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NYSHIP Certificate of Insurance

This online publication has been updated to include the Amendments through January 1, 2014. For details such as the effective dates of amendments, see your group-specific amendments in the Publications & Forms section of this site.

Section I: THE EMPIRE PLAN BENEFITS MANAGEMENT PROGRAM

Hospital, Skilled Nursing Facility and Medical Benefits Management Program

Inpatient components of The Empire Plan Benefits Management Program are administered by the Hospital Program administrator. Outpatient components are administered by the Medical/Surgical Program administrator.

You and your family must follow Benefits Management Program procedures, described below, to protect your Empire Plan benefits. Your share of the cost will be higher if you don't follow these procedures.

Applies when The Empire Plan is primary

The Empire Plan Benefits Management Program requirements apply when The Empire Plan is your primary health insurance coverage. (The Empire Plan is primary when it is responsible for paying for health benefits first, before any other group plan or HMO is liable for payment.) Requirements also apply to a Medicare-primary active employee or dependent before admission to a skilled nursing facility.

These requirements apply if you live or seek treatment anywhere in the United States, including Alaska and Hawaii.

These requirements also apply when you or your enrolled dependents have primary coverage through an HMO with secondary coverage under The Empire Plan, and you choose not to use the HMO.

If you will be admitted to a medical center or hospital operated by the U.S. Department of Veterans' Affairs, and will be using your Empire Plan benefits, you must comply with the requirements of The Empire Plan Benefits Management Program.

You must call The Empire Plan and choose the Hospital Program (see Contact Information)

You Must CallFor pre-admission certification before any elective (scheduled) hospital admission that will include an overnight stay in a hospital.

You must call before the hospital admission. Call as soon as your doctor suggests admission to the hospital. Call at least two weeks in advance of the admission, if possible. If you did not receive at least two weeks' notice from your doctor, contact the Benefits Management Program immediately. The nurse will make every effort to complete the review before your admission.

Before the birth of a child. Call as soon as the doctor confirms the pregnancy. You must call again if you are admitted to the hospital during the pregnancy for complications or for anything other than the delivery of the baby.

Within 48 hours after an emergency or urgent admission. This includes admission if you were scheduled for outpatient surgery and remained in the hospital overnight due to a complication. See Hospital admission for definitions of "emergency," "urgent" and "maternity" admissions.

For certification before admission to a skilled nursing facility, including transfer from a hospital to a skilled nursing facility.

You must call The Empire Plan for Prospective Procedure Review

You Must CallBefore having an elective (non-emergency) Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine test unless you are having the test as an inpatient in a hospital. (See Prospective Procedure Review for details.)

Who calls?

You, a member of your family or household, your doctor or a member of your doctor's staff may place the call. In the case of an emergency or urgent admission, the hospital admitting office may place the call for you.

Where this section refers to "you" making the call, keep in mind that other people may also call. However, you are responsible for seeing that The Empire Plan Benefits Management Program receives the call.

Why Benefits Management?

This program helps protect you and The Empire Plan by avoiding unnecessary service. Empire Plan enrollees need to evaluate the medical appropriateness of services they receive. Every medical procedure includes some risk. It can be unhealthy to be overtreated or undertreated. The costs associated with unnecessary services are shrinking our health benefits dollars. Money spent on unneeded services reduces the pool of money left to cover essential treatment.

The Empire Plan Benefits Management Program: Benefits and Your Responsibilities

Read 1 through 6 carefully to see how The Empire Plan Benefits Management Program's benefits and responsibilities apply to you and your family.

1. Pre-Admission Certification for hospital admission

You Must CallTo receive maximum Empire Plan benefits, you must call and choose the Hospital Program for pre-admission certification. You must call:

  • before any elective (scheduled) hospital admission;

  • before the birth of a child;

  • within 48 hours after an emergency or urgent admission.

In addition, you must call before admission to a skilled nursing facility, as explained in Pre-Admission Certification for skilled nursing facility admission.

After you call the Benefits Management Program for pre-admission certification, your Benefits Management Program nurse will call your doctor's office and speak with your doctor or the doctor's staff. If the information about your medical condition indicates that the hospital setting is medically necessary according to nationally accepted standards, the admission will be pre-certified. Pre-admission certification assures that Empire Plan benefits will be available to you to the full extent for covered services.

If the medical necessity of the admission is not confirmed, one of the Benefits Management Program's board-certified, practicing physician advisors will discuss the hospitalization with your doctor. If necessary, a second physician advisor, from the same or related specialty as your doctor, will also discuss the hospitalization and various alternatives with your doctor.

If the physician advisor does not agree that the admission is medically necessary, your admission will not be certified.

Within 24 hours after the Hospital Program administrator completes the review, the program will notify the hospital, you and your doctor whether the admission is certified.

