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Medicare &

UC Medical Benefits

UCSB Health Care Facilitator Program Laura Morgan

893-4201

UC Retirement Administration Service Center (RASC) 1-800-888-8267

This presentation is intended for communication purposes only. Please see plan documents and http://ucnet.universityofcalifornia.edu for complete information.

6/25/15

(2)

2

Agenda

Introduction to Medicare

How UC Medical Plans Work

Cost of Care

Prescription Drugs

Behavioral Health

UC Medical Premiums

Medicare Enrollment Process

(3)

Introduction to Medicare

Original Medicare

Foundation for UC Medicare Plans

(4)

6

What is Medicare?

Federal program that provides health care coverage to:

People over 65

People with disabilities

End Stage Renal Disease

Covers most medical services

Does not pay total cost of care

Foundation for all UC Medicare plans

(5)

7

Medicare Eligibility

You can be eligible for Medicare through your own work history.

OR through the work history of your spouse.

To clarify your eligibility, contact Social

Security.

(6)

8

Three Parts of Medicare

In-patient hospital

Home health care

Skilled nursing facility

Hospice care

Doctors

Lab tests

Physical therapy

Medical equipment

Preventive care

Part B - Medical Part A - Hospital

Part D – Prescription Drugs

(7)

Medical vs Long Term Care

Medicare &

Medical Insurance

Medically Necessary Care

Long Term Care Insurance

Activities of Daily Living Skilled Nursing Facility

Home Health Care Physical Therapy

Bathing Dressing

Eating

Personal Hygiene Walking

Cooking Housekeeping

9

(8)

10

3 Types of Medicare Providers

Physician “accepts assignment”

Certified with Medicare

Will accept the Medicare rate for services

Physician does not “accept assignment”

Certified with Medicare

May charge up to 15% more than the Medicare rate for services – you pay additional charge

Physician does not take Medicare

Not certified with Medicare

Medicare and UC plans will not pay for services

(9)

Medicare Costs

Premium paid to Social Security

(10)

12

2015 Medicare Costs

Part A – Hospital

No Monthly Premium

$1,260 Deductible per spell of illness

Graduated cost for stays over 60 days

Part B – Medical

$104.90 Monthly Premium (for most)

20% coinsurance for most services

Part D – Drugs

No additional cost with UC medical plans

(11)

13

Income Related Adjustment

Medicare Part B and D premiums may be higher for retirees with incomes over:

$85,000 – single

$170,000 – married

(12)

UC Retiree Medical Plans

Health Net Seniority Plus HMO Kaiser Senior Advantage HMO

Blue Shield Medicare PPO Blue Shield High Option

(13)

Transition to Medicare Plan

15 Non-Medicare Plan Medicare Plan

Health Net Blue & Gold HMO Health Net Seniority Plus HMO Kaiser HMO Kaiser Senior Advantage HMO UC Care (PPO) Blue Shield Medicare PPO

Core (Catastrophic) Blue Shield Medicare PPO Blue Shield Health Savings Blue Shield Medicare PPO

When a family member enrolls in Medicare that individual transfers to a UC Medicare plan

(14)

Split Families – Partner Plans

16 Non-Medicare Members Medicare Members

Health Net Blue & Gold HMO Health Net Seniority Plus HMO Kaiser HMO Kaiser Senior Advantage HMO UC Care (PPO) Blue Shield Medicare PPO

Core (Catastrophic) Blue Shield Medicare PPO

When a family has both

non-Medicare & Medicare members

Blue Shield Health Savings is not available to split family

(15)

How UC Medicare Plans Work

(16)

18

UC Medicare Plans

When you transition from a non-Medicare plan to a Medicare plan, you may find the plans differ in several ways:

Plan benefits

Costs

Service area

Medical providers

Behavioral Health providers

Enrollment/de-enrollment process

(17)

19

UC Medicare Plans

HMO “Advantage”

Blue Shield Medicare PPO

High Option

+

Blue Shield

Medicare PPO without Rx

Supplements

Health Net Seniority Plus

Kaiser Senior Advantage

(18)

20

Coordination with Medicare

HMO

Health Net Seniority Plus

Kaiser Senior Advantage

You assign your Medicare to the insurance plan

Cannot use Medicare outside the plan

Blue Shield PPO High Option

Medicare is primary payer

Blue Shield is secondary payer

(19)

Medical Groups

Sansum Clinic (Health Net)

Santa Barbara Select IPA

Buenaventura (Kaiser)

21

Choice of Physician

HMO

Health Net Seniority Plus

Kaiser Senior Advantage

You select PCP

PCP coordinates care

PCP refers to specialists

Specialists limited to

physicians in medical group

Blue Shield PPO High Option

Any Medicare physician

Blue Shield providers for services not covered by Medicare

(20)

22

Are you moving?

