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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 II: HOSPITAL AND RELATED EXPENSES COVERAGE CERTIFICATE OF INSURANCE

Introduction

  1. Your Hospital Program coverage under The Empire Plan. Under The Empire Plan, the Hospital Program administrator will provide benefits for hospitalization and related expenses as described in this book. These benefits will be referred to in this section of the book as "this Plan." This book is your Certificate which is evidence of your insurance. You should keep this book with your other important papers so that it is available for your future reference. It is also important for you to be aware of the provisions of your coverage because failure to comply with some of them could result in a reduction in benefits.

  2. Words the Hospital Program uses in this section. The word "you," "your" or "yours" refers to you, the employee to whom this book is issued, and to any members of your family who are also covered under this Plan.

  3. Network hospitals and facilities means hospitals and facilities that participate in the BlueCross and BlueShield Association Blue Card PPO Program through local BlueCross and/or BlueShield plans. When you use network hospitals and facilities, covered services are paid in full subject to the Benefits Management Program requirements and except for any applicable copayments that you pay.

    Non-network hospitals and facilities means hospitals and facilities that do not participate in the BlueCross and BlueShield Association Blue Card PPO® Program network. When you use non-network hospitals and facilities, you must pay a higher share of the cost of covered services. Network benefits may apply at non-network facilities under certain circumstances. (See Network and non-network benefits).

    Program administrator means the company contracted by the State of New York to administer the Empire Plan Hospital Program. The Hospital Program administrator is Empire BlueCross BlueShield. Administrative services are provided by Empire HealthChoice Assurance, Inc., a licensee of the BlueCross and BlueShield Association, an association of independent BlueCross and BlueShield Plans. The program administrator is responsible for processing claims at the level of benefits determined by The Empire Plan and for performing all other administrative functions under the Empire Plan Hospital Program.

  4. Who is covered. Eligibility for coverage is determined under Regulations of the President of the New York State Civil Service Commission. Refer to the General Information Book for information on your eligibility for coverage. Also, refer to the General Information Book for an explanation of how you enroll in The Empire Plan, which dependents are covered under The Empire Plan and when your coverage becomes effective.

  5. If you are eligible for Medicare. If you are eligible for primary Medicare coverage, your benefits under this Plan will change. Be sure to read Limitations and Exclusions and If You Qualify for Medicare, which describe benefits under this Plan for persons who are eligible for Medicare.

  6. If you are disabled on the date your coverage becomes effective. If you have a prior confinement in a hospital, skilled nursing facility or other institution for care or treatment immediately preceding the date your coverage under The Empire Plan becomes effective and the confinement continues on the day this Plan becomes effective, or you continue to be confined at home under the care of a physician or surgeon, because of a disabling sickness or injury on the date your coverage under this Plan becomes effective, the Hospital Program will not provide benefits to the extent that you have coverage under any other health care plan, including provisions for benefits after termination in the event of disability. Hospital Program benefits will be payable only to the extent that they exceed the benefits payable under the other health care plan.

  7. Empire HealthChoice Assurance, Inc., doing business as Empire BlueCross BlueShield, is an insurance company organized under the laws of New York State, and is a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. It is not acting as agent of the Blue Cross and Blue Shield Association and is solely responsible for honoring its agreement to administer The Empire Plan hospitalization and related expenses coverage.

Benefits Management Program

You must call The Empire Plan and choose the Hospital Program

You Must CallAll of the inpatient hospital benefits and skilled nursing facility benefits provided by the Hospital Program administrator under The Empire Plan are subject to the provisions of The Empire Plan's Benefits Management Program. Please read about the Benefits Management Program requirements in the preceding section of this book.

Hospital admission

If you do not follow the provisions of the Benefits Management Program, the Hospital Program administrator will still review your claim and will apply the following penalty and copayments:

  • If you did not call the Benefits Management Program for Pre-Admission Certification of an elective (scheduled) inpatient admission or an admission for the birth of a child, a $200 penalty will apply. No payment will be made for any day during which it was not medically necessary for you to be an inpatient.

  • If you called the Benefits Management Program and did not receive certification for your admission and you are admitted to the hospital as an inpatient, you will be responsible for all charges for each day it was not medically necessary for you to be an inpatient. If only a part of your inpatient stay was certified, you will be responsible for all charges for each day on which it was not medically necessary for you to be an inpatient.

  • If you did not call the Benefits Management Program within 48 hours after an emergency or urgent hospital admission, a $200 penalty will apply. In addition, you will be responsible for all charges for each day on which it was not medically necessary for you to be an inpatient.

  • You may appeal the 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 it is determined that you followed the procedures for emergency or urgent admission when you should have followed the Pre-Admission Certification procedures for an elective (scheduled) admission or admission for the birth of a child, a $200 penalty will apply. In addition, you will be responsible for all charges for each day on which it was not medically necessary for you to be an inpatient.

Emergency Admission. Emergency admissions apply to medical conditions or acute trauma such that life, limb or the body function of the patient depends on the immediacy of medical treatment. In an emergency admission, the condition requires immediate medical attention, and any delay in receiving treatment would be harmful to the patient. The patient does not have to be admitted via the emergency room to be considered an emergency admission.

Urgent Admissions. Urgent admissions involve medical conditions or acute trauma such that medical attention, while not immediately essential, should be provided very early in order to prevent possible loss or impairment of life, limb or body function.

Maternity Admissions. A maternity admission is one in which a pregnant patient is admitted to give birth. Admissions for incomplete abortion, toxemia and ectopic pregnancy are not considered maternity admissions. These will be considered as either urgent or emergency admissions, and you must call the Benefits Management Program within 48 hours. Note: Under New York State Law, the first 48 hours of hospitalization for mother and newborn after any delivery other than a cesarean section or the first 96 hours following a cesarean section are presumed to be medically necessary.

If you fail to comply with the requirements of the Benefits Management Program and your hospital admission is not certified, only the penalties referred to above will apply; your claim will not be denied completely. However, in no case will benefits be paid for services which are contractually excluded, regardless of compliance with the Benefits Management Program provisions. See Limitations and Exclusions for a list of exclusions.

Skilled nursing facility admission

  • If you did not call the Benefits Management Program to pre-certify your care in a skilled nursing facility, the Hospital Program administrator will conduct a medical necessity review of your skilled nursing facility stay. You will be responsible for the full charges for each day that it was not medically necessary for you to be in a skilled nursing facility.

