VIEWS: 5 PAGES: 34 POSTED ON: 8/9/2010
Health Insurance Choices for 2010 October 2009 For Employees of the State of New York who are unrepresented or in Negotiating Units that have agreements/awards with New York State beginning April 1, 2007, Employees of Participating Employers and for COBRA enrollees with their NYSHIP benefits (Check with your agency Health Benefits Administrator or union if you are uncertain.) Contents Pre-Tax Status, November 30 Deadline .............1 Questions and Answers..................................11 Biweekly Premium Contribution.........................1 Terms to Know ...............................................12 Information and Reminders............................1-2 Making a Choice ...........................................13 Choosing Your Health Plan ...............................2 Plans by County .......................................14-15 Benefits All NYSHIP Plans Provide .....................3 The Empire Plan Summary ........................16-21 Medicare and NYSHIP .....................................4 NYSHIP Health Maintenance Organizations ..........................................22-43 The Empire Plan or a NYSHIP HMO ..............5-8 New York State Department of Civil Service Similarities and Differences .........................9-10 Web Site..................................................44-45 During the Option Transfer Period, you may make two important choices for 2010 Choose Your Health Insurance Plan Civil Service web site at https://www.cs.state.ny.us as soon as they are approved. Click on Benefit Programs, This booklet explains the options available to you then on NYSHIP Online. Select your group if under the New York State Health Insurance Program prompted, and then click on Health Benefits & Option (NYSHIP). Choose either The Empire Plan or one of the Transfer. Choose Rates and Health Plan Choices. Your NYSHIP-approved Health Maintenance Organizations agency Health Benefits Administrator (HBA) can help (HMOs) in your area. Consider your health insurance if you have questions. COBRA enrollees may contact options carefully. You may not change your health the Employee Benefits Division at 518-457-5754 insurance option after the deadline except in special (Albany area) or 1-800-833-4344 (U.S., Canada, circumstances. (See your NYSHIP General Information Puerto Rico and the Virgin Islands). Book and Empire Plan Reports or HMO Reports for details about changing options outside the Option Transfer Period.) If you still have specific questions after you’ve read the plan descriptions, contact The Empire Plan carriers and HMOs directly. See your agency Health Benefits Administrator Rates for 2010 to change your health insurance option, and Deadline for Changing Plans enrollment or pre-tax status. The Empire Plan and HMO rates for 2010 are mailed NO ACTION IS REQUIRED IF YOU to your home and posted on our web site as soon as DO NOT WISH TO MAKE CHANGES. they are approved. (Participating Employers, such as the Thruway Authority and MTA, will notify their Changes are not automatic and deadlines apply. enrollees of 2010 rates.) The rate flyer announces You must report any change that may affect your the option change deadline and paycheck deduction coverage to your agency Health Benefits dates. You have 30 days from the date your agency Administrator. See pages 1-3 in this booklet and receives rate information to make a decision. Rates your NYSHIP General Information Book for are posted on the New York State Department of complete information. i Choices 2010/Actives Settled Choose Your Pre-Tax Contribution Program Your Biweekly Premium Contribution Status by November 30, 2009 The following does NOT apply to employees of The following does NOT apply to employees of Participating Employers. Participating Employers will Participating Employers. Ask your agency Health provide premium information. It also does not apply Benefits Administrator (HBA) if a Pre-Tax Contribution to COBRA enrollees. Program (PTCP) is available to you. Pre-tax does not New York State helps pay for your health insurance apply to COBRA enrollees. coverage. After the State’s contribution, you are Under the Pre-Tax Contribution Program, your health responsible for paying the balance of your premium insurance premiums are deducted from your pay through biweekly deductions from your paycheck. before taxes are taken out. This lowers your taxable • For Empire Plan enrollees, the State pays 90 percent income and increases your spendable income. Only of the cost of the premium for enrollee coverage and the portion of the premium that pays for Individual 75 percent of the premium for dependent coverage. coverage may be deducted on a pre-tax basis for employees who provide health benefits for non- • For HMO enrollees, the State pays 90 percent of federally qualified domestic partners. Your paycheck the premium for enrollee coverage and 75 percent stub shows whether or not you are enrolled in PTCP. for dependent coverage. However, the State’s dollar contribution for the non-prescription drug • Regular Before Tax Health appears in the Before Tax components of the HMO premium will NOT exceed Deductions section if your health insurance premium is its dollar contribution for the non-prescription drug deducted from your wages before taxes are withheld. components of The Empire Plan premium. • Regular After Tax Health appears in the After As soon as they are available, 2010 rates will be Tax Deductions section if your health insurance mailed to your home and posted on our web site at premium is deducted from your wages after taxes https://www.cs.state.ny.us. Click on Benefit Programs, are withheld. then on NYSHIP Online. Select your group if prompted, • Regular Before Tax Health appears in the Before and then click on Health Benefits & Option Transfer. Tax Deductions section AND Regular After Tax Choose Rates and Health Plan Choices. Health appears in the After Tax Deductions section if you have elected pre-tax and have a non-federally Information and Reminders qualified domestic partner or same sex spouse. Under federal law, the premium for such dependents Let Your Agency Know about Changes cannot be deducted before taxes are withheld. You must notify your agency HBA if your home address or phone number changes. If you are an active or retired Under PTCP, you can make the following changes only employee of New York State or are retired from a in November each year: Participating Employer and registered for MyNYSHIP, • Change from Family to Individual coverage while you may also make address and option changes online. your dependents are still eligible for coverage, Changes in your family status, such as gaining or • Voluntarily cancel your coverage while you are losing a dependent, may mean you need to change still eligible for coverage, or your health insurance coverage from Individual to • Opt out of PTCP. Family or from Family to Individual. If you submit a timely request, you can make most changes any time, Under Internal Revenue Service (IRS) rules, you may not just during the Option Transfer Period. See your change your health insurance deduction during the tax NYSHIP General Information Book for details. Inform year only after a PTCP-qualifying event. For a list of your agency HBA about any change promptly to PTCP-qualifying events, see your NYSHIP General ensure it is effective on the actual date of change in Information Book. To change your pre-tax selection family status. for 2010, see your agency HBA and complete a health insurance transaction form (PS-404) by November 30, 2009. Choices 2010/Actives Settled 1 Retiring or Vesting in 2010? Benefits You may change your health insurance plan when The Empire Plan and NYSHIP HMOs you retire or vest your health insurance. Retirees and vestees who continue their NYSHIP enrollment may • All NYSHIP plans provide a wide range of hospital, change health insurance options at any time once medical/surgical, and mental health and substance during a 12-month period. For more information on abuse coverage. changing options as a retiree, ask your agency HBA • All plans provide prescription drug coverage if you do for Choices for 2010 for Retirees. not receive it through a union Employee Benefit Fund. Eligible for Medicare? Benefits differ among plans. Read this booklet and the certificate/contracts carefully for details. If you or a dependent is eligible for Medicare because of age or disability, see “Medicare and NYSHIP” on page 4 for important information. Also, please read Exclusions this section if you or a dependent will be turning age • All plans contain exclusions for certain services and 65 in 2010 or if you are planning to retire in the prescription drugs. coming year and will be Medicare-eligible. • Workers’ compensation-related expenses and Choosing Your Health Plan custodial care generally are excluded. Choosing the health insurance plan to cover your For details on a plan’s exclusions, read the needs and the needs of your family requires careful NYSHIP General Information Book and Empire research. As with most important purchases, there is Plan Certificate, the HMO contract, or check with more to consider than cost. Selecting a health plan is the plan directly. an important and personal decision. Only you know your family lifestyle, health, budget and benefit Geographic Area Served preferences. Think carefully about what you need from your health plan so you are better prepared to make The Empire Plan a choice. Benefits for all covered services – not just urgent and emergency care – are available worldwide. The first step in making a good choice is understanding the similarities and the differences Health Maintenance Organizations (HMOs) between your NYSHIP options. There are two types of • Coverage is available in the HMO’s specific health insurance plans available to you under NYSHIP: service area. The Empire Plan and NYSHIP Health Maintenance Organizations (HMOs). The Empire Plan is available • An HMO may arrange care outside its service area, to all employees. Specific NYSHIP HMOs are available at its discretion in certain circumstances. in the various geographic areas of New York State. Depending on where you live or work, one or several NYSHIP HMOs will be available to you. The Empire Plan and NYSHIP HMOs are similar in many ways, but also have important differences. 