1. Big changes New choices Medical Plan Comparison Updated 11/22/13
Laura Morgan UCSB Human Resources, Benefits 1
This presentation is intended for communication purposes only. Please see plan document and for complete information. 1
11/2013

2. Topics Open Enrollment Overview Medical Plan Design 101
Medical Plan Comparisons
Residence requirements
Choice of physician
Cost of care & prescription drugs
Out of Pocket Maximum
Health Savings Account
Behavioral Health

3. Open Enrollment Ends Tuesday, November 26, 5:00 pm
Make changes online - sign in to account
All changes are effective January 1, 2014

4. 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

5. atyourservice.ucop.edu/oe
Review Options for 2014
atyourservice.ucop.edu/oe
Booklet

6. Medical Plan Chooser

7. 2014 Medical Plans 2013 2014 Anthem PPO
UC Care PPO (administered by Blue Shield)
Anthem PLUS
Anthem HRA-PPO
Blue Shield Health Savings Plan (PPO)
Health Net Blue & Gold HMO
Health Net HMO
Kaiser HMO
Core

8. Default Medical Plans 2013 Medical Plan 2014 Medical Plan
Health Net Blue & Gold HMO
Health Net HMO (full)
Kaiser HMO
Anthem PLUS
UC Care
Anthem PPO
Anthem Lumenos HRA
Blue Shield Health Savings Plan
Anthem Core
Blue Shield Core

9. 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

10. Medical Plan Design 101
HMO
PPO
POS

11. HMO – Health Maintenance Organization
Insurance plan delegates your care to a “medical group” (e.g. Sansum, SB Select IPA)
Care is coordinated by a Primary Care Physician (PCP) and medical group
Member selects PCP, PCP refers to specialists
Predictable, low cost, copay for services - no deductibles
Emergency and urgently needed care when away
Health Net Blue & Gold HMO Kaiser HMO

12. HMO Network and Access to Care
HMO Medical Group
Access to Care
Primary Care Physicians
Specialists
Labs
Radiology
Durable Medical Equip
Urgent Care
Hospitals
When you need care
go to your PCP
PCP refers you to specialist, x-ray, lab, hospital
Medical Group authorizes referrals to some specialists and treatment

13. 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

14. Deductible, Coinsurance, OOPM
January
Calendar Year
December
Deductible
You pay
Coinsurance
Copay
You share cost with plan
Out-of-Pocket Maximum
Plan pays 100%

15. Allowed Amount – In Network
PPO plans negotiate “allowed” rates to process claims.
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”
20% Coinsurance
Provider charge: $200 Allowed amount: $100
Plan pays 80%: $80
You pay 20% $20
Provider write-off: $100

16. Allowed Amount – Out of Network
PPO plans assign “allowed” rates to process claims.
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”
50% Coinsurance
Provider charge: $200 Allowed amount: $100
Plan pays 50%: $50 (50% of $100)
You pay 50%: $50
You pay balance: $100

17. PPO Claims, EOBs & Bills You receive services
You pay nothing at the time of service for in-network care
Provider sends bill The bill should match the EOB. It should reflect the in-network discount and any payments received from health plan.
Provider sends claim for services to health plan
You pay provider
Health plan sends EOB
Explanation of Benefits (EOB) outlines allowed charges, deductible and co-insurance. “This is not a bill”.

18. PPO Resources Fair Health Consumer http://www.fairhealthconsumer.org/
Health Care Blue Book
Good Rx – drug costs

19. 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 discontinued

20. Anthem PLUS Dilemma – PPO or HMO
How do you use your plan?
PPO
Use physicians out of the HMO medical group
Use out-of-network behavioral health
Deductible & Coinsurance
HMO
Use PCP and specialists in the HMO medical group
Use Optum behavioral health
Predictable copays

21. 2014 Medical Plans Health Net Blue & Gold HMO Kaiser HMO
UC Care Blue Shield Health Savings Plan
Core

22. UC Care PPO Blue Shield of California – claims administrator & network
UC Select Providers
Customized for UC Care
UC Health System + Select Blue Shield providers
Blue Shield Preferred Providers
Similar to the standard in network cost-share of the previous Anthem PPO plan
Non-Preferred Providers
Flexibility to use services from any provider outside the UC Select or Blue Shield Preferred network

23. Blue Shield Health Savings Plan
High deductible medical plan paired with a Health Savings Account +
Blue Shield PPO
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.

