Choosing between Blue Cross
plans…
…when you haveMedicare
Presented Presented By Glenn RodriguezBy Glenn RodriguezHealthCare FacilitatorHealthCare Facilitator
UC IrvineUC Irvine
2
Agenda
I. Medicare and UC
II. Medicare and Anthem Blue Cross
III.
Plan Comparisons•
Pros/Cons
• Medical coverage
• Coordination with Medicare
• Mental health coverage
• Rx
coverage
IV.
Cost vs. Benefit
Medicare and UC
4
Medicare and UC
•
Medicare is the federal health insurance program for those over 65 and some disabled
Part A: Hospital (premium-free for most)Part B: Medical ($96.40/month in 2010)
•
Costs more if you make more than $85K/year ($170K for couples)
•
UC relies on Medicare to offset the cost of retiree medical insurance
•
Retirees without Medicare cost 3 times more to insure
5
UC’s
Medicare Requirements
•
UC requires retirees and their family members to enroll in Medicare Part B:
If enrolled in medical insuranceIf eligible for Part A free of chargeFailure to comply may result in the loss of UC-sponsored medical coverageExceptions:
•
Retirees who reside outside of the U.S.•
Those who retired prior to July 1, 1991
6
Medicare Part D
•
New drug benefit as of 2006•
Subsidizes medical plan premiums
•
Retirees will automatically be enrolled in Part D by Blue Cross
No additional Part D premium•
Blue Cross members have a separate “Medicare Rx
” ID card
7
Medicare Part D
•
Retirees do not need to do anything to enroll
Exception: double coverage•
Enrollment in a non-UC Part D plan may result in loss of coverage
•
Exception:New PPO + Medicare without Rx
Medicare and Blue Cross
9
Blue Cross Plans
•
UC offers 4 Anthem Blue Cross medical plans:
Core MedicalBlue Cross PLUSBlue Cross PPOHigh Option
•
Rely upon “Evidence of Coverage”
booklets for detailed plan information:
http://www.anthem.com/ca/ucCall Blue Cross at 1-888-209-7975
10
Blue Cross Plans w/ Medicare
•
Assumption: eligible for Parts A & B•
Medicare pays primary, Blue Cross secondary
•
Use Medicare providers Providers must be certified with MedicareNo “private contracts”If Medicare will not pay a claim because the provider is not part of Medicare, then Blue Cross will not pay
11
About Medicare Providers
•
91% of U.S. physicians participate in Medicare as of 2001
•
If seeing a new doctor, be sure to ask if accepting new Medicare patients
•
Providers that do not accept Medicare “assignment”
can charge up to 15% more
•
Find doctors online:http://www.medicare.gov
12
Blue Cross Plans w/ Medicare
•
“Electronic Crossover”
programTo activate, call Blue Cross with your Medicare number and Part A/B effective datesBlue Cross will be able to access your Medicare claim informationNo need to resubmit claims after filing with Medicare
Wellness Programs
14
Blue Cross Wellness Programs•
Wellness programs:
Discounted fitness, massage therapy, yoga, weight loss, etc.Educational classes through local medical groupsToday’s Health & Wellness magazine
•
Disease management programs:Asthma/diabetes/congestive heart failure/cancer (chemotherapy)/ musculoskeletal disorders
•
Tobacco cessation
15
StayWell
Health Management
•
New Wellness benefit on top of other benefits
Exceptions: Kaiser members; family members under 18
•
Wellness benefits include:$100 gift certificate ($50 for spouse) for completing a Health Assessment (online or paper form) before 4/15/09
16
•
Wellness benefits:Access to extensive online health resources and interactive tools
•
“Look It Up”
drug research, self-care information, create reminders for preventive screenings
Health Improvement Programs include access to a health coach by phone, online or mail
