Choosing between Blue Cross plans

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Choosing betweenBlue Cross plans

• when you have
• Medicare

Presented by Guerren Solbach
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Agenda

• Medicare and UC
• Medicare and Anthem Blue Cross
• Plan Comparisons
• Pros/Cons
• Medical coverage
• Coordination with Medicare
• Mental health coverage
• Rx coverage
• Cost vs. Benefit

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Medicare and UC
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Medicare and UC

• Medicare is the federal health insurance program
  for those over 65 and some disabled
• Part A Hospital insurance
• Premium-free for most
• Part B Medical insurance
• 96.40/month in 2010
• 73 of those enrolled will pay this
• 110.50/month in 2010 for those w/o SSI
• Costs more if AGI gt85K/year (170K for couples)
• UC relies on Medicare to offset the cost of
  retiree medical insurance

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UCs 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

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Medicare Part D

• New outpatient drug benefit as of 2006
• Subsidizes medical plan premiums
• UC Part D plans no doughnut hole
• Formulary may differ from non-Medicare plan

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Medicare Part D (cont.)

• ABC Part D enrollment form required
• Duplicate Part D coverage not allowed
• Enrollment in a non-UC Part D plan may result in
  loss of coverage
• Exception PPO Medicare without Rx

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Medicare and Anthem Blue Cross
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Anthem Blue Cross Plans

• UC offers 4 ABC medical plans
• Core Medical
• Anthem Blue Cross PLUS
• Anthem Blue Cross PPO
• High Option
• More information on At Your Service
• Medicare Factsheet
• Rely upon Evidence of Coverage booklets for
  detailed plan information
• Call ABC at 1-888-209-7975

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Anthem Blue Cross Plans w/ Medicare

• Assumption eligible for Parts A B
• Medicare pays primary, Blue Cross secondary
• Enrollees must use Medicare providers
• Providers must be certified with Medicare
• No private contract physicians
• If Medicare will not pay a claim because the
  provider is not part of Medicare, then Blue Cross
  will not pay

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About Medicare Providers

• 96.5 of U.S. physicians participate in Medicare
• 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

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Anthem Blue Cross Plans w/ Medicare

• Electronic 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
  claim information
• No need to resubmit claims after filing with
  Medicare

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Wellness Programs
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Anthem Blue Cross Wellness Programs

• Discounted wellness programs
• MyHealthAdvantage alerts members to possible
  gaps in care/contraindicated medications/early
  risk for chronic disease
• Disease management programs
• Asthma/diabetes/congestive heart failure/cancer
  (chemotherapy)/ musculoskeletal disorders
• Tobacco cessation
• Subimo online decision support tool
• Diagnostic and procedure explanations, hospital
  finder

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StayWell Health Management

• New wellness benefit on top of other benefits
• Exceptions Kaiser members family members under
  18
• Wellness benefits include
• 100 gift certificate (50 for spouse) for
  completing a Health Assessment (online or paper
  form) between 1/54/15/2010

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StayWell Health Management (cont.)

• Wellness benefits (cont.)
• Access to extensive online health resources and
  interactive tools
• Look It Up drug research, self-care
  information, create reminders for preventive
  screenings
• Health Improvement Programs include access to a
  health coach by phone, online or mail
• UC Living Well
• http//uclivingwell.ucop.edu
• 1-800-721-2693

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Plan Comparisons
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Core Medical w/ Medicare

• Fee-for-Service plan
• Lowest monthly premium of all plans offered by UC
• Full Medicare Part B reimbursement
• New as of 2008 behavioral health coverage
• Must use Medicare providers

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Core Medical w/ Medicare

• Advantages ?
• 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

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Core Medical w/ Medicare

• Limits ?
• Hearing aids/exams not covered
• Sexual dysfunction drugs not covered
• Skilled nursing facility limit 120 days per
  calendar year
• Home health care limit 100 days

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Core Medical w/ Medicare

• Medicare coordination
• Blue Cross will pay 80 of their allowable
  charges
• If this is less than Medicares payment, Blue
  Cross pays nothing, member pays 20
• If more than Medicares payment, Blue Cross pays
  difference up to 80 of allowable charges

