11/3/1111
Open Enrollment HighlightsLaura MorganUCSB Human Resources, Benefits
This presentation is intended for communication purposes only. Please see plan document and http://atyourservice.ucop.edu for complete information.
Big changes New choices
11/1/2013
Updated 11/22/13
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Open Enrollment
• Ends Tuesday, November 26, 5:00 pm
• Make changes onlinehttp://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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Collective Bargaining
• For unions in “status quo” or “reopeners” the following may not change:
◊ Monthly contribution rates for plans◊ Payband levels
An individual’s MCB can go up or down
• Monthly employee contributions for the new 2014 medical plans will be the same for all participants
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Review Options for 2014atyourservice.ucop.edu/
oeBooklet
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Medical Plan ChooserLink from Open Enrollment website:http://atyourservice.ucop.edu/oe/medical
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Big Changes, New Choices
• Comprehensive review of UC's medical plan portfolio
• Ensure good benefits while limiting cost increases for employees and the university
• Maintain choices to address individual needs
• Opportunity to leverage UC's medical centers
• Respond to health care reform and a changing medical-insurance marketplace
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2014 Medical Plans
2013 2014
Anthem PPO UC Care PPO(administered by Blue Shield)Anthem PLUS
Anthem Lumenos HRA-PPOBlue Shield
Health Savings Plan (PPO)
Health Net Blue & Gold HMO Health Net Blue & Gold
HMOHealth Net HMO
Kaiser HMO Kaiser HMO
Core Core
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Default Medical Plans2013 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
Medical Plan Design 101
HMOPPOPOS
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HMO – Health Maintenance Organization
• Care is delivered by physicians in a “medical group” (e.g. Sansum, SB Select IPA)
• Care is coordinated by Primary Care Physician and medical group
• Member selects PCP, PCP refers to specialists
• Set copay for most services, no deductibles
• Emergency and urgently needed care when away
Health Net Blue & Gold HMOKaiser HMO
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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
JanuaryCalendar Year
December
Deductible
You pay
CoinsuranceCopay
You share cost with plan
Out-of-Pocket
Maximum
Plan pays 100%
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Allowed Amount – In Network
In-Network Example
Discounted rate that plan negotiates for each service with “preferred” or participating providers
• You pay the in-network coinsurance on the discounted rate.
• Provider can’t “balance bill”
Coinsurance 20%
Provider charge: $200Allowed amount: $100
Plan pays 80%: $80
You pay 20% $20
Provider write-off:$100
PPO plans negotiate “allowed” rates to process claims.
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Allowed Amount – Out of Network
Out-of-Network Example
Value that plan assigns to a service when provider is NOT a “preferred provider” (not participating)
• Plan pays out-of-network coinsurance on the allowed amount.
• Provider can “balance bill”
Coinsurance 50%
Provider charge: $200Allowed amount: $100
Plan pays 50%: $50(50% of $100)
You pay 50%: $50
You pay balance: $100
PPO plans assign “allowed” rates to process claims.
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Claims, EOBs & Bills
You receive servicesYou pay nothing at the time of service for in-network care
Provider sends claim for services to health plan
Health plan sends EOBExplanation of Benefits (EOB) outlines allowed charges, deductible and co-insurance. This is not a bill.
Provider sends billThe 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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Learn more about PPOs
Fair Health Consumerhttp://www.fairhealthconsumer.org/• Estimate cost of medical procedures• “LEARN” tab – print and video resources
◊ How plans work◊ Cost Sharing, know what you may owe
Good Rx• http://www.goodrx.com• Estimate cost of drugs (for Blue Shield
HSP)
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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
Physician• Specific
physician• More choice of
physicians and facilities
Cost• Monthly cost • Predictable
copays
What is your priority?
2014 Medical Plans
Health Net Blue & Gold HMOKaiser HMO
UC CareBlue Shield Health Savings Plan
Core
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Residence LimitationsHMO (Health Net, Kaiser)
• Employee must live in California
• PCP must be within 30 miles of where you live or work (in most cases)
Blue Shield Health Savings• Employee must live in US
• Employee may live anywhere
• Worldwide services
CORE
UC Care
• Employee may live anywhere
• Worldwide services
• Employee may live anywhere
• Worldwide services
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When traveling out of USHMO (Health Net, Kaiser)
• Limited to emergency and urgent care only
• No routine care
Blue Shield Health Savings• Limited to emergency and urgent care only
• No routine care
• Comprehensive coverage
• Plan pays Preferred benefit.
CORE
UC Care
• Comprehensive coverage
• Plan pays out-of-network benefit.
