Alternative Medical Plans for Retirees
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1 Sonoma County Alternative Medical Plans for Retirees Presentation to the JLMBC October 30, 2008 & June 18, e The Segal Company Tom Morrison Bobby Mitchell
2 Differences between Medicare and Non-Medicare Retirees Medicare Eligible Retirees Those retirees over 65 and eligible to participate in Medicare have health costs subsidized by Medicare Medicare has established by law, multiple subsidized insurance plans for this group (Part C and Part D) Insurance companies and large associations, such as AARP have capitalized on this subsidy and developed retiree products Some companies have offered low cost plans to replace Medicare
3 County of Sonoma Comparison of Group Medicare Options Offered by United Retiree Solutions AARP Medicare Supplement MedicareComplete MAPDHMO MedicareDirect PFFS Premium Basis Individual Rate Based on Age/Gender/Zip Single Blended County Rate Single Blended County Rate Availability Outside California 50 States, DC, Puerto Rico, Guam, US Virgin Islands 36 States, DC 50 States, DC Medical UndelWriting No No No Split Billing Capabilities (United can collect Retiree premium separately) Yes (Including Enrollment & Customer Service) No No Minimum Enrollment Requirements 1 5 Total (No Minimum per MarkeVRegion) 25 per MarkeVRegion Can only be offered to: CA,AZ&WA 25 per MarkeVRegion Can only be offered to: CA,AZ&WA Medicare Part B Assignment No Yes Yes Eligible to Enroll if not Medicare A Enrolled No No No Plan Year/ Rate Change Requirements Must be Jan - Dec Any Any Census Required for Rates Yes Yes Yes Rx is (or Can Be) Combined with Medical Plan No (Must Purchase PDP Separately) ($ $44.60 PMPM) Yes Yes Rate Information (PM PM) Plan C - $98 - $288 (Average based on census - $164) Plan J - $108 - $297 (Average based on census - $172) CA: $330 $369 AZ: $228 - $263 WA: $156 - $194 Major PFFS Changes Coming No quote provided 1 Plans can be offered by marketlregion if all markets will not meet the minimum enrollment requirements SEGAL United Retiree Solutions 10/28/2008
4 Medicare Retirees - Recommended Plan AARP Medicare Supplement - United HealthCare Has national recognition through AARP Group marketing contract benefits retirees Requires only 5 retirees in total to elect to enroll Available in 50 states and additional US territories Can be customized by each retiree as to benefit level and premium (varies by state and age of retiree) Separate drug benefit and cost (or Part D) Centralized billing of any contribution from retirees One centralized customer service location and phone number Guarantee of issue Portable between states
5 Medicare Retirees - Examples AARP Medicare Supplement - United HealthCare
6 Medicare Retirees - Plans Vary by Type of Contract Individual Plans Sold to the Public - Medicare Advantage HMO or PFFS - Available Now to Retirees Offers vary by state Plans Receive most of the subsidy from Medicare Lower benefits and lower or no premium other than Part B premium Medicare deductibles, carve-outs and restrictions No central administration Available without County sponsorship Guarantee of issue Examples in Appendix
7 County of Sonoma Comparison of Sonoma Medicare Plans to Individual Medicare Advantage Plans Currently Available Sonoma Plans Individual Medicare Advantage Plans Plan Kaiser PacifiCare County Health Value Plus Kaiser Secure Horizons AARP Freedom Blue Senior Advantage Secure Horizons Plan Sen/or Advantage MedicareComplete Plan I Insurer Kaiser PacifiCare Blue Cross Kaiser PacifiCare Blue Cross Network HMO HMO PPO HMO HMO Regional PPO (CA) Premium (mth) $ $ $ $82.00 $76.00 $0.00 Deductible None None $300 single / $900 family None None $1,050 per member Doctor Visit $10 co-pay $10 co-pay Inpatient Hospital Outpatient Hospital! SUrllery No charge $10 co-pay per procedure No charge No charge Ambulance $50 co-pay No charge DME co-pay No charge Drugs Covered Under Part B Drugs Covered Under Part 0 Generic: $5 co-pay Brand: $10 co-pay No charge In-Network: $20 co-pay OON: co-pay, deductible applies $125 co-pay plus In-Network: co-pay OON: co-pay $125 co-pay plus In-Network: co-pay OON: co-pay In-Network: co-pay OON: co-pay In-Network: co-pay OON: co-pay Generic: $5 co-pay Formulary Brand: $15 co-pay Non-Formulary Brand: $30 co-pay $25 co-pay Days 1-7: $225 co-pay/day Days 8-90: no charge $0 to $175 co-pay for hospital facility visit $10 co-pay (PCP); $20 co-pay (Specialist) $400 co-pay/day for each Medicare-covered stay $175 co-pay In-Network: $10-20 co-pay OON: $25-35 co-pay co-pay for each Medicare-covered stay $300 co-pay $75 co-pay $100 co-pay co-pay co-pay In-Network - $20 co-pay, or co-pay OON - co-pav In-Network: co-pay OON: 30% co-pay $10 to $35 co-pay co-pay co-pay Initial Coverage Preferred Generic Preferred Brand Non-Preferred Brand Specialty Out-at-Pocket costs between $0 - $2,510 $5 co-pay (up to 100 day supply) $10 co-pay (up to 100 day supply) $10 co-pay (up to 100 day supply) $10 co-pay (up to 100 day supply) Out-at-Pocket costs between $0 - $2,510 $5 co-pay retail; $10 co-pay mail $15 co-pay retail; $30 co-pay mail $30 co-pay retail; $60 co-pay mail $30 co-pay retail; $60 co-pay mail Out-at-Pocket costs between $0 - $2,510 $5 co-pay (retail or M.O.) $15 co-pay (retail or M.O.) $30 co-pay (retail or M.O.) Same as retail co-pay Out-at-Pocket costs between $0 - $2, 700 $10 co-pay retail; $20 co-pay mail $35 co-pay retail; $70 co-pay mail $35 co-pay retail; $70 co-pay mail 25% co-pay retail; 25% co-pay mail Out-at-Pocket costs between $0 - $2,700 $5 co-pay retail; $10 co-pay mail $32 co-pay retail; $86 co-pay mail $65 co-pay retail; $185 co-pay mail 33% co-pay retail; 33% co-pay mail Out-at-Pocket costs between $0 - $2, 700 $10 co-pay retail; $15 co-pay mail $35 co-pay retail; $87.50 co-pay mail $75 co-pay retail; $ co-pay mail 33% co-pay SEGAL Individual Comparison 10/28/2008
8 Plan Gap Coverage Preferred Generic Preferred Brand Non-Preferred Brand Specialty Catastrophic Coverage County of Sonoma Comparison of Sonoma Medicare Plans to Individual Medicare Advantage Plans Currently Available Sonoma Plans Individual Medicare Advantage Plans Kaiser PacifiCare County Health Value Plus Kaiser Secure Horizons AARP Freedom Blue Senior Advantaae Secure Horizons Plan Senior Advantaae MedicareComDlete Plan I Out-at-Pocket costs Out-at-Pocket costs Out-at-Pocket costs lout-at-pocket costs Out-at-Pocket costs Out-at-Pocket costs between $2,510 between $2,510 between $2,510 $4,050 Ilbetween $2, $4,350 between $2,700 - $4,350 between $2, $4,350 $4,050 $4,050 Covers only Formulary Covers only Preferred $5 co-pay $5 co-pay retail; Generics Generics $5 co-pay (retail or M.O.) No Coverage (up to 100 day supply) $10 co-pay mail $10 co-pay retail $10 co-pay retail $20 co-pay mail $15 co-pay mail $10 co-pay $15 co-pay retail; (up to 100 day supply) $30 co-pay mail $15 co-pay (retail or M.O.) No Coverage No Coverage No Coverage $10 co-pay $30 co-pay retail; (up to 100 day supply) $60 co-pay mail $30 co-pay (retail or M.O.) No Coverage No Coverage No Coverage $10 co-pay $30 co-pay retail; (up to 100 day supply) $60 co-pay mail Same as retail co-pay No Coverage No Coverage No Coverage Out-at-Pocket costs over Out-at-Pocket costs over Out-at-Pocket costs over Out-at-Pocket costs over Out-at-Pocket costs over Out-at-Pocket costs over $4,050 $4,050 $4,050 $4,350 $4,350 $4,350 All Drugs Generic: $3 co-pay Brand and Speciality: $10 co-pay You pay the greater of Generic: $5 co-pay You pay the greater of You pay the greater of $2.40 $2.25 co-pay for generic $2.40 co-pay for generic co-pay for generic (including (including brand drugs Formulary Brand: Generic: $5 co-pay (including brand drugs brand drugs treated as treated as generic) and $15 co-pay Brand: $12 co-pay treated as generic) and generic) and $6.00 co-pay $5.60 co-pay for all other Speciality: $12 co-pay $6.00 co-pay for all other for all other drugs, or; drugs, or; Non-Formulary Brand: drugs, or; 5% coinsurance 5% coinsurance $30 co-pay 5% coinsurance SEGAL Individual Comparison 10/28/2008
