Transcript Slide 1

Medical Plan Comparison
UCSB Human Resources, Benefits
This presentation is intended for communication purposes only.
Please see the UCnet website (http://ucnet.universityofcalifornia.edu)
and plan documents for complete information.
1
11/5/2014
Open Enrollment for 2015
• Ends Tuesday, November 25 at 5pm
• All changes effective on January 1, 2015
• No action needed if you like the plans you have,
except for Health or Dependent Flexible Spending
Accounts (must reenroll)
• ARAG legal is open for new enrollments
• Increase waiting period for Supplemental Disability,
if currently enrolled
2
How to make changes
• Go to Open Enrollment website on UCnet
http://ucnet.universityofcalifornia.edu/OE
◊ Select “Sign In”
◊ Sign-in using your AYSO ID and password
◊ Select “Open Enrollment” link
◊ Select the tab for the change you desire
◊ Confirm your selection
◊ Print your confirmation
3
Resources
 Booklets mailed to home
 Open Enrollment Website
http://ucnet.universityofcalifornia.edu/oe
o Benefit Education Videos
o Medical & Dental Plan Choosers
 Insurance Plan Websites
o Provider directories
o Plan booklets
 Local Presentations and Events
4
Topics
• Medical Terms and Concepts Video
• Medical Plan Comparisons
◊ Residence requirements
◊ Choice of physician
◊ Cost of care & prescription drugs
◊ Out of Pocket Maximum
◊ Health Savings Account
◊ Behavioral Health
◊ Chiropractic and Acupuncture
5
Benefits Videos on UCnet
Medical Terms and Concepts
https://uc.a.guidespark.com/
6
2015 Medical Plans
HMO
Health Net Blue & Gold
Kaiser
PPO
UC Care
Blue Shield Health Savings Plan
Core
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
8
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
9
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
10
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/Tier 2
benefit.
Blue Shield Health Savings
CORE
• Limited to emergency and
urgent care only
• No routine care
• Comprehensive coverage
• Plan pays out-of-network
benefit.
11
Choice of Physician
HMO
•
•
•
•
(Health Net, Kaiser)
You select PCP
PCP coordinates care
PCP refers to specialists
Specialists limited to
physicians in medical group
UC Care
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
12
UC Care Networks/Tiers
UC Select
(Tier 1)
Blue Shield
Preferred
(Tier 2)
Non-Preferred
Out-of-Network
(Tier 3)
UC Medical
Centers
&
Select
Blue Shield PPO
Blue Shield PPO in CA
Out of the
UC Select
or
Blue Shield
Preferred
Out of CA
Blue Cross Blue Shield
In Network Providers
13
UC Care – Santa Barbara Network
Providers
Status
Sansum Clinic
 UC Select/Tier 1
Quest Diagnostic Lab
Unilab
 UC Select/Tier 1
Cottage Hospital
 Blue Shield Preferred/Tier 2
Pacific Diagnostic Lab
 Blue Shield Preferred/Tier 2
Pueblo Radiology
 Blue Shield Preferred/Tier 2
Santa Barbara
Preferred Health
Partners
 Some physicians affiliated with SB
Preferred Health Partners are in
Blue Shield Preferred/Tier 2
14
UC Care - UC Select near UCSB
• UC Select/Tier 1 providers in
◊ Santa Barbara
◊ Santa Maria
◊ Lompoc
◊ Ventura
• UC Care Provider Directory
blueshieldca.com/uccareppo
Blue Shield Concierge 1-855-201-2087
15
Plan Costs
• HMOs have predictable copays for services
• PPOs have deductibles and % coinsurance
◊ Your costs are based on the network that the
provider is in and the service you receive
◊ You pay discounted rates for “in-network” providers
◊ You pay more for “out-of-network” providers
16
PPO Allowed Amount – In Network
PPO plans negotiate “allowed” rates to process claims.
In-Network
Discounted rate
that plan negotiates for each
service with “preferred” or
participating providers
Example
20% Coinsurance
Provider charge:
Allowed amount:
• You pay the in-network
Plan pays 80%:
coinsurance on the discounted You pay 20%
rate.
