Three LI hospitals rejoin Empire Plan network, but four drop out in Westchester

By SHERRY HALBROOK and LORRAINE SIMPKINS

There’s good news for members on

Eastern Long Island who are enrolled in the state’s Empire Plan, but the news is not so good for those in and around Westchester County. The news involves two different

groups of hospitals that have been participating providers in the Empire Plan network. Empire Blue Cross and Blue Shield

(EBCBS), which provides the Hospitalization insurance for the Empire Plan, has been negotiating with both groups, but has only been successful in reaching an agreement with one of them. The East End Health Alliance in

Suffolk County includes Eastern Long Island Hospital, Peconic Bay Medical Center, and Southampton Hospital. Negotiations that stalled last summer caused them to be dropped from the hospital network effective August 1, 2009. Thanks to a new agreement, all three hospitals are again in the EBCBS/Empire Plan hospital network, effective April 1 of this year. That’s good news for Empire Plan

enrollees who use these hospitals, because using them will cost less.

Unfortunately for plan

enrollees using any of the four hospitals in the Stellaris Health Network in Westchester County, negotiations failed to produce an agreement before their contract with EBCBS expired at the end of March. As a result, Lawrence

Hospital, Northern Westchester Hospital, Phelps Memorial Hospital Center, and White Plains Hospital are no longer participating in the hospital network effective April 1, 2010.

How may it affect you?

If you are enrolled in the Empire

Plan and use any of these four hospitals while they are not participating in the network, your benefits for covered services will be reduced accordingly with a few exceptions. The Empire Plan will approve in-

network coverage at a non-network hospital under the following circumstances: • Cases of emergency; • If no in-network hospital exists

Rule changed for pre-tax contributions

Retroactive to January 1, 2010, enrollees in the state Health Insurance Program,

who participate in the Pre-tax Contribution Program and who cover a dependent who is not federally qualified, may have their full premium contribution for the cost of family health insurance coverage deducted from their pre-taxable wages. This technical change benefits members who cover domestic partners or

dependents on their state health insurance. The enrollee and covered dependents will be treated the same way regarding use of

pre-tax income to pay for insurance premiums. Previously, the enrollees’ premiums have been split. The part of the premium

paying for the enrollee’s and their federally qualified dependent’s coverage would have been taken from pre-taxable income, while the part of the premium paying for the non-qualified dependent’s coverage would have been taken from taxable income. However, these enrollees who cover a federally qualified dependent will still be

responsible for reporting the value of that coverage on their federal income tax return. The state Department of Civil Service sends them form 1099-MISC showing this amount after the end of each tax year. The change will neither affect the total premium deduction, nor the imputed

income. However, the tax withholding amounts could change slightly. Please consult your tax advisor for additional information or guidance.

—Deborah Stayman

Page 8—The Communicator May 2010

that can provide the services required; • If a network hospital is not

available within a 30-mile radius from the member’s home; • For continuation of care for

pregnancy or health risk; and • For any services that were previously preauthorized.

Out-of network penalties

Other than the exceptions above,

use of a non-network hospital means: • For inpatient services, you must

pay 10 percent of billed charges up to the annual coinsurance maximum of $1,500 that applies individually to the enrollee, to their covered spouse or domestic partner, and to all covered dependent children combined. However, you may be reimbursed up to $500 of each of these coinsurance maximums through the Basic Medical Program insured by United Healthcare. • For non-emergency outpatient

services, you must pay the greater amount of either a $75 copayment or 10 percent of billed charges, up to the annual coinsurance maximum of $1,500. Again, you may request reimbursement of up to $500 of each of the coinsurance maximums from United Healthcare (UHC); and • Using radiology, anesthesiology or

pathology services as either an inpatient or outpatient at a non- network hospital will cost you more if the physician is not in the UHC network. Your benefit will be subject to a $375 annual deductible, after which UHC will pay up to 80 percent of the “reasonable and customary” charges for the services you received. For more information or for help

identifying other Empire Plan participating hospitals in that area, call 1-800-495-9323, Monday through Friday, between 7 a.m. and 8 p.m.

PEF Information Line: 1-800-553-2445

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