” said Mike Brown, vice president of Enterprise Medical Management Program and Policy. “It is our plan to continue to develop a more streamlined and simplified approach as we work to improve our medical management and bring greater value to our members.” Should you have questions regarding your hospitalization, you may contact your local Arkansas Blue Cross office.
Prenatal benefit amended for some groups For members of a group (employer-sponsored) health plan with an Arkansas’ FirstSource PPO policy or a comprehensive major medical policy from Arkansas Blue Cross and Blue Shield, the Routine Prenatal Care benefit has been amended, effective Oct. 1, 2001. The amended portion of the policy (OTHER COVERED MEDICAL SERVICES, paragraph D), now states that, subject to the applicable deductible and coinsurance, the Company (Arkansas’ FirstSource or Arkansas Blue Cross) will pay for routine prenatal care, maternity care, obstetrical care and complications of pregnancy. Previously, prenatal services were paid at 100 percent. For any pregnancy beginning after Oct. 1, routine prenatal care services will be paid at the same level as all other covered benefits of the policy, subject to the applicable deductible and co-
payment of that policy. For purposes of claims administration, this means that if a member delivers anytime on or before July 1, 2002, prenatal care services will be paid at 100 percent. If a member delivers on July 2, 2002 or after, prenatal benefits will be paid at the same level as other covered benefits. Bringing the prenatal benefit in line with all other benefits of the policy will help simplify the benefit administration process, reducing errors and speeding up the claims payment process, and ultimately help hold down costs to insured members. The amendment does not affect individual policies with Arkansas Blue Cross, nor does it affect HMO or POS policies with Health Advantage.
Members give Health Advantage a thumbs up! H
ealth Advantage fared well with its commercial HMO population according to the results of the 2001 Health Plan Employer Data Information Set (HEDIS) member satisfaction survey. Those members responding to the survey gave Health Advantage excellent ratings — virtually unchanged from last year — in several categories, including rating of personal doctor, rating of specialist, rating of all health care services, and rating of health plan. Health Advantage’s health care services and health plans in general received high satisfaction marks, almost identical to 2000’s results. The percentage of members satisfied with all health care services at Health Advantage came in at 94 percent (a rating of six or higher on a 10-point scale). Sixty-two percent of members indicated a satisfaction rate of eight or higher with their health plan (88 percent rated their plan six or higher), up from 60 percent last year and 57 percent in 1999. The survey also revealed results similar to 2000: • Only 3 percent of members were not satisfied that their claims were handled in a reasonable time. • Less than 1 percent were not satisfied that their claims were handled correctly. • Only 3 percent reported a big problem in getting the
care the member or doctor felt was necessary or in getting approval from the health plan.* • More than nine out of 10 health care providers were perceived by survey respondents to usually or always listen carefully to patients, explain things in a way the patient could understand, and show respect for what the patient had to say. • Just under nine out of 10 providers were reported to usually or always spend enough time with their patients. Based upon additional analysis of the survey results, the following service factors were determined to be the biggest predictors and drivers of members’ overall satisfaction with the health plan: • Claims processed in a reasonable time. • Claims handled correctly. • Understanding the Explanation of Benefits (EOB).
* We’d like to remind all Health Advantage members that the Health Advantage referral system is probably one of the most simple and “hassle-free” in all of the HMO industry. Health Advantage does not require a “MotherMay-I” call to Health Advantage from Health Advantage members as long as the referral is for an in-network provider. A “referral script” is completed by the primary care physician in his or her office, and it is given to the member, who then takes it to the specialist. All the specialist has to do is make sure he or she gets the “referral script” from the primary care physician and uses the number on the script pad for filing the claims.
Supporting efforts to find a cure for DIABETES A
s a good corporate citizen, Arkansas Blue Cross and Blue Shield employees participate in many community activities around the state in an effort to raise money for causes important to our members. One of those causes is the Juvenile Diabetes Research Foundation (JDRF). This year, Arkansas Blue Cross served as the title sponsor of the annual JDRF Walk to Cure Diabetes held on Saturday, Sept. 22. Sharon Allen, executive vice president and chief operating officer for Arkansas Blue Cross, served as the 2001 walk’s corporate recruitment chairperson.