Available in US

Blue Shield PPO

High Option

Must live in California

Health Net Seniority Plus HMO

Kaiser Senior Advantage HMO

Available when LIVING out of US

UC Care

(without Medicare)

Core

(without Medicare)

(21)

OneExchange – Living out of CA

Retiree living out of California

ALL family members are enrolled in Medicare

UC makes annual contribution to a Health

Reimbursement Account (HRA) for retiree and each family member

Retiree uses HRA funds to purchase individual

Medicare supplement plans through OneExchange

UC contribution is subject to graduated eligibility

Can use extra HRA funds to pay medical expenses and Part B premium

23

(22)

Cost of Medical Care

(23)

HMOs have copays for care

25

Service Copay

Deductible $0

Office Visit $20

Urgent Care $20

Emergency Room $65

Outpatient Surgical Center $100 Inpatient Hospital $250

Health Net Seniority Plus Kaiser Senior Advantage

No

Deductible

(24)

26

Blue Shield - Deductibles

Deductibles paid by Blue Shield

Medicare Part A (Hospital) = $1,260

Medicare Part B (Medical) = $147

Deductible paid by you

Plan deductible for services not covered by Medicare – see plan summary

Blue Shield PPO = $100 per individual

High Option = $50 per individual

(25)

Blue Shield – Office Visit Example

Who pays?

Medicare pays 80%

Blue Shield pays

You pay for services

27

Medicare Allowable = $150 PPO

$120

$24

$6

High Option

$120

$30

$0

(26)

Blue Shield – Hospital Example

28

Who pays?

Blue Shield pays

You pay for services

PPO

$1,260

$0

High Option

$1,260

$0 Stay of 1-60 days

Medicare Part A Deductible = $1,260

Medicare pays balance of bill

(27)

Blue Shield – Skilled Nursing Example

29

Who pays?

Blue Shield pays

You pay for services

PPO

80%

$126/day

$31.50/day

High Option

100%

$157.50/day

$0 1st to 20th day Medicare pays all approved amounts 21st to 100th day Medicare pays all but $157.50 per day

Medicare pays all but $157.50 per day

(28)

30

Are you traveling out of US?

HMO Emergency & Urgent Care only Blue Shield PPO

Comprehensive Coverage

$100 annual deductible

You pay 20%

High Option

Comprehensive Coverage

$50 annual deductible

You pay 20%

(29)

31

Paper Chase!

Medicare Summary Notice

Describes what Medicare pays

Explanation of Benefits (EOB)

Describes what the insurance plan pays

Bills & Statements

What you pay the provider

(30)

Prescription Drugs

(31)

33

Prescription Drugs - Part D

All plans have Medicare Part D

NO additional premium for Part D, for most

Copays – NO “donut hole”

Some formulary (drug list) changes

ID cards with Part D logo

HMO members receive 1 card

Blue Shield members receive 2 cards

1 medical card and 1 drug card

(32)

Prescription Drug Costs

34 Health Net*

Kaiser

Blue Shield

Retail (30 day)

• Generic

• Brand

• Non-formulary

$5

$25

$40

$10

$30

$45 Mail Order (90 day)

• Generic

• Brand

• Non-formulary

$10

$50

$80

$20

$60

$90

*NOTE: With Health Net Seniority Plus you pay 25% of the cost of some self- injectable and higher cost specialty drugs, up to $2000/year.

See Medicare Part D formulary on http://www.healthnet.com/uc

(33)

Prescription Drug Maximum

After you pay the following amount for prescriptions drugs, the plan pays 100%

of the costs for the rest of the year.

35

Medicare Plan Rx Maximum Health Net Seniority Plus $2,000

Kaiser Senior Advantage $4,700 Blue Shield Medicare PPO $4,700

High Option $1,000

(34)

37

If you have two retiree plans…

Medicare allows only 1 Part D plan

If you have a Part D benefit with a non-UC plan:

You may keep other retiree drug plan and enroll in Blue Shield Medicare PPO

without Rx.

UC will contact eligible retirees.

(35)

Behavioral Health

Mental Health &

Substance Abuse Benefits

(36)

39

Behavioral/Mental Health

Kaiser

Senior Advantage Call Kaiser Member Services Medical Plan Behavioral

Health Plan Costs Health Net

Seniority Plus Managed Health Network (MHN)

with Medicare

$20 office visit

$250 inpatient hospitalization

Notify behavioral health plan prior to your first visit

(37)

Blue Shield Behavioral Health

Medicare covers some clinician’s, Blue Shield covers others.

