Blue Cross Plus 101
Tips for Employees
Brought to you by the UCSF
Health Care Facilitator Program
HR Benefits/Financial Planning
2007
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Topics
Plan structure/design
In-Network Benefits
Out-of-Network Benefits
Specific Coverage Issues
Prescription Drug Benefits
Behavioral Health Benefits
Problem solving
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Plan Structure and Design
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What’s the Plus in Blue Cross Plus?
Blue Cross Plus* is a Point of Service plan that
gives members choice and flexibility
Blue Cross Plus combines features of both HMO
and PPO plans
Members can choose to receive health care
services from:
– In-network providers
HMO structure; PCP/medical group network or;
– Out-of-network providers
Blue Cross Preferred Provider Organization (PPO) providers or:
Non Preferred Provider Organization (PPO) providers
*Subscriber must live in the California service area to be eligible for this plan.
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The question asked most often………..
What’s the difference between Blue Cross Plus and the
Blue Cross PPO Plan?
Plans vary in
– Monthly premium
– Benefits covered
– Cost for services
PPO plan does not include an HMO network; you selfrefer for all services
Both plans provide coverage for services from PPO and
non-PPO providers – the difference is in the cost for
these services
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How does the plan work?
You Choose to........
*Select In-Network level Open Panel HMO
All care is coordinated through
a Primary Care Provider (PCP)
– Exceptions - Direct Access
Programs, OB/GYN
You pay a $20 co-pay for most
services, $250 for hospital inpatient and $75 ER co-pay
No claim forms, no deductibles
*Based on benefits, 2007
*Select Out-of-Network level PPO/non-PPO docs
Self-refer for care
After a $500 individual deductible,
$1500 family (3 or more) the plan
pays 70% of Usual Customary and
Reasonable (UCR) charges for
most services or 70% of the
contracted rate if there is one
Self-referral to PPO providers
means no balance billing
World Wide Coverage
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Blue Cross Plus
Utilizing the
In-Network Benefit Level
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How does it work?
You select a Primary Care Physician (PCP)
and Medical Group to manage your care
– PCP must be within 30 miles of your home/work
– Each family member can choose different Medical
Group and/or PCP
When your PCP determines you need a
specialized service, your PCP will refer you to
a specialist, hospital or lab that is contracted
with your Medical Group – some exceptions
Some services must first be authorized by the
Medical Group
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Blue Cross Plus, In-Network
Open Panel HMO
Blue Cross Plus
In-Network
Medical Group A
i.e. Brown & Toland
Medical Group
Primary
Care
Specialists
Providers
Hospitals
Labs
Medical Group B
i.e. Marin IPA
Primary
Care
Specialists
Providers
Hospitals
Labs
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Blue Cross Plus
Utilizing the
Out-of-Network Benefit Level
Blue Cross, Preferred Provider Organization (PPO)
and Non-PPO Providers
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What is a PPO?
PPO stands for Preferred Provider
Organization
Blue Cross PPO Providers have
contracted rates for services
– This means lower costs for services and lower
out-of-pocket expenses
– No balance billing
– Usually no claim forms
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Blue Cross Plus,
Out-of-Network
How does it work?
– You self-refer to Blue Cross Preferred Provider
Organization (PPO) providers and non-PPO doctors
– After a $500 individual deductible, $1500 for family (3
or more), the plan pays 70% of Usual, Customary and
Reasonable (UCR) charges for most services or 70%
of the contracted rate if there is one
– Self-referral to non-PPO providers means you are
responsible to pay the amounts above UCR - also
called balance billing
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How do I find a PPO Provider?
Complete a provider search through
the Blue Cross website:
– http://www.bluecrossca.com/uc
Health Scope
– License/Certification
– http://www.healthscope.org
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How are Usual, Customary and
Reasonable Charges (UCR) Determined?
Usual, Customary and Reasonable (UCR)
charges are based on guidelines set by the
Department of Insurance
Typically this includes regional data blended
with national standards for costs
It is determined annually
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What is Balance Billing?
Balance billing is the amount above the Usual,
Customary and Reasonable (UCR) charge for a
service that a non-PPO provider may charge
you, for example……
– A Non-PPO provider charges $125 for a service
Blue Cross determines that UCR is $100
Blue Cross will pay 70% of $100 or $70 and you are
responsible for paying the difference*
– You pay $55 to the provider instead of the $30 that
would have been required if the provider was
charging you the UCR rate
– The $25 difference is the ‘Balance Billing’
*Assumes you’ve met the annual deductible
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How do I obtain the UCR for services
prior to obtaining care?