Outpatient MRI, MRA, CT, PET and Nuclear Medicine tests

  • If you did not follow the Prospective Procedure Review requirements for Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scans or Nuclear Medicine tests and the procedure was performed in the outpatient department of a hospital, the Hospital Program administrator will conduct a medical necessity review. If the review does not confirm that the procedure was medically necessary, you will be responsible for the full charges. No benefits will be paid under your Hospital Program coverage. If you fail to call the Benefits Management Program and the Hospital Program administrator's review confirms that your procedure was medically necessary, but not an emergency, you will be responsible for paying the lesser of 50 percent of the covered hospital charge or $250. The applicable hospital outpatient copayment or coinsurance will be applied to the remaining covered charge.

Veterans' Hospital

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.

Network and Non-Network Benefits

The following applies to enrollees who have primary coverage through The Empire Plan.

There are two levels of benefits under the Hospital Program - Network and Non-network.

  1. Network benefits: When you use a network hospital, skilled nursing facility or hospice care facility, inpatient and outpatient covered services are paid in full except for:

    1. Any applicable hospital outpatient copayments. Hospital emergency room visits are subject to a $70 copayment, outpatient surgical expenses are subject to a $60 copayment, diagnostic outpatient services (diagnostic radiology, including mammography; diagnostic laboratory tests and administration of Desferal for Cooley's Anemia) are subject to a $40 copayment and physical therapy services are subject to a $20 copayment; and

    2. Any penalty amounts that apply as the result of your failure to follow the requirements of the Benefits Management Program.

  2. Non-network benefits: When you use a non-network hospital, skilled nursing facility or hospice care facility, you are responsible for a larger share of the cost of Covered Services, unless the criteria listed in section C apply. You are responsible for:

    1. 10 percent of the billed charges for inpatient hospital, skilled nursing facility or hospice care facility services up to the combined annual coinsurance maximum;

    2. 10 percent of the billed charges or a $75 copayment for hospital outpatient services, whichever is greater, up to the combined annual coinsurance maximum; and

    3. Any penalty amounts that apply as the result of your failure to follow the requirements of the Benefits Management Program.

  3. The covered percentage becomes 100 percent of the billed charges for inpatient services only once the combined annual coinsurance maximum is met.

    The combined annual coinsurance maximum is $3,000 for the enrollee, $3,000 for the enrolled spouse/domestic partner and $3,000 for all dependent children combined.

    Coinsurance amounts incurred under the Basic Medical, Hospital and Mental Health and Substance Abuse (MHSA) Programs are applied to the combined annual coinsurance maximum. Copayments for Participating Provider and network MHSA practitioner services also count toward the combined annual coinsurance maximum.

    Non-network coinsurance and copayment amounts apply in addition to any amounts that are your responsibility  because of your failure to meet the requirements of the Benefits Management Program.

  4. Network benefits at a non-network hospital/facility: If you use non-network hospitals and facilities you will receive network benefits for covered services:

    1. When no network facility is available within 30 miles of your residence;

    2. When no network facility within 30 miles of your residence can provide the covered services you require;

    3. When the admission is deemed an emergency or urgent inpatient or outpatient admission;

    4. When care is received outside the United States;

    5. When another plan, including Medicare is providing primary coverage.

    The payment for medically necessary covered services received in a non-network hospital is made directly to you. You pay any applicable outpatient copayment at the network level and any penalties or coinsurance amounts that apply because of your failure to follow the requirements of the Benefits Management Program. You are responsible for making the payment to the non-network hospital.

Empire Plan network hospitals, hospices and skilled nursing facilities are listed on NYSHIP Online (see Contact Information). Select Using Your Benefits and then Empire Plan Providers, Pharmacies and Services. You can also call The Empire Plan and choose the Hospital Program.

Inpatient Hospital Care

The Plan will pay for your care when you are an inpatient in a hospital or birthing center as described below. Benefits are subject to the requirements of The Empire Plan's Benefits Management Program if The Empire Plan is your primary coverage.

  1. In a hospital. The term "hospital" means only an institution which meets fully every one of the following criteria:

    • It is primarily engaged in providing on an inpatient basis diagnostic and therapeutic services for surgical or medical diagnosis, treatment and care of injured and sick persons by or under the supervision of a staff of physicians who are duly licensed to practice; and

    • It continuously provides 24-hours-a-day nursing service by or under the supervision of registered professional nurses; and

    • It is not a skilled nursing facility and it is not, other than incidentally, a place of rest, a place for the aged, a place for drug addicts, a place for alcoholics or a nursing home.

  2. Hospital services covered. The Hospital Program will usually pay, subject to network and non-network benefit levels, for all the diagnostic and therapeutic services provided by the hospital. However, the service must be given by an employee or an agent of the hospital, the hospital must bill for the service as part of the hospital's charges and the hospital must retain the money collected for the service. Those services include, but are not limited to:

    • Semi-private room. A semi-private room is a room which the hospital considers to be semi-private. If you occupy a private room, the Hospital Program will only pay the hospital's most common semi-private room charge. You will have to pay the difference between that charge and the charge for the private room.

    • Use of operating, recovery, intensive care and cystoscopy rooms and equipment

    • Laboratory and pathology examinations

    • Basal metabolism tests

    • Use of cardiographic equipment

    • Oxygen and use of equipment for administration

    • Prescribed drugs and medicines

    • Intravenous preparations, vaccines, sera and biologicals

    • Blood and/or blood products, upon satisfactory evidence that local conditions make it necessary to incur expenses for blood or blood products

    • Use of transfusion equipment

    • Dressings and plaster casts

    • X-ray examinations, radiation therapy and radioactive isotopes

    • Chemotherapy except if you are enrolled in the Centers of Excellence Program and receiving care at a Cancer Resource Services network facility.

    • Anesthesia supplies, equipment and administration by a hospital staff employee

    • Physiotherapy and hydrotherapy

    • Ambulance service when supplied by the admitting hospital

    • Maternity care for mother and newborn for at least 48 hours after any delivery other than a cesarean section and for at least 96 hours after a cesarean section. Covered hospital maternity care includes parent education, assistance and training in breast or bottle feeding, and the performance of any necessary maternal and newborn clinical assessments.

