if it's overcast, and sometimes people don't realize that. [please stand by]

>> we can see our breast cancer exceeds california and national rates, as well as our skin cancer and our prostate cancer are higher than those benchmarks as well. when we look in our nonmedicare population, on the top right, we see that we are lower than benchmark for breast and cervical and skin, but the prostate is higher than the california average in the health service system population. the next slide is doing the same sort of comparison here, but we

are looking at it by cost. instead of looking at it by prevalence, which is what the previous slide was doing. we have, again, breast cancer, leukemia, and lymphoma, all of those are our costliest cancers, and we are exceeding the california benchmark and exceeding the national rate. moving to slide 11, here we are taking a look at it from a longer to do no approach trending three years. we have 2016 through 2018, and there is a little orange dash line in there that shows you a trendline of how is our prevalence going over the years. so even though 2018 has increased over where we were in 2017, we do see, for example, in the prostate cancer and our male population, that has trended downwards over the three-year period.

our breast cancer has trended up significantly over 2017, but slightly over 2016. that is also true of the cervical cancer that has been increasing over the three year trend. >> can i ask a question? >> yes, please. >> it is curious to me that 2017 was your middle column and lower for everything. so i am just curious, do you think your data captures all the diagnoses? is there something -- there's something that is strange about why one year all the cancers would be lower. >> yeah. i think so, too. as far as we know, all of our data is there. we do know we have some anomalies with some plans that we are looking into, with that is one we are still researching. it may take a while for our investigations to identify the reasons for it. that is something we are still

continuing to look at. >> and your chronology goes from 2018 on the left, 2016 on the right. usually we are used to seeing things the opposite way. >> is that making you pay more attention? [laughter]. >> it makes me pay more attention. >> that is like when you go to trader joe's on the fourth and they have the escalator on the right side and it is now on the left. >> i know there was a reason why they -- what you did that. it does keep us awake. [laughter] >> i was wondering if we could blame it on where -- you are from england, right? so, moving on, what are you looking forward to? what we anticipate in 2020 and beyond is, first of all, that you will see about a 12 to 15% increase year-over-year going forward, and what you can see is

, globally, they are increasing the same as the rest of the world. it is expecting to increase about nine to 12%. japan is as low as 6%. from that perspective, unfortunately cancer is being treated and is being globally treated and everybody expects about the same growth rate. so then what does that mean to you all as far as this? if we are looking at the top 10 cancer episode treatment groups, what you are spending for breast is about $13.8 million. you are spending about 7.4 million dollars on leukemia.

you are spending 2.8 million on skin. i do have to draw attention to the fact that skin is orange and everything else is green. when you are thinking of acute, you usually think of appendicitis, you think of flu, but skin, because it is usually

treated and then it is gone, has one episode. so if you had a swarm his cell on your finger, they would exercise it and so it up. that would be done. they would be no additional treatment and that's why it is considered acute versus chronic versus something like breast cancer where you have chemotherapy or radiation therapy and things of that nature. if that makes sense. and so as you can see, you have kidney and urinary cancers at 2.3, but that is basically looking at your cost 182018 based on the treatments that you have, which is, at 10% of your 550 million-dollar budget. so, i will move aside. >> as we take a look at slide 14 , we are looking at a per member per year cost and we're doing that for our active and early retiring members. we do not have the financials for the medicare population. is our top cancers year-over-year, same thing where we are going left to right. and so cancer cost is trending upwards on the leukemia side. we have the cost trending downwards pretty significantly there. and our lung cancer trend upwards and same with lymphoma.

that is what the trend has been looking like over these years. same thing as applicable here in terms of what the commissioner has noted with the 2017 members that dip in some areas, not so on the cost of breast cancer, but that still is pieces that we are investigating. >> i want to talk a little bit about how treatment has changed over the past three years. if you look at the right column you will find them and you will notice that hospital inpatient stays was significant. it was almost -- it was slightly more, maybe two% more than what the outpatient services were, and radiology, which is your radiation therapy, came in at 10 million. if you fast-forward to 2018, which is the second column, you will see that your inpatient

