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JANUARY 1, 2014EMPIREPLANCERTIFICATEParticipating AgenciesNew York State Health Insurance ProgramEmpire Plan Certificate for Active Employees, Retirees, Vesteesand Dependent Survivors enrolled through Participating Agenciesand for their enrolled dependents; and for COBRA andYoung Adult Option enrolleesNew York State Department of Civil ServiceEmployee Benefits Divisionwww.cs.ny.gov
The Empire Plan Certificate of InsuranceTABLEOFCONTENTSIntroduction. 1Preventive Care Services. 1Section I: The Empire PlanBenefits Management ProgramHospital, Skilled Nursing Facility andMedical Benefits Management Program. 3Applies when The Empire Plan is primary. 3You must call The Empire Planand choose the Hospital Programfor preadmission certification. 3You must call the Empire Plan MedicalProgram for Prospective Procedure Review. 3Who calls?. 4Why Benefits Management?. 4The Empire Plan Benefits Management Program:Benefits and Your Responsibilities.4A. Preadmission certificationfor hospital admission. 4B. Concurrent review. 6C. Discharge planning. 6D. Prospective Procedure Review. 6E. Medical case management. 8F. Future Moms Program. 8Future Moms Program.8Pregnant? First steps. 8More About theBenefits Management Program.9Certification letter. 9Call again. 9The Benefits Management Program and theMental Health and Substance Abuse Program. 9Calling the Empire PlanBenefits Management ProgramIs Easy and Toll Free. 10Section II: The Empire Plan Hospital andRelated Expenses Certificate of InsuranceIntroduction.11Benefits Management Program. 12Hospital admission. 12Network and Non-Network Benefits.13Inpatient Hospital Care.14Outpatient Hospital Care. 16Copayment for emergency care. 18Copayment for outpatient hospital services. 18Skilled Nursing Facility Care. 18Hospice Care. 19Number of Days of Care. 20Empire Plan CertificatePA/2014i
Center of Excellencefor Transplants Program. 21Types of transplants. 21Centers of Excellence. 21What is covered. 22Preauthorization. 22Other benefits still available. 22Infertility Benefits. 22What is covered. 22Additional infertility benefits. 23Maximum lifetime benefit. 23Infertility: Exclusions and limitations. 23Centers of Excellence Travel Allowance. 24Hospital Program General Provisions. 24Limitations and exclusions. 24Coordination of Benefits (COB).27Which plan pays first. 27When The Empire Plan issecondary to another insurance plan. 29If You Qualify for Medicare. 29Termination of Your Empire PlanHospital Program Coverage.31Miscellaneous Provisions. 32Filing and Payment ofHospital Program Claims. 33Utilization Review Guidelines. 34Concurrent reviews. 34Retrospective reviews. 35Notice of adverse determination. 35Appeals. 35Appeal process. 35Level 1 appeals. 35Level 2 appeals. 36Appeals involving urgent situations. 36External appeals. 36Where to Get More Detailed Information. 39Section III: The Empire Plan Medical/SurgicalProgram Certificate of InsurancePlan Overview. 40If you choose a participating provider. 40If you choose the Basic Medical Program(a nonparticipating provider). 40Participating providers. 40Basic Medical (nonparticipating providers).41The Benefits Management Programrequirements apply if The Empire Planis primary.41Meaning of Terms Used.41Participating Provider Program.47Your out-of-pocket expenses are lowerwhen you choose participating providers. 47iiEmpire Plan CertificatePA/2014Finding participating providers. 47What is covered under theParticipating Provider Program. 48Basic Medical Program. 51You must meet a deductible andpay 20 percent coinsurance whenyou choose nonparticipating providers. 51What is covered under the Basic MedicalProgram (nonparticipating providers). 52Home Care Advocacy Program (HCAP). 56Network coverage: Paid-in-full benefit. 56When do requirements apply?. 58After you call. 59Your benefits andresponsibilities under HCAP. 59Network coverage: When you call HCAPand use an HCAP provider. 59Non-network coverage: If you do notcall or if you call HCAP but do not usean HCAP provider. 59Non-network benefits. 59Who calls?.60Call anytime.60More about HCAP.60180-day deadline to appeal.60Managed Physical Medicine Program. 61Coverage for chiropractic treatmentand physical therapy. 61When requirements apply. 61Network benefits. 61 20 copayments when youuse a network provider. 61How to find a network provider. 61Guaranteed access. 61Non-network benefits. 62Deductible and coinsurance apply. 62Other services. 62Questions. 62Appeals: 180-day deadline. 62Infertility Benefits. 62What is covered. 63Maximum lifetime benefit. 63Center of Excellence for Infertility. 63Infertility: Exclusions and limitations. 64Center of Excellence for Cancer Program. 64What is covered. 64Enrollment. 64Other benefits still available. 64Centers of Excellence Travel Allowance. 65
