Health plan Open Enrollment

Transcription

1 Health plan Open Enrollment Offered through Day care council - local 205, DC 1707 Welfare Fund GOLDCARE MetroPlus.org/GoldCare HEALTH PLAN FOR DAY CARE WORKERS

2 This is MetroPlus. Since 1985, MetroPlus Health Plan has built a reputation for providing access to affordable, quality health care to all residents of New York City who qualify. A wholly-owned subsidiary of NYC Health + Hospitals, the largest municipal health system in the United States, MetroPlus is the plan of choice for over half a million New Yorkers. Premium health coverage at a not-so-premium cost. Enjoy award-winning customer service and superior benefits... with no paperwork! MetroPlus GoldCare is the smart choice for Day care workers. After 30 years of covering New Yorkers, in 2016 we were proud to launch our MetroPlus and MetroPlus I health plans, available to all eligible Local 205, DC 1707 day care workers. At MetroPlus, we have a strong focus on primary and preventive care. Together with our providers, we continually work to improve member awareness of preventive services and assist members in receiving these services. Our network includes many thousands of primary care physician, specialist and other types of provider offices. In addition to hospital-based providers, our members can also obtain primary and specialty care services at many community-based doctor s offices and neighborhood family care sites. THIS IS METROPLUS.

3 Growing provider network. MetroPlus has a large and continually expanding network of participating physicians and hospitals, with providers at nearly 18,500 sites for members and over 27,500 sites for I members across New York City. MetroPlus has over 3,800 Primary Care Providers (PCPs) for members and 4,200 for I members, located in private offices, neighborhood family care sites and hospitals. You choose where you want to get your care. MetroPlus has nearly 750 obstetricians and gynecologists, nearly 10,000 specialists and 6,000 mental health providers for members, and nearly 1,300 obstetricians and gynecologists, nearly 17,000 specialists and 6,000 mental health providers for I members. Your MetroPlus PCP manages your care and will refer you to a MetroPlus specialist if medically necessary. (No referral necessary for OBGYN.) You can search for doctors in our network by going to our website, or looking at a MetroPlus Provider Directory. If your PCP is in private practice and he or she is not a MetroPlus participating provider, contact MetroPlus Customer Services. MetroPlus will attempt to recruit your PCP. MetroPlus GoldCare Member Services is available Monday through Saturday, 8 a.m. to 8 p.m. at (TTY: 711 for the hearing impaired). MetroPlus Member Services Representatives are available to assist you in over a dozen languages. At MetroPlus, we are committed to assuring access to quality comprehensive health care, health education and customer services for our culturally diverse membership. Primary, OB/GYN, behavioral health and specialty care at thousands of sites across New York City and at these great hospitals: Members: Manhattan Bellevue Hospital Center Harlem Hospital Center Metropolitan Hospital Center Queens Elmhurst Hospital Center Queens Hospital Center Brooklyn Coney Island Hospital Kings County Hospital Center Woodhull Medical Center The Bronx Jacobi Medical Center Lincoln Medical Center North Central Bronx Hospital Staten Island Richmond University Medical Center Staten Island University Hospital Additional Facilities for Care: NYC Health + Hospitals Diagnostic & Treatment Centers Cumberland D&TC East New York D&TC Gouverneur Health Morrisania D&TC Renaissance Health Care Network Segundo Ruiz Belvis D&TC and at more than 40 Urgent Care Centers Manhattan Bellevue Hospital Center Beth Israel Medical Center Harlem Hospital Center Metropolitan Hospital Center Mount Sinai Medical Center* Queens Elmhurst Hospital Center Flushing Hospital Medical Center Brooklyn Beth Israel Medical Center Kings Highway Coney Island Hospital Kings County Hospital Center NYU Lutheran Medical Center The Bronx Jacobi Medical Center Lincoln Medical Center Staten Island Richmond University Medical Center I Members: Additional Facilities for Care: NYC Health + Hospitals Diagnostic & Treatment Centers Cumberland D&TC East New York D&TC Gouverneur Health Morrisania D&TC New York Eye and Ear Infirmary* NYU Medical Center St. Luke s / Roosevelt Hospital Jamaica Hospital Medical Center Mount Sinai Hospital Queens Hospital Center Maimonides Medical Center SUNY Downstate Medical Center University Hospital of Brooklyn* Woodhull Medical Center Wyckoff Medical Center Montefiore Medical Center* North Central Bronx Hospital Staten Island University Hospital Renaissance Health Care Network Segundo Ruiz Belvis D&TC and at more than 40 Urgent Care Centers * Only specialty services at these hospitals GROWING PROVIDER NETWORK.

