1、1,Blue Cross Plus 101 Tips for Employees,Brought to you by the UCSF Health Care Facilitator ProgramHR Benefits/Financial Planning 2007,2,Topics,Plan structure/design In-Network Benefits Out-of-Network Benefits Specific Coverage Issues Prescription Drug Benefits Behavioral Health Benefits Problem sol
2、ving,3,Plan Structure and Design,4,Whats the Plus in Blue Cross Plus?,Blue Cross Plus* is a Point of Service plan that gives members choice and flexibility Blue Cross Plus combines features of both HMO and PPO plans Members can choose to receive health care services from: In-network providers HMO st
3、ructure; PCP/medical group network or; Out-of-network providers Blue Cross Preferred Provider Organization (PPO) providers or: Non Preferred Provider Organization (PPO) providers*Subscriber must live in the California service area to be eligible for this plan.,5,The question asked most often Whats t
4、he difference between Blue Cross Plus and the Blue Cross PPO Plan?,Plans vary in Monthly premium Benefits covered Cost for services PPO plan does not include an HMO network; you self-refer for all services Both plans provide coverage for services from PPO and non-PPO providers the difference is in t
5、he cost for these services,6,How does the plan work? You Choose to,*Select In-Network level - Open Panel HMO All care is coordinated through a Primary Care Provider (PCP) Exceptions - Direct Access Programs, OB/GYN You pay a $20 co-pay for most services, $250 for hospital in-patient and $75 ER co-pa
6、y No claim forms, no deductibles *Based on benefits, 2007,*Select Out-of-Network level -PPO/non-PPO docs Self-refer for care After a $500 individual deductible, $1500 family (3 or more) the plan pays 70% of Usual Customary and Reasonable (UCR) charges for most services or 70% of the contracted rate
7、if there is one Self-referral to PPO providers means no balance billing World Wide Coverage,7,Blue Cross Plus Utilizing the In-Network Benefit Level,8,How does it work?,You select a Primary Care Physician (PCP) and Medical Group to manage your care PCP must be within 30 miles of your home/work Each
8、family member can choose different Medical Group and/or PCP When your PCP determines you need a specialized service, your PCP will refer you to a specialist, hospital or lab that is contracted with your Medical Group some exceptions Some services must first be authorized by the Medical Group,9,Blue
9、Cross Plus, In-Network Open Panel HMO,10,Blue Cross Plus Utilizing the Out-of-Network Benefit Level,Blue Cross, Preferred Provider Organization (PPO) and Non-PPO Providers,11,What is a PPO?,PPO stands for Preferred Provider Organization Blue Cross PPO Providers have contracted rates for services Thi
10、s means lower costs for services and lower out-of-pocket expenses No balance billing Usually no claim forms,12,Blue Cross Plus, Out-of-Network,How does it work? You self-refer to Blue Cross Preferred Provider Organization (PPO) providers and non-PPO doctors After a $500 individual deductible, $1500
11、for family (3 or more), the plan pays 70% of Usual, Customary and Reasonable (UCR) charges for most services or 70% of the contracted rate if there is one Self-referral to non-PPO providers means you are responsible to pay the amounts above UCR - also called balance billing,13,How do I find a PPO Pr
12、ovider?,Complete a provider search through the Blue Cross website: http:/ Scope License/Certification http:/www.healthscope.org,14,How are Usual, Customary and Reasonable Charges (UCR) Determined?,Usual, Customary and Reasonable (UCR) charges are based on guidelines set by the Department of Insuranc
13、eTypically this includes regional data blended with national standards for costsIt is determined annually,15,What is Balance Billing?,Balance billing is the amount above the Usual, Customary and Reasonable (UCR) charge for a service that a non-PPO provider may charge you, for example A Non-PPO provi
14、der charges $125 for a service Blue Cross determines that UCR is $100 Blue Cross will pay 70% of $100 or $70 and you are responsible for paying the difference* You pay $55 to the provider instead of the $30 that would have been required if the provider was charging you the UCR rate The $25 differenc
15、e is the Balance Billing*Assumes youve met the annual deductible,16,How do I obtain the UCR for services prior to obtaining care?,Ask your physician to contact Blue Cross and ask for the Disclosure of Legality form Provider completes form and includes procedure codes and fees Blue Cross responds to
16、both provider and member with pricing,17,Out-of-Pocket Maximums,Your Blue Cross Plus plan has both an In-Network and Out-of-Network Out-of-Pocket Maximum (OOPM) to protect you from catastrophic out of pocket medical expenses, meaning If your co-pays, co-insurance and deductibles paid in a plan year,
