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1 1 Medical Plan Comparison Laura Morgan UCSB Human Resources, Benefits This presentation is intended for communication purposes only. Please see plan.

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Presentation on theme: "1 1 Medical Plan Comparison Laura Morgan UCSB Human Resources, Benefits This presentation is intended for communication purposes only. Please see plan."— Presentation transcript:

1 1 1 Medical Plan Comparison Laura Morgan UCSB Human Resources, Benefits This presentation is intended for communication purposes only. Please see plan document and for complete information.http://atyourservice.ucop.edu Big changes New choices 11/2013 Updated 11/22/13

2 Open Enrollment OverviewOpen Enrollment Overview Medical Plan Design 101Medical Plan Design 101 Medical Plan ComparisonsMedical Plan Comparisons Residence requirements Residence requirements Choice of physician Choice of physician Cost of care & prescription drugs Cost of care & prescription drugs Out of Pocket Maximum Out of Pocket Maximum Health Savings Account Health Savings Account Behavioral Health Behavioral Health 2

3 3 Ends Tuesday, November 26, 5:00 pmEnds Tuesday, November 26, 5:00 pm Make changes online - sign in to accountMake changes online - sign in to account All changes are effective January 1, 2014All changes are effective January 1, 2014

4 4 Change medical and/or dental planChange medical and/or dental plan Enroll in medical, dental, visionEnroll in medical, dental, vision Add eligible family membersAdd eligible family members Enroll or re-enroll in Health Flexible Spending Account (FSA)Enroll or re-enroll in Health Flexible Spending Account (FSA) unless you select the Blue Shield Health Saving Plan) unless you select the Blue Shield Health Saving Plan) Enroll or re-enroll in Dependent Care FSAEnroll or re-enroll in Dependent Care FSA

5 5 atyourservice.ucop.edu/oe Booklet

6 6

7 Anthem PPO UC Care PPO (administered by Blue Shield) Anthem PLUS Anthem HRA-PPO Blue Shield Health Savings Plan (PPO) Health Net Blue & Gold HMO Health Net HMO Kaiser HMO Core

8 Medical Plan2014 Medical Plan Health Net Blue & Gold HMO Health Net HMO (full)Health Net Blue & Gold HMO Kaiser HMO Anthem PLUSUC Care Anthem PPOUC Care Anthem Lumenos HRABlue Shield Health Savings Plan Anthem CoreBlue Shield Core

9 9 Cost to enroll – monthly premium Cost of care Predictable, low cost copays Pay a % of each service Choice of providers HMO medical group physicians PPO preferred network or any provider Effort to manage – coordinating care & bills

10 Medical Plan Design 101 HMOPPOPOS

11 Insurance plan delegates your care to a medical group (e.g. Sansum, SB Select IPA) Care is coordinated by a Primary Care Physician (PCP) and medical group Member selects PCP, PCP refers to specialists Predictable, low cost, copay for services - no deductibles Emergency and urgently needed care when away Health Net Blue & Gold HMO Kaiser HMO 11

12 12 Primary Care Physicians Specialists Labs Radiology Durable Medical Equip Urgent Care Hospitals When you need care go to your PCP PCP refers you to specialist, x-ray, lab, hospital HMO Medical Group Medical Group authorizes referrals to some specialists and treatment Access to Care

13 You direct your own care, you decide where to receive services You pay annual deductibles before plan pays After deductible, you share the cost of each service with the plan - coinsurance Your costs are lower if you select preferred providers Out-of-pocket Maximum limits your financial liability UC Care Blue Shield Health Savings Plan 13

14 January Calendar Year December Deductible You pay CoinsuranceCopay You share cost with plan Out-of-Pocket Maximum Plan pays 100% 14

15 In-NetworkExample that plan negotiates for each service with preferred or participating providers Discounted rate that plan negotiates for each service with preferred or participating providers You pay the in-network coinsurance on the discounted rate. You pay the in-network coinsurance on the discounted rate. Provider cant balance bill Provider cant balance bill 20% Coinsurance Provider charge:$200 Allowed amount:$100 Plan pays 80%:$80 You pay 20%$20 Provider write-off:$100 PPO plans negotiate allowed rates to process claims. 15

