Transcript Slide 1

Big changes
New choices
Updated
11/22/13
Open Enrollment Highlights
Laura Morgan
UCSB Human Resources, Benefits
This presentation is intended for communication purposes only. Please see plan
document and http://atyourservice.ucop.edu for complete information.
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11/3/11
11/1/2013
Open Enrollment
• Ends Tuesday, November 26, 5:00 pm
• Make changes online
http://atyourservice.ucop.edu
• All changes are effective January 1, 2014
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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
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Collective Bargaining
• For unions in “status quo” or “reopeners” the
following may not change:
◊ Monthly contribution rates for plans
◊ Payband levels
 An individual’s MCB can go up or down
• Monthly employee contributions for the new
2014 medical plans will be the same for all
participants
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Review Options for 2014
atyourservice.ucop.edu/oe
Booklet
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Medical Plan Chooser
Link from Open Enrollment website:
http://atyourservice.ucop.edu/oe/medical
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Big Changes, New Choices
• Comprehensive review of UC's medical plan
portfolio
• Ensure good benefits while limiting cost
increases for employees and the university
• Maintain choices to address individual needs
• Opportunity to leverage UC's medical centers
• Respond to health care reform and a changing
medical-insurance marketplace
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2014 Medical Plans
2013
2014
Anthem PPO
Anthem PLUS
UC Care PPO
Anthem Lumenos HRA-PPO
Health Net Blue & Gold HMO
Health Net HMO
(administered by Blue Shield)
Blue Shield
Health Savings Plan (PPO)
Health Net Blue & Gold HMO
Kaiser HMO
Kaiser HMO
Core
Core
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Default Medical Plans
2013 Medical Plan
2014 Medical Plan
Health Net Blue & Gold HMO
Health Net Blue & Gold HMO
Health Net HMO (full)
Health Net Blue & Gold HMO
Kaiser HMO
Kaiser HMO
Anthem PLUS
UC Care
Anthem PPO
UC Care
Anthem Lumenos HRA
Blue Shield Health Savings Plan
Anthem Core
Blue Shield Core
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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
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Medical Plan Design 101
HMO
PPO
POS
HMO – Health Maintenance Organization
• Care is delivered by physicians in a “medical group”
(e.g. Sansum, SB Select IPA)
• Care is coordinated by Primary Care Physician and
medical group
• Member selects PCP, PCP refers to specialists
• Set copay for most services, no deductibles
• Emergency and urgently needed care when away
Health Net Blue & Gold HMO
Kaiser HMO
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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
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Deductible, Coinsurance, OOPM
January
Calendar Year
December
Deductible
Coinsurance
Copay
Out-of-Pocket
Maximum
You pay
You share cost with plan
Plan pays
100%
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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
Coinsurance 20%
Provider charge:
Allowed amount:
$200
$100
• You pay the in-network
coinsurance on the
discounted rate.
Plan pays 80%:
$80
You pay 20%
$20
• Provider can’t “balance bill”
Provider write-off: $100
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Allowed Amount – Out of Network
PPO plans assign “allowed” rates to process claims.
Out-of-Network
Value that plan assigns
to a service when provider is
NOT a “preferred provider”
(not participating)
Example
Coinsurance 50%
Provider charge:
Allowed amount:
$200
$100
• Plan pays out-of-network
coinsurance on the allowed
amount.
Plan pays 50%:
(50% of $100)
$50
You pay 50%:
$50
You pay balance:
$100
• Provider can “balance bill”
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Claims, EOBs & Bills
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
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Learn more about PPOs
Fair Health Consumer
http://www.fairhealthconsumer.org/
• Estimate cost of medical procedures
• “LEARN” tab – print and video resources
◊ How plans work
◊ Cost Sharing, know what you may owe
Good Rx
• http://www.goodrx.com
• Estimate cost of drugs (for Blue Shield HSP)
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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
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Anthem PLUS Dilemma – PPO or HMO
What is your priority?
Physician
• Specific physician
• More choice of
physicians and
facilities
Cost
• Monthly cost
• Predictable copays
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2014 Medical Plans
Health Net Blue & Gold HMO
Kaiser HMO
UC Care
Blue Shield Health Savings Plan
Core
Residence Limitations
HMO
(Health Net, Kaiser)
• Employee must live in
California
• PCP must be within 30
miles of where you live or
work (in most cases)
UC Care
• Employee may live
anywhere
• Worldwide services
Blue Shield Health Savings CORE
• Employee must live in US
• Employee may live
anywhere
• Worldwide services
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When traveling out of US
HMO
(Health Net, Kaiser)
• Limited to emergency and
urgent care only
• No routine care
UC Care
• 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.
