1

Medicare Enrollment and Your UC Sponsored Medical Plan

Coverage

UCSF HR/Benefits

Health Care Facilitator Program 2007

2

Today’s Presentation

This presentation will provide information for individuals who:– Are currently, or will be, Medicare eligible– Have already retired from the University or will be

retiring soon– Are or will be eligible for UC sponsored retiree

medical insurance

3

Agenda

Will help you understand Medicare Will review UC policies regarding Medicare

enrollment Will explain how Medicare coordinates with

UC sponsored insurance to cover your medical expenses in retirement

Will highlight the steps to take to ensure enrollment is on track…and much more

4

Clarification Before We Start….

If you are currently working at UCSF (never retired) and covered by a UC medical plan and you (or your dependent*) are age 65 or older………

– You/your dependent may delay enrollment in Medicare until you retire, without penalty from Medicare and without penalty from the University

– We will discuss this issue in more detail in a few minutes

* Adult Dependent Relatives that become eligible for Medicare Part A may not continue their UC sponsored medical coverage.

5

Lets take a look at Medicare

6

QUIZ/FUN FACTS

In what year was Medicare established?

Who was the first individual to enroll in Medicare?

Which UC chancellor was instrumental in the establishment of Medicare?

What was the cost of the first Part B premium?

When were the first discussions held regarding adding prescription drug coverage to Medicare?

7

What is Medicare?

Medicare is a Federal Medical Insurance Program for:

– People 65 years of age and older regardless of their income or medical history

– In 1972 Medicare was expanded to include the following groups:

People with Some people with disabilities under age 65 End-Stage Renal Disease (permanent kidney failure requiring

dialysis or transplant)– In 2000, individuals with Lou Gehrig’s Disease (amyotrophic

lateral sclerosis) could enroll at time of diagnosis (rather than having to satisfy the 24-month waiting period

8

Medicare Coverage

Part A– Hospital Coverage

Part B– Medical Coverage

Part C– Medicare Advantage Program

Part D– Out-Patient Prescription Drug Coverage – began in 2006

9

Part A – Hospital Insurance

    Hospital Stays    Skilled Nursing Facility    Hospice    Home Health Care Some Other Services

Cost in 2007: FREE, if you’ve paid Medicare taxes for a total of 10 years or more. (Individuals may also qualify based on the work history of a spouse or a former spouse.

10

Part B - Medical Insurance

   Physician Services

    Outpatient Hospital Care

    Lab Tests

    Durable Medical Equipment (DME)

    Physical, Occupational and Speech Therapy

    Some Other Services

Cost in 2007: Income based – see handout

All U.S. citizens and lawfully admitted non-citizens with at least five

years of residency, age 65 or older, are eligible to enroll in Part B.

11

Part C – Medicare Advantage Program

Beneficiaries may enroll in a private managed care plan (HMO, PPO or PFFS)

These plans offer combined coverage of Part A, Part B and in most cases Part D

12

Part D – Prescription Drug Insurance

Coverage for Out-Patient Prescription Medication Coverage Varies by Plan - monthly premiums in

2006 averaged $25 across plans

For UC retirees enrolled in a UC sponsored medical plan that includes Part D coverage, there is no additional cost for the coverage.

All Medicare members eligible for Medicare A and/or B are eligible for Medicare Part D.

UC plans are all considered ‘Creditable Coverage’

13

Gaps in Medicare Coverage

If you had only Medicare insurance you would experience large gaps in coverage requiring significant out-of-pocket expenses

Your UC medical plan coverage coordinates with Medicare to reduce these gaps and decrease your out-of-pocket expenses

14

Gaps in Medicare Coverage

   Part A Gaps $992 deductible per hospital admittance/benefit

period Large co-pay for extended hospital inpatient stays

(days 61 to 90 = $248 per day and )

    Part B Gaps $131.00 deductible per year Part B pays at 80%, which means you pay 20% co-

insurance for most Part B covered services

15

Gaps in Medicare Coverage

Services Not Covered by Medicare– Care Outside U.S. – Hearing Aids– Eye care

– See www.medicare.gov for entire listing of exclusions

16

Lets take a look at the UCMedicare Enrollment Policy

17

UC’s Medicare Enrollment Requirements for Retirees

UC requires that you/your dependents enroll in Medicare Part B when you/your dependents become eligible for premium free, Medicare Part A **

– You/your dependents are transferred into the ‘Medicare-coordinated’ version of the plan

You/your dependents do not need to enroll in a non-UC sponsored Medicare Part D plan

– In most cases your plan will enroll you in Medicare Part D***

** Adult Dependent Relatives that become eligible for Medicare Part A may not continue their UC sponsored medical coverage.

