Open Enrollment May Provide Alternatives to Long Wait for Insurance Payments

By Monica M. Walk

OPEN ENROLLMENT may provide the antidote to some University employees’ health insurance woes.

UIC EMPLOYEES enrolled in the Quality Care Health Plan (QCHP) have been experiencing significant delays in payments to healthcare providers, leading some healthcare providers to demand payment for services up front. Having to pre-pay out of pocket for covered services means employees are the ones left waiting months for reimbursement.

“IT’S NOT new,” said Human Resources Administration Director Katie Ross, Ed.M., PHR, University Human Resources, of the late payments. “It’s a function of the State’s dire funding situation, and has been going on for a few years regarding payment from some medical plans. The longer it goes on, the more of an issue it becomes. People can accept it for a while, but the longer it goes on the less able people are to wait for reimbursement.”

QUALITY CARE health and dental plans are experiencing the most significant delays in the State Employees’ Group Insurance Program. The Department of Central Management Services (CMS) has a website reporting payment release dates to providers, which shows claims dated approximately a year ago are now being processed and paid. The site has been reporting such delayed payment release dates since 2009.

Other Options
BUT, THERE are other health care plans and other options for employees, Ross said.  Employees can make plan changes only once annually during open enrollment. UIC annual open enrollment for health care benefits begins Wednesday, May 1 and ends Friday, May 31; plan choices are effective July 1.

ROSS ADVISES employees to review their health care needs now to determine if they have flexibility on health care providers, which makes it easier to switch to another plan option.

“ALMOST ALL counties have at least one HMO option, and they are not experiencing the same payment issues,” Ross said.  “In the HMO, a co-pay is paid up front and the healthcare provider waits for payment from the State. There is less burden on the employee.”

IN AN HMO, a primary care provider directs all care, including referrals to specialists.  Ross acknowledges that some people don’t like this system. “Some people require the services of specific doctors for their personal health issues,” she said.

EVERY COUNTY also has an Open Access Plan (OAP), which offers a tiered benefit structure. “It’s a newer option, and combines the best of HMOs and Quality Care,” Ross said. 

THE OAP generally offers three tiers of benefits, and users pay based on which tier the practitioner is in. Tier One is most similar to an HMO with a co-pay and can be very attractive to employees, Ross commented. Tiers Two and Three offer the flexibility to see out-of-network providers at a higher out-of-pocket cost similar to Quality Care.  But unlike in a traditional HMO, OAP enrollees can go to a specialist without a referral.

It’s the Law
STATE LAW requires University employees to participate in State group health plans, Ross noted, making self-insurance and other insurance options impossible. “We are locked into it,” she said. Students are exempt from the law and have separate coverage.

EMPLOYEE DENTAL coverage under the Quality Care Dental Plan is also having similar payment delays. 

“THE STATE has only one dental plan, so there is no opportunity to switch,” Ross said.  “You are either in or out. But dentists are approaching the situation in a variety of ways and some will wait for reimbursement. Others won’t wait and will require payment of the full amount for services up front, and the employee will have to wait for reimbursement.  Employees may want to shop around for a network dentist who doesn’t require payment up front.”

CMS Advocacy
EMPLOYEES WHO find themselves in financial hardship due to payment delays or up-front payment requests for major medical services are urged to contact CMS. “CMS has been very helpful in coordinating with providers and will advocate on employees’ behalf,” Ross said.

CONTACT DETAILS, including the CMS online form to report hardship, are available from the HR NESSIE website. Links from http://illinois.edu/blog/view/1418/90794 contain especially useful information.

“THE UNIVERSITY certainly empathizes with employees,” Ross said.  “We HR and Benefits representatives are in the same health care plans and are experiencing the same issues. It is an unfortunate situation created by the State funding situation.”

OPEN ENROLLMENT vendor fairs are being held in April and May; see http://www2.illinois.gov/cms/Employees/benefits/StateEmployee/Documents/FY%202014%20Benefit%20Fairs.pdf for location details. University benefits services centers also are located on each campus and benefits specialists are available to help employees navigate benefits choices.

FOR MORE information, call (312) 996-6471 or email benefits@uillinois.edu.