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Health Net
• Full Network HMO is being discontinued
◊ In Ventura County, some medical groups will no
longer be available to Health Net members
◊ Employees should consider UC Care or Kaiser
HMO
• Health Net Blue & Gold HMO will continue with
few benefit changes
◊ In Santa Barbara County, all HMO medical
groups participate in Blue & Gold
◊ In Ventura County, not all HMO groups
participate
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Health Net Blue & Gold HMO
• You select a Primary Care Physician (PCP)
to coordinate your care
• PCP refers you to specialists
• Predictable copays for services:
◊ $20 office visit
◊ $20 urgent care
◊ $75 emergency room (if not admitted)
◊ $100 outpatient surgical center
◊ $250 hospital (in-patient)
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Kaiser HMO
•
•
•
•
Kaiser will continue in Ventura County
You select Kaiser PCP
PCP refers you to Kaiser specialists
Predictable copays for services:
◊ 20 office visit
◊ $20 urgent care
◊ $75 emergency room (if not admitted)
◊ $100 outpatient surgical center
◊ $250 hospital (in-patient)
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UC Care – New PPO
• New self-funded PPO plan
• Created for UC employees and nonMedicare retirees
• UC Medical Centers are part of the “UC
Select” network of providers
• No PCP, no referral required for specialist
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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
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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 or any physician out of US
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UC Select Network near UCSB
• UC Select providers in
◊
◊
◊
◊
Santa Barbara – Sansum Clinic
Santa Maria
Lompoc
Ventura
• Currently, Sansum Clinic is the only UC Select
providers in Santa Barbara area
◊ High cost hospital and medical groups
◊ Still negotiating
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Blue Shield Preferred at UCSB
• 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
Provider directory:
blueshieldca.com/uccareppo
or link from
http://uc-care.org/
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UC Care – Cost of Care
• Your costs depend on the service and the
network status of the provider
• UC Select – no deductible, copays for
most services but not all
• Blue Shield Preferred – deductible and
you pay 20% coinsurance for most
services
• Non-Preferred – deductible and plan
pays 50% of allowed rate
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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
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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 $100
$175
Paid
20%
Child 1
Paid $ 75
20%
Child 2
Paid $250
20%
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UC Care – Emergency Room Example
• There are two charges for emergency care
with a PPO plan design:
◊ “Facility” – billed by the hospital
◊ “Professional” – billed by the ER physicians
• Emergency Room Visit (not admitted)
◊ Emergency room: $100 per visit
◊ Emergency physician services: 20%
◊ Same coverage across all provider networks
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More information about UC Care
Shield Concierge
Blue Shield/UC dedicated line
1-855-201-2087
M-F, 7 to 7
http://uc-care.org/
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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.
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Blue Shield PPO
• You direct your own care, you decide where to
receive services
• Medical and drug expenses apply to deductible
and Out-of-Pocket Maximums (OOPM)
◊ No separate drug plan with copays
• Family members share same deductibles and
OOPMs
• Networks:
◊ Blue Shield Preferred
◊ Non-Preferred Providers
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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
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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
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Blue Shield Health Savings Plan
High deductible medical plan paired
with a Health Savings Account
Blue Shield
PPO
•
•
•
•
+
Health Savings
Account
HSA deposits are not taxes
HSA funds roll over from year to year
Tax-free interest earned
You keep the money even if you change jobs or
insurance plans
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Health Savings Account
• Health Equity manages the HSA
• UC makes annual contribution for plans that
start on January 1.
◊ UC contribution is pro-rated for mid-year
enrollments
• You may contribute through payroll deductions
• Use account to pay for eligible health expenses
(medical, dental, vision, etc)
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Employees can maximize savings
• UC Contribution (1/1/14)
◊ $500 individual
◊ $1000 family
• 2014 Maximum Contributions allowed by IRS
◊ Single-coverage: $3,300
◊ Family-coverage: $6,550
◊ Catch-up contribution, age 55+: $1,000
Tip: Contribute the money you would have
put in your Health FSA.
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Lumenos and Blue Shield HSP
• 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.