16 Out-of-NetworkExample to a service when provider is NOT a preferred provider (not participating) Value that plan assigns to a service when provider is NOT a preferred provider (not participating) Plan pays out-of-network coinsurance on the allowed amount. Plan pays out-of-network coinsurance on the allowed amount. Provider can balance bill Provider can balance bill 50% Coinsurance Provider charge:$200 Allowed amount:$100 Plan pays 50%:$50 (50% of $100) You pay 50%:$50 You pay balance:$100 PPO plans assign allowed rates to process claims. 16

17 17 You receive services You pay nothing at the time of service for in-network care Provider sends claim for services to health plan Health plan sends EOB Explanation of Benefits (EOB) outlines allowed charges, deductible and co-insurance. This is not a bill. Provider sends bill The bill should match the EOB. It should reflect the in-network discount and any payments received from health plan. You pay provider

18 Fair Health Consumer Health Care Blue Book https://www.healthcarebluebook.com/https://www.healthcarebluebook.com/https://www.healthcarebluebook.com/ Good Rx – drug costs 18

19 Combines HMO and PPO plan designsCombines HMO and PPO plan designs Limit costs by using HMO providersLimit costs by using HMO providers Can use providers outside HMO group, but cost for service will be higherCan use providers outside HMO group, but cost for service will be higher Anthem PLUS in discontinued 19

20 PPO Use physicians out of the HMO medical groupUse physicians out of the HMO medical group Use out-of-network behavioral healthUse out-of-network behavioral health Deductible & CoinsuranceDeductible & Coinsurance HMO Use PCP and specialists in the HMO medical group Use Optum behavioral health Predictable copays How do you use your plan? 20

21 2014 Medical Plans Health Net Blue & Gold HMO Kaiser HMO UC Care Blue Shield Health Savings Plan Core

22 22 Customized for UC Care UC Health System + Select Blue Shield providers UC Select Providers Similar to the standard in network cost-share of the previous Anthem PPO plan Blue Shield Preferred Providers Flexibility to use services from any provider outside the UC Select or Blue Shield Preferred network Non-Preferred Providers Blue Shield of California – claims administrator & network

23 23 Blue Shield PPO + High deductible medical plan paired with a Health Savings Account Health Savings Account The Health Savings Account is not a component of the medical plan as HRA is with Lumenos. It is a separate account that can be used to pay medical and other health expenses.

24 All medical plans cover preventive care at 100% with in-network providersAll medical plans cover preventive care at 100% with in-network providers Preventive care includes:Preventive care includes: Annual well visit and labs Annual well visit and labs Well woman visits and labs Well woman visits and labs Preventive screening tests Preventive screening tests Immunizations Immunizations See list of preventive services on the plan websitesSee list of preventive services on the plan websites 24

25 25 HMO (Health Net, Kaiser) Employee must live in CaliforniaEmployee must live in California PCP must be within 30 miles of where you live or work (in most cases)PCP must be within 30 miles of where you live or work (in most cases) Blue Shield Health Savings Employee must live in USEmployee must live in US Employee may live anywhereEmployee may live anywhere Worldwide servicesWorldwide services CORE UC Care Employee may live anywhereEmployee may live anywhere Worldwide servicesWorldwide services Employee may live anywhereEmployee may live anywhere Worldwide servicesWorldwide services

26 26 HMO (Health Net, Kaiser) Limited to emergency and urgent care onlyLimited to emergency and urgent care only No routine care when away from medical groupNo routine care when away from medical group Blue Shield Health Savings Limited to emergency and urgent care onlyLimited to emergency and urgent care only No routine careNo routine care Comprehensive coverageComprehensive coverage Plan pays Preferred benefit.Plan pays Preferred benefit. CORE UC Care Comprehensive coverageComprehensive coverage Plan pays out-of-network benefit.Plan pays out-of-network benefit.