More than 16 million Americans (about 5 million undiagnosed) suffer from diabetes, a chronic, debilitating disease that affects every organ system in the body. Someone dies from those debilitating effects every three minutes, and diabetes is the leading cause of kidney failure, adult blindness, and nontraumatic amputations, and is a leading cause of nerve damage, heart attack and stroke. The U.S. spends $105 billion each year in diabetesrelated costs. For more information on diabetes, visit the JDRF Web site at www.jdrf.org.
What’s the difference between
What’s the difference between
you are considering leaving your job in the corporate world to become self-employed … not so fast. Before you quit your job, think about your health insurance options. While you were accepted into your employer’s group health insurance plan with no hesitation, it might not be so easy when you are out on your own looking for individual health insurance.
Individual health insurance The most important thing to remember is that you enroll in a group insurance plan with your employer (you cannot be excluded), but you apply for individual health insurance. The two insurance options are unrelated; and when you leave the protection of your group insurance plan, you are starting from the beginning in your search for health coverage. Being enrolled in an Arkansas Blue Cross and Blue Shield group insurance plan does not guarantee that your application for individual health insurance will be approved. Arkansas Blue Cross members may be eligible for a COBRA and/or a Conversion policy. This is not the same as individual health insurance as discussed in this article. Additionally, being in one of Arkansas Blue Cross’ individual health insurance plans does not guarantee acceptance into another. To change plans, you must go through medical underwriting and start the whole process again — there is no transfer of credit toward meeting deductibles or pre-existing periods. “Individual business does not take into account previous health insurance coverage. If you apply for individual coverage, it doesn’t matter if you were on another Arkansas Blue Cross individual health plan or moved here from the woodlands of Canada, you are starting from scratch,” said Ron DeBerry, vice president of Statewide and Individual Business. Applicants for individual health insurance plans (Blue Select®, BlueCare PPO and BlueCare PPO Plus) at Arkansas Blue Cross are subject to the following: 1) Medical underwriting (which is the process of evaluating and assuming risks according to your insurability).
~~~~~~ Know the facts before you 2) A 12-month pre-existing condition clause. Individual health insurance plan rates are set on a singular basis and assume everyone is new to the health insurance medical underwriting process. Individual coverage plans do not offer continuous coverage or deductible credit. There are four things Arkansas Blue Cross may do when someone has requested individual coverage for himself/herself and/or family. 1) Approve as applied — Applicant will receive the coverage requested at the standard rate. 2) Approve with exclusions — Arkansas Blue Cross may exclude a condition or body part from coverage. 3) Approve with a surcharge — An applicant may be charged an additional percentage of the base rate if the applicant is a smoker, regularly uses a specific medication, etc. 4) Reject the application. Approximately 75 percent of all applicants are approved for individual health insurance, with 60 percent of applicants being approved as applied (15 percent are approved with exclusions or surcharges). Standard rates for individual health insurance plans are based on the applicant’s ability to pass full medical underwriting. When a person applies for individual health insurance and wants to include family members, each family member also must pass medical underwriting. If you misrepresent or omit medical history information and do not disclose conditions or medications you are taking, your individual coverage may be rescinded. According to DeBerry, it’s not true that health insurance companies only want healthy people in their individual health insurance plans. Medical underwriting is based on a risk perspective in relation to the applicant’s medical history. “Individual business is similar to property and casualty insurance. I can’t tell you that your 17-year-old son is going to be in a wreck in his new car, but I can tell you that it is more likely than you being in a wreck,” said DeBerry. “We look at on-going risk factors for conditions you may have had or will have. You may have a condition that will manifest itself down the road. We make our decisions based on medical records
group and individual health plans?
group and individual health plans? decide to make a switch ~~~~~~ and by nationally published underwriting guidelines. It takes a lot of the subjectivity and guesswork out of it.” Many people shopping for individual health insurance may already have group coverage but find that they can receive a more affordable rate for their children or spouse with individual coverage. Additionally, people with individual insurance only pay for the benefits they need. For example, a single 25-year-old male may share the cost of maternity coverage in a group plan but could eliminate that cost with individual health insurance. With individual plans, the insured may pay less in premium costs but may be required to pay a higher deductible or more out-of-pocket expenses and coinsurance.
