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
2007
Topics : Topics Plan structure/design
In-Network Benefits
Out-of-Network Benefits
Specific Coverage Issues
Prescription Drug Benefits
Behavioral Health Benefits
Problem solving
Plan Structure and Design : Plan Structure and Design
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
Blue Cross Plus combines features of both HMO and PPO plans
Members can choose to receive health care services from:
In-network providers
HMO structure; PCP/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.
The question asked most often………..What’s the difference between 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? Plans vary in
Monthly premium
Benefits covered
Cost for services
PPO plan does not include an HMO network; you self-refer for all services
Both plans provide coverage for services from PPO and non-PPO providers – the difference is in the cost for these services
How does the plan work?You Choose to........ : How does the plan work? 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 and $75 ER co-pay
No claim forms, no deductibles
*Based on benefits, 2007
*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
Blue Cross PlusUtilizing theIn-Network Benefit Level : Blue Cross Plus Utilizing the In-Network Benefit Level
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
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
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
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
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 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
It is determined annually
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
How do I obtain the UCR for services prior to obtaining care? : How do I obtain the UCR for services prior to obtaining 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
Out-of-Pocket Maximums : Out-of-Pocket Maximums 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
Check the plan EOC to determine what costs count towards your OOPM. (Some costs are excluded.)
Blue Cross PlusOut-of-Pocket Maximum2007 : Blue Cross Plus Out-of-Pocket Maximum 2007
Specific Coverage Issues : Specific Coverage Issues You should always verify in the EOC or with Blue Cross customer service if you have any questions, or to confirm your benefits.
Changing Your PCP/Medical Group : Changing Your PCP/Medical Group
You can change your Medical Group and/or PCP outside of open enrollment by contacting Blue Cross Customer service at the number shown on your insurance card
Usually, if you call by 15th of month, change effective 1st of next month
Blue Cross must approve your request for it to become effective
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
Student Dependents : Student Dependents 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
Direct Access Benefits : Direct Access Benefits 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
Santa Clara IPA
This information subject to change, contact your medical group to determine participation in Direct Access.
NO
Alta Bates
Marin IPA
Chinese Community
Hills Physicians
Mills-Peninsula
Sonoma County IPA
Obtaining OB/GYN services : Obtaining OB/GYN services 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
Chiropractic & Acupuncture Benefits : Chiropractic andamp; Acupuncture Benefits 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. There is no out-of-network coverage.
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
Infertility Coverage : Infertility Coverage 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
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
Emergency Care : Emergency Care Blue Cross strictly enforces the following definition of an Emergency:
'Emergency is a sudden, serious, and unexpected acute illness, injury, or condition (including without limitation sudden and unexpected severe pain) which the member reasonable perceives, could permanently endanger health if medical treatment is not received immediately. Final determination as to whether services were rendered in connection with an emergency will rest solely with us or your medical group.'
If you believe you have a medical emergency, you should seek medical treatment immediately.
Emergency Care : Emergency Care In Area Emergencies: Seek treatment and request treating provider contact your PCP/medical group as soon as possible to request medically necessary continued care.
Out of Area Emergencies (more than 20 miles from your medical group): contact Blue Cross within 48 hours if you are admitted to a hospital.
Second Opinions : Second Opinions You have the right to a second opinion by an appropriately qualified health care professional
You must have initially seen a specialist you were referred to by your PCP
If there is no appropriately qualified health care professional in the network, you may be authorized to see someone out-of-network
Reasons for requesting a Second Opinion include… : Reasons for requesting a Second Opinion include…
The treatment plan in progress is not improving your medical condition
You are diagnosed with a condition that threatens loss of limb, body function
Your PCP or the initial specialist is unable to diagnose your condition
For additional reasons, consult your EOC
Blue Cross PlusandBehavioral Health Benefits : Blue Cross Plus and Behavioral Health 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
You initiate services by contacting UBH directly
Members can choose to receive behavioral health care services from:
in-network providers (UBH network) or
non-network providers
How does UBH work?In-Network Services : How does UBH work? In-Network Services Out-Patient Therapy
– Call UBH directly, (888) 440-8225. UBH will either refer you to a provider or you can designate an in-network provider
– www.liveandworkwell.com enter access code 11280
– You pay $0 co-pay for first 5 visits, then $10 for 6+ visits
– No claim forms, no deductibles
– $500 annual out-of-pocket maximum
Inpatient Hospitalizations
– No co-pay
– Notify UBH within 48 hours for emergency admissions
Review EOC for substance abuse benefits
How does UBH work?Out-of-Network Services : How does UBH work? Out-of-Network Services 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)
$5,000 annual out-of-pocket maximum
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
Blue Cross Plusand Prescription Drugs Benefits : Blue Cross Plus and Prescription Drugs Benefits
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, 2007 : Blue Cross Plus Prescription Drugs, 2007
Prior Authorization of Medications : Prior Authorization of Medications A small number of drugs require a Prior Authorization
Ensures that patients receive medication appropriate for their condition
Limits the use of expensive medications when there are 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 for urgent requests within one day of receipt and non-urgent requests within two working days
The prescribing physician is notified of the outcome. In the event the decision is a denial, a letter is sent explaining the medical reasons for the denial
Have questions? Call (800) 700-2541
Problem Solving : Problem Solving Tips for Blue Cross Plus Members
Problem Solving : Problem Solving
Review the EOC to determine the specific process for resolving disputes with the plan
Write down your list of concerns before you make your phone call or visit
Keep a log of all 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 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 services/coststhat are not covered? : What about health care services/costs 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; includes co-pays and other out of pocket expenses
Budget carefully, if you don’t use the money set as side, you lose it!
Enroll each year during Open Enrollment
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
The EOC contains detailed information regarding what is and what is not covered by your medical plan and your cost for services
You may download a copy from the Blue Cross website or call Blue Cross to request it
www.bluecross.com/uc
(888) 209-7975
If you need to select or change your PCP/Medical group….. : If you need to select or change your PCP/Medical group…..
Things to Consider : Things to Consider 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?
Slide51 : 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/
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
customerservice@btmg.com
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
Sue Forstat, HCF, (415) 514-3324, sforstat@hr.ucsf.edu
Jason Neft, Assistant HCF, (415) 476-5269, jneft@hr.ucsf.edu
HCF Program Website: www.ucsfhr.ucsf.edu/benefits/hcf
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