blue cross plans… …when you have cross_vs_medicare.pdfpros/cons • medical coverage ......
TRANSCRIPT
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Choosing between Blue Cross
plans…
…when you haveMedicare
Presented Presented By Glenn RodriguezBy Glenn RodriguezHealthCare FacilitatorHealthCare Facilitator
UC IrvineUC Irvine
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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
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Medicare and UC
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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
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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
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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
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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
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Medicare and Blue Cross
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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
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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
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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
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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
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Wellness Programs
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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
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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
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•
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
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Plan Comparisons
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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
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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
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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
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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
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•
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
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•
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
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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
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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)
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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
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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
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Blue Cross PLUS w/ Medicare
•
In-Network Benefits (HMO)Medicare coordination
•
You pay copayment•
Medicare and Blue Cross pay the rest
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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
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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
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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
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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
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Blue Cross PLUS w/ Medicare
•
Prescription drug benefit90-day supplies for 2 copayments
•
From UC pharmacies•
Mail orderCertain drugs may require prior authorization
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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
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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
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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
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Blue Cross PPO w/ Medicare
•
Limits20-visit limit on outpatient, out-of-network behavioral health ($500 deductible)
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Blue Cross PPO w/ Medicare
•
Medicare coordination:Blue Cross pays 80% of balance after Medicare pays
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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
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Blue Cross PPO w/ Medicare
•
Prescription drug benefit90-day supplies for 2 copayments
•
From UC pharmacies•
Mail orderCertain drugs may require prior authorization
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•
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
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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
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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
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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
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High Option w/ Medicare
•
Medicare coordination: “coordination of benefits”
Plan pays 100% of balance after Medicare for most services
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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
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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
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Cost vs. Benefit
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Cost vs. Benefit
•
Compare the various plans’
total costsMonthly premiumConsider how the plans coordinate with Medicare:
•
Copays/deductibles/coinsurance•
Out-of-Pocket Maximums
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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
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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
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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
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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
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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
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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
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Cost vs. Benefit
Which plans cover benefits you are most likely to need?
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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
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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
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Cost vs. Benefit
Remember, you can always change plansduring a future Open Enrollment
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6161
Help is available
Health Care Facilitator ProgramGlenn Rodriguez
(949) 824-9065
Benefits Office(949) 824-5210
http://www.hr.uci.edu/hcf