Empire Plan Changes Coming 1/1/09

If you’re in the state’s Empire Plan, look for several benefit changes, authorized in the 2007-2011 PS&T contract, to start January 1, 2009. The changes are summarized in a chart here.

Services received at non-network hospitals and facilities – When you use a non-network hospital, skilled nursing facility or hospice care facility, you are responsible for:

·         10 percent of the billed charges for inpatient services up to the coinsurance maximum;

·         10 percent of the billed charges or a $75 copayment for outpatient hospital services, whichever is greater, up to the coinsurance maximum.

The annual coinsurance maximum for covered inpatient/outpatient services received at a non-network hospital and covered inpatient services received at a non-network skilled nursing facility or hospice care facility is $1,500 for the enrollee, $1,500 for the enrolled spouse/domestic partner, and $1,500 for all dependent children combined.  Once the employee, spouse or domestic partner, or all dependent children combined have incurred $500 in coinsurance expenses, a claim may be submitted to United HealthCare for reimbursement of up to $1,000 under the Basic Medical portion of the Plan.  Effective 1/1/09, reimbursement will decrease from $1,000 to $500.

In accordance with Timothy’s Law, this change also applies to covered inpatient mental health services received at a non-network facility.

Basic Medical annual deductible - The annual deductible for medical services performed and supplies prescribed by non-participating providers will increase from $349 to $363.  This change reflects the 4.1% increase in the medical component of the Consumer Price Index for Workers (CPI-W) for the period July 1, 2007 through June 30, 2008.

In accordance with Timothy’s Law, this change also applies to covered outpatient mental health services received from a non-network provider.

Basic Medical annual coinsurance maximum – When you reach the annual coinsurance maximum, Basic Medical reimbursement increases from 80% to 100% for covered services.  For 2008, the annual coinsurance maximum is $1,676 per employee and covered dependents combined.  Effective 1/1/09, the coinsurance maximum will be split into $1,000/employee; $1,000/spouse or domestic partner; and $1,000 per all dependent children combined.

In accordance with Timothy’s Law, this change also applies to covered outpatient mental health services received from a non-network provider.

Complementary and Alternative Medicine (CAM) Program – The discount network of acupuncturists, massage therapists and nutritionists will no longer be offered.

“Formulary Flexibility” – With the Empire Plan Preferred Drug List (or formulary), you pay the lowest copay for generic drugs (Tier 1), a higher copay for preferred brand name drugs (Tier 2) and the highest copay for non-preferred brand name drugs (Tier 3).

Effective 1/1/09, formulary flexibility will impact prescription drug benefits as follows:  1) In addition to all generic drugs, brand name drugs may be placed on Tier 1; 2) In certain therapeutic categories, there may be no Tier 2 preferred brand name drug option if there are two or more clinically sound and therapeutically equivalent generic and/or brand name drug options available on Tier 1; and  3) In select therapeutic categories, a drug may not be covered if the drug has no clinical advantage over other generic and brand name drugs in the same therapeutic category.