have to make a choice between one plan and the other with the city plan continuing to be offered along with the ppo option it's a much easier decision to make everybody has a choice of which plan to stay with in the case of blue shield it's an either/or choice we go with case management and primary care physician and coordination of specialty referrals very suss a ppo plan that doesn't offer that kind of coordination. i don't think price is really the significant issue here they're so close i don't consider that to be particularly relevant the cost of the two are so similar. we need to think about the needs of the retirees. there are some retirees that are in good health travel a lot travel nationally travel internationally but certainly travel nationally they're in

their rv's and 5th wheels driving around the country they decide to visit every state in the union and the u.s. for those people being able to see a physician where ever they are when they need it you are arguably in good health and very active makes sense some of our retirees are not active some have chronic health care needs that require close coordination of care with a primary care requestings and a network of access to specialists that are a professionals making those those decisions and b the retiree may or may not have the where with all to make informed decisions themselves those are the two populations that are sort of in competition here i find this difficult to be honest a difficult decision i don't have a preference one or the other i have been on medicare two yearses now almost the plan i

have is working fine i think the other would work pine i don't have a strong personal feeling one way or the other i'm not prepared to -- i'm prepared to vote with the majority of the other commissioners here as to which is better i'm certainly impressed with the recommendation from management that we consider the ppo plan. these are the conflicts in my mind as i look at the two together so i think there is a -- there are things to be gained and things to be lost with either decision. the retirees that live in san mateo county i think need to be considered in this so thank you. >> all right. thank you for the comment. i'm now ready to entertain a motion. >> i move that we approve the blue shield fully 65 + group medicare advantage prescription drug plan. and the blue shield access plus

medicare coordination premiums and contributions for 2016 plan year. >> is there a second? >> second >> okay it's been properly moved and seconded in ses ens we remain with the existing plan is there comment from the board? is there public comment? >> i would like to hear from some of our members if possible on this iesh ewe >> by the chair i think we have had if the public comment is going to do so they will do so without our solicitation is there public comment? we're now ready to vote. all those in favor, say, "aye." >> (multiple voices): aye. >> all those opposed. aye we're split. the motion fails. all right i'm ready to entertain

a motion. i love that we adopt the national blue shield ppo. >> i will second that motion. >> it's been properly moved and seconded. is there board comment? is there public comment? hearing no public comment we're now ready to vote all those in favor, say, "aye." >> (multiple voices): aye. >> all those opposed? >> aye. no. opposed >> we're split i will ask our council what do we do? >> i think this is why we need to have seven members on a vote and everyone showing up to vote.

>> we have gone through that. >> well at this point it's not going to pass today we know rates and benefits have to get done and i think unless people are willing to change their mind today i i will be talking to catherine what the next steps are which may include figure out a way to call a special meeting to get members here and we can take a vote again until it gets done there say charter there is a process for approving rates and benefits it has to get done in time and approved by the board of supervisorses and to give out notices and go to open enrollment unless you can convince each other you need four votes and get a unanimous decision today we will have to go back to the drawing board and figure out what the next steps are >> thank you for your counsel

director dodd? >> i have a question of blue shield in working with chris parerez on member issues you said to me we don't case manage those members medicare case manages them. where is chris? is there a medicare case management function? you might we call it's an alto-bates issue chris? if she comes up i will also point something else out in the difference between ppo and mapd plan in an mapd plan perhaps you

can do it describe the second opinion process so if i went to an on whiologycology oncologist with a ppo plan -- >> we had an interesting scenario where we had a husband and spouse one member is part of the 65 plus plan which is the mapd plan. the other lived in a different area and was in the hmo-cob plan in the mapd plan class management is done by the medical group under the hmo-cob

plan because medicare is primary technically medicare is the case manager that is no different than what you would find under the ppo plan. >> and medicare did case manage that? >> we offered that option because the member has to call medicare directly and i believe that the member elected not to do that but blue shield did assist with that particular situation without getting into a lot of detail >> but the services are proided through medicare >> thank you for that >> the second question i have forgotten director dodd if you can repeat it again >> the beginning of second opinion >> i will answer that in general terms under hmo plans general

are covered it's expected that seconds are covered under the same medical group we have a special process in place for ccsf at the request of director dodd right which makes complete sense. in that we will allow a second opinion as long as it's within the hmo network. it is an automatic process it's done through exception and would require someone to alert my team so that we could follow that to make sure it gets paid appropriately because the standard under hmo plan is a second opinion is covered within the same medical group. under the national ppo plan that would not be the case they can seek a second opinion within our vast network of doctors in

california or outside of california. >> thank you very much for that information, and that response. i'm going to declare a recess for a 15 minute period of time we have been sitting here end on end since 1:15 it's time to take a hygiene break (meeting in recess) medicare

>> okay we're now back in session. and taking prerogative of chair i'm going to call for a motion for reconsideration of the prior item. >> so moved >> is there a second for the reconsideration of the prior item >> second

>> it's been properly moved and seconded we reconsider the prior item in case anybody is confused what the prior item ises to have a national blue shield ppo or stay with the status quo plan we're reconsidering that item is there discussion by the board? comments from the general public? >> dennis kruger active and retired firefighter at first glance i like this national plan. it came a little quick to us even though they talked about it for a while. comparison says it's identical to the other plan which it isn't. silver sneakers isn't in it. i would hope that the board

considers this plan next year and they stay with the present plan even though the threat of no further action taken down in sanmatoe where i live it will cover people through the next year and they come back with this plan one card silver sneakers and make their copays identical or close to what unitedhealthcare because there is discrepancy in that as well i wish you take that into consideration thank you. >> thank you for your comment is there any public comment on the motion to reconsider this item? >> on the motion to reconsider caris vons appc i think you should reconsider i can't tell you which way to go i think you need to ask for more information we need to know more about the

network and network displacement i forgotted to ask the tualami hehechi, area might be impacted with the change in these options i think we need to know that. there are still a number of members up there we have to consider that would be retired. but i think you really should reconsider it and get more information to see if you would be able to make a decision today perhaps network information perhaps coverage it's not -- there is some things that are not clear about the presentation and i think we need to clarify where mapd ends and what the national begins and what impact this would have on members outside of the area thank you very much. and also displacement areas where there would be physician displacement >> thank you for your comment is there any more public comment on the motion to reconsider this

item. >> yes i think you should reconsider with all of the facts at hand i think the audience should have all of the facts in hand as well i think the bottom line of these proposal it's a financial advantage of blue shield beneath all of this buried is saving of cost that is fine however it has to work to our advantage too. right now it isn't clear cut. and i don't know if it's possible we can do it at this meeting they have to come forward with printed material with the advantages disadvantages what the policies are what they entail so with ve a solid background to make a solid decision i don't think this is the case at the present time. >> thank you for your comment any other public comment? seeing no other requests for public comment we're now ready to vote all those in favor of

the motion to reconsider signify by saying aye >> (multiple voices): aye. >> all opposed? so ordered the chair is ready to entertain a motion. >> i move we move 65 + care prescription drug plan and the blue shield medicare coordination of premiums and contributions for the 2016 plan year >> is there a second? >> second >> it's been prop rly moved and seconded that the plan be retained is there board comment? commissior sass? >> in the last round of voting i chose to vote against that option i'm mraenning to change my vote this time around i want to make one observation in doing so continuing with