Health Plans: Before you Choose, Know
Jan 16, 2002 3:44 PM
HEALTH PLAN CHOICES
Following are brief descriptions of the types of plans that are offered and how they provide coverage.
PPO/Indemnity Plan
A preferred provider organization (PPO) provides an independent panel of participating physicians. The Group Health Inc. Comprehensive Benefits Plan (GHI-CBP) allows members to chose from a list of panelists and pay only $10 per visit. Diagnostic services require an additional $10 copayment. Members who choose to use a non-panel physician are reimbursed according to a schedule of allowances after paying an annual deductible; this schedule of allowances may not reflect the fees that physicians charge, so you may incur out-of-pocket expenses. Hospitalization is covered by Empire Blue Cross/Blue Shield and requires pre-admission certification, which is obtained by contacting the NYC Healthline (800/521-9574), and also is subject to an annual deductible.
HMO
A health maintenance organization (HMO) is an organized system that provides medical and hospital services. There is little or no out-of-pocket expense to the member, but members are limited to physicians and services from within the HMO’s network of providers. Hospitalization is covered through the plan.When joining, members in HMO plans choose a primary care physician who will oversee your medical treatment.There is currently only one HMO — HIP Prime— that is offered at no monthly cost to the member. Additional HMO choices charge fees paid through monthly payroll deductions: AETNA, CIGNA Healthcare, Empire EPO/HMO, HealthNet, GHI-HMO and VYTRA.
POS
A point of service (POS) plan allows members to choose either a participating network panel provider or a non-network panel provider. When using a panel provider, the plan resembles an HMO. When joining, members in POS plans choose a primary care physician to oversee their medical treatment. Hospitalization is covered through the plan.If a non-panel provider is consulted, the plan operates like an indemnity plan, where copayments, deductibles and fee schedules are applicable; the POS’s schedule of allowances may not reflect the fees that physicians charge, so you may incur out-of-pocket expenses. Each POS has its own procedures with regard to obtaining out-of-network medical and hospital benefits.The POS plans include AETNA Inc. Quality Point of Service and HIP Prime POS. These POS plans have monthly payroll deductions and may
Optional Riders
Optional riders provide benefits that supplement your basic plan. If members choose GHI-CBP as their health coverage, they should consider purchasing the optional rider because it provides an enhanced reimbursement schedule for in-hospital related procedures, as well as other benefit improvements.Optional riders provided by the other health plans generally should not be taken because they duplicate benefits already provided to UFT members by the UFT Welfare Fund, such as coverage for prescription drugs.
MEDICAL SPENDING CONVERSION
If you pay for an optional rider or basic health insurance, as some HMO or POS plans require, there’s a way that you can increase your take-home pay.The Medical Spending Conversion plan (MSC) allows such Department of Education and other city employees to make these payments on a pre-tax basis, thereby reducing the salary on which taxes are computed. The amount of savings depends on the health plan, rider choice and whether you have individual or family coverage. MSC does not change your gross salary—only your net—and the overall reduction is shown on the W-2 form at the end of the year.If you have payroll deductions for health benefits, you will be automatically enrolled in MSC unless you decide you do not want to participate.Generally speaking, the UFT recommends that you participate in MSC if you take an optional rider or enroll in an HMO or POS requiring payments.
HOW TO ENROLL IN ANY PLAN
Obtain an ERB form from your school secretary and return it to her/him within 31 days of your employment.
DEPENDENT COVERAGE
If you apply for coverage within 31 days of your employment, your spouse, domestic partner and all unmarried children under age 19 are eligible for health insurance coverage effective on your date of employment. All plans provide coverage to age 23 for all dependent unmarried full-time college students. If you have unmarried children 19 and older who are unable to support themselves because they have a mental or physical disability, you should consult the city’s booklet for information regarding their coverage.
CONSIDERATIONS WHEN SELECTING A PLAN
Consider your family’s needs. Here are some guidelines. First, examine the city’s booklet, which compares the various plans in greater detail. If you want complete coverage with no out-of-pocket cost or claim forms and, if you want the convenience of an organized network of providers, you may want to consider an HMO.If you are satisfied with your current doctor and are willing to absorb out-of-pocket expenses, or if you would like to choose from a panel of doctors at a nominal out-of-pocket fee, you may want to consider GHI-CBP/Blue Cross, HIP Prime POS or the other POS plans.When you are deciding on a plan, remember to take into account any other health insurance you may have, such as through a spouse or domestic partner. If you have questions call your UFT borough office.