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Health Net
• Full Network HMO is being discontinued◊ In Ventura County, some medical groups will
no longer be available to Health Net members◊ Employees should consider UC Care or Kaiser
HMO
• Health Net Blue & Gold HMO will continue with few benefit changes◊ In Santa Barbara County, all HMO medical
groups participate in Blue & Gold◊ In Ventura County, not all HMO groups
participate
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Health Net Blue & Gold HMO
• You select a Primary Care Physician (PCP) to coordinate your care
• PCP refers you to specialists• Predictable copays for services:
◊ $20 office visit◊ $20 urgent care◊ $75 emergency room (if not admitted)◊ $100 outpatient surgical center◊ $250 hospital (in-patient)
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Kaiser HMO
• Kaiser will continue in Ventura County• You select Kaiser PCP• PCP refers you to Kaiser specialists• Predictable copays for services:
◊ 20 office visit◊ $20 urgent care◊ $75 emergency room (if not admitted)◊ $100 outpatient surgical center◊ $250 hospital (in-patient)
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UC Care – New PPO
• New self-funded PPO plan• Created for UC employees and non-
Medicare retirees• UC Medical Centers are part of the
“UC Select” network of providers• No PCP, no referral required for
specialist
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UC Care PPO
• Customized for UC Care• UC Health System + Select Blue Shield
providers
UC Select Providers
• Similar to the standard in network cost-share of the previous Anthem PPO plan
Blue Shield Preferred Providers
• Flexibility to use services from any provider outside the UC Select or Blue Shield Preferred network
Non-Preferred Providers
Blue Shield of California – claims administrator & network
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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 or any physician out of
US
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UC Select Network near UCSB
• UC Select providers in◊ Santa Barbara – Sansum Clinic◊ Santa Maria◊ Lompoc◊ Ventura
• Currently, Sansum Clinic is the only UC Select providers in Santa Barbara area◊ High cost hospital and medical groups◊ Still negotiating
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Blue Shield Preferred at UCSB
• 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
Provider directory: blueshieldca.com/uccareppo
or link fromhttp://uc-care.org/
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UC Care – Cost of Care
• Your costs depend on the service and the network status of the provider
• UC Select – no deductible, copays for most services but not all
• Blue Shield Preferred – deductible and you pay 20% coinsurance for most services
• Non-Preferred – deductible and plan pays 50% of allowed rate
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Deductible, Coinsurance, OOPM
You pay You share cost with plan
Plan pays100%
$250Deductibl
e20% Coinsurance $3000
OOPM
UC CareIndividual Coverage
Blue Shield Preferred (Tier 2)
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Deductible: Individual vs Family
$250 Individual / $750 Family
Coinsurance
Adult 1 Paid $250 20%Adult 2 Paid $100
Child 1 Paid $ 75
Child 2 Paid $250 20%
Adult 2 Paid $175 20%
20%
UC Care ExampleFamily Deductible
Blue Shield Preferred (Tier 2)
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UC Care – Emergency Room Example
• There are two charges for emergency care with a PPO plan design:◊ “Facility” – billed by the hospital◊ “Professional” – billed by the ER
physicians
• Emergency Room Visit (not admitted)◊ Emergency room: $100 per visit◊ Emergency physician services: 20%◊ Same coverage across all provider
networks
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More information about UC Care
Shield ConciergeBlue Shield/UC dedicated line
1-855-201-2087M-F, 7 to 7
http://uc-care.org/
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Blue Shield Health Savings Plan
Blue Shield PPO +
High deductible medical plan paired with a Health Savings Account
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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Blue Shield PPO
• You direct your own care, you decide where to receive services
• Medical and drug expenses apply to deductible and Out-of-Pocket Maximums (OOPM)◊ No separate drug plan with copays
• Family members share same deductibles and OOPMs
• Networks:◊ Blue Shield Preferred ◊ Non-Preferred Providers
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Deductible, Coinsurance, OOPM
You pay You share cost with plan
Plan pays100%
$1250Deductibl
e20% Coinsurance $4000
OOPM
Blue Shield Health Savings Plan Individual (Single)
Preferred Providers
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Deductible, Coinsurance, OOPM
You pay You share cost with plan
Plan pays100%
$2500Deductibl
e20% Coinsurance $6400
OOPM
Blue Shield Health Savings Plan Family
Preferred Providers
The full family deductible must be met before plan shares costs
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Blue Shield Health Savings Plan
Blue Shield PPO +
High deductible medical plan paired with a Health Savings Account
Health Savings Account
• HSA deposits are not taxes• HSA funds roll over from year to year• Tax-free interest earned• You keep the money even if you change
jobs or insurance plans
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Health Savings Account
• Health Equity manages the HSA
• UC makes annual contribution for plans that start on January 1.
◊ UC contribution is pro-rated for mid-year enrollments
• You may contribute through payroll deductions
• Use account to pay for eligible health expenses (medical, dental, vision, etc)
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Employees can maximize savings
• UC Contribution (1/1/14) ◊ $500 individual ◊ $1000 family
• 2014 Maximum Contributions allowed by IRS◊ Single-coverage: $3,300◊ Family-coverage: $6,550◊ Catch-up contribution, age 55+: $1,000
Tip: Contribute the money you would have put in your Health FSA.
