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									                                  Attachment # 4
                                February 14, 2008

    Oregon Educators Benefit Board

   Customer Service Model
   Final Recommendations:
Processes, Considerations, and
  Roles and Responsibilities
              February 2008
                                                                                 February 14, 2008
                                                                                   Attachment # 4
Administrative Workgroup Customer Service Recommendations
The OEBB Administrative Workgroup has extensively discussed several different customer
service options to determine what model will best serve school district and education service
district (ESD) employees, as well as staff, who are currently providing assistance or have a role
in administering the benefits within districts.

OEBB will have nine customer service staff in addition to the Systems Administrator and
Benefits Manager positions that support the customer service function. These activities include
providing assistance related to eligibility, enrollment, and benefits offered by OEBB. We will
have a phone call queuing system that will allow calls to be routed to the appropriate staff and
answered in the order received. There will be both a local number and an 800 number available
for district benefit management personnel and employees. These numbers will be listed on all
OEBB written communications. In addition, there will be designated staff to provide training to
districts in different venues, using different options and methods. OEBB will provide districts
with a designated OEBB contact name and number during the implementation and transition
phase. OEBB will schedule regional meetings with district Business Managers to provide
opportunity for their feedback and questions regarding process and system development and
implementation, and other topics as needed.

This Customer Service Model recommendation is based on the administrative functions currently
provided by the majority of districts and the Administration Model previously approved by the
Board. The workgroup recommends a partnership between OEBB and the districts that will
provide both effective and efficient use of resources.

The Process
OEBB sent a survey to the business managers listserv group e-mail to identify specific services
and functions related to the administration of benefits, who is performing certain activities,
including training and the amount of time spent of these functions.

The results of the survey indicate the level of customer service needed to support each district,
and help further support the recommended roles and responsibilities of carriers, districts, and
OEBB staff.

Evidence from the survey ensures that OEBB must deliver a comprehensive customer service
process that aligns resources to effectively manage the benefits offered by OEBB. The customer
service process entails:
    1. Supporting all districts and individual members with the resources to answer all benefit-
        related questions and support the administration of benefits. Resources may include
        OEBB staff, designated district personnel, carriers, and online tools.
    2. Ensuring effective policies and procedures are in place for a district or ESD to transition
        successfully to OEBB.
    3. Preventing duplication of resources.
    4. Providing districts and ESDs with the knowledge, tools, and training to maintain efficient
        operations of benefit plan management as further specified within the roles and
        responsibilities section.

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   5. Determining the level of training necessary for employees to accommodate the needs of
   6. Developing a plan to assist, guide and tutor the districts with benefit plan administration
      changes as they occur.
   7. Providing an opportunity for feedback focused on continuous improvement.

Districts and employee groups have many different eligibility rules and requirements. OEBB’s
intent is to ensure that districts maintain the first line of communication with their district
members. OEBB believes the districts have the knowledge and expertise to provide the most
accurate interpretation of the eligibility rules as determined by the district’s agreements or rules.
Thus, the Administrative Workgroup recommends that districts maintain the same level of
customer service that currently exists within their district; OEBB acknowledges that districts
have varying levels of support and wants to provide the level of customer service needed by each
district. OEBB does not plan on duplicating support and efforts in districts where these exist, but
will work with districts to ensure the appropriate tools and resources are available to administer
OEBB benefits.

This recommendation will decrease the possibility of inaccurate information being given by
OEBB staff to members, and the workgroup anticipates that districts will want to provide
interpretations, in addition to having greater knowledge, and more familiarity with their district
or group.

According to the survey results, the average time spent each week answering benefit-related
questions and completing benefit-related functions averages eight hours per week. These
questions and functions include eligibility, enrollment, benefit coverage, premium collection and
deduction, and payment.

Following are the proposed recommendations describing the roles and responsibilities related to
OEBB Customer Service benefit functions:

Roles and Responsibilities
Based on the intent and considerations made above, the Administrative Workgroup recommends
the following roles and responsibilities of districts and ESDs, OEBB staff, and plan carriers:

School District and ESD Responsibilities:
   • Determine eligibility (identify employees who meet the criteria of the SD eligibility
   • Select benefit plan options for each employee group and notify OEBB.
   • Continue current practices of providing new employee orientations, benefit information
       packets, etc.
   • Distribute information provided by OEBB regarding benefit plans, the enrollment
       process, or other related information. Information will be available both in hard copy as
       well as on the web for administrators to download, email, or print

