Consumer driven medical plan
UCSB
Benefits is pleased to be offering Definity Health as a medical
plan option. UCSB and UCSF were selected to introduce this
consumer driven medical plan to active employees in 2004 (
UC
Announcement)
Definity Health is designed to give you more flexibility and choice. It's called Consumer Driven Healthcare because it gives back to you, the consumer, more healthcare choices, more control over your decisions and more support when you need your health plan to be there for you.
The Basics of Definity Health
- No Primary Care Physicians
- No referrals needed to see specialists
- No copayments
- You choose how to spend your health care dollar
- National provider network
- Open drug formulary, no prior authorization requirement
There are four parts to the Definity Health plan:
1. Health Reimbursement Account (HRA) |
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Each year, the UC deposits a certain amount into each employee's Health Reimbursement Account. These benefit dollars are then used to pay for the employee and family member covered health, prescription drug, and wellness needs.
|
 |
Preventive care is covered 100% if you see in-network providers and does not reduce your HRA balance.
Health Reimbursement Account
| 2007 | |
| Employee | $950 |
| Employee & adult | $1,400 |
| Employee & children | $1,450 |
| Family | $1,900 |
An annual INCENTIVE of $50 each for employee and spouse will be added to the PCA for completion of a health risk assessment in the first quarter of each calendar year (before April 1). This incentive is not available to new hires (after the first quarter or mid-year transfers.
2. Member Responsibility
If expenses exceed the amount in your Health Reimbursement Account, you will be responsible to pay for up to a certain dollar amount of care. The amount of your Member Responsibility will be determined by the family members enrolled in your plan.| 2007 | |
| Employee | $550 |
| Employee & adult | $850 |
| Employee & children | $800 |
| Family | $1,100 |
3. Health Coverage
If your expenses exceed your HRA and Member Responsibility, you will use a "PPO type" plan to pay for the remaining expenses for the year. There is an "out-of-pocket maximum" or limit on the amount you will be responsible for paying before the plan pays at 100%.When you use "in-network" providers, the plan will pay 80% of the cost of care. When you use "out-of-network" providers the plan will pay 60% of the usual and customary cost of care-you pay the remaining balance.
Annual Out-of-Pocket Maximums after the deductible (HRA & Member Responsibility) is met.
The Out-of-Pocket Maximum (OOPM) limits the amount of coinsurance YOU will pay for covered expenses when using the Health Coverage part of your plan. After Health Coverage coinsurance expenses for you and your enrolled family members reach the OOPM, the plan will pay 100% of covered expenses. There are different OOPMs for in-network and out-of-network providers.
The in-network annual Out-of-Pocket Maximum (after deductible is met):
| 2007 | |
| Employee | $1,500 |
| Employee & adult | $2,250 |
| Employee & children | $2,250 |
| Family | $3,000 |
The out-of-network annual Out-of-Pocket Maximum (after deductible is met):
| 2007 | |
| Employee | $8,500 |
| Employee & adult | $12,750 |
| Employee & children | $12,750 |
| Family | $17,000 |
4. Health Tools and Resources
Definity Health has a vast array of powerful and easy-to-use information and care management tools to help consumers make better, more personally relevant health and wellness decisions.- Access to personalized educational and interactive services.
- Information to help choose providers.
- Benefit tracking and management.
- Safe, secure, private.
More Information about Definity Health
| Member Services | Call this toll free number to
talk with a Definity Health Representative.
Prospective members: 1.866.833.3463 Enrolled members: 1.866.333.4648 |
| Prospective Member Website | Learn about plan coverage, tools and resources, doctors & hospitals, health care costs, and articles about Definity Health. |
| Member Website | If you are enrolled in Definity Health, you can log on to your personal web page from this site. |
| Brochure-2006 |
See this brochure for an overview of the plan design, preventive care, examples of how the plan works and more. (PDF) |
 PowerPoint Presentation 2007 |
|
| Video | View this video on the prospective member website. In the first paragraph find the small video icon and "Click here to view". |
| Member
Handbook |
Information about how to use the Definity Health Plan. |
| Summary
Plan Description 2006 |
Details about what the plan covers and how it works. |
| Information
for Providers |
Give this information sheet to your provider. It explains how Definity Health works, how to file claims, etc. |
| Premiums
for 2007 |
Monthly costs for UCSB medical plans. |
Frequently Asked Questions
(You can also find FAQs on the Definity Health Prospective Member Website)
1) Who are the In-network providers?