Group health insurance Group health insurance plans work differently than individual health insurance plans. If you are employed with a company that offers group health insurance, generally all you have to do is enroll and pay your share of the premium, subject to the rules of the plan for timely enrollment. While large-group (50-plus employees) insurance generally is based on the group’s historical claims and medical history, for small group coverage (2 to 50 employees), you are required to complete medical applications for both yourself and family members that you plan to include in your group coverage. However, no matter what conditions you have or may have had, you can not be excluded from the group plan. Underwriting may use the information to rate the group as a whole, but it will not exclude you from receiving medical coverage. Again, just as with individual health coverage, if you omit or misrepresent medical history information or do not disclose conditions or medications you are taking, your group coverage may be rescinded or terminated, and you will not be able to obtain health insurance from Arkansas Blue Cross in the future. “If you are a diabetic and fail to disclose it on your medical enrollment form for group health insurance, you can lose your coverage. We can’t exclude you from the health insurance plan for having diabetes if it is disclosed; we just need everyone to be truthful in completing their applications for rating purposes. It’s not enjoyable for us to have to call someone and tell them their insurance is being canceled because the information on
their medical enrollment form was inaccurate. It’s a very difficult thing to have to do … something we would prefer that everyone could avoid,” said David Greenwood, director of Enterprise Underwriting. “People with health problems are aided by the small group insurance laws and regulations. While disclosure may impact the group rates, it helps ensure health insurance coverage will be there when needed,” said Greenwood. Even with group coverage, there are underwriting rules (set by the insurer) that impact the offering of coverage. Arkansas Blue Cross requires that all employers who offer group plans to their employees have a certain percentage of their eligible employees enrolled in the plan and that employers contribute a certain minimum percentage to the premium cost of group health insurance. Some people may recall the Health Insurance Portability and Accountability Act (HIPAA) and believe that it provides for portability of coverage when they change jobs — whether they are with a group or are seeking individual health insurance. That is a misconception. It does allow an individual to continue group insurance coverage when there is a job change, but it does not apply to individual health insurance. It also allows for “creditable coverage” which credits past coverage when applying pre-existing rules. Again, this applies when enrolling for group coverage with a new company but not for individual policies. Whether you are enrolled in a group or individual health insurance plan at Arkansas Blue Cross, it is always a good idea to look closely at all your options before making a career or health insurance change. If you are thinking about leaving the protection of your group health insurance plan for an individual plan — be sure to weigh all your options carefully. Health insurance should be an important part of any career decision. If you have questions about individual health insurance products, please call 1-800-392-2583 or visit our Web site at www.arkansasbluecross.com.
