Each September the Virgin Islands government is placed in the position of having to renew its employee and retiree health insurance plan. And, each year we hear complaints from members of the Legislature, government employees and retirees about how the insurance company has taken advantage of the VI government by waiting until the last possible moment to come to an agreement on a contract for the following year.
Unfortunately, much of what beneficiaries have been hearing isn’t the whole truth. In fact, Board Members of the Government Employees Service Commission (GESC) who negotiate this contract have been meeting with Cigna representatives for at least the last 6 months negotiating the best possible “deal” for the 9,547 active government employees and 6,257 retirees and their combined 30,000+ dependents. A contract of this size and detail is not something that can be done instantaneously. In fact, the Board began the process this year in March and completed the negotiations in July. Once this phase was completed the project was forwarded to the legal offices where it was finalized into a legally binding contract. Although the process is time intensive, it ensures that beneficiaries received the best possible end product.
This year however, the first major concern heard on the streets of the Virgin Islands was about Cigna’s business decision to leave Puerto Rico. For many Virgin Islanders who have traditionally chosen to travel to PR for medical care, this was problematic. But, of far greater concern was what would happen to those Virgin Islanders who had relocated to Puerto Rico after retiring from VI government service. How would their medical, hospital, dental, and vision insurance needs be met?
During a recent presentation at a Centers for Medicare/Medicaid (CMS) symposium held in St. Thomas, a Group Health Insurance representative assured VI medical providers, current government employees and policymakers that Cigna was not going to leave VI retirees out in the cold.
According to Valerie Daley, Assistant Chief of the VI Employee Group Health Plan, Cigna has developed a separate health plan specifically for retirees living in Puerto Rico. This specially designed indemnity plan gives VI retirees living in PR the same 80% / 20% benefits experienced by their counterparts residing within the territory. It covers them in Puerto Rico and anywhere else they may go. They will not be penalized by any additional out of network fees. “No one will lose their coverage,” Daley told the symposium participants.
The second major concern for individuals residing in the VI who are covered by the 2011 Cigna renewal is how they will obtain specialty care not available in the Virgin Islands. Care can still be obtained in Puerto Rico. However the care they receive will be considered out-of-network and it will be subject to out-of-network fees. Cigna will now pay 60 % of the cost, leaving the individual to pay the remaining 40%. If, however, people choose to go anywhere on the mainland USA where their Cigna benefit is accepted, they will get the same 80/20 coverage under the renewal contract.
Retirees who utilize Medicare as their primary payer must submit their claim to Medicare. Once the individual receives their Explanation of Benefits (EOB) or Medicare Summary Notice (MSN) from Medicare, they can submit that documentation to Cigna as the secondary payer. If the beneficiary has met all their deductibles for the year, Cigna will pay the balance, regardless of whether the care was received in the Virgin Islands or in Puerto Rico.
Under the terms of the contract’s renewal, Cigna remains obligated to meet the original agreement’s requirements for emergency off-island services for both active employees and retirees.