Professional Services Unit
Article 41 - Joint Committee on Health Benefits
§41.1 a. The State and UUP agree to continue a Joint Committee on Health Benefits. The Committee shall consist of no more than five representatives selected by UUP and no more than five representatives selected by the State.
b. Mutually agreed upon activities of the Joint Committee on Health Benefits, including the administrative responsibility of the Joint Committee, shall be funded pursuant to Section 21.2 of the Agreement.
c. The Joint Committee on Health Benefits shall meet within 14 days after a request to meet has been made by either side.
d. The Joint Committee shall work with appropriate State agencies to review and oversee the various health plans available to employees represented by UUP. This review shall include, but not be limited to:
1. The review of access to providers and coverage under these plans;
2. The development of Health Benefit Communication Programs related to the consumption of health care services provided under the plan;
3. The development of appropriate Health Insurance Training Programs;
4. The development, in conjunction with the carriers, of revised benefit booklets, descriptive literature and claim forms;
5. The study of recurring subscriber complaints and recommendations for the resolution of those complaints;
6. The investigation and examination of other successful programs involving wellness, cost containment and alternative health care delivery systems.
e. The Joint Committee shall request administrative/technical assistance from appropriate State agencies and/or other sources deemed necessary and approved by the Joint Committee.
f. The Joint Committee on Health Benefits shall establish methods and procedures for review of disputed medical claims.
g. The Joint Committee on Health Benefits shall work with appropriate State agencies to monitor future employer and employee health plan cost adjustment.
h. The Joint Committee shall be provided with each carrier rate renewal request upon submission and be briefed in detail periodically on the status of the development of each rate renewal.
i. The State shall require that the insurance carriers for the State Health Insurance Plan submit claims and experience data reports directly to the Joint Committee on Health Benefits in the format and with such frequency as the Committee shall determine.
j. The Joint Committee on Health Benefits shall work with appropriate State agencies to make mutually agreed upon changes in the Plan benefit structure through such initiatives as:
1. The annual HMO Review Process.
2. The ongoing review of the Managed Mental Health and Substance Abuse Care Program.
3. The ongoing review of the Benefits Management Program, Health Call, and an annual review of the list of procedures requiring Prospective Procedure Review. In addition, appeal procedures relating to the Benefits Management Program will be established by the Joint Committee on Health Benefits.
4. The development, along with the State prior to the expiration of this contract, of a proposal to modify the manner in which employer contributions to retiree premiums are calculated in order to recognize and underscore the value of the services rendered to the State by its long-term employees.
5. The Comprehensive Study of the State's Employee Health Benefits Structure concluded that the Empire Plan had been generally well managed. However, given the current trends seen by other similarly situated employers, significant opportunities exist to improve the quality of care provided to employees while reducing the cost of that care. In recognition of the recommendations provided by the Study, the State will develop the Empire Plan medical care component into a program to access comprehensive managed medical care, through the establishment of networks of preferred participating providers, including primary care physicians, specialists, hospitals, centers of excellence, and other allied health care providers, such as labs, urgent care centers, ambulatory surgery centers, and home care providers. This "Point of Service" (POS) Empire Medical Plan will be implemented as soon as practicable, but in no event earlier than January 1, 1999. The hospital component of the Empire Plan and the Managed Mental Health and Substance Abuse Program will remain in place.
In addition to services provided through the Plan's managed care networks, enrollees will have access to or have freedom of choice to use non-network providers, subject to a $500 annual deductible per enrollee, $500 per covered spouse and $500 per one or all covered dependent children, and a maximum payment of 75 percent of Reasonable and Customary (R&C) charges up to $2,000,000 per person, per lifetime.
In response to UUP's concerns regarding the viability of the network, effective with the implementation of the POS, the maximum enrollee co-insurance out-of-pocket expense under the non-network portion of the POS will be $15,000 per individual or family in any given year. The annual deductible and non-network out-of-pocket maximum will increase on each successive January 1, after implementation, by a percentage amount equal to the percentage increase in the medical care component of the CPI for Urban Wage Earners and Clerical Workers, All Cities (CPI-W) for the period July 1 through June 30 of the preceding year. A separate 48 hour annual deductible will be required before private duty nursing services are covered. A special option transfer will take place if implementation is not scheduled for the beginning of a new plan year following a regularly scheduled option transfer period. The Joint Committee on Health Benefits will work with the State on the development of program design and implementation of benefits, to include participation in the vendor selection process, if any, as well as providing input to and ongoing review of access guidelines, the development of regional networks, the evaluation of the networks, the employee satisfaction evaluation system, the network referral process, the provision of coverage out-of-State and the appropriate recognition and consideration of SUNY Health Center facilities/staff providers within the new POS plan.
6. Implementation and ongoing review of the Managed Physical Medicine Program.
7. The implementation and ongoing review of the "one-stop shopping" concept that will consolidate the various telephonic requirements enrollees must adhere to and other plan resources that they use.
8. Implementation and ongoing review of the modification to the non-network portion of the Home Care Advocacy Program (HCAP) as well as the ongoing review of the HCAP overall.
9. Review of certain administrative practices to ensure that the eligibility criteria for NYSHIP and Employee Benefit Fund coverage are being applied consistently and correctly.
10. Review of the feasibility of establishing a Section 125 Flexible Spending Account to be used for the reimbursement of dental and vision expenses not covered through the UUP Employee Benefit Fund.