Ask your physician to contact Blue Cross
and ask for the ‘Disclosure of Legality’
form
– Provider completes form and includes
procedure codes and fees
– Blue Cross responds to both provider and
member with pricing
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Out-of-Pocket Maximums
Your Blue Cross Plus plan has both an In-Network
and Out-of-Network Out-of-Pocket Maximum
(OOPM) to protect you from catastrophic out of
pocket medical expenses, meaning……
 If your co-pays, co-insurance and deductibles paid in
a plan year, equal your OOPM, additional care for
covered services in that year are paid at 100% review plan for excluded services
Check the plan EOC to determine what costs
count towards your OOPM. (Some costs are
excluded.)
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Blue Cross Plus
Out-of-Pocket Maximum
2007
Individual
In-Network Out-of Network
$1,500
$5,000
Family
$4,500
(3 or more)
$15,000
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Specific Coverage Issues
You should always verify in the
EOC or with Blue Cross customer
service if you have any questions,
or to confirm your benefits.
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Changing Your PCP/Medical Group
You can change your Medical Group and/or PCP outside
of open enrollment by contacting Blue Cross Customer
service at the number shown on your insurance card
– Usually, if you call by 15th of month, change effective 1st of next
month
– Blue Cross must approve your request for it to become effective
– If you are currently undergoing care for an escalated health care
issue, Blue Cross may limit your ability to transfer to a new
medical group
Each family member may have their own PCP/Medical
group
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Student Dependents
Student dependents living in CA
– select a PCP near their school and use the in-network
benefit level and/or;
– Self-refer to PPO and non-PPO providers and use the
out-of-network benefit level
Student dependents living out of state
– select a PCP near their CA home address and use the
in-network benefit level when visiting home and/or;
– Self-refer to PPO and non-PPO providers and use the
out-of-network benefit level when at school
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Direct Access Benefits
If your medical group participates in Direct
Access, you can self-refer to the following
specialists and receive the in-network benefit
level ($20 co-pay for office visit):
Allergists/Immunologists
Dermatologists
ENTs/Otolaryngologists
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Bay Area Medical Groups’ participation in
Blue Cross Plus Direct Access Program:
YES
– Brown & Toland
– John Muir/Mt. Diablo
– Santa Clara IPA
NO
–
–
–
–
–
–
Alta Bates
Marin IPA
Chinese Community
Hills Physicians
Mills-Peninsula
Sonoma County IPA
This information subject to change, contact your
medical group to determine participation in Direct
Access.
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Obtaining OB/GYN services
Members may self-refer to an OB/GYN
provider in their Medical Group Network
– Per the Knox Keene Health Care Service
Plan Act of 1975, members may seek
OB/GYN services from their network without
prior approval
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Chiropractic & Acupuncture
Benefits
Members may self-refer to Chiropractors and
Acupuncturists that are available through the
American Specialty Health Plan (ASHP) network
– These services are covered only at the in-network
level of the Blue Cross Plus plan and only when
provided by an ASHP network provider. There is no
out-of-network coverage.
– Members can contact the American Specialty Health
Plan (ASHP) to get a list of providers
(800) 678-9133
Review your Evidence of Coverage (EOC) booklet for
additional information
Questions? - Contact Blue Cross member services
– (888) 209-7975
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Infertility Coverage
Services related to diagnosis and treatment of
infertility are covered only at the Out-of-Network
level and only from Blue Cross PPO providers
– These services are not subject to the plan deductible
– For detailed information, review your Evidence of
Coverage (EOC) booklet
http://www.bluecrossca.com/clients/uc.htm
– Questions? - Contact Blue Cross member services,
(888) 209-7975
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Emergency Care
Blue Cross strictly enforces the following definition of an
Emergency:
“Emergency is a sudden, serious, and unexpected
acute illness, injury, or condition (including without
limitation sudden and unexpected severe pain) which the
member reasonable perceives, could permanently
endanger health if medical treatment is not received
immediately. Final determination as to whether services
were rendered in connection with an emergency will rest
solely with us or your medical group.”
If you believe you have a medical emergency, you
should seek medical treatment immediately.
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Emergency Care
In Area Emergencies: Seek treatment and
request treating provider contact your
PCP/medical group as soon as possible to
request medically necessary continued
care.
Out of Area Emergencies (more than 20
miles from your medical group): contact
Blue Cross within 48 hours if you are
admitted to a hospital.