• Provider can’t “balance bill”
$200
$100
$80
$20
Provider write-off: $100
17
PPO 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
50% Coinsurance
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”
18
Office Visit Cost
Medical Plan
Copay
Deductible
Coinsurance
HMO
$20
None
None
UC Care PPO
UC Select/Tier 1
$20
None
None
Preferred/Tier 2
Out-of-Network
$250 indiv
$750 family
$500 indiv
$1,500 family
You pay 20%
Plan pays 50%
of allowed rate
You pay balance
19
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%
20
Office Visit Costs
Medical Plan
CORE
Preferred
Out-of-Network
Blue Shield HSP
Preferred
Out-of-Network
Copay
Deductible
Coinsurance
$3000
per individual
You pay 20%
Plan pays 80%
of allowed rate
$1,300
$2,600
$2,500
$5,000
You pay 20%
single
family
single
family
Plan pays 60%
of allowed rate
Full family deductible must be met before plan shares cost
21
Hospitalization Costs
Medical Plan
Copay
Deductible
Coinsurance
HMO
$250
None
None
UC Care PPO
UC Select/Tier 1
Preferred/Tier 2
$250
None
$250 indiv
$750 family
Out-of-Network
$500 indiv
$1,500 family
None
You pay 20%
Plan pays 50%
of allowed rate
You pay balance
22
Hospitalization Costs
Medical Plan
CORE
Preferred
Out-of-Network
Blue Shield HSP
Preferred
Out-of-Network
Copay
Deductible
Coinsurance
$3000
per individual
You pay 20%
Plan pays 80%
of allowed rate
$1,300
$2,600
$2,500
$5,000
You pay 20%
single
family
single
family
Plan pays 60%
of allowed rate
Full family deductible must be met before plan shares cost
23
Emergency Room Costs
Medical Plan
HMO
UC Care PPO
UC Select/Tier 1
Preferred/Tier 2
Out-of-Network
Copay
Deductible
Coinsurance
$75
None
None
$100
$200
$100
$200
None
You pay 20% of
ER physician
You pay 20% of
ER physician
$100
$200
Waived
Waived
You pay 20% of
ER physician
24
Emergency Room Costs
Medical Plan
CORE
Preferred
Out-of-Network
Blue Shield HSP
Preferred
Copay
Deductible
Waived for
facility fee
Coinsurance
You pay 20%
You pay 20%
$1,300 single You pay 20%
$2,600 family
Out-of-Network
$2,500 single You pay 20%
$5,000 family
Full family deductible must be met before plan shares cost
25
Out-of-Pocket Maximum
• The most the insurance plan requires you to pay
in a year
• Once you have paid this amount, the insurance
plan pays 100% of future expenses.
• Includes deductible, copay, coinsurance for
medical services and prescription drugs (2015).
• Does not include amounts “not allowed” by
insurance plan when using out-of-network
providers.
26
Out-of-Pocket Maximum
Medical Plan
Health Net HMO
Kaiser HMO
OOPM
Medical & Rx
$1,000 indiv
$3,000 family
$1,500 indiv
$3,000 family
Notes
Family = 3 or more
Family = 2 or more
27
Out-of-Pocket Maximum
Medical Plan
OOPM Medical
UC Care PPO
UC Select/Tier 1 $1,500 indiv
$4,500 family
Preferred/Tier 2
$3,000 indiv
Notes
Family = 3 or more
In-Network providers
cross accumulate
$9,000 family
Out of Network
$5,000 indiv
$15,000 family
Family = 3 or more
Out-of-network
accumulates separately
28
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
29
Out-of-Pocket Maximum
Medical Plan
UC Care PPO
In-network
pharmacy
Out-of-network
Pharmacy
OOPM Rx
$3,600 indiv
$4,200 family
Notes
Family = 3 or more
Medical and Rx do not
cross accumulate
None
30
Out-of-Pocket Maximum
Medical Plan
CORE
Blue Shield HSP
Preferred
Non-Preferred
(Out-of-Network)
OOPM
$6,350 indiv
$12,700 family
Notes
Family = 2 or more
Medical & Drug
expenses apply
Full family OOPM must
be met before plan
pays 100% for any
enrollee
$4,000 indiv (single)
$6,400 family
$8,000 indiv (single) In & Out-of-network
$16,000 family
accumulate separately
Medical & Drug
expenses apply
31
Deductible, Coinsurance, OOPM
Blue Shield Health Savings Plan
Individual (Single)
Preferred Providers
You pay
You share cost with plan
Plan pays
100%
$1300
Deductible
20% Coinsurance
$4000 OOPM
32
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%
$2600
Deductible
20% Coinsurance
$6500 OOPM
33
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)
Selected Retail
• Generic
• Brand
• Non-formulary
$5
$25
$40
$10
$50
$80
Blue Shield HSP
CORE
You pay full cost of
