UnitedHealthcare/Oxford Contract with East End Hospitals in Jeopardy of Cancellation

The East End Health Alliance Hospitals (Southampton, Peconic Bay and Eastern Long Island) and UnitedHealthcare/Oxford are currently in good faith efforts to negotiate a new contract.  If they are unable to reach an agreement the current agreement may terminate on July 15, 2011.

In the event of a contract termination, the State of New York requires insurance carriers and hospitals to observe a two month “cooling off period,” which is simply a period of time after the termination of a contract when fully insured commercial and Medicare members can still access the terminated hospitals on an in-network basis in the hopes that the hospital and the carrier can reach a new agreement.

Since this cooling off period does not apply to commercial self-funded groups and members, in the event of a termination, EEHA would become non-participating for those members on July 15, 2011. For fully insured commercial, Medicare and Medicaid members, EEHA, and physicians without admitting privileges somewhere other than an EEHA hospital, would become non-participating on September 15, 2011

UnitedHealthcare/Oxford will have Transitional Care guidelines in place so members who have scheduled or ongoing medical treatments at EEHA hospitals will continue to get care as appropriate.

Fully insured commercial, Medicare and Medicaid members would continue to have access to EEHA hospitals on an in-network basis through the New York State cooling off period, which would end September 15, 2011. Transitional Care may be available after the cooling off period in accordance with the member’s Certificate of Coverage.

After July 14, 2011, a primary care physician or specialist should not refer members to an EEHA hospital for any treatment or test. Instead, members should be referred to one of the major neighboring hospitals in the network listed below.

Brookhaven Memorial, John T. Mather Hospital, St. Charles Hospital, Stony Brook University Medical Center, St. Catherine of Siena Medical Center and Southside Hospital.

Oxford Changes Tier 3 Prescription Drug Rules for NY Small Groups

As drug costs continue to rise, carriers are creating innovative ways for members to maintain affordable access to a variety of medications. Oxfords Select Designated Pharmacy Program, for example, focuses on providing members with access to lower cost alternatives to a select number of Tier 3 (high-cost) medications. This program will be implemented for Oxford fully insured New York small groups (2-50 lives) on January 1, 2011. The program does not apply to Healthy NY plans, and is optional for self-funded groups. 

About the program  Members of the program are required to choose one of three cost-saving options to continue to receive medications at the in-network benefit level:              

  • Option 1: Switch to a lower-cost medication and save
  • Option 2: Fill the prescription through the Mail-Order Pharmacy and save
  • Option 3: Do both to save 

Members are allowed two “grace” fills of their current medication at the retail pharmacy before they must select a new option. If a member chooses to continue filling a Tier 3 medication at the local retail pharmacy after the second grace fill, the member will pay the full cost of the medication, as benefits are not payable under the plan.

 Medications included in the program The targeted medications and products listed below, all in Tier 3, represent 2% of all retail prescriptions. The majority of these have multiple, lower-cost alternatives.


Lyrica, Symbicort, Avodart, Uroxatral, Lexapro, Atacand, Atacand HCT, Avapro, Avalide, Asacol, Asacol HD, Axert, Frova, Maxalt, Maxalt MLT, Zomig, Zomig ZMT, Toviaz and Detrol.

All employers will receive a letter from Oxford about the Select Designated Pharmacy Program as well as all members that are currently taking these medications. Members will also receive an outgoing call from Oxford, and point -of-sale messaging at the retail pharamacy to help them understand their options for savings.

House Health Care Reform Bill: Towers Perrin’s Cheat Sheet for Employers

If you need to quickly digest the 2,000-odd page health care reform bill passed by the House last week, you’re in luck. Towers Perrin has boiled down the key points — provisions that would have a significant impact on employers and could appear in final legislation — to a four-page cheat sheet. Stay tuned for updates as the Senate re-writes this bill.

House Health Care Reform cheat sheet

House Health Care Reform Podcast

Health Care Bill Update

On October 13, 2009, the Senate Finance Committee approved Senator Max Baucus’s (D-Montana) health care bill, the America’s Healthy Future Act, by a vote of 14 to 9. Senator Olympia Snowe (R-Maine) was the only Republican to vote with the committee’s 13 Democrats in favor of the bill. The Congressional Budget Office (CBO) estimated the cost of the bill at $829 billion over 10 years.

The bill will now be fully merged with Sen. Kennedy’s HELP bill with hands-on participation from Senate Majority Leader Harry Reid and key Administration officials. Some of the most contentious issues to be resolved in the merger include the fate of the HELP bill’s government option, the Finance Committee’s weak individual mandate penalties and new taxes and fees on the insurance industry.  

The stated aims of the legislation are to lower costs, provide quality, affordable health care coverage, make purchasing health insurance easier, prohibit discrimination due to health factors and improve the way the health care system delivers care. However, many in Congress are divided on whether the bill can meet these objectives. Opponents of the bill have argued that it will increase costs for many Americans, rather than making health care more affordable.  