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Core Medical w/ Medicare

• Prescription drug benefit
• Generic drugs on Blue Cross formulary
• 10 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

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Core Medical w/ Medicare

• Prescription drug benefit (cont.)
• 90-day supplies for 2 copayments
• From UC pharmacies
• Mail order
• Certain drugs may require prior authorization
• Specialty meds through PrecisionRx
• Sexual dysfunction drugs not covered
• 1,000 Rx Out-of-Pocket Maximum
• Excludes copays for non-formulary drugs

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Anthem Blue Cross PLUS w/ Medicare

• Point-of-Service plan
• In-Network Benefits (HMO)
• Primary Care Physician (PCP) and medical group
  coordinate care
• Out-of-Network Benefits (PPO)
• Self-refer to Medicare providers

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PLUS Behavioral Health UBH

• United Behavioral Health (UBH)
• Must use Medicare providers
• Outpatient office visits
• Visits 1-3 free
• Visits 4 15
• Inpatient hospitalization 250
• 1,000 Out-of-Pocket Max
• Per person, per year (3,000 for 3)

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Anthem Blue Cross PLUS w/ Medicare

• In-Network Benefits (HMO)
• Advantages ?
• No deductible/claim forms
• 20 physician office visit copay
• 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)

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Anthem Blue Cross PLUS w/ Medicare

• In-Network Benefits (HMO) (cont.)
• Advantages ? (cont.)
• Skilled nursing facility/home health care limit
  unlimited
• 20 Chiropractic/acupuncture copay
• American Specialty Health Plans providers only
• Maximum Copayment Liability 1,500 per person
• Lifetime maximum benefit unlimited

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Anthem Blue Cross PLUS w/ Medicare

• In-Network Benefits (HMO) (cont.)
• Limits ?
• Sutter medical groups not available
• Copayment can apply 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

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Anthem Blue Cross PLUS w/ Medicare

• In-Network Benefits (HMO) (cont.)
• Medicare coordination
• You pay copayment
• Medicare and Blue Cross pay the rest

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Anthem Blue Cross PLUS w/ Medicare

• Out-of-Network Benefits (PPO)
• Advantages ?
• 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

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Anthem Blue Cross PLUS w/ Medicare

• Out-of-Network Benefits (PPO) (cont.)
• Limits ?
• 500 per person, calendar year deductible
• 30 coinsurance
• Chiropractic/acupuncture not covered
• Out-of-Pocket Maximum 5,000 per person, per
  calendar year

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Anthem Blue Cross PLUS w/ Medicare

• Out-of-Network Benefits (PPO) (cont.)
• Medicare Coordination
• Blue Cross will pay 70 of their allowable
  charges
• If this is less than Medicares payment, Blue
  Cross pays nothing, member pays 30
• If more than Medicares payment, Blue Cross pays
  difference up to 70 of allowable charges

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Anthem Blue Cross PLUS w/ Medicare

• Prescription drug benefit
• Generic drugs on Blue Cross formulary
• 10 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),
  brand name copay applies

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Anthem Blue Cross PLUS w/ Medicare

• Prescription drug benefit (cont.)
• 90-day supplies for 2 copayments
• From UC pharmacies
• Mail order
• Certain drugs may require prior authorization
• Specialty meds through PrecisionRx

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Anthem Blue Cross PLUS w/ Medicare

• Prescription drug benefit (cont.)
• Sexual dysfunction drugs (e.g. Viagra)
• 6 tablets or units per 30-day period
• Retail pharmacies only
• 4,550 Rx Out-of-Pocket Maximum
• Excludes copays for non-formulary drugs

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Anthem Blue Cross PPO w/ Medicare

• Preferred Provider Organization plan
• Use any Medicare provider
• More flexible than PLUS (no PCP)

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PPO Behavioral Health UBH

• United Behavioral Health (UBH)
• Must use Medicare providers
• Outpatient office visits
• Visits 1-3 free
• Visits 4 15
• Inpatient hospitalization 250
• 1,000 Out-of-Pocket Max
• Per person, per year (3,000 for 3)