Medical/Surgical ProgramGeneral Provisions. 65Exclusions. 65Coordination of Benefits (COB).67When The Empire Plan issecondary to another insurance plan. 69Impact of Medicare on This Plan. 69Definitions. 69Coverage. 70How, When and Where to Submit Claims. 71How. 71When. 72Where. 72Fraud. 72Verification of claim information. 72Claim inquiries. 72Claim determinations. 72Denial of claim. 73Right to Convert to an Individual Policy. 73Deadlines apply. 74Miscellaneous Provisions.74Confined on effective date of coverage. 74Benefits after termination of coverage. 74Confined on date of change of options. 75Termination of coverage. 75Recovery of overpayments and subrogation. 75Time limits on starting lawsuits. 76Inquiries. 76Utilization Review Guidelines.76Concurrent reviews. 76Retrospective reviews.77Notice of adverse determination.77Appeals. 77Appeal process.77Level 1 appeals.77Level 2 appeals. 78Appeals involving urgent situations. 78External appeals. 78Section IV: The Empire PlanMental Health and Substance AbuseProgram Certificate of InsuranceProgram Overview. 82Coverage. 82Meaning of Terms Used. 83How to Receive Benefits for Mental Health andSubstance Abuse Care. 88Network coverage. 88Non-network coverage. 88Emergency services. 89Show your identification card. 89Release of medical records. 89What Is Covered Under the MHSA Program. 89Inpatient care. 89Outpatient care.90The MHSA Program administrator reviewsoutpatient and inpatient treatment. 91Certification denial and appeal process:Deadlines apply. 92Schedule of Benefits for Covered Services. 92Network coverage for mental healthand substance abuse care. 92Non-network coverage for mental healthand substance abuse care. 93Maximums. 93Exclusions and Limitations. 93Coordination of Benefits (COB). 95When The Empire Plan issecondary to another insurance plan. 97Impact of Medicare on This Plan.97Definitions. 97Coverage. 98Claims. 99Claim payment for covered services. 99How, when and where to submit claims. 99Fraud.100Verification of claim information.100Questions.100Miscellaneous Provisions. 100Confined on effective date of coverage.100Benefits after termination of coverage.100Confined on date of change of options.100Termination of coverage. 101COBRA: Continuation of coverage. 101Recovery of overpayments. 101Time limit for starting lawsuits. 102Utilization Review Guidelines. 102Concurrent reviews. 102Retrospective reviews. 102Notice of adverse determination. 102Appeals. 103Appeals: 180-day deadline. 103External appeals. 103Section V: The Empire Plan PrescriptionDrug Program Certificate of InsuranceMeaning of Terms Used. 106Your Benefits and Responsibilities. 109Copayments. 109Supply and coverage limits. 110Mandatory generic substitution. 110Empire Plan Flexible Formulary. 110New to You prescriptions. 111Prior authorization required for certain drugs. 111Empire Plan CertificatePA/2014iii
Specialty Pharmacy Program.112What is covered.112Exclusions and Limitations. 113How to Use Your Empire PlanPrescription Drug Program. 115Network pharmacies andvaccination network pharmacies.115Non-network pharmacies.115Deadline for filing claims.116Mail service pharmacy or thedesignated specialty pharmacy.116Using the Empire PlanFlexible Formulary drug list.116Coverage for preventive vaccinesadministered in a vaccinationnetwork pharmacy.116Contact the Empire PlanPrescription Drug Program.117Coordination of Benefits (COB).117Medicare Prescription Drug Coverage. 119Miscellaneous Provisions. 120Termination of coverage. 120Benefits after termination of coverage. 120Recovery of overpayments and subrogation. 120Audits/prescription benefit records.121Legal action.121Medical exception process fordrugs excluded from the Flexible Formulary(for non-Medicare-primary enrollees).121Appeals. 121Appeal process. 122First-level claims review. 122Second-level claims review. 122Appeals involving urgent situations. 123External appeals. 123Empire Plan Prescription Drug ProgramDrug Utilization Review (DUR). 125When you use your card. 126Safety review. 126Refill too soon. 126Confidential service. 126Education Is the Right Prescription. 126Contact InformationNYSHIP Online. 127The Empire Plan . 127If you are unable to resolve a problemwith an Empire Plan Program administrator. 130NYSHIP HMOs. 130Social Security Administration. 131Medicare Benefits and Claims. 131ivEmpire Plan CertificatePA/2014Retirement Systems. 131New York State and LocalRetirement System (NYSLRS). 131Police and Fire Retirement System (PFRS). 131New York State Teachers’Retirement System (NYSTRS). 131Health Benefits Administrator. 132Employee Benefits Division. 132U.S. Preventive ServicesTask Force (USPSTF). 132