Stayed tuned for MANY updates as this bill is vollyed about  the Senate and House.

Three New Federal Healthcare Mandates Will Impact Healthcare Costs

American’s with Disabilities Act (ADA) Amendments

    • Effective October 3, 2009 for all large and small groups.
    • Hearing Aids:
      • Coverage of hearing aids will be standard.
      • Dollar limits mirror Durable Medical Equipment (DME) and Prosthetics and vary by state and plan
      • Limited to one device as follows:
        • Connecticut every 12 months
        • New Jersey every 24 months
        • New York every 3 years 

 Mental Health/Substance Use Parity

    • Effective October 3, 2009 for large (51+ lives) groups.
    • The new law does not allow more restrictive financial requirements for mental health and substance use disorder coverage than for any other medical expense.
    • It specifically states that deductibles, copayments, coinsurance, and out-of-pocket expenses must be in parity.
    • A plan may still have an aggregate lifetime limit and an aggregate annual limit that is applied to both medical and mental health/substance use disorder benefits.
    • The law also prohibits treatment limits on mental health and substance use disorder benefits that are more restrictive than those of medical/surgical benefits. The law specifically requires the following limitations to be in parity:
      • Limits on frequency of treatment
      • Limits on number of visits
      • Limits on number of days of coverage
      • Other similar limits on the scope or duration of coverage.

 Michelle’s Law

    • Effective October 9, 2009 for individual plans, large, and small groups.
    • Prevents dependent children covered under a group health plan from losing coverage if they are forced to take a medically necessary leave of absence from school

Cuomo Battles Health Insurance Carriers and Posts a Victory for Consumers and Transparency

Cuomo Speaks Out on Victory

Back in February 2008 I reported NY Attorney General, Andrew Cuomo was investigating United Healthcare and has subpoenaed 16 other health plans including Aetna, CIGNA, Humana, and Well Point a subsidiary of Empire Blue Cross Blue Shield to determine how they calculate UCR. UCR is the usual customary and reasonable payment made for medical services rendered outside of the insurance carrier’s network.

Yesterday United Healthcare agreed to close down two Ingenix databases used to determine usual and customary payment rates for services for out of network doctors and pay 50 M to establish a new database that will be run by an independent nonprofit.  This much criticized database was run by Ingenix a subsidiary of United Healthcare. 

Cuomo’s investigation found that the UCR determined by Ingenix database for claims led to underpayments by iurers anywhere from 10 to 28 percent.   United wasn’t the only carrier using this database.


This is a huge victory for healthcare transparency for consumers. Under the agreement the new database will come with a web site that allows consumers to see how much they will be reimbursed for services in their area for out of network services

2008 Regional Healthcare Report Card

The NYS Health Accountability Foundations has published the 2008 Regional Health Care Report Card, which presents access, service and quality data for all hospitals and commercial managed care plans in New York, New Jersey, Connecticut, Vermont and Rhode Island. 

Review reportcards for Insurance Carriers and Hospitals


Insurance Carriers Will Stop Paying for Medical Errors

The Institute of Medicine had reported in 1999 that up to 98,000 people had died in hospitals as a result of medical errors.  Today the number is estimated to be 200,000+ and costing billions of dollars.  Not to mention the medical errors that occur that don’t result in death but result in increased medical costs, cost of ongoing care and disability.


Medicare, Well Point, and Cigna are taking a stand by announcing plans to stop paying for care that’s triggered by a host of medical mishaps.  Doctors will not be paid for surgical procedures on the wrong side, wrong person, wrong body part and or wrong site.  Cigna is adding a list of “potentially non-reimbursable” mishaps that will mandate quality of care.


Click here for more


Aetna adds Memorial Sloan-Kettering Cancer Center to all Network Based Plans

Effective April 1, 2008 Aetna adds the world renowned Memorial Sloan Kettering Cancer Center in NYC to all network based plans. “As one of the world’s premier cancer centers, MSKCC is committed to exceptional patient care, leading-edge research, and superb educational programs,” said John R. Gunn, Executive Vice President, Memorial Sloan-Kettering Cancer Center. “We are pleased that Aetna members will have the opportunity to access Memorial Sloan-Kettering Cancer Center on an in-network basis and we look forward to having a long-term relationship with Aetna for the benefit of its members who are or will be in our care.”

For more information click here

Aetna Takes the Lead on Personal Health Records

Aetna deserves praise for being out in front with the first-ever personalized search engine that mines information from Aetna’s vast data resources to deliver meaningful, personalized health and health benefits information to Aetna members.  Aetna partnered with Healthline Networks to develop Aetna SmartSource.  Aetna SmartSource is available online and can be accessed through Aetna Navigator®, Aetna’s member self-service website, the CareEngine-powered Personal Health Record (PHR), and Simple Steps To A Healthier Life®, Aetna’s online wellness program. Aetna will pilot Aetna SmartSource with several large, pre-selected customers throughout 2008.

Click here for more on SmartSource.

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