Health Plan Meeting Battles Weather

Hearty Members Battle Ice & Snow To Have Questions Answered

The old saying "The best laid plans of mice and men often go astray" was evident on Tuesday, February 12, 2008 when P.E.A. held a general membership meeting at Kennedy High School for the purpose of assisting members in making informed decisions about the new health coverage which takes effect on April 1, 2008. The Association had made arrangements for a speaker from NJEA to present to the membership. Department of Personnel staff members were on hand to assist staff members who needed to switch their designated plan. Microphones were set up so staff could ask questions. Unfortunately, Mother Nature decided to cast her lot with the "astray" of the saying, creating an icy mess that severely limited attendance.

Despite the limited attendance, Jim Jameson from NJEA answered questions about the new State Health Benefits Plan. Also in attendance were representatives from the Aetna and Cigna HMO's which will be a part of the new system. The busiest people at the program were the Health Benefits personnel from the Health Benefits Department who provided staff members with forms and assistance to anyone who had to fill the forms out and submit them.

Mr. Jameson was asked to explain the difference between NJ Direct 10 and NJ Direct 15, which are the plans sponsored by Horizon Blue Cross/ Blue Shield. He repeated the following:

• Traditional Plan members have been automatically assigned to the NJ Direct 10 plan.
• NJ Plus participants have been automatically assigned to the NJ Direct 15 plan.
• Current HMO plan participants could stay with Cigna or Aetna if they were already in the plan.
• If a member wishes a plan other than the one to which s/he is being assigned, then and only then, must the person fill out a new application form.

Mr. Jameson cited 3 ways that Direct 10 differs from Direct 15:

1. With direct 10 you have a $10 co-pay for in-network services, while the Direct 15 co-pay is $15.

2. If you go out of network with the Direct 10, the plan will pay 80% of the usual/customary rate after the deductible is satisfied. With the Direct 15, the payment after the deductible is 70%.

3. In the Direct 10 plan, the $10 in-network co-pay goes toward your out-of- network deductible. With the Direct 15 plan, the $15 co-pay does not.

Members asked why there was a Direct 15 if there seems to be such an advantage to taking the Direct 10. Jameson replied that for some retirees who do not have 25 years of service and must pay for their insurance, this plan was cheaper. This also holds true in some school districts where staff pay part of their health benefits cost (Paterson is not one of those districts)

Members were advised to check the United Provider Directory to see in which plans their doctors participate. Mr. Jameson did indicate physicians who participate in NJ Direct will be members of both Direct 10 and Direct 15.

The representative from Aetna indicated that one must chose a primary physician in the Aetna plan. There is also a need to get referrals for specialists. However, it was indicated that all of this is done electronically and very easily obtained. Aetna now has "a nationwide network" of physicians and hospitals. Cigna's representative indicated that his plan worked in a similar fashion. He also pointed out that they are associated with Sloan-Kettering, the famous cancer treatment center in New York City.

One other area that was discussed was the issue of coordination of benefits. As you may be aware, the State Health Benefits Commission has announced that there will not be coordination of benefits for married couples who both are covered under either of the NJ Direct plans. The only way coordination can occur is if one spouse takes an HMO and the other takes a NJ Direct Plan. Therefore, a decrease in benefits for married couples, both retired and active, will prevail if both decided to go into the Direct 10 and Direct 15 plans. Mr. Jameson was asked if NJEA is still pursuing this issue. Mr. Jameson indicated that this is an area that NJEA is not satisfied with and is still working to resolve. It is the hope of NJEA to do just that.

P.E.A. would like to thank all who came out to the meeting despite the bad weather. In addition, P.E.A. also would like to express appreciation to all of the representatives present as well as the staff from the Paterson Health Benefits office that came out to assist our members.