Welfare Fund Benefit Inforamtion

Transcription

1 Welfare Fund Benefit Inforamtion Presented by Tom Gerson, Member Welfare Fund Advisory Council

2 Definitions and Disclaimers All power to select plans and providers rests with the Trustees of the Welfare Fund. Trustees are appointed by the leadership of the PSC. Members of the Welfare Fund Advisory Council are elected by the membership of their unit.

3 Definitions and Disclaimers The Welfare Fund Advisory Council meets approximately twice a year for informational purposes. It has no decision making power no vote no clout. Members of the Welfare Fund Advisory Council serve as liaisons between the fund and their respective units.

4 Definitions and Disclaimers In short, members of the Welfare Fund Advisory Council are messengers.

5 Definitions and Disclaimers PPO: Preferred Provider Organization Organization negotiates with and establishes fees with providers. Participant is free to choose provider. HMO: Health Maintenance Organization Plan s providers must be used to receive benefits. No reimbursement if out of network provider is used.

6 Welfare Fund Benefits Changes in Benefits The following slides were provided by Larry Morgan Welfare Fund Administrator

7 PSC-CUNY: Better Benefits through the New Contract Welfare Fund IMPROVEMENTS

8 OLD Through 12/31/2006 Dental Program Guardian Life Insurance Co. Preferred Provider Organization (PPO) Network Participating Dentists charge Reduced Fee$ Dental Schedule Best Reimbursement is for Preventive work Buy-up Rider enhances schedule [annual max applies]

9 NEW Dental Program Beginning 1/1/2007 Guardian Dental Same Guardian Network of 6,600 Dentists Enhanced Dental Schedule No More Buy-up Rider New Orthodontic Benefit OR HMO - DeltaCare USA Top Quality Dentists in managed care setting Complete list of Charges in Advance No Claim Forms, annual or lifetime maximum payment Orthodontics for children and adults

10 Value of Participating Dentists Members Pay 45% of Bill Rather than 84% Non-Participating : $5,779,127 Participating : $5,244,847 16% Paid by Guardian 21% Paid by Guardian 84% 45% 34% Reduced Fee Paid by Patient Paid by Patient Source: Guardian Life. Claims Data 1/1/06 7/31/06. [Old fee Schedule]

11 Guardian Savings via Participating Dentists Preventive Services PREVENTIVE Periodic Examination Intraoral X-Ray Bitewing X-Ray Two films Adult Cleaning Child Cleaning Child Clean &Fluoride --Out-of-Pocket-- Charge Discount Your Bill Reimbursed Non-Par Par $65 $34 $31 $155 $63 $92 $45 $18 $27 $129 $64 $65 $93 $46 $47 $117 $46 $71 $24 $75 $22 $53 $38 $58 $41 $7 $80 $17 $23 $5 $76 $12 $55 $9 $59 $13 Note: New Reimbursed Amount is 4% higher than prior to 1/1/2007 for Preventive Services

12 Guardian Savings via Participating Dentists Basic and Major Services Other Dental Services Amalgam 2-Surface Root Canal - Molar Osseous Surgery Crown: Porcelain/High Metal Complete Upper Denture --Out-of-Pocket-- Charge Discount Your Bill Reimbursed Non-Par Par $ 210 $ 120 $ 90 $1,173 $ 448 $ 725 $1,067 $ 333 $ 734 $1,370 $ 582 $ 788 $1,540 $ 580 $ 960 $ 44 $ 372 $ 372 $ 180 $ 220 $ 166 $ 46 $ 801 $ 353 $ 695 $ 362 $1,190 $ 608 $1,320 $ 740 Note: New Reimbursed Amount is 450% higher than prior to 1/1/2007 for basic Services Note: New Reimbursed Amount is 400% higher than prior to 1/1/2007 for major Services

13 Guardian Savings via Participating Dentists Orthodontia Orthodontia Comprehensive Treatment Pre-Treatment Visit Orthodontic Retention --Out-of-Pocket-- Charge Discount Your Bill Reimbursed Non-Par Par $3,500 $ 887 $ 2,613 $ 350 $ 100 $ 250 $ 600 $ 175 $ 425 $ 653 $ 63 $ 106 $2,847 $1,960 $ 287 $ 187 $ 494 $ 319

