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Know your benefits
GHI-CBP/Empire BlueCross/BlueShield Hospital and Out-Patient Plan Changes
Members will be receiving this information letter (below) in the mail along with new GHI/Empire cards in late November-December.
Things to Remember
You should call NYC HEALTHLINE at 1-800-521-9574 to verify that the facility you will use is part of the Blue Cross and Blue Shield Association BlueCard ® PPO Program. l Just prior to your procedure, confirm with the facility that they are currently participating in the Blue Cross and Blue Shield Association BlueCard ® PPO Program.
Dear GHI-CBP/Empire BlueCross BlueShield Non-Medicare Member:
As a result of negotiations between the City of New York Office of Labor Relations and the Unions, represented by the Municipal Labor Committee, the following benefit changes will become effective January 1, 2010: The Empire Blue Cross/Blue Shield (Empire) portion of the plan (that is, benefits for services provided at hospitals and out-patient facilities) of our GHI-CBP/Empire BlueCross BlueShield plan will change to a Preferred Provider Organization (PPO) plan for you and your eligible dependents. With a PPO plan, you have access to both in-network and out-of-network care; but, by using a network facility you can avoid what can be high out-of-pocket expenses. Because 94% of the nation’s hospitals participate in the Blue Cross and Blue Shield Association BlueCard® PPO Program network, it should be easy to find a participating facility in a convenient location. The following Q & A will describe how to best access your benefits.
With this letter you are also receiving new identification cards. Please destroy your old cards and use these cards starting January 1, 2010.
What benefits are affected by this change?
The benefits affected by this change include services at hospitals, ambulatory surgery and hemodialysis facilities and other ancillary services and procedures connected to in-hospital and out-patient facilities. Physician services under the GHI-CBP portion of the plan are not affected by this change.
How do I find a Blue Cross and Blue Shield BlueCard® Program PPO in-network hospital, ambulatory surgery or other facility?
This information can be obtained by calling NYC HEALTHLINE (the hospital pre-certification organization); at 1-800-521-9574 and representatives will confirm whether the facility you wish to use is in the Blue Cross and Blue Shield BlueCard® Program PPO network or will direct you to an in-network facility.
When I use an in-network hospital, what will it cost me?
For in-network hospitalization, there will be no change to your benefits. You will pay a $300 inpatient deductible per person per admission, up to a maximum of $750 in a calendar year.
If I decide to use an out-of-network hospital, what will it cost me?
Effective January 1, 2010, if you use an out-of-network facility in a non-emergency you will be responsible for a $500 deductible per person per admission/visit up to a maximum of $1,250 in a calendar year.; After the deductible is met, Empire will pay 80% of the average county rate and there will be 20% coinsurance that you will have to pay.; In addition, the facility can bill you the difference between the total bill and the amount received from Empire and you; this is called balance billing.
Here’s an example of out-of-network billing:
Your Total Hospital Bill $15,000
Empire Average County Payment Rate (ACR) $11,500
Member deductible $500
Empire Pays 80% of $11,000 (ACR - member deductible) $8,800
Member coinsurance (ACR-deductible x 20%); $2,200*
*Maximum member coinsurance is $2,000
Empire pays excess above $2,000, in this case $200
Potential total member cost: $6,000 (deductible $500 + coinsurance $2,000 + balance billing $3,500)
As you can see from the example above, your out-of-pocket costs can be significantly higher when you use an out-of-network facility.
When I use an in-network ambulatory surgery center, what will my cost be?
Your current benefits will not change if surgeries or procedures (for example, colonoscopies, bunionectomies, arthroscopic surgeries, etc.) are done at an in-network ambulatory surgery center, hospital outpatient surgery department and freestanding ambulatory surgery centers. You will continue to be responsible for 20% coinsurance up to a maximum of $200 per person per calendar year.
If I decide to use an out-of-network ambulatory surgery center, what will my cost be?
Similar to the out-of-network inpatient hospital benefit (previously described), if you choose to use an out-of-network facility you may have significant out-of-pocket expenses. Depending on the procedure, this can amount to several thousand dollars instead of the maximum $200 coinsurance you pay by using a participating facility for covered services.
How will skilled nursing facilities, blood transfusions, pre-surgical testing and other ancillary services be affected?
The out-of-network benefit example given above also applies to these services. So, prior to receiving any of these services, please be sure to call NYC HEALTHLINE to make sure the facility you are using is an in-network provider.
I am currently using a hemodialysis facility for my treatment.; How will this change affect me on January 1, 2010?
Members already using a hemodialysis center prior to January 1, 2010 may continue to use the same provider without a change to your current cost.
If I need to begin hemodialysis on or after January 1, 2010, what do I need to do?
Members needing hemodialysis treatment on or after January 1, 2010, can only use an in-network provider. There is NO out-of-network benefit.; You must call NYC HEALTHLINE who can assist you in finding a participating facility.
What happens if I have an emergency and am taken to an out-of-network hospital?
In all instances, emergency services at any appropriate facility or hospital will be covered according to the current program benefits, regardless of whether a facility is in-network or out-of-network. For emergency treatment, you will pay the co-payment amount of $50 for a visit to the emergency room.; If you are admitted for inpatient care through the emergency room, the co-payment is waived and applicable in-network inpatient cost sharing applies.
My new Empire BlueCross BlueShield identification card starts with NYC but my old card has YLA.; Why did this change?
This new identification card now identifies you as having a hospital PPO plan.
If you have any questions regarding these changes, you may call the Empire BlueCross BlueShield Customer Service Area at 1-800-433-9592.
Why am I receiving a GHI identification card?
Although there are no changes to the GHI medical program, we are including a new GHI identification card that has updated information on the back of the card and an updated GHI logo on the front of the card.
If you have any questions regarding these changes, you may call the GHI Member Service Area at 212-501-4444.
How is a member covered under my family contract whose primary coverage is Medicare affected by this change?
The program changes that are detailed in this letter do not apply to anyone whose primary coverage is Medicare. However, they do apply to the covered members of your family who are not covered by Medicare.
Remember to carry your new cards with you at all times.; It is essential that you present them whenever you receive services from a hospital or medical provider starting January 1, 2010.
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