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Medical Insurance: The Basics (How to Enroll)

Who is Eligible?

• Residents (title codes 2708, 2724) and Clinical Fellows (title codes 2726, 2732) are the only groups of trainee-employees eligible for enrollment in the health insurance plans offered through the Human Resources office. All registered candidates from the above title codes in the Schools of Medicine, Nursing, Pharmacy, and Dentistry are eligible for these plans. Contrarily, this group is not eligible for the Faculty/Staff benefit plans.

• Eligible dependents – including Domestic Partners – are also eligible for coverage. They must be listed on the initial enrollment form or added on an amended enrollment form within 31 days of birth, arrival in the U.S., new marriage, etc.

• Residents need to be actively ‘opted-out’ of core insurance in the payroll system when they enroll in the Human Resources Insurance Plans, otherwise the department pays duplicate premiums through two systems for redundant coverage.

What is the Coverage?

• Residents are eligible for complete health coverage: medical, dental, vision,life and accidental death and dismemberment, as well as long-term disability insurance. Dependents are eligible for medical, dental, and vision coverage. The plans are designed for trainees and purchased just for this group.  The medical plan options are Health Net HMO and Anthem Blue Cross PPO.  Note, the plan costs and designs are different than the Faculty/Staff plans – even though both groups offer Health Net and Anthem Blue Cross as medical plan options.

• The component plans are not available individually; coverage comes as a package deal and choice of a medical plan automatically enrolls the trainee and their dependents with the other insurance carriers.

What is the Cost?

• A Resident pays $0 monthly premium for Health Net HMO.  Those choosing Anthem Blue Cross PPO pay a premium contribution of $30 for self, $60 for self plus child(ren) or self plus spouse/domestic partner and $90 for family coverage. Enrollment with Delta Dental, Vision Service Plan, LTD and life insurance is automatic once enrolled in health insurance.

What is the difference between an HMO and a PPO?

• Generally an HMO plan has lower out-of-pocket costs but limits the network of providers a patient has access to.  In an HMO, all care is generally coordinated through a Primary Care Provider (PCP) and referrals are required for most services not provided by your PCP.  If you enroll in this plan and want access to UCSF physicians you must choose a PCP that is affiliated with Hill Physicians Medical Group in San Francisco. - How to Find a PCP
• Generally a PPO plan provides access to a broader network of physicians and allows the flexibility of self-referral to specialists but generally has higher out-of-pocket costs for services from non-network physicians and you may need to pay up front and file claim forms to request reimbursement. 

When Does Coverage Begin?

• The Resident Plan Year coincides with the academic year, July 1st - June 30th. This is different from the Faculty & Staff insurance plans, which begin January 1st.

• Residents and their dependents must actively enroll within the initial 31 days after appointment to an above title code at UCSF, or within 31 days after a marriage, birth, etc. This is the PIE = Period of Initial Eligibility for the member and dependents.

• If they miss the PIE, they cannot enroll themselves or a new dependent until an Open Enrollment period. For Human Resources plans the Open Enrollment is held during the months of June and July with an effective date of July 1st (even if they enroll on July 31st, it is retroactive to July 1st.

How Does a Trainee Enroll?

• The Resident completes the Insurance Action Form, the Designation of Beneficiary Form, the COBRA Acknowledgement Form, the Declaration of Domestic Partnership Form if applicable and the Declaration of Tax Dependency/CA Registration Form if appropriate and returns the forms to the Departmental Coordinator.

• The Department Coordinator must verify the following data prior to entering it into the GME Benefits Database: 
  
  1. The employee ID number and SSN are legibly written.
  2. The enrollment ID number are legibly written if electing Health Net and there is a preference for PCP and/or medical group.
  3. The home address in CA is written ledgibly - HealthNet HMO will not enroll the employee with an out of state address.  Please do not substitute a UC department address given HIPAA protected confidential information will be mailed to the member.

• The Finance Unit of the Human Resources office makes monthly payments to all the carriers for our group plans. We then recharge these costs to the Home Departments, Divisions, and/or Hospitals. Recharges are always set-up by the Home Department at the time of enrollment.  If Blue Cross is selected, the premium contribution will be collected from the Residents through the payroll system or by the Home Department.

  Enrollees who are not paid through the UCSF payroll system will be expected to make personal payments to their departments for their monthly premium contributions.  Departments will be recharged for the full premium rate including the premium contribution amount.  To process the collections of the premium contributions, departments will need to:

  1. Upon receipt of their preliminary reports, determine which residents are required to make a premium payment and request a check for the $30, $60, or $90 co-payment, payable to the “UC Regents”.  Those that are required to make a premium payment by check include any resident who has chosen the PPO (Blue Cross) option and who is not paid through the UCSF payroll system.

  2. Once the premium contribution is received, the staffperson designated within your department to make deposits should follow their normal check depositing procedures and deposit the co-payment to the fund/DPA that the recharge will debit (this information can be found in the department’s preliminary report).

  For additional questions regarding the premium contributions, contact the Finance Office at 514-3798.

• UCSF rules do not allow duplicate UCSF coverage.  This means that you cannot be covered in a UCSF sponsored health plan as a resident AND as an eligible family member under another resident UCSF plan.  Generally this also means that you cannot be covered under a UCSF faculty/staff plan when you have your own UCSF coverage.  Children can only be covered under one parent with a UCSF health plan.  If duplicate enrollment occurs, UCSF will cancel the later enrollment.  UCSF and the plans reserve the right to collect reimbursement for any duplicate premium payments and for any benefits provided due to the duplicate enrollment.

What Are Some Qualifying Events?

• Some qualifying events may allow residents to makes changes outside of the Open Enrollment period.  Examples: marriage/DP, birth/adoption, or spouse’s/DP’s involuntary loss of coverage from their employer plan (ILOC).  The ‘Insurance Action Form’ must be submitted to the Dept Coordinator within the 31 day PIE starting with the date of the qualifying event.  Proper documentation is required for the ILOC.

• Upon termination or loss of eligibility, Residents are eligible for COBRA or conversion for most of the plans. The department is required by law to distribute COBRA information to housestaff members separating from employment with UC.  Coverage ends on the last day of the appointment.

• A coordinator is responsible for entering the termination in the GME database within the PIE. This is required so the University may inform the health plans to discontinue enrollment. 

• The Human Resources office and the departmental representative will thereafter communicate through the monthly fiscal recharge process, which is also detailed later in this documentation. However, please do not hesitate to contact us if you have questions, concerns or unusual situations, phone: 476-8093, fax: 476-4449.

Resources

• Throughout membership, the enrollees as health care consumers should address all requests for service and their claim questions exclusively to the Customer Service Representatives for the various carriers.  We provide the Residents with a contact list of phone numbers on this website. When all else has failed, an enrollee may be referred to the Human Resources office for assistance with a claim problem.

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