    • You have a paid-in-full benefit for one Maternity Home Care Visit when you choose to be discharged from a hospital or birthing center less than 48 hours after any delivery other than a cesarean section or less than 96 hours after a cesarean section. If you choose early discharge, you must request the Maternity Home Care Visit within 48 hours after any delivery other than a cesarean section or within 96 hours after a cesarean section. The Maternity Home Care Visit will be made within 24 hours of your request or your discharge, whichever is later.

    • The full length of your inpatient stay as determined by you and your doctor following lymph node dissection, lumpectomy or mastectomy for treatment of breast cancer.

  3. Birthing center. The Hospital Program will pay for the hospital services described in Item 2 above for your maternity care in a birthing center which is licensed by the state in which it operates.

See Number of Days of Care for more information.

Outpatient Hospital Care

When you receive the services described in the following sections and subject to the limitations in those sections, the Hospital Program will pay for the same services provided to you in the outpatient department of a hospital as it pays when you are an inpatient in a hospital as described under Inpatient Hospital Care. This coverage also applies to services provided at a hospital extension clinic (a remote location including outpatient surgical locations and urgent care centers) owned and operated by the hospital.

  1. Emergency Care. Emergency care is care received for an emergency condition. An emergency condition is a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

    1. placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such a person or others in serious jeopardy;

    2. serious impairment to such person's bodily functions;

    3. serious dysfunction of any bodily organ or part of such person; or

    4. serious disfigurement of such person.

  2. Surgery. However, the Hospital Program will not pay for follow-up care for surgery, such as removal of sutures and check-up visits.

  3. Diagnostic radiology, radiation therapy and laboratory tests. Diagnostic radiology, radiation therapy and laboratory tests will be paid for only if they are necessary for the treatment or diagnosis of your illness or injury and they are ordered by your doctors. You must be physically present at the outpatient department. Payment will not be made for doctors' charges for interpretations of radiology procedures or laboratory tests.

  4. Pre-admission testing. All of the following conditions must be met:

    1. The tests are ordered by a physician as a preliminary step in your admission to a hospital as a registered bed patient for surgery; and

    2. They are necessary for and consistent with the diagnosis and treatment of the condition for which surgery is to be performed; and

    3. You have a reservation for the hospital bed and for the operating room before the tests are given; and

    4. You are physically present at the hospital when the tests are given; and

    5. Surgery actually takes place within 14 days after the tests are given or is canceled as a result of the pre-admission tests.

  5. Physical therapy. The Hospital Program will pay for physical therapy only when all of the following conditions are met:

    1. The treatments are ordered by your doctor; and

    2. The treatments must start within six months from your discharge from the hospital or within six months from the date outpatient surgery was performed; and

    3. No payment will be made for physical therapy given after 365 days from the date you were discharged from the hospital or the date of the surgery.

    You pay a $20 copayment for each visit to the outpatient department of a network hospital or the greater of 10 percent of charges or $75 at a non-network hospital for physical therapy when covered by the Hospital Program. This payment is in addition to any other payment, either copayment or coinsurance, applied to outpatient services rendered on the same day.

  6. Dialysis treatment. The treatments must be ordered by your doctor.

  7. Chemotherapy. The Hospital Program pays for chemotherapy, except if you are enrolled in the Centers of Excellence Program and receiving care at a Cancer Resource Services network facility.

  8. Mammography. Coverage is available under these conditions:

    1. Upon the recommendation of a physician, a mammogram for covered persons at any age having a prior history of breast cancer, or who have a first degree relative with a prior history of breast cancer;

    2. A single baseline mammogram for covered persons 35 through 39 years of age;

    3. An annual mammogram for covered persons 40 years and older, or more frequently upon the recommendation of a physician.

  9. Administration of Desferal for treatment of Cooley's Anemia. This treatment must be ordered by your doctor and must be performed by a hospital qualified to provide this service as determined solely by the Hospital Program administrator.

  10. Bone mineral density measurements or tests. Bone mineral density measurements or tests include those measurements or tests covered under the Federal Medicare Program as well as those in accordance with the criteria of the National Institutes of Health, including dual-energy X-ray absorptiometry.

  11. The Hospital Program will pay for bone mineral density measurements or tests when delivered in the outpatient department of a hospital, if you meet the criteria of New York State Insurance Law, the Federal Medicare Program criteria or the National Institutes of Health criteria, and, at a minimum, meet the following conditions:

    1. You have been previously diagnosed as having osteoporosis or you have a family history of osteoporosis; or

    2. You have symptoms or conditions indicative of the presence, or the significant risk, of osteoporosis; or

    3. You are on a prescribed drug regimen that poses a significant risk of osteoporosis; or

    4. You have life style factors that pose a significant risk of osteoporosis; or

    5. You have age, gender and/or other physiological characteristics that pose a significant risk of osteoporosis.

Copayment for emergency care

You must pay the first $70 in charges (copayment) for emergency care in a hospital emergency room. See Outpatient Hospital Care for emergency care. Hospitals may require payment of this charge at the time of service.

The $70 emergency room copayment covers use of the facility for emergency care and services of the emergency room physician and providers who administer or interpret radiological exams, laboratory tests, electrocardiograms and pathology services. Refer to What is covered under the Basic Medical Program (non-participating providers) in your Medical/Surgical Program certificate if you receive bills for hospital emergency room service from these providers.

You will not have to pay this $70 copayment if you are treated in the emergency room and it becomes necessary for the hospital to admit you at that time as an inpatient.

Copayment for outpatient hospital services

You must pay the first $60 (copayment) for outpatient surgical expenses and the first $40 (copayment) for one or more of the diagnostic outpatient services, listed below, for each visit to a network facility or the greater of 10 percent of charges or $75 at a non-network facility. Hospitals may require payment of this charge at the time of service.

Hospital outpatient services include:

  • Diagnostic radiology, including mammography according to above guidelines

  • Diagnostic laboratory tests

  • Administration of Desferal for treatment of Cooley's Anemia

One copayment ($60 if surgery is included or $40 if it is not) covers the outpatient facility and will apply for all covered hospital outpatient services.

There is no copayment for certain preventive services received at a network hospital as required under the Patient Protection and Affordable Care Act, such as an annual mammogram for covered females age 40 and older and colonoscopies for covered enrollees age 50 to 75.

There is no copayment for covered birth control surgeries provided at a network facility.

