Choosing between
Blue Cross plans…
…when you have
Medicare
Presented By Glenn Rodriguez
HealthCare Facilitator
UC Irvine
Agenda
I. Medicare and UC
II. Medicare and Anthem Blue Cross
III. Plan Comparisons
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•
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•
•
Pros/Cons
Medical coverage
Coordination with Medicare
Mental health coverage
Rx coverage
IV. Cost vs. Benefit
2
Medicare and UC
Medicare and UC
• Medicare is the federal health insurance
program for those over 65 and some
disabled
ƒ Part A: Hospital (premium-free for most)
ƒ Part B: Medical ($96.40/month in 2010)
• Costs more if you make more than $85K/year ($170K
for couples)
• UC relies on Medicare to offset the cost of
retiree medical insurance
• Retirees without Medicare cost 3 times
more to insure
4
UC’s Medicare Requirements
• UC requires retirees and their family
members to enroll in Medicare Part B:
ƒ If enrolled in medical insurance
ƒ If eligible for Part A free of charge
ƒ Failure to comply may result in the loss of UCsponsored medical coverage
ƒ Exceptions:
• Retirees who reside outside of the U.S.
• Those who retired prior to July 1, 1991
5
Medicare Part D
• New drug benefit as of 2006
• Subsidizes medical plan premiums
• Retirees will automatically be enrolled in
Part D by Blue Cross
ƒ No additional Part D premium
• Blue Cross members have a separate
“Medicare Rx” ID card
6
Medicare Part D
• Retirees do not need to do anything to
enroll
ƒ Exception: double coverage
• Enrollment in a non-UC Part D plan may
result in loss of coverage
• Exception:
ƒ New PPO + Medicare without Rx
7
Medicare and Blue Cross
Blue Cross Plans
• UC offers 4 Anthem Blue Cross medical
plans:
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Core Medical
Blue Cross PLUS
Blue Cross PPO
High Option
• Rely upon “Evidence of Coverage” booklets
for detailed plan information:
ƒ http://www.anthem.com/ca/uc
ƒ Call Blue Cross at 1-888-209-7975
9
Blue Cross Plans w/ Medicare
• Assumption: eligible for Parts A & B
• Medicare pays primary, Blue Cross
secondary
• Use Medicare providers
ƒ Providers must be certified with Medicare
ƒ No “private contracts”
ƒ If Medicare will not pay a claim because the
provider is not part of Medicare, then Blue Cross
will not pay
10
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:
ƒ http://www.medicare.gov
11
Blue Cross Plans w/ Medicare
• “Electronic Crossover” program
ƒ To activate, call Blue Cross with your Medicare
number and Part A/B effective dates
ƒ Blue Cross will be able to access your Medicare
claim information
ƒ No need to resubmit claims after filing with
Medicare
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Wellness Programs
Blue Cross Wellness Programs
• Wellness programs:
ƒ Discounted fitness, massage therapy, yoga,
weight loss, etc.