2 Choices 2010/Actives Settled Benefits Provided by The Empire Plan and All NYSHIP HMOs Please see the individual plan descriptions in this booklet to review the differences in coverage and out-of-pocket expenses. See plan documents for complete information on benefits. • Inpatient medical/surgical hospital care • Outpatient mental health services • Outpatient medical/surgical hospital services • Alcohol and substance abuse detoxification • Physician services • Inpatient alcohol rehabilitation • Emergency services • Inpatient drug rehabilitation • Laboratory services • Outpatient alcohol and drug rehabilitation • Radiology services • Family planning and certain infertility services • Diagnostic services (Call The Empire Plan carriers or HMO for details.) • Diabetic supplies • Out-of-area emergencies • Maternity, prenatal care • Hospice benefits (at least 210 days) • Well child care • Home health care in lieu of hospitalization • Chiropractic services • Prescription drug coverage including injectable medications, self-injectable medications, • Physical therapy contraceptive drugs and devices and fertility drugs • Occupational therapy (unless you have coverage through a union Employee Benefit Fund) • Speech therapy • Enteral formulas covered through either HCAP for • Prosthetics and durable medical equipment The Empire Plan or the HMO’s prescription drug • Orthotic devices program (unless you have coverage through a union • Bone density tests Employee Benefit Fund) • Mammography • Second opinion for cancer diagnosis • Inpatient mental health services Choices 2010/Actives Settled 3 Medicare and NYSHIP for original Medicare benefits if you receive treatment outside your HMO. If you are an active employee, NYSHIP (The Empire Plan or a NYSHIP HMO) provides primary coverage • If you are enrolled in The Empire Plan and join for you and your dependents, regardless of age or a Medicare Advantage Plan that is not part of disability. NYSHIP: If you receive services that are not authorized by your Medicare Advantage Plan, Exceptions: Medicare is primary for your domestic The Empire Plan will not pay for Medicare-covered partner age 65 or over, or for an active employee or services that would have been covered by the dependent with end-stage renal disease (waiting Medicare Advantage Plan. period applies). Medicare Part D is the Medicare prescription drug NYSHIP requires you and your dependents to be benefit for Medicare-eligible persons. NYSHIP enrolled in Medicare Parts A and B when first eligible provides prescription drug benefits to you and your for Medicare coverage that pays primary to NYSHIP. dependents under The Empire Plan or a NYSHIP If you are planning to retire, and you or your spouse HMO. Enrolling in a Medicare Part D plan separate is 65 or older, contact your Social Security office three from your NYSHIP coverage may drastically reduce months before active employment ends to enroll in your benefits overall. For example: Medicare Parts A and B. Medicare becomes primary • If you are Medicare-primary and enrolled in both to your NYSHIP coverage the first day of the month The Empire Plan and a Medicare Part D plan, you following a “runout” period of 28 days after the will not be able to use your Empire Plan coverage to payroll period in which you retire. receive benefits at the pharmacy. You must use your If you or a dependent is eligible for Medicare Medicare drug coverage first. To receive secondary coverage primary to NYSHIP but fails to enroll in drug coverage, you must submit a claim to The Parts A and B, The Empire Plan or HMO will not Empire Plan Prescription Drug Program along with provide benefits for services Medicare would have documentation of the amount covered by Medicare. paid if you or your dependent had enrolled. • If you are enrolled in a NYSHIP Medicare If you are planning to retire or vest in 2010, know Advantage HMO and then enroll in a Medicare how your NYSHIP benefits will be affected when Part D plan or another Medicare Advantage Plan Medicare is your primary coverage: outside of NYSHIP, Medicare will terminate your • If you are enrolled in original Medicare enrollment in the NYSHIP HMO. (Parts A and B) and have secondary coverage If you are eligible for the extra help from the Medicare under The Empire Plan: The Empire Plan coordinates Part D Low Income Subsidy, or if you are interested in benefits with Medicare. Since Medicare does additional drug coverage offered by a Medicare not provide coverage outside the United States, Part D plan, be sure you understand how joining a The Empire Plan pays primary for covered services Medicare prescription drug plan will change your received outside the United States. NYSHIP coverage before enrolling. If you do enroll in • If you enroll in a NYSHIP HMO Medicare Medicare Part D, you will not be reimbursed for the Advantage Plan: You replace your original fee-for- Medicare Part D premium. service Medicare coverage with benefits offered by If you receive prescription drug coverage through the Medicare Advantage Plan. Benefits under the a union Employee Benefit Fund, contact the fund for HMO’s Medicare Advantage Plan may differ from information about Medicare Part D. your benefits as an active employee. To qualify for For more information about NYSHIP and Medicare, benefits, you must follow plan rules (except for see your NYSHIP General Information Book or ask emergency or out-of-area urgently needed care). your agency HBA for a copy of Choices for 2010 for • If you enroll in a NYSHIP HMO that coordinates Retirees, Planning for Retirement, Medicare & NYSHIP coverage with Medicare: You receive the same benefits or Medicare for Disability Retirees. from the HMO as an active employee and still qualify 4 Choices 2010/Actives Settled The Empire Plan or a NYSHIP HMO What’s New in 2010? The Empire Plan All NYSHIP Plans The Empire Plan is a unique plan designed exclusively for New York State’s public employees. The Empire • Effective July 1, 2009, continuation coverage Plan has many managed care features, but enrollees has been extended from 18 to 36 months for all are not required to choose a primary care physician COBRA enrollees. and do not need referrals to see specialists. However, • Effective January 1, 2010, unmarried children of certain services, such as hospital and skilled nursing NYSHIP enrollees who are under age 30 and not facility admissions, certain outpatient radiological eligible for health insurance through their own tests, mental health and substance abuse treatment, employer may enroll in the same NYSHIP option home care and some prescription drugs, require as their parents if they live or work in the NYSHIP preapproval. Coverage is available worldwide. It is plan’s service area. These young adult dependents not limited to your geographic area. The New York will pay the full cost of Individual coverage. NYSHIP State Department of Civil Service contracts with major enrollees will receive detailed information regarding insurance companies (carriers) to insure and administer eligibility, cost and enrollment for young adult different parts of the Plan. children through age 29 in October 2009. The Empire Plan provides: • On January 1, 2010, the federal parity law for • Network and non-network inpatient and outpatient substance abuse benefits takes effect. The law requires hospital coverage for medical, surgical and that benefit levels for substance abuse care must be the maternity care; same as those for hospital/medical benefits. • Medical and surgical coverage. Coverage under the NYSHIP HMOs Participating Provider Program or the Basic Medical Effective January 1, 2010 Program and Basic Medical Provider Discount • Univera Healthcare will no longer be offered under Program if you choose a non-participating provider; NYSHIP. If you are enrolled in Univera Healthcare, you • Home care services, durable medical equipment and must enroll in The Empire Plan or a NYSHIP-approved certain medical supplies (including diabetic and HMO in the area where you live or work. If you do ostomy supplies), enteral formulas and diabetic shoes not take action, you will automatically be enrolled through the Home Care Advocacy Program (HCAP); in The Empire Plan for the 2010 program year. • Physical medicine (chiropractic treatment and • Oneida County returns to CDPHP’s Medicare physical therapy) coverage; Advantage Plan (NYSHIP code number 300). • Inpatient and outpatient mental health and • MVP Central Region (NYSHIP code number 330) substance abuse coverage; expands into Tompkins County. • Prescription drug coverage; • Preferred Care changed its name to MVP Health • Centers of Excellence Programs for cancer, Care as of April 30, 2009. transplants and infertility; Choices 2010/Actives Settled 5 • 24-hour Empire Plan NurseLineSM for health information and support; and Consider Cost • Worldwide coverage. Although New York State pays most of the Cost Sharing premium cost for your coverage regardless of Under The Empire Plan, benefits are available for which plan you choose, differences in plan covered services when you use a participating or benefits among the various health insurance non-participating provider. However, your share of options result in different employee contributions the cost of covered services depends on whether the for coverage. (See Your Biweekly Premium provider you use is participating or non-participating Contribution on page 1.) However, when under the Plan. considering cost, think about all your costs If you use an Empire Plan participating or network throughout the year, not just your biweekly provider for medical, surgical, mental health or paycheck deduction. Keep in mind out-of-pocket substance abuse services, you pay a copayment for expenses you are likely to incur during the year, certain services; some are covered at no cost to you. such as copayments for prescriptions and other The provider files the claim and is reimbursed by services, coinsurance and any costs of using The Empire Plan. providers or services not covered under the You are guaranteed access to network benefits for plan. Add the annual premium for that plan to certain services when you contact the program before these costs to estimate your total annual cost receiving services and follow program requirements: under that plan. Do this for each plan you are considering and compare the costs. Watch for • Inpatient hospital stays; the NYSHIP Rates & Deadlines for 2010 flyer • Mental Health and Substance Abuse that will be mailed to your home and posted on Program services; our web site, https://www.cs.state.ny.us, as • Managed Physical Medicine Program services soon as rates are approved. Along with this (physical therapy and chiropractic care); and booklet, which provides copayment information, NYSHIP Rates & Deadlines for 2010 will • Home Care Advocacy Program (HCAP) services provide the information you need to figure your (home care and services, including durable medical annual cost under each of the available plans. equipment). If you use a non-participating provider for medical and surgical services, benefits for covered services are paid under the Basic Medical Program. After you Basic Medical Provider Discount Program satisfy an annual deductible: If you are Empire Plan-primary, The Empire Plan • The Empire Plan pays 80 percent of the reasonable also includes a program to reduce your out-of-pocket and customary charge. costs when you use a non-participating provider. This program, The Empire Plan Basic Medical Provider • You are responsible for the 20 percent coinsurance Discount Program, offers discounts from certain and charges in excess of the reasonable and physicians and providers who are not part of The customary charge. Empire Plan participating provider network. These • After you reach the out-of-pocket maximum, you will providers are part of the nationwide MultiPlan be reimbursed up to 100 percent of the reasonable and group, a provider organization contracted with customary charge. See the chart on page 8 for the Basic UnitedHealthcare. Empire Plan Basic Medical Provider Medical deductible and coinsurance maximum amounts Discount Program provisions apply and you must meet that apply to you, based on your employee group. the annual deductible. • You are responsible for paying the provider and Providers in the Basic Medical