PEF HEALTH NOTES
Empire Plan makes changes for 1999

By LORRAINE SIMPKINS
A list of what members want from a health plan is bound to include a choice of providers who participate in the plan, and quick and accurate processing of claims. United HealthCare (UHC) is taking steps to ensure these demands are met for enrollees in the state's Empire Plan.
Par-provider payments changing

PEF and the other state-employee unions have agreed to change the fee schedule used to reimburse Empire Plan participating providers to a "resource-based relative-value schedule" or RBRVS, effective January 1, 1999.

The new schedule will reimburse physicians based on the work they do or the "resources" (time and intensity) they use on a given task, the costs of their practices, and professional-malpractice-liability expenses.

Relative-value-based fee schedules have become the industry standard for "fee-for-service" health plans, such as the Empire Plan. For instance, Medicare - the federal health-benefits program for the elderly and disabled - has been using an RBRVS to reimburse providers since the early 1990s.

After comparing the Empire Plan's current fee schedule with those used by other payers, United HealthCare (UHC) determined that the allowances for many primary-care services, such as exams and physician visits, were well below current market trends, while many for surgery were significantly above.

Under the new fee schedule, allowances for many primary-care services will be increased, but allowances for many surgical procedures will be reduced.

UHC expects the change to help it retain and add new primary-care physicians to the participating-provider panel. Many of these physicians have expressed dissatisfaction with the current fee schedule.

Since the surgeons have agreed to accept lower allowances from other payers, UHC does not anticipate they will leave the Empire Plan. The overall effects of the changes will be monitored very closely.

Out-of-NYS-provider list changing

Empire Plan enrollees who live outside New York state know how difficult it can be to find a participating provider. This is going to change.

Beginning January 1, UHC will replace the current Empire Plan participating-provider panel for New Jersey, Connecticut and Florida (this mainly affects retirees) with another, national, UHC provider network.

The number of participating providers will be more than 6,500 in New Jersey, 4,300 in Connecticut, and 12,000 in Florida.

The NYS Department of Civil Service is sending a letter with more information, including a directory, to enrollees living in these states.

Since the national UHC network is different from the current panel, these enrollees should immediately determine the participation status of their current provider(s). Not all of the current Empire Plan participating providers are in the national UHC net-work.

The change to the national UHC network is being done in stages. After the change is completed in these first three states, other areas outside of New York state will be considered. This includes Chicago and Washington D.C.

New claims processing system

UHC is converting to a new claims-processing system.The system enhancement is year 2000 (Y2K) compliant and will improve the claims payment and reporting processes.

Claims for services performed on or after January 1, 1999 will be processed using the new system.

No new enrollment for HIP-NJ in '99
The NYS Joint Labor-Management Committees on Health Benefits have agreed to close HIP-NJ to new enrollees in 1999. New York state officials are concerned the HMO's financial problems are adversely affecting HIP-NJ enrollees' access to care.

In an attempt to improve the HMO's financial standing, it has been placed under the supervision of the state of New Jersey. Those New York state employees represented by PEF who are currently enrolled in HIP-NJ may choose to remain enrolled with it.

The state, however, will not approve any requests for new enrollment in HIP-NJ during the coming annual option-transfer period.

United HealthCare replaces MetLife
By LORRAINE SIMPKINS

MetLife has insured the medical component of the state's Empire Plan since the Empire Plan began in January 1986, but it won't be for much longer.

In January 1995, the health-care-benefits portion of MetLife merged with the health-care-benefits portion of Travelers to form MetraHealth. And, by mid-1995, United HealthCare (UHC) announced it was purchasing MetraHealth.

As a result of that acquisition, UHC Insurance Company of New York will replace MetLife as the insurer of the Empire Plan's participating-provider, basic-medical, home-care-advocacy and managed-physical-medicine programs.

Beginning in January 1999, enrollees will notice that plan documents and communication materials reflect the change in insurers. Otherwise, the transition will not affect enrollees.

Contracts renewed for Empire Plan Rx-program vendors
Cigna will continue to insure the Empire Plan Prescription Drug Program with Express Scripts/ValueRx serving as administrator.

The state awarded the new contract to the current vendors following completion of the competitive-bid selection process. The new contract is effective January 1, 1999 through December 31, 2004.