ƒ Educational classes through local medical
groups
ƒ Today’s Health & Wellness magazine
• Disease management programs:
ƒ Asthma/diabetes/congestive heart
failure/cancer (chemotherapy)/ musculoskeletal
disorders
• Tobacco cessation
14
StayWell Health Management
• New Wellness benefit on top of other
benefits
ƒ Exceptions: Kaiser members; family members
under 18
• Wellness benefits include:
ƒ $100 gift certificate ($50 for spouse) for
completing a Health Assessment (online or paper
form) before 4/15/09
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StayWell Health Management
• Wellness benefits:
ƒ Access to extensive online health resources and
interactive tools
• “Look It Up” drug research, self-care information,
create reminders for preventive screenings
ƒ Health Improvement Programs include access to
a health coach by phone, online or mail
• UC Living Well
ƒ http://uclivingwell.ucop.edu
ƒ 1-800-721-2693
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Plan Comparisons
Core Medical w/ Medicare
• Fee-for-Service plan
• Lowest monthly premium of all plans
offered by UC
ƒ Full Medicare Part B reimbursement
• New as of 2008: behavioral health coverage
ƒ Must use Medicare providers
18
Core Medical w/ Medicare
• Advantages
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Self-refer to 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
19
Core Medical w/ Medicare
• Limits
ƒ Hearing aids/exams not covered
ƒ Sexual dysfunction drugs not covered
ƒ Skilled nursing facility limit: 120 days per
calendar year
ƒ Home health care limit: 100 days
20
Core Medical w/ Medicare
• Medicare coordination:
ƒ 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
21
Core Medical w/ Medicare
• Prescription drug benefit
ƒ Generic drugs on Blue Cross formulary
• $15 for a 30-day supply
ƒ Brand name drugs on formulary
• $25 for a 30-day supply
ƒ Non-formulary drugs
• $40 for a 30-day supply
• If physician writes “dispense as written” (DAW), $25
brand name copay applies
22
Core Medical w/ Medicare
• Prescription drug benefit
ƒ 90-day supplies for 2 copayments
• From UC pharmacies
• Mail order
ƒ Certain drugs may require prior authorization
ƒ Sexual dysfunction drugs not covered
ƒ $1,000 Rx Out-of-Pocket Maximum
• Excludes copays for non-formulary drugs
23
Blue Cross PLUS w/ Medicare
• Point-of-Service plan
ƒ In-Network Benefits (HMO)
• Primary Care Physician (PCP) and medical group
coordinate care
ƒ Out-of-Network Benefits
• Self-refer to Medicare providers
• Behavioral health benefits
ƒ Administered through United Behavioral
Health
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Blue Cross PLUS w/ Medicare
• In-Network Benefits (HMO)
ƒ Advantages
• No deductible/claim forms
• $20 physician office visit copay
ƒ Waived for preventive physical exam & certain
immunizations
•
•
•
•
$75 ER copay (waived if admitted)
$250 inpatient hospitalization copay
$20 hearing exam
50% coinsurance on hearing aids (max benefit of
$2,000)
25
Blue Cross PLUS w/ Medicare
• In-Network Benefits (HMO)
ƒ Advantages
• Skilled nursing facility/home health care limit:
unlimited
• $20 Chiropractic/acupuncture copay
ƒ American Specialty Health Plans providers only
• Maximum Copayment Liability: $1,500 per person
• Lifetime maximum benefit: unlimited
26
Blue Cross PLUS w/ Medicare
• In-Network Benefits (HMO)
ƒ Limits
• Sutter medical groups not available
• Copayment applies even if balance after Medicare is
less than copayment
• 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
27
Blue Cross PLUS w/ Medicare
• In-Network Benefits (HMO)
ƒ Medicare coordination
• You pay copayment
• Medicare and Blue Cross pay the rest
28
Blue Cross PLUS w/ Medicare
• Out-of-Network Benefits (PPO)
ƒ Advantages
• Can see any Medicare doctor without going through
PCP