How coverage decisions are made
Members with our various health insurance products occasionally receive a benefit explanation from us that indicates a particular service has not been paid for because the service was considered investigational. “Investigational,” as defined in the Arkansas Blue Cross and Blue Shield health plan benefit certificate, means that the service (procedure, treatment, supply, device, equipment, facility or drug) does not meet one or more of the following criteria: 1) does not have final approval from the appropriate government regulatory body; 2) is being provided under a study that requires approval by an institutional review board or similar body; 3) is being evaluated in a controlled clinical trial or is otherwise under study to determine its safety or effectiveness; 4) is subject to question because the majority of published expert opinion holds that further studies are needed to determine its safety or effectiveness, or the majority of published expert opinion shows lack of consensus either way; or 5) the majority of published expert opinion holds that it is unsafe or ineffective in the specific situation for which the service has been performed. Pressure to pay for treatment based on inadequate studies, early results of trials, and claims of effectiveness from promoters of the service, has become intense as more new medical services have been developed. As an insurer, we have a dual obligation to pay all valid claims and to deny those claims that are not covered under a member’s health plan. Paying invalid claims could raise premium costs for all our policyholders. In fulfilling this obligation, we have developed a process for determining whether a service is “investigational” that we believe serves our entire membership most appropriately. Our initial step is an analysis of the published medical literature on the subject. This research is conducted by me or under my direction as medical director and is reviewed by me or by our assistant medical director. To help with this analysis, we review what several other independent technology assessment groups have said about the service. We also look for any position papers on the subject that have been published by
By James Adamson, M.D., medical director for Arkansas Blue Cross and Blue Shield certain national physician organizations. All usable studies published in peer-reviewed medical literature are reviewed (unfortunately, many studies of the medical literature have shown that most research reports do not contain usable data, and for emerging technologies, no studies may exist). Advice then is requested from practitioners who would be most knowledgeable about the service. After completion of this review, the collected information is sent for review to medical management committees in the various Arkansas Blue Cross regions. These committees are made up of practicing physicians of multiple specialties. Once a service is deemed investigational by this process, claims for that service will be denied. If a member or his/her physician questions the initial claims decision, it is reviewed by a registered nurse to determine if the denial was adjudicated correctly and to determine if, for the particular member, the service was investigational in view of the member’s condition and treatment regimen. If the nurse determines upon “re-review” that the service is not investigational as defined in the health plan and should be allowed, the initial denial of the service is reversed. If the nurse determines that the denial was correct, the claim is then reviewed by a physician who is employed by Arkansas Blue Cross. If this physician also agrees that the service is investigational, the specific claim is referred for review to an outside physician in a specialty that commonly provides the service. After receiving the outside physician’s opinion, we then communicate the “re-review” decision to the member. At this point, if the “re-review” decision is to deny benefits as “investigational,” the member has the right to formally appeal to the Arkansas Blue Cross appeals coordinator, who will evaluate all of the available information and render a final claims decision. A great deal has been written that health insurers, in order to reduce claims payment, rely upon non-medical personnel to make coverage decisions on whether services are investigational or not. Arkansas Blue Cross has gone to great lengths to make certain that these decisions are made by medical personnel.
The Phar macist is in Do you have any questions? A
pharmacist is a valuable asset within the health care delivery system. It’s good to know that patients have questions about the medications that have been prescribed for them. The thousands of medications available create an aura of mystery and curiosity to patients untrained in this fast-changing world of pharmaceutical therapies. With this comes some anxiety and uncertainty for the patient. Having a healthy respect for any medication you consume, whether prescribed by your physician or purchased over the counter, is important. So, “The Pharmacist is in.” On a regular basis in Blue & You, the Arkansas Blue Cross pharmacy director will answer questions in this column submitted by customers and employers. Following is one of the most frequently asked questions and the answer. Q: Why am I sometimes asked to change to a preferred drug rather than the one I am taking? A: Some prescription medications are becoming exorbitantly expensive and are driving up pharmacy costs into price ranges where they are becoming unaffordable. These drug costs are among the factors driving the steeply rising insurance premiums across our nation. Most people who must pay cash for their medications now are being faced
ace For The Cure. If you are interested in raising money and awareness for the fight against breast cancer, join 30,000 people who share your aspiration and participate in the Susan G. Komen Breast Cancer Foundation’s 2001 Arkansas Race For The Cure on Saturday, Sept. 29, in downtown Little Rock. For more information, please call 501-202-4009. Race Recap Television Special. Then, tune into the 2001 Race For The Cure Recap Show, presented by Arkansas Blue Cross and Blue Shield, at 6 p.m. on Sept. 29, on FOX 16-TV and again at 11 a.m. on Sunday, Sept. 30, on UPN 38-TV. You’ll get to relive the moments of the day during the 30-minute television special which will highlight Race Day activities. You may even see yourself “proud in the crowd.” Run the race, then relax and watch the show.
