Choosing between Blue Cross plans… : Choosing between Blue Cross plans… …when you have
Medicare Presented by Guerren Solbach
UCD/UCDHS Health Care Facilitator Program
December 13, 2007
Agenda : Agenda Medicare and UC
Medicare and Blue Cross
Plan Comparisons
Pros/Cons
Medical coverage
Coordination with Medicare
Mental health coverage
Rx coverage
Cost vs. Benefit
Medicare and UC : Medicare and UC
Medicare and UC : Medicare and UC Medicare is the federal health insurance program for those over 65 and some disabled
Part A (premium-free for most)
Part B ($93.50/month in 2007)
Costs more if you make more than $80K/year ($160K for couples)
UC relies on Medicare to offset the cost of retiree medical insurance
Retirees without Medicare cost 3 times more to insure
UC’s Medicare Requirements : UC’s Medicare Requirements UC requires retirees and their family members to enroll in Medicare Part B:
If enrolled in medical insurance
If eligible for Part A free of charge
Failure to comply may result in the loss of UC-sponsored medical coverage
Exceptions:
Retirees who reside outside of the U.S.
Those who retired prior to July 1, 1991
Medicare Part D : Medicare Part D New drug benefit as of 2006
Subsidizes medical plan premiums
The Rx coverage of most UC medical plans is equivalent to or better than Part D
Considered creditable coverage
Medicare Part D (cont.) : Medicare Part D (cont.) Retirees will automatically be enrolled in Part D by their medical plan
No additional Part D premium
Retirees do not need to do anything to enroll
Exception: double coverage
Enrollment in a non-UC Part D plan will result in loss of coverage
Medicare and Blue Cross : Medicare and Blue Cross
Blue Cross Plans : Blue Cross Plans UC offers 4 Blue Cross of CA medical plans:
Core Medical
Blue Cross PLUS
Blue Cross PPO
High Option
Rely upon “Evidence of Coverage” booklets for detailed plan information:
http://www.bluecrossca.com/uc
Call Blue Cross at 1-888-209-7975
Blue Cross Plans w/ Medicare : 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 Medicare
No “private contracts”
If Medicare will not pay a claim because the provider is not part of Medicare, then Blue Cross will not pay
About Medicare Providers… : 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
Blue Cross Plans w/ Medicare : Blue Cross Plans w/ Medicare Medicare Crossover program
To activate, call Blue Cross with your Medicare number and Part A/B effective dates
Blue Cross will be able to access your Medicare EOBs (Explanation of Benefits)
No need to resubmit claims after filing with Medicare
Plan Comparisons : Plan Comparisons
Wellness/DM Programs : Wellness/DM Programs Wellness programs:
Discounted fitness, massage therapy, yoga, weight loss, etc.
Educational classes through local medical groups
Today’s Health & Wellness magazine
Disease management programs:
Asthma/diabetes/congestive heart failure/cancer (chemotherapy)/musculoskeletal disorders
Tobacco cessation
Core Medical w/ Medicare : Core Medical w/ Medicare Fee-for-Service plan
No net premium (full Medicare Part B reimbursement)
Core Medical w/ Medicare : Core Medical w/ Medicare Pros
Access any Medicare provider
Deductible: $100
Chiropractic/acupuncture coverage
Out-of-Pocket maximum: $1,260
Separate Rx Out-of-Pocket Maximum: $1,000
Lifetime maximum benefit: $2,000,000/person
Core Medical w/ Medicare : Core Medical w/ Medicare Cons
$2,260 out-of-pocket maximum
Hearing aids/exams not covered
Behavioral health not covered
Skilled nursing facility limit: 120 days per calendar year
Core Medical w/ Medicare : 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
Core Medical w/ Medicare : Core Medical w/ Medicare Prescription drug benefit
Generic drugs on Blue Cross formulary
$15 for a 30-day supply
$30 for a 90-day supply (mail order)
Brand name drugs on formulary
$25 for a 30-day supply
$50 for a 90-day supply (mail order)
Core Medical w/ Medicare : Core Medical w/ Medicare Prescription drug benefit (cont.)
Non-formulary drugs
Certain drugs may require prior authorization
$40 for a 30-day supply
$80 for a 90-day supply (mail order)
If doctor writes “dispense as written” (DAW) or “do not substitute” (DNS) on prescription, brand copay applies
Core Medical w/ Medicare : Prescription drug benefit (cont.)
