Westchester Medical Center Health Network Currently Out-of-Network


On or after June 1, 2019, Westchester Medical Center Health Network will be considered Out-of-Network based upon ongoing negotiations between EmpireCross Blue Shield and the Westchester Medical Center Health Network.

Westchester Medical Center Hospital covered charges will be paid in full less the $200 copay for inpatient admissions. For emergency room and other covered outpatient hospital services the standard SWSCHP copays will continue to apply. If the physicians are in negotiations and drop out they will be considered out of network, so deductible and coinsurance will apply.

Please refer to this FAQ for more information and check back frequently for updates.

Quest Releases Statement on Data Incident

Quest Diagnostics, the lab testing partner of SWSCHP, has announced a data incident with a third party billing collections provider. Please read below for further information on the company’s response and what it will do when its forensic investigation is complete.

SECAUCUS, N.J., June 03, 2019 -- American Medical Collection Agency (AMCA), a billing collections service provider, has informed Quest Diagnostics that an unauthorized user had access to AMCA’s system containing personal information AMCA received from various entities, including from Quest. AMCA provides billing collections services to Optum360, which in turn is a Quest contractor. Quest and Optum360 are working with forensic experts to investigate the matter.

AMCA first notified Quest and Optum360 on May 14, 2019 of potential unauthorized activity on AMCA’s web payment page. On May 31, 2019, AMCA notified Quest and Optum360 that the data on AMCA’s affected system included information regarding approximately 11.9 million Quest patients. AMCA believes this information includes personal information, including certain financial data, Social Security numbers, and medical information, but not laboratory test results.

AMCA has not yet provided Quest or Optum360 detailed or complete information about the AMCA data security incident, including which information of which individuals may have been affected.  And Quest has not been able to verify the accuracy of the information received from AMCA.

Quest is taking this matter very seriously and is committed to the privacy and security of our patients’ personal information. Since learning of the AMCA data security incident, we have suspended sending collection requests to AMCA.

Quest will be working with Optum360 to ensure that Quest patients are appropriately notified consistent with the law.

We are committed to keeping our patients, health care providers, and all relevant parties informed as we learn more.

CVS Announces Split From Walmart

Active and pre-retiree members should take note that CVS Health has announced that as of April 30, 2019, Walmart will no longer be a part of the CVS Caremark Pharmacy Networks. (This change does not affect our Medicare members). Our records indicate that 76 SWSCHP active/pre-retiree members are users of the network through Walmart. These members will have to secure prescription medications through other pharmacies.

You can read the CVS press release on this matter:

CVS Health Announces Walmart Decision to Leave CVS Caremark Commercial and Managed Medicaid Retail Pharmacy Networks

I am writing to inform you that, despite our good-faith efforts and diligent negotiations, Walmart has opted to leave the CVS Caremark pharmacy benefit management commercial and managed Medicaid retail pharmacy networks. Any network change must place patient care as the highest priority and, as such, CVS Caremark has requested that Walmart continue to fill prescriptions as an in-network participating pharmacy through April 30, 2019. This transition does not affect Walmart’s participation in the CVS Caremark Medicare Part D pharmacy network. In addition, Walmart’s Sam’s Club division remains in the CVS Caremark pharmacy networks.

At a time when everyone is working hard to find ways to reduce health care costs, Walmart requested rates that would ultimately result in higher costs for our clients and members. While we have enjoyed a long relationship with Walmart as a low-cost provider in our broad national networks, based on our commitment to helping our clients and consumers manage rising pharmacy costs, we simply could not agree to their recent demands for an increase in reimbursement.

Our focus now is an orderly transition for any affected plan members and ensuring we place patient care as our highest priority. With continuity-of-care in mind, we have requested that Walmart continue to fill prescriptions as an in-network participating pharmacy through April 30, 2019, and are awaiting a response on the transition period.

CVS Caremark’s priority will be to ensure members do not have a disruption in therapy and that their transition to a new pharmacy is simple and as convenient as possible. Members affected by this network change will be notified and will have access to information to help them identify nearby in-network pharmacies where they can fill their prescriptions, including independently owned, community-based pharmacies, other local pharmacies in grocery stores and mass merchants, as well as regional and national chains.