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Second Opinions
You have the right to a second opinion by
an appropriately qualified health care
professional
You must have initially seen a specialist
you were referred to by your PCP
If there is no appropriately qualified health
care professional in the network, you may
be authorized to see someone out-ofnetwork
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Reasons for requesting a Second
Opinion include…
The treatment plan in progress is not
improving your medical condition
You are diagnosed with a condition that
threatens loss of limb, body function
Your PCP or the initial specialist is unable to
diagnose your condition
For additional reasons, consult your EOC
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Blue Cross Plus
and
Behavioral Health Benefits
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What are the
Behavioral Health Benefits?
Behavioral Health Benefits are ‘carved out’
meaning there is a separate plan administrator
United Behavioral Health (UBH) is the
administrator
You initiate services by contacting UBH directly
Members can choose to receive behavioral
health care services from:
– in-network providers (UBH network) or
– non-network providers
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How does UBH work?
In-Network Services
Out-Patient Therapy
– Call UBH directly, (888) 440-8225. UBH will either refer you to a
provider or you can designate an in-network provider
– www.liveandworkwell.com enter access code 11280
– You pay $0 co-pay for first 5 visits, then $10 for 6+ visits
– No claim forms, no deductibles
– $500 annual out-of-pocket maximum
Inpatient Hospitalizations
– No co-pay
– Notify UBH within 48 hours for emergency admissions
Review EOC for substance abuse benefits
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How does UBH work?
Out-of-Network Services
Out-Patient Therapy
You call UBH and notify them that you are self-referring
for care at the out-of-network level
After a $500 individual deductible, the plan pays 70% of
UCR for most services (only 50% of UCR if you fail to
notify first)
$5,000 annual out-of-pocket maximum
Most providers require payment in full up front and you
submit claim forms to UBH to request reimbursement
Out-patient, out-of-network visits limited to 20 per
individual annually
Review EOC for in-patient care and substance abuse
benefits
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Other Behavioral Health Resources
UCSF Faculty and Staff Assistance
Program (FSAP)
– FSAP provides confidential short term
assessment and counseling,* and when
appropriate, coordinates referral services to
your HMO provider or other community
/health care services resources
(415) 476-8279
www.ucsfhr.ucsf.edu/assist
*One to three sessions
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Blue Cross Plus
and
Prescription Drugs Benefits
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What are the Prescription Drug Benefits?
Prescription drug benefits are administered by
WellPoint, parent company of Blue Cross of CA
Three tier design providing coverage for
– generic drugs
– Brand name drugs
– Non-formulary drugs (drugs not listed on the formulary)
Questions? Contact WellPoint Pharmacy Mgt
– (800) 700-2541
– Precision RX, Mail Order
(866) 274-6825
https://www.precisionrx.com/wpx/index.jsp
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Blue Cross Plus
Prescription Drugs, 2007
Drug status
Formulary
subject to change
RETAIL – 30
Day Supply
Formulary
Generic
Formulary
Brand
Name
NonFormulary
$15 Co-pay
$25 Co-pay
$40 Co-pay
$30 Co-pay
$50 Co-pay
$80 Co-pay
Network
Pharmacy
MAIL - 90
Day Supply
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Prior Authorization of Medications
A small number of drugs require a Prior Authorization
– Ensures that patients receive medication appropriate for their
condition
– Limits the use of expensive medications when there are less
expensive alternatives
– Designed to help contain drug costs and ensure the University
can continue to offer excellent health coverage for a fair premium
during a time when medical and prescription drug costs are
rising
– List of drugs requiring PAB available on line:
www.bluecrossca.com/uc, select ‘Pharmacy Programs’
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Prior Authorization of Benefits
(PAB) Process
– Physician completes appropriate form and faxes form
to WellPoint Pharmacy Management, 888-831-2243
– WellPoint Pharmacy Management completes review
for urgent requests within one day of receipt and nonurgent requests within two working days
– The prescribing physician is notified of the outcome. In
the event the decision is a denial, a letter is sent
explaining the medical reasons for the denial
– Have questions? Call (800) 700-2541
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Problem Solving
Tips for Blue Cross Plus
Members
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Problem Solving
Review the EOC to determine the specific
process for resolving disputes with the
plan
Write down your list of concerns before
you make your phone call or visit
Keep a log of all communication
– Names of representatives you speak with
– Dates of calls
– Information provided to you
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What if you get a bill for a service?
Typically you should not get any bills for services
received when using the HMO level, the innetwork level of your plan, if you do……
– Call the customer service number on the bill and ask,
“why am I being billed”?