There is no copayment for the following covered hospital outpatient services:

  • Pre-admission testing and/or pre-surgical testing prior to inpatient admission

  • Chemotherapy

  • Radiation therapy

  • Dialysis

  • When the above services are provided at a non-network facility, you must pay the greater of 10 percent of charges or $75.

Skilled Nursing Facility Care

Benefits are subject to the requirements of The Empire Plan's Benefits Management Program. The Empire Plan does not provide Skilled Nursing Facility benefits, even for short-term rehabilitative care, for Retirees, Vestees and Dependent Survivors or their Dependents who are eligible for primary benefits from Medicare.

  1. Conditions for skilled nursing facility care. The Hospital Program will pay for your care in a skilled nursing facility described in Item 2 below when you meet the following conditions:

    1. Care in a skilled nursing facility must be medically necessary. Care is medically necessary when it must be furnished by skilled personnel to assure your safety and achieve the medically desired result.

    2. Custodial care, which is care which is primarily assistance with the activities of daily living, is not covered.

      The Benefits Management Program requirement to call for pre-admission certification applies to skilled nursing facility admissions including transfers from a hospital.

    3. Coverage will only be provided for as long as inpatient hospital care would have been required if care in a skilled nursing facility were not provided. If your care 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 cease.

    4. Benefits in a skilled nursing facility are not provided by the Hospital Program if you are eligible to receive primary benefits from Medicare, even if you fail to enroll in Medicare. You are not eligible to receive Hospital Program benefits if your Medicare benefits for skilled nursing facilities have been exhausted.

    5. Refer to the General Information Book for information on primary coverage under Medicare.

  2. Covered skilled nursing facilities. Benefits for covered services are provided if the facility is either:

    1. a facility that is accredited as a skilled nursing facility by the Joint Commission on Accreditation of Healthcare Organizations; or

    2. certified as a participating skilled nursing facility under Medicare.

    Coverage is subject to the network and non-network level of benefits.

  3. Covered services. The Hospital Program will pay the charges of a skilled nursing facility for:

    • a semi-private room. If you occupy a private room, the Hospital Program will pay an amount equal to the facility's most common charge for a semi-private room. You must pay the excess portion of the charge.

    • physical, occupational and speech therapy

    • medical social services

    • the drugs, biologicals, supplies, appliances and equipment furnished for use in the facility and which are ordinarily provided by the facility to inpatients

    • other services necessary for your health which are generally provided by the facility.

See Number of Days of Care for more information.

Hospice Care

  1. Hospice organizations. The Hospital Program will pay for hospice care provided by a hospice organization that has an operating certificate issued by the New York State Department of Health. If the hospice care is provided outside of New York State, the hospice organization must have an operating certificate issued under criteria similar to those used in New York by a state agency in the state where the hospice care is provided.

    Coverage is subject to the network and non-network level of benefits.

  2. Hospice agreements. The hospice organization must have an operating agreement with a Blue Cross Plan. The operating agreement must state the method which will be used to pay for the hospice care.

  3. Hospice care covered. Hospice care is covered during the period when the hospice has accepted you for its hospice program. The following services provided by the hospice organization are covered:

    1. Bed patient care either in a designated hospice unit or in a regular hospital bed.

    2. Day care services provided by the hospice organization.

    3. Home care and outpatient services which are provided by the hospice and for which the hospice charges you. The services may include at least the following:

      1. intermittent nursing care by an R.N., L.P.N. or Home Health Aides

      2. physical therapy

      3. speech therapy

      4. occupational therapy

      5. respiratory therapy

      6. social services

      7. nutritional services

      8. laboratory examinations, X-rays, chemotherapy and radiation therapy when required for control of symptoms

      9. medical supplies

      10. drugs and medications prescribed by a physician and which are considered approved under the U.S. Pharmacopoeia and/or National Formulary. The Hospital Program will not pay when the drug or medication is of an experimental nature, except as otherwise required by law.

      11. medical care provided by the hospice physician

      12. respite care

      13. bereavement services provided to your family during your illness and until one year after death.

Centers of Excellence for Transplants Program

If you choose to participate in the Centers of Excellence for Transplants Program, you receive enhanced benefits as detailed below. The enhanced benefits include travel reimbursement and a paid-in-full benefit for services covered under the Program and performed at a qualified Center of Excellence. Participation in the Centers of Excellence for Transplants Program is voluntary, but the enhanced benefits under the Program are available only when you are enrolled in the Program, when The Empire Plan is your primary coverage and your transplant services are pre-authorized by the Hospital Program administrator.

If an enrollee has secondary coverage under The Empire Plan, and the enrollee's primary coverage/Health Maintenance Organization (HMO) denies coverage at a facility described below that is covered under the Centers of Excellence for Transplants Program, The Empire Plan will be considered the enrollee's primary coverage for purposes of this section. The enrollee or the enrollee's primary health plan must send the denial letter to the Hospital Program. For assistance with this process, contact The Empire Plan and choose the Hospital Program.

Types of transplants

The benefits under the Centers of Excellence for Transplants Program are available for the following types of transplants:

  • Bone Marrow

  • Cord Blood Stem Cell

  • Heart

  • Heart-Lung

  • Kidney

  • Liver

  • Lung

  • Pancreas

  • Pancreas after Kidney

  • Peripheral Stem Cell

  • Simultaneous Kidney/Pancreas

This is the list of procedures available at the date of printing. As additional Centers of Excellence are added to the Transplant Program this list may change. Call The Empire Plan and choose the Hospital Program for the most up to date information on the types of transplants covered.

Centers of Excellence

Facilities covered under the Centers of Excellence for Transplants Program include:

  • BlueCross and BlueShield Association's Blue Quality Centers for Transplant (BQCT), a national network of transplant providers with demonstrated success in achieving positive outcomes

  • Facilities in New York State that have been identified by the Hospital Program administrator for their excellence in kidney transplantation

What is covered

You receive paid-in-full benefits for the following services:

  • Pre-transplant evaluation

  • Inpatient and outpatient hospital and physician care related to the transplant, including 12 months of follow-up care at the center where the transplant was performed. The twelve month period begins on the date of your transplant.

Pre-authorization

To receive the paid-in-full benefit and the travel benefit, you must call The Empire Plan and choose the Hospital Program to pre-authorize the covered services. To enroll in the Program and receive these benefits, The Empire Plan must be your primary coverage.

