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Premium member Presentation Transcript Blue Cross Plus 101Tips for Employees: Blue Cross Plus 101 Tips for Employees Brought to you by the UCSF Health Care Facilitator Program HR Benefits/Financial Planning 2005 What’s the Plus in Blue Cross Plus? : What’s the Plus in Blue Cross Plus? Blue Cross Plus* is a Point of Service plan that gives members choice and flexibility Members can choose to receive health care services from: In-network providers HMO style, 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. How does the plan work?At your Point of Service you Choose to........: How does the plan work? At your Point of Service 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 in-patient No claim forms, no deductibles *Based on benefits, 2005 *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 Where can I find this information?: Where can I find this information? Almost all the information being covered today is outlined in your Evidence of Coverage (EOC) booklet, and I will be making numerous references to this document The EOC contains detailed information regarding what is and what is not covered by your medical plan You may download a copy from the Blue Cross website or call Blue Cross to request it www.bluecross.com/uc (888) 209-7975 In your handouts is an abbreviated form, which we generally refer to as a ‘grid’. Blue Cross PlusUtilizing theIn-Network Benefit Level: Blue Cross Plus Utilizing the In-Network Benefit Level Open Panel HMO What is an Open Panel HMO?: What is an Open Panel HMO? HMO stands for Health Maintenance Organization An open panel HMO is a Health Maintenance Organization that pays a medical group to maintain contractual agreements between doctors, labs, hospitals, and other providers or facilities in a specific geographical area How does it work?: 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 Blue Cross Plus, In-NetworkOpen Panel HMO: Blue Cross Plus, In-Network Open Panel HMO How do I Select a PCP/Medical Group?: How do I Select a PCP/Medical Group? 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/ Things to Consider whenSelecting a PCP/Medical Group : Things to Consider when Selecting a PCP/Medical Group 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? You should be aware that….. : You should be aware that….. You can change your Medical Group and/or PCP outside of open enrollment by contacting Blue Cross, (888) 209-7975 Usually, if you call by 15th of month, change effective 1st of next month 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 You should be aware that…..: You should be aware that….. 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 You should be aware that…..: You should be aware that….. 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 Bay Area Medical Groups’ participation in Blue Cross Plus Direct Access Program:: Bay Area Medical Groups’ participation in Blue Cross Plus Direct Access Program: YES Brown andamp; Toland John Muir/Mt. Diablo Marin IPA Sante Community Valley of the Moon This information subject to change, contact your medical group to determine participation in Direct Access – see blue handout for contact info. NO Alta Bates Cedars-Sinai Chinese Community Hills Physicians Mills-Peninsula You should be aware that…..: You should be aware that….. 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 You should be aware that…..: You should be aware that….. 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 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 Blue Cross PlusUtilizing theOut-of-Network Benefit Level: Blue Cross Plus Utilizing the Out-of-Network Benefit Level Blue Cross, Preferred Provider Organization (PPO) and Non-PPO Providers Blue Cross Plus,Out-of-Network: 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 What is a PPO?: 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 How do I find a PPO Provider?: 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 How do I find the ‘Contracted Rates’ for services from a PPO provider?: How do I find the ‘Contracted Rates’ for services from a PPO provider? 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 How are Usual, Customary and Reasonable Charges (UCR) Determined?: 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 To determine the UCR for services prior to receiving 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 What is Balance Billing?: 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 You should be aware that…..: You should be aware that….. 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 See bottom of page 3 on the Blue Cross Plus Grid, handout 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 You should be aware that…: You should be aware that… 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 Blue Cross PlusOut-of-Pocket Maximum2005: Blue Cross Plus Out-of-Pocket Maximum 2005 Blue Cross PlusBehavioral Health and Prescription Drugs Benefits: Blue Cross Plus Behavioral Health and Prescription Drugs Benefits What are theBehavioral Health Benefits?: 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 Members can choose to receive behavioral health care services from: in-network providers (UBH network) or non-network providers How does UBH work?: How does UBH work? In-Network - *Out-Patient Therapy You call UBH, (888) 440-8225 UBH refers you to a provider www.liveandworkwell.com, enter access code of 11280 You pay $0 co-pay for first 5 visits, then $10 for 6+ visits No claim forms, no deductibles Review EOC for in-patient care and substance abuse benefits *Coverage for services based on clinical necessity, substance abuse and inpatient care also covered, see 2005 EOC for additional details. Out-of-Network - *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) 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 Other Behavioral Health Resources: 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 