11/3/1111

Open Enrollment HighlightsLaura MorganUCSB Human Resources, Benefits

This presentation is intended for communication purposes only. Please see plan document and http://atyourservice.ucop.edu for complete information.

Big changes New choices

11/1/2013

Updated 11/22/13

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Open Enrollment

• Ends Tuesday, November 26, 5:00 pm

• Make changes onlinehttp://atyourservice.ucop.edu

• All changes are effective January 1, 2014

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Actions

• Change medical and/or dental plan• Enroll in medical, dental, vision• Add eligible family members• Enroll or re-enroll in Health Flexible

Spending Account (FSA) ◊ unless you select the Blue Shield Health

Saving Plan)

• Enroll or re-enroll in Dependent Care FSA

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Collective Bargaining

• For unions in “status quo” or “reopeners” the following may not change:

◊ Monthly contribution rates for plans◊ Payband levels

An individual’s MCB can go up or down

• Monthly employee contributions for the new 2014 medical plans will be the same for all participants

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Review Options for 2014atyourservice.ucop.edu/

oeBooklet

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Medical Plan ChooserLink from Open Enrollment website:http://atyourservice.ucop.edu/oe/medical

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Big Changes, New Choices

• Comprehensive review of UC's medical plan portfolio

• Ensure good benefits while limiting cost increases for employees and the university

• Maintain choices to address individual needs

• Opportunity to leverage UC's medical centers

• Respond to health care reform and a changing medical-insurance marketplace

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2014 Medical Plans

2013 2014

Anthem PPO UC Care PPO(administered by Blue Shield)Anthem PLUS

Anthem Lumenos HRA-PPOBlue Shield

Health Savings Plan (PPO)

Health Net Blue & Gold HMO Health Net Blue & Gold

HMOHealth Net HMO

Kaiser HMO Kaiser HMO

Core Core

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Default Medical Plans2013 Medical Plan 2014 Medical Plan

Health Net Blue & Gold

HMO

Health Net Blue & Gold

HMO

Health Net HMO (full) Health Net Blue & Gold

HMO

Kaiser HMO Kaiser HMO

Anthem PLUS UC Care

Anthem PPO UC Care

Anthem Lumenos HRA Blue Shield Health Savings

Plan

Anthem Core Blue Shield Core

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What is your priority?

• Cost to enroll – monthly premium

• Cost of care ◊ Predictable, low cost copays◊ Pay a % of each service

• Choice of providers◊ HMO medical group physicians◊ PPO preferred network or any provider

• Effort to manage – coordinating care &

bills

Medical Plan Design 101

HMOPPOPOS

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HMO – Health Maintenance Organization

• Care is delivered by physicians in a “medical group” (e.g. Sansum, SB Select IPA)

• Care is coordinated by Primary Care Physician and medical group

• Member selects PCP, PCP refers to specialists

• Set copay for most services, no deductibles

• Emergency and urgently needed care when away

Health Net Blue & Gold HMOKaiser HMO

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PPO – Preferred Provider Organization

• You direct your own care, you decide where to receive services

• You pay annual deductibles before plan pays• After deductible, you share the cost of each

service with the plan - coinsurance• Your costs are lower if you select preferred

providers• “Out-of-pocket Maximum” limits your

financial liability

UC Care Blue Shield Health Savings Plan

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Deductible, Coinsurance, OOPM

JanuaryCalendar Year

December

Deductible

You pay

CoinsuranceCopay

You share cost with plan

Out-of-Pocket

Maximum

Plan pays 100%

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Allowed Amount – In Network

In-Network Example

Discounted rate that plan negotiates for each service with “preferred” or participating providers

• You pay the in-network coinsurance on the discounted rate.

• Provider can’t “balance bill”

Coinsurance 20%

Provider charge: $200Allowed amount: $100

Plan pays 80%: $80

You pay 20% $20

Provider write-off:$100

PPO plans negotiate “allowed” rates to process claims.

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Allowed Amount – Out of Network

Out-of-Network Example

Value that plan assigns to a service when provider is NOT a “preferred provider” (not participating)

• Plan pays out-of-network coinsurance on the allowed amount.

• Provider can “balance bill”

Coinsurance 50%

Provider charge: $200Allowed amount: $100

Plan pays 50%: $50(50% of $100)

You pay 50%: $50

You pay balance: $100

PPO plans assign “allowed” rates to process claims.

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Claims, EOBs & Bills

You receive servicesYou pay nothing at the time of service for in-network care

Provider sends claim for services to health plan

Health plan sends EOBExplanation of Benefits (EOB) outlines allowed charges, deductible and co-insurance. This is not a bill.