4 Welcome to MetroPlus GoldCare. MetroPlus GoldCare benefits include: Low-premium health care: Monthly premiums as low as $17 50 for and $95 82 for I*. No deductibles: There are no deductibles for any covered services, so you can start saving right away. No paperwork: There are no bills or claim forms for in network services. Low co-pays for specialists, lab and X-rays. Comprehensive benefit package: Covered benefits include preventive care, well-child care, primary care, maternity care, specialty services, hospital care, emergency care, mental health services, lab services, prescription drug coverage, and care management programs for members with chronic diseases and other health issues. For more information on covered benefits, please refer to the MetroPlus GoldCare Certificate of Coverage. Extensive provider and hospital network: MetroPlus has providers for members at nearly 18,500 sites across the five boroughs and over 27,500 sites for I members. MetroPlus has agreements with more than a dozen hospitals in NYC for GoldCare I members and over 20 hospitals for I members including NYC Heath + Hospitals facilities and Diagnostic and Treatment Centers. MetroPlus has Care Management Programs to help members with chronic conditions stay healthy and provides support to help them manage their illness. Diabetes and Asthma programs to encourage members to partner with their PCPs to reduce complications from illnesses and lead healthier lives. Care Management for high-risk pregnant women. Partnership in Care helps people living with HIV/AIDS manage their condition and stay healthy. Care Management is also available for members with Behavioral Health or Complex Medical Transplant. The Care Management Action Line is (TTY: 711). * I premium rates are proposed only and subject to approval by NYS Department of Financial Services METROPLUS GOLDCARE.

5 Value-Added Benefits. ENROLLMENT INFORMATION FOR YOUR HEALTH PLAN After-hours access to a medical provider for urgent medical issues. Easy access to your member account online: Select (or change) your Primary Care Physician Order a new ID card View family accounts View claims...and more! OPEN ENROLLMENT September 25, 2017 October 6, 2017 Effective Dates of Coverage December 1, 2017 September 30, 2018 YOUR ACTION IS REQUIRED If you want to enroll in MetroPlus or MetroPlus I, please fill in the enrollment form(s) included in this packet and submit them to your center Bookkeeper no later than October 6, Go For the Gold. You can select MetroPlus or MetroPlus I when you are hired as a new employee or during the annual Open Enrollment period. During the Annual Open Enrollment you will receive information on how to select or change your insurance plan. Or you can contact the bookkeeper at your day care center and complete an enrollment form. If you need more information, contact MetroPlus at or visit our website, For enrollment information contact the Day Care Council Local 205, DC 1707 Welfare Fund at If you want to: Enroll in MetroPlus or II coverage and the Welfare Fund: Fill out the Welfare Fund Enrollment Form. Check the name of the plan you wish to enroll in. Include the names of the eligible dependents that you wish to be covered for health insurance. Do not include dependents that are not to be enrolled. Opt-out of coverage: Fill out the Enrollment Waiver to Opt-Out of enrollment in the Fund and its benefits including health insurance coverage. The Enrollment Waiver must be notarized and proof of other insurance coverage must be submitted to your center bookkeeper along with the waiver. Regardless of your current coverage, you MUST take action for the plan period of December 1, 2017 September 30, 2018 AT A GLANCE.

6 ENROLLING IN THE PLAN Once you have made your selection (no later than October 6, 2017), you will not be able to make changes to your benefits until the next open enrollment period (unless you experience a qualifying life event that will make you eligible for a special enrollment period). Opting Out WHAT FORMS DO I FILL OUT? ENROLLING Welfare Fund Enrollment Form OPTING OUT Waiver Form You may opt-out of enrollment in the Welfare Fund and its benefits if you are enrolled in another insurance plan. To opt out, provide the enclosed Enrollment Waiver, signed and notarized, along with proof of other insurance coverage, to your center bookkeeper for processing. Your disenrollment from the Fund and its benefits will be effective November 30, 2017, provided that we receive the Enrollment Waiver and required proof of other coverage within the required deadline. Out-of-Area Employees You may request an out-of-area enrollment package, if you live outside of the MetroPlus service area by calling the Welfare Fund at The service area consists of the following boroughs: Manhattan, Brooklyn, Queens, Bronx, Staten Island. Or you may choose to enroll in MetroPlus or II. What happens if you don t enroll? Eligible employees with no proof of other insurance who do not submit an enrollment form will automatically be enrolled in. You will not be able to make changes at a later date (other than during open enrollment period) unless you experience a life qualifying event that would allow you the opportunity to enroll, make changes or opt out of coverage. If you do not require coverage, you must opt out of the plan by completing the necessary waiver form and submitting proof of other insurance coverage. A qualifying life event, as defined by IRS regulations, allows you to make a change to your benefit coverage if you experience any of the following: Change in status, including, but not limited to: Marriage or divorce Death of a dependent Birth or adoption of a dependent Change in employment status Dependent satisfying or ceasing to satisfy plan s eligibility requirements Loss of your current coverage or loss of a spouse s coverage Judgment, decree or court order WHO IS ELIGIBLE FOR WELFARE FUND BENEFITS? Eligibility All verified permanent and non-administrative employees who work in an Administration for Children s Services/Agency for Child Development (ACS/ACD) funded Day Care and/or Family Day Care Centers that are a party to a Labor-Management contract with the Community and Social Agency Employees Union, District Council 1707, Local 205, AFSCME and who work a minimum of 30 hours a week, are eligible for the Welfare Fund enrollment. Part time employees working at least 20 hours but less than 30 hours per week are eligible to enroll in ONLY, with the same health insurance payroll deductions as employees working 30 hours or more per week. AT A GLANCE.