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   •   Notify OEBB staff of member eligibility status via online entry or electronic file.
   •   Answer eligibility, benefit and plan design questions for members at the district level (if
       the district has the capability)
   •   Send premium payments to OEBB
   •   Assist in administering the open enrollment process (notification to employees, educate
       on options, etc)
   •   Update member eligibility records with Qualified Status Changes
   •   Reconcile eligibility to the premium payments

OEBB Staff Responsibilities:
Provide training, assistance, and the following information to school district and ESD personnel
who assist in the administration of employee benefits. This includes, but is not limited to:
   • Systems and processes related to member online eligibility and enrollment
           o Training possibilities might include things such as presenting during the annual
                mandated “in service” day (this would typically be covering open enrollment)
           o Making certain that the appropriate carriers are available during any open
                enrollment training that OEBB staff may be presenting
           o Utilizing remote training opportunities using applications such as Goto Assist
   • Premium payments and reconciliation
   • Questions about plan design and benefits
   • Open enrollment materials (summaries, documents, etc.)

Provide members with assistance as needed. OEBB staff will partner with, and support school
districts and ESDs to ensure members receive assistance through designated district personnel.
OEBB staff will provide member assistance as requested by districts due to lack of internal
resources. This may include assistance with:
    • Processes related to member online eligibility and enrollment
    • Enrollment or qualified status change confirmation or questions
    • Plan comparisons or differences
    • Benefit or service coverage questions
    • Links on the website for members to gain access to the member handbooks and other
         benefit information related to their benefit options

Carrier Responsibilities:
   • Provide member assistance regarding claim processing questions such as payments and
   • Provide member assistance regarding referral and prior authorization questions
   • Provide a claim and benefit coverage complaint and appeals process
   • Issue Member I.D. cards
   • Mail Member Handbooks if member requests
   • Attend district benefit fairs and open enrollment sessions to provide district
      administrators and employees information and answer questions about plan options and

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OEBB staff has reviewed the survey results, as well as followed up with several SD/ESD’s to
understand the current process. The survey indicated the majority of districts were handling
COBRA benefits including the communications, eligibility, premium collection, and payment to
carriers. Upon further discussion with the advisory group we also found that there were some
districts that were utilizing a TPA service for COBRA administration.

We recommend COBRA be administered by OEBB staff. Administering COBRA centrally will
provide a consistent and efficient process for districts and members alike. Because this is an
area of high visibility and liability, we feel the risk is reduced considerably by administering
these functions centrally. Although COBRA was not addressed in the initial legislatively
approved staffing model, we can request these additional positions at an E-Board hearing or
through an 09-11 Policy Option Package.

Following are the pros and cons of administering COBRA centrally at OEBB.

   • Provide consistency and standardization across the SD and ESD’s
   • Decreases the administrative burden placed on the school districts/ESD’s to provide the
      service or pay for a TPA/broker to provide
   • Each carrier would only receive one payment for OEBB COBRA participants, instead of
      receiving COBRA payments from each district; thereby reducing the administrative costs
      for both the districts and the carriers.
   • Eliminate the need for School districts/ESD’s to perform collection functions.
   • Consensus from the majority of our SD/ESD participants that COBRA was a process
      that they could support being administered centrally

   • Central administration would require SD/ESD’s to communicate to their employees
      leaving benefit eligible positions that the employee will receive communication and work
      directly with OEBB for continuing their benefits.

OEBB staff has reviewed the survey results, as well as followed up with several SD/ESD’s to
understand the current process. The survey indicated the majority of districts were handling
retiree benefits including the communications, eligibility, premium collection, and payment to
carriers. Upon further discussion with the advisory group, they all communicated that they
handle the retiree benefits process internally. We recognize that the retiree population within the
SD/ESD’s has very unique situations as it relates to stipends that are received by some retirees.
With that being said, OEBB would recommend that the retiree function continue to be
administered by the SD/ESD’s. OEBB will plan to have these participating retirees on the
SD/ESD’s coverage be reported as an eligible retiree in the OEBB system, which will allow
OEBB to invoice the SD/ESD for all eligible populations, and receive payment to send to the
carriers. With this method in place, the SD/ESD continues to maintain the relationship with the
retiree as well as the various payment methods and processes that currently exist. Additionally,

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the current process will be improved by adding communication materials on the OEBB website
and being able to field benefit option questions for this population if wanted or needed. Because
this is an area of high visibility and liability, OEBB will continue to evaluate this process to
determine whether this function should be administered centrally.