27 27 HMO (Health Net, Kaiser) You select PCPYou select PCP PCP coordinates carePCP coordinates care PCP refers to specialistsPCP refers to specialists Specialists limited to physicians in medical groupSpecialists limited to physicians in medical group Blue Shield Health Saving In-Network You select Blue Shield PPOYou select Blue Shield PPO Out-of-Network You select non-Blue ShieldYou select non-Blue Shield In-Network – You select UC SelectUC Select Blue Shield Preferred PPOBlue Shield Preferred PPO Out-of-Network You select non-Blue ShieldYou select non-Blue Shield CORE UC Care In-Network You select Blue Shield PPOYou select Blue Shield PPO Out-of-Network You select non-Blue ShieldYou select non-Blue Shield

28 UC Select All UC medical centers, facilities and physicians Additional select Blue Shield PPO providers in areas where UC medical centers and physicians are not accessible Blue Shield Preferred PPO in California 97% of Anthem PPO are also Blue Shield Preferred Blue Shield outside of CA and US Blue Cross Blue Shield Network out of CA BlueCard Network out of US 28

29 UC Select providers in Santa Barbara – Sansum Clinic Santa Maria Lompoc Ventura Currently, Sansum Clinic is the only UC Select provider in Santa Barbara area High cost hospital and medical groups Still negotiating 29

30 Most Anthem Plus and PPO providers are also in the UC Care Blue Shield Preferred network Cottage Hospital and Sansum Clinic are Blue Shield Preferred providers UC Care Provider directory blueshieldca.com/uccareppo Search tool defaults to UC Select network Change selection to find Blue Shield Preferred UC Care Blue Shield Concierge

31 Medical PlanCopayDeductibleCoinsurance 31 HMO$20None UC Care PPO UC Select$20None Preferred $250 indiv $750 family You pay 20% Out-of-Network $500 indiv $1,500 family Plan pays 50% of allowed rate You pay balance

32 32 UC Select (Tier 1) Copay Blue Shield Preferred (Tier 2) Deductible Coinsurance Non-Preferred Out-of-Network (Tier 3) Deductible Coinsurance Your costs are based on the tier/network that the provider is in Not all services are covered at the UC Select benefit tier Some services are covered only at the Blue Shield Preferred and Non-Preferred tiers

33 33 You pay You share cost with plan Plan pays 100% $250 Deductible 20% Coinsurance $3000 OOPM UC Care Individual Coverage Blue Shield Preferred (Tier 2)

34 34 $250 Individual / $750 FamilyCoinsurance Adult 1Paid $250 20% Adult 2Paid $100 Child 1Paid $ 75 Child 2Paid $250 20% Adult 2Paid $175 20%20% UC Care Example Family Deductible Blue Shield Preferred (Tier 2)

35 35 Blue Shield HSP Preferred $2,500 family $1,250 single $2,500 family You pay 20% Out-of-Network $5,000 family $2,500 single $5,000 family Plan pays 60% of allowed rate Full family deductible must be met before plan shares cost CORE Preferred $3000 per individual You pay 20% Out-of-NetworkPlan pays 80% of allowed rate Medical PlanCopayDeductibleCoinsurance

36 36 You pay You share cost with plan Plan pays 100% $1250 Deductible 20% Coinsurance $4000 OOPM Blue Shield Health Savings Plan Individual (Single) Preferred Providers

37 37 You pay You share cost with plan Plan pays 100% $2500 Deductible 20% Coinsurance $6400 OOPM Blue Shield Health Savings Plan Family Preferred Providers The full family deductible must be met before plan shares costs

38 Medical PlanCopayDeductibleCoinsurance 38 HMO$250None UC Care PPO UC Select$250None Preferred $250 indiv $750 family You pay 20% Out-of-Network $500 indiv $1,500 family Plan pays 50% of allowed rate You pay balance

39 39 Blue Shield HSP Preferred $2,500 family $1,250 single $2,500 family You pay 20% Out-of-Network $5,000 family $2,500 single $5,000 family Plan pays 60% of allowed rate Full family deductible must be met before plan shares cost CORE Preferred $3000 per individual You pay 20% Out-of-NetworkPlan pays 80% of allowed rate Medical PlanCopayDeductibleCoinsurance

