2022 Medical plan provider networks and third-party administrator (TPA) transition Frequently asked questions
Overview
Q: What is the difference between the Tier 1 and Tier 2 networks?
A: Northwell offers three medical plans, Value, Buy-up and the HDHP. Each of these plans consist of a Tier 1 network and Tier 2 network. The Tier 1 network offers you providers and facilities contracted by Northwell, allowing for the lowest out-of-pocket expense to you. The Tier 2 network is an extended network which has higher out-of-pocket expenses. The Tier 1 network will always be more cost-effective for you than the Tier 2 network.
Q: Are there any changes to the medical plan design?
A: Yes. Below outlines the plan design changes to our Value, Buy-up and HDHP for 2022.
- Fertility plan update: The three-cycle maximum for infertility treatments and fertility preservation procedures will be converted and replaced with a $45,000* lifetime maximum. Treatment received outside of Northwell Health Fertility is not covered.
- Home healthcare and home infusion therapy: This will only be covered when using the Tier 1 Northwell Direct network. Team members will be responsible for 100% of the cost when using outside providers. This does not apply to Out-of-Area (OOA) plan participants.
- Urology care: Deductibles will increase when not using the Tier 1 Northwell Direct network providers for urology care. Please see the deductible amounts per medical plan and tier below. This does not apply to OOA plan participants.
- Value and Buy-up
- Tier 2: $5,750 individual/$11,500 family
- Out-of-Network (OON): $8,500 individual/$17,000 family
- Value and Buy-up
- NEW! Hearing aid benefit: Team members are eligible for two hearing aids up to $5,000 every five years at Northwell Health Hearing Aid Dispensaries
Q: Are benefit guides be available?
A: 2022 benefit guides are available on the myBenefits site.
Q: Where can I go to view a summary of what’s new in our benefits plans for 2022?
A: Please visit the ‘What’s new in 2022’ page on the myBenefits site to view important updates, including plan design changes and a link to the new myMedical site outlining the changes to provider networks for all three team member plans and the third-party administrator for the Value and Buy-up plans.
Medical plans
Provider network changes
Q: What does this change mean for those enrolled in Northwell’s Value, Buy-up and HDHP? And when do the network and third-party administrator (TPA) changes go into effect?
A: The Northwell Direct network** became effective on Jan. 1, 2022, and is the Tier 1 network for our team member Value and Buy-Up medical plans replacing the Northwell Clinical Integration IPA (CIIPA) network. The Tier 2 network for the New York and New Jersey area is the MagnaCare network. CIGNA is the Tier 2 network outside of New York and New Jersey.
The Northwell Direct network and MagnaCare network already serve as the Tier 1 and 2 networks for the HDHP. For 2022, the Tier 2 network for all states outside of New York and New Jersey for HDHP is changing from First Health to CIGNA.
We transitioned from UnitedHealthcare to Brighton Health Plan Solutions (Brighton) as a plan administrator to administer and manage medical plan aspects such as claims processing and more.
The Northwell Direct network and MagnaCare network already serve as the Tier 1 and 2 networks for the HDHP. For 2022, the Tier 2 network for all states outside of New York and New Jersey for HDHP is changing from First Health to CIGNA.
We transitioned from UnitedHealthcare to Brighton Health Plan Solutions (Brighton) as a plan administrator to administer and manage medical plan aspects such as claims processing and more.
Q: What does this change mean for union-sponsored plans administered by Northwell?
A: The TPA for union-sponsored plans administered by Northwell changed from UnitedHealthcare to Brighton as a plan administrator on Jan. 1, 2022. Brighton is used for claims processing and customer service while the new provider and facility network in the New York and New Jersey area is the MagnaCare network. CIGNA is the network outside of New York and New Jersey should you or a dependent need access to a provider outside of the area.
Q: Why are we moving away from UnitedHealthcare and to Northwell Direct powered by Brighton?
A: Team member care has always been our top priority, and by partnering directly with Northwell Direct, we believe we can provide care directly to our team members without an intermediary through the Northwell Direct network. We can improve team member experience by using Brighton for claims processing and customer service, and the Northwell Direct network for expanded access to a comprehensive network of high-quality providers to members living in areas not currently covered by our Tier 1 providers.
Q: Am I still considered to be part of an OOA plan?
A: The Northwell Direct network has more providers and facilities available in New Jersey, the Bronx, Westchester and Connecticut than previously available for you and your family to utilize. With this increased availability, there are more areas that were previously considered OOA now determined as in-area. Search for providers and facilities here or call (855) 340-7737, Monday through Friday, 8:00 am to 6:00 pm, to assist with your provider search.
Click here to view which zip codes are now in-area and OOA.
Q: Do the provider network and TPA changes impact my dental and vision insurance?
A: No. This change does not impact any other benefit plan for Value, Buy-up and HDHP.
Q: Where will I go to view my Explanation of Benefits (EOBs)?
