UC Medical Plans - University of California, Irvine · Health Assessment. 1/1-4/15/2009, get...
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Your UC Your UC Medical Insurance Medical Insurance An overview for active employees An overview for active employees By Glenn Rodriguez By Glenn Rodriguez HealthCare Facilitator HealthCare Facilitator UC Irvine UC Irvine
Transcript of UC Medical Plans - University of California, Irvine · Health Assessment. 1/1-4/15/2009, get...
Your UCYour UC
Medical InsuranceMedical Insurance An overview for active employeesAn overview for active employees
By Glenn RodriguezBy Glenn RodriguezHealthCare FacilitatorHealthCare Facilitator
UC IrvineUC Irvine
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Agenda
I. Your options
II. Pre-paid medical
III.
Other insurance plans
IV.
Conclusion
Your options
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Your optionsUC offers four types of medical plans
HMO plans (3)POS planPPO plans (2)FFS plan
Availability determined by zip codeMedical Benefits Summaries
http://atyourservice.ucop.edu
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Pre-paid medical plansHealth Maintenance Organizations
Health NetKaiser PermanenteWestern Health Advantage
Point-Of-Service
plan
Anthem Blue Cross PLUS
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Other medical insurance plansPreferred Provider Organizations
Anthem Blue Cross PPO
CIGNA Choice Fund PPO
Fee-For-Service plan
Core Medical (through Anthem Blue Cross)
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Medical plan comparison
Cost
Flexibility
HMO
POS
PPO
FFS
(Anthem Blue Cross PLUS)
(Anthem Blue Cross PPO, CIGNA Choice Fund PPO)
(Core Medical)
(Health Net, Kaiser, WHA)
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Changing plansOpen Enrollment (October -
November)
Changes effective January 1st
HMO Transfer ProgramProvider group disruptions
Other life eventsMove outside plan service area
Acquire a newly eligible family member
Involuntary loss of other coverage
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About our plansNo pre-existing conditions exclusions
No UC-sponsored double coverage
Primary vs. secondary insuranceEmployees’ plans are primary for themBirthday rule
Medical benefits often separate from Mental Health benefits and Pharmacy benefits
For details, see Plan Booklets (Evidence of Coverage) http://atyourservice.ucop.eduUnder Forms & Publications
Pre-paid Medical plans
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About HMOsThe insurance company prepays a monthly per capita rate (called capitation) to each Medical Group
Your Primary Medical Group is responsible for your care for that month
You choose a Primary Care Physician (PCP) who acts as your gatekeeper to care through the Medical Group (to change PCPs, just call plan)
Exception: emergencies covered anywhere; call 911 or go to the nearest hospital. Let PCP know ASAP.
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Hospitals/ERPhysicians Lab/Imaging
How do HMOs work?
Medical Group
Insurance Company
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Advantages of HMOsLower monthly premiums
Low copayments
No claim forms
No deductibles/coinsurance
Provides low-cost preventive careNew as of 2008: no cost preventive care
Encourages relationship with PCP
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Limits of HMOsMust select PCP from the network of medical groups
Most specialty care must be referred by PCP (including second opinions)
Must use your Medical Group’s network of specialists/hospitals/labs
Preauthorization process required
Service area limited to certain urban zip codes
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HMO coverageModest copayments
Physician office visit: $15Waived for preventive care including certain immunizations
ER: $50Emergencies covered worldwide
Inpatient hospitalization: $250
Out-of-Pocket Maximum: $1,000Per person, per calendar year ($3,000 for family of 3+)Kaiser: $1,500 ($4,500 for family of 3+)
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HMO mental healthCoverage “carved out”
to United Behavioral Health (UBH)
Call UBH directly for service
http://www.liveandworkwell.com
Provider search: use Access Code 11280
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UBH benefitsOutpatient mental health benefits:
First 3 visits freeVisits 4+: $15
Inpatient mental health benefits$250 per admission
Out-of-Pocket Maximum: $1,000Per person, per calendar year ($3,000 for family of 3+)
Substance abuse benefits also available
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HMO Rx