Provider sends billThe bill should match the EOB. It should reflect the in-network discount and any payments received from health plan.

You pay provider

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Learn more about PPOs

Fair Health Consumerhttp://www.fairhealthconsumer.org/• Estimate cost of medical procedures• “LEARN” tab – print and video resources

◊ How plans work◊ Cost Sharing, know what you may owe

Good Rx• http://www.goodrx.com• Estimate cost of drugs (for Blue Shield

HSP)

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POS - Point of Service

• Combines HMO and PPO plan designs• Limit costs by using HMO providers• Can use providers outside HMO

group, but cost for service will be higher

Anthem PLUS in 2013 - discontinued

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Anthem PLUS Dilemma – PPO or HMO

Physician• Specific

physician• More choice of

physicians and facilities

Cost• Monthly cost • Predictable

copays

What is your priority?

2014 Medical Plans

Health Net Blue & Gold HMOKaiser HMO

UC CareBlue Shield Health Savings Plan

Core

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Residence LimitationsHMO (Health Net, Kaiser)

• Employee must live in California

• PCP must be within 30 miles of where you live or work (in most cases)

Blue Shield Health Savings• Employee must live in US

• Employee may live anywhere

• Worldwide services

CORE

UC Care

• Employee may live anywhere

• Worldwide services

• Employee may live anywhere

• Worldwide services

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When traveling out of USHMO (Health Net, Kaiser)

• Limited to emergency and urgent care only

• No routine care

Blue Shield Health Savings• Limited to emergency and urgent care only

• No routine care

• Comprehensive coverage

• Plan pays Preferred benefit.

CORE

UC Care

• Comprehensive coverage

• Plan pays out-of-network benefit.

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Health Net

• Full Network HMO is being discontinued◊ In Ventura County, some medical groups will

no longer be available to Health Net members◊ Employees should consider UC Care or Kaiser

HMO

• Health Net Blue & Gold HMO will continue with few benefit changes◊ In Santa Barbara County, all HMO medical

groups participate in Blue & Gold◊ In Ventura County, not all HMO groups

participate

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Health Net Blue & Gold HMO

• You select a Primary Care Physician (PCP) to coordinate your care

• PCP refers you to specialists• Predictable copays for services:

◊ $20 office visit◊ $20 urgent care◊ $75 emergency room (if not admitted)◊ $100 outpatient surgical center◊ $250 hospital (in-patient)

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Kaiser HMO

• Kaiser will continue in Ventura County• You select Kaiser PCP• PCP refers you to Kaiser specialists• Predictable copays for services:

◊ 20 office visit◊ $20 urgent care◊ $75 emergency room (if not admitted)◊ $100 outpatient surgical center◊ $250 hospital (in-patient)

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UC Care – New PPO

• New self-funded PPO plan• Created for UC employees and non-

Medicare retirees• UC Medical Centers are part of the

“UC Select” network of providers• No PCP, no referral required for

specialist

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UC Care PPO

• Customized for UC Care• UC Health System + Select Blue Shield

providers

UC Select Providers

• Similar to the standard in network cost-share of the previous Anthem PPO plan

Blue Shield Preferred Providers

• Flexibility to use services from any provider outside the UC Select or Blue Shield Preferred network

Non-Preferred Providers

Blue Shield of California – claims administrator & network

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UC Care: In-Network Providers

• UC Select ◊ All UC medical centers, facilities and

physicians◊ Additional select Blue Shield PPO providers

in areas where UC medical centers and physicians are not accessible

• Blue Shield Preferred PPO in California◊ 97% of Anthem PPO are also Blue Shield

Preferred• Blue Shield outside of CA and US

◊ Blue Cross Blue Shield Network out of CA◊ BlueCard Network or any physician out of

US

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UC Select Network near UCSB

• UC Select providers in◊ Santa Barbara – Sansum Clinic◊ Santa Maria◊ Lompoc◊ Ventura

• Currently, Sansum Clinic is the only UC Select providers in Santa Barbara area◊ High cost hospital and medical groups◊ Still negotiating

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Blue Shield Preferred at UCSB

• Most Anthem Plus and PPO providers are also in the UC Care Blue Shield Preferred network

• Cottage Hospital and Sansum Clinic are Blue Shield Preferred providers

Provider directory: blueshieldca.com/uccareppo

or link fromhttp://uc-care.org/

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UC Care – Cost of Care

• Your costs depend on the service and the network status of the provider

• UC Select – no deductible, copays for most services but not all

• Blue Shield Preferred – deductible and you pay 20% coinsurance for most services

