State Health Benefit Changes



Avoid out-of-pocket costs
By Using Preferred "Site of Service" (SOS) Labs, Radiology and Imaging Services




Changes to state health benefits first introduced last year affect everyone. This message explains how you can avoid out-of-pocket costs beginning March 1 - particularly when using labs, radiology and other imaging services.

State employees will continue to have 100 percent coverage ($0 copay) for lab tests, X-rays and other high-cost imaging services, like MRIs and CT scans, when they select a preferred "Site of Service" (SOS) provider.

WHAT IS A PREFERRED "SITE OF SERVICE" (SOS) PROVIDER?

Site of Service (SOS) providers are labs, radiology and imaging centers that have proven to deliver high-quality, low-cost services.

They are generally community-based providers that operate apart from an acute care hospital and offer only outpatient services.

HOW MUCH WILL I PAY OUT OF POCKET?

Using a Site of Service (SOS) provider will allow you to pay nothing for lab, radiology and imaging services. However, if you obtain these services at an in-network provider that is NOT a Site of Service (SOS) provider, here is what you could pay out of pocket:

  • You will be charged 20 percent of the cost of the service (potentially hundreds of dollars out of pocket) when you obtain these services at providers not participating in the Site of Service (SOS) program.
  • You pay the standard copay for these services when they are performed during the course of an office visit at a physician or specialist's office (for a Preferred Provider office visit, the standard copay is $0 and for all others it's $15). Imaging and lab work performed at your physician's offices is covered under this new Site of Service program at no cost to you.
  • And finally, employees could pay 40 percent of the costs for using an out-of-network provider.

HOW DO I FIND A PREFERRED "SITE OF SERVICE" (SOS) PROVIDER?

Before going to a preferred Site of Service provider always call ahead to ensure they perform the tests or services you require.


Anthem

Anthem Members
www.anthem.com/statect

Choose the Find a Doctor link and follow the prompts. Providers listed under Lab/Pathology/Radiology programs will have an "SOS" indicator beneath their names if they are in the Site of Service program.


United

UnitedHealthCare Members
https://stateofct.welcometouhc.com/

Under the "Benefits" drop-down menu at the top of the page, click on "Find a Doctor or Facility." Scroll down to the section for "Site of Service Lab and Radiology in Connecticut" Where you can choose from "CT Preferred Radiology Centers" or "CT Preferred Laboratories." Each link will produce a list of all Preferred SOS providers for radiology or laboratories.


FREQUENTLY ASKED QUESTIONS:

What if I have been admitted to the hospital and need lab or radiology services during my stay; will I be expected to pay 20 percent of the cost?

No. Services associated with an inpatient hospital stay are always covered at the applicable member copay: - $0.

What if I am in the emergency room and need lab or radiology services; will I be expected to pay 20 percent of the cost?

No; however, the member will be subject to an ER co-pay of $250 (copayments may be waived if admitted).

What if my doctor tells me that, for medical reasons, I must use a specific radiology or lab provider?

If your doctor believes it is medically necessary for you to use a non-preferred Site of Service (SOS) lab or radiology provider you must have the doctor fill out a medical necessity waiver form for lab and radiology services in order to have out-of-pocket costs waived.*

What about ongoing cancer treatment, which may require lab tests and radiology in a hospital setting; will I have to pay 20 percent of the cost?

No. Costs for lab and radiology services associated with ongoing cancer treatment at a non-preferred provider can be waived by filling out a medical necessity waiver form.*

What if I am pregnant and require radiology services associated with the pregnancy at the hospital or other non-preferred provider; will I have to pay 20 percent of the cost?

No. Costs for radiology services at non-preferred providers associated with pregnancy can be waived by filling out a medical necessity waiver form.* Please note that lab services associated with a pregnancy will only be waived if utilizing a non-preferred provider was found to be medically necessary.

If my young child needs specialty pediatric radiology services, will I have to pay 20 percent of the cost if performed by a non-preferred provider?

No. Radiology services at non-preferred providers for patients under the age of 10 can be waived by filling out a medical necessity waiver form.*

What if a preferred Site of Service (SOS) lab or radiology provider is not available in my area?

If a preferred Site of Service (SOS) lab or radiology provider is not available within a reasonable distance of your home or that of your dependent the cost share can be waived by filling out a medical necessity waiver form.*

Are preferred Site of Service (SOS) lab and radiology providers available nationwide?

The preferred Site of Service (SOS) program only applies to lab or radiology services obtained in Connecticut and counties bordering Connecticut in New York, Massachusetts and Rhode Island.


*The Lab and Radiology waiver form can be found at http://www.osc.ct.gov/benefits/medical.htm