Generic: $10/30-day supply(Kaiser: 100-day supply)
Brand name: $20/30-day supply(Kaiser: 100-day supply)
Non-formulary: $35/30-day supply(does not apply to Kaiser)
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HMO Rx
UC pharmacies:
90-day supplies for 2 co-pays (does not apply to Kaiser)
Mail-order:
90-day supplies for 2 co-pays (does not apply to Kaiser)
Some meds require preauthorization
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Wellness ProgramsKaiser members: Kaiser HealthWorks
Take a Health Assessment 1/1-4/15/2009, get entered to win $500 spa gift card or other valuable prizes
StayWell Health Management
(members of plans other
than Kaiser)$100 gift card for completion of Health Assessment from 1/2-4/15/2009 ($50 for spouse)Union members: UC-AFT and SETC union members only; CUEhas separate assessment timelineDoes not apply to employees hired after 1/1/09
Individual health assessment results are not shared with the University, but are used to customize the information and tools offered to employees
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Health NetLarge provider network, contracted with most medical groups
NCQA: “Excellent”
Decision PowerTrack your health issues/knowledgebaseHealth coach (nurse, respiratory therapist, dietician)24-hour nurse line
Medical group/hospital comparison reports
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Health NetWellRewards discount programs
Acupuncture, chiropractic, massage therapy, fitness centersAmerican Specialty Health Network
Vitamins, books, videos, weight loss programs, etc.
Disease Management programs:Asthma/diabetes/heart disease/depressionSmoking cessation
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Health NetPrescription drugs:
Purchase 90-day supplies from UC pharmacies for 2 copayments
If brand is dispensed when generic is available, member is charged generic copay + difference in price between generic & brand unless doctor indicates “Do Not Substitute”
New mail order vendor: CareMark (12/1/08)
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Kaiser PermanenteKaiser Foundation Health Plan contracts with one large group, the Permanente Medical Group
NCQA: “Excellent”
Audio library, classes, pamphlets, cassettes and videos on a wide variety of health topics; online weight, stress management & nutrition programs
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Kaiser PermanenteHealthwise Handbook free to members
Prevent or treat 180+ common health issues
Discount programsAcupuncture, chiropractic, massage therapy
American Specialty Health Network
Fitness club, vitamins, books & videos, etc.
Disease management programsAsthma/diabetes/heart disease
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Kaiser PermanenteMental health: two choices
Go through PCP: $7 for group therapyAnd/or use UBH
Prescription drugs:100-day supplies dispensedNo coverage for non-formulary Rx
If brand is dispensed when generic is available, member is charged brand copayment
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Anthem Blue Cross PLUSAnthem Blue Cross
Point-Of-Service plan
Combines features of HMOs and PPOs
Benefit level determined by point of service
NCQA: “Commendable”
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How does PLUS work?In-Network
(HMO)Like HMO, a Medical Group gets capitation
The prepaid Medical Group is responsible for your care for that month
PCP directs care
Member pays flat copayments for care
Physician office visit $20
ER $75
Inpatient hospitalization: $250
$1,500 Out-of-Pocket Maximum
Per person, per calendar year ($4,500 for family of 3+)
Out-of-Network
(PPO)Like PPO, self-refer to providers$500 deductible
Per person, per calendar year ($1,500 for family of 3+)
30% coinsurance$5,000 Out-of-Pocket Maximum
Per person, per calendar year ($15,000 for family of 3+)
You pay 30% of allowable charges (+ balance if provider is not preferred)
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PLUS Out-of-Network
PPOProviders
OtherProviders
1 Deductible $500 $500
2 Coinsurance 30% 30%+ balance
3 Out-of-Pocket Maximum $5,000 $5,000
+ balance
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Advantages of PLUSIn-Network coverage offers modest copayments for care
Chiropractic/acupuncture coverage through American Specialty Health Plans
Out-of-Network coverageBoth preferred and non-Blue providersOut-of-Pocket Max $5,000 (lower than PPO)
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Limits of PLUSIn-Network: same limitations that apply to HMOs
Sutter medical groups unavailable In-Network
No Out-of-Network chiropractic/acupuncture
