Time for Annual Health Plan Checkup

The annual window for changing your health plan option will open as soon as the premium rates for 2003 are set. This is likely to take place in November.

You will have 30 days after the rates are delivered to the state agencies to change health plans. If you don’t request a change during that period, you will automatically remain enrolled with the same health plan you are in.

Not all health plans are alike, and the one that was the best for you this year may no longer be your best choice. It’s well worth your effort to compare them.

Empire Plan or HMO?

Consider such factors as accessibility, benefits, quality, cost and ask yourself these questions:

• What are the potential out-of-pocket expenses?  These expenses can include deductibles, coinsurance costs, copayments, and non-covered expenses such as charges by health care providers that exceed the maximum allowed under the plan's reimbursement schedule.

For instance, if charges for services covered under the Basic Medical portion of the Empire Plan cannot exceed the "reasonable and customary (R&C) charge" for those services as determined by the administrator, United HealthCare, you will have to pay the difference.

• Are you required to file your own claims? If so, what is the process for filing claims?  How long does it take to be reimbursed or to dispute a claim determination?

HMO enrollees often report less paperwork and administrative hassle than those enrolled in a fee-for-service plan like the Empire Plan.

• What are your health-care needs? Do you or a dependent require services for a chronic medical condition or mainly for acute or urgent conditions?  Which plans cover these services and how extensive is the coverage?  Does the plan insure against serious financial losses?

What benefits are available for the treatment of mental health conditions and alcohol or chemical dependency?  What facilities and clinicians in your area are in the plan’s network? Look for any contract provisions or plan procedures that restrict your access to care or limit the benefits available.

• What benefits are available for prescription drugs?  Is there a maintenance-drug program, including a mail-order pharmacy? How many copayments do you have to pay for a 90-day supply of maintenance drugs? Are benefits limited to only those drugs included on a formulary (list of preferred drugs)? Is there a mandatory generic-drug substitution requirement?  Are dentists’ prescriptions covered?  Which pharmacies are affiliated with the plan?

If an HMO will pay only for drugs on its formulary, you may be required to change to another drug if the one you are using is removed from the formulary at some point in the future. Exceptions may be made upon appeal from you or your physician

• Who are the providers affiliated with the plan?  Is there an adequate number of providers? How many of the plan’s physicians are board-certified or board-eligible?

"Board certification" means the doctor has had two or more years of training in a specialty field after medical school and has then passed a national exam.  Doctors who have completed the training but not the exam are board-eligible.  When looking for a good doctor, board certification is an important consideration.

• How important is it to keep the doctor you have?  Does the plan restrict your ability to use providers of your choice? Will you need a referral to see a specialist?

Under a managed care program, benefits may be denied or reduced if you don’t use a participating provider, or if you receive services from a specialist (even one affiliated with the plan) without a referral.

• What if you use a non-participating provider? Will you receive any benefits at all under the plan? HMOs do not provide benefits for non-participating providers under most circumstances. The Empire Plan provides benefits for services performed by both participating and non-participating providers. However, your out-of-pocket expenses will be higher if you use a non-participating provider. 

• How will your doctor’s reimbursement affect your care?  Does the plan penalize your doctor financially if you need frequent visits, referrals, or expensive tests and treatments?

Doctors may be paid by: salary; fee-for-service; fee-for-service less a withhold; or capitation (the same payment per patient no matter how many or how few services you receive.  

• Will coverage be limited if you or a covered dependent needs medical care while out of the plan’s service area? Many HMOs provide very limited benefits for care received outside their service areas.  If you travel or have dependent children who live or attend college outside of an HMO's service area, pay particular attention to the criteria that must be met to receive benefits.  Your child may have to return home for non-urgent medical care.

Finally, you may want to ask these questions:

Confused?  Need help?

Do you need help choosing the health plan that's right for you? Check out these sources of additional information.

Choosing Your Health Plan – These flyers were mailed to enrollees’ homes in October. If you did not receive one, your agency Health Benefits Administrator should be able to give you one. It is also available on the NYS Department of Civil Service web site www.cs.state.ny.us. Click on Employee Benefits, then click on Publications and Forms.

Your Personnel Office – In November, your agency Health Benefits Administrator will receive a supply of Choices. The Choices booklet explains the health plan options available to you and provides a benefit summary for each plan. If you are interested in the Empire Plan, ask for The Empire Plan at a Glance 2003. An Empire Plan Participating Provider Directory should also be available for reference purposes.  

NYS Department of Civil Service (DCS) –  Choices and other Option Transfer publications will be available online as soon as they are approved for printing. Rates will also be posted promptly upon approval. The DCS web site address is www.cs.state.ny.us. Click on Employee Benefits. This site also includes a link to the Empire Plan Participating Provider Directory.

NYS Department of Insurance (DOI) – Use the 2002 New York Consumer Guide to Health Insurers to learn how to choose a plan and to compare the plans available to you. In addition to allowing you to compare plans based on the number of complaints, grievances, and utilization review appeals, this guide also offers a comprehensive review and comparison of major quality-of-care indicators and other performance measures. Call 800-342-3736 or go to the DOI web site at www.ins.state.ny.us. 

National Committee on Quality Assurance (NCQA) - NCQA sets standards for the quality of care and service that health plans provide to their members. Health plans that meet these standards receive NCQA Accreditation, which is nationally recognized as a seal of approval. Use NCQA's health plan report card to compare HMOs. Go to the NCQA web site at www.ncqa.org. In the right-hand scroll-bar, click on Health Plan Report Card. Or, call 888-275-7585 to get the accreditation status of an HMO.