14 Delta Delta HMO : Payments & Dentists Preventive Services at no cost Almost Always Lower out-of-pocket Decision Making Process should Ascertain Availability in your area or of YOUR Dentist Review Limitations Be Aware of Optional Schedule

15 Delta Delta Dental: Member Payment to Dentist Periodic Examination $ 0 Intraoral X-Ray $ 0 Bitewing X-Ray Two films $ 0 Adult Cleaning $ 0 Child Cleaning $ 0 Child Clean &Fluoride $ 0 Amalgam 2-Surface $ 0 Root Canal Molar $ 180 Osseous Surgery $ 250 Crown: Porcelain/High Metal $ 195 Complete Upper Denture $ 225 Comprehensive Ortho Treatment $ 1,950 Pre-Treatment Ortho Visit $ 200 Orthodontic Retention $ 0

16 Quality Assurance Welfare Fund will Step Up reviews Statistical Analysis of Utilization Patterns Membership Satisfaction Surveys Provider Panel Monitoring for Guardian and Delta Reliance Upon Membership Feedback Explanation of Benefits Survey Responses Member to Member Recommendations

17 Your decision Availability of Dentists Guardian Panel Over 6,600 in the Tri-state Area Agree to Accept Lowered Fees Delta HMO Smaller Panel, but meets Geo-Access Standards Not (yet) available in some states Agree to Per Capita Income & Set Member Fees Work within Managed Care Guidelines

18 Your decision Whom to Contact Carriers For Guardian Panel Dentists Enter Zip Code For DeltaCare USA HMO Dentists Skip Log-In and PIN. Go to Looking for a Dentist? Click on Dentist Search. Select a State. Welfare Fund Website

19 Your decision Whom to Contact Carriers For Guardian Panel Dentists Enter Zip Code DentalGuard Preferred

20 Your decision Whom to Contact Carriers For DeltaCare USA HMO Dentists Skip Log-In and PIN. Go to Looking for a Dentist? Click on Dentist Search. Select a State. DeltaCare USA

21 Par and Non-Par are calculated using averages. Actual amounts may differ substantially. Your decision Bottom Line : What Does it Cost? Out-of-Pocket ---- Common Procedures Periodic Examination Intra oral X-Ray Bitewing X-Ray Two films Adult Cleaning Child Cleaning Child Prophylaxis and Fluoride Amalgam - two surfaces Root Canal-Molar Osseous Surgery Crown-porcelain / High metal Complete Denture - upper Comprehensive Ortho Treatment Pre-Ortho Treatment Visit Ortho Retention Non-Par Par $41 $7 $80 $17 $23 $5 $76 $12 $55 $9 $59 $13 $166 $46 $801 $353 $695 $362 $1,190 $608 $1,320 $740 $2,847 $1,960 $287 $187 $494 $319 Delta HMO $0 $0 $0 $0 $0 $0 $0 $180 $250 $195 $225 $1,950 $200 $0

22 Current Major Medical CIGNA For Actives and Non-Medicare Retirees with GHI Basic Deductible For those who purchase the optional rider through GHI the deductible is $1,000 for individual plan and $2,000 for a family plan; For those who do not purchase the GHI optional rider the deductible is $4,000 for an individual plan and $8,000 for a family plan Coinsurance After deductible is met, Cigna pays 50% of R&C not paid by GHI Comparative Schedule is at 70 th percentile of Fee Ranges After coinsurance outlays exceed $3,000 for individual or $6,000 for family in a calendar year, CIGNA will pay 100% of R & C not paid by GHI

23 THE NEW Extended Medical Better Service GHI replaces CIGNA For Actives and Non-Medicare Retirees with GHI Basic Deductible For those who purchase the optional rider through GHI the deductible is $1,000 for individual plan and $2,000 for a family plan; For those who do not purchase the GHI optional rider the deductible is $4,000 for an individual plan and $8,000 for a family plan Coinsurance After deductible is met, GHI Major Medical will pay 60% of R&C not paid by GHI Basic Comparative Schedule is at 80 th percentile of Fee Ranges After coinsurance outlays exceed $3,000 for individual or $6,000 for family in a calendar year, GHI Major Medical will pay 100% of R & C not paid by GHI Basic