blue cross plans… …when you have cross_vs_medicare.pdfpros/cons • medical coverage ......

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

glennr@uci.edu

Benefits Office(949) 824-5210

http://www.hr.uci.edu/hcf