*** Kaiser Mid-Atlantic and New Mexico United Health Care plans do not coordinate with Medicare Part D, so no enrollment is initiated or required.

18

UC’s Medicare Enrollment Requirements for Retirees

If you are enrolled in an Health Maintenance Organization plan (HMO) -- Health Net, Kaiser, PacifiCare, or WHA -- Medicare Parts A, B and D must be ‘assigned/locked’ into the plan

– You cannot use Medicare outside the plan

19

UC’s Medicare Enrollment Requirements for Retirees

Retirees and their dependents risk de-enrollment from UC sponsored medical coverage if they….

– Do not enroll in Medicare Part B when eligible for premium free Medicare Part A

– Enroll in a non-UC sponsored Medicare Part D plan

– Are HMO members that do not assign/lock Medicare to the plan and/or use Medicare outside of the plan

20

Exceptions to UC Medicare Mandate

Retirees that didn’t pay Medicare taxes are usually not eligible for premium free Medicare Part A

– UC does not require retirees not eligible for premium free Medicare Part A, to enroll in Part B.

These retirees may continue with their current non-Medicare medical plan.

– Please note however, that a retiree may qualify for premium free Medicare Part A through a spouse or former spouse. Contact Social Security, 1-800-772-1213

If you are eligible for premium free Medicare Part A, UC Part B and Part D enrollment policies apply.

21

Exceptions to UC Medicare Mandate

UC does not require you to enroll in MedicarePart B if:

– You reside outside the United States you must enroll in Medicare if you return You may incur a penalty from Medicare when you re-enroll

– You are still working at UCSF and have health coverage as an employee (never retired from UC)

– You have UC sponsored health coverage through your spouse or domestic partner who is still working at UC

22

Why UC MandatesMedicare Enrollment

Retirees over age 65 without Medicare cost at least twice as much to insure as those with Medicare

Enrollment in Medicare partially reduces the cost of the plan, which keeps the UC premiums affordable for all

Allows UC to continue to fund health benefits for retirees

– Many employers are dropping or reducing retiree health coverage

23

Medicare Enrollment Chart

If you don’t know if you are eligible for Medicare, contact Social Security– 1-800-772-1213

Remember if you don’t qualify on your own, you may qualify through a current or former spouse

If you don’t qualify now but continue to work you may qualify in the future

24

Medicare Enrollment Next Steps…

Lets Review the Medicare Enrollment Chart (handout)

Determine which status best fits your personal circumstances

Review the UC requirements Follow the action steps to ensure compliance

with UC policy

25

Tips for Enrolling in Medicare

If you will be, or are retired, when you reach age 65, apply for Medicare three months before your reach age 65.

If you are receiving SS benefits at the time, you will automatically be enrolled in both Part A and Part B and a Medicare card will be sent to you about 3 months before your birthday.

If you are not receiving SS benefits you will need to initiate enrollment into Medicare yourself.

26

Tips For Enrolling in Medicare

Approximately 3 months prior to your 65th birthday UC will send you the following documents (if you are retired):

– UC Medicare Declaration Form– Universal Medicare Advantage Form

UCOP will transfer your medical plan enrollment to the Medicare version of the plan once they receive your documents and adjust your plan premiums as indicated

Your family members enrolled as dependents who are not eligible for Medicare will remain in the basic non-Medicare version of the plan

27

“Period of Darkness”

There is usually a three week period of transition from a non-Medicare plan to the Medicare version of the plan

During this time period it can appear that your coverage has been terminated. It hasn’t!