ƒ 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
29
Blue Cross PLUS w/ Medicare
• Out-of-Network Benefits (PPO)
ƒ Limits
•
•
•
•
$500 per person, calendar year deductible
30% coinsurance
Chiropractic/acupuncture not covered
Out-of-Pocket Maximum = $5,000 per person, per
calendar year
30
Blue Cross PLUS w/ Medicare
• Out-of-Network Benefits (PPO)
ƒ Medicare Coordination:
• Blue Cross will pay 70% of their allowable charges
ƒ If this is less than Medicare’s payment, Blue Cross pays
nothing, member pays 30%
ƒ If more than Medicare’s payment, Blue Cross pays
difference up to 70% of allowable charges
31
Blue Cross PLUS w/ Medicare
• Prescription drug benefit
– Generic drugs on Blue Cross formulary
• $15 for a 30-day supply
– Brand name drugs on formulary
• $25 for a 30-day supply
– Non-formulary drugs
• $40 for a 30-day supply
• If physician writes “dispense as written” (DAW), $25
brand name copay applies
32
Blue Cross PLUS w/ Medicare
• Prescription drug benefit
ƒ 90-day supplies for 2 copayments
• From UC pharmacies
• Mail order
ƒ Certain drugs may require prior authorization
33
Blue Cross PLUS w/ Medicare
• Prescription drug benefit
ƒ Sexual dysfunction drugs (e.g. Viagra)
• 6 tablets or units per 30-day period
• Retail pharmacies only
ƒ $4,350 Rx Out-of-Pocket Maximum
• Excludes copays for non-formulary drugs
34
Blue Cross PPO w/ Medicare
• Preferred Provider Organization plan
ƒ Use any Medicare provider
• More flexible than PLUS (no PCP)
• Behavioral health benefits
ƒ Administered through United Behavioral Health
ƒ In- and Out-of-Network benefits
35
Blue Cross PPO w/ Medicare
• Advantages
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Access any Medicare provider
Deductible: $100 per person, per calendar year
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
36
Blue Cross PPO w/ Medicare
• Limits
ƒ 20-visit limit on outpatient, out-of-network
behavioral health ($500 deductible)
37
Blue Cross PPO w/ Medicare
• Medicare coordination:
ƒ Blue Cross pays 80% of balance after Medicare
pays
38
Blue Cross PPO w/ Medicare
• Prescription drug benefit
ƒ Generic drugs on Blue Cross formulary
• $15 for a 30-day supply
ƒ Brand name drugs on formulary
• $25 for a 30-day supply
ƒ Non-formulary drugs
• $40 for a 30-day supply
• If physician writes “dispense as written” (DAW),
$25 brand name copay applies
39
Blue Cross PPO w/ Medicare
• Prescription drug benefit
ƒ 90-day supplies for 2 copayments
• From UC pharmacies
• Mail order
ƒ Certain drugs may require prior authorization
40
Blue Cross PPO w/ Medicare
• Prescription drug benefit
ƒ Sexual dysfunction drugs (e.g. Viagra)
• 6 tablets or units per 30-day period
• Retail pharmacies only
ƒ $4,350 Rx Out-of-Pocket Maximum
• Excludes copays for non-formulary drugs
41
High Option w/ Medicare
• Medicare supplement plan
• All enrolled family members must have
Medicare Parts A & B
• Highest monthly premium among plans
that UC offers
• Behavioral health benefits:
ƒ Use Medicare providers
42
High Option w/ Medicare
• Advantages
ƒ Access any Medicare provider
ƒ Deductible: $50 per person, per calendar year
• Applies to benefits not covered by Medicare
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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
43
High Option w/ Medicare
• Limits
ƒ Preventive hearing/vision exams not covered
ƒ $50 deductible applies to preventive physical
exam
ƒ Hearing aids not covered
ƒ Sexual dysfunction drugs not covered
ƒ Outpatient mental health visits: coverage limited
to 10 per person, per calendar year
ƒ No behavioral health Out-of-Pocket Maximum
• Facility-based care for more than 60 days: you pay
20% with no upper limit
44
High Option w/ Medicare
• Medicare coordination: “coordination of
benefits”
ƒ Plan pays 100% of balance after Medicare for
most services