Race & Watch
with serious decisions regarding the high cost of prescribed drugs. Those paying for health coverage are faced with the same dilemma through their rising premium expense. Some employers have even discontinued prescription coverage in their health benefit plan and some people are going without needed medications. The objective of recommending a preferred drug is to provide quality pharmacy coverage at an affordable price. When the price of something becomes unaffordable, we just do without. This may be acceptable in regard to what we “want,” but it is not acceptable when it comes to what we need to control diabetes, blood pressure or some other chronic medical condition requiring medication. If you were making the decision, you would want an effective drug that is safe and reasonably priced. These same standards guide our decisions. It is important that we work together on this issue. Arkansas Blue Cross is dedicated to working closely with our members to help them understand more about what is transpiring in the area of pharmacy and why particular things are happening with medications. If you have a question about medications or drug coverage policies, please submit your question via e-mail to BNYou-Ed@arkbluecross.com. Questions submitted by customers will be answered in this column in future issues of Blue & You as space permits.
More discounts for members! Arkansas Blue Cross and Blue Shield is hard at work canvassing the state looking for “wellness” discounts with health clubs, fitness centers and more — just for our members. Fitness FX in Little Rock and the Jacksonville Community Center are the newest fitness centers in Arkansas to offer discounts to our members. If you are curious about whether your favorite fitness spot offers a discount, visit the Arkansas Blue Cross Web site at www.arkansasbluecross.com for a complete list of participating fitness vendors. If you don’t see your workout site on the list but would like Arkansas Blue Cross to contact them about offering a discount to our members, just send the name and location of your fitness center to BNY-Ed@arkbluecross.com and we’ll take it from there.
Arkansas Blue Cross and Blue Shield Financial Information Privacy Notice
t Arkansas Blue Cross and Blue Shield, we understand how important it is to keep your private information just that — private. Because of the nature of our business, Arkansas Blue Cross must collect some personal information from our members, but we also are committed to maintaining, securing and protecting that information.
Customer Information Arkansas Blue Cross only compiles information necessary for us to provide the services that you, our member, request from us and to administer your business. Arkansas Blue Cross collects non-public personal financial information (defined as any information that can be tied back to a specific person and is gathered by any source that is not publicly available) about our members from: • Applications for insurance coverage. The application includes information such as name, address, personal identifiers such as Social Security number and medical information that you authorize us to collect. • Payment history and related financial transactions from the purchase and use of our products. • Information related to your status as a current or former member.
Sharing of Information Arkansas Blue Cross does not disclose, and does not wish to reserve the right to disclose, non-public personal information about you to our affiliates or other parties except as permitted or required by law. Examples of instances in which Arkansas Blue Cross will provide information to affiliates or other third parties are: • To service or process products that you have requested. • To provide information as permitted and required by law to accrediting agencies. • To provide information to comply with federal, state or local laws in an administrative or judicial process.
How We Protect Your Information Arkansas Blue Cross uses various security mechanisms to protect your personal data including electronic and physical measures as well as company policies that limit employee access to non-public personal financial
information. Improper access and use of confidential information by an employee can result in disciplinary action up to and including termination of employment.
Disclosure of Privacy Notice Arkansas Blue Cross recognizes and respects the privacy concerns of potential, current and former customers. Arkansas Blue Cross is committed to safeguarding this information. As required by a new state regulation, we must notify our members about how we handle non-public financial information of our members. Nothing has changed in the way we conduct our business. If you would like to review the Financial Information Privacy Notices for all Arkansas Blue Cross members, you can visit our Web site at www.arkansasbluecross.com or call the appropriate Arkansas Blue Cross company to receive the Privacy Notice. Our Customer Service areas are open 8 a.m.– 4:30 p.m., Monday through Friday. To receive a copy of the Privacy Notice, members should call: Medi-Pak HMO — 1-800-354-9904 Arkansas Blue Cross — 1-800-238-8379 USAble Administrators — 1-888-USABLE1 (Call between 8:15 a.m. – 4:30 p.m., Central Time, Monday through Friday. USAble Administrators is a division of The First Pyramid Life Insurance Company of America that provides third-party administrator services.) First Pyramid Life — 1-800-519-2583 Health Advantage — 1-800-843-1329.
