Health Notes
Having medical lab tests? Don’t get ‘stuck’ twice
By SHERRY HALBROOK When is a participating provider in
your health plan, not a participating provider? Answer: when the provider participates in one Empire Plan network, but not another. Knowing the answer to that riddle
could definitely save you money. PEF Region 9 member Gloria Indik
nearly ran headlong into the problem, in spite of her best efforts to avoid it. Indik has family coverage under the
state Empire Plan (EP), so when her husband needed a blood test she called the EP Information Center to verify the laboratory at nearby Phelps Memorial Hospital Center in Westchester County is a participating provider and was told the lab is. However, when they went to the lab at
Phelps, her husband was asked to sign a statement that he would be responsible for any charges not covered by his insurance. Indik said that made them uneasy, so
they tried to call a Stellaris (which operates Phelps Hospital) patient advocate to resolve their misgivings. When they received no response from Stellaris, the Indiks left Phelps and went, instead, to a LabCorp facility they knew to be an EP participating provider and had his blood drawn and tested there.
What was that all about? Afterward, Indik called PEF health
benefits specialist Lorraine Simpkins to find out if her concerns had been needless and, together, they solved the riddle. “She was right to have misgivings
about using the Phelps lab in this situation,” Simpkins said. “I checked into it, and it turns out the Phelps lab is a participating provider under the EP
Medical Program for tests on blood or other specimens sent to them from outside the hospital. But if the blood is drawn or the sample is taken at Phelps Hospital, then the lab is not considered a par provider because the hospital is operated by Stellaris, which recently dropped out of the EP Hospital Program network.” It’s a very fine distinction that can
easily catch PEF members and their covered dependents unaware. “I was very lucky,” Indik said. “This
could be a big problem and people are not aware of it.”
Not so simple Just making sure all of your lab
samples are taken at your doctor’s office is not enough to protect you from unexpectedly high charges, Simpkins said. “If you or your covered dependents
have samples taken at your physician’s office, ask if they are being sent out for analysis and, if so, will it be done by a lab participating in the EP Medical Program network. “As long as your physicians use par
labs, you pay just a $20 copayment for covered tests,” Simpkins said.
Where you go matters However, your physician may write you an order for lab services and allow you to
choose where to have the specimen collected. Your least expensive option is to go to
LabCorp or to a hospital lab that’s subcontracted to LabCorp. It will cost you a $20 copayment for covered tests. The list of hospital-owned labs that are
subcontracted by LabCorp to serve as draw sites are listed in the directory of EP par providers with the words ‘LCA subcontracted’ before the name of the facility. However, if you go to a hospital lab
that’s not an LCA-subcontracted facility for testing, the lab services you receive may be covered under the EP Hospital Program, and that will cost you at least $35. That’s the copayment for covered services at hospitals participating in the EP Hospital Program network. If you go to a hospital-linked lab that’s
not in the EP hospital network, you will pay at least $75 or 10 percent of what the lab charges, whichever is greater. “Depending on the number of tests and
the kinds of tests that are performed, the member’s cost for using a non-par- provider hospital lab could be a big step up from the $20 copay for specimens sent to a lab that participates in the EP lab network,” Simpkins said. As Indik discovered, hospital labs may
be par providers in the EP Medical Program, but not in the EP Hospital Program. To find the most current listing of par
lab providers in the Medical Program go online to
www.cs.state.ny.us and select “Benefit Programs.” Follow the instructions to access NYSHIP Online and then select “Find a Provider.” You may also get this information by
calling United Healthcare at 1-877- 7NYSHIP (1-877-769-7447).
Gov sticks NYSHIP enrollees with $30M Medicare tab For years, the state has been trying to
unload the now $30 million annual cost of Medicare Part B reimbursements onto its employees and retirees. In 2006, PEF went to court and
successfully blocked it. Now, the governor is doing it again and this time he changed the section of state Civil Service Law on which PEF based its 2006 court case. However, PEF has already filed a
class-action grievance challenging the new cost shift as a violation of the PS&T contract. The monthly reimbursements are paid
www.pef.org
to those enrollees in the state Health Insurance Plan (NYSHIP) who are required to buy Medicare Part B medical coverage. That cost is deducted from their monthly Social Security checks. Now, the cost for reimbursing them
will be spread among all of the NYSHIP enrollees, both state employees and retirees. It’s retroactive to April 1. The total nine-month cost to Empire
Plan enrollees will be approximately $31 for individual coverage and $77 for family coverage, according to the state Civil Service Department (DCS). The cost to
HMO enrollees will vary and some will actually see a premium decrease. DCS says it will start adding the cost
to your premiums in August, with the retroactive cost spread over the remainder of the year. The governor got his new cost shift
through the Legislature by adding it to his June 7 emergency budget extender bill. The legislators cannot amend such bills and it would close state government services if they defeat the emergency legislation.
– Sherry Halbrook The Communicator July-August 2010—Page 13
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