Here’s what is changing in health insurance for thousands of Las Vegas teachers

By Ian Whitaker

Tuesday, Oct. 20, 2015 | 2 a.m.

Here’s something nobody ever wants to hear: Brace for changes to your current health care plan.

But that’s exactly what’s happening with the Teachers Health Trust, the nonprofit health care manager for about 40,000 teachers and their family members in Clark County.

The trust, established by the Clark County Education Association around 30 years ago in response to rising premiums, has been facing financial problems in recent years.

To avoid going bankrupt, the trust is reorganizing and adopting a new method of providing health care that will go into effect in 2016.

Here’s the new system: Families will have to choose a primary care doctor, pediatrician and OB/GYN, who will serve as a “home base” for all of their health care needs. Those doctors will function as a sort of first line of defense for identifying health problems and recommending treatment. Additionally, patients are required to get a physical every year.

The system is referred to as a Patient Centered Medical Home, a model designed in recent years to try to reduce unnecessary medical costs. Some have compared it to an HMO in that patients pick a primary doctor, but it’s slightly different. Policy holders can go outside of the network, but it costs more.

Under the union’s new plan, patients who don’t stay within the network must pay upward of a $600 deductible as well as higher copays. The plan also doesn’t include coverage for preventive care outside the network, among other cutbacks.

The union picked the system because it’s expected to save the health trust money — around $9.6 million, according to CCEA executive director John Vellardita. That, combined with $9.8 million in premium increases CCSD recently agreed to pay, should keep the trust afloat for the foreseeable future, Vellardita said.

“If we do what we need to do at the trust … we not only will have savings, we will restore financial stability and be able to build reserves,” he said.

In the past, the trust was forced to burn through its reserves in order to keep the trust going when the economy tanked and education spending was slashed following the recession.

The THT’s outgoing plan is called the Diamond PPO, which even Vellardita described as a “Cadillac plan.”

In a world of rising costs and a changing health care industry due to the Affordable Care Act, it just wasn’t working out. Critics have accused the union of mismanaging the trust, while its defenders have pointed to the fact that the Clark County School District refused to pay enough into the fund to keep it self-sustaining. Until recently, the school district’s premium payments had remained stagnant since 2008.

“The type of revenue needed to sustain a plan like that has essentially been flat for several years,” he said.

So they started looking for another model around a year ago. It turns out they didn’t have to look far. MGM Resorts’ highly praised DirectCare health care plan also operates like a patient-centered medical home, and so the union started consulting with health care experts about a possible switch.

“We thought that model was a perfect match for us,” said Vellardita.

They decided to contract with WellHealth, a local provider founded in 2011, to administer the new plan.

Teachers have been understandably skeptical of the changes, as reflected on the Teachers Health Trust’s Facebook page.

“I'm a tad confused. Right now I can just pick up the phone, call my doctor, and make an appointment,” read one comment. “Are we still able to do this or do we have to use a computer and/or a health care advocate now? Seems like a lot of hoops to jump through to see a doctor.”

(Answer: You can still pick up the phone and make appointments directly through your doctor.)

Another added, “None of this means nothing to me if my wife has to find a new general doc for her and a new pediatrician for our girls.”

And that’s where much of the confusion exists now. Teachers want to know whether their existing doctors are choosing to stay on under the new plan. The trust has not yet released a complete list and noted that some providers won’t be renewed due to their charging more than the trust is willing to pay.

The union is expected to reveal more information about the provider list in a series of mandatory open enrollment sessions, which start Saturday.