Some of the cancer information in this issue of Blue & You was provided by the American Cancer Society. For more information on cancer — and cancer prevention — you may contact the nearest chapter of the American Cancer Society or call 1-800-ACS-2345 or visit them on-line at www.cancer.org.
Growing by sheeps and bounds In less than two years, the BlueAnn Health and Class Clubs have grown by sheeps and bounds. To date, almost 12,000 kids are learning important health lessons from Arkansas Blue Cross and Blue Shield’s health ambassador, BlueAnn Ewe, a big, blue sheep! The BlueAnn Clubs are part of the Arkansas Blue Cross Blue & Youth Health Program, a health education effort designed to improve the well-being of Arkansas citizens, beginning with the young people of the state. The BlueAnn Health Club is a free health club with a two-year membership, designed to provide individual children ages 5 to 10 with opportunities to learn about healthy lifestyles and participate in activities, with the goal of encouraging overall healthy behaviors and involving parents in the process. The Health Club includes incentives and rewards for participating in activities and includes an ID card and membership certificate. Following the initial membership packet, Health Club members receive quarterly packets, which include a newsletter, activity sheet and a special gift.
Health Club members periodically receive in the mail health-andwellness newsletters and a colorful BlueAnn poster for their wall.
Packets also contain information and activities on health topics, including nutrition, exercise, safety, hygiene, dental health, emotions and drug/tobacco prevention. To date, 1,661 individuals have joined the Health Club. The BlueAnn Class Club is the classroom equivalent of the Health Club. This free club is designed for kindergarten and first-grade classrooms. Teachers enroll their classes and utilize the Class Club materials at their
Ice cream chef BlueAnn visits Carver Magnet Elementary School Class Club in Little Rock for a “Build a Healthy Sundae” party.
discretion. Membership is for one school year and also provides incentives and rewards for practicing healthy behaviors. Class Clubs get three packets of information and activities during the school year focused on physical and emotional health. In the 2000-01 school year, 448 classes were enrolled in the Class Club with a total of 10,062 elementary school-aged students reached with fun health messages. If you are a parent or teacher and would like to enroll your kids or students in one of the clubs, please call tollfree 1-800-515-BLUE (2583). Or you can visit BlueAnn’s Wild and Woolly Web site at www.BlueAnnEwe-ark.com. It’s fun. It’s free. And you can help your kids be their healthy best with the assistance of a woolly blue friend. Note: You can learn who the Class Club “Build a Healthy Sundae” party winners for the 2000-01 school year were in the Blue & Your Community section of this issue of Blue & You on Page 23.
ASE/PSE members —
IMPORTANT NOTICE FOR PUBLIC SCHOOL AND STATE EMPLOYEES
The state of Arkansas Employee Benefits Division has announced the addition of a new Behavioral Health Program for Public School Employees and Arkansas State Employees, effective Oct. 1, 2001, and Jan. 1, 2002, respectively. CORPHEALTH, Inc., a national behavioral health company, has been selected by the Arkansas Employee Benefits Division to administer mental health and substance abuse benefits and an employee assistance program. In order to qualify for reimbursement, all behavioral health care services must be pre-authorized and managed by CORPHEALTH. In addition, a CORPHEALTH network provider must deliver all covered nonemergency care. Call the CORPHEALTH Arkansas Help Line toll-free at 1-866-378-1645 for more information. The toll-free Help Line is available to members and providers 24 hours a day, 365 days a year.
This program and CORPHEALTH are not affiliated with Arkansas Blue Cross and Blue Shield or Health Advantage. Please note that on the effective date of the program, mental health and substance abuse claims should not be submitted to Arkansas Blue Cross or Health Advantage, as these benefits are excluded and there is no secondary coverage. For public school and state employees, our directories of participating providers will no longer list any mental health providers. Primary care physicians are no longer responsible for referrals or pre-certifying mental health and substance abuse care.
responsible for contacting CORPHEALTH to coordinate transition of care. All mental health and substance abuse care and employee assistance provided on or after the effective date must be precertified by CORPHEALTH. Questions regarding CORPHEALTH should be referred to the toll-free number, 1-866-378-1645.