Provider Discount will be reimbursed by the Plan for covered charges. Program accept a discounted fee for covered services. Your 20 percent coinsurance is based on the lower of 6 Choices 2010/Actives Settled the discounted fee or the reasonable and customary • Coverage outside the specified geographic area is limited. charge. The provider submits your claims and • Enrollees usually choose a primary care physician UnitedHealthcare pays The Empire Plan portion of (PCP) from the HMO’s network for routine medical the provider fee directly to the provider if the services care and for referrals to specialists and hospitals qualify for the Basic Medical Provider Discount when medically necessary. Program. Your Explanation of Benefits, which details claims payments, shows the discounted amount • HMO enrollees usually pay a copayment as a applied to billed charges. per-visit fee or coinsurance (percentage of cost). To find a provider in The Empire Plan Basic Medical • HMOs have no annual deductible. Provider Discount Program, ask if the provider is an • Referral forms to see network specialists usually Empire Plan MultiPlan provider or call The Empire Plan are required. toll free at 1-877-7-NYSHIP (1-877-769-7447), • Claim forms rarely are required. choose The Empire Plan Medical Benefits Program and ask a representative for help. You can also visit the • HMO enrollees who use doctors, hospitals or New York State Department of Civil Service web site at pharmacies outside the HMO’s network must, in https://www.cs.state.ny.us. Click on Benefit Programs, most cases, pay the full cost of services (unless then on NYSHIP Online. Select the group if prompted, authorized by the HMO or in an emergency). and then click on Find a Provider. All NYSHIP HMOs provide a wide range of health The best savings are with participating providers. services. Each offers a specific package of hospital If you choose a non-participating or non-network medical, surgical and preventive care benefits. These provider for services covered under the Mental Health services are provided or arranged by the primary care and Substance Abuse Program, the Managed Physical physician selected by the enrollee from the HMO’s staff Medicine Program or the Home Care Advocacy or physician network. Program, benefits for non-network coverage are lower All NYSHIP HMOs cover inpatient and outpatient and subject to separate deductibles and coinsurance. hospital care at a network hospital and offer Under the Managed Physical Medicine Program, non- prescription drug coverage unless it is provided network coverage is also subject to benefit limits. For through a union Employee Benefit Fund. more information on coverage provided under The Empire Plan, see the publication, Reporting on NYSHIP HMOs are organized in one of two ways: Network Benefits. You can find this publication on our • A Network HMO provides medical services that can web site at https://www.cs.state.ny.us. Or, ask your include its own health centers as well as outside agency HBA for a copy. participating physicians, medical groups and multi-specialty medical centers. Providers • An Independent Practice Association (IPA) HMO Under The Empire Plan you can choose from over 275,000 provides medical services through private practice participating physicians and other providers nationwide, physicians who have contracted independently with and from more than 50,000 participating pharmacies the HMO to provide services in their offices. across the United States or a mail service pharmacy. Members enrolling in Network and IPA model HMOs Medically necessary visits to specialists are covered may be able to select a doctor they already know if that without referral or prior authorization. Basic Medical doctor participates with the HMO. or non-network benefits are available for covered services received from non-participating providers, See the individual HMO pages in this booklet for depending on the type of service. additional benefit information and to learn if the HMO serves your geographic area. NYSHIP Health Maintenance Organizations A Health Maintenance Organization (HMO) is a managed care system in a specific geographic area that provides comprehensive health care coverage through a network of providers. Choices 2010/Actives Settled 7 Empire Plan Basic Medical Program and Non-Network Mental Health/Substance Abuse Practitioner Services Effective January 1, 2010 Employee Group Annual Deductible1 Coinsurance Maximum1 (per enrollee; per spouse or (Out-of-Pocket Expense per domestic partner; per all contract for Council 82, ALESU and dependent children combined) NYSCOPBA (Contract Affected) or per enrollee; per spouse or domestic partner; per all dependent children combined for all other groups listed below) Executive Branch CSEA $250 $500/$3003 DC-37 $290 CPI2 $620 CPI2/$3003 PBA - Troopers $375 CPI2 $826 CPI2 PBA - Supervisors $375 CPI2 $826 CPI2 PIA $375 CPI2 $826 CPI2 Council 82 $375 CPI2 $1,389 CPI2 ALESU $375 CPI2 $1,389 CPI2 NYSCOPBA (Contract Affected) $375 CPI2 $1,389 CPI2 NYSCOPBA (Represented) $375 CPI2 $800 UUP $375 CPI2 $1,033 CPI2 PEF $375 CPI2 $1,033 CPI2 M/C $375 CPI2 $1,033 CPI2 Legislature $375 CPI2 $1,033 CPI2 Participating Employers $375 CPI2 $1,033 CPI2 Unified Court System $250 $500/$3003 Retirees, Vestees, Dependent Survivors $375 CPI2 $1,033 CPI2 and Preferred List 1 Each program’s deductible, coinsurance and maximum coinsurance amount for medical, MPN, mental health and substance abuse services is separate and not combined with any other deductible, coinsurance or maximum coinsurance amount. 2 These changes reflect the 3.3% increase in the medical care component of the Consumer Price Index for Urban Wage Earners and Clerical Workers, all Cities (C.P.I.-W.) for the period July 1, 2008 through June 30, 2009. 3 The coinsurance maximum out-of-pocket expense will be reduced to $300 for calendar year 2010 for employees in (or equated to) salary grade 6 or below on January 1, 2010. This reduction is not available to Judges and Justices. Note: You have no deductible or coinsurance when you use Empire Plan participating providers. 8 Choices 2010/Actives Settled The Empire Plan and NYSHIP HMOs: Similarities and Differences The Empire Plan NYSHIP HMOs Can I use the hospital of my choice? Yes. You have coverage worldwide, but your benefits Except in an emergency, you generally do not have differ depending on whether you choose a network coverage at non-participating hospitals unless or non-network hospital1. Your benefits are highest at authorized by the HMO. network hospitals participating in the BlueCross and BlueShield Association BlueCard® PPO Program, or for mental health or substance abuse care in the OptumHealth network. Network hospital inpatient: Paid-in-full hospitalization benefits. Network hospital outpatient and emergency care: Subject to network copayments. Non-network hospital inpatient and outpatient: 10 percent coinsurance2 up to an annual maximum of $1,500 per enrollee; per spouse or domestic partner; per all dependent children combined. Note: $500 of $1,500 coinsurance maximum is reimbursable under the Basic Medical Program. If I am diagnosed with a serious illness, can I see a physician or go to a hospital that specializes in my illness? Yes. You can use the specialist of your choice. You should expect to choose a participating You have Basic Medical Program benefits for non- physician and a participating hospital. Under certain participating providers and Basic Medical Provider circumstances, you may be able to receive a referral Discount Program benefits for non-participating to a specialist care center outside the network. providers who are part of The Empire Plan MultiPlan group1. (See pages 6 and 7 for more information on the Basic Medical Provider Discount Program.) Your hospital benefits will differ depending on whether you choose a network or non-network hospital1. (See above for details.) Can I be sure I will not need to pay more than my copayment when I receive medical services? Yes. Your copayment should be your only expense Yes. As long as you follow HMO requirements and if you: receive the appropriate referral, your copayment • Choose a participating provider; (or coinsurance) should be your only expense. • Receive inpatient or covered outpatient hospital services at a network hospital and follow Benefits Management Program requirements1. Choices 2010/Actives Settled 9 The Empire Plan NYSHIP HMOs Will I be covered for care I receive away from home? Yes. Under The Empire Plan, your benefits are the Under an HMO, you are covered away from home same wherever you receive care. only for emergency care. Some HMOs provide coverage for routine care if the HMO has reciprocity with another HMO. Some HMOs provide coverage for college students away from home if the care is urgent or if follow-up care has been preauthorized. See the Out of Area Benefit description on each HMO page for more information. What kind of care is available for physical therapy and chiropractic care? You have guaranteed access to unlimited medically Coverage is available for a specified number of necessary care when you choose participating days/visits each year, as long as you follow the providers and follow Plan requirements. HMO’s requirements. What if I need durable medical equipment, medical supplies or home nursing? You have guaranteed, paid-in-full access to medically Benefits are available and vary depending on the necessary home care, equipment and supplies3 HMO. Benefits may require a greater percentage through the Home Care Advocacy Program (HCAP) of cost-sharing. when preauthorized and arranged by the Plan. 1 Applies only to Empire Plan-primary enrollees 2 Greater of 10 percent coinsurance or $75 for outpatient 3 Diabetic shoes have an annual maximum benefit of $500. Note: These responses are generic and highlight only general differences between The Empire Plan and NYSHIP HMOs. Details for each plan are available on individual plan pages beginning on page 16 of this booklet, in the Empire Plan Certificate (available from your agency Health Benefits Administrator) and in the HMO contract (available from each HMO). 