care actually dropped by almost $5 million, which is a significant change and your outpatient stayed somewhat flat, although it did go down a little bit at 14 million, but what you will see is that your pharmaceutical treatment of cancer increased by about, a little over $2 million. about 30%. so from that perspective, you see your growth and your outpatient because if you were to have maintains the 5050 ratio , you would expect the outpatient would have been around 11 million and instead, it is at 14 million and your pharmacy increase, where is radiation, what you would have expected may have caught up, but hasn't really changed year-over-year during the same time period. so from that perspective, the good thing is that you are being able to treat people,

outpatients, which means they are able to be in their own home and in their own setting. the difficult part is that was the changes in the treatment patterns with the drugs and the costs now are on the outpatient side. questions? >> what would other be. >> that would be dme. wheelchairs, it could be some of the genetic testing that would fall in there. it would be home health, hospice , things of that nature. >> thank you. >> any other questions? so one of the things that people often forget about when you think of cancer is long-term survivorship.

there is a significant impact of cancer, and it remains high year-over-year. it may be you are no longer being treated, but let's say you need to be fitted with a special appliance for a breast, let's say you did not have reconstruction, or you had a deformity caused by the removal of the cancer. all of those costs will continue as your body changes and ages, you will need to update. those costs will continue. one of the stories that i'm sure some people have heard, but i always -- it just comes to mind, i had a family. i am a clinician. the wife had lung cancer. they were at a university facility not in california and they were being treated aggressively and she passed. her passing meant her husband not only lost his wife, which

they were incredibly close, but he lost his house because he didn't have enough insurance to pay for it. he not only was grieving the loss of his house and his wife, he now had to figure out where he was going to live. and so those costs that go along with cancer lingered for many, many years after the active treatment. that is one of the things that often we forget about going forward. so earlier on in the presentation, i mentioned that the positive things that we are seeing with your increased screening is the earlier detection. so if we look at pages 17, 18, and 19, i will not go over -- i will not go over all three pages , but focus on the active, is what you see is that, for breast cancer, the disease stage

zero, which means there is no test to says, there is no lymph nodes involvement, it is a localized lesion, is significant that out of your 680 people that were identified, almost 90 of them were at stage zero, and only, again i will use 90, my measurements might be slightly off here, were at stage three. the rest were stage stage one. that means it is very receptive to treatment and it is a positive finding. if you go down and look at the list, you will find very few stage four. you will find a few unspecified, a few, if my colours are correct here in the oral cancers, but very few stage four.

you do have a fair amount of stage three, which is the yellow , particularly in lung cancer, and in colon cancer his. but overall, you are finding your cancers earlier, and that pattern is seen both in the pre 65 retirees as well as medicare retirees. so in conclusion, what we are going to watch for going forward is we will be reporting back on cancer because unfortunately i anticipate it will remain in a top consumer of your resources. so we will pay attention to the stage of the disease, when it was diagnosed. we are going to hopefully look for increasing screening rates, again for cervical, breast, in colon cancer as compared to the national averages, and we are

going to really keep on top of the prevalences by each type of cancer to see if there is any targeted interventions or wellness activities or outreaches that we can collaborate with your various health plans on to improve screening and early detection. any questions? >> i have a question. thank you for the very thorough presentation. i'm wondering if you have a breakdown by gender or by race or anything further broken down that breaks down the types of cancer. >> at this point we do have the data available to us by gender. some of the cancers in this report we have made some comments about specific genders, for example, on the breast cancer, both genders can get breast cancer, but we have looked at it with a male population and without. that is not a problem. as far as looking at things by

race and ethnicity, that is not something we are able to do today. it is a focus under our strategic plan and the direction we are going. >> thank you for this. is a really thorough presentation. i'm not sure what your reasoning is, but i applaud the exclusion of prostate cancer from early screening. it is my understanding that prostate cancer in the united states, the issue around early detection and early identification of men with prostate cancer is still quite controversial in the developed countries. the europeans feel that the americans diagnosed early, label men with prostate cancer, treat, and yet their survival rates at 10 years, 15 years, are actually identical to their history, which is a much later diagnosis time, and so the fact that we are not necessarily encouraging early screening while this question is still being

identified, and i know a lot of men with prostate cancer who have entered clinical trials looking to see what the history might be, and not necessarily accepting medical or surgical interventions. so i don't know if that is the rationale for your failure to follow that, or it is coincidence, but i applaud it. >> no, actually, it is a usps task force. the united states has taken it off a recommendation at this point in time. that is why we took it off of our screening policy. any other questions? thank you. >> any public comment on this item? seeing none. would anyone prefer a break right now rather than charge through? >> yes. [laughter]. >> we will take

