plan 06

Choosing betweenBlue 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 betweenBlue Cross plans…: 

Choosing between Blue Cross plans… …when you have Medicare Presented by Guerren Solbach UCD/UCDHS Health Care Facilitator Program December 13, 2007