10 Choices 2010/Actives Settled Questions and Answers to have the provider’s services covered. In most circumstances, HMOs do not provide benefits for Q: Can I join The Empire Plan or any NYSHIP- services by non-participating providers or hospitals. approved HMO? Under The Empire Plan, you have benefits for A: The Empire Plan is available worldwide, wherever participating and non-participating providers. you live or work. To enroll or continue enrollment in Participating providers change. You cannot change a NYSHIP-approved HMO, you must live or work in your plan outside the Option Transfer Period that HMO’s service area. If you move permanently because your provider no longer participates. out of and/or no longer work in your HMO’s service area, you must change options. See Plans Q: I have a preexisting condition. Will I have by County on pages 14 and 15 and the individual coverage if I change options? HMO pages in this booklet to check the counties A: Yes. Under NYSHIP, you can change your option each HMO will serve in 2010. and still have coverage for a preexisting condition. Q: How do I find out which providers and hospitals There are no preexisting condition exclusions in any participate? What if my doctor or other provider NYSHIP plan. However, coverage and exclusions leaves my plan? differ. Ask the plan you are considering about coverage for your condition. A: Check with your providers directly to see whether they participate in The Empire Plan for New York Q: What if I retire in 2010 and become eligible State government employees or in a NYSHIP HMO. for Medicare? For Empire Plan providers: A: Regardless of which option you choose, as a retiree, you and your dependent must be enrolled • Visit https://www.cs.state.ny.us; click on Benefit in Medicare Parts A and B when either of you first Programs, then on NYSHIP Online. Select your becomes eligible for primary Medicare coverage. group if prompted, and then click on Find a Please read about Medicare and NYSHIP and Provider. Medicare Part D on page 4. • Ask your agency Health Benefits Administrator for Please note, especially, that your NYSHIP benefits The Empire Plan Participating Provider Directory. become secondary to Medicare and that your benefits • Call The Empire Plan toll free at 1-877-7-NYSHIP may change when you enroll in some HMOs. (1-877-769-7447) and select the appropriate Q: I am a COBRA dependent in a Family plan. program for the type of provider you need. Can I switch to Individual coverage and select a For HMO providers: different health plan from the rest of my family? • Visit the web sites (web site addresses are A: Yes. As a COBRA dependent, you may elect to provided on the individual HMO pages in this change to Individual coverage in a plan different booklet) for provider information. from the enrollee’s Family coverage. During the • Call the telephone numbers on the HMO pages in Option Transfer Period, you may enroll in The this booklet. Ask which providers participate and Empire Plan or choose any NYSHIP-approved which hospitals are affiliated. HMO in the area where you live or work. If you choose a provider who does not participate in your plan, check carefully whether benefits would be available to you. Ask if you need authorization Choices 2010/Actives Settled 11 Terms to Know Practice Association (IPA), that are offered under NYSHIP. • Coinsurance: The enrollee’s share of the cost of covered services; a fixed percentage of medical • Managed Care: A health care program designed to expenses. ensure you receive the highest quality medical care for the lowest cost, in the most appropriate health • Copayment: The enrollee’s share of the cost of care setting. Most managed care plans require you covered services that is a fixed dollar amount paid to select a primary care physician employed by (or when medical service is received, regardless of the who contracts with) the managed health care system. total charge for service. He/she serves as your health care manager by • Deductible: The dollar amount an enrollee is coordinating virtually all health care services you required to pay before health plan benefits begin receive. Your primary care physician provides your to reimburse for services. routine medical care and refers you to a specialist • Fee-for-service: A method of billing for health care if necessary. services. A provider charges a fee each time an • Medicare: A federal health insurance program enrollee receives a service. that covers certain people age 65 or older, disabled • Formulary: A list of preferred drugs used by a persons under 65, and those who have end-stage health plan. If a plan has a closed formulary, you renal disease (permanent kidney failure). Medicare have coverage only for drugs that appear on the list. is directed by the federal Centers for Medicare & An incented formulary encourages use of preferred Medicaid Services (CMS) and administered by the drugs to non-preferred drugs based on a tiered Social Security Administration. copayment schedule. In a flexible formulary, • Medicare Advantage Plan: Medicare option wherein brand-name prescription drugs may be assigned the HMO agrees with Medicare to accept a fixed to different copayment levels based on value to the monthly payment for each Medicare enrollee. In plan and clinical judgment. In some cases, drugs exchange, the HMO provides or pays for all medical may be excluded from coverage under a flexible care needed by the enrollee. If you join a Medicare formulary if a therapeutic equivalent is covered Advantage Plan, you replace your original Medicare or available as an over-the-counter drug. coverage (Parts A and B) with benefits offered by • Health Benefits Administrator (HBA): Personnel the HMO and all of your medical care (except for located in each State agency, often in the Human emergency or out-of-area urgently needed care) Resources or Personnel Office, who work with the must be provided, arranged or authorized by the Employee Benefits Division in the Department of Medicare Advantage Plan. Most Medicare Civil Service to process enrollment transactions Advantage Plans include Medicare Part D drug and answer health insurance questions. You are coverage. The benefits under these HMOs are set in responsible for notifying your agency HBA of accordance with Medicare’s guidelines for Medicare changes that might affect your enrollment. Advantage Plans. • Health Maintenance Organization (HMO): A • Network: A group of doctors, hospitals and/or other managed care delivery system organized to deliver health care providers who participate in a health health care services in a geographic area. An HMO plan and agree to follow the plan’s procedures. provides a predetermined set of benefits through a • New York State Health Insurance Program network of selected physicians, laboratories and (NYSHIP): NYSHIP covers over 1.2 million public hospitals for a prepaid premium. Except for employees, retirees and dependents and is one of the emergency services, you and your enrolled largest group health insurance programs in the country. dependents may have coverage only for services The Program provides health care benefits through The received from your HMO’s network. See NYSHIP Empire Plan or a NYSHIP-approved HMO. Health Maintenance Organizations on page 7 for • Option: A health insurance plan offered through more information on HMOs including descriptions NYSHIP. Options include The Empire Plan and NYSHIP- of the two different types, Network and Independent approved HMOs within specific geographic areas. 12 Choices 2010/Actives Settled Making a Choice your group if prompted and then choose Health Benefits & Option Transfer. Click on Rates and Health Decision-Making Checklist Plan Choices and then NYSHIP Plan Comparison. Choosing a health insurance plan is an important Select your group and the counties in which you live decision. Think about what health care you and your and work. Then, check the box next to the plans you family might need during the next year. Review the want to compare and click on Compare Plans to plans and ask for more information. Here are several generate the comparison table. questions to consider: Things to Remember • What benefits does the plan have for doctor visits • Gather as much information as possible. and other medical care? How are durable medical equipment and other supplies covered? What is my • Consider the unique needs of yourself and your family. share of the cost? • Compare the coverage and cost of your options. • What benefits does the plan have for prescription • Look for a health plan that provides the best balance drugs? Will the medicine I take be covered under of cost and benefits for you. the plan? (Employees of Participating Employers: If you receive your drug coverage from a union What You Need to Do Employee Benefit Fund, that coverage will not be The Empire Plan and NYSHIP HMOs are summarized affected by a change in your health insurance plan.) in this booklet. The Empire Plan is available to all What is my share of the cost? What type of formulary employees. NYSHIP HMOs are available to employees does the plan have? Am I required to use the mail in areas where they live or work. Pick the plans that service pharmacy? would serve your needs best and call each for details • What choice of providers do I have under the plan? before you choose. (Ask if the provider or facilities you use are covered.) If you decide to change your benefit plan: How would I consult a specialist if I needed one? • See your agency Health Benefits Administrator Would I need a referral? before the Option Transfer deadline announced • What is my premium for the health plan? in the rate flyer. • What will my out-of-pocket expenses for health • Complete the necessary PS-404 form. Or change care be? your option online using MyNYSHIP if you are • Does the plan cover special needs? Are there any an active employee of a New York State agency. benefit limitations? (If you or one of your dependents How to Use the Choices has a medical or mental health/substance abuse Benefit Charts, Pages 16 – 43 condition requiring specific treatment or other special needs, check on coverage carefully. Don’t All NYSHIP plans must include a minimum level assume you’ll have coverage. Ask The Empire Plan of benefits (see page 3). For example, The Empire Plan carriers or HMOs about your specific treatment.) and all NYSHIP HMOs provide a paid-in-full benefit for medically necessary inpatient medical/surgical • Are routine office visits and urgent care covered for hospital care at network hospitals. out-of-area college students, or is only emergency health care covered? Use the charts to compare the plans. The charts list out-of-pocket expenses and benefit limitations effective • How much paperwork is involved in the health on or about January 1, 2010. See plan documents for plan – do I have to fill out forms? complete information on benefit limitations. To generate an easy-to-read side-by-side comparison A Reminder of the benefits provided by each of the NYSHIP plans in your area, use the NYSHIP Plan Comparison tool, Most benefits described in this booklet are subject available on the Department of Civil Service web site. to medical necessity and may involve limitations or Go to our home page at https://www.cs.state.ny.us, exclusions. Please refer to plan documents, or call click on Benefit Programs then NYSHIP Online. Select the plans directly for details. Choices 2010/Actives Settled 13 Plans by County Health Maintenance Organizations (HMOs) The Empire Plan Most NYSHIP enrollees have a choice among HMOs. You may enroll, or continue to be enrolled, in any The Empire Plan is available to all enrollees in the NYSHIP-approved HMO that serves the area where New York State Health Insurance Program (NYSHIP). you live or work. You may not be enrolled in an HMO You may choose The Empire Plan regardless of where outside your area. This list will help you determine which you live or work. Coverage is worldwide. See pages HMOs are available by county. The pages indicated will 16-21 for a summary of The Empire Plan. describe benefits available from each HMO. Page in Choices 16 22 24 26 26 26 28 30 30 30 32 32 34 36 36 38 40 40 40 40 42 Independent Health* Empire BlueCross Empire BlueCross Empire BlueCross Community Blue* BlueShield HMO BlueShield HMO BlueShield HMO The Empire Plan Blue Choice* GHI HMO GHI HMO HMOBlue HMOBlue CDPHP* CDPHP* CDPHP* Aetna* MVP* MVP* MVP* MVP MVP HIP* 001 210 066 063 300 310 067 280 290 320 220 350 050 072 160 059 060 330 340 360 058 NYSHIP CODE Albany • • • • • Allegany • • • Bronx • • • • Broome • • • • Cattaraugus • • • Cayuga • • • Chautauqua • • • Chemung • • Chenango • • • • Clinton • • • Columbia • • • • • Cortland • • • Delaware • • • • • • Dutchess • • • • • Erie • • • Essex • • • • Franklin • • • Fulton • • • • • Genesee • • • • Greene • • • • • Hamilton • • • Herkimer • • • • Jefferson • • • Kings • • • • Lewis • • • Livingston • • • Madison • • • • *Medicare-primary NYSHIP enrollees will be enrolled in this HMO’s Medicare Advantage Plan. For more information about NYSHIP Medicare Advantage Plans, ask your agency Health Benefits Administrator for a copy of Choices for 2010 for Retirees. 