Impotence/sexual dysfunction drugs (e.g. Viagra) not covered
90-day supplies from UC pharmacies
2 copayments
$1,000 Rx out-of-pocket maximum
Excludes copays for non-formulary drugs
Core Medical w/ Medicare
Blue Cross PLUS w/ Medicare : Blue Cross PLUS w/ Medicare Point-of-Service plan
In-Network Benefits
Primary Care Physician (PCP) and medical group coordinate care
Out-of-Network Benefits
Self-refer to Medicare providers
Higher premium than Core and PPO
Behavioral health benefits
Administered through United Behavioral Health
In- and Out-of-Network benefits
Blue Cross PLUS w/ Medicare : Blue Cross PLUS w/ Medicare In-Network Benefits
Pros
No deductible/claim forms
$20 physician office visit copay
$75 ER copay (waived if admitted)
$250 inpatient hospitalization copay
$20 hearing exam
50% coinsurance on hearing aids (max benefit of $2,000)
Blue Cross PLUS w/ Medicare : Blue Cross PLUS w/ Medicare In-Network Benefits (cont.)
Pros (cont.)
Skilled nursing facility limit: 240 days/calendar year
$20 Chiropractic/acupuncture copay
American Specialty Health Plans providers only
Maximum copayment liability: $1,500 per person
Lifetime maximum benefit: unlimited
Blue Cross PLUS w/ Medicare : Blue Cross PLUS w/ Medicare In-Network Benefits (cont.)
Cons
Sutter medical groups not available
Sutter West, Sutter Medical Group, Sutter Independent Physicians
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
Blue Cross PLUS w/ Medicare : Blue Cross PLUS w/ Medicare In-Network Benefits (cont.)
Medicare coordination
You pay copayment
Medicare and Blue Cross pay the rest
Blue Cross PLUS w/ Medicare : Blue Cross PLUS w/ Medicare Out-of-Network Benefits
Pros
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
Blue Cross PLUS w/ Medicare : Blue Cross PLUS w/ Medicare Out-of-Network Benefits (cont.)
Cons
$500 per person, calendar year deductible
Not waived for preventive exam
30% coinsurance
Chiropractic/acupuncture not covered
Out-of-Pocket Maximum = $5,000 per person, per calendar year
Separate $500 deductible for non-UBH behavioral health
Outpatient mental health coverage limited to 20 visits/year
Blue Cross PLUS w/ Medicare : Blue Cross PLUS w/ Medicare Out-of-Network Benefits (cont.)
Medicare Coordination:
Blue Cross will pay 70% of their allowable charges
If 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
Blue Cross PLUS w/ Medicare : Blue Cross PLUS w/ Medicare Prescription drug benefit
Generic drugs on Blue Cross formulary
$15 for a 30-day supply
$30 for a 90-day supply (mail order)
Brand name drugs on formulary
$25 for a 30-day supply
$50 for a 90-day supply (mail order)
Blue Cross PLUS w/ Medicare : Blue Cross PLUS w/ Medicare Prescription drug benefit (cont.)
Non-formulary drugs
Certain drugs may require prior authorization
$40 for a 30-day supply
$80 for a 90-day supply (mail order)
If doctor writes “dispense as written” (DAW) or “do not substitute” (DNS) on prescription, brand copay applies
Blue Cross PLUS w/ Medicare : Prescription drug benefit (cont.)
Impotence/sexual dysfunction drugs (e.g. Viagra)
6 tablets or units per 30-day period
Retail pharmacies only
90-day supplies from UC pharmacies
2 copayments
$3,850 Rx out-of-pocket maximum
Excludes copays for non-formulary drugs
Blue Cross PLUS w/ Medicare
Blue Cross PPO w/ Medicare : Blue Cross PPO w/ Medicare Preferred Provider Organization plan
Use any Medicare provider
Lower premium than PLUS
More flexible than PLUS (no PCP)
Behavioral health benefits
Administered through United Behavioral Health
In- and Out-of-Network benefits
Blue Cross PPO w/ Medicare : Blue Cross PPO w/ Medicare Pros
Access any Medicare provider
Deductible: $100 per person, per calendar year
Waived for preventive physical exam
Coinsurance: 20% of balance after Medicare
Hearing exam/hearing aids (up to $2,000): 20%
Chiropractic/acupuncture: 20%
Skilled nursing facility limit: 240 days
Out-of-pocket maximum: $1,500
Lifetime maximum benefit: $5,000,000/member
Blue Cross PPO w/ Medicare : Blue Cross PPO w/ Medicare Cons
20-visit limit on outpatient, out-of-network behavioral health ($500 deductible)
Blue Cross PPO w/ Medicare : Blue Cross PPO w/ Medicare Medicare coordination:
Blue Cross pays 80% of balance after Medicare pays
Blue Cross PPO w/ Medicare : Blue Cross PPO w/ Medicare Prescription drug benefit
Generic drugs on Blue Cross formulary
$15 for a 30-day supply
$30 for a 90-day supply (mail order)
Brand name drugs on formulary
$25 for a 30-day supply
$50 for a 90-day supply (mail order)
Blue Cross PPO w/ Medicare : Blue Cross PPO w/ Medicare Prescription drug benefit (cont.)