Other benefits still available

Since the Centers of Excellence for Transplants Program is voluntary, you are still eligible for Empire Plan benefits for your medically necessary transplant if you do not use the Program. However, you will have to comply with the requirements of the Benefits Management Program and will have to pay any applicable deductible, coinsurance and copayments. You must call the Hospital Program administrator for pre-admission certification of admissions for any transplant.

Infertility Benefits

For the purposes of this benefit, infertility is defined as a condition of an individual who is unable to achieve a pregnancy because the individual and/or partner has been diagnosed as infertile by a physician. Infertility does not include the condition of an individual who is able to achieve a pregnancy but has been unable to carry a fetus to full term.

Infertility benefits, including Qualified Procedures, are subject to the same copayments, deductibles, coinsurance maximums and percentages payable as benefits for other medical conditions under the Participating Provider and Basic Medical programs. Qualified Procedures are subject to a $50,000 lifetime maximum.

What is covered

Covered Services and Supplies include but are not limited to:

  • Artificial/intra-uterine insemination

  • Inpatient and/or outpatient surgical or medical procedures, performed in the hospital, which would correct malfunction, disease or dysfunction resulting in infertility or enhance reproductive capability.

  • Services in relation to diagnostic tests and procedures necessary:

    1. to determine infertility; or

    2. in connection with any surgical or medical procedures to diagnose or treat infertility.

The covered diagnostic tests and procedures include: Hysterosalpingogram; Hysteroscopy; Endometrial Biopsy; Laparoscopy; Sono-Hysterogram; Post-Coital Tests; Testis Biopsy; Semen Analysis; Blood Tests; Ultrasound; and other Medically Necessary Diagnostic Tests and Procedures, unless by law.

The Hospital Program will not exclude coverage for medically necessary care for the diagnosis and treatment of correctable medical conditions otherwise covered by the Plan solely because the medical condition results in infertility.

Additional Infertility Benefits - Additional Infertility Benefits, called Qualified Procedures (specialized procedures that facilitate a pregnancy but do not treat the cause of the infertility), may be available under the Medical/Surgical Program.

You must call The Empire Plan and choose the Medical Program for prior authorization for Qualified Procedures.

Certain procedures, called Qualified Procedures, obtained in the inpatient or outpatient departments of a hospital, are covered under the Hospital Program portion of this Certificate only if you call in advance and receive prior authorization. If the Medical/Surgical Program authorizes the Qualified Procedures, the following are covered:

  • Assisted Reproductive Technology (ART) procedures including:

    • In vitro fertilization and embryo placement

    • Gamete Intra-Fallopian Transfer (GIFT)

    • Zygote Intra-Fallopian Transfer (ZIFT)

    • Intracytoplasmic Sperm Injection (ICSI) for the treatment of male factor infertility

    • Assisted hatching

    • Microsurgical sperm aspiration and extraction procedures, including:

      • Microsurgical Epididymal Sperm Aspiration (MESA), and

      • Testicular Sperm Extraction (TESE)

  • Sperm, egg and/or inseminated egg procurement and processing and banking of sperm or inseminated eggs. This includes expenses associated with cryopreservation (that is, freezing and storage of sperm or embryos).

Maximum lifetime benefit

Benefits paid for Qualified Procedures under The Empire Plan are subject to a lifetime maximum of $50,000 per covered individual. This maximum applies to all covered hospital, medical, travel, lodging and meal expenses that are associated with Qualified Procedures.

Infertility: Exclusions and limitations

Charges for the following expenses are not covered or payable:

  • Experimental infertility procedures. (Infertility procedures performed must be accepted as non-experimental by the American Society of Reproductive Medicine.)

  • Fertility drugs prescribed in conjunction with Assisted Reproductive Technology and dispensed by a retail pharmacy are not covered under this benefit. Benefits for infertility-related drugs are payable on the same basis as for any other prescription drugs payable under The Empire Plan.

  • Medical expenses or other charges related to genetic selection

  • Medical expenses or any other charges in connection with surrogacy

  • Any donor compensation or fees charged in facilitating a pregnancy

  • Any charges for services provided to a donor in facilitating a pregnancy

  • Assisted Reproductive Technology services for persons who are clinically deemed to be high risk if pregnancy occurs, or who have no reasonable expectation of becoming pregnant

  • Psychological evaluations and counseling. See the Mental Health and Substance Abuse Program Certificate for coverage that may be provided for psychological evaluations and counseling.

Other exclusions and limitations that apply to this benefit are included under Exclusions in the General Provisions section of this Certificate.

Centers of Excellence Travel Allowance

When you enroll in the Centers of Excellence for Transplants Program or are preauthorized for Infertility Benefits, you will not have to make any copayments for services performed at a qualified Center of Excellence. A travel, lodging and meal expenses benefit is available to you for travel within the United States. The travel and meals benefit is available to the patient and one travel companion when the facility is more than 100 miles (200 miles for airfare) from the patient's home. If the patient is a minor child, the benefit will include coverage for up to two travel companions. Benefits will also be provided for one lodging per day. Reimbursement for lodging and meals will be limited to the United States General Services Administration per diem rate. Reimbursement for automobile mileage will be based on the Internal Revenue Service medical rate. Only the following travel expenses are reimbursable: lodging, meals, auto mileage (personal and rental car), economy class airfare and coach train fare. Once you arrive at your lodging and need transportation from your lodging to the Center of Excellence, certain costs of local travel are also reimbursable, including local subway, taxi or bus fare; shuttle, parking and tolls.

Number of Days of Care

The Hospital Program will pay up to 365 benefit days of care for each spell of illness. The days of care may be for inpatient hospital care, maternity care in a birthing center, or skilled nursing facility care.

A spell of illness begins when:

  • you are admitted to a hospital or birthing center; or

  • you are admitted to a skilled nursing facility.

The spell of illness ends when, for a period of at least 90 days, you have not:

  • been a patient in a hospital or birthing center; or

  • been a patient in a skilled nursing facility.

  1. Inpatient hospital care. Each day of inpatient hospital care or care in a birthing center counts as one day of care toward the 365-benefit-day limit.

  2. Skilled nursing facility care. Each day of care in a skilled nursing facility counts as one-half benefit day of care. For example, 20 days in a skilled nursing facility count as 10 benefit days of care toward the 365-benefit-day limit. To check when benefits will end for care in a skilled nursing facility, contact the Hospital Program administrator. You will not be sent notice.