Only available in certain CA zip codes
Higher premium than HMOs
Out-of-Network access more expensive compared to PPO In-Network coverage for preferred providers
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PLUS mental healthSame UBH coverage as the HMOs
See slides 17-18
As of 2008: no Out-of-Network mental health coverage
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PLUS Rx
Generic: $15/30-day supply
Brand name: $25/30-day supply
Non-formulary: $40/30-day supplyIf physician writes “dispense as written” (DAW), brand name copay applies
Mail-order: 90-day supplies for 2 copayments
UC pharmacies: 90-day supplies for 2 copayments
Some meds require prior authorization
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Anthem Blue Cross Plans: Wellness Programs
Disease management programsDiabetes, asthma, congestive heart failure
Tobacco cessation
“Healthy Extensions”Discounted fitness/massage therapy/nutrition/weight loss programs and more
Subimo online decision support toolDiagnostic and procedure explanations, hospital and drug comparisons
MedCall (nurse advice line)
Preferred Provider Organizations: Anthem Blue Cross (ABC) PPO
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Anthem Blue Cross PPOAnthem Blue Cross
More than 85 percent of all doctors and hospitals throughout the U.S. contract with Blue Cross/Blue Shield Plans
~46,000 Anthem Blue Cross network doctors in CA~700,000 Blue Cross/Blue Shield network doctors nation-wide
NCQA: “Commendable”
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How does ABC PPO work?In-Network
Self-refer to preferred providers$250 deductible
Per person, per calendar year ($750 for family of 3+)
20% coinsurance$3,000 Out-of-Pocket Maximum
Per person, per calendar year ($9,000 for family of 3+)
Hospitalization: be sure facility AND doctors are preferred providers
Out-of-NetworkSelf-refer to non-Blue Cross providers
$500 deductible
Per person, per calendar year ($1,500 for family of 3+)
40% coinsurance
$6,000 Out-of-Pocket Maximum
Per person, per calendar year ($18,000 for family of 3+)
Balance billing
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Anthem Blue Cross PPO
PPOProviders
OtherProviders
1 Deductible $250 $500
2 Coinsurance 20% 40%+ balance
3 Out-of-Pocket Maximum $3,000 $6,000
+ balance
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Advantages of ABC PPONo PCP, self-refer to specialists
No Primary Medical Group
Large, national provider network
Out-of-Network coverage
Comprehensive world-wide coverage
Chiropractic/acupuncture coverage
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Limits of ABC PPODeductibles/coinsurance rather than flat copayments
Separate In- and Out-of-Network deductibles
Preauthorization required for non-emergency hospitalization
Out-of-Network access to non-preferred providers more expensive than under PLUS
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ABC PPO mental healthIn-Network (UBH)
Same as HMO coverageSee slides 17-18
Out-of-Network$500 deductible
Per person, per calendar year ($1,500 for family of 3+)
40% coinsuranceOffice visit coinsurance 60% without notification
$6,000 Out-of-Pocket MaxPer person, per calendar year ($18,000 for family of 3+)
Office visits limited to 20/yearBalance billing
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ABC PPO Rx
Generic: $15/30-day supply
Brand name: $25/30-day supply
Non-formulary: $40/30-day supplyIf physician writes “dispense as written” (DAW), brand name co-pay applies
Mail-order: 90-day supplies for 2 copayments
UC pharmacies: 90-day supplies for 2 copayments
Some meds require prior authorization
Preferred Provider Organizations: CIGNA Choice Fund
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CIGNA Choice Fund PPOPreferred provider network offers:
~45,000 network doctors in CA~520,000 network doctors nation-wide
Health Reimbursement Account
(HRA)
Pays for care and drugs before member paysUnused HRA dollars roll over to next year
NCQA: “Full”(highest accreditation for PPOs)
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How does the CIGNA PPO work?
HRA pays firstMedical care & Rx paid at 100% by HRAMember pays nothing until HRA is depletedHRA shared by all family members
Member pays annual deductibleDeductible shared by all family members
After meeting deductible, member pays 20% for CIGNA providers/40% for non-preferred providers
CIGNA pays 100% after Out-of-Pocket Maximum is reached by member
OOP Max includes expenses for medical and Rx
Non-preferred providers can “balance bill”
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How does the CIGNA PPO work?
