 Premiums
not the only cost to consider
Be careful when
choosing your health plan
By Lorraine Simpkins
The annual window for changing your health plan option
will open as soon as the premium rates for 2003 are set.
You will have 30 days after the rates are delivered to
the state agencies to change health plans. If you
don’t request a change during that period, you will
automatically remain enrolled with the same health plan
you are in.
Not all health plans are alike, and the one that was the
best for you this year may no longer be your best choice.
It’s well worth your effort to compare them.
In deciding among the Empire Plan and the HMO options,
Consider such factors as accessibility, benefits,
quality, cost and ask yourself these questions:
• What are the potential out-of-pocket expenses?
These expenses can include deductibles, coinsurance
costs, copayments, and non-covered expenses such as
charges by health care providers that exceed the maximum
allowed under the plan's reimbursement schedule.
• Are you required to file your own claims? If so,
what is the process for filing claims? How long does
it take to be reimbursed or to dispute a claim
determination?
HMO enrollees often report less paperwork and
administrative hassle than those enrolled in a
fee-for-service plan such as the Empire Plan.
• What are your health-care needs? Do you or a
dependent require services for a chronic medical
condition or mainly for acute or urgent conditions?
Which plans cover these services and how extensive is the
coverage? Does the plan insure against serious financial
losses?
• What benefits are available for the treatment of
mental health conditions and alcohol or chemical
dependency? What facilities and clinicians in your
area are in the plan’s network? Look for any
contract provisions or plan procedures that restrict your
access to care or limit the benefits available.
• What benefits are available for prescription
drugs? Is there a maintenance-drug program, including a
mail-order pharmacy? How many copayments do you have to
pay for a 90-day supply of maintenance drugs? Are
benefits limited to only those drugs included on a
formulary (list of preferred drugs)? Is there a mandatory
generic-drug substitution requirement? Are
dentists’ prescriptions covered? Which
pharmacies are affiliated with the plan?
• Who are the providers affiliated with the
plan? Is there an adequate number of providers? How
many of the plan’s physicians are board-certified or
board-eligible?
• How important is it to keep the doctor you have?
Does the plan restrict your ability to use providers of
your choice? Will you need a referral to see a
specialist?
• What if you use a non-participating provider? Will
you receive any benefits at all under the plan? HMOs do
not provide benefits for non-participating providers
under most circumstances. The Empire Plan provides
benefits for services performed by both participating and
non-participating providers. However, your out-of-pocket
expenses will be higher if you use a non-participating
provider.
• How will your doctor’s reimbursement affect
your care? Does the plan penalize your doctor financially
if you need frequent visits, referrals, or expensive
tests and treatments?
Doctors may be paid by: salary; fee-for-service;
fee-for-service less a withhold; or capitation (the same
payment per patient no matter how many or how few
services you receive).
• Will coverage be limited if you or a covered
dependent needs medical care while out of the plan’s
service area? Many HMOs provide very limited benefits for
care received outside their service areas. If you
travel or have dependent children who live or attend
college outside of an HMO’s service area, pay
particular attention to the criteria that must be met to
receive benefits. Your child may have to return home
for non-urgent medical care.
File your
HCSAccount claims by Mar. 31
File your claims now for reimbursement from your 2002
Health Care Spending Account (HCSAccount).
Only eligible services provided between January 1 and
December 31, 2002 will be reimbursed.
All claims for 2002 services must be submitted by March
31, 2003. You will lose any money remaining in your 2002
HCSAccount after that date.
If you’re enrolled in the HCSAccount, any
unreimbursed medically necessary health care expense can
be reimbursed from your account as long as the service is
provided to you, your spouse, or your tax dependents.
Reimbursable expenses include office visit, hospital and
prescription drug copayments, physical therapy,
chiropractic care, laser eye surgery, annual deductibles,
eyeglasses, contact lenses and contact lens solutions,
hearing aids, and dental treatment.
You may also be reimbursed for transportation and lodging
expenses incurred as a result of obtaining medically
necessary health care. Reimbursement request (claims)
forms are available at www.flexspend.state.ny.us. Or call
the Flex Spending Account hotline at 1-800-358-7202 to
request forms or ask questions about the eligibility of
your health care expenses. — Deborah Stayman
 GO TO HEALTH BENEFITS WEBSITE
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Features
PEF’s political action
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Union's top COPE-people take
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Nurses protest at SUNY
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Long view snags threat to
PEF jobs
PEF Scholarships and
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- January time to apply for student financial aid
- PEF to award 10 Scacalossi Scholarships
- Unions offer $$$ to top students
- Neil Boyle lives on through scholarships
- Tap into a Union Plus
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Departments
President's Message: Ready
for '03 challenges
You Said It: Member's
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Member Mobilization:Building
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Nurses' Station: Fight for
healthier health care
Health Notes: Choosing your
health plan
Retirees In Action:
Legislative battles ahead
Member In Action: Highlights
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PEF Membership Benefits
Program & Travel Corp
Union Matters
Trustees Report to the '02
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Agency-fee procedure
outlined
Financial Supplement (Audit)
PEF helps spotlight poor
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Members’ 9/11 tribute
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Union striving to keep
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Members' vacation credits
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Members on military leave health insurance safe
Court: GOER must enforce
order at SIF
PEF rallies to aid injured
member at DOT
Test drive online training
Contract offers DOCS members
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ERI windows already opened
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File your HCSAccount claims
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E- Board makes decisions at
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Black Caucus to host Holiday
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