– Billing error - Rep may need to re-direct claim to medical
group or health plan
– Authorization issue - You may need to contact referring
physician for verification of authorization
– Eligibility issue - You may need to contact UCSF HR
and/or your health plan to verify and update your
eligibility
– If the above doesn’t work, contact Blue Cross and let
them know you have been billed for a service that you
think should be covered by the plan
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What if You Can’t Get a Timely
Appointment With Your PCP?
Per the California State Department of the Patient
Advocate, you have the right to get health care without
waiting too long and to get an appointment when you
need one
If you can’t get an appointment within a reasonable
time frame…..
– Ask to speak to the office supervisor and firmly request
that they fit you in at an earlier date
– File a grievance with your health plan
– Contact the Department of Managed Care
1-888-466-2219
– Select a new PCP
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What if You Receive a ‘Denial’ for a
Covered Service?
Request an ‘Appeal’ if Your Medical
Group or Plan Denies Requested Services
– If you’ve received a denial of service, follow the
appeal process outlined in the denial letter
– The appeal process is also outlined in Evidence of
Coverage (EOC) booklet
– Decision should be provided in writing within 30 days
of receipt
– Not satisfied with the results of the grievance
process?
Contact the CA Department of Managed Care
1-888-466-2219
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What if You Are Dissatisfied with
the Plan’s Customer Service?
Submit a Complaint
– Blue Cross allows you to ‘call in’ to initiate the
formal complaint process, or you can submit
your complaint in writing to the plan
– This process is outlined in Evidence of
Coverage (EOC) booklet
– Not satisfied with the results of the grievance
process?
Contact the CA Department of Managed Care
1-888-466-2219
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What about health care
services/costs
that are not covered?
Health Care Reimbursement Account
– Allows you to set money aside on a pre-tax
basis to pay for qualifying health care
expenses through a monthly payroll deduction
Eligible expenses based on IRS rules
Limited to expenses not covered by insurance; includes copays and other out of pocket expenses
Budget carefully, if you don’t use the money set as side, you
lose it!
– Enroll each year during Open Enrollment
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Where can I find this information?
Almost all the information being covered today is
outlined in your Evidence of Coverage (EOC)
booklet
The EOC contains detailed information
regarding what is and what is not covered by
your medical plan and your cost for services
You may download a copy from the Blue Cross
website or call Blue Cross to request it
– www.bluecross.com/uc
– (888) 209-7975
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If you need to select or
change your PCP/Medical
group…..
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Things to Consider
Determine your needs
– Do you want a physician that specializes with specific client
groups?
– Would you prefer a physician of the same gender, age, race,
religion or language?
– Do you want a physician that contracts with a specific medical
group?
Contact the provider office
–
–
–
–
Is the practice accepting new patients with your insurance?
What hours are available for appointments?
What are the standards for wait time and visit length?
Did you receive good customer service from the office staff?
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Complete a provider search through the
Blue Cross website:
– http://www.bluecrossca.com/uc
– Members must select a PCP that is within 30 miles of
the home or work address
Health Scope
– For License/Certification information
– California Health Care Quality Ratings
– http://www.healthscope.org
Office of the Patient Advocate
– Annual Quality of Care Report Card
– http://www.opa.ca.gov/
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Help is available!
As mentioned previously you may be able to
get information and assistance from:
– Your physician or specialist’s office
– Blue Cross customer service
(888) 209-7975
– Blue Cross Website
www.bluecrossca.com/uc
Includes a link to the Evidence of Coverage Booklet and
many other documents, forms and tools
– CA Department of Managed Health Care (DMHC)
www.hmohelp.ca.gov
(888) 466-2219
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Help is available!
Local Resources:
Brown and Toland Medical Group
– (415) 553-6588
– customerservice@btmg.com
UCSF Medical Center
http://www.ucsfhealth.org/
–
–
–
–
UCSF Referral Service: (415) 885-7777
UCSF Hospital Billing: (415) 673-1111
UCSF Physician Billing: (415) 353-3333
UCSF Patient Relations: (415) 353-1936
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Help is available!
For escalated problems you cannot solve
on your own, contact:
– UCSF Health Care Facilitator Program
Sue Forstat, HCF, (415) 514-3324,
sforstat@hr.ucsf.edu
Jason Neft, Assistant HCF, (415) 476-5269,
jneft@hr.ucsf.edu
HCF Program Website:
www.ucsfhr.ucsf.edu/benefits/hcf
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