If you experience problems obtaining medical care or accessing your pharmacy benefits during this time, call your Health Care Facilitator

28

Lets take a look at UC Sponsored Health Plans and how they Coordinate

with Medicare

Information based on coverage for plan year, 2007

29

Medicare vs. Non-Medicare Plans

All the UC medical plans have a separate “Medicare -coordinated” version

When you become eligible for Medicare you will coordinate your current medical plan with Medicare. You may change your plan during OE, during a new PIE or if the Medicare version of your current plan is not available in your service area

The Medicare-coordinated version of a plan may differ in:– Plan benefits– Costs– Service area– Network providers– Enrollment/de-enrollment process

30

Medicare Coordination withHMO plans (Medicare Advantage Plans)

Information based on coverage for plan year, 2007

31

Medicare Coordination withHMO plans (Advantage Plans), 2007

Kaiser Senior Advantage Health Net Seniority Plus PacifiCare Secure Horizons Western Health Advantage Care +

– Available in the Sacramento service area only

32

Medicare Coordination withHMO plans (Advantage Plans)

You must live in the plan’s CA service area You assign your Medicare benefits to the HMO*

– You must complete forms with UC and your plan

Medicare pays a flat fee to the HMO each month - the HMO agrees to accept full responsibility for your care

You pay a low monthly premium

*You cannot use Medicare outside the plan

33

Medicare Coordination withHMO plans (Advantage Plans), 2007

You select a primary care provider (PCP) to coordinate your care though your medical group

– PCP must be within 30 miles of your home address – Preauthorization required for many services– Referrals are limited to providers within the medical group

You pay a small co-pay when you receive services– $15 physician services– $250 hospital inpatient– $10, $20, $35, Prescription drug filled at network retail

pharmacy

No need to submit claim forms

34

Medicare Coordination withBlue Cross Plans

Information based on coverage for plan year, 2007

35

Medicare Coordination withBlue Cross Plans, 2006

High Option Supplement to Medicare Blue Cross PPO (Preferred Provider

Organization) Blue Cross Plus POS (Point of Service Plan)

– Includes in-network (HMO), and out-of-network coverage

– Must live in the CA service area

Blue Cross Core

36

Medicare Coordination withBlue Cross Plans, 2006

You may see any Medicare provider*– Find doctors using the Participating Physician Directory

online at: http://www.medicare.gov

Medicare pays as primary

Each plan has an annual deductible* - Once the deductible is met, Blue Cross coordinates their payment after Medicare pays, to cover a percentage of your expenses

*Exceptions – Blue Cross Plus in-network

37

Medicare Coordination withBlue Cross Plans – Medicare Terms

Provider Accepts Assignment– Provider will accept Medicare contracted rates for services

Provider Does not Accept Assignment– Provider can charge up to 15% above Medicare contracted

rates

Provider Opts Out of Medicare or Does Not Have a Medicare Contract

– Claims from a provider that has opted out of Medicare or from a provider without a Medicare certificate number will not be paid by Medicare and will not be paid by your UC sponsored health plan

38

Medicare Coordination Supplement

The next 4 slides provide examples of how Blue Cross coordinates its payment after Medicare pays for covered services

Review the Medical Benefits Summary: 2007 (for members with Medicare) for additional examples

39

Medicare Coordination High Option Supplement to Medicare

Medicare pays as primary

Generally, the plan pays the difference between the amount Medicare pays and the medical plan’s reasonable and customary charge for services

Medicare pays 80% of allowable; plan pays the balance; retiree pays nothing

The plan covers Medicare deductibles

$50 annual deductible applies for some services not covered by Medicare

40

Medicare CoordinationBlue Cross PPO

Medicare pays as primary

After a $100 individual deductible, Medicare pays 80% of Medicare allowable; plan pays 80% of the balance; you pay the remaining balance

41

Medicare CoordinationBlue Cross Plus

In-Network You select a PCP All care is coordinated

through PCP You pay co-pay of $20 for

most services, $250 for hospital in-patient

Medicare and the plan coordinate benefits behind the scenes

Seamless to member

Out-of-Network Medicare pays as primary After a $500 individual

deductible the plan compares its benefit (70% of UCR) to what Medicare has already paid and pays the difference if any

42

Medicare Coordination Blue Cross Core

Medicare pays as primary

After a $100 deductible the plan will compare its benefit (80% of URC) to what Medicare has already paid and pay the difference if any