You pay a higher share of the cost if you do not follow The Empire Plan Benefits Management Program procedures

If you do not follow the pre-admission certification requirements:

If you did not call the Benefits Management Program for pre-admission certification of an elective (scheduled) inpatient hospital admission or an admission for the birth of a child,

or

if you did not call the Benefits Management Program within 48 hours after an emergency or urgent admission,

or

if you followed the procedures for emergency or urgent admissions when you should have followed the pre-admission certification procedures for an elective (scheduled) admission or an admission for the birth of a child, you will be required to pay:

  • a $200 penalty if it is determined that any portion of your hospitalization was medically necessary

and

  • you will be responsible for all charges for any day it is determined that your hospitalization is not medically necessary.

You may appeal any penalty imposed for failure to call within 48 hours, if you did not call within the required 48 hours after an emergency or urgent hospital admission due to circumstances beyond your control (for example, due to your illness), but did call as soon as was reasonably possible.

If you call the Benefits Management Program and if hospitalization for you or your family member is not certified, you may choose to go ahead with the hospitalization. If you do, you will be required to pay all charges.

Certification does not guarantee coverage

Certification of a hospital admission means that The Empire Plan Benefits Management Program has found the inpatient setting appropriate. This certification does not guarantee coverage. The Empire Plan program administrators will determine eligibility and benefits as part of the claims review process. For example, although the inpatient setting may be certified for your spouse's surgery, benefits are not available if you discontinued his or her coverage before the admission. As another example, if the hospital setting was approved for surgery that the program administrators later determine to be cosmetic surgery or an experimental or investigative procedure, benefits are not available. The Empire Plan does not cover cosmetic surgery and experimental or investigative procedures or related hospital care. Call the Hospital Program or the Medical Program if you have questions about benefits for hospitalization or a certain procedure.

Pre-Admission Certification for skilled nursing facility admission

You Must CallYou must call The Empire Plan and choose the Hospital Program for pre-certification before admission to a skilled nursing facility, including transfer from a hospital to a skilled nursing facility. By calling prior to admission, you will know whether your care in a skilled nursing facility meets the criteria for Empire Plan benefits. Also, if your stay is pre-certified, you, your doctor, and the facility will be notified no later than the day before your certification for skilled nursing facility care will end.

If The Empire Plan is your primary coverage, skilled nursing facility care is covered under The Empire Plan if:

  • The care in a skilled nursing facility is medically necessary. Care is medically necessary when it must be provided by skilled personnel to assure your safety and achieve the medically desired result; and

  • Inpatient hospital care would have been required if care in a skilled nursing facility were not provided.

If the above conditions are not met, the skilled nursing facility care is not covered under The Empire Plan.

Custodial care, which is primarily assistance with the activities of daily living, is not covered under The Empire Plan.

Pre-admission certification for transplant surgeries

You Must CallYou must call The Empire Plan and choose the Hospital Program for pre-admission certification of admissions for the following transplant surgeries: bone marrow, peripheral stem cell, cord blood stem cell, heart, heart-lung, kidney, liver, lung and simultaneous kidney-pancreas. This requirement applies whether or not you choose to participate in the Centers of Excellence for Transplants Program.

2. Concurrent Review

Once you or your enrolled dependent is hospitalized, The Empire Plan's Benefits Management Program will continue to monitor your progress through the concurrent review program. The goal of concurrent review is to encourage the appropriate use of inpatient care. If the Benefits Management Program determines that inpatient care is no longer medically necessary, you, your doctor and the facility will be notified in writing no later than the day before the day on which Empire Plan inpatient benefits cease.

Note: The Benefits Management Program only gives advance notice that inpatient benefits will cease because inpatient care is no longer medically necessary. To check when your hospital benefits will cease for other reasons, contact the Hospital Program (see Contact Information).

3. Discharge Planning

If you or your enrolled dependent needs special services after hospitalization, the Hospital Program discharge planning unit nurses can help in consultation with hospital discharge planners. In consultation with your doctor, the discharge planning nurse will help arrange for medically necessary services and coordinate these services for you and your family. These services will be covered in accordance with Empire Plan provisions. For home health care and durable medical equipment/supplies, you must call the Home Care Advocacy Program, as explained in the Home Care Advocacy Program section.

4. Prospective Procedure Review

You Must CallTo receive maximum Empire Plan benefits, you must call The Empire Plan if you or one of your enrolled dependents is scheduled for an elective (non-emergency) Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine test unless you are having the test as an inpatient in a hospital.

Call as soon as your doctor suggests one of the above procedures. Call at least two weeks before the scheduled test. If you did not receive at least two weeks notice from your doctor, call The Empire Plan Benefits Management Program immediately. The nurse will make every effort to complete the review prior to your scheduled test. If you do not receive written confirmation from The Empire Plan, call your Benefits Management Program nurse before you go ahead with the procedure.

