Carpenters Indemnity Plan - 3 Ways to Manage Healthcare Costs

The Trustees of the Carpenters Health and Welfare Fund are committed to keeping healthcare costs as low as possible without sacrificing quality or coverage, even as costs continue to rise at a rate well above normal inflation. By working together to follow Indemnity Plan rules and take advantage of cost savings, NorCal Carpenters and their families can benefit everyone and, in turn, help keep money in your paycheck.

When you or a family member has a health issue, there are some simple steps to take that can have a major impact on cost. Today we will focus on three ways you can save on health care costs for you and the Trust Fund.

1.      Surgery.  Care performed in hospitals is expensive, and costs are often difficult to determine. Charges for surgical procedures can vary greatly among hospitals and facilities; yet, there is little evidence of a higher quality of care at a higher cost facility.

Some surgeries can be performed outside traditional hospital settings at outpatient clinics that specialize in same day surgery. These are called Ambulatory Surgical Centers, or ASCs. Ambulatory Surgical Centers can provide high quality care, often at a much lower cost than a hospital.

Your health plan is designed to encourage you to use ASCs for outpatient surgeries whenever possible. To help control costs, your plan will limit the payment amount if you choose to go to a hospital instead of an Ambulatory Surgery Center. The maximum payment amount is the highest amount your plan will pay for certain surgeries when you receive care without being admitted or for a stay of less than 24 hours. Any amount over the maximum will be your responsibility to pay. The maximum payable benefits listed below will apply to the following procedures when received in an outpatient hospital setting:

• Colonoscopy - $1,500
• Sigmoidoscopy - $1,000
• Esophagoscopy – $2,000
• Upper gastrointestinal endoscopy without biopsy – $1,500; with biopsy $2,000  
• All other Endoscopies – $1,000
• Cataract Surgery - $2,000
• Tonsillectomy and/or adenoidectomy (for a Member under age 12) – $3,000
• Nasal/Sinus - submucous resection inferior turbinate services – $3,000; septoplasty - $3,500
• Arthroscopy - $6,000
• Laparoscopic gall bladder removal – $5,000
• Hysteroscopy uterine tissue sample (with biopsy, with or without dilation and curettage) – $3,500
• Lithotripsy – $7,000
• Hernia inguinal repair (over age 5, nonlaparoscopic) – $4,000; repair of laparoscopic inguinal hernia - $5,500 

By using a Contract Ambulatory Surgery Center, you will receive the maximum benefits payable and save yourself and the Plan money.

If you receive care at an Ambulatory Surgical Facility, the maximum allowable charge will be determined based on whether you receive services at a Contract or Non-Contract Facility. There is a daily maximum benefit of $300 for all services received at a Non-Contract Ambulatory Surgical Facility. To find or confirm a Contract Facility, use the Anthem Blue Cross Sydney Health Mobile App, or visit anthem.com.

Exceptions Process - There are certain times you may not be able to use a provider, hospital, or outpatient surgery center who has agreed to accept the maximum allowable charge. Therefore, in the following situations, contact the Fund Office prior to surgery and the Fund may make an exception for you:

• · If your access to a provider, hospital, or outpatient surgery center that will accept the maximum allowable charge is unavailable or the service cannot be obtained within a reasonable wait time or travel distance; and
• · If the quality of services for you or your Dependent(s) could be compromised with the provider, hospital, or outpatient surgery center (e.g., if comorbidities present complications or patient safety issues)

2.      Specialty Medications

 

Complex conditions, such as cancer, anemia, hepatitis C, multiple sclerosis, asthma and rheumatoid arthritis, are often treated with specialty medications. Specialty medications are typically injectable Drugs administered by you or a healthcare professional, and they often require special handling.

To help control costs, there are strict limitations on Specialty Drugs. Specialty Drugs are covered only if they are obtained from specialty care pharmacy Accredo Health Group. These Drugs will not be available from a retail network pharmacy and will not be covered by the Indemnity Medical Plan, with the exception of certain oncology and emergency drugs. It’s important to confirm with your doctor that your specialty medications are ordered through Accredo.

Benefits for specialty medications not obtained from Accredo will be limited to what the Fund would have paid if the Drug had been obtained through Accredo, and you will be responsible for any remaining charges. This could leave you with significant out-of-pocket expenses. If you have questions about Specialty medications, call Accredo at (800) 803-2523; or, for any questions or issues regarding prescription drugs, you can contact Express Scripts at express-scripts.com, or call (800) 939-7093.

 

3.      Hip or Knee Replacement. Joint replacement is a special category of surgery. Inpatient hospital Plan benefits are limited to $35,000 for single hip joint replacement or single knee joint replacement surgery. The maximum applies to all hospital facility costs but does not include professional fees such as anesthesia or surgical fees.

There are specific PPO hospitals throughout California where these surgeries can be performed which will minimize your out-of-pocket costs beyond the Plan’s deductible and coinsurance, called Value Based Facilities.

If you require hip or knee replacement surgery, the Trust Fund Office will provide you with a list of hospitals that accept the maximum allowable benefit for particular inpatient or outpatient services related to knee and hip replacement surgery.

Visit the Trust Fund Office website at carpenterfunds.com and search for “Value Based” or call the Trust Fund Office at (888) 547-2054 for the list of hospitals that can provide services at a lower cost.

To recap, remember these three things to minimize costs and maximimize your health plan benefit:

1. Visit Contract Ambulatory Surgery Centers for outpatient surgeries.
2. Always obtain specialty medications through Accredo.
3. Use Value Based Facilities for knee and hip replacement.

Following these rules can help you make the most of your Carpenters Indemnity Health Plan. Working together, Nor Cal Carpenters and their families can help control health costs and maintain a strong Health and Welfare benefit.