43

Things to Consider in a Health Plan

Your total annual health plan costs:– Services that are and are not covered– Medicare and UC Health Plan Premiums– Deductibles and Co-insurance

Include both medical, prescription drugs and behavioral health

– Factor in your Out-of-Pocket Maximum (OOPM) protection

If your co-pays, co-insurance and deductibles paid equal your OOPM, additional care in the plan year for covered expenses is paid at 100% - review the plan for excluded items

44

Things to ConsiderOut-of-Pocket Maximums, 2007

Plan Kaiser Senior Advantage

Health Net Seniority Plus

PacifiCare Secure Horizons

WHA Care +

Medical $1500 $0 $0 $1000

Prescription Drugs

$3850 $2000 $2000 $3850

Per Individual AnnuallyPer Individual AnnuallyReview EOC for LimitationsReview EOC for Limitations

45

Things to ConsiderOut-of-Pocket Maximums, 2007

Plan High Option

PPO Plus

In-Network

Plus

Out-of-Network

Core

Medical $1050 $1500 $1500 $5000 $1260

Prescription Drugs

$1000 $3850 $3850 $1000

Per Individual AnnuallyPer Individual AnnuallyReview EOC for LimitationsReview EOC for Limitations

46

Things to Consider - HMO PlanPrescription Drug Co-Pays, 2007

RxKaiser Senior

Advantage

Health Net

Seniority Plus

PacifiCare Secure

Horizons

WHA Care +

Retail

30 Day Supply

Generic - $10

Brand - $20

(Up to 100

day supply)

Generic - $10

Brand - $20

Non-

Formulary - $35

Generic - $10

Brand - $20

Non-

Formulary - $35

Generic - $10

Brand - $20

Non-

Formulary - $35

Mail Order 90

Day Supply

Can be arranged

Generic - $20

Brand - $40

Non-

Formulary - $70

Generic - $20

Brand - $40

Non-

Formulary - $70

Generic - $20

Brand - $40

Non-

Formulary - $70

47

Things to Consider - Blue Cross Prescription Drug Co-Pays, 2006

Rx High Option PPO PLUS Core

Retail 30 Day

Supply

Generic - $15

Brand - $25

Non-

Formulary - $40

Generic - $15

Brand - $25

Non-

Formulary - $40

Generic - $15

Brand - $25

Non-

Formulary - $40

Generic - $15

Brand - $25

Non-

Formulary - $40

Mail Order 90

Day Supply

Generic - $30

Brand - $50

Non-

Formulary - $80

Generic - $30

Brand - $50

Non-

Formulary - $80

Generic - $30

Brand - $50

Non-

Formulary - $80

Generic - $30

Brand - $50

Non-

Formulary - $80

48

How much will my medical plan cost?

If you began work at UC prior to 1/1/90 and did not have a break in covered service for more than 120 days, you will receive 100% of UC’s maximum contribution toward the medical monthly premium. You will still pay the employee/retiree portion of the cost

If you began work on or after 1/1/90 you will be subject to graduated eligibility. You will receive a percentage of UC’s maximum contribution. Your percentage corresponds to your years of UC service credit. In addition, you will still pay the employee/retiree portion of the cost

49

Part B Reimbursement

Reimbursement for Part B may apply if UC’s contribution for a plan is greater than the gross premium

Maximum reimbursement currently is $93.50 per person

50

Additional ConsiderationsChanging Plans…..

Open Enrollment (OE) When you retire you will continue to have the option to change

plans during November Open Enrollment, the change will be effective the first of the following January

Move Out of the Service Area If you move out of your plan’s service area you will have a

‘Period of Initial’ eligibility to switch plans outside of Open Enrollment

Process: Call UCOP customer service, alert them of your new address. The rep will mail you a form so you can select a new plan. If the form is returned to UCOP by the 15th of the month, typically the change is effective the first of the following month

– UCOP Customer Service 1-800-888-8267

51

Additional ConsiderationsChanging Plans

Plan options if you move outside California– Blue Cross PPO, High Option Supplement to