What are the Prescription Drug Benefits? : 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 Blue Cross PlusPrescription Drugs, 2005: Blue Cross Plus Prescription Drugs, 2005 You should be aware that…..: You should be aware that….. Brand Name, Non-Formulary drugs If your physician writes 'Dispense as Written' (DAW) on the prescription, the lower brand name formulary co-pay will apply You should be aware that……..: You should be aware that…….. A small number of drugs require a Prior Authorization of Benefits (PAB) Ensures that patients receive medication appropriate for their condition Limits the use of expensive medications which might have 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’ Prior Authorization of Benefits(PAB) Process: 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 (48 hours) Letter stating outcome is mailed to both physician and member If physician or pharmacist conclude that member’s health is in serious and imminent danger, a 72 hour emergency supply of medication may be dispensed until a determination of coverage is made Have questions? Call (800) 700-2541 Blue Cross Plus and theBlue Cross PPO Plan: Blue Cross Plus and the Blue Cross PPO Plan The question asked most often……….. What’s the difference between Blue Cross Plus and the Blue Cross PPO Plan?: 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 Both plans provide coverage for services from PPO and non-PPO providers – the difference is in the cost for these services Blue Cross PlusYou remember this slide…………: Blue Cross Plus You remember this slide………… *In-Network – Open Panel HMO You select a PCP All care is coordinated through PCP Exception - Direct Access Programs, OB/GYN, You pay a $20 co-pay for most services, $250 for hospital in-patient No claim forms, no deductibles *Based on benefits, 2005 *Out-of-Network - PPO/non-PPO docs You self-refer for care After a $500 individual deductible ($1500 family) the plan pays 70% of UCR for most services or 70% or the contracted rate if there is one Self-referral to PPO providers means no balance billing Coverage World Wide Blue Cross PPO Plan The PPO Plan has no HMO networkno PCP – instead all self-referral: Blue Cross PPO Plan The PPO Plan has no HMO network no PCP – instead all self-referral *In-Network - Blue Cross PPO Providers You self refer to PPO provider After a $250 individual deductible ($750 family), plan pays 80% for most services Typically no claim forms needed for PPO providers Rates are contracted so there is no balance billing Coverage World Wide *Based on Benefits, 2005 *Out-of-Network - Non-PPO Providers You self-refer to a non-PPO provider After a $500 individual deductible ($1500 family), plan pays 60% of UCR for most services You may need to submit claim forms You are subject to balance billing Coverage World Wide Problem Solving: Problem Solving Tips for Blue Cross Plus Members Problem Solving: Problem Solving Write down your list of concerns before you make your phone call or visit Keep a log of communication Names of representatives you speak with Dates of calls Information provided to you What if you get a bill for a service?: 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 in-network 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 What if You Can’t Get a Timely Appointment With Your PCP?: 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 What if You are not Satisfied with theIn-Network Services You Need?: What if You are not Satisfied with the In-Network Services You Need? Request a Second Opinion – typically you may request a second opinion when….. The treatment plan in progress is not improving your medical condition, or; You are diagnosed with a condition that threatens loss of limb, body function, or; Your PCP or referral Physician is unable to diagnose your condition Note, your request is subject to approval and based on medical necessity Review your Evidence of Coverage (EOC) booklet for detailed information Questions? - Contact Blue Cross member services (888) 209-7975 What if You Receive a ‘Denial’ for a Covered Service?: 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 What if You Are Dissatisfied with the Plan’s Customer Service?: 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 What about health care servicesthat are not covered?: What about health care services 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 Maximum contributions of $5000 per individual annually Budget carefully, if you don’t use the money set as side, you lose it! Enroll each year during Open Enrollment Visit the benefits website for more information http://www.ucsfhr.ucsf.edu/benefits/info.html?x=1256 Administered by SHPS, Inc. www.shps.net (800) 678-6684 What if You Experience“Provider Disruption?”: What if You Experience 'Provider Disruption?' Provider Disruption is a term used when contracts between plans, medical groups, and/or providers are cancelled or not renewed What can you do? Follow your PCP to the new medical group Notify your health plan Select a new PCP Notify your health plan Use the out-of-network level of your plan Help is available!: 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 Help is available!: Help is available! Local Resources: Brown and Toland Medical Group (415) 553-6588 firstname.lastname@example.org 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 Help is available!: Help is available! For escalated problems you cannot solve on your own, contact: UCSF Health Care Facilitator Program Pamela Hayes, HCF, (415) 514-3324, email@example.com Susan Descalso, Assistant HCF, (415) 476-5269, firstname.lastname@example.org Handout: 'Health Care Facilitator Program' The EndPlease complete your pink evaluation form and leave it on the back table/desk: The End Please complete your pink evaluation form and leave it on the back table/desk Thank You for Participating You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.