Consider carefully when choosing your health plan
The annual window for changing your health plan option will open as soon as the premium rates for 2012 are set. 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. In deciding among the Empire Plan and the HMO options, consider such factors as premium cost, freedom to choose your own providers, benefit levels and limitations, and ask yourself these questions:
• What are your health care needs? A person who is generally healthy may only need routine/preventive care and, occasionally, urgent care. While, someone with a chronic medical condition may need several health care services along with prescription drugs. Consider the plan’s level of benefits and choice of providers in light of the needs of yourself and your family.
• 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 a child who resides or attends 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.
• What are the potential out-of-pocket costs? These expenses can include deductibles, coinsurance amounts, copayments, and non-covered charges.
• Are the providers you and your family use in the plan’s network? When you choose a health plan, your goal should be to stay in-network for your care. This is the best way to control your out-of-pocket costs.
• What if you use a non-network provider? Will you receive any benefits at all under the plan? HMOs do not provide benefits for non-network providers under most circumstances. The Empire Plan provides benefits for services performed by both network and non-network providers. However, your out-of-pocket expenses will be higher if you use a non-network provider.
• 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.
• Are benefits for certain services or items excluded or limited to a maximum dollar amount or number of visits/number of days covered? All health plans have exclusions and limitations. Make sure you understand what is and is not covered.
• What benefits are available for prescription drugs? Will the prescription drugs you and your family use be covered under the plan? What will your copayment be for these prescription drugs? Are you required to use the mail service pharmacy to obtain a 90-day supply of medication? The Empire Plan does not cover certain prescription drugs. Be sure to check the most current Empire Plan Flexible Formulary to determine which drugs are not covered.
Confused? Need help?
Do you need help choosing the health plan that's right for you? Check out these sources of additional information.
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. A printed Empire Plan Participating Provider Directory should also be available for reference purposes.
NYS Department of Civil Service (DCS) web site – You can access health benefit and option transfer information using the DCS web site, www.cs.state.ny.us. On the home page, click on “Benefit Programs” and follow the instructions to access NYSHIP Online. Click on “Health Benefits & Option Transfer”, and then “Rates and Health Plan Choices”. Use the “NYSHIP Plan Comparison” tool to generate a side-by-side comparison of the benefits provided by each health plan option. You can also access Empire Plan benefit information and links to the Empire Plan directories of network hospitals and participating providers using NYSHIP Online.
NYS Department of Insurance (DOI) – The 2011 New York Consumer Guide to Health Insurers provides consumers with information about the quality of care health insurers and HMOs in New York State are providing, and ranks each based on consumer complaints to the DOI. Call 800-342-3736 or go to the DOI web site at www.ins.state.ny.us.
NCQA’s Health Plan Report Card - The National Committee for Quality Assurance (NCQA) uses rigorous and comprehensive standards to evaluate an HMO’s quality of care and service. Based on this review, NCQA gives an accreditation rating ranging from provisional to excellent. To determine an HMO’s accreditation rating and create a customized Report Card that shows results for the HMOs you want to know about, go to www.ncqa.org.