Medicare, and Core– A few other plans are available but have limited

service areas

Plan options if you move outside the U.S.– Blue Cross PPO, High Option, and Core

Will switch to Non-Medicare version of plan Higher premiums, different coverage levels

52

Additional ConsiderationsChanging Plans

Use the Medical Plan Wizard to find the medical plans available in your service area– You will need a zip code– http://mars.mcr-inc.com/01291/index.php

– Always call the plan for the most current information because service areas are subject to change

53

Additional ConsiderationsReemployment after Retirement

The University has some very specific policies which must be followed if you decide to return to work after retirement

Today I will only be addressing issues related to medical coverage for UC rehired retirees with Medicare

54

Additional ConsiderationsReemployment after Retirement

The threshold for employee medical coverage eligibility is an appointment of 43.75% or more

If your re-appointment makes you eligible for UC’s employee medical coverage, Medicare Secondary Payer law requires that Medicare no longer be a primary payer for you and your eligible family members

To comply with this regulation, UC requires you to enroll in the non-Medicare version of your plan with Medicare as the secondary payer

– The University will require you to continue your Medicare Part B enrollment

In some cases you may be required to suspend (cancel) your retiree health coverage and enroll as an employee

Your medical plan monthly premium will likely increase and if you are receiving a Part B reimbursement it will stop

55

Additional ConsiderationsReemployment after Retirement

To avoid Medicare Secondary Payer law issues, ensure that you are re-appointed at no more than 43.74% time

For more information:– Review page 3 of the Medicare Factsheet in your handouts– Review the ‘Returning to UC Employment After Retirement’

Factsheet and Waiver Available on the ‘At Your Service’ website, under ‘Forms and

Publications’, http://atyourservice.ucop.edu/

56

Tips for Planning Ahead

Read Open Enrollment materials each year to track changes in coverage

Stay informed of general developments in Medicare and medical insurance

Use your UC online resources for retirees– UC ‘At Your Service’ Website

http://atyourservice.ucop.edu/ – UCSF HCF Website

http://ucsfhr.ucsf.edu/benefits/hcf

57

Tips for Planning Ahead

Use your Medicare resources• www.medicare.gov -• Medicare General Information – 1-800-633-4227• Social Security – 1-800-772-1213• Health Insurance Counseling and Advocacy Program

(HICAP) – 1-800-434-0222 Still have questions?

– UC Retiree, Health and Welfare - 1-800-888-8267– Contact Your Health Plan – UCSF Health Care Facilitator (HCF) Pgrm – (415) 514-3324

sforstat@hr.ucsf.edu

58

Lets Review

What do you remember…….

59

Quiz

1. Medicare Part A provides coverage for….?a. Physician visits

b. Prescription drugs

c. In-patient hospital care

d. All of the above

e. None of the above

60

Quiz

2. Medicare Part B provides coverage for….? a. In-patient hospital care

b. Prescription drugs

c. Physician visits

d. All of the above

e. None of the above

61

Quiz

3. Medicare provides coverage for medical services received both inside and outside of the U.S.?

a. True

b. False

62

Quiz

4. UC requires UC retiree health plan members, eligible for premium free Medicare Part A, to enroll in Medicare Part B if they would like to continue UC sponsored health care coverage?

a. True

b. False

63

Quiz

5. The Medicare coordinated Blue Cross PPO plan provides coverage for services from…?

a. Blue Cross PPO providers only

b. Medicare providers only

c. Any credentialed physician

d. None of the above

64

Quiz

6. Retirees enrolled in a UC sponsored HMO Medicare Advantage plan may use their Medicare benefits outside their HMO which provides flexibility and choice?

a. True

b. False

65

QUIZ

7. All UC employees must enroll in Medicare by the time of their 65th birthday or they will be de-enrolled from their UC sponsored medical plan?

a. True

b. False

66

Questions???????????

This is a complicated subject! Review the written materials Be sure to use your on-line resources Contact the UCSF Health Care Facilitator

Program with any individual questions or concerns

67

The End

Please complete the evaluation form

THANK YOU FOR PARTICIPATING!

Presentation materials, along with additional information about Medicare, will be available on the

Health Care Facilitator website at: www.ucsfhr.ucsf.edu/hcf