By
LORRAINE SIMPKINSIf you’re in the state’s Empire Plan, look for several benefit changes, authorized in the 2007-2011 PS&T contract, to start January 1, 2009. These changes include:
Non-network hospitals and facilities – When you use a non-network hospital, skilled nursing facility or hospice care facility, you are responsible for:
• 10 percent of the billed charges for inpatient services up to the coinsurance maximum;
• 10 percent of the billed charges or a $75 copayment for outpatient hospital services, whichever is greater, up to the coinsurance maximum.
The annual coinsurance maximum for covered inpatient/outpatient services received at a non-network hospital and covered inpatient services received at a non-network skilled nursing facility or hospice care facility is $1,500 for the enrollee, $1,500 for the enrolled spouse/domestic partner, and $1,500 for all dependent children combined. Currently, once the employee, spouse or domestic partner, or all dependent children combined have incurred $500 in coinsurance expenses, a claim may be submitted to United HealthCare for reimbursement of up to $1,000 under the Basic Medical portion of the Plan. Effective January 1, that maximum reimbursement will drop to $500.
This change also applies to covered inpatient mental health services received at a non-network facility.
Basic Medical annual deductible – The annual deductible for medical services performed and supplies prescribed by non-participating providers will increase from $349 to $363. This change reflects the 4.1 percent increase in the medical component of the Consumer Price Index for Workers (CPI-W) for the period July 1, 2007, through June 30, 2008. This change also applies to covered outpatient mental health services received from a non-network provider.
Basic Medical annual coinsurance maximum – When you reach the annual coinsurance maximum, Basic Medical reimbursement increases from 80 percent to 100 percent for covered services. For 2008, the annual coinsurance maximum is $1,676 per employee and covered dependents combined. Starting January 1, the coinsurance maximum will be split into $1,000 for the employee, $1,000 for the spouse or domestic partner; and $1,000 for all dependent children combined. This change also applies to covered outpatient mental health services received from a non-network provider.
Complementary and Alternative Medicine (CAM) Program – The discount network of acupuncturists, massage therapists and nutritionists will no longer be offered.
“Formulary Flexibility” – With the Empire Plan Preferred Drug List (or formulary), you pay the lowest copay for generic drugs (Tier 1), a higher copay for preferred brand-name drugs (Tier 2) and the highest copay for non-preferred brand-name drugs (Tier 3).
Effective January 1, formulary flexibility will affect prescription drug benefits as follows:
1 In addition to all generic drugs, brand-name drugs may be placed on Tier 1;
2 In certain therapeutic categories, no Tier 2 preferred brand-name drug option may be offered if two or more clinically sound and therapeutically equivalent drug options are available on Tier 1; and
3 In select therapeutic categories, a drug may not be covered if the drug has no clinical advantage over other drugs in the same therapeutic category.