45
High Option w/ Medicare
• Prescription drug benefit
ƒ Generic drugs on Blue Cross formulary
• $15 for a 30-day supply
ƒ Brand name drugs on formulary
• $25 for a 30-day supply
ƒ Non-formulary drugs
• $40 for a 30-day supply
• If physician writes “dispense as written” (DAW), $25
brand name copay applies
46
High Option w/ Medicare
• Prescription drug benefit
ƒ 90-day supplies for 2 copayments
• From UC pharmacies
• Mail order
ƒ Certain drugs may require prior authorization
ƒ Sexual dysfunction drugs not covered
ƒ $1,000 Rx Out-of-Pocket Maximum
• Excludes copays for non-formulary drugs
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Cost vs. Benefit
Cost vs. Benefit
• Compare the various plans’ total costs
ƒ Monthly premium
ƒ Consider how the plans coordinate with
Medicare:
• Copays/deductibles/coinsurance
• Out-of-Pocket Maximums
49
Cost vs. Benefit:
Get to know Medicare
• Medicare rates for 2009: Part A
ƒ Part A premium: N/A
ƒ Part A deductible: $1,068 per benefit period
ƒ For each benefit period you pay:
• A total of $1,068 for a hospital stay of 1-60 days
• $267 per day for days 61-90 of a hospital stay
• $534 per day for days 91-150 of a hospital stay
(Lifetime Reserve Days)
• All costs for each day beyond 150 days
50
Cost vs. Benefit:
Get to know Medicare
• Medicare rates for 2009: Part A
ƒ Skilled nursing facility coinsurance:
• $133.50 per day for days 21 through 100 each benefit
period
51
Cost vs. Benefit:
Get to know Medicare
• Medicare rates for 2009: Part B
ƒ Part B premium: ≥$96.40 per month
ƒ Part B deductible: $135 per year
ƒ Part B coinsurance: 20%
• Medicare rates for 2009: Part D
ƒ Part D premium: N/A
ƒ Part D deductible: N/A
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Cost vs. Benefit
COSTS
Core
Annual
Deductible
$100
Coinsurance
Annual
Out-of-Pocket
Maximum
PLUS
PLUS
PPO
High
Option
In-Network
Out-ofNetwork
N/A
$500
$100
$50
N/A
$1,050
20%
Flat
copayments
30%
20% of
balance
after
Medicare
$1,260
$1,500
Max Copay
Liability
$5,000
$1,500
53
Cost vs. Benefit
Rx
Core
PLUS
PPO
High
Option
Benefit
30-day supply:
$15/$25/$40
90-day supply:
$30/$50/$80
30-day supply:
$15/$25/$40
90-day supply:
$30/$50/$80
30-day supply:
$15/$25/$40
90-day supply:
$30/$50/$80
30-day supply:
$15/$25/$40
90-day supply:
$30/$50/$80
3
3
$4,350
$4,350
Sexual
dysfunction
drugs
Annual
Rx Out-ofPocket Max
$1,000
$1,000
54
Cost vs. Benefit
Which plans give you access to the doctors
you want to see?
Plan
Provider
Network
Core
PLUS
InNetwork
PLUS
Out-ofNetwork
PPO
High
Option
Medicare
PCP/
medical
group
Medicare
Medicare
Medicare
55
Cost vs. Benefit
Which plans cover benefits you are most
likely to need?
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Cost vs. Benefit
COVERAGE
Core
Hearing
exam/aids
Acupuncture
3
$500 Limit
PLUS
InNetwork
PLUS
Out-ofNetwork
PPO
3
3
3
3
3
High
Option
3
$500 Limit
Skilled
Nursing
Facility
120 days
No limit
240
days
240
days
130
days
Home Health
Care
100 days
No limit
100 days
100 days
No limit
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Cost vs. Benefit
PLUS
Out-ofNetwork
PPO
InNetwork
PPO
Out-ofNetwork
Preferably
Medicare
$6,000
per person
Core
PLUS
InNetwork
Provider
Network
Medicare
United
Behavioral
Health
Medicare
United
Behavioral
Health
Out-ofPocket
Maximum
$1,260
(includes
medical)
$1,000
per person
Medicare
coverage
only
$1,000
per person
BEHAVIORAL
HEALTH
High
Option
Medicare
Note: Outpt
10 visit limit
N/A
58
Cost vs. Benefit
Remember, you can always change plans
during a future Open Enrollment
59
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Help is available
Health Care Facilitator Program
ƒ Glenn Rodriguez
ƒ (949) 824-9065
ƒ [email protected]
ƒ Benefits Office
ƒ (949) 824-5210
http://www.hr.uci.edu/hcf
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