Consider carefully when choosing your health plan

The annual window for changing your health plan option will open as soon as the premium rates for 2006 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:

• W hat 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 like the Empire Plan.

• W hat are your health-care needs? Do you or a dependent require services for a ch ron ic medical condition or mainly for acute or urgent conditions?  W hich plans cover these services and how extensive is the coverage?  Does the plan insure against serious financial losses?

W hat benefits are available for the treatment of mental health conditions and alcohol or chemical dependency?  W hat 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.

• W hat 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?  W hich pharmacies are affiliated with the plan?

• W ho 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? W ill you need a referral to see a specialist?

• W hat if you use a non-participating provider? W ill 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.

• W ill 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.

Confused?  Need help?

Do you need help choosing the health plan that's right for you? Check out these sources of additional information.

Your Personnel Office – In November, your agency Health Benefits Administrator will receive a supply of Choices. The Choices booklet explains the health plan options available to you and provides a benefit summary for each plan. If you are interested in the Empire Plan, ask for The Empire Plan At A Glance. A printed Empire Plan Participating Provider Directory should also be available for reference purposes. 

NYS Department of Civil Service (DCS) – You can access Option Transfer publications including Choices and Rates and Deadlines using the DCS web site.  Go to www.cs.state.ny.us and click on Employee Benefits. This site also includes Empire Plan benefit information and links to the Empire Plan directories of network hospitals and participating providers

NYS Department of Insurance (DOI) – The 2005 New York Consumer Guide to Health Insurers offers information on how to choose a health plan, and easy-to-read tables with comparisons of health insurers and HMOs that offer plans in New York State.  One of the guide's highlights is the Insurance Department's annual complaint ratio ranking of HMOs.  Call 800-342-3736 or go to the DOI web site at www.ins.state.ny.us.

The New York State Health Accountability Foundation – You can use the 2005 NYS HMO Report Card to compare access, service and quality data for New York’s HMOs.   The report card is available at www.abouthealthquality.org.  

U.S. News & W orld Report – The National Committee for Quality Assurance (NCQA) and U.S. News & W orld Report have collaborated to rank the nation’s health plans based on clinical performance, member satisfaction and NCQA Accreditation.  The rankings are available on U.S. News Online at www.usnews.com.