The 2015 UHC Advantage Plan News
We were told on October 31st that the chart on page 7 of the guide for the 2015 Advantage plan was incorrect and that there were no changes in the plan for 2015 (in other words, the plan for 2015 is the same as the plan for 2014. We were told that a letter would be sent to all retirees with a corrected page 7 chart. I received the letter and the chart yesterday (November 6,2014). You may can also see the new chart on the UHC Advantage Plan website (see below).
The UHC Advantage Plan website for MembersThe The
The spring meeting of the Metropolitan Retiree Association took place at the auditorium of the Gustavus Adolphus Lutheran Church on 22nd Street in Manhattan on March 19th, 2014. Over one hundred persons attended.
Our speaker was Lisa Jaenisch,Strategic Account Executive of United Health care. Lisa has been with UHC for 13 years. Before that she was an Account Manager for Medicare Part D and has had extensive experience with AARP Medicare Supplement Plans.
Lisa explained that UHC has been in the Medicare business for 30 years and its Medicare Advantage Plan covers 18,000 of MetLife’s Medicare-eligible participants(changed “retirees” to participants because this number includes Medicare-eligible retirees and spouses). It is partially funded by the federal government,and that is why retirees must continue to pay premium to the government for Medicare Part B which is generally deducted from a retiree's social security payment. (Medicare Part A is generally free to eligible retirees over the age of 65.)
Lisa was asked some of the following questions:
· Why did MetLife change to Medicare Advantage instead of retaining Medicare as the primary insurer and using Aetna and United Health care as secondary insurers?
MetLife annually evaluates its health plans and how it manages costs. UHC was selected to administer a Group Medicare Advantage Plan. A Medicare Advantage plan generally offers coverage at a lower cost to retirees and the Company, thus making the MetLife Retiree Medical plan more sustainable for the immediate future. Employer-Sponsored Medicare Advantage plans differ from an individual Medicare Advantage plan, which often have lower benefit reimbursement and more limited access to doctors and providers; and they provide a more efficient delivery model, supporting better coordination of care and introducing clinical management.
- Why do retirees have to pay more during the deductible phase of the Plan than they did last year?
Last year, for 2013, after the Medicare Part B deductible was paid ($147), Medicare paid 80% of Medicare Part B claims (outpatient medical services). This year, after UHC’s annual deductible is met (which varies by plan design, but exceeds the Part B amount and in some cases is $600), the plan pays it’s applicable cost share up to the applicable out of pocket maximum. However, now the plan’s deductible includes Part A and B versus separate deductibles.
The Annual Deductible is the amount you have to pay out-of-pocket before UHC will pay its share for covered medical services (the deductible does not apply to Medicare-covered Annual Wellness exams, which are covered at100%). Your annual deductible applies to both Part A and Part B services,and equals the previous deductible provided under the Aetna/UHC secondary insurance. You now have one deductible for covered Part A and B services(e.g. the 2013 deductible under Medicare Part A was $1,184 per in patient hospital visit & under the UHC-MA plan covered hospitalization services are included in the overall annual deductible, which is lower.)
When you consider both the Medicare Part A and B deductibles and plan design/benefits, looking at last year's and this year's plans as a whole,they are actuarially equivalent. A retiree may spend more out-of-pocket upfront if only Part B services are received, or less if Part A services are received.
- How is Emergency Room coverage paid?
There is a $65.00 co-payment per visit for Emergency Services. And there is a copay for visits to a walk in medical service or Immediate/Urgent Care center of $55. These co-pays do not count toward the annual deductible, but any other charges which might arise from the Emergency/Urgent Care service above the $65/$55 co-pays count toward the annual deductible.
While Emergency/Urgent care co-pays do NOT apply to the plan’s annual deductible, they DO apply to the overall out of pocket maximum.
- Are there separate Out-of-Pocket (OOP) Maximums for in-network and out-of-network services?
The UHC Medicare Advantage Plan’s out of pocket maximum applies both to in network and out of network services. There are not two out of pocket maximums - just one combined.
- Can you use a provider that does not accept Medicare at all (i.e. opts out of Medicare)?
If you use a doctor or other healthcare provider that does not accept Medicare at all, then there will be no reimbursement from UHC unless it is an emergency. In an emergency, the reimbursement will be up to the amount it would have been if the provider accepted Medicare.
- How does it work if you use an in-network provider?
UHC has over 500,000 health care providers in its network. Each network provider has a contract with UHC. You can find a nearby network provider by going to the web site UHC retiree.com/MetLife and entering your zip code or by calling customer service to request a printed directory. The directory will include providers in your immediate area. A directory was included with your United Health care Welcome Kit.
- How does it work if you use an out of network provider who accepts Medicare but does not accept UHC Medicare Advantage?
If you go to a non-network provider, UHC will reimburse the non- network provider the same as Medicare would pay him or her (based on the Medicare fee schedule). If a doctor participates in Medicare, he or she may or may not accept Medicare assignment. If the doctor accepts Medicare assignment,he or she must accept the Medicare allowable amount. If a doctor does not accept Medicare assignment, he or she may charge up to the limiting charge, which is up to 15% more than the Medicare allowable amount. If the doctor charges the limiting charge, the plan considers that amount and the insured is usually responsible for 20% of the allowable charge(after the annual deductible is met). The doctor may NOT charge more than the Medicare allowable/limiting charge, what is called "Balanced Billing.” By Federal law, the doctor cannot charge more than the Medicare allowed amount. If this occurs, the member should contact their provider and UHC to assist with recouping any overpayment (especially if services were paid for up-front).
