How to Get the Best Value
This is the second installment of a two-part series documenting new requirements in NYC health plans.
If you receive health insurance through the New York City Employee Benefits Program, you should have recently found in your mailbox an announcement of changes to the city’s two basic plans, the Group Health Incorporated Comprehensive Benefits Plan (GHI-CBP) and the Health Insurance Plan Health Maintenance Organization (HIP HMO), both of which are administered by EmblemHealth. These include a revised co-payment structure under which some new services will be available with no co-payments, while the co-payments for some existing services will be increased. The changes apply to workers under either of these two city plans, and are designed to emphasize primary care and reduce the city’s costs by providing alternatives to emergency room and urgent care visits. To get the best value from your plan, you’ll want to carefully review these revisions, summarized below. All of the changes begin July 1, 2016.
GHI-CBP coverage, in which 72 percent of PSC members at CUNY participate, has no premium charge to the employee for the basic plan; the city unions have fought hard to keep the most popular plans free of payroll deductions. GHI’s participating physicians charge patients a prescribed co-payment per visit or service.
As of July 1, the GHI-CBP program will provide in-network preventive services with no co-payments for routine physicals, immunizations, colonoscopies and mammograms.
Co-payments are eliminated for office visits to a new tier of GHI primary care doctors and specialists who are members of AdvantageCare Physicians (ACP) – a multi-specialty practice. The list of preventive services and ACP physicians and facilities is available at emblemhealth.com/city.
GHI-CBP’s longtime system of in-network providers (who are not part of the new ACP service) is still in place. Members who visit doctors who are part of the GHI network but not part of the AdvantageCare system will see no change to the current $15 charge for a visit to a standard in-network primary care provider.
The co-payment for a standard in-network specialty doctor will increase from $15 per visit to $30. (Remember, there are specialists available through the ACP practice from whom you can receive in-office treatment and consultation for no co-payment.) There will also be increases to the co-payments for the following GHI network services – regardless of whether ordered by an ACP provider, a standard in-network provider or an out-of-network provider:
• Diagnostic lab tests increase from $15 to $20.
• Physical therapy increases from $15 per visit to $20.
• Radiology and high-tech scans increase from $15 per test to $50.
The most significant GHI co-payment increases are for outpatient urgent care and emergency room care. Co-payments for a participating urgent care center will increase to $50, up from $15, and co-payments for hospital emergency room visits will increase to $150, up from $50, to discourage inappropriate use of these higher-cost services. The co-payment is waived if the patient is admitted to the hospital from the emergency room.
For hospital coverage, the GHI plan partners with Empire Blue Cross.
The Affordable Care Act mandates a maximum out-of-pocket (MOOP) payment limit per year, which limits total coinsurance payments and deductibles that a member can be charged each year, but does not apply to charges for out-of-network doctors in excess of the GHI allowances. In other words, there is a cap on members’ co-payments and deductibles for in-network medical services.
The GHI medical MOOP is $4,350 (up to a combined maximum of $8,700 for a family). The Blue Cross hospital MOOP is $2,500 (up to a combined maximum of $5,000 for a family). If a MOOP is reached during a given year, no further co-pays are charged until the following year. However, payments to out-of-network doctors over and above the GHI or Blue Cross allowance for a particular service do not apply to the MOOP total.
The HIP HMO, through which 20 percent of PSC members at CUNY get their health care, also has no premium charge for the basic plan. It does not, however, reimburse for the cost of out-of-network services, except for legitimate emergency care. For the very first time, HIP will draw a distinction within their own Prime Network between “preferred” providers and all other in-network providers. If a preferred primary care provider is selected, all primary care visits – as well as visits to specialists – will continue with no co-payment. But if the HIP subscriber chooses to visit an in-network provider who is not on the Prime Network roster, a $10 co-payment will apply to all primary and specialty visits.
The list of participating and preferred physicians is available at emblemhealth.com/city.
DRUG BENEFIT EXPANSION
Most prescription drug needs for members at CUNY are handled by the PSC-CUNY Welfare Fund, now administered through CVS Caremark.
Longtime exceptions include diabetic medicines that by New York State mandate are provided through your basic health insurance (GHI-CBP or HIP HMO), as well as injectable and chemotherapy drugs, which come under the city-wide PICA program.
Effective July 1, there will be additional exceptions: GHI-CBP members will be able to receive certain preventive medications, including contraceptives, mandated by the Affordable Care Act to be provided at no co-payment. This change does not extend to HIP HMO members or enrollees with other insurers of the New York City Employee Benefits Program.
Those covered under the GHI-CBP basic health insurance will, starting July 1, receive contraceptives prescribed by their doctors through GHI, instead of through the PSC-CUNY Welfare Fund. A new card will be issued to make this clear. This is true, as well, of several other categories of preventive prescription medicines, such as prescribed preparations for colonoscopies. A full list of the ACA-compliant drugs is expected to be available soon at emblemhealth.com/city.
Because of the potential for confusion while these changes take place, members might want to have on hand all three cards (the Welfare Fund’s CVS/Caremark card, as well as your cards for GHI and PICA) when filling a prescription.
HEALTH IMPROVEMENT PROGRAMS
The New York City Employee Benefits Program is offering special rates for Weight Watchers, one of the most respected programs in the diet field. All employees covered through the city plan can pay a discounted monthly meeting fee of $30 and additionally receive a subsidy that would reduce that already discounted fee by half (to $15). Covered employees can enjoy discounted monthly pricing on the online version of Weight Watchers for $14 (with the subsidy, the fee comes down to $7 a month). Covered dependents can also enjoy the reduced pricing on either the meetings or online program but are not eligible for the subsidy.
Meetings are available in most communities. Programs may be brought to workplaces where members demonstrate sufficient interest. You may want to check with your benefits officer to see if a workplace Weight Watchers program is feasible for you and your colleagues.
In addition to this program, the city has been sponsoring free flu shot programs for several years.
BETTER HEALTH CARE ACCESS
Two programs are being developed to improve access to health care: a telemetric system and an appointment system that accommodates city employees and retirees.
Amwell is a service that allows eligible members access to a physician over the phone or via video interface 24 hours a day. The co-payment is $15, and members who have Skype or FaceTime capabilities can even have a (limited) visual examination. Clearly the service is not intended as an alternative to good primary care visits, but it can help determine what level of care is needed.
Zocdoc is an online service that can be used to make an appointment among a wide variety of local physicians. It’s easily sorted by location, specialty and earliest available appointment. For those who receive their health care through the NYC Employee Benefits program, a customized Zocdoc service will be made available to identify providers by basic insurance network participation. There is no charge for the Zocdoc service.
Each of these programs has an app available for your smartphone, and more information may be available through campus benefits offices.