Your call will start the review process

A Benefits Management Program representative will call your doctor to discuss his or her recommendation. If the Medical/Surgical Program administrator determines that the Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine test is medically necessary and appropriate, the procedure will be approved and covered in accordance with Empire Plan provisions. Written notice will be mailed to you within 24 hours. If you call at least two weeks ahead, The Empire Plan Benefits Management Program will also send you a brochure which explains your procedure.

If the Medical/Surgical Program administrator determines that the Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine test is not medically necessary, and you choose to proceed with the procedure, you will be responsible for the full cost of the procedure. You will receive no Empire Plan benefits.

You do not have to call the Medical/Surgical Program administrator before an emergency Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine test. When the Hospital or Medical/Surgical Program receives the claim for the procedure, they will determine whether the procedure was performed on an emergency basis and whether the procedure was medically necessary.

A Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine test is performed on an emergency basis when it is given within 72 hours after an accident or within 24 hours after the first appearance of the symptoms of the illness when all of the following conditions are met: there is a sudden, unexpected onset of a medical condition; and immediate care is necessary to prevent what could reasonably be expected to result in either placing your life in jeopardy or serious impairment to your bodily functions.

There are penalties for not complying with the Prospective Procedure Review requirements

If you fail to call the Empire Plan Benefits Management Program, the Hospital Program administrator and/or the Medical/Surgical Program administrator will conduct a medical necessity review. If the review does not confirm that the Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine test was medically necessary, you will be responsible for the full charges. No benefits will be paid under your Empire Plan coverage.

If you fail to call the Benefits Management Program and the Hospital and/or Medical/Surgical Program administrator review confirms that the Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine test was medically necessary but not an emergency, you will be responsible for paying the following:

  • When the procedure is performed in the outpatient department of a hospital, you are liable for the payment of the lesser of 50 percent of the covered hospital charge or $250. You will also be responsible for the applicable outpatient hospital copayment or coinsurance.

  • When the provider(s) administering and/or interpreting the procedure is an Empire Plan participating provider under the Medical/Surgical Program, you are liable for the payment of the lesser of 50 percent of the scheduled amounts or $250. You will also be responsible for the Medical/Surgical Program copayment.

  • When the provider(s) administering and/or interpreting the procedure is not an Empire Plan participating provider, you are liable for the lesser of 50 percent of the reasonable and customary charges or $250. In addition, you must meet your combined annual deductible and you must pay the coinsurance and any provider charges above the reasonable and customary amount. (The coinsurance is the 20 percent you pay for covered services by non-participating providers, up to an annual maximum.)

Voluntary Specialist Consultant Evaluation

You may request a voluntary specialist consultant evaluation for any scheduled procedure. Call The Empire Plan and choose the Medical Program for a list of up to three physicians whose specialty is similar to your doctor's. After you determine which of these doctors you prefer to see, the Benefits Management Program will arrange for the specialist consultant evaluation. The consultation will be provided at no cost to you.

However, if the specialist from whom you obtained the specialist consultant evaluation performs the procedure, the specialist consultant evaluation will not be considered a covered expense under The Empire Plan; you will be responsible for the cost of the evaluation.

Once the evaluation is completed, it is up to you whether to have the procedure or surgery. But remember, if you decide to go ahead and you will be hospitalized for the procedure, you must call The Empire Plan and choose the Hospital Program for preadmission certification.

5. Medical Case Management

Medical case management is a voluntary program to help you identify and coordinate covered services that the patient needs.

Some catastrophic or complex cases, such as head injuries, neonatal (newborn) complications or certain chronic conditions, may require extended care. If you or a member of your family requires this type of care, you may be faced with many decisions about treatment plans and facilities. The Benefits Management Program can provide information that may help you make the choices that are best for you.

Pre-admission certification and concurrent review help the Benefits Management Program determine if medical case management would be appropriate. If the Benefits Management Program decides that this service could help you and your family, a nurse coordinator, who is familiar with benefits available under The Empire Plan and local and regional health care resources, will contact you. The nurse will meet with you and your family to discuss the patient's medical situation.

Your acceptance of this service is voluntary. With your written consent, the nurse and your attending physician will identify treatment options covered under The Empire Plan so that you and your family have the information available to make the best medical decisions possible. The nurse will also identify any community resources which may be available for you or your family.

When you accept Medical Case Management, your care will be coordinated by a nurse from the appropriate program.

6. High Risk Pregnancy Program

The Empire Plan Benefits Management Program offers special help for pregnancies. Call The Empire Plan and choose the Hospital Program as soon as you know you're pregnant. The Benefits Management Program will help identify possible problems and will work with you and your doctor. See the following for details.