40 Medical PlanCopayDeductibleCoinsurance 40 HMO$75None UC Care PPO UC Select$100NoneYou pay 20% of ER physician Preferred$100WaivedYou pay 20% of ER physician Out-of-Network$100WaivedYou pay 20% of ER physician

41 41 Blue Shield HSP Preferred $2,500 family $1,250 single $2,500 family You pay 20% Out-of-Network $5,000 family $2,500 single $5,000 family You pay 20% Full family deductible must be met before plan shares cost CORE Preferred Waived for facility fee You pay 20% Out-of-NetworkYou pay 20% Medical PlanCopayDeductibleCoinsurance

42 Medical PlanOOPMNotes 42 Health Net HMO$1,000 indiv $3,000 family Family = 3 or more Kaiser HMO$1,500 indiv $3,000 family Family = 2 or more

43 Medical PlanOOPMNotes 43 UC Care PPO UC Select$1,500 indiv $4,500 family Family = 3 or more In-Network providers cross accumulate Preferred$3,000 indiv $9,000 family Out of Network $5,000 indiv $15,000 family Family = 3 or more Out-of-network accumulates separately

44 Medical PlanOOPMNotes 44 Blue Shield HSP Preferred $4,000 indiv (single) $6,400 family Full family OOPM must be met before plan pays 100% for any enrollee In & Out-of-network accumulate separately Medical & Drug expenses apply Non-Preferred (Out-of-Network) $8,000 indiv (single) $16,000 family CORE $6,350 indiv $12,700 family Family = 2 or more Medical & Drug expenses apply

45 HMO UC Care Blue Shield HSP CORE Retail (30 day) Generic Generic Brand Brand Non-formulary Non-formulary$5$25$40 You pay full cost of medication until you satisfy the deductible After deductible, you pay 20% at preferred pharmacies Mail Order (90 day) Generic Generic Brand Brand Non-formulary Non-formulary$10$50$80 45 Preferred Drug List (Formulary) is different for each carrier

46 46 Blue Shield PPO + High deductible medical plan paired with a Health Savings Account Health Savings Account The Health Savings Account is not a component of the medical plan as HRA is with Lumenos. It is a separate account that can be used to pay medical and other health expenses.

47 47 Deductible Health Reimbursement Account (HRA) Member pays PPO Coinsurance Lumenos Blue Shield PPO Deductible Member pays PPO Coinsurance UC Contributions Member Contributions Lumenos HRA Rollover Health Savings Account

48 Remaining Lumenos HRA money will roll-over into the Health Savings Account (4/1/14) Lumenos HRA $ are treated differently than HSA $ by IRS Lumenos HRA $ becomes a Post Deductible Health Reimbursement Account = PDHRA You must pay the Blue Shield HSP deductible with other funds BEFORE you can use the PDHRA to pay eligible expenses.

49 49 Single Deductible$1,250Single Deductible$1,250 UC Contribution to HSA$500UC Contribution to HSA$500 Remaining balance$750Remaining balance$750 Pay with personal funds or Pay with your contributions to HSA Pay with personal funds or Pay with your contributions to HSA Lumenos PDHRA can be used to pay 20% coinsurance after deductible is satisfiedLumenos PDHRA can be used to pay 20% coinsurance after deductible is satisfied

50 50 You keep the money even if you change jobs or insurance plans You can make contributions at any time It has triple tax advantage No Federal taxes on contributions No taxes when funds are used No taxes on earnings HSA funds rollover from year to year; no use it or lose it as with Health FSA

51 UC Contribution (1/1/14) $500 individual $1000 family You can contribute up to (optional): Single-coverage: $2,800 Family-coverage: $5,550 Catch-up contribution, age 55+: $1,000 Tip: Contribute the money you would have put in your Health FSA.

