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 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