24. Preventive Care
All medical plans cover preventive care at 100% with in-network providers
Preventive care includes:
Annual well visit and labs
Well woman visits and labs
Preventive screening tests
Immunizations
See list of preventive services on the plan websites

25. Residence Limitations
HMO (Health Net, Kaiser)
UC Care
Employee must live in California
PCP must be within 30 miles of where you live or work (in most cases)
Employee may live anywhere
Worldwide services
Blue Shield Health Savings
CORE
Employee must live in US
Employee may live anywhere
Worldwide services

26. When traveling out of US
HMO (Health Net, Kaiser)
UC Care
Limited to emergency and urgent care only
No routine care when away from medical group
Comprehensive coverage
Plan pays Preferred benefit.
Blue Shield Health Savings
CORE
Limited to emergency and urgent care only
No routine care
Comprehensive coverage
Plan pays out-of-network benefit.

27. Choice of Physician UC Care HMO (Health Net, Kaiser)
You select PCP
PCP coordinates care
PCP refers to specialists
Specialists limited to physicians in medical group
In-Network – You select
UC Select
Blue Shield Preferred PPO
Out-of-Network
You select non-Blue Shield
Blue Shield Health Saving
CORE
In-Network
You select Blue Shield PPO
In-Network
You select Blue Shield PPO
Out-of-Network
You select non-Blue Shield
Out-of-Network
You select non-Blue Shield

28. 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 out of US

29. UC Care: UC Select near UCSB
UC Select providers in
Santa Barbara – Sansum Clinic
Santa Maria
Lompoc
Ventura
Currently, Sansum Clinic is the only UC Select provider in Santa Barbara area
High cost hospital and medical groups
Still negotiating

30. UC Care: Blue Shield Preferred
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
UC Care Provider directory
blueshieldca.com/uccareppo
Search tool defaults to UC Select network “Change selection” to find Blue Shield Preferred
UC Care
Blue Shield Concierge

31. Office Visit Cost Medical Plan Copay Deductible Coinsurance HMO $20
None
UC Care PPO UC Select
$20
None
Preferred
$250 indiv
$750 family
You pay 20%
Out-of-Network
$500 indiv
$1,500 family
Plan pays 50% of allowed rate
You pay balance

32. UC Care Costs
UC Select (Tier 1)
Copay
Blue Shield Preferred (Tier 2)
Deductible
Coinsurance
Non-Preferred Out-of-Network (Tier 3)
Deductible
Coinsurance
Your costs are based on the tier/network that the provider is in
Not all services are covered at the UC Select benefit tier
Some services are covered only at the Blue Shield Preferred and Non-Preferred tiers

33. Deductible, Coinsurance, OOPM
UC Care Individual Coverage
Blue Shield Preferred (Tier 2)
You pay
You share cost with plan
Plan pays
100%
$250 Deductible
20% Coinsurance
$3000 OOPM

34. Deductible: Individual vs Family
UC Care Example Family Deductible
Blue Shield Preferred (Tier 2)
$250 Individual / $750 Family
Coinsurance
Adult 1
Paid $250
20%
Adult 2
Paid $175
Adult 2
Paid $100
20%
Child 1
Paid $ 75
Child 2
Paid $250
20%

35. Full family deductible must be met before plan shares cost
Office Visit Costs
Medical Plan
Copay
Deductible
Coinsurance
CORE Preferred
$3000 per individual
You pay 20%
Out-of-Network
Plan pays 80% of allowed rate
Blue Shield HSP Preferred
$1,250 single $2,500 family
You pay 20%
Out-of-Network
$2,500 single $5,000 family
Plan pays 60% of allowed rate
Full family deductible must be met before plan shares cost

36. Deductible, Coinsurance, OOPM
Blue Shield Health Savings Plan
Individual (Single)
Preferred Providers
You pay
You share cost with plan
Plan pays
100%
$1250 Deductible
20% Coinsurance
$4000 OOPM