14 Choices 2010/Actives Settled Page in Choices 16 22 24 26 26 26 28 30 30 30 32 32 34 36 36 38 40 40 40 40 42 Independent Health* Empire BlueCross Empire BlueCross Empire BlueCross Community Blue* BlueShield HMO BlueShield HMO BlueShield HMO The Empire Plan Blue Choice* GHI HMO GHI HMO HMOBlue HMOBlue CDPHP* CDPHP* CDPHP* Aetna* MVP* MVP* MVP* MVP MVP HIP* 280 290 320 001 210 066 063 300 310 067 220 350 050 072 160 059 060 330 340 360 058 NYSHIP CODE Monroe • • • Montgomery • • • • • Nassau • • • • New York • • • • Niagara • • • Oneida • • • • Onondaga • • • Ontario • • • Orange • • • • • • Orleans • • • • Oswego • • • Otsego • • • • Putnam • • • • • Queens • • • • Rensselaer • • • • • Richmond • • • • Rockland • • • • • Saratoga • • • • • Schenectady • • • • • Schoharie • • • • Schuyler • • Seneca • • • St. Lawrence • • • Steuben • • • Suffolk • • • • Sullivan • • • • • Tioga • • • • Tompkins • • • Ulster • • • • • Warren • • • • • Washington • • • • • Wayne • • • Westchester • • • • Wyoming • • • • Yates • • • New Jersey • • *Medicare-primary NYSHIP enrollees will be enrolled in this HMO’s Medicare Advantage Plan. For more information about NYSHIP Medicare Advantage Plans, ask your agency Health Benefits Administrator for a copy of Choices for 2010 for Retirees. Choices 2010/Actives Settled 15 The Empire Plan NYSHIP Code Number 001 This section summarizes benefits available under each Under The Empire Plan Benefits Management portion of The Empire Plan as of January 1, 20101. You Program, you must call UnitedHealthcare for may also visit https://www.cs.state.ny.us, or call toll free certification before an elective (scheduled) Magnetic 1-877-7-NYSHIP (1-877-769-7447), the one number Resonance Imaging (MRI), Magnetic Resonance for The Empire Plan carriers. Call to connect to: Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear The Empire Plan Medical Benefits Program Medicine test unless you are having the test as an UnitedHealthcare inpatient in a hospital. Medical and surgical coverage through: When arranged by UnitedHealthcare, voluntary, • Participating Provider Program – More than paid-in-full Specialist Consultant Evaluation is available. 160,000 physicians and other providers participate; Voluntary outpatient Medical Case Management certain services are subject to a $15 or $20 is available to help coordinate services for copayment, depending on your group. serious conditions. • Basic Medical Program – If you use a non- The Empire Plan Hospital Benefits Program participating provider. See Cost Sharing (page 6) for an explanation of reimbursement Empire BlueCross BlueShield under The Empire Plan Basic Medical Program. The following benefit level applies when covered • Basic Medical Provider Discount Program – If you services are received at a BlueCross and BlueShield use a non-participating provider who is part of The Association BlueCard® PPO network hospital: Empire Plan MultiPlan group (see pages 6 and 7). • Medical or surgical inpatient stays are covered at Home Care Advocacy Program (HCAP) – no cost to you. Paid-in-full benefit for home care, durable medical • Hospital outpatient and emergency care are subject equipment and certain medical supplies (including to network copayments. diabetic and ostomy supplies), enteral formulas and • When you use a network hospital, anesthesiology, diabetic shoes. Diabetic shoes have an annual maximum pathology and radiology provider charges for benefit of $500. Guaranteed access to network benefits covered hospital services are paid in full under nationwide. Limited non-network benefits available. the Medical Benefits Program if The Empire Plan (See the Empire Plan Certificate/Reports for details). provides your primary coverage. Managed Physical Medicine Program – Chiropractic • Certain covered outpatient hospital services provided at treatment and physical therapy through a Managed network hospital extension clinics are subject to hospital Physical Network (MPN) provider are subject to a outpatient and emergency care copayments. Other $15 or $20 copayment, depending on your group. provider charges will be paid in full if using a network Unlimited network benefits when medically necessary. provider. Non-network provider charges will be paid in Guaranteed access to network benefits nationwide. accordance with the Basic Medical portion of the Limited non-network benefits available. Medical Benefits Program. 16 Choices 2010/Actives Settled The following benefit level applies for services received • All charges for any day determined not to be at non-network hospitals (for Empire Plan-primary medically necessary. enrollees only 2): Voluntary inpatient Medical Case Management is • Non-network hospital inpatient stays and outpatient available to help coordinate services for serious services – 10 percent coinsurance3 up to an annual conditions. maximum of $1,500 per enrollee; per spouse or domestic partner; per all dependent children The Empire Plan Mental Health combined. Up to $500 of the coinsurance may and Substance Abuse Program be reimbursed under the Basic Medical Program. UnitedHealthcare/OptumHealth The Empire Plan will approve network benefits at The Empire Plan Mental Health and Substance Abuse a non-network facility if: Program offers two levels of benefits. If you call OptumHealth before you receive services and follow • Your hospital care is emergency or urgent. their recommendations, you receive: • You do not have access to a network facility Network Benefits within 30 miles of your residence. (unlimited when medically necessary) • No network facility can provide the medically • Inpatient (paid in full) necessary services. • Crisis intervention (up to three visits per crisis paid in full) • Another insurer or Medicare provides your primary coverage (pays first). • Outpatient including office visits, home-based or telephone counseling and nurse practitioner services Preadmission Certification Requirements $15 or $20 copayment, depending on your group. Under The Empire Plan Benefits Management • Outpatient rehabilitation to an approved Structured Program, if The Empire Plan is your primary coverage, Outpatient Rehabilitation Program for substance abuse you must call Empire BlueCross BlueShield for subject to a $15 or $20 copayment, depending on certification of any inpatient stay: your group. • Before a maternity or scheduled (non-emergency) If you do NOT follow the requirements for network hospital admission, coverage, you receive: • Within 48 hours after an emergency or urgent Non-Network Benefits4 hospital admission, and (unlimited when medically necessary) • Before admission or transfer to a skilled nursing facility. • For Practitioner Services: OptumHealth will consider If you do not follow the preadmission certification up to 80 percent of reasonable and customary charges requirement, you must pay: for covered services after you meet the applicable • A $200 hospital deductible if it is determined mental health care annual deductible and the any portion was medically necessary, and applicable substance abuse annual deductible for outpatient practitioner services per enrollee; per Choices 2010/Actives Settled 17 spouse or domestic partner; per all dependent children • For a 31- to 90-day supply of a covered drug combined5. After the applicable coinsurance maximum through a participating retail pharmacy, you pay is reached per enrollee, per spouse or domestic a $10 copayment for Level 1 or generic drugs, $30 partner, per all dependent children combined5, copayment for Level 2 or preferred brand-name the Plan pays up to 100 percent of reasonable drugs and $70 copayment for Level 3 or non- and customary charges for covered services. preferred brand-name drugs. • For Approved Facility Services: You are responsible • For a 31- to 90-day supply of a covered drug for 10 percent coinsurance up to an annual maximum through the mail service pharmacy, you pay a of $1,500 per enrollee; per spouse or domestic $5 copayment for Level 1 or generic drugs, $20 partner; per all dependent children combined. Each copayment for Level 2 or preferred brand-name coinsurance maximum is applied as follows: drugs and $65 copayment for Level 3 or non- • You pay the first $500 of coinsurance, then preferred brand-name drugs. • The Program reimburses you for the next $500 of • When you fill a prescription for a covered brand- coinsurance, upon written request of the enrollee, then name drug that has a generic equivalent, you pay the Level 3 or non-preferred brand-name copayment • You pay the final $500 of coinsurance. plus the difference in cost between the brand-name After the coinsurance maximum is met, the Plan pays drug and the generic equivalent, not to exceed the 100 percent of billed charges for covered services. full retail cost of the drug. Exceptions apply. Please contact your agency HBA for more information. Outpatient treatment sessions for family members of an alcoholic, alcohol abuser or substance abuser are • The Empire Plan has a flexible formulary that excludes covered for a maximum of 20 visits per year for all a small number of brand-name drugs from coverage family members combined. (does not apply to CSEA, Courts, Council 82, ALESU, NYSCOPBA (Contract Affected)). Coverage for Note: The amount you pay for inpatient and outpatient prescription drugs excluded under The Empire Plan services does NOT count toward meeting your Basic benefit plan design are not subject to exception. Medical deductible or Basic Medical and non-network hospital coinsurance maximum. Deductibles, • Prior authorization is required for certain drugs. coinsurance and maximum coinsurance amounts are • A pharmacist is available 24 hours a day to answer separate and not combined with any other deductible, questions about your prescriptions. coinsurance or maximum coinsurance amounts. • You can use a non-participating pharmacy or pay The Empire Plan Prescription Drug Program cash at a participating pharmacy (instead of using UnitedHealthcare/Medco Health Solutions your Empire Plan benefit card) and fill out a claim form for reimbursement. In almost all cases, you • When you use a participating retail pharmacy or will not be reimbursed the total amount you paid the mail service pharmacy for up to a 30-day supply for the prescription, and your out-of-pocket expenses of a covered drug, you pay a $5 copayment for may exceed the usual copayment amount. To reduce Level 1 or generic drugs, $15 copayment for Level 2 your out-of-pocket expenses, use your Empire Plan or preferred brand-name drugs and $40 copayment benefit card whenever possible. for Level 3 or non-preferred brand-name drugs. 