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Participating AgenciesJanuary 1, 2021 Empire Plan CertificateNew York State Health Insurance ProgramEmpire Plan Certificate for Active Employees, Retirees, Vestees and Dependent Survivorsenrolled through Participating Agencies and for their enrolled Dependents; and for COBRAand Young Adult Option EnrolleesNew York State Department of Civil Service, Employee Benefits Divisionwww.cs.ny.gov/employee-benefits
The Empire Plan Certificate of Insurance.1TABLE OFCONTENTSIntroduction. 1Preventive Care Services. 1Combined Out-of-Pocket Limits.2In-Network Out-of-Pocket Limit. 2Out-of-Network Combined Annual Deductible. 2Combined Annual Coinsurance Maximum. 2Section I: The Empire PlanBenefits Management Program. 3Hospital, Skilled Nursing Facilityand Medical/Surgical BenefitsManagement Program.3When to use the BenefitsManagement Program. 3You must call The Empire Planand choose the Hospital Program forpreadmission certification. 3You must call the Empire Plan Medical/SurgicalProgram for Prospective Procedure Review. 4Who calls?. 4Why Benefits Management?. 4The Empire Plan Benefits ManagementProgram: Benefits and Your Responsibilities.4A. Preadmission certificationfor hospital admission. 4B. Concurrent review. 6C. Discharge planning. 6D. Prospective Procedure Review. 6E. Medical case management.7F. Future Moms Program. 8Future Moms Program.8More About the BenefitsManagement Program.9Certification letter. 9Call again. 9The Benefits Management Programand the Mental Health and SubstanceUse Program. 9Calling the Empire PlanBenefits Management ProgramIs Easy and Toll Free.9Section II: The Empire PlanHospital Program and Related ExpensesCertificate of Insurance. 11Introduction.11Benefits Management Program. 12Hospital admission. 12Network and Non-Network Benefits.14Inpatient Hospital Care. 15Empire Plan CertificatePA/2021i
Outpatient Hospital Care. 16Copayment for emergency care. 18Copayment for outpatient hospital services. 19Telemedicine Benefit. 19LiveHealth Online. 19Skilled Nursing Facility Care. 20Hospice Care. 21Number of Days of Care. 22Hospital Coverageoutside of the United States. 22Center of Excellencefor Transplants Program. 23Types of transplants. 23Centers of Excellence. 23What is covered. 23Preauthorization. 24Other benefits still available. 24Infertility Benefits. 24What is covered. 24Maximum lifetime benefit. 25Fertility preservation services. 25Infertility: Exclusions and limitations. 26Centers of Excellence Travel Allowance. 26Hospital Program General Provisions. 26Exclusions and limitations. 26Coordination of Benefits (COB). 30Which plan pays first. 30When The Empire Plan is secondaryto another insurance plan. 32If You Qualify for Medicare. 32Termination of Your Empire PlanHospital Program Coverage. 33Miscellaneous Provisions. 34Filing and Payment ofHospital Program Claims. 35Utilization Review Guidelines. 36Concurrent reviews. 37Retrospective reviews. 37Notice of adverse determination. 37Grievance Procedures. 38Grievances. 38Filing a Grievance. 38Grievance determination. 38Second-level Grievance/administrative Appeal. 38Assistance. 39Appeals. 39Appeal process. 39Level 1 appeals. 39Level 2 appeals. 40Appeals involving urgent situations. 40External appeals. 40iiEmpire Plan CertificatePA/2021Where to Get More Detailed Information. 43Section III: The Empire PlanMedical/Surgical ProgramCertificate of Insurance. 44Plan Overview. 44If You choose a Participating Provider. 44If You choose the Basic Medical Program(a Nonparticipating Provider). 44Special Medical/Surgical Programs. 44Basic Medical (Nonparticipating Providers). 44The Benefits Management Programrequirements apply if The Empire Planis primary. 45Definitions. 45Participating Provider Program. 52Your out-of-pocket expenses are lowerwhen You choose Participating Providers. 53Combined out-of-pocket limit. 53Finding Participating Providers. 53What is covered under theParticipating Provider Program. 54Transitional Care. 60Continuity of care: When YourProvider leaves the network.60Transition of care: New course of treatment. 60Basic Medical Program. 61Assignment of benefits to aNonparticipating Provider is not permitted. 61You must meet a Deductible and pay20 percent Coinsurance when You chooseNonparticipating Providers. 61How to estimateNonparticipating Provider costs. 62What is covered under the Basic MedicalProgram (Nonparticipating Providers). 63Out-of-Network Referral. 68Home Care Advocacy Program (HCAP). 68Network coverage: Paid-in-full benefit. 68What is covered. 69When do requirements apply?. 71After You call. 71Your benefits and responsibilitiesunder HCAP. 71Non-network benefits. 72Who calls?. 72Call anytime. 72More about HCAP. 73180-day deadline to Appeal. 73Managed Physical Medicine Program. 73Coverage for chiropractic treatment,physical therapy and occupational therapy. 73