  3. Outpatient hospital care and hospice care. Outpatient hospital care is provided whenever you meet the requirements. See Outpatient Hospital Care for details. The 365-benefit-day limitation does not apply to outpatient hospital care. Hospice care is provided for the length of time that the hospice has accepted you for its program. The 365-benefit-day limitation does not apply to hospice care. See Hospice Care for more information.

Hospital Program General Provisions

Limitations and Exclusions

What is not covered

You are not covered by the Hospital Program for benefits for hospitalization or related expenses described in Inpatient Hospital Care, Outpatient Hospital Care, Skilled Nursing Facility Care, Hospice Care, Centers of Excellence for Transplants Program or Infertility Benefits when any of the following apply to you:

  1. Care received prior to your coverage under The Empire Plan. Payment will not be made for services or supplies provided to you before you became covered under The Empire Plan.

  2. Care, services or supplies which are not medically necessary. The Hospital Program requires that the service or care you receive be medically necessary. Medically necessary care is care which, according to the Program administrator's criteria, is:

    • consistent with the symptoms or diagnosis and treatment of your condition, disease, ailment or injury;

    • in accordance with generally accepted medical practices;

    • not solely for your convenience, or that of your doctor or other provider; and

    • the most appropriate supply or level of service which can be safely provided to you.

    Examples of unnecessary care are: when you are admitted to a hospital for care which could have been provided in a doctor's office, or provided without admission to a hospital as a bed patient; when you are in a hospital for longer than is necessary to treat your condition; when hospitalized, you receive ancillary services not required to diagnose or treat your condition; when the care is provided in a more costly facility or setting than is necessary; or when a surgical procedure is performed when a medical treatment would have achieved the desired result.

    In these situations, the Hospital Program administrator's determination of medical necessity will be made after considering the advice of trained medical professionals, which may include physicians, who will use medically recognized standards and criteria. In making the determination, the Program administrator will examine all of the circumstances surrounding your condition and the care provided, including your doctor's reasons for providing or prescribing the care, and any unusual circumstances.

    The fact that your doctor prescribed the care does not automatically mean that the care qualifies for payments under this Plan.

    However, if an External Appeal Agent, in accordance with the external appeal provisions under Appeals overturns the Hospital Program administrator's determination that care was medically unnecessary, the Program administrator will cover the hospitalization or related expense to the extent that the hospitalization or related expense is otherwise covered under this Certificate.

  3. Eye and hearing care. Payment will not be made for eyeglasses, contact lenses or hearing aids and examinations for the prescription or fitting of those items.

  4. Cosmetic surgery. Payment will not be made for services in connection with elective cosmetic surgery which is primarily intended to improve your appearance. However, payment will be made for services in connection with reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the part of the body involved. For a child covered under The Empire Plan, payment will also be made for reconstructive surgery because of congenital disease or anomaly (structural defects at birth) which has resulted in a functional defect.

  5. Custodial care. Payment will not be made for services rendered in connection with a hospital stay or a portion of a hospital stay in connection with physical check-ups, custodial or convalescent care, rest cures or sanitarium-type care. Care is considered custodial when it is primarily for the purpose of meeting personal needs and could be provided by persons without professional skills or training. For example, custodial care includes help in walking, getting in and out of bed, bathing, dressing, eating and taking medicine.

  6. Workers' compensation. Payment will not be made for care for any injury, condition or disease if payment is available to you under a Workers' Compensation Law or similar legislation. Payments will not be made even if you do not claim the benefits you are entitled to receive under the Workers' Compensation Law. Also, payments will not be made even if you bring a lawsuit against the person who caused your injury or condition and even if you received money from that lawsuit and you have repaid the hospital and other medical expenses you received payment for under the Workers' Compensation Law or similar legislation.

  7. Veterans' facility. Payment will not be made for services provided in a veterans' facility or other services furnished, even in part, under the laws of the United States and for which no charge would be made if coverage under The Empire Plan were not in effect. However, this exclusion will not apply to services provided in a medical center or hospital operated by the U.S. Department of Veterans' Affairs for a non-service connected disability in accordance with the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 and amendments.

  8. War. Payment will not be made for services for care of illness or injury due to war, declared or undeclared, which occurs after December 5, 1957.

  9. Free care. Payment will not be made for any care if the care is furnished or would normally be furnished to you without charge. You are not covered for services rendered by a provider for which no legally enforceable charge is incurred.

  10. Medicare. Payment will be reduced by the amount available to you under the federal government's Medicare program. When eligible for primary Medicare coverage, you must enroll in Medicare and file for all benefits available to you under Medicare. Refer to If You Qualify for Medicare for further information.

  11. No-Fault automobile insurance. Payment will not be made for any service which is covered by mandatory automobile No-Fault benefits. However, services not covered under No-Fault, such as when there is a deductible, will be covered by the Hospital Program.

  12. Experimental/investigative procedures. The Hospital Program will not cover any treatment, procedure, drug, biological product or medical device (hereinafter "technology") or any hospitalization in connection with such technology if, in our sole discretion, it is not medically necessary in that such technology is experimental or investigational. Experimental or investigational means that the technology is:

    1. not of proven benefit for the particular diagnosis or treatment of your particular condition; or

    2. not generally recognized by the medical community as reflected in the published peer-reviewed medical literature as effective or appropriate for the particular diagnosis or treatment of your particular condition.

    The Hospital Program will also not cover any technology or any hospitalization in connection with such technology if, in our sole discretion, such technology is obsolete or ineffective and is not used generally by the medical community for the particular diagnosis or treatment of your particular condition.

    Governmental approval of a technology is not necessarily sufficient to render it of proven benefit or appropriate or effective for a particular diagnosis or treatment of your particular condition.

    The Hospital Program administrator may apply the following criteria in exercising its discretion and may in its discretion require that any or all of the criteria be met:

    • any medical device, drug or biological product must have received final approval to market by the United States Food and Drug Administration for the particular diagnosis or condition. Any other approval granted as an interim step in the FDA regulatory process, e.g., an Investigational Device Exemption or an Investigational New Drug Exemption, is not sufficient. Once FDA approval has been granted for a particular diagnosis or condition, use of the medical device, drug or biological product for another diagnosis or condition may require that any or all of the criteria be met.