17、 equal your OOPM, additional care for covered services in that year are paid at 100% - review plan for excluded services Check the plan EOC to determine what costs count towards your OOPM. (Some costs are excluded.),18,Blue Cross Plus Out-of-Pocket Maximum 2007,19,Specific Coverage Issues,You should
18、 always verify in the EOC or with Blue Cross customer service if you have any questions, or to confirm your benefits.,20,Changing Your PCP/Medical Group,You can change your Medical Group and/or PCP outside of open enrollment by contacting Blue Cross Customer service at the number shown on your insur
19、ance cardUsually, if you call by 15th of month, change effective 1st of next month Blue Cross must approve your request for it to become effective If you are currently undergoing care for an escalated health care issue, Blue Cross may limit your ability to transfer to a new medical groupEach family
20、member may have their own PCP/Medical group,21,Student Dependents,Student dependents living in CA select a PCP near their school and use the in-network benefit level and/or; Self-refer to PPO and non-PPO providers and use the out-of-network benefit levelStudent dependents living out of state select
21、a PCP near their CA home address and use the in-network benefit level when visiting home and/or; Self-refer to PPO and non-PPO providers and use the out-of-network benefit level when at school,22,Direct Access Benefits,If your medical group participates in Direct Access, you can self-refer to the fo
22、llowing specialists and receive the in-network benefit level ($20 co-pay for office visit):Allergists/Immunologists Dermatologists ENTs/Otolaryngologists,23,Bay Area Medical Groups participation in Blue Cross Plus Direct Access Program:,YES Brown & Toland John Muir/Mt. Diablo Santa Clara IPAThis inf
23、ormation subject to change, contact your medical group to determine participation in Direct Access.,NO Alta Bates Marin IPA Chinese Community Hills Physicians Mills-Peninsula Sonoma County IPA,24,Obtaining OB/GYN services,Members may self-refer to an OB/GYN provider in their Medical Group NetworkPer
24、 the Knox Keene Health Care Service Plan Act of 1975, members may seek OB/GYN services from their network without prior approval,25,Chiropractic & Acupuncture Benefits,Members may self-refer to Chiropractors and Acupuncturists that are available through the American Specialty Health Plan (ASHP) netw
25、ork These services are covered only at the in-network level of the Blue Cross Plus plan and only when provided by an ASHP network provider. There is no out-of-network coverage. Members can contact the American Specialty Health Plan (ASHP) to get a list of providers (800) 678-9133 Review your Evidenc
26、e of Coverage (EOC) booklet for additional information Questions? - Contact Blue Cross member services (888) 209-7975,26,Infertility Coverage,Services related to diagnosis and treatment of infertility are covered only at the Out-of-Network level and only from Blue Cross PPO providers These services
27、are not subject to the plan deductible For detailed information, review your Evidence of Coverage (EOC) booklet http:/ Questions? - Contact Blue Cross member services, (888) 209-7975,27,Emergency Care,Blue Cross strictly enforces the following definition of an Emergency:“Emergency is a sudden, serio
28、us, and unexpected acute illness, injury, or condition (including without limitation sudden and unexpected severe pain) which the member reasonable perceives, could permanently endanger health if medical treatment is not received immediately. Final determination as to whether services were rendered
29、in connection with an emergency will rest solely with us or your medical group.” If you believe you have a medical emergency, you should seek medical treatment immediately.,28,Emergency Care,In Area Emergencies: Seek treatment and request treating provider contact your PCP/medical group as soon as p
30、ossible to request medically necessary continued care. Out of Area Emergencies (more than 20 miles from your medical group): contact Blue Cross within 48 hours if you are admitted to a hospital.,29,Second Opinions,You have the right to a second opinion by an appropriately qualified health care profe
31、ssional You must have initially seen a specialist you were referred to by your PCP If there is no appropriately qualified health care professional in the network, you may be authorized to see someone out-of-network,30,Reasons for requesting a Second Opinion include,The treatment plan in progress is
32、not improving your medical conditionYou are diagnosed with a condition that threatens loss of limb, body function Your PCP or the initial specialist is unable to diagnose your condition For additional reasons, consult your EOC,31,Blue Cross Plus and Behavioral Health Benefits,32,What are the Behavio
33、ral Health Benefits?,Behavioral Health Benefits are carved out meaning there is a separate plan administrator United Behavioral Health (UBH) is the administrator You initiate services by contacting UBH directly Members can choose to receive behavioral health care services from: in-network providers
