January 16, 2004
IMPORTANT INFORMATION CONCERNING YOUR MEDICAL BENEFITS
Dear Participants:
The new Empire BlueCrossBlueShield(Empire) identification cards have been mailed out. Present this card to your doctor or to the hospital
when you receive hospital and medical care on or after February 1, 2004.
Why is Empire issuing new identification cards ?
The Welfare Fund has elected to change its hospital and medical provider network from Empire's Preferred Provider Organization
(PPO) to Empire's Exclusive Provider Organization (EPO).
Why is the Welfare Fund changing from a PPO to an EPO ??
The Board of Trustees wants to maintain the high level of benefits you've come to expect. In order to do so, the Trustees need to
contain costs wherever possible. Empire negotiates discounts for all of the services provided by the doctors and hospitals in their networks.
These discounts mean that when you receive care from an in-network (or participating) provider, the Welfare Fund pays less than the usual
amount charged by healthcare providers. When you receive care from an in-network provider, your out-of-pocket expense, if any, is limited to
a small copayment. Perhaps just as important, you help the Welfare Fund contain costs when you receive care from in-network
providers.
Many of the doctors and hospitals who participate in Empire's PPO network also participate in their EPO network. Empire has negotiated even
deeper discounts with the hospitals and physicians in their EPO network. When you receive care from a provider who participates in both the
PPO and the EPO networks, the Welfare Fund will receive the greater EPO discount. Your out-of-pocket expense will remain the same and, at the
same time, the Welfare Fund will save valuable health care dollars.
I like my PPO doctor. Do I have to find a new doctor – one who participates in the Empire's EPO ?
No, you will continue to have the same access to all of the doctors and hospitals who participate in Empire's PPO network. As noted
above, many of the providers who participate in Empire's PPO network also participate in Empire's EPO network. If your doctor or
hospital does not belong to the EPO, you will receive the same in-network benefit as long as your provider continues to participate in
Empire's PPO network.
Are my hospital and medical benefits changing ?
No, your in-network and out-of-network benefits and coverage remain the same. Same in-network copayments, same out-of network
deductibles and coinsurance !
There is one important administrative change you do need to know about. If you use out-of-network healthcare providers on and after
February 1, 2004, your out-of-network claims will not be processed by Empire. The Welfare Fund will continue to provide the same
out-of-network coverage that was provided prior to February 1, 2004, however, in order to receive the deeper EPO discounts noted above,
the Welfare Fund needs to take out-of-network claims processing away from Empire.
After careful consideration and review, the Board of Trustees has retained C & R Consulting, Inc. to process claims for out-of-network
providers incurred on and after February 1, 2004.
C & R Consulting, Inc. has successfully administered the Welfare Fund's Medicare Part A and Part B Supplemental benefits program since
January 1, 2003.
Where do I submit my out-of-network claim ?
If you incur expenses with an out-of-network medical provider after January 31, 2004, submit your claim to:
C & R Consulting, Inc
1501 Broadway
Suite1724
New York, NY 10036
Tell your out-of-network medical provider to keep this information about C & R Consulting, Inc. on file for future reference.
You can contact C & R Consulting, Inc. by calling (866) 320-3807.
Claims for out-of-network expenses incurred prior to February 1, 2004 should continue to be submitted to Empire.
How do I know if my provider is in-network or out-of-network ?
In any non-emergency situation, it's always a good idea to ask your provider before any services are rendered whether or not they are
participating Empire providers.
If you have access to the internet, you can visit Empire's website at www.empireblue.com. You can search for providers by name, address,
language spoken, specialty and hospital affiliation.To request a participating provider directory or to check the status of your provider,
call Empire at 1-800-553-9603.
I'm scheduled to receive care at a hospital. What should I do ?
Since it's unusual when a hospital doesn't participate with Empire or with your local BlueCross BlueShieldplan, hospital charges
should be submitted to Empire or to the local plan. In most cases, you will not need to file a claim; the hospital will do it for you.
If surgery is performed in a network hospital, you will receive in-network benefits for the anesthesiologist whether or not the anesthesiologist
is in Empire's network. Therefore, please be sure to submit all anesthesia claims to Empire or to the local BlueCross BlueShield plan.
Remember to call Empire's Medical Management Program at 1-800-553-9603 at least two weeks prior to any planned surgery or hospital
admission. By calling Medical Management prior to your hospital admission, you'll be assured that your hospital is in-network and that
your stay will be covered in full. For an emergency admission or emergency surgical procedure, you or a family member should call Medical
Management within 48 hours or as soon as reasonably possible.
Benefit reductions apply to all care related to the admission, including physician services, if your admission or surgery is not precertified by
Medical Management.
What about out-of-network deductibles and coinsurance ?
Your out-of-network coverage requires that you satisfy a deductible before any payment is made. There is also a family deductible.
Once you meet your deductible, the Welfare Fund pays a percentage of the remaining balance and you pay a percentage of the remaining
balance. We call the percentage that you're required to pay coinsurance. You can find more information about your deductible and
coinsurance amounts in your Summary Plan Description. Please bear in mind that the deductible and coinsurance apply to out-of-network
claims only. The fee you pay when you use an in-network provider is called the copayment.
Out-of-network deductible and coinsurance amounts are calculated on a calendar year basis. Since we're changing the out-of-network
claims administrator after the start of a new calendar year, you may meet all or part of your deductible with expenses incurred prior to
February 1, 2004 (Empire). If you only satisfy part of your deductible, you'll have to satisfy the amount that remains with expenses incurred
after January 31, 2004 (C & R).
Empire will provide information to C & R on any out-of-network deductible and coinsurance amounts credited to you for 2004. However,
there's always going to be a lag between the time expenses are incurred, when claims are reported and when Empire provides the information
to C & R.
We strongly suggest that you attach the Empire Explanation of Benefits (EOB) statement showing you met all or part of your 2004
out-of-network deductible to any claim you submit to C & R for expenses incurred after January 31. This will enable C & R to process your
claim correctly.
Is there anything else I need to know ?
You still have the same out-of-network coverage and benefits you had previously. Only the out-of-network claims administrator is
changing. Behavioral health care claims, both in-network and out-of-network, are still administered by CIGNA.
This notice constitutes a summary of material modifications.
Keep these important phone numbers handy in case we haven't answered all of your questions:
Empire (800) 553-9603 for in-network hospital and medical claims and benefits
C & R Consulting (866) 320-3807 for out-of-network medical claims and benefits
CIGNA (888) 325-3986 for all behavioral health care claims
Fund office (800) 529-3863 for all health and welfare related issues
Sincerely,
BOARD OF TRUSTEES