•
UC Living Wellhttp://uclivingwell.ucop.edu1-800-721-2693
StayWell
Health Management
Plan Comparisons
18
Core Medical w/ Medicare
•
Fee-for-Service plan•
Lowest monthly premium of all plans offered by UC
Full Medicare Part B reimbursement•
New as of 2008: behavioral health coverage
Must use Medicare providers
19
Core Medical w/ Medicare
•
AdvantagesSelf-refer to any Medicare providerDeductible: $100Chiropractic/acupuncture coverageOut-of-Pocket Maximum: $1,260Separate Rx Out-of-Pocket Maximum: $1,000Lifetime maximum benefit: $2,000,000/person
20
Core Medical w/ Medicare
•
LimitsHearing aids/exams not coveredSexual dysfunction drugs not coveredSkilled nursing facility limit: 120 days per calendar yearHome health care limit: 100 days
21
Core Medical w/ Medicare
•
Medicare coordination:Blue Cross will pay 80% of their allowable charges
•
If this is less than Medicare’s payment, Blue Cross pays nothing, member pays 20%
•
If more than Medicare’s payment, Blue Cross pays difference up to 80% of allowable charges
22
•
Prescription drug benefitGeneric drugs on Blue Cross formulary
•
$15
for a 30-day supply
Brand name drugs on formulary•
$25
for a 30-day supply
Non-formulary drugs•
$40
for a 30-day supply•
If physician writes “dispense as written”
(DAW), $25 brand name copay
applies
Core Medical w/ Medicare
23
•
Prescription drug benefit90-day supplies for 2 copayments
•
From UC pharmacies•
Mail orderCertain drugs may require prior authorizationSexual dysfunction drugs not covered$1,000 Rx Out-of-Pocket Maximum
•
Excludes copays
for non-formulary drugs
Core Medical w/ Medicare
24
Blue Cross PLUS w/ Medicare
•
Point-of-Service planIn-Network Benefits (HMO)
•
Primary Care Physician (PCP) and medical group coordinate care
Out-of-Network Benefits•
Self-refer to Medicare providers
•
Behavioral health benefitsAdministered through United Behavioral Health
25
Blue Cross PLUS w/ Medicare
•
In-Network Benefits (HMO)Advantages
•
No deductible/claim forms•
$20 physician office visit copayWaived for preventive physical exam & certain immunizations
•
$75 ER copay
(waived if admitted)•
$250 inpatient hospitalization copay•
$20 hearing exam•
50% coinsurance on hearing aids (max benefit of $2,000)
26
Blue Cross PLUS w/ Medicare
•
In-Network Benefits (HMO)Advantages
•
Skilled nursing facility/home health care limit: unlimited
•
$20 Chiropractic/acupuncture copayAmerican Specialty Health Plans providers only
•
Maximum Copayment Liability: $1,500 per person•
Lifetime maximum benefit: unlimited
27
Blue Cross PLUS w/ Medicare
•
In-Network Benefits (HMO)Limits
•
Sutter medical groups not available•
Copayment applies even if balance after Medicare is less than copayment
•
Must go through PCP to get to specialists•
PCP will usually refer you only to doctors/hospitals in the same medical group
•
Routine vision exams not covered•
Chiropractic/acupuncture: American Specialty Health Plan providers only
28
Blue Cross PLUS w/ Medicare
•
In-Network Benefits (HMO)Medicare coordination
•
You pay copayment•
Medicare and Blue Cross pay the rest
29
Blue Cross PLUS w/ Medicare
•
Out-of-Network Benefits (PPO)Advantages
•
Can see any Medicare doctor without going through PCP
Includes Sutter doctors•
50% coinsurance on hearing aids (max benefit of $2,000)
•
Skilled nursing facility limit: 240 days/calendar year•
Lifetime maximum benefit: $2,000,000/member
30
Blue Cross PLUS w/ Medicare
•
Out-of-Network Benefits (PPO)Limits
•
$500 per person, calendar year deductible•
30% coinsurance•
Chiropractic/acupuncture not covered•