We expect minimal member disruption because, with more than 63,000 other pharmacies that will remain in our national network, we continue to exceed industry benchmarks with regards to network pharmacy access by a significant margin. In fact, the average distance that a member would need to travel to reach an in-network pharmacy remains virtually unchanged.

Widely adhered to Tricare access standards specify:

  • 90 percent of urban members must have an in-network pharmacy within 2 miles

  • 90 percent of suburban members must have an in-network pharmacy within 5 miles

  • 70 percent of rural members must have an in-network pharmacy within 15 miles

With Walmart participating in our retail pharmacy networks, we meet these access standards:

  • 99.15 percent of urban plan members can access an in-network pharmacy within 0.9 miles

  • 99.66 percent of suburban plan members can access an in-network pharmacy within 1.2 miles

  • 98.46 percent of rural plan members can access an in-network pharmacy within 5.9 miles

With Walmart no longer participating in our retail pharmacy networks, the average distance a member must travel to an in-network pharmacy is virtually unchanged. Fewer than one-tenth of 1 percent of members would experience any access change:

  • 99.08 percent of urban plan members can access an in-network pharmacy within 0.9 miles

  • 99.60 percent of suburban plan members can access an in-network pharmacy within 1.2 miles

  • 98.43 percent of rural plan members can access an in-network pharmacy within 5.9 miles

As we begin to prepare members for a transition, we are hopeful that Walmart will agree to work amicably with us in the best interest of patients. Our priority is to ensure that patients continue to have access to their medications during this transition period. We also remain open to continuing timely, good-faith negotiations with Walmart in the hopes of reaching an agreement to provide quality pharmacy care at a reasonable cost.

Aetna/Montefiore Resolve New Contract

Dear SWSCHP Member,

I write to you today with an important message about how SWSCHP is working to help ALL MEMBERS navigate the uncertainties of health care services today.

In early September, Aetna and the Montefiore Health System agreed upon a new contract. In the weeks prior to this agreement, many of our retired members, who receive their health services through the Aetna Medicare Advantage plan, became concerned that they would no longer have access to their doctors and the hospitals within the Montefiore system, or that they would be responsible for costs that were otherwise paid by their plan. That concern was elevated by hospitals in the network who sent out “warning” letters, and and unclear communication from Aetna.

The services for our retired members were never in danger of being lost or financially compromised. Under the terms of our plan, all doctors and hospitals would have still been available, and all normal coverages would have applied. SWSCHP would not allow our members to be abandoned!

This incident points to a larger concern: Can we always trust that everything will remain the same in terms of our expectations for health care services? In fact, even though this case only raised concern for our retired members, related issues could always arise in the future that affect ALL members of SWSCHP.

The dispute that took place between Aetna and Montefiore is all too common. It’s similar to the disputes between large cable television distributors and content providers, as consumers are held hostage while corporate contractual disputes are resolved. In addition, there are a host of factors that have created upheaval in the health care world: large corporate mergers, network provider consolidation, the broad implications of technology, political upheaval, and, of course, the “squeeze” that insurers put on the insured.

The executive board and I are keenly aware of how these developments potentially imperil your expectations for high-quality health care. Remember, our job is to serve our members by providing quality health care benefits in the most effective, competitive and fiscally responsible manner. So how do we accomplish this?

SWSCP – our Executive Board – has ultimate responsibility for hiring good partners who, in turn, negotiate directly with health insurers, on behalf of our members. We empower these partners – companies like Alicare and Wright Risk Management – to meet our mission and work in your interest. But change – even with SWSCHP by your side – is inevitable. If, for example a five-year agreement with a prescription drug provider can be replaced with a different company that is deemed better for our members, we will be obligated to carefully consider it. If a health insurance provider is not living up to its obligations, we will doggedly pursue a relationship that does right for SWSCHP members.

