Improved In-Network Physical Therapy and Chiropractic Benefits Along With a New Limit - Effective January 1, 2010

As you might already know, one of the main areas of concern in the economy is the continued the rapid rise of yearly health care costs. Unfortunately, Equity-League has experienced these same problems. Our Plan alone saw a 12% increase in claims cost per member relative to the prior year. In order to better understand the causes of these increases, the Trustees ordered the most far reaching claims analysis ever to be performed for the Health Fund. The plan actuaries, The Segal Company, Care Data (a claims analytics firm) and CIGNA worked together on the analysis and one of the real areas of concern was a high utilization of certain Physical Therapy and Chiropractic services, especially among out-of-network providers.

The study indicated that the utilization of certain Physical Therapy and Chiropractic services by Fund participants was many times the level that is typically seen within health plans. In addition, while more than 75% of the overall medical care received by plan participants is from providers within the CIGNA network, more than 75% of care from Physical Therapists and Chiropractors is from out-of-network providers. These two factors combined - high utilization of Chiropractic/Physical Therapy services and high utilization of out-of-network providers - has led to a cost level for these treatments that is much higher than for most health plans. Only a portion of the high costs can be explained by the high level of physical activity characteristic of certain Fund participants (e.g. dancers).

Chiropractic and Physical Therapy Changes - Effective January 1, 2010

"While the knee jerk" reaction to high therapy and chiropractic costs is often to reduce benefits, the Trustees took a much more balanced approach. First, noting the poor utilization of network therapy and chiropractic providers, they have requested that CIGNA make vigorous efforts to recruit more Physical Therapy and Chiropractic Providers into their network, particularly the providers who treat our participants in high volumes. And this is an area where the Fund can use your help. If you currently obtain these services through an out-of-network provider, please ask your provider to consider joining the CIGNA network. If they do, costs will be reduced for both you and the Fund. If your provider has any interest, please contact the Fund Office and we will ask the CIGNA Provider's Relation Department to get in touch with your provider. Although adding a provider to a network takes time, in many cases it can be accomplished.

Second, the Trustees are actually reducing co-pays for in-network Physical Therapy and Chiropractic providers from $25 to $15 in hopes of encouraging members to use in-network benefits, even if doing so means changing a provider. On the other hand, allowable amounts for services incurred by out-of-network providers have been reduced to approximately the same level as those for in-network providers. This will mean that in many cases, if you use an out-of-network provider, your responsibility for costs will increase. This increase may be quite substantial in certain cases. Please remember that the Fund generally reimburses 70% of the cost of out-of-network providers once the annual deductible has been met, but only up to the allowable charge for that procedure. Any remaining balance above the Fund’s allowable charge is your responsibility in full. So if your provider charges $100 for a given procedure, and CIGNA’s allowance for that procedure is only $80 (assuming the deductible has been satisfied), CIGNA will pay 70% of the $80 (or $56) and you will be responsible for the other 30% (or $24) plus the amount above $80 (or $20, for a total of $44). Therefore, if you use an out-of-network provider, we urge you to find out before you begin services what the provider will charge for those services and compare that with what CIGNA will allow (which you can find out by calling CIGNA with the provider’s charge – CIGNA will tell you whether that charge exceeds their allowance and if so by how much).

Finally, a $4,000 combined calendar year annual cap (January through December of each year) will be placed on certain Chiropractic and Physical Therapy treatments in order to limit costs to the plan. However, if you have suffered a severe injury or have a severe illness and you are participating in CIGNA’s Case Management program, benefits above $4,000 may be authorized by CIGNA as part of an approved treatment plan.

Case Management is a voluntary CIGNA service that assists individuals with treatment needs that extend beyond the acute care/Hospital setting. The goal of Case Management is to ensure that patients receive appropriate care in the most effective setting possible whether at home, as an outpatient, or an inpatient in a Hospital or specialized facility. Case Management is a proactive, collaborative program to ensure appropriate resources are used at the appropriate time.

The types of illnesses and injuries that are appropriate for Case Management typically include:

Amputations


Multiple fractures


Spinal cord injuries


Cerebral vascular accident


Head Trauma


AIDs


MS


High risk pregnancies


Severe burns


ALS


End stage cancer

The above conditions and illnesses are generally identified during a hospitalization. At this time, a Case Management professional will work closely with the patient, his or her family and the attending Physician to determine appropriate treatment options which will best meet the patient's needs. The Case Manager will help coordinate the treatment program and arrange for necessary resources. Case Managers are also available to answer questions and provide ongoing support for the family in times of medical crisis. The Case Manager can authorize physical therapy benefits above the $4,000 annual maximum if the treatments are part of an approved medically necessary treatment plan.

You, your dependent or an attending Physician can request Case Management services by calling the toll-free number shown on your CIGNA ID card during normal business hours, Monday through Friday.

Note that participation in the program is voluntary - no penalty or benefit reduction is imposed if you do not wish to participate in Case Management. Case Management participation at the initial onset of a serious injury or illness is important to assist with the management of Fund benefits. Please note that case management will not become involved retrospectively, once the benefit is exhausted.

It is hoped that this combination of initiatives will rein in the high cost of care in these areas while actually enabling plan participants to enjoy better benefits by utilizing network providers.

For questions regarding these changes, please contact the Health Department within the Fund Office and a customer service representative can assist you".