Your UC Medical Insurance An overview for active employees

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Your UCMedical InsuranceAn overview for active
employees
Presented by Guerren Solbach
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Agenda

• Your options
• Pre-paid medical
• Other insurance plans
• Conclusion

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Your options
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Your options

• UC offers four types of medical plans
• HMO plans (3)
• POS plan
• PPO plans (2)
• FFS plan
• Availability determined by zip code
• Medical Benefits Summaries
• http//atyourservice.ucop.edu

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Pre-paid medical plans

• Health Maintenance Organizations
• Health Net
• Kaiser Permanente
• Western Health Advantage
• Point-Of-Service plan
• Blue Cross PLUS

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Other medical insurance plans

• Preferred Provider Organizations
• Blue Cross PPO
• CIGNA Choice Fund PPO
• Fee-For-Service plan
• Core Medical (through Blue Cross)

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Medical plan comparison
FFS
(Core Medical)
PPO
(Blue Cross PPO, CIGNA Choice Fund PPO)
Cost
POS
(Blue Cross PLUS)
HMO
(Health Net, Kaiser, WHA)
Flexibility
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Changing plans

• Open Enrollment (November)
• This year 10/30-11/25/2008
• Changes effective January 1st
• HMO Transfer Program
• Provider group disruptions

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Changing plans (cont.)

• Move outside plan service area
• Acquire a newly eligible family member
• Involuntary loss of other coverage

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About our plans

• No pre-existing conditions exclusions
• No UC-sponsored double coverage
• Primary vs. secondary insurance
• Employees plans are primary for them
• Birthday rule
• For details, see Plan Booklets (Evidence of
  Coverage)
• http//atyourservice.ucop.edu
• Under Forms Publications

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Pre-paidmedical plans
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About HMOs

• The 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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How do HMOs work?
Insurance Company
Medical Group
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Advantages of HMOs ?

• Lower monthly premiums
• Low copayments
• No claim forms
• No deductibles/coinsurance
• Provides low-cost preventive care
• New as of 2008 no cost preventive care
• Encourages relationship with PCP

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Limits of HMOs ?

• Must select PCP from the network of medical
  groups
• Most specialty care must be referred by PCP
  (including second opinions)
• Must use your Medical Groups network of
  specialists/hospitals/labs
• Preauthorization process required
• Service area limited to certain urban zip codes

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HMO coverage

• Modest copayments
• Physician office visit 15
• Waived for preventive care including certain
  immunizations
• ER 50
• Emergencies covered worldwide
• Inpatient hospitalization 250
• Out-of-Pocket Maximum 1,000
• Per 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 health

• Coverage 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 benefits

• Outpatient mental health benefits
• First 3 visits free
• Visits 4 15
• Inpatient mental health benefits
• 250 per admission
• Out-of-Pocket Maximum 1,000
• Per 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 copays (does not apply to
  Kaiser)
• Mail-order
• 90-day supplies for 2 copays (does not apply to
  Kaiser)
• Some meds require preauthorization

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Wellness Programs

• Kaiser members Kaiser HealthWorks
• Take a Health Assessment, 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
• Does 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 Net

• Large provider network, contracted with most UC
  Davis area medical groups
• NCQA ???? Excellent
• Decision Power
• Track your health issues/knowledgebase
• Health coach (nurse, respiratory therapist,
  dietician)
• 24-hour nurse line
• Medical group/hospital comparison reports

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Health Net (cont.)

• WellRewards discount programs
• Acupuncture, chiropractic, massage therapy,
  fitness centers
• American Specialty Health Network
• Vitamins, books, videos, weight loss programs,
  etc.
• Disease Management programs
• Asthma/diabetes/heart disease/depression
• Smoking cessation

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Health Net (cont.)

• Prescription 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 Permanente

• Kaiser Foundation Health Plan contracts with one
  large group, the Permanente Medical Group
• NCQA accreditation ???? 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 Permanente (cont.)

• Healthwise Handbook free to members
• Prevent or treat 180 common health issues
• Discount programs
• Acupuncture, chiropractic, massage therapy
• American Specialty Health Network
• Fitness club, vitamins, books videos, etc.
• Disease management programs
• Asthma/diabetes/heart disease

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Kaiser Permanente (cont.)

• Mental health two choices
• Go through PCP 7 for group therapy
• And/or use UBH
• Prescription drugs
• 100-day supplies dispensed
• No coverage for non-formulary Rx
• If brand is dispensed when generic is available,
  member is charged brand copayment

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WHA

• Local health plan, only available in certain
  local counties
• Owned in part by UC Davis Health System
• NCQA ???? Excellent
• Advantage Referrals you can be referred to
  specialists in other WHA medical groups

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WHA (cont.)