Out-of-Pocket Maximum = $5,000 per person, per calendar year
31
Blue Cross PLUS w/ Medicare
•
Out-of-Network Benefits (PPO)Medicare Coordination:
•
Blue Cross will pay 70% of their allowable chargesIf this is less than Medicare’s payment, Blue Cross pays nothing, member pays 30%If more than Medicare’s payment, Blue Cross pays difference up to 70% of allowable charges
32
Blue Cross PLUS w/ Medicare
•
Prescription drug benefit–
Generic
drugs on Blue Cross formulary
•
$15
for a 30-day supply
–
Brand name
drugs on formulary•
$25
for a 30-day supply
–
Non-formulary
drugs•
$40
for a 30-day supply•
If physician writes “dispense as written”
(DAW), $25 brand name copay
applies
33
Blue Cross PLUS w/ Medicare
•
Prescription drug benefit90-day supplies for 2 copayments
•
From UC pharmacies•
Mail orderCertain drugs may require prior authorization
34
Blue Cross PLUS w/ Medicare
•
Prescription drug benefitSexual dysfunction drugs (e.g. Viagra)
•
6 tablets or units per 30-day period•
Retail pharmacies only
$4,350 Rx Out-of-Pocket Maximum•
Excludes copays
for non-formulary drugs
35
Blue Cross PPO w/ Medicare
•
Preferred Provider Organization planUse any Medicare provider
•
More flexible than PLUS (no PCP)•
Behavioral health benefits
Administered through United Behavioral HealthIn- and Out-of-Network benefits
36
Blue Cross PPO w/ Medicare
•
AdvantagesAccess any Medicare providerDeductible: $100 per person, per calendar yearCoinsurance: 20% of balance after MedicareHearing exam/hearing aids (up to $2,000): 20%Chiropractic/acupuncture: 20%Skilled nursing facility limit: 240 daysOut-of-Pocket Maximum: $1,500Lifetime maximum benefit: $5,000,000/member
37
Blue Cross PPO w/ Medicare
•
Limits20-visit limit on outpatient, out-of-network behavioral health ($500 deductible)
38
Blue Cross PPO w/ Medicare
•
Medicare coordination:Blue Cross pays 80% of balance after Medicare pays
39
Blue Cross PPO w/ Medicare
•
Prescription drug benefitGeneric drugs on Blue Cross formulary
•
$15
for a 30-day supply
Brand name drugs on formulary•
$25
for a 30-day supply
Non-formulary drugs•
$40
for a 30-day supply•
If physician writes “dispense as written”
(DAW), $25 brand name copay
applies
40
Blue Cross PPO w/ Medicare
•
Prescription drug benefit90-day supplies for 2 copayments
•
From UC pharmacies•
Mail orderCertain drugs may require prior authorization
41
•
Prescription drug benefitSexual dysfunction drugs (e.g. Viagra)
•
6 tablets or units per 30-day period•
Retail pharmacies only
$4,350 Rx Out-of-Pocket Maximum•
Excludes copays
for non-formulary drugs
Blue Cross PPO w/ Medicare
42
High Option w/ Medicare
•
Medicare supplement plan•
All enrolled family members must have Medicare Parts A & B
•
Highest monthly premium among plans that UC offers
•
Behavioral health benefits:Use Medicare providers
43
High Option w/ Medicare•
Advantages
Access any Medicare providerDeductible: $50 per person, per calendar year
•
Applies to benefits not covered by MedicareCoinsurance: none for many servicesChiropractic: no copay if covered by MedicareAcupuncture: 20% after deductibleSkilled nursing facility limit: 130 daysOut-of-Pocket Maximum: $1,050Rx Out-of-Pocket Maximum: $1,000$2,000,000 lifetime maximum benefit
44
High Option w/ Medicare
•
LimitsPreventive hearing/vision exams not covered$50 deductible applies to preventive physical examHearing aids not coveredSexual dysfunction drugs not coveredOutpatient mental health visits: coverage limited to 10 per person, per calendar yearNo behavioral health Out-of-Pocket Maximum
•
Facility-based care for more than 60 days: you pay 20% with no upper limit
