Regents approve medical plans for UT
The UT System Board of Regents recently approved the following group medical insurance
plans for the Austin area to be effective Sept. 1, 1998:
- UT Select Plan administered by CIGNA Healthcare
- Prudential HealthCare, which will provide an insured HMO plan
- Humana, which will provide an insured HMO plan
The following plans in Austin will be discontinued after Aug. 31, 1998:
- Triple Option Point of Service Plan administered by Anthem
- PCA HMO plan
- NYLCare HMO plan
Since all three new medical plans are different or have the potential of being different from
the current plans, a decision has been made by the UT System Employee Group Insurance
Office to automatically enroll every employee in the Austin area in the UT Select Plan.
Thus, employees and retirees currently enrolled in medical plans that will be discontinued
and those currently enrolled in Prudential HealthCare will be rolled over or defaulted to the
UT Select Plan. This means all employees and retirees will have coverage under UT Select
on Sept. 1, 1998, unless they elect coverage under one of the other two medical plans
during Annual Enrollment. Every employee and retiree should carefully consider the
benefits provided for each plan, the premium costs and the costs within the plans for
various services.
What is UT Select?
The name "UT Select" was chosen because the plan is designed by:
* selecting some of the most popular benefits of an HMO, such as copays for office visits
and some preventive benefits, and
* combining those benefits with some of the more valued benefits of a PPO, such as the
freedom to receive treatment from a specialist without receiving a referral from a primary
care physician and the option to utilize out of network benefits.
UT Select is neither a true HMO nor a PPO, but rather a combination of these two types of
plans. Overall the cost for UT Select may be more than for either HMO, but the UT Select
plan incorporates access to a more expansive network of physicians without requiring a
referral.
Is the role of the Family Care Physician (FCP) under the UT Select Plan the same as that of a Primary Care Physician (PCP) under an HMO?
The important difference in the FCP and the PCP is that in an HMO, the PCP is intended to
be the manager of a patient's care. In an HMO, a member is required to select a PCP in an
HMO who then can refer the patient to a specialist. Under UT Select, a member will have
access to all providers without obtaining a referral from the FCP. Also, the member is not
required to designate one FCP but rather can utilize various FCPs at any time.
Family Care Physicians are those who are listed as such in the provider directory. They
will be in general practice, family practice, internal medicine, pediatrics and OB/GYN
categories of the directory. If the physician is listed in the directory as one of the five types
of physicians that qualify as FCPs, the member's copay for a routine office visit (other than
preventive) will be $10 even though the physician may also practice in a specialty field.
Summary of benefits for the UT Select Plan
Network Benefits - There are three levels of services:
Level One Services
To qualify as a Level One Service:
* The allowed charges must not exceed $250 for services provided by the same physician
on the same day in their office or for services received at an urgent care facility.
* The service must not be one of the services listed under Level Two Services.
For Level One Services, the plan member pays as follows:
* $10 copay for services provided within the office of a Family Care Physician who is
listed in the Network directory. Family Care Physicians (FCP's) are physicians whose
primary practice is in the fields of general medicine, family medicine, pediatrics, internal
medicine or OB/GYN.
* $25 copay for services provided by a specialist. Specialists are physicians listed in the
network directory who are not Family Care Physicians.
* $50 copay for true emergency services received in an emergency room ($50 copay covers
up to $500 in physician and facility fees).
* $25 copay for urgent care services received at an urgent care facility.
* $15 copay for outpatient mental health or substance abuse treatment (subject to plan
limitations).
If the charges exceed $250 for an office visit or $500 for emergency room services, then
the full bill will be considered a Level Three Service.
Level Two Services
Level Two services are preventive services, such as well child care, periodic physical
exam, and well woman exam.
* The member will pay 15 percent of allowed charges for preventive services and no
deductible applies.
* The maximum amount of preventive benefits paid per plan member is $300 per plan year.
* Preventive Services in excess of $300 are the responsibility of the plan member.
Level Three Services
Services under this level include all other covered services not described under Levels One
and Two Services or later described as a special benefit.
For Level Three Services, the plan member first pays a $250 deductible and then is
responsible for 15 percent of allowable charges after the deductible has been satisfied.
Important information about Copayment and the Annual Deductible for Network Benefits
* Copayments for Level One and Level Two benefits will not count toward the annual
deductible or the out-of-pocket maximum amounts.
* Annual deductible of $250.
* The Network deductible will not count toward the out-of-network deductible, but the out-
of-network deductible will count toward the Network deductible.
* After three members of a family have satisfied the annual deductible, no other family
member will be required to satisfy the annual deductible.
* Benefits are paid at 100 percent of allowed charges after a member has paid $1500 in
deductibles and co-insurance.
* After a family has paid $4500 in allowed charges in deductibles and coninsurance, the
plan will pay 100 percent of reasonable and customary.
Out-of-Network Services
* Annual deductible of $500
* After three family members have satisfied an annual deductible, no further family member
deductibles will be required.
* After deductible has been satisfied, the plan will pay 65 percent of reasonable and
customary charges.