PRESCRIPTION DRUG COVERAGE FOR PUBLIC SCHOOL AND ARKANSAS STATE EMPLOYEES
The decision to use CORPHEALTH is similar to the public school and state employees using Advanced PCS for prescription drug benefits. For both of these programs, Arkansas Blue Cross and Health Advantage are not affiliated with and cannot provide information on coverage or benefits. Questions regarding Advanced PCS should be referred to the tollfree number 1-877-456-9586.
TRANSITION SERVICES ON OR AFTER THE EFFECTIVE DATE
If members are actively involved in mental health or substance abuse treatment or employee assistance, the member(s) will be
Women’s Health and Cancer Rights Act The provisions of the Act apply to all group health T he Women’s Health and Cancer Rights Act of 1998 introduced changes in insurance coverage for mastectomy. In accordance with the law, all group and individual health plans that provide medical and surgical benefits for mastectomy now cover reconstructive breast surgery, if elected by the covered individual following mastectomy, including: • Reconstructive surgery on the breast on which the mastectomy was performed. • Reconstructive surgery on the unaffected breast needed to “produce a symmetrical appearance.” • Prostheses and treatment of complications of any stage of a mastectomy, including lymphedema.
insurance coverage effective on the first day of the plan year (which in most cases is the anniversary date of the group contract) after Oct. 21, 1998. The law went into effect on all individual insurance policies issued, renewed or in effect on or after Oct. 21, 1998. These provisions apply to all policies issued by Arkansas Blue Cross and Blue Shield, Health Advantage and USAble Administrators and are subject to the applicable co-payments, coinsurance, benefit limitations, exclusions and benefit maximums. If you have questions about your insurance coverage, contact your group benefits administrator or your local Arkansas Blue Cross office.
23 rkansas Blue Cross and Blue Shield strives to be a A good corporate citizen. Our employees raise money and spend many hours helping those causes near and dear to the hearts of Arkansans. Mid-week Sundaes Elementary school students in six schools in Arkansas made creamy creations with the assistance of BlueAnn Ewe, ambassador of health and wellness for Arkansas Blue Cross at “Build a Healthy Sundae” parties in their classroom. The students, who are members of the BlueAnn Class Club, completed a Healthy Habits Activity Calendar under the direction of their teachers to become eligible for a “Build a Healthy Sundae Party” with BlueAnn in their classroom. (A random BlueAnn Ewe shows students of drawing was held among Union Elementary in Texarkana the eligible classrooms.) how a “chef in sheep’s clothing” To complete the Healthy serves up ice cream sundaes. Habits Activity Calendar, students practiced at least one healthy habit each day — brushed their teeth, etc. — and recorded their habits with a sticker on a calendar for 20 school days. As a reward for their efforts, BlueAnn Ewe visited six classrooms and served the students frozen vanilla yogurt which they topped off with healthy treats such as granola and fresh bananas. The students played games with BlueAnn, and watched and learned the words to BlueAnn’s music health videos. Winners of the Spring 2001 sundae parties were: (Northwest) First Grade Teacher: Sheila Curtis, School: Northside Elementary in Siloam Springs; (West Central) First Grade Teacher: Deborah Marshall, School: Sutton Elementary in Fort Smith; (Southwest) First Grade Teacher: Tonya Dounphy, School: Union Elementary in Texarkana; (Central) Second Grade Teacher: June Joseph, School: Carver Magnet in Little Rock; (Southeast) K-5 After-school program Teacher: Frances Moncrief, School: Holy Rosary in Stuttgart; and (Northeast) Kindergarten Teacher: Margie Roach, School: Westside Elementary in Jonesboro.