45
High Option w/ Medicare
•
Medicare coordination: “coordination of benefits”
Plan pays 100% of balance after Medicare for most services
46
High Option w/ Medicare
•
Prescription drug benefitGeneric drugs on Blue Cross formulary
•
$15
for a 30-day supply
Brand name drugs on formulary•
$25
for a 30-day supply
Non-formulary drugs•
$40
for a 30-day supply•
If physician writes “dispense as written”
(DAW), $25 brand name copay
applies
47
High Option w/ Medicare
•
Prescription drug benefit90-day supplies for 2 copayments
•
From UC pharmacies•
Mail orderCertain drugs may require prior authorizationSexual dysfunction drugs not covered$1,000 Rx Out-of-Pocket Maximum
•
Excludes copays
for non-formulary drugs
Cost vs. Benefit
49
Cost vs. Benefit
•
Compare the various plans’
total costsMonthly premiumConsider how the plans coordinate with Medicare:
•
Copays/deductibles/coinsurance•
Out-of-Pocket Maximums
50
Cost vs. Benefit: Get to know Medicare
•
Medicare rates for 2009: Part APart A premium: N/APart A deductible: $1,068 per benefit periodFor each benefit period you pay:
•
A total of $1,068 for a hospital stay of 1-60 days•
$267 per day for days 61-90 of a hospital stay•
$534 per day for days 91-150 of a hospital stay (Lifetime Reserve Days)
•
All costs for each day beyond 150 days
51
Cost vs. Benefit: Get to know Medicare
•
Medicare rates for 2009: Part ASkilled nursing facility coinsurance:
•
$133.50 per day for days 21 through 100 each benefit period
52
Cost vs. Benefit: Get to know Medicare
•
Medicare rates for 2009: Part BPart B premium: ≥$96.40 per monthPart B deductible: $135 per yearPart B coinsurance: 20%
•
Medicare rates for 2009: Part DPart D premium: N/APart D deductible: N/A
53
Cost vs. Benefit
COSTS Core PLUS In-Network
PLUS Out-of-
NetworkPPO High
Option
AnnualDeductible
$100 N/A $500 $100 $50
Coinsurance 20% Flat copayments 30%
20% of balance
after Medicare
N/A
AnnualOut-of-Pocket
Maximum$1,260
$1,500Max Copay
Liability$5,000 $1,500 $1,050
54
Cost vs. Benefit
Rx Core PLUS PPO High Option
Benefit
30-day supply:$15/$25/$40
90-day supply:$30/$50/$80
30-day supply:$15/$25/$40
90-day supply:$30/$50/$80
30-day supply:$15/$25/$40
90-day supply:$30/$50/$80
30-day supply:$15/$25/$40
90-day supply:$30/$50/$80
Sexualdysfunction
drugs
AnnualRx Out-of-
Pocket Max$1,000 $4,350 $4,350 $1,000
55
Cost vs. Benefit
Which plans give you access to the doctors you want to see?
Plan CorePLUS
In- Network
PLUSOut-of-
NetworkPPO High
Option
Provider Network Medicare
PCP/medicalgroup
Medicare Medicare Medicare
56
Cost vs. Benefit
Which plans cover benefits you are most likely to need?
57
Cost vs. Benefit
COVERAGE CorePLUS
In- Network
PLUS Out-of-
NetworkPPO High
Option
Hearing exam/aids
Acupuncture$500 Limit $500 Limit
Skilled Nursing Facility
120 days No limit240days
240days
130days
Home Health Care 100 days No limit 100 days 100 days No limit
58
Cost vs. Benefit
BEHAVIORAL HEALTH Core
PLUSIn-
Network
PLUSOut-of-
Network
PPOIn-
Network
PPOOut-of-
Network
High Option
Provider Network Medicare
United Behavioral
HealthMedicare
United Behavioral
Health
Preferably Medicare
MedicareNote: Outpt 10 visit limit
Out-of- Pocket
Maximum
$1,260(includes medical)
$1,000per person
Medicare coverage
only
$1,000per person
$6,000per person
N/A
59
Cost vs. Benefit
Remember, you can always change plansduring a future Open Enrollment
60
6161
Help is available
Health Care Facilitator ProgramGlenn Rodriguez
(949) 824-9065
Benefits Office(949) 824-5210
http://www.hr.uci.edu/hcf
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