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
Agenda
Introduction to Medicare
How UC Medical Plans Work
Cost of Care
Prescription Drugs
Behavioral Health
UC Medical Premiums
Medicare Enrollment Process
Introduction to Medicare
Original Medicare
Foundation for UC Medicare Plans
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
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.
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
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
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
Medicare Costs
Premium paid to Social Security
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
13
Income Related Adjustment
Medicare Part B and D premiums may be higher for retirees with incomes over:
$85,000 – single
$170,000 – married
UC Retiree Medical Plans
Health Net Seniority Plus HMO Kaiser Senior Advantage HMO
Blue Shield Medicare PPO Blue Shield High Option
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
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
How UC Medicare Plans Work
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
19
UC Medicare Plans
HMO “Advantage”
Blue Shield Medicare PPO
High Option
+
Blue ShieldMedicare PPO without Rx
Supplements
Health Net Seniority Plus
Kaiser Senior Advantage
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
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
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)
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
Cost of Medical Care
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
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
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
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
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
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%
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
Prescription Drugs
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
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
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
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.
Behavioral Health
Mental Health &
Substance Abuse Benefits
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
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
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.
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
UC Medical Premiums
Deducted from UC Pension Check
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.
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
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
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”
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
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
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”
51
If you have “Graduated Eligibility”
you can find your rates on this tool.
https://uc2015.chooser2.pbgh.org
52
53
Enrolling in Medicare
1) Enroll in Medicare
2) Complete UC forms
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
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.
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
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
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.
60
Exception to Medicare Mandate