Public Employee Press

News about your benefits
Changes in BlueCross BlueShield

Beginning in January, participants in the GHI-CBP/ Empire BlueCross BlueShield plan must get treatment at a network of hospitals and other outpatient facilities to avoid potentially hefty co-payments.

The change was part of an agreement reached in June between the city and the municipal unions that called for $400 million in health-care savings over two years and postponed 1,000 layoffs for 90 days.

On Jan. 1, GHI-CBP/BCBS will change from an indemnity program to a preferred provider organization. Indemnity plans cover all services without restrictions while PPOs require participants to use networks of physicians and facilities to avoid significant co-payments.

The changes affect the Empire BlueCross BlueShield portion of the health-care benefit. Empire covers treatment at hospitals, ambulatory surgical centers, skilled nursing and other out-patient facilities.

For in-network hospitalization, participants will continue to have a $300 inpatient deductible per person for each admission up to a maximum of $750 a year.

For treatment outside the network, participants will pay a $500 deductible up to a maximum of $1,250 in a calendar year. After patients meet the out-of-network deductible, they must pay coinsurance of 20 percent of the average county rate while Empire will cover 80 percent. In addition, patients are responsible for the difference between the total bill and their co-payment and payment from BlueCross BlueShield.

By and large, participants shouldn’t be too concerned about hospitalization network restriction, because 94 percent of the hospitals in the country participate under the BlueCross BlueShield PPO network. To ensure you are treated by an Empire BlueCross BlueShield PPO network provider, call the NYC HEALTHLINE pre-certification number at 800-521-9574.

The benefit for in-network treatment at ambulatory surgery centers and facilities for blood transfusions, presurgical testing, skilled nursing and other services remains the same — a 20 percent coinsurance up to a maximum of $200 a year. Getting out-of-network treatment at these facilities may result in several thousands of dollars of out-of-pocket expenses, so it’s very important to contact NYC HEALTHLINE to ensure you go to a network facility.

Hemodialysis treatment will only be covered at an in-network facility. However, if you are currently being treated at a non-network hemodialysis during FY 2009, you will be grandfathered and treated as if you are at an in-network facility.

Patients don’t have to worry about hefty bills for emergency treatment at an out-of-network hospital. The co-pay for an emergency room visit is waived if you are admitted for inpatient care.

These program changes do not apply to anyone covered by Medicare.

Soon, GHI and BlueCross BlueShield will send participants new insurance cards.