We will always realize outcomes that are consistent with our mission and put our members ahead of every decision. There will be changes within our control, and changes that are out of our control. But make no mistake: Wherever and whenever needed, SWSCHP will work to ease the uncertainties and impacts of a restless market.

Sincerely,

Dr. Peter Mustich, Executive Director

LabCard

August 6, 2018

IMPORTANT NOTICE

Dear SWSCHP Retiree,

As an Aetna Medicare Advantage member you have been identified as a retiree that utilizes the Montefiore Health System. You may have received a letter from Aetna that as of September 8, 2018 Montefiore Health System will no longer be in the Aetna Medicare Advantage PPO network of participating providers. 

Aetna is required by the Centers for Medicare and Medicaid Services (CMS) to send notices when a provider no longer participates with the plan. Please do not be alarmed, you will be able to continue to receive services from Montefiore Health System.  The SWSCHP Aetna Medicare Advantage PPO ESA plan designed for SWSCHP Medicare primary members does not require you to see providers that are in the Aetna network. As long as the provider accepts Medicare and willing to bill the plan you can continue to receive services and you will have the same cost share as if you were receiving services from a participating provider, just like you do today.

Aetna continues to work with Montefiore Health System and may reach an agreement prior to September 8, 2018. Should an agreement be reached Aetna will send out a notice making you aware. Regardless, of whether an agreement is reached; SWSCHP wants you to know that you do not need to make any changes to the providers you see today.

For any questions regarding this letter or about your Montefiore Health System, please contact Aetna at 1-855-395-9722 Monday through Friday from 8 am to 6 pm in all time zones. 

Regards,

 

Peter Mustich

SWSCHP Executive Director

 

Are You Using the Quest Diagnostics Lab Card?


24 July 2018 - The Lab Card program allows you to obtain laboratory testing services at NO COST to you when you use a Quest Diagnostics laboratory. When the testing is covered and approved by your health benefit plan and provided through Quest Diagnostics —you pay no deductibles, no copays and no coinsurance.*

At your physician’s office, show your SWSCHP healthcare card and/or your separate Quest Diagnostics Lab Card and verbally request to use the LabCard Program. The testing must be covered and approved by your health benefit plan and Lab Card must be clearly marked on the paperwork that accompanies your specimens.

Your physician can collect your specimens in the office and call for the specimens to be picked up. Or you can contact your Care Coordinators at 1-888-779-7247 www.swschp.org or visit www.LabCard.com or call 1-800-646-7788 for an approved Lab Card collection site. Quest Diagnostics performs the tests and sends the results to your doctor (usually the next day).

YOU SAVE! No deductibles, no copays

What if I receive a bill for lab work?
If you receive a bill from Quest Diagnostics after receiving an explanation of benefits or denial for services from your health benefit plan, and you disagree with the denial, contact your Care Coordinator for assistance. If the denial of services is due to lack of health benefit plan coverage, you will be responsible for payment. If you have questions about whether or not specific testing is covered, please consult your health benefit plan.

Can testing under the Lab Card Program be sent to any Quest Diagnostics laboratory?
Yes. To ensure you receive the benefit of the Lab Card Program, you should show your SWSCHP healthcare card and/or Quest Diagnostics Lab Card and verbally request to use the Lab Card Program. Your physician should clearly mark Lab Card on your laboratory orders and call 1-800-646-7788 for a Lab Card pick up. Or, visit our website: www.LabCard.com to locate an approved
collection facility, which will collect your specimen, send it to an approved Quest Diagnostics laboratory and the results will be sent
back to your physician, typically the next day.

Hello From Dr. Mustich, Executive Director of SWSCHP

Dear SWSCHP Member, 

As the new Executive Director of SWSCHP, it is my pleasure to introduce myself. Some of you may know that I was the Rye Neck superintendent for 25 years until retiring in December 2016. My former district was one of the founding partners of the plan and I was a member of the SWSCHP Board of Directors for many years. My family has benefited from this excellent plan under my status as both an active member and retiree, and I am honored to have been named Executive Director. I look forward to communicating with our members on a regular basis through a new digital newsletter and posts to this site.