Protect your young adult children’s health

By LORRAINE SIMPKINS
As your young adult children come to the end of their school year or graduate, they may lose eligibility for coverage under your state health insurance and you will need to act quickly to prevent a break in coverage.

Your unmarried dependent children ages 19 through 24 are still eligible for dependent coverage in the NYS Health Insurance Program (NYSHIP) while they are full-time students at an accredited secondary or preparatory school, college or other educational institution, and are otherwise not eligible for employer group or military health care coverage (such as a cadet at a U.S. military academy).

Your full-time student dependent who completes a semester will continue to be covered under NYSHIP until the last day of the third month following the month when he completes the semester, unless he loses eligibility in some other way.

For example, if he completes the Spring semester in May, his last day of coverage would be August 31. However, if he’s 25 before August 31, his coverage will end on his birthday. This 3-month coverage extension applies to each full-time semester he completes, including the one when he graduates.

Check your NYSHIP General Information Book for eligibility information on students who leave school mid-semester.

Continuing under NYSHIP
If your child is no longer eligible, you must act quickly in one of the two following ways to continue his or her NYSHIP coverage without interruption:

• Continue health, dental and vision coverage in NYSHIP for up to 36 months under the federal Consolidated Omnibus Budget Reconciliation Act (COBRA) at a monthly cost this year of $509.95 (for the Empire Plan option), or

• Continue health (not dental or vision) coverage in NYSHIP under the Young Adult Option (YAO) through age 29 at a monthly cost this year of $499.07 (for the Empire Plan option).

If you wait more than 60 days after your covered dependent loses NYSHIP eligibility to inform the Employee Benefits Division (EBD) of the state Department of Civil Service, you can scratch COBRA off your list of options. It will not be available.

Other coverage options
If you rule out both COBRA and YAO, you may still have options for covering your dependent, but outside NYSHIP.
You may be eligible to:
• Convert to a direct-pay contract with the Empire Plan carriers or the HMO you have been using, but the benefit package and the premium costs will be different than under NYSHIP. You must apply directly to the carriers or the HMO;

• Enroll in Family Health Plus, a comprehensive NYS public health insurance program provided through participating managed care plans for adults ages 19-64 with too much income to qualify for Medicaid; or

• Enroll in Healthy New York, a NYS program to help small business owners provide health coverage to employees and their families. Also, uninsured sole proprietors and workers whose employers do not provide health insurance may buy comprehensive coverage directly through Healthy NY.

Where to get help
For more information and instructions on how to enroll in these programs, go online to www.cs.state.ny.us  and select “Benefit Programs.” Then follow the instructions to access NYSHIP Online. Then, for information on:
• COBRA – select “Health Benefits & Option Transfer” and then “NYSHIP General Information Book,” and scroll down to “COBRA: Continuation of Coverage;”

• YAO – select “What’s New,” and scroll down to “Young Adult Option Coverage;”

• Direct-pay contracts – select “Health Benefits & Option Transfer” and then “NYSHIP General Information Book,” and scroll down to “Changing from NYSHIP to a Direct-Pay Conversion Contract.”

For information on:
• Family Health Plus – visit www.health.state.ny.us/nysdoh/fhplus/

• Healthy NY – call (866) 432-5849 or go online to www.ins.state.ny.us and select “Healthy NY.”

Starting January 1, 2011, the new federal health care reform will require NYSHIP to provide coverage for dependent children through age 25. Details such as eligibility criteria and cost are not yet available.

Please note:
The information provided here applies to 2010. However, see this story for information about how the recent national health care reform will likely affect health insurance coverage for young adults starting next year.

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 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.

Rule changed for pre-tax contribution
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