>> we are back in session. we are on item number 11. >> item 11. item 11 is a presentation on delta dental teaching network and utilization report this will be presented by the account manager from delta dental. >> is it on? okay. you have a presentation that we will go through. it is really some information and updated stats regarding some of the programs we have implemented as of january first of 2019. so with the first item, we are actually going to talk about our dentist accreditation. there were some questions regarding how we go through that process and so we do credential all of our dentists in the network.

before a dentist can be permitted to those networks to actually be listed as a provider we go through the credentialing and utilize the standards of the national committee of quality and assurance. and our common practice is that in order, we do have a unit within delta dental that is fully responsible for this credential process. so making sure we are continuing to do this on an annual basis. the credential process, we actually obtain a state license making sure that also the dentist has evidence of malpractice coverage. they also have to provide us with a drug enforcement

administration certificate and specialty training verification. that would be for a pediatric dentist or an orthodontist where they are having to have additional training because they are providing a specialty within the dentist world. we do verify this annually and we do utilize the national practitioner data bank to make sure that license is up-to-date. we also read credential at least once every three years all the dentists. so making sure, again, not -- that their license is up-to-date , we have a current malpractice insurance policy, we are also making sure that we are sharing with the dentist employee satisfaction surveys, or any kind of grievance and appeal that we received for

people who are enrolled in their specific practice. >> so this is only in? >> this is for the p.p.o. and our premier network. those are our two networks. >> okay. >> yes. i don't know, but is there continuing medical education requirements for dentists like there are for physicians? in california they have to show so many hours. some are specific for certain kinds of training, but most was not. if you are a neurosurgeon, you can -- your credits can be for -- the specialty boards now are requiring recertification every 10 years for all the specialties

, both surgical and nonsurgical. are there requirements for dentists? >> i believe there are, but i don't know the specific our requirements because i do know that we do specific webinars for our dentists, and then i know that they also participate in a lot of the dental association congress national seminars and conferences that they attend. i can definitely -- >> i just want some information. if you are relying on re licensure, which the state does, obviously, and that requires cme, we would note that because you are not asking for independent verification of hours, you're just relying on the state. they will be fine, but we would know that.

>> there are continuing education requirements for dentists in the state of california to the extent that we can provide more detailed information. >> just to know that there are. >> yes. >> the next set of slides will talk about the network and under the p.b.o. plan. and remember that we have two sets of contracts. p.p.o. contracts and premier contracts with our dentists. and then all members are eligible to seek services by a noncontracted dentist with us. so the first slide is on active, your active population. it is for the p.b.o. contracted dentist, and we ran this report specific to your geographic locations and the particular of the data, or criteria of the

data, was within a 10-mile radius. you can see on the first slide, it is almost 100%. 99.7% of your members that are enrolled in delta dental who have access to a p.p.o. dentist with less than a mile away from their location. on the next slide, it is our premier dentist network. again, very close, 99.8% within a 0.8-mile radius. our next slide is focused on retirees, and again, p.b.o. we are presenting first. 99.3 in a 1.2 mile radius. they have access to a p.p.o. dentist. and then on the next page, premier, 99.8, a little less than a mile.

we are going to transition into your smile way wellness program benefits. this first slide is a reminder as to what that benefit is. you did approve that benefit to be installed into your plan both active and retiree plans. this is a specific wellness that for individuals that have diabetes, heart disease, h.i.v. or aids, rheumatoid arthritis or stroke, they can and roll in this plan either by phone, by calling our customer service, or online through their online portal, and in role in this plan , and they get additional benefits. typically this is the scaling where it is the deep cleaning of the teeth that individuals that

have inflammation of the gums, and in all five of these chronic conditions, have a result of inflammation, and so typically there's that need to have additional dental work. so now you are providing that free of charge, meaning no charge to the member to have these additional services. >> i'm sorry, i am asking questions. so the rheumatoid arthritis jumped out. maybe i have asked this before or maybe i didn't know this, i didn't know if rheumatoid arthritis, per se, has a specific dental complication due to inflammation, or whether it was sort of bedcovers different syndromes and dry mouth associated with a -- other autoimmune diseases or whether it is because of mechanical issues that many people cannot do their own oral hygiene as well. is that the first, is there a special inflammatory condition