Preventive care is covered at 100% when an in-network provider delivers it. This network also serves as the in-network physicians for the "Health Coverage" part of the plan.Effective 6/1/05 the provider network has changed to United Healthcare. Go to the Doctors & Hospital area of the Definity Health Prospective Member Website to search for a United Healthcare provider.
2) What medical services are covered at 100% by the Preventive Care component of the plan?
Definity Heath and UC have identified Preventive Care services that will be covered at 100%. Go to the Definity Health Prospective Member Website for a complete list of Preventive Care benefits.Select "Benefit Amounts and Covered Services".
3) Which behavioral health providers will be available with Definity Health?
United Behavioral Health (UBH) will be the "carve out" plan for members of the Definity Health plan.The behavioral health care will be administered as a separate program by UBH. None of the Definity Health "Health Reimbursement Account" dollars or other plan benefits can be used to pay for behavioral health care.
The UBH plan has "in-network" and "out-of-network" options for providers. You will have a copay for office visits to in-network clinicians.
If you see an out-of-network clinician:
- $500 individual deductible
- 40% coinsurance with notification
- 60% coinsurance without notification
- Limited to 20 visits per year
UBH Benefits Grid - 2007
UBH Provider List: http://www.ubhprovdirect.com/
4) What are the monthly premiums for the Definity Health plan?
Total cost is, of course, very important. Remember, if you plan to incur any out-of-pocket costs, you can help offset those costs by planning ahead. You can put pre-tax dollars into the Health Care Reimbursement Account (HCRA).If you're comparing Definity Health with other plans, we encourage you to consider cost but also to take a broader look at all of the benefits and services offered by those plans.
2007
Monthly Employee Premiums
5) What is the lifetime maximum for the Definity Health plan?
In 2005, the $2 million life time maximum will increase to $5 million for in-network expenses, and remain at $2 million for out-of network expenses, with out-of-network expenses applicable to the in-network maximum.6) What is a health assessment?
The Health Assessment is an online tool used to assess your general health. You access the assessment from your private Definity website. Definity Health will use the assessment to provide you with personalized information and assistance.An annual incentive of $50 each for employee and spouse will be added to the Health Reimbursement Account (HRA) for completion of the Health Assessment in the first quarter of each calendar year (before April 1). This bonus is not available to new hires (after 1st quarter) or mid-year transfers.
7) How are Medical expenses processed?
- No copays at time of service from network providers
- Claims are processed by Definity Health and applied to HRA, Member Responsibility or Health Coverage as appropriate
- For in-network services, provider submits claims to Definity Health; you get Explanation of Benefits (EOB) in the mail for each claim; provider bills you for portion of payment as appropriate
- For out-of-network providers, you send receipts and claim form to Definity; you may need to pay all or part of the provider’s bill at the time of service; Definity reimburses you as appropriate
- Claim forms are available on the Definity web or from Definity Member Services
8) How are Prescription Drugs expenses processed?
Provided through retail pharmacies contracted with Medcohealth:1-800-922-1557, www.medcohealth.com
Prescriptions are treated as any other medical expense; they
are subject to plan deductible and payable through HRA and
Health Coverage.
Pharmacy costs:
- If funds in HRA, member pays $0 at pharmacy
- If expense is Member Responsibility, member pays full cost at pharmacy
- If expense is paid with Health Coverage, member pays $0 at pharmacy; Definity bills member for amount due
- Payment(s) for mail order prescriptions work the same way
- Generic drugs are cheaper than brand