Healthy Babies

The Empire Plan Benefits Management Program Helps Identify Risks Early

Pregnant? First steps

Every year about 9,000 babies are born to employees and their family members who are covered under The Empire Plan. We want every mother and baby to have the best possible start. That's why The Empire Plan gives mother and baby the coverage they need. And that's why The Empire Plan Benefits Management Program offers special services for pregnancy for enrollees who have The Empire Plan as their primary coverage.

The first steps for a healthy baby are up to you - they're steps you take long before your baby's born:

Step 1 Call your doctor

Pregnant? Call your doctor! The first three months of pregnancy are when you can do the most for your baby. Start your doctor visits during the first month of pregnancy.

Step 2 Call The Empire Plan and choose the Hospital Program

Doctors report problems in three out of every ten pregnancies. But there's good news: Early diagnosis and care can mean a healthy baby.

The Benefits Management Program helps identify possible problems and works with mother and doctor throughout the pregnancy. This partnership can make a world of difference!

Call The Empire Plan and choose the Hospital Program as soon as you know you are pregnant. Call early - during the first month is best. (If you don't call before your maternity hospital admission, you pay a higher share of the cost.)

Tell the Benefits Management Program you're calling about your pregnancy. The maternity specialist will ask you several easy questions such as, "Is this your first pregnancy/have you had problems during previous pregnancies?" - questions to help determine if you or your baby is at risk.

The questions take five minutes, at the most. And your answers are strictly confidential.

Free book can help you: When you call, the Benefits Management Program will offer to send you a free book on pregnancy.

Follow-up: If the maternity specialist identifies any possible problems, the specialist will ask to keep in telephone contact with you every four to six weeks. Your participation is voluntary.

One of the program's registered nurses who specializes in maternity or newborn care will call you back. During the calls, the nurse will talk with you about your progress and any problems you are experiencing. The nurse also will call your doctor to discuss progress and possible follow-up.

You may ask questions, too. During the calls, the Benefits Management Program nurse will answer general questions. And, if you need help determining what questions to ask your doctor, the nurse will help you think through those questions.

Step 3 Be informed

Ask a lot of questions: ask your doctor, the nurse, the Benefits Management Program and community resources. There is information available to help you have a healthy baby.

Remember to contact your Health Benefits Administrator within 30 days of the date of birth to add your newborn to your Empire Plan coverage.

More About the Benefits Management Program

Certification letter

The Benefits Management Program will mail a letter to you within 24 hours after The Empire Plan prospective procedure review and/or pre-admission certification review is completed. If your letter has not arrived, call the Benefits Management Program before your procedure or admission to find out the results of the review.

Call again

You must call the Benefits Management Program again in certain situations:

  • Admission postponed: If you received pre-admission certification for admission to a hospital or skilled nursing facility and there is a change in the scheduled date of your admission, you must call the Benefits Management Program again to change the date.

  • Re-admission: If you received pre-admission certification for a hospital or skilled nursing facility admission and you must be re-admitted for the same problem, you must call the Benefits Management Program again.

  • Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) or Nuclear Medicine tests postponed: If the Benefits Management Program approved your procedure but you and your doctor decide to postpone the procedure for more than six months, you must call again for another review when the procedure is rescheduled.

  • Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) or Nuclear Medicine test repeated: If you followed prospective procedure review requirements for a procedure and the procedure is scheduled to be repeated, you must call the Benefits Management Program again.

The Benefits Management Program and the Mental Health and Substance Abuse Program

The Benefits Management Program does not replace The Empire Plan Mental Health and Substance Abuse Program. Call The Empire Plan and choose the Mental Health and Substance Abuse Program before seeking care for mental health and substance abuse problems, including alcoholism.

At times, a person's condition may be so complicated that it is difficult to determine if the required care is medical or mental health/substance abuse related. If you cannot decide, call either the Mental Health and Substance Abuse Program or the Benefits Management Program for help determining which program applies.

Calling The Empire Plan Benefits Management Program is easy and toll-free

You may call The Empire Plan and choose the Hospital Program or the Medical Program, depending on the services to be pre-certified (see Contact Information). If you call outside normal business hours or on holidays, leave a message and a representative will return your call. Please leave your name and the best time and place to reach you (with the area code and telephone number) on the following business day. If you don't get a return call in one business day, your message may not have been clear. Please call again.

Be ready to supply the following information to the nurse:

  1. Enrollee identification number (from Empire Plan Benefit Card)

  2. Patient's address and phone number (including area code)

  3. Doctor's name, address and phone number (including area code)

  4. Name of hospital or skilled nursing facility

  5. Anticipated date of admission for Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) or Nuclear Medicine test.