| Negotiated changes to health benefits starting Jan. 1, 2006 Enhancements and other changes to the health benefits negotiated in the 2003-2007 PS&T contract will take effect January 1, 2006. “We’ve received a number of complaints about the GHI dental plan’s out-of-network differential,” said PEF health benefits specialist Lorraine Simpkins. When basic and major restorative services are performed by a non-participating dentist, the GHI plan has been paying 80 percent of the allowable charge. The enrollee has had to pay the remaining 20 percent of the allowable charge (referred to as the out-of-network differential), plus the difference between the non-participating dentist’s actual charge and the allowable charge. Starting January 1, GHI will pay 100 percent of the allowable charge for both participating and non-participating dentists. “The penalty for using non-participating dentists has applied even in situations where no participating dentist was available Members will be glad to know that differential will no longer apply in 2006,” Simpkins added. Also under the GHI Preferred Dental Plan, the annual maximum benefit will increase from $1,800 to $2,300 per person, per calendar year. Simpkins said the new year also will bring changes for members enrolled in the Empire Plan. The benefit for hearing aids is improving, but members using a non-participating provider will see their costs increase. The maximum Empire Plan reimbursement for hearing aid evaluation, fitting and purchase of hearing aids will increase from $1,200 to $1,500 per hearing aid, per ear. The Empire Plan Basic Medical Program annual deductible for medical services performed and supplies prescribed by non-participating providers will increase from $309 to $322. And if your expenses under the Empire Plan Basic Medical Program exceed $1,548 (up from $1,486), the plan will pay 100 percent of the “reasonable and customary” charges. These changes result from a 4.2 percent hike in the medical component of the Consumer Price Index for Workers (CPI-W) for the period July 1, 2004, through June 30, 2005. |
CDPHP, MVP service areas expanding No new HMO enrollments allowed for Aetna in 2006 The NYS Joint Labor-Management Committees on Health Benefits (JLMC) has announced it is sanctioning Aetna for missing the deadline to submit documentation the JLMC needs to evaluate the HMO’s participation in the New York State Health Insurance Program (NYSHIP). Aetna will not be permitted to enroll state employees or retirees as new members or transfers in 2006. However, if you are currently enrolled in the Aetna plan, you may continue in it for 2006 or change to a different plan. The other HMOs currently participating in NYSHIP will be available to both current and new enrollees in 2006. The JLMC also approved two expansion requests. CDPHP is adding Dutchess county to its service area, and MVP is adding Rockland and Sullivan counties to its service area. If you are enrolled in an HMO that will change its benefits for next year, you will be sent a side-by-side benefit comparison no later than October 21. The following HMOs are making various changes to their benefits for 2006: Aetna, Blue Choice, CDPHP, Empire Blue Cross Blue Shield, HMO Blue (Utica and Central New York regions), Independent Health, MVP and Preferred Care. As soon as premium rates for 2006 are available, they will be mailed to NYSHIP participants. Be sure to review the rate flyer carefully. The enrollee’s share of HMO premiums may increase significantly from one year to the next. — Lorraine Simpkins |
New vendor will operate Empire Plan Rx program The state has awarded a three-year contract to manage Empire Plan prescription drug benefits to Empire Blue Cross Blue Shield (BCBS) and Caremark Rx, effective January 1, 2006. The contract is currently held by CIGNA and Express Scripts Inc. This change in vendor does not affect PEF members enrolled in HMOS. Empire Plan enrollees will continue to receive the same level of benefits, including what prescription drugs and medicines are covered, copayment amounts, and reasonable access to in-network retail pharmacies, as well as a mail-service pharmacy. As more information becomes available, members will be notified immediately of any changes that may affect them. Empire BCBS currently has the contract to insure Empire Plan hospital benefits. Caremark Rx, one of the nation’s largest pharmacy-benefit managers, manages prescription drug benefits for more than 70 million people. The Empire BCBS/Caremark Rx bid was selected from four bidders after being evaluated by staff from the state Department of Civil Service (DCS), the Governor’s Office of Employee Relations, and the Division of Budget. The PEF Joint Labor/ Management Committee on Health Benefits was involved in the vendor-selection process by reviewing the draft request for proposals (RFP), evaluating the technical component of each of the bidder’s proposals, and participating in the bidder interviews. DCS will give the committee an overview of the vendor-selection process, including premium cost information, in the near future. For more information, contact Lorraine Simpkins or Deborah Stayman at 1-800-342-4306, ext. 283 or e-mail them at health_benefit@pef.org. |
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