1. Look beyond the premium.
Sure, the monthly premium is predictable and will remain unchanged for the plan year, but the full cost of the plan to you will depend on a number of factors. This is true whether you’re considering the lowest-premium plan or even the highest-premium plan. Think about how the plan you select will work for you: your access to doctors, the range of benefits and what you pay when you use the services.
2. Identify your needs.
Think about what’s important to you.
- Do you want to keep your costs for medical services as low as possible?
- Are you satisfied with being restricted to a specific group of doctors and having your services referred and authorized by a primary care doctor and medical group? Or are you willing to pay a higher premium in order to access specialists directly, without authorizations?
- Do you or a family member want to see specific doctors, and are those doctors available under the health plan you are considering?
- Are there specific services or treatments you would like covered?
- Do you or a family member regularly use prescription drugs, and are the drugs you need on the plan formulary or list of preferred drugs?
3. Understand the basics of how plans work.
UC offers different types of plans and they all work very differently.
- HMOs (Health Maintenance Organizations) limit covered services to specific doctors and hospitals, and many services, including consultations with specialists, must be authorized in advance by your primary-care doctor, medical group or health plan. With HMOs, you pay set copays for most services. HMOs generally are more restrictive than PPO plans, but they help keep your costs for covered services lower. UC offers three HMOs: Health Net Blue & Gold, Kaiser and Western Health Advantage (UC Davis area only).
- A PPO (Preferred Provider Organization) plan allows you to direct your own care and decide where to obtain most services. You are not required to obtain authorization to consult specialists, but the plan should pre-certify some services — surgeries, for example. If you use the plan’s participating providers, you pay less than if you use providers who are not contracted with the plan. Under a PPO, you are subject to annual deductibles and coinsurance for most services. UC Care is a PPO plan. In addition to the usual PPO in-network and out-of-network tiers, it has an extra tier, called UC Select. If you see a provider in UC Select, you pay a copay rather than coinsurance.
- A PPO with Health Savings Account plan is a high-deductible PPO plan with a Health Savings Account (HSA) to help pay eligible expenses. The HSA can be funded by the employer and employee, up to IRS limits, and can be used to help cover the deductible and pay eligible expenses. Until you meet the deductible, you pay, from your own funds or from the HSA, the full cost for services and prescription drugs. After the deductible is met PPO benefits begin, and you pay a coinsurance or percent of the cost of care. You may see any provider you choose, but choosing a plan-contracted provider helps keep your costs lower. The UC Health Savings Plan is UC’s PPO with HSA, and UC funds an initial contribution to the HSA for you.
- The fee-for-service indemnity plan that UC offers, called Core, has a very high deductible. You pay all costs until the deductible is met. Then Core provides coverage for basic medical services, for which you pay a coinsurance. Under the Core plan, you may choose any provider, but Anthem Blue Cross PPO network providers cost less.
4. Consider out-of-pocket costs.
Your out-of-pocket costs are the amounts you should expect to pay for services under your plan. In general, with HMOs you pay set copayments, and with PPOs you are subject to annual deductibles and coinsurance amounts for most services. There may be services for which you must pay a coinsurance under an HMO (for example, infertility treatment on some plans). As a result of health care reform legislation, certain preventive care services are provided at no charge. You can review a plan’s schedule of benefits to learn what your share of the cost will be for specific services.
Plans also have annual maximum out-of-pocket amounts, which are often overlooked. A plan’s out-of-pocket maximum protects you from paying an unlimited amount for services. Once you reach the maximum out-of-pocket, the plan pays 100 percent of most medical services for the remainder of the calendar year.
5. Determine the plan's covered benefits and exclusions.
Review the range of benefits the plan covers, as well as what is not covered, in light of your specific needs. Some plans offer enhancements, such as coverage for chiropractic care and acupuncture. Infertility coverage differs among UC plans.
6. Think about what happens when you travel, or if your son or daughter is in college.
If you travel or have a family member who lives out of the area, you may want to select a plan that provides services out of the area. HMO plans cover only emergency and urgently needed services when you are outside of your plan’s service area, with the exception of Kaiser’s Visiting Member Benefits. UC Health Savings Plan, UC Care and Core provide coverage when you are outside of your area. UC Care and Core provide the full range of plan benefits when you are outside the US; the UC Health Savings Plan provides coverage for emergency care only when outside the US.
7. Consider whether you expect any life changes in the new year.
If you are anticipating changes to your family, or if you are planning to retire, you should consider what your needs may be after your circumstances change. UC allows you to change plans outside of Open Enrollment when you have a newly eligible family member. A new family member may result in premium increases and a change in the plan services you and your family will be using.
Retirement and coordination with Medicare may affect your plan benefits. You generally cannot change plans at the time of retirement, with a few exceptions, such as moving out of your plan's service area or transitioning to your plan's Medicare plan. After you retire, you can change plans at the next open enrollment. If you are retiring mid-year, anticipating how your plan will work in retirement — with Medicare, if you are eligible — can be important.
8. Consider coverage for prescription drugs.
Copays and coinsurance for prescription drugs vary among plans. With most UC plans, you pay set copays for most covered prescription drugs. UC Health Savings Plan and Core members are responsible for the full cost of prescription drugs until the annual deductible is met. Most plans have formularies or lists of preferred drugs. If your drug is on the plan’s formulary, your copays or coinsurance for the drug are lower than if the drug is a non-formulary medication. Check the plan formulary to see if your drugs are on it to help keep your costs lower.
9. Know what behavioral health benefits are being offered.
All of UC's medical plans include behavioral health benefits for mental health services and substance abuse treatment. Here are a few things you should know:
- If you select an HMO plan and do not have Medicare, you may access care from Optum in-network providers. Kaiser members may access care from Kaiser behavioral health providers or from Optum in-network providers.
- Retirees with a Medicare HMO (Health Net Seniority Plus or Kaiser Senior Advantage) are not covered by Optum. Kaiser Senior Advantage members must use Kaiser providers. Health Net Seniority Plus members should refer to the plan member handbook or call the plan to find out where and how to obtain care.
- If you select a PPO plan, you may access care from Anthem Blue Cross in-network providers. You may also access care from out-of-network providers, but your costs will be higher and you may need to pay your provider directly for services and submit a claim for reimbursement.
- UC retirees with Medicare and an Anthem plan can select Medicare, Anthem or out-of-network behavioral health pvoiders, but using a Medicare provider, when possible, will result in lower costs to you.
- Regardless of whether you select an HMO or PPO, you do not need a referral from your primary care provider or health plan to see a behavioral health provider. Some services, such as extended length therapy sessions (beyond 50 minutes) and treatment programs, do require preauthorization.
Congratulations! You're on the road to finding the “best” plan for you and your family.
The UC-sponsored plans are varied and none can be said to be the best one overall. If you review the plan benefits and costs, and consider your personal circumstances, you will be prepared to select the best plan for you.
Special thanks to Bridget Sheehan-Watanabe, UCLA health care facilitator.