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Big changes New choices Medical Plan Comparison Updated 11/22/13

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Presentation on theme: "Big changes New choices Medical Plan Comparison Updated 11/22/13"— Presentation transcript:

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

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

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

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

5 atyourservice.ucop.edu/oe
Review Options for 2014 atyourservice.ucop.edu/oe Booklet

6 Medical Plan Chooser

7 2014 Medical Plans 2013 2014 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 Default Medical Plans 2013 Medical Plan 2014 Medical Plan
Health Net Blue & Gold HMO Health Net HMO (full) Kaiser HMO Anthem PLUS UC Care Anthem PPO Anthem Lumenos HRA Blue Shield Health Savings Plan Anthem Core Blue Shield Core

9 What is your priority? 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 HMO PPO POS

11 HMO – Health Maintenance Organization
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

12 HMO Network and Access to Care
HMO Medical Group Access to Care 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 Medical Group authorizes referrals to some specialists and treatment

13 PPO – Preferred Provider Organization
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

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

15 Allowed Amount – In Network
PPO plans negotiate “allowed” rates to process claims. In-Network Example Discounted rate that plan negotiates for each service with “preferred” or participating providers You pay the in-network coinsurance on the discounted rate. Provider can’t “balance bill” 20% Coinsurance Provider charge: $200 Allowed amount: $100 Plan pays 80%: $80 You pay 20% $20 Provider write-off: $100

16 Allowed Amount – Out of Network
PPO plans assign “allowed” rates to process claims. Out-of-Network Example 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. 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

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

18 PPO Resources Fair Health Consumer http://www.fairhealthconsumer.org/
Health Care Blue Book https://www.healthcarebluebook.com/ Good Rx – drug costs

19 POS - Point of Service Combines HMO and PPO plan designs
Limit costs by using HMO providers Can use providers outside HMO group, but cost for service will be higher Anthem PLUS in discontinued

20 Anthem PLUS Dilemma – PPO or HMO
How do you use your plan? PPO Use physicians out of the HMO medical group Use out-of-network behavioral health Deductible & Coinsurance HMO Use PCP and specialists in the HMO medical group Use Optum behavioral health Predictable copays

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

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

23 Blue Shield Health Savings Plan
High deductible medical plan paired with a Health Savings Account + Blue Shield PPO 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 Preventive Care All medical plans cover preventive care at 100% with in-network providers Preventive care includes: Annual well visit and labs Well woman visits and labs Preventive screening tests Immunizations See list of preventive services on the plan websites

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

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

27 Choice of Physician UC Care HMO (Health Net, Kaiser)
You select PCP PCP coordinates care PCP refers to specialists Specialists limited to physicians in medical group In-Network – You select UC Select Blue Shield Preferred PPO Out-of-Network You select non-Blue Shield Blue Shield Health Saving CORE In-Network You select Blue Shield PPO In-Network You select Blue Shield PPO Out-of-Network You select non-Blue Shield Out-of-Network You select non-Blue Shield

28 UC Care: In-Network Providers
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

29 UC Care: UC Select near UCSB
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

30 UC Care: Blue Shield Preferred
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 Office Visit Cost Medical Plan Copay Deductible Coinsurance HMO $20
None UC Care PPO UC Select $20 None 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 UC Care Costs 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 Deductible, Coinsurance, OOPM
UC Care Individual Coverage Blue Shield Preferred (Tier 2) You pay You share cost with plan Plan pays 100% $250 Deductible 20% Coinsurance $3000 OOPM

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

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

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

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

38 Hospitalization Costs
Medical Plan Copay Deductible Coinsurance HMO $250 None UC Care PPO UC Select $250 None 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 Hospitalization Costs
Medical Plan Copay Deductible Coinsurance CORE Preferred $3000 per individual You pay 20% Out-of-Network Plan pays 80% of allowed rate Blue Shield HSP Preferred $1,250 single $2,500 family You pay 20% Out-of-Network $2,500 single $5,000 family Plan pays 60% of allowed rate Full family deductible must be met before plan shares cost

40 You pay 20% of ER physician
Emergency Room Costs Medical Plan Copay Deductible Coinsurance HMO $75 None UC Care PPO UC Select $100 None You pay 20% of ER physician Preferred Waived Out-of-Network

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

42 Out-of-Pocket Maximum
Medical Plan OOPM Notes 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 Out-of-Pocket Maximum
Medical Plan OOPM Notes 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 Out-of-network accumulates separately

44 Out-of-Pocket Maximum
Medical Plan OOPM Notes CORE $6,350 indiv $12,700 family Family = 2 or more Medical & Drug expenses apply 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

45 Preferred Drug List (Formulary) is different for each carrier
Prescription Drugs Preferred Drug List (Formulary) is different for each carrier HMO UC Care Blue Shield HSP CORE Retail (30 day) Generic Brand 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) $10 $50 $80

46 Blue Shield Health Savings Plan
High deductible medical plan paired with a Health Savings Account + Blue Shield PPO 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 Lumenos vs Blue Shield HSP
Blue Shield PPO Deductible Health Reimbursement Account (HRA) Member pays PPO Coinsurance Deductible Member pays PPO Coinsurance Health Savings Account UC Contributions Member Contributions Lumenos HRA Rollover

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

50 Why is HSA better? 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 Employees can maximize savings
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 Who is eligible for HSA? 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 else’s tax return

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

54 HSA vs FSA The 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 it 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

55 Use the HSA to pay for… Deductible Coinsurance
Any IRS Publication 502 Expenses, including: Medical Dental Vision Prescription drug Long Term Care insurance premiums

56 Using your Health Savings Plan
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 doctor’s 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 For more information HealthEquity Member Services is available every hour of every day Call the Blue Shield/UC dedicated line say “Health Savings Account”

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

59 Behavioral/Mental Health
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)

60 Behavioral/Mental Health
Medical Plan OPTUM Network Out-of-Network UC Care Visits 1-3 no copay Visits 4+ $20 Inpatient $250 $500 deductible Plan pays 50% allowed You pay balance Blue Shield HSP Deductible: $1,250 indiv $2,500 family You pay 20% Deductible: $2,500 indiv $5,000 family Plan pays 60% allowed You pay balance

61 Behavioral/Mental Health
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 Chiropractic & Acupuncture
Medical Plan Providers Costs HMO American Specialty Health 25% discount UC Care Preferred Blue Shield After deductible, You pay 20% Out-of-Network Non-Blue Shield 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

63 Chiropractic & Acupuncture
Medical Plan Providers Costs Blue Shield HSP Preferred Blue Shield After deductible, You pay 20% Out-of-Network Non-Blue Shield 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

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

65 http://atyourservice.ucop.edu/oe Resources Medical Plans Other plans
Plan contacts Plan rates Medical Plans Benefit summaries Links to plan websites Links to provider directories Other plans Dental, vision, FSA

66


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