EMPLOYEE BENEFITS at BINGHAMTON UNIVERSITY Updated Dec Understanding the Empire Plan

The Empire Plan is a specially-made plan for New York State employees... Various insurance companies (carriers who are otherwise unaffiliated) have agreed to provide coverage under the general contract of the Empire Plan HOSPITAL Empire Blue Cross & Blue Shield PRESCRIPTIONS Caremark MAJOR MEDICAL United HealthCare MENTAL HEALTH & SUBSTANCE ABUSE PROGRAMS GHI/ ValueOptions Contract with Carriers

Managed care features, but primary/referrals not required More choice, flexibility, but more self-management Participating providers: co-pays, no deductible Out of network providers: meet deductible, partial reimbursement Overview: Empire Plan

PRESCRIPTIONS Empire BlueCross Blue Shield/ Caremark 2006: New Prescription Carrier   Replaces Express Scripts   More information: on-line, Choices 2006   Auto transfer of existing maintenance prescriptions, except: – –Controlled substances – –Combination drugs – –Billing information   Same co-pay structure   Check list for preferred, generic, etc.

Empire Blue Cross & Blue Shield United HealthCare Hospital Coverage   Hospital charges go to Empire Blue Cross/ Blue Shield   Major medical services received in hospital are covered by United HealthCare

Hospital Coverage   Anesthesiology – – Included in hospital billing, covered by United HealthCare when using participating hospital   Network of Hospitals – – 95% of USA hospitals participate – – If not, expenses are covered at non-network levels HOSPITAL Empire Blue Cross & Blue Shield

Major Medical Coverage (United HealthCare) What are major medical charges?   Your doctors (in or out of hospital)   Tests and diagnosticians (labs, radiologists, blood work, X-rays...)   Physical therapy, chiropractic, other special services   Ambulance

Major Medical Coverage MAJOR MEDICAL United HealthCare   If you use a participating provider – –No annual deductible – –Small copayments – –Less out-of-pocket cost – –Doctor submits your claims   If you use a NON-participating provider – –Reimbursement is according to BASIC MEDICAL or MultiPlan

Meet annual deductible 80% reimbursement of reasonable & customary expenses (you are responsible for 20% plus differential) Submit claims If doctor is out-of network, but participates with MultiPlan: 80% reimbursement is based on discounted doctor charges; you are only responsible for the 20% balance Provider’s office submits claims Major Medical Coverage – using NON-participating providers  Reimbursement will be: Basic MedicalMultiPlanOR Meet annual deductible

for more MultiPlan details

Save $$ by using a participating provider Ask the office if they participate with the NYS Empire Plan (the carrier is United HealthCare) If not, are they a MultiPlan provider? Find providers on the web page (or call ), and always ask the doctor’s office directly if they still participatewww.cs.state.ny.us Are you a participating provider with the New York State Empire Plan?... the major medical carrier is United HealthCare... MAJOR MEDICAL United HealthCare

Save $$ by using a participating provider When you need lab work or X-rays...   Ask if the service your doctor orders will be done in a facility that participates with your plan (not necessarily so, even if your doctor participates)   Your tests might be analyzed by radiologists or diagnosticians that don’t have your insurance information. If you get bills from these places, contact them with your insurance information! MAJOR MEDICAL United HealthCare

Lab/Radiology Tests   Empire Blue Cross/Blue Shield pays if: – – You go to outpatient area of hospital for tests, or a hospital-owned clinic/facility (you’ll have hospital co-pays)   United HealthCare pays if: – – Test is done at doctor’s office or other non- hospital facility (you’ll have co-pays if participating; Basic Medical or MediPlan if not participating) Co-pays are higher when the same test is done in a hospital (outpatient basis) than when done in an office facility

Centers of Excellence  Cancer Centers of Excellence: –Paid-in-full coverage with no co-pays for cancer-related medical received through nationwide network (includes Sloan- Kettering, Roswell Park, Dana Farber, etc.). Can coordinate with local care. –Travel, lodging, meals reimbursed – Call , nurse/info  Transplant Centers  Infertility Centers HOSPITAL Empire Blue Cross & Blue Shield MAJOR MEDICAL United HealthCare

