Campus to Preview Health Option

By VIC COX

Come open enrollment this November, UCSB will be one of only two UC campuses to offer a new medical plan that will increase enrollees' choices and allow them more control over health care dollars–but it also will demand informed participation. Called Definity Health, the UC version, which is expected to spread to other campuses, is a far cry from the standard Health Maintenance Organization (HMO) model that provides most Californians their health care, according to Human Resources benefits officials.

"It will be a new way of thinking (about medical costs and planning for care) for those of us who have lived in the world of managed care," said Laura Morgan, UCSB health care facilitator. Added Tricia Heimstra, benefits manager, "This will not be the plan for everyone."

Though still an insurance plan, Definity does away with HMO-style gatekeepers and asks the insured employee to work with physicians in local and national networks in taking care of her or his own health. No pre-approvals are necessary for referrals to specialists; no nonmedical person second-guesses the family doctor; and there are no co-pays going through the system.

Definity has costs and limitations, as can be expected. After a deductible is met, charges for out-of-pocket expenses split 80-20 (plan-enrollee) if service is from a network provider, 60-40 if service is out-of-network. Out-of-network claims must be filed for reimbursement, though the provider will usually do that. While UC has yet to announce what the premium will be for enrollees–local benefits officials expect that information next month–the basic outline of this option is available at <http://hr.ucsb.edu/benefits/definity.php>.

The foundation of UC's Definity Health is a Personal Care Account (PCA) that the University will fund to a total of between $750 and $1,500 a year, depending on whether the employee is single or has signed up a spouse and/or children. The enrollee largely controls that money and, if not spent within the calendar year, the remainder can be added to next year's funding.

An amount equal to the PCA is called the "member responsibility." Combining the two sums equals the member's total deductible. Some of the traditional healthcare expenses paid out of the PCA also count toward meeting the deductible. "In essence," explains the Definity Health Web site, "your organization pays part of your deductible."

However, you can pay for certain health services, such as smoking cessation and doctor-ordered weight loss, from the PCA, but they will not count toward satisfying the deductible. Also, premiums are not considered in calculating member responsibility, according to Morgan. She and her assistant, Debra Herrera (x2186), are the chief campus contacts for plan information.

After the deductible is met, the next stage is out-of-pocket health coverage. Except for certain preventive services, which are covered 100 percent by the plan, these expenses follow the 80-20 or 60-40 cost formula mentioned above. The UC plan caps out-of-pocket expenses at $2,750 for singles and $5,500 for families who stay within Definity's network of providers, hospitals and pharmacies.

Going out-of-network can triple the so-called "Out-of-Pocket Maximum." In addition, Definity pays out-of-network providers 100 percent of what it deems the "usual and customary" rate for the service. If the provider charges more than this rate, the enrollee picks up the difference.

The next HR-organized meeting about Definity, one of four more, is set for Oct. 7 at 1:30 p.m. in SAASB 3101. A Definity representative is scheduled to appear at the Nov. 5 afternoon meeting in Corwin Pavilion.

Human Resources benefits officials think that many who are dissatisfied with HMOs will try Definity Health. "It's similar in many ways to a PPO (Preferred Provider Organization) with its flexibility and options," said Heimstra, the benefits manager. "In that sense, it's a throwback to how medicine was delivered in the 1970s."