that distinguishes from other autoimmune diseases or other kinds of arthritic teas? >> i think your first and your third observation are the best in this particular circumstance. one meaning that there is a heightened inflammation that we really can associate with just specifically rheumatoid arthritis. i have had some of your members come and approach during your health affairs or wellness and ask the question, well, i have arthritis. why aren't you covering that? it is specific to rheumatoid arthritis. and then the third observation that you made aware there's a lot of deformity, that is associated usually with rheumatoid arthritis, meaning the crippling of the hands or different body parts. that does then cause a greater complication for a member to really be able to do that

preventative dental cleaning and assistance to their teeth. so then you have more of the sliding scale of having more disease, finding more tooth decay. so the next slide is -- and just kind of a snapshot of the four different months and looking at the enrolment in the smile way program. actives are on the left-hand side, retirees are on the right-hand side. his the retirees are doing really well in this sense of the are embracing this plan, they are enrolling in this plan, and so you can see that uptick. also with the actives. i mean there is definitely a response to this program and, you know, we went from 20 enrollees to 112 as of september

really positive in that regard as to a self elect process, meaning they are self electing and calling us for their enrolling online. so some different suggestions to increase the participation within the smile way program. currently what we have been doing is the contact centre, the delta dental or -- dental contact centre when you're calling the customer service line, the representatives know to promote the smile way benefit and where i say in parentheses, a banner within our system, basically what that is it is a highlighted -- it is highlighted one a member were to call in from h.s.s., we pool up -- pull up their member record, it immediately they see them big, bold, yellow highlight that your

membership has access to the small way benefit, and so as they are going through the process of answering the question for the member, they are also promoting this program. and then the other aspect that we have been providing flyers. so you have an active flyer and retiree flyer. they are just a little bit different nuances within the benefit, and meaning not nuanced and benefits for the smile way program, but we show a comparison of what your existing benefit is and what you get through the smile way benefit. so that is why there is the difference in the flyers. but we have been promoting these at the health fair. i actually helped two of your retirees in role at the health fair just recently. they were really excited to learn about the program and that was really the conversation that

we had during the health affairs the next slide is what you are currently doing. you are promoting on your plan resource section the delta dental wellness highlight. so both of the flyers are on your website and you also have a smile way program section and it actually gives the instructions to members on how they can and role in the plan. and then what i didn't put on here, and i'm so sorry, but you did promote smile way. you have, both in the retiree and the active benefit guides for 2020. you have a paragraph and there is a smile way pattern on there. and also there is a little footer on the benefit summary page in case they didn't read

the content. there is a reference on the benefit highlight peace as well. you also previously promoted the smile way program in your "in the news" section on your website as of april 11th. so some future possibilities or considerations on how we can continue to promote this wellness benefit, one would be to add how to enrolled in the smalley program on your dedicated page within delta dental. so i gave the website -- we have a specific website that is just for your membership, and by going out to and doing the little slash, that will take you directly to your delta dental webpage and it has you benefit highlight sheets on there, your evidence of coverage, and then smile way and some other things.

so just putting the two flyers front and centre on that page, so i am working internally to do that as we speak. retiree outreach. i don't know if there is an association newsletter or meetings or presentations that could possibly that i could attend or provide content. targeted messaging, so e-mails to actives and retirees who have signed up for the delta dental online account, or have an online account with us. we are capturing when you create your own line delta dental accounts through the enrollee portal, we capture your e-mail address. it most likely is probably a personal ad just. we have the capability of being able to target messages to you.