• AssistAmerica provides travel assistance
• Medical emergencies if 100 miles or outside
  U.S.
• Medical repatriation/evacuation, care of minor
  children, repatriation of remains, Rx assistance
• Not contracted with Sutter Medical Groups
• 176 members losing access to Sutter (Solano)
  Regional Medical Foundation effective 1/1/09

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WHA (cont.)

• Prescription 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 even if doctor
  indicates Do Not Substitute

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Blue Cross PLUS

• Anthem Blue Cross
• Point-Of-Service plan
• Combines features of HMOs and PPOs
• Benefit level determined by point of service
• NCQA ???? Excellent

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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
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Advantages of PLUS ?

• In-Network coverage offers modest copayments for
  care
• Chiropractic/acupuncture coverage through
  American Specialty Health Plans
• Out-of-Network coverage
• Both preferred and non-Blue providers
• Out-of-Pocket Max 5,000 (lower than PPO)

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Limits of PLUS ?

• In-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 health

• Same 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 supply
• If 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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Blue Cross PlansWellness Programs

• Disease management programs
• Diabetes, asthma, congestive heart failure
• Tobacco cessation
• Healthy Extensions
• Discounted fitness/massage therapy/nutrition/weigh
  t loss programs and more
• Subimo online decision support tool
• Diagnostic and procedure explanations, hospital
  and drug comparisons
• MedCall (nurse advice line)

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Preferred Provider OrganizationsBlue Cross PPO
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Blue Cross PPO

• Anthem Blue Cross
• More than 85 percent of all doctors and hospitals
  throughout the U.S. contract with Blue Cross/Blue
  Shield Plans
• 46,000 Blue Cross network doctors in CA
• 700,000 Blue Cross/Blue Shield network doctors
  nation-wide
• NCQA ??? Full
• (highest accreditation for PPOs)

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How does BC 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-Network
• Self-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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Blue Cross PPO (cont.)
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Advantages of BC PPO ?

• No 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 BC PPO ?

• Deductibles/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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BC PPO mental health

• In-Network (UBH)
• Same as HMO coverage
• See slides 17-18

• Out-of-Network
• 500 deductible
• Per person, per calendar year (1,500 for family
  of 3)
• 40 coinsurance
• Office visit coinsurance 60 without notification
• 6,000 Out-of-Pocket Max
• Per person, per calendar year (18,000 for family
  of 3)
• Office visits limited to 20/year
• Balance billing

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BC PPO Rx

• Generic 15/30-day supply
• Brand name 25/30-day supply
• Non-formulary 40/30-day supply
• If 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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Preferred Provider OrganizationsCIGNA Choice
Fund
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CIGNA Choice Fund PPO

• Preferred 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 pays
• Unused 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 first
• Medical care Rx paid at 100 by HRA
• Member pays nothing until HRA is depleted
• HRA shared by all family members
• Member pays annual deductible
• Deductible 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?
Total Out-of-Pocket 2,000 In-Network 9,000
Out-of-Network
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
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
PPO Health Coverage80/60
PPO Health Coverage80/60
PPO Health Coverage80/60
PPO Health Coverage80/60
Member Responsibility500
Member Responsibility1,000
Member Responsibility750
Member Responsibility750
100 Preventive Care
100 Preventive Care
100 Preventive Care
100 Preventive Care
HRA1,000
HRA2,000
HRA1,500
HRA1,500
EMPLOYEE
EMPLOYEE ADULT
EMPLOYEE FAMILY
EMPLOYEE CHILD(REN)
In-Network Coverage Level/Out-of-Network
Coverage Level
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Advantages of CIGNA PPO ?

• First-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 PPO ?

• Deductibles/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 health

• Same UBH coverage as HMOs and Blue Cross PLUS
• See slides 17-18

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CIGNA Rx

• No drug formulary
• No flat copayments
• HRA pays first
• Use CIGNA website to price drugs at local
  pharmacies
• Rx expenses apply toward Out-of-Pocket Maximum

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Fee-For-Service planCore Medical
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Core Medical

• Custom plan for UC
• Administered by Anthem Blue Cross Life Health
  Insurance Co.
• Some PPO features
• Not accredited by NCQA

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Core Medical (cont.)

• Catastrophic medical plan
• More like car insurancedoesnt pay for oil
  change
• Little or no coverage for preventive services
• New as of 2008 behavioral health coverage

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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 providers
• Self-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 Core ?

• No 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 Core ?

• High 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/OOP Max

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Conclusion
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Help is available

• Health Care Facilitator Program
• Guerren Solbach
• [phone] (Davis)
• [phone] (Sacramento)
• Erika Castillo
• [phone] (Davis)
• [phone] (Sacramento)

http//www.hr.ucdavis.edu/hcf
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Your UCMedical InsuranceAn overview for active
employees
Presented by Guerren Solbach