When requirements apply. 73Network benefits. 73 25 Copayments whenYou use a Network Provider. 74How to find a Network Provider. 74Guaranteed access. 74Non-network benefits. 74Deductible and Coinsurance apply. 74Other services. 74Questions?. 74Appeals: 180-day deadline. 74Infertility Benefits.75What is covered. 75Maximum lifetime benefit. 76Fertility preservation services. 76Center of Excellence for Infertility.76Infertility: Exclusions and limitations. 76Center of Excellence for Cancer Program. 77What is covered.77Enrollment.77Other benefits still available.77Centers of Excellence Travel Allowance. 77Medical/Surgical ProgramGeneral Provisions.78Exclusions and limitations. 78Coordination of Benefits (COB). 80When The Empire Plan is secondaryto another insurance plan. 82Impact of Medicare on This Plan. 83Definitions. 83Coverage. 83How The Empire Plan calculatesbenefits when Medicare is Primary. 85How, When and Where to Submit Claims. 85How. 85When. 86Where. 86Fraud. 86Verification of claim information. 86Claim inquiries. 86Claim determinations. 86Denial of claim. 87Right to Convert to an Individual Policy.87Deadlines apply. 88Miscellaneous Provisions. 88Protection from Surprise Bills. 88Benefits after termination of coverage. 89Confined on date of change of options. 89Confined on date of coverage cancellation.90Termination of coverage. 90Recovery of overpayments and subrogation. 90Time limits on starting lawsuits. 91Inquiries. 91Utilization Review Guidelines. 91Concurrent reviews. 92Retrospective reviews. 92Notice of adverse determination. 92Grievance Procedures. 93Grievances. 93Filing a Grievance. 93Grievance determination. 93Second-level Grievance/administrative Appeal. 94Assistance. 94Appeals. 94Utilization Review/Clinical Appeal process. 94Level 1 Appeals. 95Level 2 Appeals. 95Appeals involving urgent situations. 95External Appeals. 96Section IV: The Empire PlanMental Health and Substance UseProgram Certificate of Insurance.100Program Overview. 100Coverage. 100Meaning of Terms Used. 101How to Receive Services for MentalHealth Care and Substance Use Care. 107If You choose Network Coverage. 107If You choose Non-Network Coverage. 107If You need Emergency Care. 108Show Your identification card. 108Release of medical records. 108What Is Covered Underthe MHSU Program. 108Inpatient Services. 108Outpatient Services. 109The Program Administrator reviewsOutpatient and Inpatient Services. 110Certification denial and appeal process:Deadlines apply. 110Schedule of Benefits for Covered Services. 111Network Coverage for Mental Health Careand Substance Use Care.112Non-Network Coverage for Mental HealthCare and Substance Use Care.112Maximums. 113Exclusions and Limitations. 113Coordination of Benefits (COB). 114When The Empire Plan issecondary to another insurance plan.116Impact of Medicare on This Plan.117Definitions. 117Coverage. 117Empire Plan CertificatePA/2021iii
Claims. 118Claim payment for Covered Services.118How, when and where to submit claims.119Fraud.119Verification of claim information.119Questions.119Miscellaneous Provisions. 119Confined on effective date of coverage.119Benefits after termination of coverage. 120Confined on date of change of options. 120Termination of coverage. 120COBRA: Continuation of coverage. 120Recovery of overpayments. 120Time limit for starting lawsuits.121Utilization Review Guidelines. 121Concurrent Reviews.121Retrospective reviews. 122Notice of adverse determination. 122Appeals. 122Appeals: 180-day deadline. 122Appeals involving urgent situations. 122External appeals. 123Section V: The Empire PlanPrescription Drug ProgramCertificate of Insurance.126Meaning of Terms Used. 126Your Benefits and Responsibilities. 129Copayments. 129Supply and coverage limits. 130Mandatory generic substitution. 130Dispense as Written Exception Requests. 130Empire Plan Advanced Flexible Formulary. 130Prior authorization required for certain drugs.131Specialty Pharmacy Program. 131What is covered. 132Exclusions and Limitations. 133How to Use Your Empire PlanPrescription Drug Program. 135Network Pharmacies andVaccination Network Pharmacies. 135Non-Network Pharmacies. 135Deadline for filing claims. 136Mail Service Pharmacy orthe Designated Specialty Pharmacy. 136Using the Empire PlanAdvanced Flexible Formulary drug list. 136Coverage for preventive vaccinesadministered in a VaccinationNetwork Pharmacy. 136Contact the Empire PlanPrescription Drug Program.137Coordination of Benefits (COB).137Medicare Prescription Drug Coverage. 139Miscellaneous Provisions. 140Termination of coverage. 140Benefits after termination of coverage. 140Recovery of overpayments and subrogation.140Audits/Prescription benefit records. 141Legal action. 141Medical Exception Program for drugs excludedfrom the Advanced Flexible Formulary(for Empire Plan-primary enrollees). 141Appeals. 141Appeal process. 142First-level claims review. 142Second-level claims review. 142Appeals involving urgent situations. 143External Appeals. 143Empire Plan Prescription Drug ProgramDrug Utilization Review (DUR). 145When You use Your card. 146Safety review. 146Refill too soon. 146Confidential service. 146Education Is the Right Prescription. 146Contact Information. 147The policies and benefits described in this booklet are established by the State of New York throughnegotiations with State employee unions and administratively for unrepresented groups. Policies andbenefits may also be affected by federal and state legislation and court decisions. The Department ofCivil Service, which administers the New York State Health Insurance Program (NYSHIP), makes policydecisions and interpretations of rules and laws affecting these provisions.ivEmpire Plan CertificatePA/2021