1 These benefits are subject to medical necessity and to limitations and exclusions described in the Empire Plan Certificate and Empire Plan Reports/Certificate Amendments. 2 If Medicare or another plan provides primary coverage, you receive network benefits for covered services at both network and non-network hospitals. 3 Greater of 10 percent or $75 for outpatient. 4 You are responsible for obtaining OptumHealth certification for care obtained from a non-network practitioner or facility. 5 Annual deductibles and coinsurance maximums vary by group. See page 8 for details. 18 Choices 2010/Actives Settled The Empire Plan NurseLine SM Provides 24-hour access to health information and support. The Empire Plan Centers of Excellence Programs Empire Plan Benefits Are Available Worldwide The Centers of Excellence for Cancer Program The Empire Plan gives you the freedom to choose a includes paid-in-full coverage for cancer-related participating provider or a non-participating provider. expenses received through Cancer Resource Teletypewriter (TTY) numbers Services (CRS). CRS is a nationwide network For callers who use a TTY device because of a hearing including many of the nation’s leading cancer or speech disability. All TTY numbers are toll free. centers. The enhanced benefits, including travel reimbursement, are available only when you UnitedHealthcare are enrolled in the Program. TTY only:.....................................1-888-697-9054 Empire BlueCross BlueShield TTY only:.....................................1-800-241-6894 The Centers of Excellence for Transplants OptumHealth Program provides paid-in-full coverage for TTY only:.....................................1-800-855-2881 services covered under the Program and The Empire Plan Prescription Drug Program performed at a qualified Center of Excellence. TTY only:.....................................1-800-759-1089 The enhanced benefits, including travel reimbursement, are available only when you are enrolled in the Program and The Empire Plan is your primary coverage. Precertification is required. Infertility Centers of Excellence are a select group of participating providers contracted by UnitedHealthcare and recognized as leaders in reproductive medical technology and infertility procedures. Benefits are paid in full, subject to the lifetime maximum benefit of $50,000. A travel allowance is available. Precertification is required. For details on The Empire Plan Centers of Excellence Programs, see the Empire Plan Certificate/Reports and Reporting on Centers of Excellence available at https://www.cs.state.ny.us or from your agency HBA. Choices 2010/Actives Settled 19 The Empire Plan Benefits Network Hospital Benefits1 Participating Provider Non-Participating Provider Office Visits $15 or $20/visit2 Basic Medical3 Specialty Office Visits $15 or $20/visit2 Basic Medical3 Diagnostic/Therapeutic Services Radiology $40/outpatient visit $15 or $20/visit2 Basic Medical3 Lab Tests $40/outpatient visit $15 or $20/visit2 Basic Medical3 20 Choices 2010/Actives Settled Pathology No copayment $15 or $20/visit2 Basic Medical3 EKG/EEG $40/outpatient visit $15 or $20/visit2 Basic Medical3 Radiation, Chemotherapy, Dialysis No copayment No copayment Basic Medical3 Women’s Health Care/OB GYN Pap Tests $40/outpatient visit $15 or $20/visit2 Basic Medical3 Mammograms $40/outpatient visit $15 or $20/visit2 Basic Medical3 Pre and Postnatal Visits No copayment Basic Medical3 Bone Density Tests $40/outpatient visit $15 or $20/visit2 Basic Medical3 Family Planning Services $15 or $20/visit2 Basic Medical3 Infertility Services $40/outpatient visit $15 or No copayment at designated $20/visit2; Basic Medical3 Centers of Excellence4 ($50,000 lifetime allowance for Qualified Procedures) Contraceptive Drugs and Devices $15 or $20/visit2 Basic Medical3 (also covered under The Empire Plan Prescription Drug Program5 subject to drug copayment) Emergency Room $60 or $70/visit2 No copayment Basic Medical3,6 Urgent Care $15 or $20/visit2 Basic Medical3 Ambulance No copayment7 $35 copayment $35 copayment Mental Health Practitioner Services $15 or $20/visit2 Applicable annual deductible2, 80% of (OptumHealth) reasonable and customary; after applicable coinsurance max2, 100% of reasonable and customary (See pages 17-18 for details.) Approved Facility Mental Health Services No copayment; unlimited when 90% of billed charges; after $1,500 coinsurance medically necessary (OptumHealth) max, covered in full (See pages 17-18 for details.) Outpatient Drug/Alcohol Rehabilitation $15 or $20/visit2 Applicable annual deductible2, 80% of to approved Structured Outpatient reasonable and customary; after applicable Rehabilitation Program; unlimited when coinsurance max2, 100% of reasonable and medically necessary (OptumHealth) customary (See pages 17-18 for details.) Inpatient Drug/Alcohol Rehabilitation No copayment; unlimited when 90% of billed charges; after $1,500 coinsurance medically necessary (OptumHealth) max, covered in full (See pages 17-18 for details.) Durable Medical Equipment No copayment (HCAP) 50% of network allowance (See the Empire Plan Certificate/Reports) Prosthetics No copayment8 Basic Medical3,8 $1,500 lifetime maximum benefit for prosthetic wigs Orthotic Devices No copayment8 Basic Medical3,8 External Mastectomy Prostheses Covered in full benefit for one single or double prosthesis per calendar year under Basic Medical, not subject to deductible or coinsurance3,8 (precertification may be required) Rehabilitative Care – Acute No copayment when an inpatient; Physical or occupational therapy $250 annual deductible, Care Facility $15 or $20/visit2 for outpatient $15 or $20/visit (MPN)2 50% of network allowance physical therapy following related Speech therapy $15 or $20/visit2 $1,500 annual maximum benefit surgery or hospitalization Basic Medical3 Diabetic Supplies No copayment (HCAP) 50% of network allowance (See the Empire Plan Certificate/Reports) Insulin and Oral Agents (covered under The Empire Plan Prescription Drug Program subject to drug copayment) Hospice No copayment, no limit Skilled Nursing Facility No copayment up to 365 benefit days4 No benefits if Medicare-primary Prescription Drugs (see page 18) Additional Benefits Dental (preventive) Not covered Not covered Vision (routine only) Not covered Not covered Hearing Aids Up to $1,200 or $1,500 per aid per ear Up to $1,200 or $1,500 per aid per ear every 4 years (every 2 years for children) every 4 years (every 2 years for children) if medically necessary if medically necessary Diabetic Shoes $500 annual maximum benefit 75% of network allowance up to an annual maximum benefit of $500 (See the Empire Plan Certificate/Reports) Out of Area Benefit Under The Empire Plan, your benefits are the same wherever you receive care. Inpatient Hospital No copayment4 No copayment Basic Medical3 Outpatient Surgery9 $40 or $60 per visit2 $15 or $20/visit2 Basic Medical3 24-hour NurseLineSM for health information and support Voluntary Disease Management Programs available for conditions such as asthma, attention deficit hyperactivity disorder (ADHD), cardiovascular disease, chronic kidney disease (CKD), chronic obstructive pulmonary disease, congestive heart failure, depression, diabetes and eating disorders. Diabetes Education Centers available to enrollees who have a diagnosis of diabetes. 1 Services provided by Empire HealthChoice Assurance, Inc., a licensee of the BlueCross 6 Attending emergency room physicians and providers who administer or interpret and BlueShield Association. Inpatient stays at network hospitals are paid in full. Provider radiological exams, laboratory tests, electrocardiograms and/or pathology services charges are covered under the Medical Benefits Program. Non-network hospital are paid in full. Other providers covered subject to deductible and coinsurance. coverage provided subject to coinsurance (see page 9). 7 If service is provided by admitting hospital. 2 Copayments, annual deductibles, coinsurance maximums and/or some benefits vary 8 Benefit paid up to cost of device meeting individual’s functional need. depending on your group. 9 In outpatient surgical locations, the copayment for the facility charge is $40 or $60 3 See page 6 for an explanation of reimbursement under the Basic Medical Program. per visit or Basic Medical benefits apply depending upon the status of the center. 4 Preadmission certification required. (Check with the center or The Empire Plan carriers.) 5 Coverage excludes contraceptive intrauterine devices (IUDs) that do not contain any FDA-approved hormone prescription drug products. Choices 2010/Actives Settled 21 Benefits Enrollee Cost Prosthetics 50% coinsurance Orthotics 50% coinsurance Rehabilitative Care, Physical, Speech and Occupational Therapy Benefits Enrollee Cost Inpatient, max 60 days No copayment Outpatient Physical, Speech, Occupational and Office Visits $25 per visit Pulmonary Therapy Routine Adult Physicals $5 per visit max 30 visits combined $40 per visit Well Child Care No copayment PCP visits for sick children to age 19 $5 per visit Diabetic Supplies $25 per item Specialty Office Visits $40 per visit Insulin and Oral Agents $25 per item Diagnostic/Therapeutic Services Hospice, max 210 days No copayment Radiology $40 per visit Skilled Nursing Facility Lab Tests $25 per visit max 45 days per admission Pathology $25 per visit 360-day lifetime max No copayment EKG/EEG $40 per visit Prescription Drugs Radiation $25 per visit Retail, 30-day supply Chemotherapy $25 for injection Rx $10 Tier 1/$30 Tier 2/$50 Tier 33 and $25 office copayment. Max 2 copayments per day. Mail Order, up to 90-day supply Women’s Health Care/OB GYN $20 Tier 1/$60 Tier 2/$100 Tier 33 Pap Tests1 $5 per visit There is a separate copayment for each 30-day supply Mammograms $5 per visit purchased at a retail pharmacy. You can order up to Pre and Postnatal Visits $5 per visit a 90-day supply through our mail order program with (first 10 visits only) two copayments per 90-day supply. Coverage includes Bone Density Tests $25 per visit contraceptive drugs and devices and fertility drugs, Family Planning Services Applicable copayment applies injectable and self-injectable medications and enteral formulas. Infertility Services Applicable copayment applies Specialty Drugs Contraceptive Drugs and Devices Designated specialty medications are covered only when Applicable Rx copayment applies purchased at a participating network specialty pharmacy. Emergency Room $100 per visit Medications purchased from a specialty pharmacy are subject to the same days supply and cost-sharing Urgent Care $35 per visit requirements that apply to the retail pharmacy benefit. Ambulance2 $100 per trip Mail order does not apply and these medications cannot be filled at mail order. Outpatient Mental Health A current list of specialty medications and participating unlimited visits $40 per visit specialty pharmacies is available on our web site at Inpatient Mental Health www.excellusbcbs.com. unlimited days No copayment 1 There are two services rendered for a Pap Test – the Outpatient Drug/Alcohol Rehab professional service by the OB GYN and the lab exam of the unlimited visits $25 per visit pap smear. There is a $5 copayment for the OB GYN exam, Inpatient Drug/Alcohol Rehab while the pap smear test is covered in full. NYSHIP members unlimited days No copayment will see a $5 copayment for the “Pap Test.” 2 Air ambulance coverage is excluded. Durable Medical Equipment 50% coinsurance 3 Should a doctor select a brand-name drug when an FDA- approved generic equivalent is available, the member will have to pay the difference between the cost of the generic and the brand-name plus any applicable copayments. 