>> when they use the cost estimate -- estimator tool, it will bring up what deductibles they have satisfied, how much they have used of their annual maximum, and it will then calculate the benefit that they are looking at. so we have a number of different suggested, soto of the most

common such as a feeling, or a crown, or braces, and it will actually bring up who they last saw so the dentist that they last sought services from, and then it will calculate for them what that out-of-pocket cost versus what we, delta dental, will pay for that procedure. so on your next page, this is the staff as of the launch date on january through september. so for actives we have 367 utilizers, and for retirees, we have 61. and the dental procedure inquiry , that means out of that active 367 users, they looked at two different procedures. they may have looked at a cleaning and what the cost of that is, and a feeling for braces and a crown.

and so you can see retirees were looking at a couple of additional. they may have been looking at the implant versus the crown and one other. so we continued to publicize this benefit as well during your health affairs. so i think these numbers will also increase by year-end. >> does this cover also you're out of plan dentist or only your premier and p.p.o.? >> very good question. it actually shows when a member is going in and selecting, such as a filling. they will show the latest dentist and that will show whether it is an in network, a p.p.o. premier dentists, or a noncontracted dentist. it will then list three or four in network, contracted dentists,

and then it will do out-of-network. is a great tool to shop for your dentist for major services because you are not locked into a dentist. you can go to anyone. so it really demonstrates by utilizing that p.p.o. or premier dentist comparative to someone that is just noncontracted with us. oh, the next slide we have active utilization and retiree utilization. this was specific to cleanings. we were talking about engaging members and getting their cleanings, and then just some other -- how they are utilizing the services. whether it is a basic service or a major or orthodontic. so for actives, we have the first part which is your cleaning procedures, and so

36-point 5% have not received a cleaning. that is what that none means and then 42% have received at least one cleaning for year-to-date. so as you know, we are kind of in that cycle of getting that second remainder of the year. usually you do it every six months. these members -- these numbers could increase a little bit from the none to one or none to two. also, then the next line is your basic services. that would be fillings. twenty-eight% utilization there. major services would be more like a crown. 9% and orthodontic. your active plan has a 2500 calendar year maximum, so 41 we looked at the membership and the

utilization there, 2.4% were exceeding the 2500. that is still a very low number. we usually look at a 10% threshold as to then we need to start looking at increasing the annual maximum to a higher amount. and then the final piece on this particular slide is the network utilization. so 38% using p.p.o., 58% premier , then you have the 3% for noncontracted. >> just a comment on the slide. it is kind of strange that you have 36.5% of the reimbursed who haven't even gone to the dentist i don't know what is going on with those numbers. you should at least have at least one cleaning or two cleanings a year. it is kind of strange that we

have 36.5. >> thank you. we agree. it is a free, covered 100% benefit, everyone should get one cleaning a year. and an exam to identify other problems within your mouth. >> how much outreach is there? >> that is a great question as well. we actually just launched a campaign to really focus on the cleanings and getting more individuals that haven't sought cleanings to go and, as a fronting reminder. so i am working with your executive team to determine if we will establish or push that campaign out. it is basically an e-mail campaign. so that is something that we just launched and we are slowly but surely getting clients on

board. >> this is going to be a health issue, as well when you don't take care of your teeth. >> correct. >> we have talked several times would delta dental and have an ongoing conversation about how to do a deep dive into understanding why people don't go to the dentist. i think we all have our theories and i think it is important that we continue engaging our membership through focus groups or surveys or whatever to try and understand what the barriers are because it is an alarming number of people that are not having basic services and it can and will lead to other health problems. i think it is a huge indicator of a preventive service that is disappointingly underutilized. it is something i think we will continue to work on. >> thank you. >> your next slide is on retirees.

almost 33% of people are not getting cleanings, 36.2% for one cleaning, and for individuals that have had at least one basic service, 35%. one major service, 18%, and individuals that are exceeding the $1,250, six-point 1%. and then your utilization for p.p.o. versus premier versus non contracted dentist is 41 versus 53 and then five are going noncontracted. that concludes my presentation i am more than happy to take any additional questions. >> i have a question. i have a tough time figuring out what is the difference between the premier and out-of-network because the cost is much the

same for the member, you know, the out-of-pocket cost is pretty much the same. i am wondering why, what is the difference between a premier and in out-of-network? >> right. the cost is premium. there is a very big difference in the experience to the member. so for anyone that is going to a p.p.o. or a premier contracted dentist through delta dental, when they go and seek services from that contracted dentist, all the paperwork is taken care of for them. so they come in, they are already precertified in the dentist office make sure they know what benefits that member has and is eligible for. they then create or have the exam or whatever the circumstance and they're coming in for a filling.