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Anthem Blue Cross PPO w/ Medicare

• Advantages ?
• 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

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Anthem Blue Cross PPO w/ Medicare

• Limits ?
• 4,550 Rx Out-of-Pocket Maximum

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Anthem Blue Cross PPO w/ Medicare

• Medicare coordination
• Blue Cross pays 80 of balance after Medicare
  pays

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Anthem Blue Cross PPO w/ Medicare

• Prescription drug benefit
• Generic drugs on Blue Cross formulary
• 10 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

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Anthem Blue Cross PPO w/ Medicare

• Prescription drug benefit (cont.)
• 90-day supplies for 2 copayments
• From UC pharmacies
• Mail order
• Certain drugs may require prior authorization
• Specialty meds through PrecisionRx

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Anthem Blue Cross PPO w/ Medicare

• Prescription drug benefit (cont.)
• Sexual dysfunction drugs (e.g. Viagra)
• 6 tablets or units per 30-day period
• Retail pharmacies only
• 4,550 Rx Out-of-Pocket Maximum
• Excludes copays for non-formulary drugs

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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
• Through Medicare providers
• REMOVED Outpatient mental health visits limited
  to 10 per person, per year

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High Option w/ Medicare

• Advantages ?
• Access any Medicare provider
• Deductible 50 per person, per calendar year
• Applies to benefits not covered by Medicare
• 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

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High Option w/ Medicare

• Limits ?
• Preventive hearing/vision exams not covered
• 50 deductible applies to preventive physical
  exam
• Hearing aids not covered
• Sexual dysfunction drugs not covered

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High Option w/ Medicare

• Medicare coordination coordination of
  benefits
• Plan pays 100 of balance after Medicare for most
  services
• Exceptions 20 coinsurance for
• Acupuncture
• TMJ
• Outpatient private duty nurse
• Diabetes education
• DME if not covered by Medicare

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High Option w/ Medicare

• Prescription drug benefit
• Generic drugs on Blue Cross formulary
• 10 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

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High Option w/ Medicare

• Prescription drug benefit (cont.)
• 90-day supplies for 2 copayments
• From UC pharmacies
• Mail order
• Certain drugs may require prior authorization
• Specialty meds through PrecisionRx
• Sexual dysfunction drugs not covered
• 1,000 Rx Out-of-Pocket Maximum
• Excludes copays for non-formulary drugs

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Cost vs. Benefit
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Cost vs. Benefit

• Compare the various plans total costs
• Monthly premium
• Consider how the plans coordinate with Medicare
• Copays/deductibles/coinsurance
• Out-of-Pocket Maximums

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Cost vs. BenefitGet to know Medicare

• Medicare rates for 2010 Part A
• Part A premium N/A
• Part A deductible 1,100 per benefit period
• For each benefit period you pay
• A total of 1,100 for a hospital stay of 1-60
  days
• 275 per day for days 61-90 of a hospital stay
• 550 per day for days 91-150 of a hospital stay
  (Lifetime Reserve Days)
• All costs for each day beyond 150 days

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Cost vs. BenefitGet to know Medicare

• Medicare rates for 2009 Part A (cont.)
• Skilled nursing facility coinsurance
• 137.50 per day for days 21 through 100 each
  benefit period

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Cost vs. BenefitGet to know Medicare

• Medicare rates for 2010 Part B
• Part B premium 96.40 per month
• Part B deductible 155 per year
• Part B coinsurance 20
• Medicare rates for 2010 Part D
• Part D premium N/A
• Part D deductible N/A

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Cost vs. Benefit
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Cost vs. Benefit
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Cost vs. Benefit

• Which plans give you access to the doctors you
  want to see?

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Cost vs. Benefit
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Cost vs. Benefit

• Which plans cover benefits you are most likely to
  need?

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Cost vs. Benefit
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Cost vs. Benefit

• Remember, you can always change plans during a
  future Open Enrollment

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Choosing betweenBlue Cross plans

• when you have
• Medicare

Presented by Guerren Solbach