Use of non-participating facilities can be expensive
On January 1, 2010, the Blue Cross program for city
employees and retirees became a Preferred Provider Organization (PPO).
All active employees and non-Medicare retirees
enrolled in GHI-CBP/Blue Cross must receive all inpatient and outpatient
hospital care at participating facilities or be subject to payment
penalties. It is important to note that "hospital coverage" can include
a number of outpatient procedures that may be performed outside of a
typical hospital setting (see below).
This change is among several for people enrolled in the City’s health
plan, under an agreement between the Municipal Labor Committee and the
City of New York to secure overall stability in health coverage. The
agreement ensured continuation of health benefits without major expense
to members. However, those expenses are avoided only if PPO facilities
are used.
All acute-care general hospitals in the metropolitan New York area
currently participate in Blue Cross – but it is always prudent to check.
Verifying that a hospital participates becomes more important outside of
the New York metro area, where the percentage of participating
facilities drops to about 94%. In all areas, there is a significant
proportion of ambulatory surgical facilities that do not currently
participate (see below).
Based upon the best information currently available, the revised
benefits are reflected below. For updated information, you must contact
your insurance provider.*
Inpatient Care**: The current deductible is $300 per admission
with a maximum of $750 per year. This will remain the same if you use a
Blue Cross-participating hospital.
If you use a non-participating hospital, there will be three types of
financial exposure:
1) $500 individual deductible per admission with a maximum
deductible of $1,250 per year
2) individual co-insurance of 20% on the "Allowed Amount" to
a maximum $2,000 per year.
3) a balance billed by the hospital to cover the difference
between the hospital’s charge and Blue Cross’s payment.
Outpatient: The current co-insurance is 20% with a $200 annual
maximum. This will remain the same if you use a Blue Cross-participating
facility.
If you use a non-participating facility, there will be three types of
financial exposure:
1) $500 individual deductible per visit with a maximum
deductible of $1,250 per year
2) individual co-insurance of 20% on the "Allowed Amount" to
a maximum $2,000 per year.
3) a balance billed by the facility to cover the difference
between the facility’s charge and Blue Cross’s payment.
Be aware that many standard referral procedures (colonoscopy, for
example) may be performed at ambulatory surgical facilities and are then
covered by Blue Cross, not GHI. Even if it is a procedure that
doesn’t seem like surgery (which most people associate with scalpels), a
procedure done at an ambulatory surgical facility is a Blue Cross matter
and subject to PPO rules. If you are unsure whether your coverage for a
procedure is through Blue Cross or GHI, ask the procedure’s provider if
the procedure will be performed in an ambulatory surgical facility
Referral to a facility by a doctor – even a GHI
participating doctor – is not assurance that a facility is
participating under the Blue Cross PPO. A referring doctor may not
have sufficient knowledge of the program or may have other incentives to
direct a patient toward a non-participating site. All
enrollees must assume personal responsibility for verifying that the
facility is a Blue Cross participant.
Identifying participating hospitals and facilities:
Members will be able to verify a facility’s Blue Cross participation
by calling NYC
Healthline, 800-521-9574, or by using the Blue Cross website,
www.empireblue.com.
* Important note: Because details are still subject to change and
interpretation, contact your insurance carrier for the most current
information. The PSC and the Welfare Fund cannot be responsible for
harm, financial or otherwise, related to any reliance on this article.
