Medicare & UC Medical Benefits

Transcription

1 Medicare & UC Medical Benefits UCSB Health Care Facilitator Program Laura Morgan UC Retirement Administration Service Center (RASC) This presentation is intended for communication purposes only. Please see plan documents and 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 2

3 Introduction to Medicare Original Medicare Foundation for UC Medicare Plans

4 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 6

5 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. 7

6 Three Parts of Medicare Part A - Hospital In-patient hospital Home health care Skilled nursing facility Hospice care Part B - Medical Doctors Lab tests Physical therapy Medical equipment Preventive care Part D Prescription Drugs 8

7 Medical vs Long Term Care Medicare & Medical Insurance Medically Necessary Care Skilled Nursing Facility Home Health Care Physical Therapy Long Term Care Insurance Activities of Daily Living Bathing Dressing Eating Personal Hygiene Walking Cooking Housekeeping 9

8 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 10

9 Medicare Costs Premium paid to Social Security

10 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 $ Monthly Premium (for most) 20% coinsurance for most services Part D Drugs No additional cost with UC medical plans 12

11 Income Related Adjustment Medicare Part B and D premiums may be higher for retirees with incomes over: $85,000 single $170,000 married 13

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 When a family member enrolls in Medicare that individual transfers to a UC Medicare plan Non-Medicare Plan Health Net Blue & Gold HMO Kaiser HMO UC Care (PPO) Core (Catastrophic) Blue Shield Health Savings Medicare Plan Health Net Seniority Plus HMO Kaiser Senior Advantage HMO Blue Shield Medicare PPO Blue Shield Medicare PPO Blue Shield Medicare PPO 15

14 Split Families Partner Plans When a family has both non-medicare & Medicare members Non-Medicare Members Health Net Blue & Gold HMO Kaiser HMO UC Care (PPO) Core (Catastrophic) Medicare Members Health Net Seniority Plus HMO Kaiser Senior Advantage HMO Blue Shield Medicare PPO Blue Shield Medicare PPO Blue Shield Health Savings is not available to split family 16

15 How UC Medicare Plans Work

16 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 18

17 UC Medicare Plans HMO Advantage Health Net Seniority Plus Kaiser Senior Advantage Supplements Blue Shield Medicare PPO High Option +Blue Shield Medicare PPO without Rx 19

18 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 20

19 Choice of Physician HMO Health Net Seniority Plus Kaiser Senior Advantage Medical You select Groups PCP PCP Sansum coordinates Clinic (Health care Net) PCP Santa refers Barbara to specialists Select IPA Specialists limited to physicians Buenaventura in medical (Kaiser) group Blue Shield PPO High Option Any Medicare physician Blue Shield providers for services not covered by Medicare 21

20 Are you moving? Must live in California Health Net Seniority Plus HMO Kaiser Senior Advantage HMO Available in US Blue Shield PPO High Option Available when LIVING out of US UC Care (without Medicare) Core (without Medicare) 22

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 Health Net Seniority Plus Kaiser Senior Advantage Service Copay Deductible $0 Office Visit $20 Urgent Care $20 No Deductible Emergency Room $65 Outpatient Surgical Center $100 Inpatient Hospital $250 25

24 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 26

25 Blue Shield Office Visit Example Medicare Allowable = $150 Who pays? Medicare pays 80% Blue Shield pays You pay for services PPO $120 $24 $6 High Option $120 $30 $0 27

26 Blue Shield Hospital Example Stay of 1-60 days Medicare Part A Deductible = $1,260 Who pays? Blue Shield pays You pay for services PPO $1,260 $0 High Option $1,260 $0 Medicare pays balance of bill 28

27 Blue Shield Skilled Nursing Example 1 st to 20 th day Medicare pays all approved amounts 21 st to 100 th day Medicare pays all but $ per day Who pays? Blue Shield pays You pay for services PPO 80% $126/day $31.50/day High Option 100% $157.50/day $0 Medicare pays all but $ per day 29

28 Are you traveling out of US? HMO Blue Shield PPO High Option Emergency & Urgent Care only Comprehensive Coverage $100 annual deductible You pay 20% Comprehensive Coverage $50 annual deductible You pay 20% 30

29 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 31

30 Prescription Drugs

31 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 33

32 Prescription Drug Costs Retail (30 day) Generic Brand Non-formulary Mail Order (90 day) Generic Brand Non-formulary Health Net* Kaiser $5 $25 $40 $10 $50 $80 Blue Shield $10 $30 $45 $20 $60 $90 *NOTE: With Health Net Seniority Plus you pay 25% of the cost of some selfinjectable and higher cost specialty drugs, up to $2000/year. See Medicare Part D formulary on 34

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. Medicare Plan Health Net Seniority Plus $2,000 Kaiser Senior Advantage $4,700 Blue Shield Medicare PPO $4,700 High Option $1,000 Rx Maximum 35

34 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. 37

35 Behavioral Health Mental Health & Substance Abuse Benefits

36 Behavioral/Mental Health Notify behavioral health plan prior to your first visit Medical Plan Health Net Seniority Plus Kaiser Senior Advantage Behavioral Health Plan Managed Health Network (MHN) with Medicare Call Kaiser Member Services Costs $20 office visit $250 inpatient hospitalization 39

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 No prior authorization required. Medical Plan Blue Shield PPO High Option Medicare Clinician You pay 20% of balance after Medicare You pay zero Non-Medicare Blue Shield Clinician After deductible, You pay 20% After deductible, You pay 20% 41

39 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 42

40 UC Medical Premiums Deducted from UC Pension Check

41 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. 44

42 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 45

43 Eligibility for UC Contribution 100% of Maximum UC Contribution Hired prior to 1/1/1990 (entered UCRP) OR Maximum UC Contribution 20 or more years of UCRP service credit Graduated Eligibility % of 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 46

44 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 47

45 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 48

46 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 49

47 Graduated Eligibility - Example Service credit = 15 years UC pays 75% of maximum UC Contribution $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 50

48 If you have Graduated Eligibility you can find your rates on this tool. 51

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51 Enrolling in Medicare 1) Enroll in Medicare 2) Complete UC forms

52 How to enroll in Medicare UC retiree or family member, turning 65 and. Receiving Social Security pension now NOT yet receiving Social Security pension 55

53 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. 56

54 NOT receiving Social Security About three months before you turn 65 Go to local Social Security office OR enroll on Enroll in Medicare Parts A & B If NOT eligible for Medicare request a denial letter from Social Security 57

55 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 58

56 Medicare Enrollment Timeline UC sends notice to enroll. UC sends Certified Letter. If no response, penalty deducted from pension check. $385 $385 $385 JAN FEB MAR APR MAY JUN JUL 65th Birthday Permanently dropped from medical benefits. 59

57 Exception to Medicare Mandate If you live outside the USA, you are not required to enroll in Medicare. 60