The Empire Plan Certificate of InsuranceIntroductionThe Empire Plan is the result of collective bargaining between the State and unions representing itsemployees. It has been designed to provide you with a complete health insurance benefits package atthe lowest possible cost. A number of features have been included in The Empire Plan to manage bothyour 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 BlueCross andBlueShield plans (copayments apply for certain outpatient hospital services). Medical/surgical benefits administered by UnitedHealthcare Insurance Company of New York(UnitedHealthcare) for a 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 for prior authorization of hospital and skillednursing facility admissions and through UnitedHealthcare for prospective procedure review 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/OptumTM Physical Health, whichincludes Managed Physical Network, Inc. and OptumHealth Care Solutions, LLC, for chiropractictreatment, physical therapy and occupational therapy. Center of Excellence for Transplants Program through Empire BlueCross. Center of Excellence for Infertility Program through UnitedHealthcare. Center of Excellence for Cancer Program through UnitedHealthcare. Mental Health and Substance Use Program through Beacon Health Options. Prescription drug coverage through CVS Caremark.Familiarize yourself with The Empire Plan by reading this Certificate so you can effectively use thePlan’s benefits.Pay particular attention to the information about the Empire Plan Benefits Management Program,the Home Care Advocacy Program, the Managed Physical Medicine Program, Transplants Program,Infertility Benefits, the Mental Health and Substance Use Program and prior authorization requirementsfor certain drugs. Designed to control costs and provide you with the most appropriate care, thesefeatures have requirements that must be met to receive the highest level of benefits.Refer to your Amendments for changes that may occur to the out-of-network combined annualdeductible, combined annual coinsurance maximum and copayments.Preventive Care ServicesThe federal Patient Protection and Affordable Care Act (PPACA) provides the following services received froman Empire Plan participating provider or Network Hospital paid at 100 percent (not subject to copayment): Evidence-based items or services that have a rating of “A” or “B” in the current recommendations ofthe United States Preventive Services Task Force. Recommended immunizations from the Advisory Committee on Immunization Practices (ACIP) of theCenters for Disease Control and Prevention.Empire Plan CertificatePA/20211
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 in thecomprehensive 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/Surgical 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.Combined Out-of-Pocket LimitsAs a result of federal PPACA provisions, there is a limit on the amount you will pay out of pocket forin-network services/supplies during the Plan year.In-Network Out-of-Pocket LimitEffective January 1, 2022, the annual out-of-pocket limits for in-network expenses are as follows:Individual Coverage 5,650 for in-network expenses incurred under the Hospital, Medical/Surgical and Mental Healthand Substance Use Programs 3,050 for in-network expenses incurred under the Prescription Drug Program (does not apply toMedicare-primary enrollees or dependents)Family Coverage 11,300 for in-network expenses incurred under the Hospital, Medical/Surgical and Mental Healthand Substance Use Programs 6,100 for in-network expenses incurred under the Prescription Drug Program (does not apply toMedicare-primary enrollees or dependents)Out-of-Network Combined Annual DeductibleThe combined annual deductible is 1,250 for the enrollee and 1,250 for the enrolled spouse/domesticpartner. All dependent children have a combined annual deductible of 1,250.The combined annual deductible must be met before Basic Medical Program expenses, non-networkexpenses under the Home Care Advocacy Program and outpatient, non-network expenses under theMental Health and Substance Use Program will be considered for reimbursement.Combined Annual Coinsurance MaximumThe combined annual coinsurance maximum is 3,750 for the enrollee and 3,750 for the enroll
Empire Plan Certificate 1 PA/2021 The Empire Plan Certificate of Insurance Introduction The Empire Plan is the result of collective bargaining between the State and unions representing its employees. It has been designed to provide you with a complete health insurance benefits package at the lowest possible cost.