34、(UBH network) or non-network providers,33,How does UBH work? In-Network Services,Out-Patient Therapy Call UBH directly, (888) 440-8225. UBH will either refer you to a provider or you can designate an in-network provider enter access code 11280 You pay $0 co-pay for first 5 visits, then $10 for 6+ v
35、isits No claim forms, no deductibles $500 annual out-of-pocket maximumInpatient Hospitalizations No co-pay Notify UBH within 48 hours for emergency admissionsReview EOC for substance abuse benefits,34,How does UBH work? Out-of-Network Services,Out-Patient Therapy You call UBH and notify them that yo
36、u are self-referring for care at the out-of-network level After a $500 individual deductible, the plan pays 70% of UCR for most services (only 50% of UCR if you fail to notify first) $5,000 annual out-of-pocket maximum Most providers require payment in full up front and you submit claim forms to UBH
37、 to request reimbursement Out-patient, out-of-network visits limited to 20 per individual annually Review EOC for in-patient care and substance abuse benefits,35,Other Behavioral Health Resources,UCSF Faculty and Staff Assistance Program (FSAP) FSAP provides confidential short term assessment and co
38、unseling,* and when appropriate, coordinates referral services to your HMO provider or other community /health care services resources (415) 476-8279 www.ucsfhr.ucsf.edu/assist*One to three sessions,36,Blue Cross Plus and Prescription Drugs Benefits,37,What are the Prescription Drug Benefits?,Prescr
39、iption drug benefits are administered by WellPoint, parent company of Blue Cross of CA Three tier design providing coverage for generic drugs Brand name drugs Non-formulary drugs (drugs not listed on the formulary) Questions? Contact WellPoint Pharmacy Mgt (800) 700-2541 Precision RX, Mail Order (86
40、6) 274-6825 https:/ Cross Plus Prescription Drugs, 2007,39,Prior Authorization of Medications,A small number of drugs require a Prior AuthorizationEnsures that patients receive medication appropriate for their condition Limits the use of expensive medications when there are less expensive alternativ
41、es Designed to help contain drug costs and ensure the University can continue to offer excellent health coverage for a fair premium during a time when medical and prescription drug costs are rising List of drugs requiring PAB available on line: select Pharmacy Programs,40,Prior Authorization of Ben
42、efits (PAB) Process,Physician completes appropriate form and faxes form to WellPoint Pharmacy Management, 888-831-2243WellPoint Pharmacy Management completes review for urgent requests within one day of receipt and non-urgent requests within two working daysThe prescribing physician is notified of t
43、he outcome. In the event the decision is a denial, a letter is sent explaining the medical reasons for the denialHave questions? Call (800) 700-2541,41,Problem Solving,Tips for Blue Cross Plus Members,42,Problem Solving,Review the EOC to determine the specific process for resolving disputes with the
44、 plan Write down your list of concerns before you make your phone call or visit Keep a log of all communication Names of representatives you speak with Dates of calls Information provided to you,43,What if you get a bill for a service?,Typically you should not get any bills for services received whe
45、n using the HMO level, the in-network level of your plan, if you do Call the customer service number on the bill and ask, “why am I being billed”? Billing error - Rep may need to re-direct claim to medical group or health plan Authorization issue - You may need to contact referring physician for ver
46、ification of authorization Eligibility issue - You may need to contact UCSF HR and/or your health plan to verify and update your eligibility If the above doesnt work, contact Blue Cross and let them know you have been billed for a service that you think should be covered by the plan,44,What if You C
47、ant Get a Timely Appointment With Your PCP?,Per the California State Department of the Patient Advocate, you have the right to get health care without waiting too long and to get an appointment when you need one If you cant get an appointment within a reasonable time frame Ask to speak to the office
48、 supervisor and firmly request that they fit you in at an earlier date File a grievance with your health plan Contact the Department of Managed Care 1-888-466-2219 Select a new PCP,45,What if You Receive a Denial for a Covered Service?,Request an Appeal if Your Medical Group or Plan Denies Requested
49、 Services If youve received a denial of service, follow the appeal process outlined in the denial letter The appeal process is also outlined in Evidence of Coverage (EOC) booklet Decision should be provided in writing within 30 days of receipt Not satisfied with the results of the grievance process? Contact the CA Department of Managed Care 1-888-466-2219,46,What if You Are Dissatisfied with the Plans Customer Service?,