• Non-Preferred – deductible and plan pays 50% of allowed rate

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Deductible, Coinsurance, OOPM

You pay You share cost with plan

Plan pays100%

$250Deductibl

e20% Coinsurance $3000

OOPM

UC CareIndividual Coverage

Blue Shield Preferred (Tier 2)

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Deductible: Individual vs Family

$250 Individual / $750 Family

Coinsurance

Adult 1 Paid $250 20%Adult 2 Paid $100

Child 1 Paid $ 75

Child 2 Paid $250 20%

Adult 2 Paid $175 20%

20%

UC Care ExampleFamily Deductible

Blue Shield Preferred (Tier 2)

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UC Care – Emergency Room Example

• There are two charges for emergency care with a PPO plan design:◊ “Facility” – billed by the hospital◊ “Professional” – billed by the ER

physicians

• Emergency Room Visit (not admitted)◊ Emergency room: $100 per visit◊ Emergency physician services: 20%◊ Same coverage across all provider

networks

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More information about UC Care

Shield ConciergeBlue Shield/UC dedicated line

1-855-201-2087M-F, 7 to 7

http://uc-care.org/

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Blue Shield Health Savings Plan

Blue Shield PPO +

High deductible medical plan paired with a Health Savings Account

Health Savings Account

• The Health Savings Account is not a component of the medical plan as HRA is with Lumenos.

• It is a separate account that can be used to pay medical and other health expenses.

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Blue Shield PPO

• You direct your own care, you decide where to receive services

• Medical and drug expenses apply to deductible and Out-of-Pocket Maximums (OOPM)◊ No separate drug plan with copays

• Family members share same deductibles and OOPMs

• Networks:◊ Blue Shield Preferred ◊ Non-Preferred Providers

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Deductible, Coinsurance, OOPM

You pay You share cost with plan

Plan pays100%

$1250Deductibl

e20% Coinsurance $4000

OOPM

Blue Shield Health Savings Plan Individual (Single)

Preferred Providers

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Deductible, Coinsurance, OOPM

You pay You share cost with plan

Plan pays100%

$2500Deductibl

e20% Coinsurance $6400

OOPM

Blue Shield Health Savings Plan Family

Preferred Providers

The full family deductible must be met before plan shares costs

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Blue Shield Health Savings Plan

Blue Shield PPO +

High deductible medical plan paired with a Health Savings Account

Health Savings Account

• HSA deposits are not taxes• HSA funds roll over from year to year• Tax-free interest earned• You keep the money even if you change

jobs or insurance plans

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Health Savings Account

• Health Equity manages the HSA

• UC makes annual contribution for plans that start on January 1.

◊ UC contribution is pro-rated for mid-year enrollments

• You may contribute through payroll deductions

• Use account to pay for eligible health expenses (medical, dental, vision, etc)

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Employees can maximize savings

• UC Contribution (1/1/14) ◊ $500 individual ◊ $1000 family

• 2014 Maximum Contributions allowed by IRS◊ Single-coverage: $3,300◊ Family-coverage: $6,550◊ Catch-up contribution, age 55+: $1,000

Tip: Contribute the money you would have put in your Health FSA.

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Lumenos and Blue Shield HSP

• Remaining Lumenos HRA money will roll-over into the Health Savings Account (4/1/14)

• Lumenos HRA $ are treated differently than HSA $ by IRS

• Lumenos HRA $ becomes a “Post Deductible Health Reimbursement Account” = PDHRA

• You must pay the Blue Shield HSP deductible with other funds BEFORE you can use the PDHRA to pay eligible expenses.

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Who is eligible for HSA?

To own an HSA you need to:

• Be covered ONLY by an HSA-qualified health plan◊ Other health coverage may disqualify you,

including Health FSA, Medicare or traditional health plan

◊ Health FSA must have a $0 balance on Dec. 31, 2013 (complete any claims reimbursement by Dec. 31, 2013)

• Not be claimed as a dependent on someone else’s tax return

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“Seamless Consumer Experience”

• Blue Shield and Health Equity share information

• Employee receives welcome kit and live debit card

• Use the “smart card” to pay for eligible health expenses

• Can track and pay claims on Blue Shield website

• Invest HSA dollars when account balance reaches $2000 – no fees to invest

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For more information

Health Equity Member Services is available every hour of every day:

