Lots to consider in choosing health plan
By LORRAINE SIMPKINS The annual window for state
employees to change health plans will open as soon as the premium rates for 2012 are set, which usually occurs in November or early December. You have 30 days after the rates are
delivered to the state agencies to change health plans, so watch for that notice in your mail. If you don’t request a change then,
you’ll automatically remain enrolled in your current plan.
What should you consider? The plan that was the best for you this
year may no longer be your best choice. It’s well worth comparing them. In choosing from among the Empire
Plan and the HMO options, consider such factors as premium cost, freedom to choose your own providers and benefit levels and limitations. 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. 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 outside their service areas. Pay close attention to the criteria that must be met to receive benefits for such care. • What are the potential out-of-
pocket costs, such as deductibles, coinsurance, copayments, and non- covered charges? • Are the providers you and your
family use in the plan’s network? It costs you more if you use providers who aren’t in your plan’s network. The Empire Plan provides reduced benefits for services performed by non-network providers and HMOs don’t provide any benefits for using them under most circumstances. • Must you submit your own claims? If
so, what’s the process? How long does it take to be reimbursed or dispute a rejected claim? HMO enrollees often report less paperwork and administrative hassle than those enrolled in fee-for- service plans. • Are benefits for certain services or
items excluded or limited to a maximum dollar amount, number of visits or number of days?
Walgreens drops out of workers’ comp Rx network
If you’ve been hurt or made sick on the job, you could be in for
another “ouch!” in your pocketbook next year. It will depend on whether you fill your workers’ comp prescriptions
at Walgreens, Duane Reade, Happy Harry’s or OptionCare pharmacies. Walgreens, which owns the other pharmacies, announced recently they are dropping out of the Express Scripts Inc (ESI) network of participating providers effective January 1, 2012.
ESI is under contract with the State Insurance Fund to provide prescription
medications to individuals receiving workers’ compensation benefits for their work-related injuries or illnesses. This doesn’t affect prescriptions you purchase through the Empire Plan or
your HMO. Workers who fill workers’ comp prescriptions at a pharmacy in the ESI
network avoid a co-pay. ESI is writing to members with workers’ comp-covered illnesses or injuries to
help them transition to other network pharmacies. These letters identify the three ESI network pharmacies which are nearest the employees’ homes as alternatives. For more information go to
www.Express-Scripts.com/workerscompensation or call 866-533-7011.
—Deborah Stayman Page 10—The Communicator November 2011 PEF Information Line: 1-800-553-2445
• What benefits are available for prescription drugs? Check the plan’s most current formulary to
see if it covers the prescription drugs you and your family use. What will your copayments be? Must you use the mail-service pharmacy to obtain a 90-day supply of medication?
Want some help? For more information, check out
these sources: • Your agency’s personnel office – In
November, your agency’s health benefits administrator will receive a supply of the Choices booklet which 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. • NYS Department of Civil Service
(DCS) website – You can access health- benefit and option-transfer information online at
www.cs.ny.gov. Use the “NYSHIP Plan Comparison”
tool to generate a side-by-side comparison of the benefits provided by each 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 Financial
Services (DFS) – The 2011 New York Consumer Guide to Health Insurers provides information about the quality of care that health insurers and HMOs in New York state are providing, and ranks them based on consumer complaints to the DFS. Call 800-342-3736 or visit
www.dfs.ny.gov; • NCQA’s Health Plan Report Card –
The National Committee for Quality Assurance (NCQA) evaluates HMOs’ quality of care and service. Based on this review, NCQA then gives accreditation ratings ranging from provisional to excellent. To see an HMO’s accreditation rating and create customized “report cards” showing results for the HMOs that interest you, go to
www.ncqa.org; and • Consumer Reports – The November
2011 issue includes NCQA insurance- plan rankings, plus tips on how to choose a health plan. Read it online at
www.consumerreports.org.
Health Notes
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