9 PacifiCare # /28/2008
10 Differences between Medicare and Non-Medicare Retirees Non-Medicare Eligible Retirees Retirees under 65, or not participating in Medicare Highest cost group because there is no government subsidy Limited solutions available Joint Purchasing Arrangements (Value Trust, Exclusive Care Select) are all or nothing arrangements Exclusive Care Select: Limited network (tier 1) and lower benefits (90%/80%/60%) Monthly rates are $583/$1,058/$1,523 High deductible plans can be offered by the County (amount of per person annual deductible, e.g., $1,250 to $1,500 would reduce premium by -12%)
11 High Deductible Plan Example (Illustrative of other Blue Cross Quotations) Annual Deductible Per Person - $1,500 (excluding drugs) Current Retiree Premium Per Person per month (CHP2) - $ 702 Illustrative Premium for High Deductible Plan - $ 612 Annual premium savings to retiree - $1,080 Annual exposure to retiree - $1,500 Current deductible in CHP 2 - $ 300 Additional exposure per year per retiree - $1,200 Additional exposure per year per retiree less savings - $ (120)
12 Exclusive Care Select Maximum Lifetime Benefit Coinsurance Maximum (Per person/family Per plan year) 1st Dollar Deductible - applies to coinsurance NOT copays Non Preauthorization Patient Penalty $1,500/$4,500 $250 I $750 reduction in benefits outpatient and outpatient diagnostic testing $5,000,000 $2,500 I $7,500 $500f$1,500 50% reduction in benefits for inpatient, outpatient and outpatient diagnostic $5,000' $15,000 $1,000 I $3,000 50% reduction in benefits for inpatient, outpatient and outpatient diagnostic testing deductible does not apply, Medco pharmacies only 2 times retail (Medco phannades only) MRI, NMR (Outpatient) X-ray, Lab (Inpatient) X-ray, Lab (Outpatient including ER) :.. physical, speech, occupational, cardiac, or pulmonary - physical, speech, occupational, cardiac, or pulmonary $50 capay plus $100 oopay plus $100 capay plus d Life Threatening Conditior - PhysicallFacillty/ER (After Hours) (Specialty Care) (Inpatient) (Outpatient Including ER) Test, CT Scan, MRI, NMR (Office) Test, X-ray, Lab (Office) Test, X-ray, Lab (Outpatient Induding ER) Test, X-ray, Lab (Inpatient) Pathology (inpatient) Pathology (outpatient induding ER) Pathology (office) CENTERS OF EXCELLENCE ONLy3 including ER) (Office) (Inpatient) (Outpatient induding ER) (In lieu of Hospital; up to 100 days) copay $20copay $20copay $10copay $10copay $10 copay oopay oopay condition :overed.. $25COpay $50copay $50copay $25copay $25copay $25 copay.m $25copay $25copay _1.xIslECS Benefits 4
13 Facility Ancillary - CENTERS OF EXCELLENCE ONLy3 Facility Physician Visits - CENTERS OF EXCELLENCE illness; then covered like any other benefrt unless a severe mental illness; then covered like any other benefit unless a severe mental illness; then covered like any other benefit (2) Bariatric Surgery is exctuded from coverage. OrthopediC, Cardiac, Oncology (3) Centers of Excellence are designated by Exclusive Care and Blue Shield and are characterized by exemplary results in the area of specialty. Note: Deductible does not apply to any copays and does apply to coinsurance. Note: Deductibles and coinsurance maximums do not cross apply through Tiers. Note: Tier 3 coverage is based on Medically Necessary Reasonable and Customary charges _1.xlS/ECS Benefits 5
14 PacifiCare # /28/2008
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