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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
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“Seamless Consumer Experience”
• Blue Shield and Health Equity share information
• Employee receives welcome kit and live debit
card
• Use the “smart card” to pay for eligible health
expenses
• Can track and pay claims on Blue Shield website
• Invest HSA dollars when account balance reaches
$2000 – no fees to invest
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For more information
Health Equity Member Services is available
every hour of every day:
Call the Blue Shield/UC dedicated line
1.855.201.8375
say
“Health Savings Account”
http://www.healthequity.com/ed/uc
http:// www.blueshieldca.com/uc
(select "go" in the health savings plan section)
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CORE
•
•
•
•
High deductible PPO
Administered by Blue Shield
$3000 deductible per individual
Out-of-pocket Maximum is decreasing
2013: $7,600 per individual
2014: $6,350 individual / $12,700 family
• Blue Shield PPO and non-PPO providers
• Behavioral Health by Blue Shield PPO
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Prescription Drugs
Preferred Drug List (Formulary) is different for each carrier
HMO
UC Care
Retail (30 day)
• Generic
• Brand
• Non-formulary
Mail Order (90 day)
• Generic
• Brand
• Non-formulary
$5
$25
$40
Blue Shield HSP
CORE
After you satisfy the
deductible,
you pay 20%
at preferred pharmacies
$10
$50
$80
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Rx – Mandatory Generic Drugs
Health Net & UC Care
• Generic drugs will automatically be dispensed
• Brand name drugs when generic is available will
cost the member more
◊ $5 generic copay + (brand price – generic price)
• Brand name is available if “medically
necessary”
◊ e.g. Allergic to inactive ingredient
◊ Requires prior authorization from plan
◊ DAW, DNS does not = medical necessity
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Rx – Mandatory Generic Drugs
Core & Blue Shield Health Savings Plan
• Generic drugs will automatically be dispensed
• Brand name drugs when generic is available will
cost the member more
◊ Generic coinsurance + (brand price – generic price)
• Brand name is available if “medically necessary”
◊ e.g. Allergic to inactive ingredient
◊ Requires prior authorization from plan
◊ DAW, DNS does not = medical necessity
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Nicotine Replacement Therapy
• All UC Medical Plans continue to provide RX for
smoking cessation at $0 cost (e.g., Chantix, Zyban)
• Over the Counter NRT covered at $5 (generic
copay)
 OTC = Gum – Patch – Lozenge
 Doctor’s Prescription Required
 Kaiser Only - $0 Copay for both RX and OTC
products
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Optum – Behavioral Health
All medical plans, except CORE, use Optum therapists,
psychologists and psychiatrists for in-network care.
• Health Net Blue & Gold and Kaiser
◊ In-network benefit
• UC Care, Blue Shield Health Savings Plan
◊ In-network and out-of-network benefit
• Core
◊ In-network with Blue Shield clinicians and
out-of-network benefit
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Transition / Continuity of Care
• All plans provide temporary transition or
continuity of care service so members may
complete a course of treatment and arrange for
a safe transfer from a non-plan provider.
• Members who lost their current coverage due to
plan disruption and were required to enroll in
another health plan, AND are currently
receiving services may be eligible for
transition of care assistance.
• Please call member services to discuss your
situation.
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Other Plans & Programs
Delta & Vision
DeltaCare USA
 Added Benefits
◊Procedures to assess the level of risk associated with
dental decay
◊Gingival irrigation, a procedure to treat gums with medical
solutions for health purposes
Vision Service Plan
 Diabetic Eye Care Plus Program
◊Now extended to cover both Type I & II Diabetic
members.
◊Provides diabetic eye exam in addition to the routine vision
examination ($20 copay)
 Retiree Vision open for Enrollment
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Legal Plan
• Closed to new enrollment
• Current members will continue
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Flexible Spending Accounts
YOU MUST
RE-ENROLL
EACH YEAR
Health Flexible Spending Account
• Enroll or re-enroll in Health FSA
• Annual limit is $2,500
• Blue Shield HSP members CANNOT enroll in a
Health FSA
Dependent Care Account
• Enroll or re-enroll in DepCare FSA
• Annual limit remains at $5,000 ($2,500 if married and
filing a separate tax return)
61
New Wellness Program
• New program – branded as UC Living Well
• New provider – Optum
• Increased employee eligibility
More information in 2014
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Family Member Eligibility Verification
• Employees adding family members during Open
Enrollment will be required to verify the eligibility of
those family members with SECOVA
• Employees who have previously verified their family
members should NOT need to re-verifyeligibility
◊ If an employee receives a request from SECOVA
for a previously verified family member, please
ask him/her to call SECOVA at 1-877-632-8126
http://atyourservice.ucop.edu/family-member-verification/
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ACA & Covered California
• Employees covered by or eligible for UC Benefits,
don’t need to take action in the new health
Affordable Care Act insurance marketplace.
• Covered California is the ACA marketplace in CA
https://www.coveredca.com/
• Employees can explore options with Covered
California if:
◊ They are not eligible for UC-sponsored benefits
◊ They have family members who age out or are
no longer eligible for UC plans
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