37. Deductible, Coinsurance, OOPM
Blue Shield Health Savings Plan
Family Preferred Providers
The full family deductible must be met before plan shares costs
You pay
You share cost with plan
Plan pays
100%
$2500 Deductible
20% Coinsurance
$6400 OOPM

38. Hospitalization Costs
Medical Plan
Copay
Deductible
Coinsurance
HMO
$250
None
UC Care PPO UC Select
$250
None
Preferred
$250 indiv $750 family
You pay 20%
Out-of-Network
$500 indiv $1,500 family
Plan pays 50% of allowed rate
You pay balance

39. Hospitalization Costs
Medical Plan
Copay
Deductible
Coinsurance
CORE Preferred
$3000 per individual
You pay 20%
Out-of-Network
Plan pays 80% of allowed rate
Blue Shield HSP Preferred
$1,250 single $2,500 family
You pay 20%
Out-of-Network
$2,500 single $5,000 family
Plan pays 60% of allowed rate
Full family deductible must be met before plan shares cost

40. You pay 20% of ER physician
Emergency Room Costs
Medical Plan
Copay
Deductible
Coinsurance
HMO
$75
None
UC Care PPO UC Select
$100
None
You pay 20% of ER physician
Preferred
Waived
Out-of-Network

41. Full family deductible must be met before plan shares cost
Emergency Room Costs
Medical Plan
Copay
Deductible
Coinsurance
CORE Preferred
Waived for facility fee
You pay 20%
Out-of-Network
Blue Shield HSP Preferred
$1,250 single $2,500 family
You pay 20%
Out-of-Network
$2,500 single $5,000 family
Full family deductible must be met before plan shares cost

42. Out-of-Pocket Maximum
Medical Plan
OOPM
Notes
Health Net HMO
$1,000 indiv $3,000 family
Family = 3 or more
Kaiser HMO
$1,500 indiv
$3,000 family
Family = 2 or more

43. Out-of-Pocket Maximum
Medical Plan
OOPM
Notes
UC Care PPO UC Select
$1,500 indiv
$4,500 family
Family = 3 or more
In-Network providers
cross accumulate
Preferred
$3,000 indiv
$9,000 family
Out of Network
$5,000 indiv
$15,000 family
Out-of-network accumulates separately

44. Out-of-Pocket Maximum
Medical Plan
OOPM
Notes
CORE
$6,350 indiv $12,700 family
Family = 2 or more
Medical & Drug expenses apply
Blue Shield HSP Preferred
$4,000 indiv (single) $6,400 family
Full family OOPM must be met before plan pays 100% for any enrollee
In & Out-of-network accumulate separately
Medical & Drug expenses apply
Non-Preferred (Out-of-Network)
$8,000 indiv (single)
$16,000 family

45. Preferred Drug List (Formulary) is different for each carrier
Prescription Drugs
Preferred Drug List (Formulary) is different for each carrier
HMO UC Care
Blue Shield HSP CORE
Retail (30 day)
Generic
Brand
Non-formulary $5
$25
$40
You pay full cost of medication until you satisfy the deductible
After deductible, you pay 20% at preferred pharmacies
Mail Order (90 day)
$10
$50
$80

46. Blue Shield Health Savings Plan
High deductible medical plan paired with a Health Savings Account +
Blue Shield PPO
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.

47. Lumenos vs Blue Shield HSP
Blue Shield PPO
Deductible
Health Reimbursement Account (HRA)
Member pays
PPO Coinsurance
Deductible
Member pays
PPO Coinsurance
Health Savings Account
UC Contributions
Member Contributions
Lumenos HRA Rollover

48. Lumenos HRA Rollover
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.

49. Example: Lumenos PDHRA
Single Deductible $1,250
UC Contribution to HSA $500
Remaining balance $750
Pay with personal funds or Pay with your contributions to HSA
Lumenos PDHRA can be used to pay 20% coinsurance after deductible is satisfied

50. Why is HSA better?
You keep the money even if you change jobs or insurance plans
You can make contributions at any time
It has triple tax advantage
No Federal taxes on contributions
No taxes when funds are used
No taxes on earnings
HSA funds rollover from year to year; no use it or lose it as with Health FSA

51. Employees can maximize savings
UC Contribution (1/1/14)
$500 individual
$1000 family
You can contribute up to (optional):
Single-coverage: $2,800
Family-coverage: $5,550
Catch-up contribution, age 55+: $1,000
Tip: Contribute the money you would have put in your Health FSA.