Following are the pros and cons of administering retiree coverage centrally at OEBB.
    • Consistent information to retirees regarding what their options are
    • Create efficiency by standardizing some processes
    • SD/ESD’s would not be responsible for collecting retiree’s premium payments
    • SD/ESD’s that wanted to could continue their relationship with their employees as they
       decide to retire, talking to them about their options and providing them with materials.
       For those that do not want to do this, OEBB would certainly have materials online that
       the retiree could refer to, as well as OEBB customer service would be able to field
       benefit option questions
    • Would allow the carriers to receive one payment for retiree participants

   • Varied and complex processes between and within districts/ESDs. Further planning and
      considerations would need to be performed prior to changing any business processes.
   • Retirees would be impacted by this change
   • OEBB would be receiving split payments needing to be tracked and reconciled monthly.

Roles and responsibilities for administration of COBRA and retiree benefits
School District and ESD Responsibilities:
   • Determine and notify employees when they are eligible for COBRA as required by law.
   • Notify OEBB staff of member eligibility status via online entry or electronic reporting
       tools (created by OEBB)
   • Continue to answer questions for members at the district level such as if a member is
       eligible for COBRA or retiree coverage. Districts and ESDs will receive continued
       support and communications from OEBB to assist in this effort
   • For retirees, would continue to collect whatever portion (or all) of the retiree premium
       and add that to what the SD’s responsibility is in order to pay the monthly invoice that
       will be received from OEBB
   • Notification to employees that leaves are about to end, or that they no longer meet
       eligibility requirements for employer paid coverage, and that they will be eligible for
       COBRA (and to contact OEBB)

OEBB Staff Responsibilities:
  • Partner with, and support school districts and ESDs with tools and training regarding
     identifying members that are eligible for COBRA/retiree benefits
  • Distribute all correspondence, letters, and communications to eligible individuals for
  • Invoice and collect premium payments and remit to carriers
  • Answer questions from members about plan design and benefits

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Carrier Responsibilities:
   • Provide member assistance regarding claim processing questions such as payments for
      services rendered and denials
   • Provide member assistance regarding referral and prior authorization questions
   • Provide a claim and benefit coverage complaint and appeals process
   • Issue Member I.D. cards
   • Comply with Customer Service requirements as agreed upon in the contract.
   • Comply with other administrative requirements as specified by law or contract.

Appeals – Eligibility and Enrollment
The survey results indicate that the majority of responding districts and ESDs currently handles
the complaints or appeals of eligibility and enrollment.

We recognize that districts have the most accurate knowledge of their own employee population
and current CBA language. Therefore, we would recommend the following appeal process:
   • The initial problem/complaint would be handled by the district
   • If a district is unable to resolve the problem or complaint at that level, OEBB will have
       an internal step appeals process (TBD). OEBB would incorporate the information
       acquired at the district and move the appeal through the internal OEBB appeal process as
       needed or requested.

Appeals – Benefit Coverage or Claim Denials
Review of the survey results verifies that although some districts do provide the function of
handling complaints and appeals for benefit coverage or claim denials, the majority do not.
OEBB concurs with this business practice.

Therefore, we recommend that complaints and appeals for benefit coverage or claim denials
should be as follows:
   • The initial complaint will be handled through the carrier’s complaint appeal process. The
       member would follow the appeal rights and procedures process found in each plans’
       respective member handbook
   • OEBB will provide a review of the appeal if it is not resolved at the carrier level. Since
       OEBB holds the contract with the approved carriers, we can review appeals to verify if
       this is a covered service. We would develop an internal complaint appeals process.

Annual Survey
The Customer Service Model will include an annual customer service survey to identify the level
of satisfaction as well as areas that can be improved. These surveys will be discussed with the
OEBB Board and will help determine goals and objectives for the upcoming year.

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Plan Follow up
This plan will require OEBB staff to:
   • Develop internal appeals policies and procedures that is complimentary to the carrier and
       district complaint and appeals process.
   • Develop COBRA and early retiree policies and procedures to align with the approved
       Customer Service Model
   • Provide Board regular updates as additional information becomes available
   • Create two advisory committees that have representation from small, medium, and large
       districts and ESD’s or adequate representation in other areas, systems or processes as
       determined. One committee would be to partner with OEBB to test and troubleshoot the
       benefit management system, with ongoing needs to prioritize requests for enhancements
       and modifications to the enrollment system. The other committee will partner with
       OEBB in drafting Oregon Administrative Rules to be recommended to the
       Administrative Workgroup and the full Board for approval.
   • Continual and regular communication, including monthly meetings with Business
       Managers regarding development and implementation of systems and processes.

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