MANAGED PHYSICAL MEDICINE (United HealthCare)  Chiropractic Treatment and Physical Therapy VALUEOPTIONS (GHI)  Mental Health and Substance Abuse Treatment HOMECARE ADVOCACY PROGRAM “HCAP” (United HealthCare) Home Care Services and/or Durable Medical Equipment/Supplies EMPIRE BLUE CROSS & BLUE SHIELD u Before Maternity or Scheduled Hospital Admissions u Within 48 Hours of Emergency/Urgent Hospital Admission UNITED HEALTHCARE u Before Scheduling an MRI MUST CALL ! NYSHIP Managed Care Coverage Call for network providers and pre-authorizations

Caremark Prescription Drug Coverage  Three levels of drug coverage: – Generic – Preferred Brand-name – Non-preferred Brand-name  Mail order will save you money on co-pays  90-day prescription will save the cost of one co-pay at the pharmacy

Supply Dispensedgenericpreferred brand-name non-preferred brand-name Up to a 30-day supply from a participating retail pharmacy or through Mail Order $5 copay$15 copay$30 copay 31 to 90-day supply through Mail Order $5 copay$20 copay$55 copay 31 to 90-day supply from a participating retail pharmacy $10 copay$30 copay$60 copay 2006 Prescription Drug Co-pays

Helpful Hints: Use Participating Providers When Possible  Check first to see if your doctors, hospital, facilities, labs, etc. participate with the NYS Empire Plan  If you’re using a non-participating provider: – –Ask if they participate with MultiPlan – –If not, you can request a “pre-determination of benefits” to see if you’ll be reimbursed for a “reasonable and customary” fee. Contact : United HealthCare Insurance Company of New York P.O. Box 1600 Kingston, NY

Helpful Hints: Check and Follow Plan Rules  Always check requirements for “you must call” situations: hospital admissions, MRI’s, managed care, other major services  Don’t assume! If in doubt about a rule/procedure, call the Empire Plan directly

Helpful Hints: Stay Up to Date with Claims  The NYS Empire Plan carrier’s web sites help you self-manage your plan, and access your claim information at any time. (click on Employee Benefits) United HealthCare Empire Blue Cross Blue Shield (ExpressScripts) until end of 2005

Helpful Hints: Understand the Explanation of Benefits REMARK CODE PLAN BENEFITS 73 (73) PLEASE HAVE THE HOSPITAL SEND THESE CHARGES TO UNITED HEALTHCARE FOR PAYMENT.  Look for the “Remark Code” and its explanation below.  If problem/question, call your doctor’s billing office … or the insurance company that sent you the Explanation of Benefits (United HealthCare, Empire Blue Cross Blue Shield, GHI/Value Options) 0.00 %

Helpful Hints: Resolve Problems Promptly  Be pro-active with any bills and Explanation of Benefits you receive. If it doesn’t look right, ask! Look at your claim on-line, call the Empire Plan, or ask your doctor’s billing office to clarify.  Keep copies of claims you’ve sent in, at least until they’re resolved (or, you can print your EOB’s from the website) If I ignore these bills, maybe they’ll go away!

Helpful Hints  Make sure bills are submitted (either by you or the hospital/doctor’s billing office) before March 30, 2006 for charges incurred in 2005  If neither you nor the provider submits the bill in time, the insurance carriers do not have to reimburse any amount (as stated in Certificates).

Helpful Hints: Plan Ahead, Get Yourself Informed!  Try thinking of health insurance somewhat like car insurance: understand the carrier agreement (Empire Plan General Information Book & Certificate) follow carrier rules & procedures shop for health care providers that offer reasonable cost with good service anticipate deductibles, “maintenance” costs, and other out-of-pocket expenses

For More Information  Refer to the Empire Plan General Information Book & Certificate. Check the web site:  Read the Empire Reports you receive in the mail. Save for future reference.