Medicare covers Psychologists,

psychiatrists, clinical social workers who are contracted with Medicare.

Blue Shield covers Marriage Family

Therapists (MFT, MFCC) who are not allowed to contract with Medicare. This is a non-

Medicare benefit added to the UC plan.

40

(38)

Behavioral/Mental Health

Medical Plan Medicare

Clinician Non-Medicare Blue Shield

Clinician Blue Shield PPO You pay 20% of

balance after Medicare

After deductible, You pay 20%

High Option You pay zero After deductible, You pay 20%

41

No prior authorization required.

(39)

42

Retiree Vision Options

Routine eye exam and eyewear

Vision Services Plan (VSP)

Enroll during Open Enrollment

Retiree pays full monthly premium

Health Net Seniority Plus (EyeMed)

Coverage included in medical premium

Benefit is similar to VSP

(40)

UC Medical Premiums

Deducted from UC Pension Check

(41)

44

Future UC Contributions

UC may reduce the overall level of

contribution to systemwide retiree health

programs by 3% percent per year, to a floor of 70%.

Each year, UCOP will reassess the level of

contribution.

(42)

45

Maximum UC Contribution

Each year UC determines the maximum amount that UC will pay toward a retiree’s medical and dental insurance

Some retirees receive the “maximum UC contribution”

Some retirees have “graduated eligibility” and receive a

% of the maximum amount

The amount of the UC contribution depends on:

Retiree health eligibility rules

Years of UCRP service credit

(43)

46

Eligibility for UC Contribution

100% of Maximum UC Contribution

Hired prior to 1/1/1990 (entered UCRP)

OR

20 or more years of UCRP service credit

Graduated Eligibility

% of Maximum UC Contribution

Maximum UC Contribution

5% of Maximum UC Contribution per year of service credit

Hired after 1/1/1990 (entered UCRP) and

Less than 20 years of UCRP service credit

(44)

47

Guide to UC Medical Premiums

Premiums change when you or a family member enroll in Medicare

Maximum UC Contribution – find premiums on rate chart

Graduated Eligibility – find premiums on

UCnet with “Medical Plan Chooser”

(45)

48

Maximum UC Contribution – Rate Chart

All family members in Medicare

One or more are not in Medicare

Non-Medicare Plans

All family members under 65

Non-Medicare Age 65 and Over

UC Retiree did not coordinate with Social Security when employed

No one in family eligible for Medicare

Rates are same as employees in category 2

(46)

49

Medicare Part B Reimbursement

If your UC medical plan premium is zero, you may receive a full or partial

"reimbursement" of your Medicare Part B premium – example:

$0.00

$44.49 > added to UC pension

The amount of the reimbursement depends on the premium UC is charged by the

insurance carrier for your plan

(47)

50

Graduated Eligibility - Example

$326 Maximum UC Contribution

(single/Medicare)

$244 75% of maximum UC Contribution

$344 Gross premium

(single/Health Net Seniority Plus)

- $244 75% of maximum UC Contribution

$100 = Monthly premium paid by retiree

Service credit = 15 years

UC pays 75% of maximum “UC Contribution”

(48)

51

If you have “Graduated Eligibility”

you can find your rates on this tool.

https://uc2015.chooser2.pbgh.org

(49)

52

(50)

53

(51)

Enrolling in Medicare

1) Enroll in Medicare

2) Complete UC forms

(52)

55

How to enroll in Medicare

UC retiree or family member, turning 65 and….

Receiving Social Security pension now

NOT yet receiving Social Security pension

(53)

56

Receiving Social Security Now

You are automatically enrolled by SSA.

Social Security will send you a Medicare card in the mail a few months before you turn 65.

The card should have “effective dates” for

Medicare Parts A & B.

(54)

57

NOT receiving Social Security

About three months before you turn 65

Go to local Social Security office

OR enroll on http://www.ssa.gov/

Enroll in Medicare Parts A & B

If NOT eligible for Medicare request a

denial letter from Social Security

(55)

58

UC Enrollment Forms

Three months before you or a family member turns 65, UC will mail you the enrollment form for your medical plan

UC will transfer your enrollment to the Medicare version of your medical plan

UC will enroll you in a Medicare Part D

(drug) plan

(56)

59

Medicare Enrollment Timeline

JAN FEB MAR APR MAY JUN JUL

If no response, penalty deducted from pension check.

UC sends notice to enroll.

UC sends

Certified Letter.

$385 $385 $385

65th Birthday Permanently dropped from medical benefits.

(57)

60

Exception to Medicare Mandate

If you live outside the USA,

you are not required to enroll in

Medicare.

References

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