they are having that procedure done. the dentist submits that procedure and that claim to us and we process that claim and then we send an explanation of benefit statement indicating here is how much we paid, here's how much your cost is. now let's take the experience of someone that is noncontracted with us. a dentist, you still have the ability and you can see from the numbers that you've got a population that is still utilizing noncontracted dentists , so when they go and seek services, that dentist will either call us ahead of time to verify that they've got coverage or not. when they had their procedures done, the member will have to pay 100% of that cost upfront. that member will have to submit their own claim form to us to get reimbursed or, in essence, basically to find out how much we will pay on that claim, and the dentist can balance the bill

so we have contracted amounts of what we consider as contracted fees or contract allowance for a filling or a crown. with a noncontract dentist we have no ruling over them or governing power over them, so if they charge what we consider exceeding the allowance, they actually can balance built the member. so let's say that cleaning was $100, and the noncontract dentist charges 120, we pay $100 that $20 will be balance billed to the member. >> and what is the difference in the premier and the p.p.o. as far as how they get reimbursed from you or what they can charge >> there are two different contract arrangements. premier was what we started out with way, way back. many of our dentists are still

premier dentists. however,, we have now negotiated different rates on the p.p.o. contract to afford the dentist having more access, meaning just to the members, and it is also giving a discount to the members when they are going and seeking services from that p.p.o. dentist, as well as our clients. so actually h.s.s., every year that is a reimbursement. we shared those savings with h.s.s. in our premium and in our overall cost to you. >> so are the premier dentists paid less by you? >> they are paid a little bit more. >> all right.

and so you say you have pretty good oversight over the dentist if they are having problems or if somebody comes to you with an issue with a dentist, you will carry it out. in the past i have had at least three incidents and nothing was really ever done. my dentist had serious problems. and they are still practising. so i don't know how it is today or how much oversight there is. >> we would definitely want to know that specific dentist. hopefully the member or yourself has called into our customer service and reported. >> they did at the time, absolutely. >> because then there is a report that is generated and then that goes back to our specific unit. we have secret shoppers that go out to those particular dentists we are sharing. as i mentioned, enrollee satisfaction, as well as different surveys that we are doing, and if there's anyone

that has had a number of complaints, we reevaluate our relationship and we have cancelled the contracts in the past for it not being up to our standard. >> i hope so. thank you. any other questions? >> thank you for the information any public comment on this item? seeing none, public comment is closed. all right. now item number 12, please. >> approve this s. of h.s.s. infertility benefit clarification. this is an action item. >> good afternoon, commissioners you have received in your package, and we can display for the public if you wish the memo

that i have written to you regarding the modification of the infertility benefit. we have had this discussion several times at the board and many discussions with our plans and the time in between and i appreciate everyone's patience and persistence in seeing this discussion go through. as you know, we approved and infertility benefit in 2017 and since that time, we have seen the benefits administration of that, too, and we have been noticing that we have some difficulties with one of our health plans in the way the benefit was being administered and it caused us to do a deep dive in understanding how benefits were being administered by the plans. and it was very enlightening to go through this inquiry.

there is a grid that we are -- contract staff have prepared for you to see the list of benefits that are -- or services that are covered under the infertility benefit and again we found an opportunity to both clarify and add some services to that benefit. so today, i'm asking for the board to approve these additional services and to support the clarification statement that i have written in the document in that, as i said, these questions that have arisen early are around procedures that are in current practice being considered diagnostic. so the clarification statement is that these services covered under the infertility benefit that was approved in 2017 is

required so h.s.s. can continue to ensure that covered infertility services are available to all members regardless of age, domestic partner status, gender, gender identity, marital status, genetic information, sex or sexual orientation. situations when a member require services to determine the member 's ability to achieve or cause pregnancy, the least invasive services are diagnostic in nature and may lead to ruling in or out to the diagnosis of infertility. so this decision to proceed with these services is often determined by the member in consultation with the member's physician and so we are making these clarifying statements to ensure these services are available to all members. the added services that you will find on the grid are the oral medications, injectable hormones and intrauterine insemination.

so we continued to have really robust conversations and relationships with our plans, all three. blue shield in particular has been very forthright and aggressive in identifying barriers to the proper administration of this benefit and are taking steps to ensure that that is corrected and that our members are not running into problems as we have now uncovered that there had been some. so with that, i hope that this clarifies for the board what we recognize is a situation in which the plans are really willing to properly administer this benefit so it is available to all our members and this clarification discussion has been quite beneficial to all parties involved.