Call the Blue Shield/UC dedicated line 1.855.201.8375

say“Health Savings Account”

http://www.healthequity.com/ed/uc

http:// www.blueshieldca.com/uc (select "go" in the health savings plan

section)

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CORE

• High deductible PPO • Administered by Blue Shield• $3000 deductible per individual• Out-of-pocket Maximum is decreasing 2013: $7,600 per individual

2014: $6,350 individual / $12,700 family

• Blue Shield PPO and non-PPO providers• Behavioral Health by Blue Shield PPO

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Prescription Drugs

HMOUC Care

Blue Shield HSP CORE

Retail (30 day)• Generic• Brand• Non-formulary

$5$25$40

After you satisfy the deductible, you pay 20% at preferred pharmaciesMail Order (90

day) • Generic• Brand• Non-formulary

$10$50$80

Preferred Drug List (Formulary) is different for each carrier

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Rx – Mandatory Generic Drugs

Health Net & UC Care• Generic drugs will automatically be dispensed• Brand name drugs when generic is

available will cost the member more◊ $5 generic copay + (brand price – generic

price)• Brand name is available if “medically

necessary”◊ e.g. Allergic to inactive ingredient◊ Requires prior authorization from plan◊ DAW, DNS does not = medical necessity

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Rx – Mandatory Generic Drugs

Core & Blue Shield Health Savings Plan• Generic drugs will automatically be dispensed• Brand name drugs when generic is available

will cost the member more◊ Generic coinsurance + (brand price – generic price)

• Brand name is available if “medically necessary”◊ e.g. Allergic to inactive ingredient◊ Requires prior authorization from plan◊ DAW, DNS does not = medical necessity

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Nicotine Replacement Therapy

• All UC Medical Plans continue to provide RX for smoking cessation at $0 cost (e.g., Chantix, Zyban)

• Over the Counter NRT covered at $5 (generic copay)

OTC = Gum – Patch – Lozenge

Doctor’s Prescription Required

Kaiser Only - $0 Copay for both RX and OTC products

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Optum – Behavioral Health

All medical plans, except CORE, use Optum therapists, psychologists and psychiatrists for in-network care.

• Health Net Blue & Gold and Kaiser◊ In-network benefit

• UC Care, Blue Shield Health Savings Plan◊ In-network and out-of-network benefit

• Core◊ In-network with Blue Shield clinicians

and out-of-network benefit

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Transition / Continuity of Care

• All plans provide temporary transition or continuity of care service so members may complete a course of treatment and arrange for a safe transfer from a non-plan provider.

• Members who lost their current coverage due to plan disruption and were required to enroll in another health plan, AND are currently receiving services may be eligible for transition of care assistance.

• Please call member services to discuss your situation.

Other Plans & Programs

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Delta & Vision

DeltaCare USA Added Benefits

◊ Procedures to assess the level of risk associated with dental decay

◊ Gingival irrigation, a procedure to treat gums with medical solutions for health purposes

Vision Service PlanDiabetic Eye Care Plus Program

◊ Now extended to cover both Type I & II Diabetic members. 

◊ Provides diabetic eye exam in addition to the routine vision examination ($20 copay)

Retiree Vision open for Enrollment

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Legal Plan

• Closed to new enrollment• Current members will continue

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Flexible Spending Accounts

Health Flexible Spending Account• Enroll or re-enroll in Health FSA• Annual limit is $2,500 • Blue Shield HSP members CANNOT enroll in a

Health FSA Dependent Care Account• Enroll or re-enroll in DepCare FSA• Annual limit remains at $5,000 ($2,500 if

married and filing a separate tax return)

YOU MUST

RE-ENROLL

EACH YEAR

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New Wellness Program

• New program – branded as UC Living Well

• New provider – Optum• Increased employee eligibility

More information in 2014

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Family Member Eligibility Verification

• Employees adding family members during Open Enrollment will be required to verify the eligibility of those family members with SECOVA

• Employees who have previously verified their family members should NOT need to re-verifyeligibility

◊ If an employee receives a request from SECOVA for a previously verified family member, please ask him/her to call SECOVA at 1-877-632-8126

http://atyourservice.ucop.edu/family-member-verification/

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ACA & Covered California• Employees covered by or eligible for UC Benefits,

don’t need to take action in the new health Affordable Care Act insurance marketplace. 

• Covered California is the ACA marketplace in CA  https://www.coveredca.com/

• Employees can explore options with Covered California if:◊ They are not eligible for UC-sponsored benefits◊ They have family members who age out or are

no longer eligible for UC plans