7 Dependents Eligibility For benefits provided and/or administered by the Welfare Fund, eligible dependents include: Your spouse to whom you are legally married. Your unmarried dependent children (natural, step-children, adopted or placed for adoption) until the end of the month in which they reach age 26. Your unmarried children over age 26 who are unable to do any work to support themselves because of mental illness, developmental disability or mental retardation as defined by New York Mental Hygiene Law, or physical handicap. The incapacity must have started before the child reached age 26 and may have to be certified by a physician. If you are a new employee or new participant in the Welfare Fund, you must submit proof of dependency status for all persons when you enroll them for coverage. These proofs include copies of marriage certificates, birth certificates, and court orders of adoption summary of benefits GOLDCARE I MAJOR COPAYMENT Deductible $0 Out of Pocket Maximum PCP office visits Specialist office visits Hospital admission Emergency room copay (waived if admitted) Prescription drugs $6,850 single / $13,700 family $20 copay per visit $40 copay per visit $300 copay per hospital admission $100 copay per visit $25 generic / $50 brand / $75 Non Formulary / Mail 2.5X TYPES OF COVERAGE AVAILABLE Employee: Covers the employee only Employee/Children: Covers the employee and his/her child(ren) Employee & Spouse: Covers the employee and his/her legal spouse Family: Covers the employee, his/her legal spouse and their child(ren) MONTHLY CONTRIBUTION RATES Employee Employee & Child(ren) Employee & Spouse Family $17.50 $35.00 $52.50 $70.00 I* Employee Employee & Child(ren) Employee & Spouse Family $95.82 $ $ $ * I premium rates are proposed only and subject to approval by NYS Department of Financial Services INPATIENT HOSPITAL SERVICES Hospital and physician services Semi-private room and board Operating and recovery room, intensive and special care units, general nursing care, prescribed drugs, anesthesia, X rays and lab tests Labor and delivery Short-term speech, physical, occupational and respiratory therapy (when part of an acute admission) Speech, physical, occupational and respiratory therapy (when part of a rehabilitation admission) Radiation therapy and chemotherapy Pre-admission testing Human organ transplants Subject to hospital admission copay, short-term only 90 days per calendar year

8 MAJOR COPAYMENT MAJOR COPAYMENT OUTPATIENT MEDICAL CARE SPECIAL KINDS OF CARE PCP office visits $20 copay per visit Emergency and urgent care Specialist office visits Preventive care including physical exams, ear exams, health education and counseling, pap smear, mammography and immunizations Well-child care Diagnostic services including X-rays, lab tests and EKGs Prenatal and postnatal care in physician s office Ambulatory surgery Second medical and surgical opinion Routine foot care Chiropractic services MENTAL HEALTH AND SUBSTANCE USE DISORDER Mental health care: inpatient Treatment of mental illness Mental health care: outpatient Treatment of mental illness Substance use disorder Inpatient detoxification Inpatient rehabilitation treatment Outpatient rehabilitation treatment $40 copay per visit Specialist Copay: $40 in OP Facility, $100 in hospital $100 copay (same in OP facility or physician office) Not covered $40 copay per visit $20 copay; unlimited visits per calendar year $20 copay In hospital emergency room In urgent care facility In physician s office Ambulance service to the hospital Home health care Hospice care Skilled nursing facility care Dialysis treatment Diabetes equipment, supplies and education Outpatient physical, speech, occupational and respiratory therapy Family planning services Durable medical equipment Private duty nursing Cochlear implants Subject to emergency room copay ($100 copay, waived if admitted) Subject to specialist office visit copay ($25 copay) Subject to PCP office visit copay ($20 copay) $20 copay; 200 visits per calendar year ; 210 days $300 copay; unlimited days per calendar year $20 copay per visit $20 copay per month Subject to specialist office visit copay; 90 visits per calendar year Covered 20% coinsurance Covered in full 20% coinsurance Unless it is an emergency, you must visit a provider who is in the MetroPlus network. If you visit a provider who is not in our network, you will not be covered for those services.