- How do you submit claims when you use out-of-network providers?
Most providers are willing to bill UHC directly; however, the provider may bill you directly or require you to pay prior to receiving services. If the provider bills you, please submit the claim to UHC and UHC will reimburse the provider directly. If you paid the provider directly, you can submit for reimbursement to UHC and UHC will reimburse you instead. UHC does not recommend a member fill out the detailed claim form (HCFA 1500)which is usually available to medical providers. What you must submit to UHC is your name and your member number from your ID card (or a copy of the card), a brief explanation as to why you are submitting the claim yourself (e.g. the doctor refuses to submit the claim himself),a copy of the itemized bill from the doctor which include the diagnosis code and the amount charged and proof if you paid this charge (like a copy of the credit card receipt or copy of the check). The correct address to send claims to is in the booklet called "Evidence of Coverage". It is UHC, P.O. Box 29675, Hot Springs, AR71903-9675. The claim address shown on the back of the ID card in Salt Lake City, Utah is really for provider’s usage but will also work,but it will take longer to process. UHC says less than 5% of doctors nationwide who participate in Medicare will not bill UHC; however, this depends on the area, the type of services being rendered and the provider practice’s preference.
Please reference the UHC Evidence of Coverage for further information regarding claims payment and submission.
- What laboratories bill UHC?
Lisa said that national labs such as Quest and LabCorp typically bill UHC directly.
- What is the coverage for rehabilitative therapy (physical, speech,occupational)?
Under the prior secondary UHC/Aetna coverage, there was a maximum amount of visits for physical therapy (90 visits combined for physical,occupational and speech therapies). Under the UHC Medicare Advantage plan there is no maximum (services continue to require medical necessity for continuous coverage). After the annual deductible has been met,the member is responsible for 20% of the allowable amount as coinsurance for each Medicare-covered therapy visit with no visit maximum.
- What extra benefits does UHC provide under this plan?
The Plan provides home visits by a healthcare professional, the HouseCalls program. It also provides behavioral health benefits. And, the Silver Sneakers program provides for free membership in a network of exercise centers across the nation. In addition as we had last year, Medicare Advantage provides a 24 hour, seven days a week nurse line to give you advice.
- What will happen at this fall’s open enrollment?
From year to year, retirees will receive an annual notice of changes(ANOC) from UHC. No significant changes are anticipated for next year. To remain in the Plan next year, you do not have to take any particular action yourself. However, please review any materials received from UHC and MetLife during the annual enrollment period for complete details.
Remember that once you opt out of the MetLife sponsored Medicare Advantage Plan; you are not eligible to re-enroll in MetLife sponsored medical/prescription drug benefits in the future.
- What is the difference between a "copay" when applied to general practitioners and Specialists and "coinsurance"?
Our ID cards say there is a "Co-pay" of 20% for general practitioners and 15% for Specialist. This could be confusing since the word "Co-pay" is often used to mean an amount required to be made to the doctor's office at the time of the visit. The use of"copay" in this context means “Coinsurance” which is the part(or percentage) of a medical bill you must pay when you get the bill for medical services. However, until you have paid the annual deductible of medical bills in 2014, you generally have to pay 100% of the charges that are allowed to be billed per Medicare and the Medicare Advantage plan rules. You generally do not have to pay anything at the time of your visit unless it is a service that requires a flat co-payment (e.g.Emergency/Urgent Care). After you have satisfied the annual deductible,UHC Medicare Advantage will pay allowable doctors’ charges except for the"co-payments" or “coinsurance” mentioned above (i.e., your share of the cost). Once you have reached your out of pocket maximum which varies based on your MetLife status, you generally do not have to pay these co-payments or coinsurance; at that point, UHC will pay 100% of all covered health services for both in and out of network.
- Does the co-pay go towards the OOP?
Once the annual deductible is satisfied, any applicable co-pay or coinsurance will be the member’s responsibility. The annual deductible applies to the annual out-of-pocket maximum as do most co-pays (e.g.Emergency/Urgent care services) and coinsurance amounts.
Co=pays do NOT apply to the annual deductible; however, they DO apply to the out of pocket maximum.
*Not all MetLife sponsored plans have the same deductible and out of pocket maximums. For example, the $600deductible and $1600 OOP apply generally to someone who retired after 1991 but prior to 2004. There are other designs including those who retired prior to1991, retired after 2004 or surviving dependents. See your booklet called"Evidence of Coverage" for details or call UHC to further confirm benefits.
Group Number 12355 (Health Care Choices, pre-1991)
Annual Deductible/OOP Maximum, $500/$500
Group Number 12357 (Health Care Choices, pre-1991)
Annual Deductible/OOP Maximum, $500/$1,500
Group Number 12356 (MetLife Choices, surviving dependents)
Annual Deductible/OOP Maximum, $600/$1,000
Group Number 12358 (MetLife Choices, pre-2004 retirees)
Annual Deductible/OOP Maximum, $600/$1,600
Group Number 12359 (MetLife Choices, post-2004 retirees)
Annual Deductible/OOP Maximum, $600/$2,250