Non-formulary drugs
Certain drugs may require prior authorization
$40 for a 30-day supply
$80 for a 90-day supply (mail order)
If doctor writes “dispense as written” (DAW) or “do not substitute” (DNS) on prescription, brand copay applies
Blue Cross PPO w/ Medicare : Blue Cross PPO w/ Medicare Prescription drug benefit (cont.)
Impotence/sexual dysfunction drugs (e.g. Viagra)
6 tablets or units per 30-day period
Retail pharmacies only
90-day supplies from UC pharmacies
2 copayments
$3,850 Rx out-of-pocket maximum
Excludes copays for non-formulary drugs
High Option w/ Medicare : High Option w/ Medicare Medicare supplement plan
Highest monthly premium among plans that UC offers
Behavioral health benefits:
Use any Medicare provider
High Option w/ Medicare : High Option w/ Medicare Pros
Access any Medicare provider
Deductible: $50 per person, per calendar year
Coinsurance: none for many services
Chiropractic: no copay if covered by Medicare
Acupuncture: 20% after deductible
Skilled nursing facility limit: 130 days
Out-of-pocket maximum: $1,050
Rx out-of-pocket maximum: $1,000
$2,000,000 lifetime maximum benefit
High Option w/ Medicare : High Option w/ Medicare Cons
Hearing aids/exam not covered
Sexual dysfunction drugs not covered
No behavioral health out-of-pocket maximum
High Option w/ Medicare : High Option w/ Medicare Medicare coordination: “coordination of benefits”
Plan pays balance after Medicare
High Option w/ Medicare : High Option w/ Medicare Prescription drug benefit
Generic drugs on Blue Cross formulary
$15 for a 30-day supply
$30 for a 90-day supply (mail order)
Brand name drugs on formulary
$25 for a 30-day supply
$50 for a 90-day supply (mail order)
High Option w/ Medicare : High Option w/ Medicare Prescription drug benefit (cont.)
Non-formulary drugs
Certain drugs may require prior authorization
$40 for a 30-day supply
$80 for a 90-day supply (mail order)
If doctor writes “dispense as written” (DAW) or “do not substitute” (DNS) on prescription, brand copay applies
High Option w/ Medicare : High Option w/ Medicare Prescription drug benefit (cont.)
Impotence/sexual dysfunction drugs (e.g. Viagra) not covered
90-day supplies from UC pharmacies
2 copayments
$1,000 Rx out-of-pocket maximum
Excludes copays for non-formulary drugs
Cost vs. Benefit : Cost vs. Benefit
Cost vs. Benefit : Cost vs. Benefit Compare the various plans’ total costs
Monthly premium
Copays/deductibles/coinsurance
Out-of-pocket maximums
Cost vs. Benefit : Cost vs. Benefit
Cost vs. Benefit : Cost vs. Benefit Medicare rates for 2007
Part B premium: ≥$93.50 per month
Part B deductible: $131 per year
Part A deductible: $992 per benefit period
Cost vs. Benefit : Cost vs. Benefit Medicare rates for 2007 (cont.)
Part A
For each benefit period you pay:
A total of $992 for a hospital stay of 1-60 days
$248 per day for days 61-90 of a hospital stay
$496 per day for days 91-150 of a hospital stay (Lifetime Reserve Days)
All costs for each day beyond 150 days
Cost vs. Benefit : Cost vs. Benefit Medicare rates for 2006 (cont.)
Part A
Skilled nursing facility coinsurance:
$124 per day for days 21 through 100 each benefit period
Cost vs. Benefit : Cost vs. Benefit
Cost vs. Benefit : Cost vs. Benefit Which plans give you access to the doctors you want to see?
Cost vs. Benefit : Cost vs. Benefit
Which plans cover benefits you are most likely to need?
Cost vs. Benefit : Cost vs. Benefit
Cost vs. Benefit : Cost vs. Benefit
Cost vs. Benefit : Cost vs. Benefit
Remember, you can always change plans during a future Open Enrollment…
Choosing between Blue Cross plans… : Choosing between Blue Cross plans… …when you have
Medicare Presented by Guerren Solbach
UCD/UCDHS Health Care Facilitator Program
December 13, 2007