52 To own an HSA you need to: Be covered ONLY by an HSA-qualified health plan Other health coverage may disqualify you, including Health FSA, Medicare or traditional health plan Health FSA must have a $0 balance on Dec. 31, 2013 (complete any claims reimbursement by Dec. 31, 2013) Not be claimed as a dependent on someone elses tax return

53 UC makes annual contribution for plans that start on January 1. You may contribute through payroll deduction or make post-tax contributions to HealthEquity HSA debit cardUse a HSA debit card to pay for health expenses HealthEquity websiteUse HealthEquity website to pay medical and other health claims Invest HSA dollarsInvest HSA dollars when account balance reaches $2000 – no fees to invest

54 The HSA is NOT like the Health FSA where you have access to the entire annual contribution starting on January 1The HSA is NOT like the Health FSA where you have access to the entire annual contribution starting on January 1 The HSA is like a checking account – the money must be in the account before you can spend itThe HSA is like a checking account – the money must be in the account before you can spend it You make monthly contributions through payroll deduction, you can change the contribution amount during the year You make monthly contributions through payroll deduction, you can change the contribution amount during the year You can make one time contributions through Health Equity You can make one time contributions through Health Equity 54

55 Deductible Coinsurance Any IRS Publication 502 Expenses, including: Medical Dental Vision Prescription drug Long Term Care insurance premiums 55

56 Go to your doctor Later – check your HealthEquity account online to see required payment to the doctor Pay with your HSA funds through your HealthEquity online account. OR Pay with another source (e.g. check, credit card) Give doctors office your Blue Shield card so BSC can… process the claim and get you their special provider discounts and send info about your amount of claim responsibility to Health Equity

57 HealthEquity Member Services is available every hour of every day Call the Blue Shield/UC dedicated line say Health Savings Account

58 58 Optum coordinates behavioral health care for all medical plans (except CORE)Optum coordinates behavioral health care for all medical plans (except CORE) psychiatrist psychologist therapist substance abuse treatment No referral required from physicianNo referral required from physician Call Optum to notify prior to first visitCall Optum to notify prior to first visit

59 59 Medical Plan OPTUM Network Out of Network Health Net Blue & Gold Visits 1–3 no copay Visits 4+ $20 $250 inpatient hospitalization Emergency only Kaiser (Optum & Kaiser Providers) Emergency only

60 Medical PlanOPTUM NetworkOut-of-Network UC CareVisits 1-3 no copay Visits 4+ $20 Inpatient $250 $500 deductible Plan pays 50% allowed You pay balance Blue Shield HSPDeductible: $1,250 indiv $2,500 family You pay 20% Deductible: $2,500 indiv $5,000 family Plan pays 60% allowed You pay balance 60

61 61 Medical Plan Blue Shield Network Out of Network Core $3000 deductible You pay 20% Plan pays 80% allowed You pay balance Note for all plans: The medical and behavioral health deductibles cross- accumulate. The medical and behavioral health coinsurance cross- accumulate toward a common out-of-pocket maximum. In-network and out-of-network deductibles and out-of- pocket maximums do NOT cross accumulate.

62 Medical PlanProvidersCosts HMO American Specialty Health 25% discount UC Care PreferredBlue Shield After deductible, You pay 20% Out-of-NetworkNon-Blue ShieldAfter deductible, Acupuncture: Plan pays 80% allowed Chiropractic: Plan pays 60% allowed Note: Benefit is limited to 24 visits per calendar year combined for Acupuncture and Chiropractic visits 62

63 Medical PlanProvidersCosts Blue Shield HSP PreferredBlue Shield After deductible, You pay 20% Out-of-NetworkNon-Blue ShieldAfter deductible, Acupuncture: Plan pays 80% of allowed Chiropractic: Plan pays 60% of allowed Note: Benefit is limited to 24 visits per calendar year combined for Acupuncture and Chiropractic visits 63

64 64 Medical Plan Provider Out of Network Core PreferredBlue Shield After deductible, You pay 20% Out-of-networkNon-Blue ShieldAfter deductible, Acupuncture: Plan pays 80% allowed Chiropractic: Plan pays 80% allowed Note: Plan payment maximum up to $500 per calendar year

65 ResourcesResources Plan contacts Plan contacts Plan rates Plan rates Medical PlansMedical Plans Benefit summaries Benefit summaries Links to plan websites Links to plan websites Links to provider directories Links to provider directories Other plansOther plans Dental, vision, FSA Dental, vision, FSA 65

66 66


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