medication until you
satisfy the deductible
After deductible,
you pay 20%
at preferred
pharmacies
34
Blue Shield Health Savings Plan
High deductible medical plan paired
with a Health Savings Account
+
Medical Coverage
Blue Shield PPO
Health Savings Account
HealthEquity
35
STOP – Consider HSA Limitations
To own an Health Savings Account (HSA):
• May not be enrolled in Medicare A or other
medical plan
• Must have a $0 balance in Health FSA on
December 31, 2014 (complete any claims
reimbursement by Dec. 31, 2014)
• May not be claimed as a dependent on someone
else’s tax return
• Consult with HealthEquity
Health Savings Account
• 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
37
HSA can maximize savings
• UC Contribution (plan starting on 1/1/15)
◊ $500 individual
◊ $1000 family
• You can contribute up to (optional):
◊ Single-coverage: $3,350 – $500 = $2,850
◊ Family-coverage: $6,650 – $1,000 = $5,650
◊ Catch-up contribution, age 55+: $1,000
Use the HSA to pay for…
• Deductible
• Coinsurance
• Any IRS Publication 502 Expenses, including:
◊
◊
◊
◊
Medical
Dental
Vision
Prescription drug
◊ Long Term Care insurance premiums
39
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
Lumenos Rollover from 2013
Lumenos Post-Deductible HRA can be used to pay
20% coinsurance or other eligible expenses after
Blue Shield PPO deductible is satisfied
Example:
• Single Deductible
$1,300
• UC Contribution to HSA
$500
• Remaining balance
$750
◊ Pay with personal funds
or
Pay with your personal contributions to HSA
41
For more HSA information
HealthEquity Member Services is available
every hour of every day
1.866.212.4729
www.healthequity.com/ed/uc
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
43
Behavioral/Mental Health
Medical Plan
Health Net
Blue & Gold
Kaiser
(Optum &
Kaiser
Providers)
OPTUM Network
Out of Network
Emergency only
Visits 1–3 no copay
Visits 4+ $20
$250 inpatient
hospitalization
Emergency only
44
Behavioral/Mental Health
Medical Plan
UC Care
Blue Shield
HSP
OPTUM Network
Visits 1-3 no copay
Visits 4+ $20
Inpatient $250
Deductible:
$1,300 indiv
$2,600 family
You pay 20%
Out-of-Network
$500 deductible
Plan pays 50%
allowed
You pay balance
Deductible:
$2,500 indiv
$5,000 family
Plan pays 60%
allowed
You pay balance
45
Behavioral/Mental Health
Medical Plan
Core
Blue Shield
Out of Network
Network
$3000 deductible
You pay 20%
Plan pays 80% allowed
You pay balance
Note for all plans:
• The medical and behavioral health deductibles crossaccumulate.
• The medical and behavioral health coinsurance crossaccumulate toward a common out-of-pocket maximum.
• In-network and out-of-network deductibles and out-of46
pocket maximums do NOT cross accumulate.
Chiropractic & Acupuncture
Medical Plan
Health Net
Kaiser
Providers
Costs
American Specialty $20 copay
Health
Self-referral
24 visits/year combined
American Specialty $15 copay
Health
Self-referral
24 visits/year combined
Kaiser
$20 copay
acupuncture only
47
Chiropractic & Acupuncture
Medical Plan
UC Care
Preferred
Providers
Blue Shield
Out-of-Network Non-Blue Shield
Costs
After deductible,
You pay 20%
After deductible,
Acupuncture:
Plan pays 80% allowed
Chiropractic:
Plan pays 50% allowed
Note: Benefit is limited to 24 visits per calendar year combined
for Acupuncture and Chiropractic visits
48
Chiropractic & Acupuncture
Medical Plan
Blue Shield HSP
Preferred
Providers
Blue Shield
Costs
After deductible,
You pay 20%
Out-of-Network Non-Blue Shield After 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
49
Chiropractic & Acupuncture
Medical Plan
Core
Preferred
Provider
Blue Shield
Out of Network
After deductible,
You pay 20%
Out-of-network Non-Blue Shield After deductible,
Acupuncture:
Plan pays 80% allowed
Chiropractic:
Plan pays 80% allowed
Note: Benefit is limited to 24 visits per calendar year
combined for Acupuncture and Chiropractic visits
50
http://ucnet.universityofcalifornia.edu
• Resources
◊ Plan contacts
◊ Plan rates
• Medical Plans
◊ Benefit summaries
◊ Links to provider directories
◊ Links to plan websites
• Other plans
◊ Dental, vision, FSA
51
52