The Empire Plan Certificate of InsuranceIntroductionThe Empire Plan is the result of collective bargaining between your employer and unions representingits employees. It has been designed to provide you with a complete health insurance benefits packageat the lowest possible cost. A number of features have been included in The Empire Plan to manageboth your and your employer’s costs and to ensure that you receive the most appropriate care.This Certificate of Insurance describes the coverage provided by The Empire Plan. The Plan isadministered by the Department of Civil Service and includes the following basic elements of coverage: Hospital and related expense coverage administered by Empire HealthChoice Assurance, Inc., alicensee of the BlueCross and BlueShield Association, an association of independent BlueCrossand BlueShield plans (copayments apply for certain outpatient hospital services). Medical/surgical benefits administered by UnitedHealthcare Insurance Company of New York(UnitedHealthcare) for a modest copayment for certain services when you choose participating providers. Basic Medical coverage through UnitedHealthcare when you receive medical/surgical coverage fromnonparticipating providers. Benefits Management Program through Empire BlueCross BlueShield for prior authorization of hospitaland skilled nursing facility admissions and through UnitedHealthcare for Prospective ProcedureReview of MRI, CT, PET scans and nuclear medicine tests. Home Care Advocacy Program through UnitedHealthcare for home care services, durable medicalequipment and certain supplies. Managed Physical Medicine Program through UnitedHealthcare/Managed Physical Network, Inc.,for chiropractic treatment and physical therapy. Center of Excellence for Transplants Program through Empire BlueCross BlueShield. Center of Excellence for Infertility Program through UnitedHealthcare. Center of Excellence for Cancer Program through UnitedHealthcare. Mental Health and Substance Abuse Program through ValueOptions. Prescription drug coverage through CVS/caremark.You should familiarize yourself with The Empire Plan by reading this Certificate so that you willeffectively be able to use the benefits the Plan provides.Pay particular attention to the information about the Empire Plan Benefits Management Program, theHome Care Advocacy Program, the Managed Physical Medicine Program, Transplants Program, InfertilityBenefits, the Mental Health and Substance Abuse Program and prior authorization requirements forcertain drugs. Designed to control costs and provide you with the most appropriate care, these featureshave requirements that must be met to receive the highest level of benefits.Preventive Care ServicesThe federal Patient Protection and Affordable Care Act (PPACA) provides the following servicesreceived from an Empire Plan participating provider or network hospital paid at 100 percent (not subjectto copayment): Evidence-based items or services that have a rating of “A” or “B” in the current recommendationsof the United States Preventive Services Task Force. Recommended immunizations from the Advisory Committee on Immunization Practices of the Centersfor Disease Control and Prevention.Empire Plan CertificatePA/20141
With respect to infants, children and adolescents, evidence-informed preventive care andscreenings provided for in the comprehensive guidelines supported by the Health Resourcesand Services Administration. With respect to women, such additional preventive care and screenings as are provided for incomprehensive guidelines supported by the Health Resources and Services Administration.A list of covered preventive services is available at www.healthcare.gov. Use the search bar at the topof the homepage to search for “preventive services.” You may also receive a printed copy of the list bycalling The Empire Plan and choosing the Medical Program.Copayments, deductibles and coinsurance may apply to services provided during the same visit asthe preventive services. For example, if a preventive service is provided during an office visit but thepreventive service is not the primary purpose of the visit, any copayment, deductible or coinsurancethat would otherwise apply to the office visit will still apply.2Empire Plan CertificatePA/2014
