RE: GHI Preferred Dental Plan

At the request of many PEF elected leaders, we are providing this update regarding the numerous complaints received about the GHI Preferred Dental Plan. As the PEF Health Benefits staff who must deal with this issue during contract negotiations and every day thereafter when members express their dissatisfaction, we want to explain to you how the dental plan works, what the specific problems are, what has been done to address these problems, and what PEF is planning to do in the future. We ask that you distribute this memo to all stewards and as widely as possible to the general membership. It will be posted on the PEF website at www.pef.org in Current News on the Health Benefits News page.

1. How the Dental Plan Works

Members who live in areas with an abundance of dentists who must compete for patients, e.g., New York City and a dwindling number of upstate cities, have ready access to GHI participating dentists. These members receive many services with little or no out-of-pocket cost. Members in other areas have extremely limited, if any, access to participating (par) dentists and must pay all fees charged by non-par dentists. Claims for non-par dentist services usually result in reimbursement checks that are significantly less than the total charge billed.

The reason for the disparity in access to par dentists is clear: the State refuses to pay more for employee dental benefits and as a result, the fee schedule is so low that par dentists leave the plan when they no longer have to compete for patients. You must remind our members that New York State pays the entire premium for dental benefits. Despite widespread belief to the contrary, PEF members do not contribute to the premium and union dues do not pay for dental benefits either. It is the State's own decision to hold down its costs that prevents the fee schedule from being more realistic and making the dental plan a program acceptable to more dentists.

2. Specific Problems

a. GHI's inaccurate listings of par dentists--When a member calls GHI to request a listing of par dentists, GHI sends a directory printed in June 2000 which incorrectly lists many dentists in the wrong location and dentists who no longer participate. Although the on-line directory is more accurate, it also has errors. We asked GHI to correct the errors and provide callers with a listing printed from the on-line directory. GHI agreed to monitor the accuracy of the on-line directory but said it's currently not possible to send listings printed from the on-line directory.

b. Additional par dentists leaving the plan--For the period 1/1-5/31/01, 40 par dentists dropped out of the plan. The loss of these dentists has affected a significant number of PEF members. In many cases, these dentists had been participating for many years. They continued to participate out of loyalty to their patients, but GHI's fees are so low they can't afford to participate any longer.

c. Members unable to resolve their problems through GHI's Customer Service Department--We routinely receive complaints from members who contact GHI's Customer Service Department to resolve a problem and are not satisfied with the service they receive. The most frequently expressed complaint is the length of time it takes GHI to resolve an inquiry. In some cases, the member has waited months before seeking our help because the problem is still unresolved. PEF members are not the only enrollees affected this way. Through our contacts at NYSCOPBA, Council 82, GOER and the Department of Civil Service, we know that all State employees with GHI dental benefits receive similar unacceptable service.

d. GHI denied claims for general anesthesia in error--In the 1999-2003 PEF/NYS contract, the State agreed to provide benefits for general anesthesia effective 10/1/00. GHI incorrectly limited the benefit to I.V. sedation and, as a result, denied claims that should have been paid. There has been a lengthy delay in identifying and re-processing the incorrectly denied claims. GHI promised to re-process all of these claims by Friday, 6/22/01.

e. GHI is not responsive to PEF's concerns--Since PEF members began receiving dental benefits from GHI in 1993, it has been our experience that GHI is not responsive to the concerns we repeatedly bring to their attention. Other unions as well as management are similarly frustrated.

3. What Has Been Done to Address These Problems?

PEF members began receiving dental benefits through the GHI Spectrum Plus plan in 1993, when the Public Employees Benefit Fund closed. Based on members' dissatisfaction with Spectrum Plus reimbursement levels, PEF negotiated an upgrade to the GHI Preferred plan in the 1995-99 PEF/NYS contract.

Since 1995 the GHI Preferred fee schedule has been upgraded three times. The first increase on 7/1/97 was for orthodontia treatment. The second increase on 9/1/97 was for endodontic treatment (e.g., root canals) and periodontic treatment (e.g., periodontic scaling). On 1/1/01 there was an average weighted increase of 5%, targeted at the most frequently performed procedures. The State has also approved 3% increases to be implemented on 1/1/03 and 1/1/05.

During the 1999-2003 contract negotiations, PEF proposed upgrading non-par reimbursement from 80% to 100% of the fee schedule (i.e., eliminating the out-of-network differential), and covering sealants for dependent children and general anesthesia. PEF also proposed putting the dental program out to bid in the hope that another vendor would provide higher quality services to the membership.

The State refused to upgrade non-par reimbursement to 100% of the fee schedule; as a compromise, they agreed to increase the annual maximum from $1,200 to $1,800 per enrollee. Although the program was put out to bid in 2000 and PEF was involved in that process through the Joint Committee on Health Benefits, other vendors who submitted proposals had problems potentially more serious than GHI's. PEF asked the State to throw out the bids and start the bidding process over again but the State refused. PEF did successfully negotiate coverage for sealants and general anesthesia, which became effective on 10/1/00.

4. What is PEF Planning for the Future?

Article 9.16 of the PEF/NYS contract empowers the Joint Committee on Health Benefits (JCHB) to oversee PEF members' health benefits. The JCHB meets regularly to discuss member concerns and also meets with the State and health benefit plan vendors as needed to bring certain issues to their attention. The JCHB met with the State and GHI on 4/20/01 to discuss our ongoing concerns about their performance. If necessary, the JCHB can recommend that the State terminate GHI's 5-year contract for the dental program early, which the State has the authority to do.

Membership Benefits is considering offering a supplemental dental plan to members. The State was planning to offer a supplemental plan as an employee-pay-all benefit, but our latest information is that this initiative may be on hold.

We realize that this is a significant amount of information about dental benefits, but hope it will be useful to you and to all PEF members who are frustrated with these continuing concerns. Please contact Lorraine Simpkins or Deborah Stayman at 1-800-342-4306 or 518-785-1900 x283 with any further questions. You may also e-mail us at lsimpkins@pef.org or dstayman@pef.org .