24 Choices 2010/Actives Settled Additional Benefits Pharmacies and Prescriptions Dental ......................................................Not covered Blue Choice members may have their prescriptions filled Vision ...................................................$40 for exams at any of our over 60,000 participating pharmacies associated with disease or injury only nationwide. Simply show the pharmacist your ID card. Hearing Aids................Children to age 19: $600 max, Blue Choice offers an incented formulary. Call every 3 years PrimeMail at 1-866-260-0487 for mail order Diabetic Shoes prescriptions. Fertility, injectable and self-injectable up to 3 pairs per calendar year...........No copayment prescription drugs are covered. Out Of Area....................................Our BlueCard and Away From Home Care Programs provide routine and Medicare Coverage urgent care coverage while traveling, for students Medicare-primary enrollees are required to enroll in away at school, members on extended out-of-town Medicare Blue Choice, the Excellus BlueCross BlueShield business and for families living apart. Medicare Advantage Plan. To qualify, you must be Surgery enrolled in Medicare Parts A and B and live in one of Physician-inpatient.............Lesser of $200 copayment the counties listed below. Once you become eligible for or 20% coinsurance Medicare, some of your Medicare Blue Choice Physician-outpatient at a hospital, copayments will vary from the copayments of NYSHIP- facility or surgery center ....................$40 copayment primary enrollees. Please call the Medicare Blue Choice Physician’s office .................Lesser of $50 copayment number below for further details. or 20% coinsurance Outpatient Surgical Care (Facility) ........$50 copayment Maternity Physician’s charge for delivery .................Lesser of $200 copayment or 20% coinsurance Plan Highlights for 2010 With Blue Choice, count on us to deliver the high-quality coverage you want and the value you need. Rely on Blue Choice for discounts on services that encourage you to develop a healthy lifestyle. • Two copayments for up to a 90-day supply for prescription drugs through PrimeMail. • Well child care is covered in full. • Pay a $5 copayment for PCP visits for sick children to NYSHIP Code Number 066 age 19. • Pay a $5 copayment for preventive services such A Network HMO serving individuals living or working as adult routine physicals, mammograms, OB GYN in Livingston, Monroe, Ontario, Seneca, Wayne and exams and prostate screenings. Yates counties. Participating Physicians Blue Choice With over 3,200 providers available, Blue Choice offers 165 Court Street you more choice of doctors than any other area HMO. Rochester, NY 14647 Talk to your doctor about whether Blue Choice is the right plan for you. For information: Blue Choice: 585-454-4810 or 1-800-462-0108 Affiliated Hospitals TTY: 1-877-398-2282 All operating hospitals in the Blue Choice service area Medicare Blue Choice: 1-877-883-9577 are available to you. Others outside the service area are Web site: www.excellusbcbs.com also available. Please call the number to the right for a directory, or check our web site at: www.excellusbcbs.com. Choices 2010/Actives Settled 25 Benefits Enrollee Cost Rehabilitative Care, Physical, Speech and Occupational Therapy Inpatient, max 45 days No copayment Outpatient, max 20 visits $10 per visit Diabetic Supplies $10 per item Benefits Enrollee Cost Insulin and Oral Agents $10 per item Office Visits $10 per visit Well Child Care No copayment Hospice, unlimited No copayment Specialty Office Visits $10 per visit Skilled Nursing Facility, max 50 days No copayment Diagnostic/Therapeutic Services Prescription Drugs Radiology $10 per visit Retail, 30-day supply $5 generic/ Lab Tests No copayment1 $15 formulary brand/$35 non-formulary Pathology No copayment Mail Order, 90-day supply $15 generic/ EKG/EEG $10 per visit $45 formulary brand/$105 non-formulary Radiation $10 per visit Coverage includes contraceptive drugs and devices, Chemotherapy $10 per visit prenatal vitamins and vitamins with fluoride, fertility drugs, injectable/self-injectable medications, enteral Women’s Health Care/OB GYN formulas, insulin and oral diabetic agents. Most Pap Tests No copayment injectable drugs are subject to prior approval. Member Mammograms No copayment2 communication materials will be mailed to the member Pre and Postnatal Visits No copayment3 upon enrollment explaining the mail order process and Bone Density Tests $10 per visit how to submit a mail order prescription. Family Planning Services $10 per visit Specialty Drugs Infertility Services $10 per visit 4 Specialty drugs are available through mail order at the applicable copayment. Contraceptive Drugs and Devices Approved generic oral contraceptives covered at 100% 1 For services at a stand-alone lab (must use Quest) or Emergency Room $50 per visit outpatient hospital that participates as a Quest Diagnostics hospital draw site. Lab services performed in Urgent Care $10 per visit conjunction with outpatient surgery or an emergency room Ambulance $50 per trip visit will also be paid in full. 2 Routine only Outpatient Mental Health 3 $10 copayment will only be taken on the initial office visit unlimited visits5 $10 per visit to confirm the pregnancy. 4 Inpatient Mental Health For services to diagnose and treat infertility. 5 unlimited days5 No copayment Subject to medical necessity. Outpatient Drug/Alcohol Rehab unlimited visits5 $10 per visit Inpatient Drug/Alcohol Rehab unlimited days5 No copayment Durable Medical Equipment 20% coinsurance Prosthetics 20% coinsurance Orthotics 20% coinsurance 28 Choices 2010/Actives Settled Additional Benefits Pharmacies and Prescriptions 6 Dental ...................................................20% discount Community Blue members may obtain prescriptions from at select providers, free second annual exam a nationwide network of nearly 45,000 participating Vision ....................VisionPLUS Program (details below) pharmacies. Prescriptions are filled for up to a 30-day Hearing Aids ............................................Not covered supply (including insulin) when filled at a participating Diabetic Shoes..........................................Not covered pharmacy. Community Blue offers an incented Out Of Area ................................Worldwide coverage formulary. Member’s copayment will reflect $5 for emergency and urgent care through the BlueCard formulary generic, $15 formulary brand, $35 non- Program, a network of BlueCross and BlueShield formulary prescriptions. Enrollees may also take providers across the country and around the world. advantage of the convenience of obtaining a 90-day Guest membership for routine care away from home supply of their medications through mail order. that enables members on extended business trips or family members away at school to join a nearby Blue Medicare Coverage HMO and enjoy the same benefits they do at home. Medicare-primary enrollees are required to enroll in VisionPLUS Program ...............Community Blue members Senior Blue HMO, the Community Blue Medicare are entitled to a complete eyecare program that includes Advantage Plan. To qualify you must be enrolled in routine eye exams and discounts from participating Medicare Parts A and B and live in one of the counties VisionPLUS providers. Discounts included on frames, listed below. lenses, contact lenses and supplies. Artificial Insemination ........................20% coinsurance 7 6 Preventive 7 Other artificial means to induce pregnancy (in-vitro, embryo transfer, etc.) are not covered. Plan Highlights for 2010 Members have access to our BlueLife wellness programs, which provide innovative wellness and health management programs through online and community- based resources. Discounts are available on acupuncture, massage therapy, nutritional counseling, fitness centers and spas. Members also have access to a 24/7 patient advocacy program – Health Advocate – which assists NYSHIP Code Number 067 patients with locating providers and scheduling appointments and offers a variety of other services. An IPA HMO serving individuals living or working in Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Participating Physicians Niagara, Orleans and Wyoming counties. Community Blue has over 3,000 physicians and health care professionals in our network who see patients in Community Blue their private offices throughout our service area. The HMO of BlueCross BlueShield of Western New York P.O. Box 80 Buffalo, NY 14240-0080 Affiliated Hospitals Community Blue contracts with all Western New York hospitals to provide health care services to our members. For information, call Community Blue members may be directed to other Buffalo: 716-887-8840 or 1-877-576-6440 hospitals to meet special needs when medically necessary. Olean: 716-376-6000 or 1-800-887-8130 Jamestown: 716-484-1188 or 1-800-944-2880 TTY: 1-888-249-2583 Web site: www.bcbswny.com Choices 2010/Actives Settled 29 Benefits Enrollee Cost Prosthetics No copayment 2 Orthotics No copayment Rehabilitative Care, Physical, Speech and Occupational Therapy Benefits Enrollee Cost Inpatient, max 45 days No copayment Outpatient, max 20 visits Office Visits $10 per visit combined per year $15 per visit Specialty Office Visits $10 per visit Diabetic Supplies Diagnostic/Therapeutic Services Retail, 30-day supply $10 per item Radiology $15 per visit Mail Order Not available Lab Tests No copayment Insulin and Oral Agents $10 per item or Pathology No copayment applicable pharmacy rider, whichever is less EKG/EEG $10 per visit Radiation $15 per visit Hospice, unlimited No copayment Chemotherapy $10 per visit Skilled Nursing Facility, max 45 days No copayment Women’s Health Care/OB GYN Prescription Drugs Pap Tests No copayment Retail, 30-day supply $5 tier I, most generic drugs/ Mammograms No copayment $15 tier II, most preferred brand-name drugs/ Pre and Postnatal Visits No copayment $30 tier III, all other drugs Bone Density Tests No copayment Mail Order, 90-day supply 2.5 copayments Family Planning Services $10 per visit for maintenance drugs Coverage includes contraceptive drugs and devices, Infertility Services $10 per visit injectable and self-injectable medications, fertility drugs and Contraceptive Drugs and Devices enteral formulas. Tier I oral contraceptives covered in full. Applicable Rx copayment applies Specialty Drugs Emergency Room $50 per visit Benefits are provided for specialty drugs by two contracted specialty pharmacy vendors, Curascript Urgent Care $10 per visit1 Pharmacy and OptionCare Pharmacy. Specialty drugs, Ambulance $50 per trip available through the prescription drug benefit, include select high-cost injectables and oral agents such as oral Outpatient Mental Health oncology drugs. Specialty drugs require prior approval unlimited visits $10 per visit and are subject to the applicable Rx copayment based on Inpatient Mental Health the formulary status of the medication. Members pay one unlimited days No copayment copayment for each 30-day supply. Outpatient Drug/Alcohol Rehab 1 Within the service area. Outside the service area - $10 unlimited visits $10 per visit copayment plus the difference in cost between Independent Inpatient Drug/Alcohol Rehab Health’s payment and the provider’s charges, if any. $35 unlimited days No copayment per visit to a participating After Hours Care Facility. 