California Ironworkers Field Welfare Plan
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FREQUENTLY ASKED QUESTIONS
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Building a Bridge to Health -
Reinforcing Smart Choices
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12/30/2011
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Comprehensive health care benefits are coming your way. The health choices we make every day affect the costs to both you and the Plan. We, along with your union and your employer, are taking action to contain the rising costs of your health care.
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Introduction of NEW HEALTH BENEFITS PROGRAM
New health care benefit program information will be identified with the new "Reinforcing Smart Choices" logo. Each mailing will contain important information regarding these changes and each participant should read the notices and ask questions in order to avoid any misunderstandings on the available benefits.
There will be a series of seven mailings regarding the upcoming changes. Five mailings from IEBC and two will be sent directly by EnvisionRx. These mailings are designed to explain what's changing and what each member must do to conform to these changes.
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Plan Change
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Whose idea was it to make these changes and whose decision was it to implement these changes?
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The Board of Trustees in reviewing the cost to the Trust for health care realized that changes needed to be made in order to keep up with the upward cost of benefits.
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Plan Change
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Is this a new health plan?
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No - your health plan remains the same based on the changes that were sent to you on June 1, 2011. This new health benefits program will help you to help us control the high costs of health care that continue to rise and outlines a new way for you to use your benefits wisely.
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Plan Change
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Is this different from our Fee-For-Service Plan?
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No - your plan benefits have not changed. Reinforcing Smart Choices will give you an opportunity to control costs by utilizing contracted providers and facilities that may be able to offer the same services at a lower cost.
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Plan Change
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Why the change?
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We want to help you make smart choices when it comes to your benefits and we need to find a way to control the cost of health care going forward. These changes will encourage active participants and non-Medicare retirees on our Fee-For-Service Plan to use their benefits more efficiently and, therefore, contribute to the reduction in health care costs.
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Purpose
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What is the purpose or end goal of all of these changes?
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We want to help you focus on improving your health and control the cost of your care.
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Benefit Costs
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Does the cost of health care really
continue to rise and cost more?
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Most definitely - history tells us that the cost of health care has been rising at approximately 12% per year.
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Benefit Costs
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What is the current cost per
participant in the Plan?
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In 2011, the Plan will pay an estimated $19,800 per participant for health benefits.
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Benefit Costs
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Can you estimate what the future
cost of the same benefits will be in five years or ten years?
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Yes - In five years we estimate the cost would increase to $31,800 per participant; in ten years - $51,300.
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Benefit Costs
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What causes a rise in
health care costs?
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An aging population where people live longer is one of the reasons for increased costs. The general population has also seen a huge spike in obesity and the prevalence of chronic illnesses:
• diabetes
• heart disease
• chronic pain
All of these conditions require ongoing treatment and causes an increase in costs.
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Benefit Costs
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What else causes a rise in
health care costs?
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All procedures do not cost the same from provider to provider. There are no set fees. An MRI or a knee surgery can vary greatly among network providers and facilities, and it's your Plan that picks up most of the tab.
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Benefit Costs
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Does who I pick for my health care really make a difference?
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Absolutely - your health and the choices you make every day can affect the cost of your benefits.
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Care Counselor
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What is a Care Counselor?
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A Care Counselor is someone you will need to talk to before you receive any non-emergency services from anyone other than your primary doctor. The Care Counselor program will be explained more fully in a subsequent mailing scheduled to be mailed to you in January 2012.
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Effective Date
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What is the effective date of
these changes?
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The effective date is March 1, 2012.
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First Mailing
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What are you trying to tell me?
This letter doesn't tell me much.
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This mailing is the first in a series of important messages regarding upcoming changes to your benefits in 2012 and is intended to be a general overview of the upcoming changes. More detailed information is forthcoming in the next two months.
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First Mailing
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Am I going to get more information?
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You will receive additional information in future mailings. Some will be specific to particular changes and will explain how those changes should be used and how it will affect your benefits. Please read each piece of communication carefully.
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In-Network
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Will it still matter if my
providers are in-network or
out-of-network?
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Absolutely - the greatest savings to the Plan and to you is when you use an in-network provider. However, the cost of in-network providers can vary greatly from one to another. A Care Counselor will be able to assist you in finding a provider that is both in-network and cost effective for the Plan and for you.
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Maximum Allowable Charges (MAC)
Five Identified Procedures
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What are the five procedures
and the associated maximum allowable charges (MACs)?
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Five (5) Procedures and Associated Caps:
In-Patient Services performed at a hospital that is NOT a designated hospital:
MAC is▼
1. Routine Total Hip Replacement $ 30,000
2. Routine Total Knee Replacement $ 30,000
Please note that these MAC caps only apply to the facility charge and the prosthesis for the knee and/or the hip replacement. Professional charges such as surgeon fees and anesthesia would not apply to the MAC.
Out-Patient Services performed at a hospital based out-patient surgery facility:
MAC is▼
3. Arthroscopic Surgery $ 6,000
4. Cataract Surgery $ 2,000
5. Colonoscopy $ 1,500
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Maximum Allowable Charges (MAC)
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Why are these Maximum Allowable Charges (MAC) being implemented
for the California participants only?