A: Please sign up for the member portal at Northwell.edu/myMedical to access your digital ID card, review claims and Explanation of Benefits (EOBs), check coverage and benefits, and continue searching for providers and facilities.
In-network provider and facility coverage
In-network provider and facility coverage
Q: Where can I search for in-network providers and facilities?
A: Whether you are on the Value, Buy-up, HDHP or union-sponsored plan administered by Northwell, you can now search for in-network doctors, and other healthcare providers and facilities, all in one place. Access the in-network provider and facility search on Northwell.edu/myMedical.
Q: What do I do if I can’t find my provider in the Northwell Direct network?
A: Providers are continually being evaluated for participation within the Northwell Direct network. If you would like assistance with identifying a current Tier 1 provider or are interested in nominating a provider to be evaluated for Tier 1 network participation, please call member services at (855) 340-7737.
Q: Can I use other providers/facilities if mine is not part of the Tier 1 Northwell Direct network?
A: If your provider or facility is not included in the Tier 1 network, you can use the MagnaCare network, the Tier 2 network for New York and New Jersey. If you need a Tier 2 provider or facility outside of New York and New Jersey, you would use the CIGNA network. There are increased costs if you visit the Tier 2 networks, but if the provider does not participate in either the Northwell Direct, MagnaCare or CIGNA networks, they are considered a non-participating provider (also called an out-of-network provider). If you choose to use providers that are out-of-network you will pay significantly more. In addition, where specified in our plan summaries, Tier 1 providers/facilities must be used in NY/NJ for the below services:
- Home healthcare
- Home infusion
- Bariatric surgery
- Fertility
- Growth hormones for height related treatment
Q: I have a dependent who lives/attends school out of state. Which network do they use?
A: If you or your dependent need to use a provider outside of the New York and New Jersey area, you will use the Tier 2 CIGNA network to find in-network providers and facilities.
Q: Who do I say is my insurance provider when I need to make an appointment, update my information or go to a new provider/facility – by phone, online or in the DPX mobile app?
A: For team members part of the Value, Buy-up and HDHP, you should identify that you are a Northwell team member that accesses the Northwell Direct network administered by Brighton Health Plan Solutions when speaking with your in-network provider or facility. If you are using the Tier 2 network, you should identify your plan as MagnaCare in New York or New Jersey and CIGNA outside of New York and New Jersey. Online websites and applications may vary how they list and identify the plan. You should always confirm with your provider/facility using your member and group ID found on your medical benefit ID card.
Q: I’m receiving specific medical care (e.g., maternity/delivery care, chemotherapy, pre-scheduled surgery) that will continue into 2022, and want to ensure I can still see my provider. Who can I speak with if I cannot find them in the provider search?
A: For team members and dependents currently undergoing specific medical services (e.g., a scheduled surgery, continuation of maternity and delivery care, chemotherapy) utilizing a provider that is not in-network, Brighton will work directly with you to be considered for continued care with that dedicated provider until April 1, 2022, and for maternity care until July 1, 2022. To initiate a discussion on transition of care for out-of-network providers, team members and their families should contact Brighton at (855) 340-7737.
Q: Is the coverage for my prescribed medications changing?
A: No. Prescription coverage has not changed. Vivo Health offers convenient services such as mail order, a specialty pharmacy and a mobile app for your on-the-go pharmacy needs. Vivo Health has a large pharmacy network, which includes ten Vivo Health Pharmacy locations, mail order and more than 64,000 participating retail pharmacies. Visit Northwell.edu/myMeds for information about Vivo Health and in-network pharmacies.
Q: Do any of the team member medical plans require referrals?
A: No. Team members on the Value, Buy-up, HDHP or union-sponsored medical plans administered by Northwell do not require referrals when utilizing the Tier 1 and/or Tier 2 provider or facility networks.
Q: What if I need to visit the emergency room?
A: In the event of a medical life-threatening emergency, you should go to the closest emergency room. There is a $200 emergency room co-pay, which is waived if you are admitted within 24 hours. If you have a health concern that is not life-threatening, you may consider calling our ER on Demand service at (516) 918-6005. You will speak with a triage expert who will evaluate your symptoms and when appropriate connect you with one of our Emergency Medicine physicians to help decide next steps of care.
Support
Q: Where can I go for more information on the provider networks and TPA changes to the medical plans?
A: Please sign up on Northwell.edu/myMedical where you can search for providers and facilities, view and share your digital ID card, review claims and your Explanation of Benefits (EOBs) and check coverage and benefits.
Q: Who can I contact for additional support?
A: For additional questions and support on the medical plan TPA and provider/facility networks, please call Brighton at (855) 340-7737, Monday through Friday, 8:00 am to 6:00 pm or email [email protected].
*The $45,000 lifetime limit is retroactive and includes prior completed procedures.
**Network is held by Northwell Direct Administrative Services Organization, Inc.