Health Plan Changes FAQ – VHHSBP

It has come to our attention that some of you have been charged, in error, for care you received after your Annual Out-of-Pocket Maximum was reached. This error was caused by our health plan carrier, Empire Blue Cross Blue Shield, and is understandably creating confusion and frustration. We hope the following Frequently Asked Questions can help resolve these issues.

1. Last year my Annual Out-of-Pocket Maximum for Out-Of-Network care was $500. What happened?

On July 31, you received a Summary of Material Modification by email from the Benefits Office explaining that the Annual Out-of-Network Out-of-Pocket Maximum would increase to $2,000 from $500 starting on October 1, 2019. We also added a new Annual In-Network Out-of-Pocket Maximum for medical care of $1,500 (individual) and $3,000 (family) so no one has to pay more than $1,500 or $3,000 in a given plan year for In-Network medical care. We also added a new Annual In-Network Out-of-Pocket Maximum for prescription drugs of $2,500 (individual) and $5,000 (family).

2. Why have I been billed for Out-Of-Network care that exceeds the Annual Out-of-Pocket Maximum of $2,000 (individual) or $5,000 (family)?

Empire Blue Cross Blue Shield made an error. They treated our Plan as if it had a $3,000 out-of-pocket maximum for out-of-network care for individuals, and $7,000 for families. This is incorrect. At our insistence, Empire has rectified this mistake, effective immediately.

3. If I already paid more than the applicable Annual Out-of-Network Out-of-Pocket Maximum, can I get my money back?

Yes! Empire has pledged to directly refund members after reprocessing their claims. You will still be responsible for any charges beyond the Allowed Amount according to the CPT code your provider charged for the services. Please contact the Empire customer service phone number on the back of your health insurance card at 1-844-243-5566 if you have questions on how your claims were processed.

4. What about the Annual Out-of-Network Deductible?

We know health care plan changes can be challenging. We want to make sure you can continue to get the care you need during this transition.

For the 2019 Plan Year and the 2020 Plan Year, the Benefits Office has adopted a reimbursement program that will reimburse participants for the Annual Individual $1,000 Out-of-Network Deductible for expenses for Out-of-Network care that they would not have paid under the prior Plan terms. Here’s how it works: Retroactive to July 1, 2019 to June 30, 2020 (2019 Plan Year), participants will be eligible for a reimbursement of the Annual Individual Out-of-Network Deductible for expenses that would have been paid by the Plan under the $100 deductible that was in place prior to October 1, 2019 but that were not paid because the new Annual Individual Out-of-Network Deductible of $1,000 had not yet been satisfied. This reimbursement will also apply to the 2020 Plan Year, which runs from July 1, 2020 to June 30, 2021. To obtain reimbursement, participants must submit an Empire Explanation of Benefits (EOB) and proof of payment within 120 days after the end of the Plan Year.

5. What if I already paid more than $2,000 so far this plan year? Shouldn’t my visits be paid at 100%?

Empire will reprocess the claims and issue reimbursements for those who’ve paid more than the $2,000 Annual Individual Out-of-Network Out-Of-Pocket Maximum.

6. Is there anything else I need to know?

Yes! You can keep your Out-of-Network Out-of-Pocket costs lower than ever by using only In-Network providers. This is the first year we have launched an Annual Out-of-Pocket Maximum for In-Network medical care, meaning that an individual participant will not pay more than $1,500 throughout the plan year (or $3,000 for a family). (There is a separate Annual In-Network Out-of-Pocket Maximum for Prescription Drugs of $2,500 (individual) and $5,000 (family)). And remember – our members continue to enjoy FREE monthly insurance premiums, which are paid in full by your employer.

Out-of-Network Plan Changes

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Health Plan Changes FAQ