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Lumenos and Blue Shield HSP
• 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.
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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
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“Seamless Consumer Experience”
• Blue Shield and Health Equity share information
• Employee receives welcome kit and live debit card
• Use the “smart card” to pay for eligible health expenses
• Can track and pay claims on Blue Shield website
• Invest HSA dollars when account balance reaches $2000 – no fees to invest
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For more information
Health Equity Member Services is available every hour of every day:
Call the Blue Shield/UC dedicated line 1.855.201.8375
say“Health Savings Account”
http://www.healthequity.com/ed/uc
http:// www.blueshieldca.com/uc (select "go" in the health savings plan
section)
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CORE
• High deductible PPO • Administered by Blue Shield• $3000 deductible per individual• Out-of-pocket Maximum is decreasing 2013: $7,600 per individual
2014: $6,350 individual / $12,700 family
• Blue Shield PPO and non-PPO providers• Behavioral Health by Blue Shield PPO
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Prescription Drugs
HMOUC Care
Blue Shield HSP CORE
Retail (30 day)• Generic• Brand• Non-formulary
$5$25$40
After you satisfy the deductible, you pay 20% at preferred pharmaciesMail Order (90
day) • Generic• Brand• Non-formulary
$10$50$80
Preferred Drug List (Formulary) is different for each carrier
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Rx – Mandatory Generic Drugs
Health Net & UC Care• Generic drugs will automatically be dispensed• Brand name drugs when generic is
available will cost the member more◊ $5 generic copay + (brand price – generic
price)• Brand name is available if “medically
necessary”◊ e.g. Allergic to inactive ingredient◊ Requires prior authorization from plan◊ DAW, DNS does not = medical necessity
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Rx – Mandatory Generic Drugs
Core & Blue Shield Health Savings Plan• Generic drugs will automatically be dispensed• Brand name drugs when generic is available
will cost the member more◊ Generic coinsurance + (brand price – generic price)
• Brand name is available if “medically necessary”◊ e.g. Allergic to inactive ingredient◊ Requires prior authorization from plan◊ DAW, DNS does not = medical necessity
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Nicotine Replacement Therapy
• All UC Medical Plans continue to provide RX for smoking cessation at $0 cost (e.g., Chantix, Zyban)
• Over the Counter NRT covered at $5 (generic copay)
OTC = Gum – Patch – Lozenge
Doctor’s Prescription Required
Kaiser Only - $0 Copay for both RX and OTC products
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Optum – Behavioral Health
All medical plans, except CORE, use Optum therapists, psychologists and psychiatrists for in-network care.
• Health Net Blue & Gold and Kaiser◊ In-network benefit
• UC Care, Blue Shield Health Savings Plan◊ In-network and out-of-network benefit
• Core◊ In-network with Blue Shield clinicians
and out-of-network benefit
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Transition / Continuity of Care
• All plans provide temporary transition or continuity of care service so members may complete a course of treatment and arrange for a safe transfer from a non-plan provider.
• Members who lost their current coverage due to plan disruption and were required to enroll in another health plan, AND are currently receiving services may be eligible for transition of care assistance.
• Please call member services to discuss your situation.
Other Plans & Programs
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Delta & Vision
DeltaCare USA Added Benefits
◊ Procedures to assess the level of risk associated with dental decay
◊ Gingival irrigation, a procedure to treat gums with medical solutions for health purposes
Vision Service PlanDiabetic Eye Care Plus Program
◊ Now extended to cover both Type I & II Diabetic members.
◊ Provides diabetic eye exam in addition to the routine vision examination ($20 copay)
Retiree Vision open for Enrollment
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Legal Plan
• Closed to new enrollment• Current members will continue
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Flexible Spending Accounts
Health Flexible Spending Account• Enroll or re-enroll in Health FSA• Annual limit is $2,500 • Blue Shield HSP members CANNOT enroll in a
Health FSA Dependent Care Account• Enroll or re-enroll in DepCare FSA• Annual limit remains at $5,000 ($2,500 if
married and filing a separate tax return)
YOU MUST
RE-ENROLL
EACH YEAR
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New Wellness Program
• New program – branded as UC Living Well
• New provider – Optum• Increased employee eligibility
More information in 2014
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Family Member Eligibility Verification
• Employees adding family members during Open Enrollment will be required to verify the eligibility of those family members with SECOVA
• Employees who have previously verified their family members should NOT need to re-verifyeligibility
◊ If an employee receives a request from SECOVA for a previously verified family member, please ask him/her to call SECOVA at 1-877-632-8126
http://atyourservice.ucop.edu/family-member-verification/
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ACA & Covered California• Employees covered by or eligible for UC Benefits,
don’t need to take action in the new health Affordable Care Act insurance marketplace.
• Covered California is the ACA marketplace in CA https://www.coveredca.com/
• Employees can explore options with Covered California if:◊ They are not eligible for UC-sponsored benefits◊ They have family members who age out or are
no longer eligible for UC plans