>> can you just clarify, in terms of -- you alluded to the fact that one of the plans if there had been problems and you have been working diligently with them to identify them, maybe look for denials that, in fact, were reported to h.s.s. to look to see if there are other bigger problems. are there complaints from the other two health plans? or is it limited to one plan? >> we have not received complaints regarding the health plan coverage at kaiser nor with unitedhealth. and we have the one member who has come forth regarding the concerns of blue shield and has been a very strong advocate and is very, very helpful in informing us and blue shield where the barriers have -- that she has experienced as barriers. so, as in some of these other situations that were mentioned under previous agenda items here

, it is always hard to find problems when you don't have specifics. so blue shield has been very helpful in trying to find any denials that they have record of and they now have a case manager who is dedicated to our account and to this benefit to investigate all of those and reach out to the members to get the full story because they may or may not have been appropriate we don't know at this circumstance. i share the concern that sometimes word-of-mouth advertising can be your best friend or your worst enemy. i do think that in the circumstance, we will work with the plan to make sure that our members are aware that this benefit is available to them. >> again, just to reiterate, we have mechanisms when there are concerns over denial of benefit, et cetera, that we have h.s.s.

staff that can field those and help go through the process to make sure that those benefits are understood or appropriated, and then the board would know what the outcomes were if there were problems that were presented that we need to correct. >> absolutely. a key service that member services provides is taking this call from members that are having all kinds of questions and struggles. in fact, i know a number of the board members have called on behalf of members and we take those quite seriously. we are able to be a strong advocate for members and are really wanting to do that. as you know in our strategic plan, we did call for an additional position of the communications director who we are actually calling an engagement specialist because we know 126,000 members are not all the same, and there's various different issues whether it be the underutilization of dental care, the misunderstanding and negative experience with the

ministration of a benefit. we have a wide range of issues that we have to do a better job communicating with our members. we are in a good position to assist us in doing that. >> with regards to this action item, if the board passes it, what would be the difference of experience be for members who are trying to utilize this benefit. >> the aim is to limit any benefit to things that currently exist. >> okay. >> so you were going to give more of a presentation on this? >> anton is. i was here to be called upon as needed. >> does anyone need any more information on this? i would entertain a motion. >> i move we accept the staff recommendation to approve and clarify the infertility benefit.

>> i second. >> second. >> is there any public comment on this item? >> hi there. good afternoon. i wanted to thank the department and the commission. i know this has taken up a lot of time that was unexpected time i did send an e-mail this morning. i don't have a medical background, i am not part of the insurance company, and so i understand that it is incredibly complicated and i appreciate your work. having said that, is one of the most senior legislative aides here at city hall, i know a little bit about policy. when policies are made, typically there is a problem identified and backed by data like in this case. there is the goal that you want, which is, in this case, his

equity and access to all members without barriers. and then you create a policy to address both the problem and to get you at your goal. in this case, there are no changes being made to the current policy at hand. what is being recommended today is a change in language for clarification. so the language, just like a policy, the language needs to be incredibly clear so there's no room for interpretation. i think this line is what the director read and it is getting at the crux of the problem, which is that at least -- the least invasive services are diagnostic so they can be covered, which i think gets at the issue that was shared. however, i want to point out that in all the other documents, it clearly says that in order for the service to be covered, it must be determined to be

medically necessary. so my question to you is a lesbian couple or someone who is a single mom by choice does not necessarily have infertility, but does need access to reproductive technology in order to conceive. so is this saying that an iu why can can be used as diagnostic before they have a medical diagnosis, are they going to be reimbursed? do they have access to this before the diagnosis? it is unclear to me, but that is less important. it is more important if it is clear to you as commissioners of the department and to the insurance providers. that is my public comment. >> thank you. >> any other public comment on this item?

>> can i comment on this? i think it is clear to me because i was concerned from some of our previous discussions around the use of the word fertility and infertility. after some discussion, and have encoded a lot of encounters, there are preliminary encounters of diagnoses such as infertility so if a woman were to come in with the desire to be pregnant and in a lesbian couple or a single woman or whatever situation it maybe, if they would be infertile until proven fertile and if the procedure led to pregnancy, then you wouldn't put them on a permanent problem list of infertility, but that problem that was coded for that encounter would, in fact, solve -- be considered payable