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Tuesday, October 15, 2013

Tuesday, October 15, 2013


By Berkeley Anonymous

Previous posts have identified problems with UC Care for employees at non-medical campus and a particular problem with the coverage around UCSB.

But there are broader problems with replacing Anthem’s Blue Cross Plus Program with UC Care. 

Anthem Blue Cross Plus had three tiers including an HMO which I guess most people used most of the time.  But it also allowed flexibility to get out-of-HMO care if needed

UC Care purports to be similar with three ostensibly corresponding tiers 1 - UC Select, 2 - PPO network, and 3 - out-of-network.  But as we heard before, the UC Care Select network excludes many doctors in the Anthem Blue Cross Plus HMO network.  Even the broader UC Care PPO omits some that were part of the PLUS HMO (including one of mine).  Going to Tier3 out-of-network means you’ll probably pay a majority of the cost out of pocket.  UC Care also seems to cover fewer prescriptions; specialty drugs cost some fourfold more.

Perhaps the biggest difference is that one could meet all medical needs using the Anthem Blue Cross Plus HMO -- never needing to pay deductible or co-insurance, even for some out-of-network consultations with specialists and while traveling.  Alternative medicine (acupuncture and chiropractic) were also covered at fixed co-pays without deductible.  Vast swaths of HMO medical expenses were free.  These included: laboratory tests & X-rays not at a hospital, outpatient ambulatory surgery, home health care, medical equipment & devices, hospice care, skilled nursing facilities, home infusion and nurses, emergency physician services, and ambulance.  Free!

UC Care is different.  The UC Care Select tier doesn’t cover most of those free services at all.  Instead, most are bumped to the PPO tier (along with alternative medicine), requiring deductable and co-insurance.   If the type of specialist you need isn’t in UC Care Select, you must go to the PPO tier.  Even some physician services at UC Care Select facilities seem to be billed as co-insurance.  It seems some illnesses will require some PPO tier treatment, with its substantially greater costs.

In short, Anthem Blue Cross Plus mixed low HMO co-pays with out-of-network flexibility when needed.  UC Care is just a PPO with deductibles and co-insurance, except for some Select types of coverage with Select doctors.

* * *
In light of this it is worth looking at the other UC PPO option.  At the bottom of the totem pole in the UC insurance world is the Core plan, the only choice for employees who do not work enough hours to qualify for full or mid-level benefits. However, the costs and benefits of the new UC Care plan make the Core plan look comparatively attractive.
The Core plan has a $0 employee premium.  Though it has a $3000 deductable and co-insurance on drugs, its _maximum_ out-of-pocket cost of $6,350 is not vastly higher than -- or even lower than -- the employee family premium alone for the UC Care program ($4,392 in IncomeBandII, $6,917 in IncomeBandIV -- though bear in mind that premiums are pre-tax).  Its out-of-network benefits look better than UC Care.

So, the Core plan could be the most cost-effective plan for many families, considering premium plus out-of-pocket costs.

CORRECTION:  http://atyourservice.ucop.edu/oe/medical/core.html says “Annual out-of-pocket maximums ($6,350 per member) limit what you pay.”   In my original post I assumed “member” meant employee or family.  However, it turns out that “member” means “family member;” i.e., the out of pocket is $6,350 per person, and for a family the maximum is $12,700.  This is listed in the new detailed plan description, at https://www.blueshieldca.com/sites/uc/documents/2014-OE-Brochure-Non-Medicare.pdf (page 12).   Given this, it turns our that Core will not be as appealing as I previously suggested.

UPDATE: Also, there is a confusing statement at http://atyourservice.ucop.edu/oe/tools-resources/discontinued-plans/anthem-plus-plan.html which says:

"If you do nothing
 You will be enrolled in the new UC Care plan, with the same dependent coverage you have now. UC Care has the same in-network and out-of-network coverage you have now, with much more."

This statement on the UCOP website is only true if "with much more" is interpreted to mean "with more out-of-pocket expense, for deductible and co-insurance charges."


W Zame said...