2 Excludes shoe inserts. Durable Medical Equipment 50% coinsurance 38 Choices 2010/Actives Settled Additional Benefits Medicare Coverage 3 Dental ..................$50 per cleaning and 20% discount Independent Health Medicare-primary retirees must on additional services at select providers enroll in Medicare Encompass, a Medicare Advantage Vision4 ...................$10 per visit once every 12 months Plan. Copayments will differ from the copayments of a Hearing Aids .......Discounts available at select locations NYSHIP-primary enrollee. Call for detailed information. Diabetic Shoes one pair per calendar year .................No copayment Out Of Area .............................While traveling outside the service area, members are covered for emergency and urgent care situations only. Home Health Care, max 40 visits ..............$10 per visit Eyeglass lenses ......................$35/single vision lenses; Frames 50% off retail price up to $130 and member pays 80% of balance over $130 (if any). Urgent Care in Service Area for After Hours Care ................................$35 per visit 3 Preventive 4 Routine only Plan Highlights for 2010 Independent Health has led the way in providing Western New York with innovative solutions that set the standard for quality and service for health plans. We’ve consistently earned top ratings from NCQA, which is why you can feel comfortable and confident choosing us for your health coverage needs. Participating Physicians Independent Health is affiliated with over 3,000 physicians and health care providers throughout the eight counties of Western New York. Affiliated Hospitals NYSHIP Code Number 059 Independent Health members are covered at all Western An IPA HMO serving individuals living or working in New York hospitals to which their physicians have Allegany, Cattaraugus, Chautauqua, Erie, Genesee, admitting privileges. Members may be directed to other Niagara, Orleans and Wyoming counties. hospitals when medically necessary. Independent Health Pharmacies and Prescriptions 511 Farber Lakes Drive Over 350 pharmacies including many national chains. Buffalo, NY 14221 Members may obtain prescriptions out of the service area by using our National Pharmacy Network. For information: Independent Health offers an incented formulary. Customer Service:1-800-501-3439 TTY: 716-631-3108 Web site: www.independenthealth.com Choices 2010/Actives Settled 39 Benefits Enrollee Cost Durable Medical Equipment 20% coinsurance Prosthetics 20% coinsurance serving the Rochester area Orthotics 20% coinsurance Rehabilitative Care, Physical, Speech Benefits Enrollee Cost and Occupational Therapy Office Visits $20 per visit Inpatient, unlimited No copayment PCP Sick Visits for Children age 0-4 No copayment Outpatient, max 30 visits combined $20 per visit PCP Sick Visits for Children age 5-18 $10 per visit Diabetic Supplies Specialty Office Visits $20 per visit Retail, 30-day supply $20 per item Mail Order, 90-day supply $50 per item Diagnostic/Therapeutic Services Radiology $20 per visit Insulin and Oral Agents Lab Tests $5 per day Retail, 30-day supply $20 per item Pathology $5 per day Mail Order, 90-day supply $50 per item EKG/EEG $20 per visit Hospice, unlimited No copayment Radiation No copayment Skilled Nursing Facility Chemotherapy $20 per visit max 120 days/year; 360 days/life No copayment Women’s Health Care/OB GYN Prescription Drugs Pap Tests $15 per visit Retail, 30-day supply $10 Tier 1/ Mammograms No copayment $30 Tier 2/$50 Tier 3 Pre and Postnatal Visits $50 copayment Mail Order, up to 90-day supply $20 Tier 1/ per pregnancy $60 Tier 2/$100 Tier 3 Bone Density Tests $20 per visit If a member requests a brand-name drug to the Family Planning Services $20 per visit prescribed generic drug, he/she pays the difference Infertility Services $20 per visit between the cost of the generic and the brand-name plus the Tier 1 copayment. Coverage includes fertility drugs, Contraceptive Drugs and Devices No copayment injectable and self-injectable medications and enteral Emergency Room $50 per visit formulas. Approved prescription generic contraceptive drugs and devices and those without a generic equivalent Urgent Care $25 per visit are covered at 100 percent under retail and mail order. Ambulance $50 per trip Specialty Drugs Outpatient Mental Health MVP Rochester works with CuraScript, a specialty unlimited visits $20 per visit pharmacy services company that provides specialty injectable medications to our members with chronic Inpatient Mental Health conditions to maximize their medication management. unlimited days No copayment Prescriptions are delivered by next-day service to the Outpatient Drug/Alcohol Rehab member’s home or office. Refer to www.curascript.com unlimited visits $20 per visit for additional information. Inpatient Drug/Alcohol Rehab unlimited days No copayment 42 Choices 2010/Actives Settled Additional Benefits Pharmacies and Prescriptions Dental ......................................................Not covered MVP Rochester offers an incented formulary. MVP Vision.....................................$20 per visit for routine; Rochester members simply present their card at any $20 per visit for diagnostic pharmacy in our extensive network. At an out-of-network Hearing Aids.......................................$600 allowance/ pharmacy, members pay their copayment plus the costs three calendar years/up to age 19 above the MVP Rochester network rate. Diabetic Shoes, unlimited pairs............20% coinsurance Out Of Area ...............................Coverage is provided Medicare Coverage for urgent and emergent care when traveling outside Medicare-primary enrollees must enroll in the Gold Plan, of the MVP Rochester service area. MVP Rochester’s Medicare Advantage Plan. Once you Eye Wear................................................20% discount become eligible for Medicare, some of the Gold Plan’s Home Health Care, max 40 visits ..............$20 per visit copayments will differ from the copayments of NYSHIP- Acupuncture, max 10 visits.................50% coinsurance primary enrollees. Please call for more details. Plan Highlights for 2010 MVP Rochester is not just an insurance plan – we’re a health plan committed to helping you live well. We work closely with our community’s physicians to make sure you receive the quality, value and service you should expect from a health plan. Below are just a few of the many reasons to choose MVP Rochester in 2010: • Our Commercial HMO plans are rated among “America’s Best Health Plans 2008-09” by U.S. News & World Report and the National Committee for Quality Assurance. • No referral required! See any specialist in the MVP Network without a referral. • Each MVP Rochester subscriber receives $50 HealthDollars to spend on health, wellness and fitness programs! Participating Physicians MVP Rochester takes the quality of your medical care seriously. That’s why we make sure the more than 27 ,500 NYSHIP Code Number 058 physicians and other health care professionals in our An IPA HMO serving individuals living or working in network have the proper training and licenses. We respect Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, their knowledge – therefore, they are key to developing Steuben, Wayne, Wyoming and Yates counties. our medical policies. And, should a serious health problem arise, MVP Rochester will work closely with you MVP Rochester and your doctor to make sure you get the care you need. 220 Alexander Street Rochester, NY 14607 Affiliated Hospitals MVP Rochester members are covered at area hospitals For information: to which their participating physicians have admitting MVP Rochester’s Member Services Department: privileges. Members may be directed to other hospitals 585-325-3113 or 1-800-950-3224 to meet special needs. TTY: 585-325-2629 Web site: www.mvphealthcare.com Choices 2010/Actives Settled 43 NYSHIP Online NYSHIP Online is designed to provide you with targeted information about your NYSHIP benefits. Visit the New York State Department of Civil Service web site at https://www.cs.state.ny.us and click on Benefit Programs, then NYSHIP Online. Select your group if prompted. If the group at the top of the NYSHIP Online home page is not your employee group, be sure to choose Change Your Group. If you do not have access to the internet, your local library may offer computers for your use. Ask your agency HBA for a copy of the NYSHIP Online flyer that provides helpful navigation information. Reminder: If you are an active or retired employee of New York State or are retired from a Participating Employer and a registered user of MyNYSHIP, you may change your option online during the Option Transfer Period. See your agency HBA if you have questions. 44 Choices 2010/Actives Settled How to find answers to your benefit questions and gain access to additional important information: • If you are an active State employee, contact your agency Health Benefits Administrator (HBA), usually located in your agency’s Personnel Office. • If you have questions regarding health insurance claims for The Empire Plan, call 1-877-7-NYSHIP (1-877-769-7447) toll free and choose the appropriate program on the main menu. HMO enrollees should contact their HMO directly. • A comprehensive list of contact information for HBAs, HMOs, government agencies, Medicare and other important resources is available on NYSHIP Online in the Using Your Benefits section. Telephone Numbers Health Benefits Administrators Choices 2010/Actives Settled 45 New York State Department of Civil Service Alfred E. Smith State Office Building Albany, NY 12239 https://www.cs.state.ny.us It is the policy of the State of New York Department of Civil Service to provide reasonable accommodation to ensure effective communication of information in benefits publications to individuals with disabilities. These publications are also available on the Department of Civil Service web site (https://www.cs.state.ny.us). Click on Benefit Programs then NYSHIP Online for timely information that meets universal accessibility standards adopted by New York State for NYS Agency web sites. If you need an auxiliary aid or service to make benefits information available to you, please contact your agency Health Benefits Administrator. COBRA Enrollees: Contact the Employee Benefits Division. Choices was printed using recycled paper and environmentally sensitive inks. AL0929 Choices 2010/Actives Settled The New York State Department of Civil Service, which administers NYSHIP, produced this booklet in cooperation with The Empire Plan carriers and Joint Labor/Management Committees on Health Benefits. Care has been taken to ensure the accuracy of the material contained in this booklet. However, the HMO contracts and the certificate of insurance from The Empire Plan carriers with amendments are the controlling documents for benefits available under NYSHIP.
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