9 summary of benefits GOLDCARE II MAJOR COPAYMENT Deductible $0 Out of Pocket Maximum PCP office visits Specialist office visits Hospital admission I $6,850 single / $13,700 family $30 copay per visit $50 copay per visit $500 copay per hospital admission MAJOR COPAYMENT OUTPATIENT MEDICAL CARE PCP office visits Specialist office visits Preventive care including physical exams, ear exams, health education and counseling, pap smear, mammography and immunizations Well-child care Diagnostic services including X-rays, lab tests and EKGs I I $30 copay per visit $50 copay per visit Specialist Copay: $50 in OP Facility, $150 in hospital Emergency room copay (waived if admitted) $150 copay per visit Prenatal and postnatal care in physician s office Prescription drugs $25 generic / $50 brand / $75 Non Formulary / Mail 2.5X Ambulatory surgery $200 copay (same in OP facility or physician office) INPATIENT HOSPITAL SERVICES Hospital and physician services Semi-private room and board Operating and recovery room, intensive and special care units, general nursing care, prescribed drugs, anesthesia, X rays and lab tests Labor and delivery I Subject to hospital admission copay Second medical and surgical opinion Routine foot care Chiropractic services MENTAL HEALTH AND SUBSTANCE USE DISORDER Mental health care: inpatient Treatment of mental illness Not covered $50 copay per visit I Short-term speech, physical, occupational and respiratory therapy (when part of an acute admission) Speech, physical, occupational and respiratory therapy (when part of a rehabilitation admission) Radiation therapy and chemotherapy, short-term only 90 days per calendar year Mental health care: outpatient Treatment of mental illness Substance use disorder Inpatient detoxification $30 copay; unlimited visits per calendar year Pre-admission testing Human organ transplants Inpatient rehabilitation treatment Outpatient rehabilitation treatment $30 copay

10 MAJOR COPAYMENT I SPECIAL KINDS OF CARE Emergency and urgent care In hospital emergency room In urgent care facility In physician s office Ambulance service to the hospital Home health care Hospice care Skilled nursing facility care Dialysis treatment Diabetes equipment, supplies and education Outpatient physical, speech, occupational and respiratory therapy Family planning services Durable medical equipment Private duty nursing Cochlear implants I Subject to emergency room copay: ($150 copay, waived if admitted) Subject to specialist office visit copay ($50 copay) Subject to PCP office visit copay ($30 copay) $30 copay; 200 visits per calendar year ; 210 days $500 copay; unlimited days per calendar year $30 copay per visit $30 copay per month Subject to specialist office visit copay; 90 visits per calendar year Covered 20% coinsurance Covered in full 20% coinsurance Unless it is an emergency, you must visit a provider who is in the MetroPlus I network. If you visit a provider who is not in our network, you will not be covered for those services. Prescription Drug Benefit. As a member of MetroPlus GoldCare your prescription drug benefit is managed through CVS Caremark. The CVS Caremark network includes CVS pharmacies and thousands of other pharmacies throughout New York City. You can find out which drugs are covered by your plan formulary and their tier by checking our website: metroplus.org. You may obtain your prescription either through a participating retail store or through mail order. You may obtain a one month supply at a participating retail store with the following copays. $25 Copay for Tier 1 Drugs (Generic Drugs) Your costs for a one month (30 day) supply: $50 Copay for Tier 2 Drugs (Brand Name Drugs) $75 Copay for Tier 3 Drugs Non-Preferred/Non Formulary Certain drugs can be received by mail order. These are usually drugs you take for a chronic condition, and you will need to fill a prescription for three months of the drug. $62.50 Copay for Tier 1 Drugs (Generic Drugs) Your costs for a 90 day supply through mail order: $125 Copay for Tier 2 Drugs (Brand Name Drugs) $ Copay for Tier 3 Drugs Non-Preferred/Non Formulary In order to be covered for your prescription, you must have it filled at a participating retail or mail order pharmacy. You can find a pharmacy close to you by checking your Provider/Pharmacy Directory (available at metroplus.org, or by calling us at ). Order forms and more information about our mail order program can be found online at metroplus.org or members can call CVS Caremark at to set up their mail order prescriptions or if they have any questions regarding their pharmacy benefits. Upon enrollment, MetroPlus GoldCare members will receive a Welcome Kit which includes the formulary and mail order form. This prescription drug coverage is credible under Medicare rules. PRESCRIPTION DRUG BENEFIT

11 Join the plan of choice for more than half a million new yorkers! GOLDCARE MetroPlus.org/GoldCare Offered through Day care council - local 205, DC 1707 Welfare Fund This brochure provides only a brief summary of the benefits available under the Day Care Council Local 205, D.C Welfare Fund Plan. In the event of a discrepancy between this summary and the Plan Document, the Plan Document will prevail. The Day Care Council Local 205, D.C Welfare Fund retains the right to modify or eliminate these or any other benefits at any time and for any reason HEALTH PLAN FOR DAY CARE WORKERS MBR