    • conclusive evidence from the published peer-reviewed medical literature must exist that the technology has a definite positive effect on health outcomes; such evidence must include well-designed investigations that have been reproduced by nonaffiliated authoritative sources, with measurable results, backed up by the positive endorsements of national medical bodies or panels regarding scientific efficacy and rationale.

    • demonstrated evidence as reflected in the published peer-reviewed medical literature must exist that over time the technology leads to improvement in health outcomes, i.e., the beneficial effects outweigh any harmful effects.

    • proof as reflected in the published peer-reviewed medical literature must exist that the technology is at least as effective in improving health outcomes as established technology, or is usable in appropriate clinical contexts in which established technology is not employable.

    • proof as reflected in the published peer-reviewed medical literature must exist that improvement in health outcomes, as defined above, is possible in standard conditions of medical practice, outside clinical investigatory settings.

    • Empire Plan benefits have been paid or approved by the Medical/Surgical Program administrator for the technology based on a determination that the technology is covered under The Empire Plan.

    This exclusion does not apply to cancer drugs as required by Section 4303(q) of the New York State Insurance Law.

    Experimental/Investigational procedures shall also be covered when approved by an External Appeal Agent in accordance with an external appeal. See the external appeal provisions under Appeals. If the External Appeal Agent approves coverage of an Experimental or Investigational procedure, only the costs of services required to provide the procedure to you according to the design of the clinical trial will be covered. Coverage will not be provided for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing research, or costs not otherwise covered by The Empire Plan for non-experimental or non-investigational treatments provided in connection with such clinical trial.

  13. Mental or nervous condition or substance abuse, including alcoholism. The Hospital Program administrator will not pay for diagnostic services or care associated with mental and nervous conditions or treatment of alcoholism in the following settings:

    • inpatient hospital

    • day or night centers

    • outpatient department of a hospital

    • skilled nursing facility

    • home care

    • ambulance service

  14. Home Care. The Hospital Program will not pay for home health care services, including home nursing, home infusion therapy and home health aides. The Program will not pay for the following services or supplies provided outside a hospital or skilled nursing facility: physical, occupational and speech therapy; prescription drugs; and laboratory services. Exception: home health benefits are available under circumstances outlined under Maternity Care.

  15. Autologous and Directed Blood Donations. The Hospital Program will not pay for services rendered in connection with the drawing, processing, disposal and/or storage of blood drawn from the enrollee, or from a donor selected by the enrollee, for the enrollee's own use unless it is medically documented to the satisfaction of the Program administrator that the enrollee's condition requires the use of autologous or directed blood.

  16. Preventable Adverse Events and Conditions. The Hospital Program will not pay for services related to events or errors in medical care that are clearly identifiable, preventable and serious in their consequences. The enrollee will not be responsible for these expenses.

    • Preventable adverse events include foreign object retained after surgery, surgery performed on the wrong patient, wrong surgical procedure performed or surgery performed on the wrong body part.

    • Preventable conditions include stage III and IV pressure ulcers, catheter-associated urinary tract infections, surgical site infections, manifestations of poor glycemic control, deep vein thrombosis and pulmonary embolism following certain orthopedic procedures.

Please refer to the instructions under Appeals if you wish to appeal a total or partial denial of your claim.

Coordination of Benefits (COB)

Which plan pays first

If you are covered by an additional group health insurance program such as through your spouse's employer, The Empire Plan will coordinate benefit payments with the other program. In this case, one program pays its full benefit as the primary coverage, and the other program pays secondary benefits. This prevents duplicate payments and overpayments. In no event shall payment exceed 100 percent of a charge.

The Empire Plan does not coordinate benefits with any health insurance policy which you or your dependent carries on a direct-pay basis with a private plan.

The procedures followed by the Hospital Program when Empire Plan benefits are coordinated with those provided under another program are detailed below.

  1. "Coordination of Benefits" means that the benefits provided for you under The Empire Plan are coordinated with the benefits provided for you under another plan. The purpose of coordination of benefits is to avoid duplicate benefit payments so that the total payments under The Empire Plan and under another plan are not more than the actual charge for a service which is covered under both group plans.

  2. Definitions

    1. "Plan" means a plan which provides benefits or services for or by reason of hospital, medical or dental care and which is:

      1. a group insurance plan; or

      2. a blanket plan, except for blanket school accident coverages or such coverages issued to a substantially similar group where the policyholder pays the premium; or

      3. a self-insured or non-insured plan; or

      4. any other plan arranged through any employee, trustee, union, employer organization or employee benefit organization; or

      5. a group service plan; or

      6. a group prepayment plan; or

      7. any other plan which covers people as a group; or

      8. a governmental program or coverage required or provided by any law except Medicaid or a law or plan when, by law, its benefits are excess to those of any private insurance plan or other non-governmental plan.

    2. "Order of Benefit Determination" means the procedure used to decide which plan will determine its benefits before any other plan.

    3. Each policy, contract or other arrangement for benefits or services will be treated as a separate plan. Each part of The Empire Plan which reserves the right to take the benefits or services of other plans into account to determine its benefits will be treated separately from those parts which do not.

  3. When coordination of benefits applies and The Empire Plan is secondary, payment under The Empire Plan will be reduced so that the total of all payments or benefits payable under The Empire Plan and under another plan is not more than the actual charge for the service you receive.

  4. Payments under The Empire Plan will not be reduced on account of benefits payable under another plan if the other plan has a coordination of benefits or similar provision with the same order of benefit determination as stated in Item 5 and under that order of benefit determination, the benefits under The Empire Plan are to be determined before the benefits under the other plan.

  5. When more than one plan covers the person making the claim, the order of benefit payment is determined using the first of the following rules which applies:

    1. The benefits of the plan which covers the person as an enrollee are determined before those of other plans which cover that person as a dependent;

    2. When this plan and another plan cover the same child as a dependent of different persons called "parents" and the parents are not divorced or separated: (For coverage of a dependent of parents who are divorced or separated, see paragraph C below.)