* Plan member is responsible for the remaining 35 percent of reasonable and customary
charges and any charges exceeding reasonable and customary.
* After out-of-pocket maximum of $3000 of allowed charges has been paid, plan will pay
100 percent of reasonable and customary charges.
* Benefits will be paid at 100 percent of reasonable and customary charges after a family
unit has paid $9000 of allowed charges in deductibles and coinsurance during a plan year.
* No preventive care benefits are paid for services received from out-of-network providers.
Out-of-Area Services
* Only plan members who reside outside the network service area or who have traveled
outside the network service area for a reason other than to receive medical care are eligible
to receive out-of-area benefits.
* Annual deductible of $250 for services received out of area.
* After three family members have satisfied the annual deductible, no further deductibles
will be required of other family members.
* Benefits paid at 80 percent of reasonable and customary charges.
* Member is responsible for 20 percent of the reasonable and customary charges and for
any charges exceeding reasonable and customary.
* Benefits paid at 100 percent of reasonable and customary after a member has paid $1500
in deductibles and coinsurance.
* After a family has paid $4500 in allowed charges in deductibles and coinsurance, the plan
will pay 100 percent of reasonable and customary charges.
* No preventive care benefits are paid for services received outside the service area.
Special Benefits
Medicare Retiree Services - If a retiree who has primary coverage under Medicare Part A
and Part B receives services from a provider who accepts Medicare assignment, UT Select
will pay all charges allowed but not paid by Medicare. The annual deductible of Medicare
or UT Select does not need to have been satisfied to receive this benefit. The provider does
not need to be a member of the network. Any charges by a provider who does not accept
Medicare will be treated in the same manner as all other claims.
Hearing Aid Services - UT Select provides up to $500 in benefits for the purchase of a
hearing aid. This benefit is available for each ear once every five years. Benefits will be
paid at 80 percent with no requirement that the annual deductible be met. The hearing aid
need not be purchased from a network provider.
Immunizations for Children up to age 6 - Immunizations for children up to age 6 are not
subject to deductibles, copayments or coinsurance. This applies to the administration of
immunizations only and any associated well or routine exam is still subject to the applicable
deductible, copayment or coinsurance.
Summary of benefits provided by Humana and Prudential HMOs
The benefits provided by these two medical insurance plans are similar to those provide by
the HMOs that UT Austin currently has. A comparison of the benefits provided by both
plans includes:
* $10 copay for Primary Care Physician office visits for diagnosis, treatment, and routine
physical exams, immunizations, well child care, lab tests, x-rays, hearing and speech
exams
* Inpatient care, no charge
* Visits to specialists must be authorized by the Primary Care Physician
* Emergency care
-Humana, $50 copayment per visit when not admitted
-Prudential, $75 copayment per visit when not admitted
* Mental health care, outpatient care, up to 20 visits per year
-Humana, $5 copayment per visit
-Prudential, $35 per visit
* Allergy tests
-Humana, $10 copay
-Prudential, 50 percent of charge
Where can I obtain more information about the approved plans?
Not all of the details of the plans are available as yet. The Employee Group Insurance
Office at UT System is still working with the administrators to finalize details and
premiums for the plans. Information about the benefits for each plan, along with
continuously updated lists of network providers, will be available in the coming weeks.
This information will be available on the Employee Group Insurance website,
http://www.utsystem.edu/egi. The website for the Office of Human Resources will be linked to the UT System website.
Other Insurance Information
Dental Insurance in Austin
The dental insurance plan administrators, Delta Dental and United, will not change. The
Delta Dental plan will have a 6.4 percent increase in the premium, but the United Dental
premium will not increase.
Prescription Drug Service
The PCS drug program will be continued in Austin and will serve the UT Select Plan.
There will be no changes in the copayments or benefit design. The Humana HMO and
Prudential HMO will have their own prescription drug service.
Vision Insurance
Superior Vision will continue with no changes in premiums or benefits.
Plans for UT Austin employees/retirees residing in other areas of the state
The following health plans have been approved for 1998-99 in areas outside Austin:
* UT Select will be offered in all areas
* Dual Option Plan (POS) in Galveston/Houston
* Prudential HealthCare HMOs in El Paso, Galveston/Houston and San Antonio.
* NYLCare Valley EPO in Brownsville and Edinburg area
* UT Southwestern Health network HMO in Arlington/Dallas
* Texas Universities Health Plan providing an HMO with out of network benefits plan in
Arlington/Dallas
The plans in other areas of the state that are being discontinued are: Plan A and Plan B,
administered by Anthem; Kaiser HMO in Arlington/Dallas; PCA in San Antonio; and
NYLCare PPO in Galveston/Houston.
Information on premiums and out-of-pocket costs for medical and dental plans
Employee only coverage for any combination of the health and dental plans will continue to
be offered at zero cost to the employee.
Complete information on the premiums for each of the plans and out-of-pocket costs will
be available by June 1. This information should be available on the web and from the
Insurance and Retirement Group, 471-4343.
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