Blue at the Zoo Of all the unique animals at the Little Rock Zoo, BlueAnn Ewe was the only blue, woolly one seen walking around during Zoo Days held June 9 and 10. BlueAnn was on hand to greet kids of all ages who visited the animal attractions during the zoo’s annual event designed to raise money for and awareness of its programs and wild residents. More than 8,500 people came through the gates — more than twice as many as the past two years combined — during the two-day celebration which featured lots of fun and educational activities, special guests and live entertainment for the entire family. River Market Fiesta Hoppin’ jalapeños! The River Market in Little Rock was a hot, happenin’ place on July 7 as Arkansas Blue Cross helped celebrate the site’s anniversary at its Fifthyear Fiesta. Feeling right at home in the midst of the Farmer’s Market, BlueAnn Ewe greeted kids and their parents who stopped in to select fresh produce and participate in festivities. Kids enjoyed watching the making (and taking home) of balloon animals, petting real animals, and trying to break colorful piñatas for the surprises inside. More than 50 kids signed up for the BlueAnn Health Club at the event. “Corporation of the Year” Arkansas Blue Cross recently was recognized as the “Corporation of the Year” at the 15th Annual Arkansas Minority Business Opportunity Fair luncheon held Wednesday, June 13. The award was given for excellence and dedication in utilizing minority businesses in Arkansas, and acknowledges that the company’s “commitment and long-term support have established Arkansas Blue Cross as a leader and pacesetter in corporate America.” Garold Lessig, Arkansas Blue Cross purchasing agent, accepted the award on behalf of Arkansas Blue Cross. “Recognition of this nature is a result of our combined efforts within Purchasing and other departments to establish quality relationships with small businesses,” said Lessig. “Although this award recognizes the initiative of doing business with Arkansas minority businesses, considerable activity also takes place with minority businesses outside of the state,” he added.
www.arkansasbluecross.com & www.healthadvantage-hmo.com
embers and policyholders of Arkansas Blue Cross and Blue Shield and Health Advantage often have questions about their health care benefits and services. Arkansasbluecross.com and healthadvantage-hmo.com offer several ways to find answers.
Contact Us In the “Contact Us” section, accessible from the bottom of the home page or the navigation bar to the left of the internal pages, a link called “Helpful Information” provides a list of phone numbers. On both sites, visitors will find local and toll-free numbers for specific health plans and Customer Service. The page also contains a link to a regional offices map and directory and a link to the Customer Service e-mail. Providers of medical services will find a list of numbers especially for them under “Provider Information Lines.” They also will find a list of network development representatives under the “Contact Our Regional Offices” heading.
Regional Offices Web site visitors can find the “Regional Offices” link by going to the footer at the bottom of the home page or the navigation bar on the left side of the internal pages and clicking on “Contact Us,” “About Us” or “Customer Service.” On the “Regional Offices” page, a map outlines our seven regions; and a directory lists each regional executive’s name, a mailing address, a local and toll-free customer service number and a fax number.
Customer Service The “Customer Service” section of both sites, accessible from the bottom of the home page or the navigation bar to the left of the internal pages, contains information on these topics: • Fraud and Abuse — how to report suspected insurance fraud and abuse; • FAQ — questions commonly asked by customers; • Glossary of Terms; • Wellness Discounts — health clubs, fitness equipment dealers, diet centers and other businesses that offer discounts to health-plan members.
Value-Added Services “Health Plans and Services,” found on both sites, links from the home-page footer or the bar to the left of each major internal page. In this section is a link called “Value-Added Services,” which are services provided to members and policyholders at no additional cost: • Special Delivery — helps educate expectant mothers; • BlueCard® — extends health care benefits while members are temporarily out of the service area; • Health Education Programs — features programs for specific diseases; • Utilization Management — helps control costs.
E-mail Customer Service and Webmaster On the home page of both sites and at the bottom of each major page, the link called “E-mail Customer Service” goes to a mailbox for customer service representatives. Site visitors should be aware, however, that this e-mail is not totally secure. It is better not to send personal medical information this way. Visitors who experience problems with the site or have suggestions should use the “E-mail Webmaster” link.
* * * Don’t Forget To ... * * * … return the survey cards found in this issue of Blue & You for a chance to win one of three $50 Best Buy gift cards or one of three $50 Wal-Mart gift certificates. Arkansas Blue Cross and Blue Shield P.O. Box 2181 Little Rock, AR 72203-2181