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The Plan is constantly negotiating with Anthem on the number of facilities and locations. The program is just getting underway, but we anticipate expanding the number of facilities in California, as well as providing similar cost savings for our participants in Nevada and Arizona.
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Maximum Allowable Charges (MAC)
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How does this affect me if I
don't live in California?
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It does not affect you at all.
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Maximum Allowable Charges (MAC)
In-Patient Designated Hospitals
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Why has Anthem Blue Cross
identified certain hospitals
as their designated hospitals?
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Currently, approximately 50 hospitals in the Anthem Blue Cross Preferred Provider Network (aka Prudent Buyer Network) have agreed to keep their facility charges for their in-patient hospital fees (including the hip or knee prosthesis) to no more than $30,000. These facilities will be recognized as "designated hospitals" or "value-based facilities" because of their willingness to cap their room service charges and the cost of the prosthesis to the maximum allowable charge. Again, any professional fees for the surgeon, anesthesiologist, etc. are not included in the MAC.
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Maximum Allowable Charges (MAC)
Ambulatory Surgery Center (ASC)
COMPARED TO A
Hospital-Based
Out-Patient Surgery Facility
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Why would you only apply the MAC to a hospital based out-patient surgery facility and
NOT an ambulatory surgery center?
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It is much more costly to operate a Hospital than it is to operate a free standing surgery center (that is not associated with a hospital). Costs for out-patient surgeries done at a hospital based out-patient surgery facility are typically much more expensive than the same procedure done at an ambulatory surgery center. It is also a misconception that increased costs translates to increased quality.
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Maximum Allowable Charges (MAC)
In-Patient Designated Hospitals
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How will the benefit changes
save me money?
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First of all, you save money each time you use an in-network provider or facility. These doctors and facilities have all agreed to a set fee for their services and are contracted with our Plan to adhere to those agreed upon fees. Also, if you use a physician or facility recommended by the Care Counselor that offers the same services at a lower fee, your financial responsibility can be reduced proportionately.
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More Mailings
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When will I get more
information regarding the changes?
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We have developed a set schedule to give you time to read and understand all of the changes. The schedule will give you an opportunity to ask questions.
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New Logo
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Why the new logo?
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Every time we have new health care benefits information to share with you, it will have this new logo. Each time you receive any information on this new way to manage your health costs, it will have this new logo in order to identify the message as important for you and your family.
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Open
Enrollment
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Why weren't we told about
these changes during open enrollment?
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Unfortunately, there are many parts to the implementation of these changes and while we have been studying what we could do and how we could bring down the cost of health care to the Trust, we simply were not prepared with all of the answers when it was time to start open enrollment. There was no point in giving you only part of the information.
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Participant Responsibility
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What do I have to do?
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You will be receiving specific information on the various parts of these plan changes. You need to read them carefully and then you need to ask questions. The only way we can all be effective in reducing the costs of health care to the Plan is to be fully educated on how the changes will help and what each of you need to do to make it happen.
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Plan
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Do these changes supersede
the Health Care Reform
changes?
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No - we have taken great care to incorporate all of the Health Care Reform changes and regulations into these plan changes?
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Plan Funding
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Where does the money come from to support the California Ironworkers Field Welfare Plan?
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As part of the negotiations in the collective bargaining process the funds to pay your claims comes from an allocation of YOUR MONEY. Your employer forwards your contributions to the Plan on your behalf in order to pay for the cost of your health benefits. As the costs go up, the contributions negotiated to provide your health benefits must go up, too. This directly affects the dollars available for your wages and retirement, and it gives you a good reason to help contain health care costs. There is no insurance company in the sky paying your bills. If you become a smarter Health Care consumer, it will mean that money can be saved and there will be more money available for your wages and retirement benefits.
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Pre-Authorization
for Services
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Will I need to get a pre-authorization
in order to see a doctor or receive services?
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NO - Pre-authorization will not always be needed but the Care Counselor will be able to advise you on what you need to do in order to adhere to the benefit changes and save you money.
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Pre-Authorization
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What are the procedures
that will require pre-authorization?
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►All outpatient surgeries and procedures.
►Diagnostic and lab tests (e.g. - MRI, PET and CT scans)
►Physical therapy visits
►Durable medical equipment
►Chemotherapy or radiation treatment
►Genetic testing
X-rays and ultrasounds performed in your physician's office during a regular office visit will not require a pre-authorization. However, if you leave the doctor's office and go to a free-standing facility for services, a pre-authorization will be required.
Failure to receive pre-authorization from a Care Counselor for any of the designated services listed in the 2012 Health Benefit Changes information notices, specifically Care Counseling: An Important New Benefit {see the above list}, there will be an additional 10% reduction in the participant’s reimbursement rate. If it is a PPO facility, instead of the reimbursement being 90%, the benefit would drop to 80% as a result of not receiving pre-authorization for any of the listed services.
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Prescriptions
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What do you mean by the
lowest cost prescription drugs?
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Generic medications are the lowest cost prescription drugs available - far cheaper than any brand name medication. That's cheaper for both you and the Plan and saves money.
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Primary Doctor(s)
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What is considered my primary
doctor(s)?
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Primary doctors include your family/general practice physicians, internists, pediatricians, and OB-GYN's.
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