Section I: The Empire PlanBenefits Management ProgramHospital, Skilled Nursing Facility and Medical Benefits Management ProgramInpatient components of the Empire Plan Benefits Management Program are administered by theHospital Program administrator. Outpatient components are administered by the Medical/SurgicalProgram administrator.You and your family must follow Benefits Management Program procedures, described as follows,to receive maximum Empire Plan benefits. Your share of the cost will be higher if you don’t followthese procedures.Applies when The Empire Plan is primaryThe Empire Plan Benefits Management Program requirements apply when The Empire Plan is yourprimary health insurance coverage. (The Empire Plan is primary when it is responsible for paying forhealth benefits first, before any other group plan, Health Maintenance Organization [HMO] or Medicareis liable for payment.) These requirements do not apply if Medicare is primary to your Empire Plancoverage. Requirements also apply to a Medicare-primary active employee or dependent beforeadmission to a skilled nursing facility.These requirements apply if you live or seek treatment anywhere in the United States, including Alaskaand Hawaii.These requirements also apply when you or your enrolled dependents have primary coverage throughan HMO with secondary coverage under The Empire Plan, and you choose not to use the HMO.If you will be admitted to a medical center or hospital operated by the U.S. Department of Veterans’Affairs, and will be using your Empire Plan benefits, you must comply with the requirements of theEmpire Plan Benefits Management Program.You must call The Empire Plan and choose the Hospital Program forpreadmission certificationFor preadmission certification before any elective (scheduled) hospital admission that willinclude an overnight stay in a hospital. You must call before the hospital admission. Call assoon as your doctor suggests admission to the hospital. Call at least two weeks in advance ofthe admission, if possible. If you did not receive at least two weeks’ notice from your doctor, contact theBenefits Management Program immediately. The nurse will make every effort to complete the reviewbefore your admission.Before the birth of a child. Call as soon as the doctor confirms the pregnancy. You must call again ifyou are admitted to the hospital during the pregnancy for complications or for anything other than thedelivery of the baby.Within 48 hours or as soon as reasonably possible after an emergency or urgent admission. Thisincludes admission if you were scheduled for outpatient surgery and remained in the hospital overnightdue to a complication (see Hospital admission, pages 12–13, for definitions of “emergency,” “urgent” and“maternity” admissions).For certification before admission to a skilled nursing facility, including transfer from a hospital to askilled nursing facility.You must call the Empire Plan Medical Program for Prospective Procedure ReviewBefore having an elective (nonemergency) magnetic resonance imaging (MRI), magneticresonance angiography (MRA), computerized tomography (CT), positron emission tomography(PET) or nuclear medicine test, unless you are having the test as an inpatient in a hospital(see Prospective Procedure Review, page 6, for details).Empire Plan CertificatePA/20143
Who calls?You, a member of your family or household, your doctor or a member of your doctor’s staff may placethe call.Where this section refers to “you” making the call, keep in mind that other people may also call.However, you are responsible for seeing that the Empire Plan Benefits Management Prog
Empire Plan Certificate 1 PA/ The Empire Plan Certificate of Insurance Introduction The Empire Plan is the result of collective bargaining between your employer and unions representing its employees. It has been designed to provide you with a complete health insurance benefits package at the lowest possible cost.
