Presentation Transcript

1. Medical Plan Comparison UCSB Human Resources, Benefits This presentation is intended for communication purposes only.Please see the At Your Service website (http://atyourservice.ucop.edu) and plan documents for complete information. 1 12/2013
2. Topics 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. 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

4. Medical Plan Design 101

   HMO PPO PLUS
5. 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 HMOKaiser HMO
6. HMO Network and Access to Care Access to Care HMO Medical Group When you need care go to your PCP Primary Care Physicians Specialists Labs Radiology Durable Medical Equip Urgent Care Hospitals PCP refers you to specialist, x-ray, lab, hospital Medical Group authorizes referrals to some specialists and treatment
7. 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
8. PPO Deductible, Coinsurance, OOPM
9. PPO Allowed Amount – In Network PPO plans negotiate “allowed” rates to process claims.
10. PPO Allowed Amount – Out of Network PPO plans assign “allowed” rates to process claims.
11. PPO Claims, EOBs & Bills Provider sends billThe bill should match the EOB. It should reflect the in-network discount and any payments received from health plan. You receive services You pay nothing at the time of service for in-network care Provider sends claimfor 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”.
12. PPO Resources Fair Health Consumer http://www.fairhealthconsumer.org/ Health Care Blue Book https://www.healthcarebluebook.com/ Good Rx – drug costs http://www.goodrx.com
13. 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 2013 - discontinued
14. Anthem PLUS Dilemma – PPO or HMO PPO Use physicians out of the HMO medical group Use out-of-network behavioral health Deductible & Coinsurance How do you use your plan? HMO Use PCP and specialists in the HMO medical group Use Optum behavioral health Predictable copays

15. 2014 Medical Plans

    Health Net Blue & Gold HMO Kaiser HMO UC CareBlue Shield Health Savings Plan Core
16. 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
17. Employee may live anywhere Worldwide services Employee may live anywhere Worldwide services Residence Limitations UC Care HMO (Health Net, Kaiser) 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 CORE Blue Shield Health Savings Employee must live in US
18. When traveling out of US UC Care HMO (Health Net, Kaiser) Limited to emergency and urgent care only No routine care when away from medical group Comprehensive coverage Plan pays Preferredbenefit. Blue Shield Health Savings CORE Limited to emergency and urgent care only No routine care Comprehensive coverage Plan pays out-of-network benefit.
19. 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
20. UC Care PPO Blue Shield of California – PPO network & claims administrator
21. UC Care: In-Network Providers UC Select 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 Blue Shield PPO providers Blue Shield outside of CA and US Blue Cross Blue Shield Network out of CA BlueCard Network out of US
22. 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
23. UC Care: Blue Shield Preferred Most Anthem Plus and PPO providers are also in the UC Care “BlueShield Preferred” network Providers include: Cottage Hospital System, Pacific Diagnostic Labs, Jackson Group, many SB Select IPA physicians and independent physicians Check the provider directory to confirm the status of providers important to you UC Care Provider directory blueshieldca.com/uccareppo Blue Shield Concierge 1-855-201-2087
24. Office Visit Cost
25. UC Care Costs 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
26. Deductible, Coinsurance, OOPM UC CareIndividual Coverage Blue Shield Preferred (Tier 2)
27. Deductible: Individual vs Family UC Care ExampleFamily Deductible Blue Shield Preferred (Tier 2) 20% 20%
28. Office Visit Costs
29. Deductible, Coinsurance, OOPM Blue Shield Health Savings Plan Individual (Single) Preferred Providers
30. Deductible, Coinsurance, OOPM Blue Shield Health Savings Plan FamilyPreferred Providers The full family deductible must be met before plan shares costs
31. Hospitalization Costs
32. Hospitalization Costs
33. Emergency Room Costs
34. Emergency Room Costs
35. Out-of-Pocket Maximum
36. Out-of-Pocket Maximum
37. Out-of-Pocket Maximum
38. Prescription Drugs Preferred Drug List (Formulary) is different for each carrier
39. 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.
40. Lumenos vs Blue Shield HSP Blue Shield PPO Lumenos Health Savings Account
41. 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.
42. Example: Lumenos PDHRA Single Deductible $1,250 UC Contribution to HSA $500 Remaining balance $750 Pay with personal fundsorPay with your contributions to HSA Lumenos PDHRA can be used to pay 20% coinsurance after deductible is satisfied
43. 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
44. Employees can maximize savings UC Contribution (plan starting on 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.
45. 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
46. 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
47. HSA vs FSA The HSA is NOTlike 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
48. Use the HSA to pay for… Deductible Coinsurance Any IRS Publication 502 Expenses, including: Medical Dental Vision Prescription drug Long Term Care insurance premiums
49. 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
50. For more information HealthEquityMember Services is available every hour of every day Call the Blue Shield/UC dedicated line 1.855.201.8375 say “Health Savings Account” www.healthequity.com/ed/ucwww.blueshieldca.com/uc
51. Optum(formerly United Behavioral Health) Optumcoordinates 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
52. Behavioral/Mental Health
53. Behavioral/Mental Health
54. Behavioral/Mental Health 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.
55. Chiropractic & Acupuncture
56. Chiropractic & Acupuncture
57. Chiropractic & Acupuncture
58. http://atyourservice.ucop.edu/oe Resources Plan contacts Plan rates Medical Plans Benefit summaries Links to plan websites Links to provider directories Other plans Dental, vision, FSA