Find out now how to minimize your
out-of-pocket cost
Unwitting Empire Plan enrollees can face huge bills for
chemotherapy
Click Here for chart
 By
LORRAINE SIMPKINS
As if having cancer isn’t bad enough, several Empire
Plan enrollees have learned too late that their
out-of-pocket expenses for chemotherapy will be much
higher than they expected. In fact, very quickly they
have found themselves stuck with bills for more than
$4,000.
You can avoid these charges if you know what triggers
them.
The benefits for chemotherapy differ significantly
depending on whether the provider administering the
therapy has joined the Empire Plan panel of participating
providers and agreed to accept the plan’s
reimbursement as payment in full.
When it comes to chemotherapy, par-provider status can be
deceptive. But where it’s provided can be a tip-off.
Usually a patient has chemotherapy as an outpatient, in
one of the following locations:
• a hospital-affiliated clinic;
• a physician’s office; or
• the outpatient department of a hospital.
A hospital-affiliated clinic may be located in the
hospital, in a separate building on the hospital grounds,
or away from the hospital.
Even if the hospital is a participating provider which
operates the clinic and bills for the clinic’s
services, these services are not covered by Empire Blue
Cross and Blue Shield under the hospital portion of the
Empire Plan. Instead, they are covered by United
HealthCare under either the Participating Provider or
Basic Medical Programs, depending on the clinic’s
rather than the hospital’s, participating-provider
status.
In most cases, these affiliated clinics are not Empire
Plan par providers.
Easy to get stuck
If you receive outpatient chemotherapy in a non-par
physician’s office or at a non-par
hospital-affiliated clinic, you will be reimbursed under
the Basic Medical Program subject to the annual
deductible ($271 in 2002) and coinsurance.
After you satisfy the deductible, the plan will reimburse
you for 80 percent of the reasonable and customary
(R&C) charges, or the billed charges, whichever is
less.
The reimbursement increases to 100 percent of the R&C
charges, after the combined coinsurance amount for you
and your covered dependents exceeds $1,303. However, you
still must pay for any amount that exceeds the R&C
charge, which may be a lot lower than the billed charge.
The R&C charge used to reimburse enrollees for
chemotherapy drugs administered in a non-par
physician’s office or hospital-affiliated clinic is
often much less than the billed amount.
By the time these claims are processed and you receive an
explanation-of-benefits statement, you could have
incurred tens of thousands of dollars in expenses that
will not be reimbursed.
Why such a big
difference?
The big difference between the amount charged by many
providers for chemotherapy drugs and the R&C charge
for reimbursement results from the providers’
efforts to maximize their income, and the Empire
Plan’s efforts to hold down rising health care
costs.
UHC uses the average wholesale price of the medication as
the R&C charge for prescription drugs administered in
a physician’s office or hospital-affiliated
extension clinic.
However, for other medical services, UHC uses the charges
actually billed by providers to determine the R&C
charge.
Avoid the trap
If you receive chemotherapy in a non-par physician’s
office or hospital-affiliated clinic, you can protect
yourself from these costs.
Instead of having a non-par provider dispense your
chemotherapy drugs, buy them from an Empire Plan
participating retail or mail-order pharmacy where you
will have just a small copayment. Then bring the drug(s)
with you to the physician’s office or clinic where
they are to be administered. By using a participating
provider, including the outpatient department of a
participating hospital, you can avoid the problem
completely.
Your choice of provider will determine how much you have
to pay out-of-pocket (see chart).
If you have questions about what the plan will pay if you
receive outpatient chemotherapy in a setting other than
the outpatient department of a hospital, call UHC at
1-800-942-4640.
|
The Communicator
July/August 2002
The Official Online Edition of
The New York State Public Employees
Federation
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Contract Success: Schools
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