HRA $1,000
Member Responsibility
$500
PPO HealthCoverage 80%/60%*
100%
Pre
vent
ive
Car
e
EMPLOYEE EMPLOYEE + ADULT
EMPLOYEE + CHILD(REN)
EMPLOYEE & FAMILY
*In-Network Coverage Level/Out-of-Network Coverage Level
Ded
uctib
le
HRA $1,500
Member Responsibility
$750
PPO HealthCoverage 80%/60%*
100%
Pre
vent
ive
Car
e
Ded
uctib
le
PPO HealthCoverage 80%/60%*
100%
Pre
vent
ive
Car
e
Ded
uctib
le
PPO HealthCoverage 80%/60%*
100%
Pre
vent
ive
Car
e
Ded
uctib
le
HRA $1,500
Member Responsibility
$750
HRA $2,000
Member Responsibility
$1,000
Total Out-of-Pocket$2,000 In-Network$9,000 Out-of-Network
Out-of-Pocket Max$1,500 In-Network
$8,500 OON
Out-of-Pocket Max$2,250 In-Network
$12,750 OON
Out-of-Pocket Max$2,250 In-Network
$12,750 OON
Out-of-Pocket Max$3,000 In-Network
$17,000 OON
Total Out-of-Pocket$3,000 In-Network$13,500 Out-of-Network
Total Out-of-Pocket$3,000 In-Network$13,500 Out-of-Network
Total Out-of-Pocket$4,000 In-Network$18,000 Out-of-Network
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Advantages of CIGNA PPOFirst-dollar coverage by HRA
Unused HRA dollars roll to next year
No PCP, self-refer to specialists
No primary medical group
Large, national provider network
Out-of-Network coverage
Chiropractic/acupuncture coverage
Deductible/OOP Max shared with family members
OOP Maximum includes Rx
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Limits of CIGNA PPODeductibles/coinsurance rather than flat copayments
Preauthorization required for non-emergency
Hospitalization and other facility-based care
OOP Max does not include deductible
OOP Max higher for non-CIGNA providers
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CIGNA mental healthSame UBH coverage as HMOs and Anthem Blue Cross PLUS
–
See slides 17-18
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CIGNA Rx
No drug formulary
No flat copayments
HRA pays first
Use CIGNA web site to price drugs at local pharmacies
Rx expenses apply toward Out-of-Pocket Maximum
FeeFee--ForFor--Service plan:Service plan: Core MedicalCore Medical
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Core MedicalCustom plan for UC
Administered by Anthem Blue Cross Life & Health Insurance Co.
Some PPO features
Not accredited by NCQA
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Core MedicalCatastrophic medical plan
Little or no coverage for preventive services
New as of 2008: behavioral health coverage
No employee Cost
$3,000 deductable
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How does Core work?PPO Network
Self-refer to preferred providers$3,000 deductible
Per person, per calendar year
20% coinsurance$7,600 Out-of-Pocket Maximum
Per person, per calendar year
Other providersSelf-refer to non-Blue Cross providers
$3,000 deductible
Per person, per calendar year
20% coinsurance
$7,600 Out-of-Pocket Maximum
Per person, per calendar year
Balance billing
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Advantages of CoreNo monthly premium
No PCP, self-refer to specialists
Large, national preferred provider network
Out-of-Network/world-wide coverage
Chiropractic/acupuncture coverage
No drug formulary
Drug expenses apply toward OOP Max
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Limits of CoreHigh deductible
High OOP Max
No coverage for hearing aids
No preventive care
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Core Rx
No drug formulary
Pay for drugs, then file claims for reimbursement at 80% (after deductible)
Drug expenses apply toward your deductible/Out Of Pocket Max
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Help is available
Health Care Facilitator ProgramGlenn Rodriguez
(949) 824-9065
Benefits Office(949) 824-5210
http://www.hr.uci.edu/hcf