52. 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

53. How does HSA work?
UC makes annual contribution for plans that start on January 1.
You may contribute through payroll deduction or make post-tax contributions to HealthEquity
Use a HSA debit card to pay for health expenses
Use HealthEquity website to pay medical and other health claims
Invest HSA dollars when account balance reaches $2000 – no fees to invest

54. HSA vs FSA
The HSA is NOT like the Health FSA where you have access to the entire annual contribution starting on January 1
The HSA is like a checking account – the money must be in the account before you can spend it
You make monthly contributions through payroll deduction, you can change the contribution amount during the year
You can make one time contributions through Health Equity

55. Use the HSA to pay for… Deductible Coinsurance
Any IRS Publication 502 Expenses, including:
Medical
Dental
Vision
Prescription drug
Long Term Care insurance premiums

56. Using your Health Savings Plan
Go to your doctor.
Later – check your HealthEquity account online to see required payment to the doctor.
Pay with your HSA funds through your HealthEquity online account. OR
Pay with another source (e.g. check, credit card)
Give doctor’s office your Blue Shield card so BSC can…
process the claim and get you their special provider discounts and
send info about your amount of claim responsibility to Health Equity

57. For more information
HealthEquity Member Services is available every hour of every day Call the Blue Shield/UC dedicated line say “Health Savings Account”

58. Optum (formerly United Behavioral Health)
Optum coordinates behavioral health care for all medical plans (except CORE)
psychiatrist
psychologist
therapist
substance abuse treatment
No referral required from physician
Call Optum to notify prior to first visit

59. Behavioral/Mental Health
Medical Plan
OPTUM Network
Out of Network
Health Net Blue & Gold
Visits 1–3 no copay
Visits 4+ $20
$250 inpatient hospitalization
Emergency only
Kaiser
(Optum & Kaiser Providers)

60. Behavioral/Mental Health
Medical Plan
OPTUM Network
Out-of-Network
UC Care
Visits 1-3 no copay
Visits 4+ $20
Inpatient $250
$500 deductible
Plan pays 50% allowed
You pay balance
Blue Shield HSP
Deductible:
$1,250 indiv $2,500 family You pay 20%
Deductible: $2,500 indiv $5,000 family Plan pays 60% allowed You pay balance

61. Behavioral/Mental Health
Medical Plan
Blue Shield Network
Out of Network
Core
$3000 deductible
You pay 20%
Plan pays 80% allowed
You pay balance
Note for all plans:
The medical and behavioral health deductibles cross-accumulate.
The medical and behavioral health coinsurance cross-accumulate toward a common out-of-pocket maximum.
In-network and out-of-network deductibles and out-of-pocket maximums do NOT cross accumulate.

62. Chiropractic & Acupuncture
Medical Plan
Providers
Costs
HMO
American Specialty Health
25% discount
UC Care Preferred
Blue Shield
After deductible,
You pay 20%
Out-of-Network
Non-Blue Shield
Acupuncture: Plan pays 80% allowed
Chiropractic: Plan pays 60% allowed
Note: Benefit is limited to 24 visits per calendar year combined for Acupuncture and Chiropractic visits

63. Chiropractic & Acupuncture
Medical Plan
Providers
Costs
Blue Shield HSP Preferred
Blue Shield
After deductible,
You pay 20%
Out-of-Network
Non-Blue Shield
Acupuncture: Plan pays 80% of allowed
Chiropractic: Plan pays 60% of allowed
Note: Benefit is limited to 24 visits per calendar year combined for Acupuncture and Chiropractic visits

64. Chiropractic & Acupuncture
Medical Plan
Provider
Out of Network
Core Preferred
Blue Shield
After deductible,
You pay 20%
Out-of-network
Non-Blue Shield
Acupuncture: Plan pays 80% allowed
Chiropractic: Plan pays 80% allowed
Note: Plan payment maximum up to $500 per calendar year

65. http://atyourservice.ucop.edu/oe Resources Medical Plans Other plans
Plan contacts
Plan rates
Medical Plans
Benefit summaries
Links to plan websites
Links to provider directories
Other plans
Dental, vision, FSA