Big changes
New choices
Updated
11/22/13
Medical Plan Comparison
Laura Morgan
UCSB Human Resources, Benefits
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This presentation is intended for communication purposes only. Please see plan
document and http://atyourservice.ucop.edu for complete information.
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11/2013
Topics
• Open Enrollment Overview
• Medical Plan Design 101
• Medical Plan Comparisons
◊ Residence requirements
◊ Choice of physician
◊ Cost of care & prescription drugs
◊ Out of Pocket Maximum
◊ Health Savings Account
◊ Behavioral Health
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Open Enrollment
• Ends Tuesday, November 26, 5:00 pm
• Make changes online - sign in to account
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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Review Options for 2014
atyourservice.ucop.edu/oe
Booklet
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Medical Plan Chooser
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2014 Medical Plans
2013
2014
Anthem PPO
Anthem PLUS
UC Care PPO
Anthem 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
• Insurance plan delegates your care to a
“medical group” (e.g. Sansum, SB Select IPA)
• Care is coordinated by a Primary Care Physician
(PCP) and medical group
• Member selects PCP, PCP refers to specialists
• Predictable, low cost, copay for services
- no deductibles
• Emergency and urgently needed care when away
Health Net Blue & Gold HMO
Kaiser HMO
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HMO Network and Access to Care
HMO Medical Group
Primary Care Physicians
Specialists
Labs
Radiology
Durable Medical Equip
Urgent Care
Hospitals
Access to Care
When you need care
go to your PCP
PCP refers you to
specialist, x-ray, lab,
hospital
Medical Group authorizes
referrals to some
specialists and treatment
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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
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
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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
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
• Provider can “balance bill”
You pay 50%:
$50
You pay balance:
$100
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PPO 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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PPO Resources
Fair Health Consumer
• http://www.fairhealthconsumer.org/
Health Care Blue Book
• https://www.healthcarebluebook.com/
Good Rx – drug costs
• http://www.goodrx.com
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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
How do you use your plan?
PPO
• Use physicians out of
the HMO medical
group
• Use out-of-network
behavioral health
• Deductible &
Coinsurance
HMO
• Use PCP and
specialists in the
HMO medical group
• Use Optum
behavioral health
• Predictable copays
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2014 Medical Plans
Health Net Blue & Gold HMO
Kaiser HMO
UC Care
Blue Shield Health Savings Plan
Core
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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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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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
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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
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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
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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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
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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 out of US
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UC Care: UC Select near UCSB
• UC Select providers in
◊
◊
◊
◊
Santa Barbara – Sansum Clinic
Santa Maria
Lompoc
Ventura
• Currently, Sansum Clinic is the only UC Select
provider in Santa Barbara area
◊ High cost hospital and medical groups
◊ Still negotiating
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UC Care: Blue Shield Preferred
• 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
UC Care Provider directory
blueshieldca.com/uccareppo
Search tool defaults to UC Select network
“Change selection” to find Blue Shield Preferred
UC Care http://uc-care.org/
Blue Shield Concierge 1-855-201-2067
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Office Visit Cost
Medical Plan
Copay
Deductible
Coinsurance
HMO
$20
None
None
UC Care PPO
UC Select
$20
None
None
Preferred
Out-of-Network
$250 indiv
$750 family
$500 indiv
$1,500 family
You pay 20%
Plan pays 50%
of allowed rate
You pay balance
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UC Care Costs
UC Select
(Tier 1)
Blue Shield
Preferred
(Tier 2)
Non-Preferred
Out-of-Network
(Tier 3)
Copay
Deductible
Deductible
Coinsurance
Coinsurance
• Your costs are based on the tier/network that the
provider is in
• Not all services are covered at the UC Select benefit tier
• Some services are covered only at the Blue Shield
Preferred and Non-Preferred tiers
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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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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
$1,250 single
$2,500 family
You pay 20%
$2,500 single
$5,000 family
Plan pays 60%
of allowed rate
Full family deductible must be met before plan shares cost
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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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Hospitalization Costs
Medical Plan
Copay
Deductible
Coinsurance
HMO
$250
None
None
UC Care PPO
UC Select
$250
None
None
Preferred
Out-of-Network
$250 indiv
$750 family
$500 indiv
$1,500 family
You pay 20%
Plan pays 50%
of allowed rate
You pay balance
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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
$1,250 single
$2,500 family
You pay 20%