I believe the analysis is much more complicated than you suggest. "Out of pocket maximums" is not a well-defined phrase. At least some insurance plans -- perhaps Anthem currently and UC Care prospectively -- cover only the amount they would pay a participating provider. So if you had a $100,000 expense that the participating provider rate would cover only $20,000 then the difference of $80,000 would NOT be covered as part of the out of pocket maximum. In fact, some "experimental" procedures would not be covered at all. After my wife's death I was asked to pay $100,000 for her radiation therapy which was not covered ... this in addition to the out of pocket maximum. Thus using a non-participating provider can wind up being incredibly expensive. This also has enormous implications for the choice of the CORE plan as well.

obat herbal stroke said...
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Anonymous said...

Yeah Tier 1 can be a scam as well. My son had a minor procedure (upper GI -- took 5 mins, under modest sedation) at Rady Children's Hospital SD (a tier 1 facility, we even checked with blue shield ahead of time). They billed the procedure for $16k (absurd if you ask me), into Tier 1, so they hit me for the standard $100 outpatient surgery. Ok. Then I get another bill from the Anesthesiologist (same procedure, same facility, same claim even) as Tier 2! So they bill like $600 (also absurd, we're talking isoflurane). So they bill me the Tier 2 deductible $250, plus 20% which after discounts is another $45 or so. So in fact, the outpatient "surgery" of an upper GI is costing me $395, not $100. Mind you under the old plan this would have been I think $0. Never mind if you get unlucky enough to have to go to the E.R., where physician services are billed at 20%, and if you happen to say have a heard attack out of state, you are talking 50%+. Overall, quite absurd. Obviously I will fight it since it reminds of the old (and now illegal) Balance Billing hospitals used to do, but I wouldn't be surprised if they think it makes sense. Obviously, if this had been something major you could easily be paying $1000's of dollars.

Anonymous said...

I have never been so dissatisfied or upset with an insurance company in my life! We had
Health Net HMO for 6 years... I never, repeat NEVER had a referral for treatment denied.
Yet, in my first experience with Blue Shield they perfunctorily denied Supartz shots for Osteoarthritis of my knees, giving all manner of reasons. The letter was extremely vague stating the FDA hadn't approved Supartz for the treatment requested and/or there was no scientific research to support that more then 2 series of injections were beneficial.. The FDA disagrees and I am filing a complaint., Additionally, I found Blue shield websites for 5 other states that state the corporate operating codes for Supartz and not only are they covered for additional treatments they have numerous links to articles and reports on how Supartz helps with pain and gait, range of motion and limiting further degeneration of the joint and cartilage.. I guess the standard of care for California is a lesser standard then for other states. Shame on Blue Shield and Shame on the U.C. Healthcare Administrators for putting such an incredible financial burden on it's employees! Not to mention emotional! I am in constant, debilitating pain. I have tried everything. the rational is irrational!
The costs a family will incur if family members have chronic health problems is obscene. I feel like we are giving our money away this year because I was so upset that I feel like boycotting my own health care! It is my understanding that for a family of 3. U.C. Davis is paying approximately 15-1600. per month while the employees pay anywhere from 4-600. per month.
We were told that HealthNet was discontinued because the U.C. system was trying to help consumthis hardly seems like a "Benefit" more like a "Punishment"

Anonymous said...

Additionally, We will NEVER, NEVER, EVER, sign up for Blue Shield or U.C. Care again!

Chris Newfield said...

thank you for letting us know. The UCOP claim that Blue Shield = Blue Cross wasn't convincing last year, and now the demonstration in coming in, piece by piece. I'm sorry to hear about what you are being put through by this change.

Anonymous said...

UC CARE is the worst conceivable health insurance plan. Everything is covered at the absolutely minimum level and diagnostic tests are not approved, being called explorative. Any modern technology is expensive and is not considered standard procedure. They really do not care to diagnose you early.I hate myself that I am stuck in such a low quality system. The premiums are very low, but that's what you get at the end.

Franklin, Assisted Living Provider said...

That HMO you describe sounds pretty excellent. We switched to a Health Net PPO and have had excellent service so far (to be fair I haven't needed to use anything too odd). The basics are all covered! Not sure how some of these insurance companies can get away with providing partitioned health care at exorbitant prices. Ugh. Thanks for the post!

Metro West Insurance said...

Health insurance is so rough right now - none of the metrics they use to tell you how they're different actually mean anything. Is the maximum out-of-pocket payment an actual maximum, or are they going to find some loophole to get you to pay more? I have no idea and the company won't tell me. Wish they would actually regulate this industry.

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