Your HMO is still in
By LORRAINE SIMPKINS
The Joint Labor/Management Committee on Health Benefits (JLMC) has completed reviewing proposals submitted by HMOs for inclusion or continued participation in the New York State Health Insurance Program (NYSHIP). The committee limited new requests for inclusion in NYSHIP, as well as expansion requests from those already participating, to seven underserved counties: Chemung, Franklin, Jefferson, St. Lawrence, Schuyler, Steuben and Tompkins.
The committee approved requests from all of the HMOs currently participating in NYSHIP to continue to be available in 2005. The JLMC also approved a request from MVP Health Care to expand its service area to include Jefferson County.
If you are enrolled in an HMO that will be making a benefit change for 2005, you will be sent a side-by-side benefit comparison by October 20th. HMOs making benefit changes include: Blue Choice; CDPHP; Empire Blue Cross Blue Shield; HMO Blue (Utica and Central New York regions); Independent Health; and Preferred Care.
Premium rate information for 2005 is not yet available. Please review the rate flyer carefully, as HMO premium contributions may increase significantly from one year to the next.
Arbitrator: Empire Plan reimbursed member too little for cancer drugs
An arbitrator has ruled the Empire Plan shortchanged a PEF member with cancer when it based its reimbursement for chemotherapy drugs she received on the wrong standard.
And the arbitrator directed the state to pay her the difference and make sure other PEF members who receive chemotherapy or other prescription drugs are not similarly shortchanged in the future.
Arbitrator Stuart M. Pohl made the ruling in a grievance PEF filed August 23, 2001. The union charged the state failed to meet its health-benefit obligations under the PS&T contract by using the average wholesale price (AWP), rather than the average retail price to reimburse for prescription drugs covered by the Empire Plan’s Basic Medical Program.
This case arose when the member received chemotherapy at a clinic connected with a Blue Cross network hospital. Only after she received a bill from the clinic for nearly $30,000, did the member learn that the clinic, itself, was not considered a participating provider in the Empire Plan, and that her benefit covered only a percentage of the “reasonable and customary” charges for the drugs dispensed by the clinic.
PEF associate counsel Lisa Newmark argued that United HealthCare (UHC), which administers the Empire Plan’s Basic Medical Program failed to follow the definition of “reasonable and customary” charges set forth in its certificate of insurance.
— Sherry Halbrook
The
Communicator October 2004
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