$2,500 single
$5,000 family
Plan pays 60%
of allowed rate
Full family deductible must be met before plan shares cost
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Emergency Room Costs
Medical Plan
Copay
Deductible
Coinsurance
HMO
$75
None
None
UC Care PPO
UC Select
$100
None
You pay 20% of
ER physician
Preferred
$100
Waived
Out-of-Network
$100
Waived
You pay 20% of
ER physician
You pay 20% of
ER physician
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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%
$1,250 single You pay 20%
$2,500 family
Out-of-Network
$2,500 single You pay 20%
$5,000 family
Full family deductible must be met before plan shares cost
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Out-of-Pocket Maximum
Medical Plan
Health Net HMO
Kaiser HMO
OOPM
$1,000
$3,000
$1,500
$3,000
indiv
family
indiv
family
Notes
Family = 3 or more
Family = 2 or more
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Out-of-Pocket Maximum
Medical Plan
UC Care PPO
UC Select
OOPM
$1,500 indiv
$4,500 family
Preferred
$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
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Out-of-Pocket Maximum
Medical Plan
CORE
Blue Shield HSP
Preferred
Non-Preferred
(Out-of-Network)
OOPM
$6,350 indiv
$12,700 family
$4,000 indiv (single)
$6,400 family
Notes
Family = 2 or more
Medical & Drug
expenses apply
Full family OOPM must
be met before plan
pays 100% for any
enrollee
$8,000 indiv (single) In & Out-of-network
$16,000 family
accumulate separately
Medical & Drug
expenses apply
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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
$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
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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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Lumenos vs Blue Shield HSP
Lumenos
Deductible
 Health
Reimbursement
Account (HRA)
 Member pays
PPO Coinsurance
Blue Shield PPO
Deductible
 Member pays
PPO Coinsurance
Health Savings Account
UC Contributions
Member Contributions
Lumenos HRA Rollover
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Lumenos HRA Rollover
• 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.
Example: Lumenos PDHRA
• Single Deductible
• UC Contribution to HSA
• Remaining balance
$1,250
$500
$750
◊ Pay with personal funds
or
Pay with your contributions to HSA
• Lumenos PDHRA can be used to pay 20%
coinsurance after deductible is satisfied
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Why is HSA better?
• 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
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Employees can maximize savings
• UC Contribution (1/1/14)
◊ $500 individual
◊ $1000 family
• You can contribute up to (optional):
◊ Single-coverage: $2,800
◊ Family-coverage: $5,550
◊ Catch-up contribution, age 55+: $1,000
Tip: Contribute the money you would have
put in your Health FSA.
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
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
HSA vs FSA
• The HSA is NOT like the Health FSA where you
have access to the entire annual contribution
starting on January 1
• The HSA is like a checking account – the money
must be in the account before you can spend it
◊ You make monthly contributions through
payroll deduction, you can change the
contribution amount during the year
◊ You can make one time contributions
through Health Equity
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Use the HSA to pay for…
• Deductible
• Coinsurance
• Any IRS Publication 502 Expenses, including:
◊
◊
◊
◊
Medical
Dental
Vision
Prescription drug
◊ Long Term Care insurance premiums
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Using your Health Savings Plan
1. Go to your doctor.
2. Later – check your
HealthEquity account
online to see required
payment to the doctor.
3. Pay with your HSA funds
through your HealthEquity
online account.
OR
Pay with another source
(e.g. check, credit card)
• Give doctor’s office
your Blue Shield card
so BSC can…
 process the claim and
get you their special
provider discounts and
 send info about your
amount of claim
responsibility to Health
Equity
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For more information
HealthEquity Member Services is available
every hour of every day
Call the Blue Shield/UC dedicated line
1.855.201.8375
say
“Health Savings Account”
www.healthequity.com/ed/uc
www.blueshieldca.com/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
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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
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Behavioral/Mental Health
Medical Plan
OPTUM Network
Out-of-Network
UC Care
Visits 1-3 no copay
Visits 4+ $20
Inpatient $250
$500 deductible
Plan pays 50%
Blue Shield
HSP
Deductible:
$1,250 indiv
$2,500 family
You pay 20%
allowed
You pay balance
Deductible:
$2,500 indiv
$5,000 family
Plan pays 60%
allowed
You pay balance
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Behavioral/Mental Health
Medical Plan
Blue Shield
Network
Core
Out of 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-of61
pocket maximums do NOT cross accumulate.
Chiropractic & Acupuncture
Medical Plan
HMO
UC Care
Preferred
Providers
American Specialty
Health
Blue Shield
Out-of-Network Non-Blue Shield
Costs
25% discount
After deductible,
You pay 20%
After deductible,
Acupuncture:
Plan pays 80% allowed
Chiropractic:
Plan pays 60% allowed
Note: Benefit is limited to 24 visits per calendar year combined
for Acupuncture and Chiropractic visits
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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
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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: Plan payment maximum up to $500 per calendar year
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http://atyourservice.ucop.edu/oe
• Resources
◊ Plan contacts
◊ Plan rates
• Medical Plans
◊ Benefit summaries
◊ Links to plan websites
◊ Links to provider directories
• Other plans
◊ Dental, vision, FSA
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