      1. The benefits of the plan of the parent whose birthday falls earlier in the year are determined before those of the plan of the parent whose birthday falls later in the year; but

      2. If both parents have the same birthday, the benefits of the plan which has covered one parent for a longer period of time are determined before those of the plan which has covered the other parent for the shorter period of time;

      3. If the other plan does not have the rule described in subparagraphs (1) and (2) above, but instead has a rule based on gender of the parent, and if as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefits;

      4. The word "birthday" refers only to month and day in a calendar year, not the year in which the person was born;

    3. If two or more plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order:

      1. First, the plan of the parent with custody of the child;

      2. Then, the plan of the spouse of the parent with custody of the child; and

      3. Finally, the plan of the parent not having custody of the child; and

      4. If the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. This paragraph does not apply to any benefits paid or provided before the entity had such knowledge.

    4. The benefits of a plan which covers a person as an employee or as the dependent of an employee who is neither laid-off nor retired are determined before those of a plan which covers that person as a laid-off or retired employee or as the dependent of such an employee. If the other plan does not have this rule, and if as a result, the plans do not agree on the order of benefits, this rule D is ignored.

    5. If none of the rules in A through D above determined the order of benefits, the plan which has covered the person for the longest period of time determines its benefits first.

  6. For the purpose of applying this provision, if both spouses/domestic partners are covered as employees under The Empire Plan, each spouse/domestic partner will be considered as covered under separate plans.

  7. Any information about covered expenses and benefits, which is needed to apply this provision, may be given or received without the consent of or notice to any person, except as required by Article 25 of the General Business Law.

  8. If an overpayment is made under The Empire Plan before it is learned that you also had other coverage, there is a right to recover the overpayment. You will have to refund the amount by which the benefits paid on your behalf should have been reduced. In most cases, this will be the amount that was received from the other plan.

  9. If payments which should have been made under The Empire Plan have been made under other plans, the party which made the other payments will have the right to receive any amounts which are considered proper under this provision.

When The Empire Plan is secondary to another insurance plan

If a provider receives prior approval to provide services from the plan providing primary coverage, The Empire Plan will not deny a claim for services on the basis that no prior approval from The Empire Plan was received. However, the fact that the plan providing primary coverage has given prior approval for services does not preclude The Empire Plan from determining that the services that were provided were not medically necessary or otherwise not covered under the certificate language.

If You Qualify for Medicare

Your Empire Plan Hospital Program coverage changes when you become eligible for primary coverage under Medicare.

If you or your enrolled dependent is eligible for Medicare at age 65, or because of disability or end stage renal disease, refer to the General Information Book for information on which plan provides your primary coverage.

If you are eligible for primary coverage under Medicare - even if you fail to enroll - your covered hospital and medical expenses will be reduced by the amount that would have been paid by Medicare, and the Hospital Program will consider the balance for payment under the terms of The Empire Plan.

If you or your dependent is eligible for primary coverage under Medicare and you enroll in a Health Maintenance Organization under a Medicare Advantage plan, your Empire Plan benefits will be dramatically reduced under some circumstances, as explained under Medicare Advantage plans and your Empire Plan coverage.

  1. Retired employees and/or their dependents 65 years of age and older.

    1. General. If you are eligible for Medicare, you must enroll in both Part A (hospitalization and skilled nursing facilities) and Part B (medical services and supplies) of Medicare. If you are not eligible for Part A of Medicare, you must still enroll in Part B. You may enroll for Medicare by applying at your local Social Security office.

    2. Medicare and your Empire Plan Hospital Program coverage. The Hospital Program will pay for the following benefits which are not paid for by Medicare:

      1. The initial deductible in each spell of illness.

      2. The coinsurance amount for the 61st through the 90th day of hospital care in each spell of illness.

      3. After you have used the 90 days of hospital care paid for by Medicare, the Empire Plan Hospital Program will pay for additional days of inpatient care in each spell of illness, until Medicare and the Hospital Program have together paid for a total of 365 days of care.

      4. You also have 60 Medicare reserve days in your lifetime. Each reserve day requires a copayment. You may use the reserve days at any time, including after the 90th hospital day when you are using what remains of your 365 Empire Plan Hospital Program benefit days. If you use your Medicare reserve days and Empire Plan Hospital Program benefit days at the same time, the Empire Plan Hospital Program will pay only the copayment. However, each day for which the Hospital Program pays only the copayment applies against the 365 day maximum. Therefore, it is to your advantage to use the reserve days after you have used your 365 Empire Plan Hospital Program benefit days. Refer to your Empire Plan Medical/Surgical Program certificate for information on using your Medical/Surgical Program coverage and Medicare reserve days.

      All of the other benefits provided by Empire Plan Hospital Program under this Plan become available to you after you have exhausted any benefits available to you under Medicare, except for care in a skilled nursing facility.

    3. Payment of Medicare claims. When admitted to a hospital, always show your Empire Plan Benefit Card and your Medicare Identification Card. The hospital will then file claims with Medicare and the Empire Plan Hospital Program. You should not be billed for any charges covered under either of these programs.

    If the hospital does not deal directly with the Empire Plan Hospital Program administrator, submit the Explanation of Benefits form you received from Medicare to the Empire Plan Hospital Program administrator. Covered expenses will then be processed for payment. See Filing and Payment of Claims to find out which plan should receive the claim.

    Remember: Bills go to Medicare, then to the Empire Plan Hospital Program administrator.

    For more information on Medicare benefits and claims, call Medicare or check the Web site (see Contact Information).

  2. Active employees and/or their dependents. If you are an active employee or the dependent of an active employee (except for a domestic partner eligible for Medicare due to age), regardless of age, you automatically have full coverage under this Plan unless you elect in writing to make Medicare the primary coverage. In that case, your coverage under this Plan will terminate.

  3. These benefits will be supplemented by those benefits under Medicare for which you have enrolled. Call your local Social Security office for information on how to file a claim for these supplemental benefits.

    Note for domestic partners: Under Social Security law, Medicare is primary for an active employee's domestic partner who becomes Medicare eligible at age 65. If the domestic partner becomes Medicare eligible due to disability, NYSHIP is primary.

    Contact your personnel office or refer to the General Information Book for further information.

  4. Disability. Medicare provides coverage for persons under age 65 who are disabled according to the provisions of the Social Security Act. The Empire Plan is primary for disabled active employees and disabled dependents of active employees. Retired employees, vested employees and their enrolled dependents who are eligible for primary Medicare coverage because of disability must enroll in Parts A and B of Medicare and apply for available Medicare benefits. Benefits under this Plan are reduced to the extent that Medicare benefits could be available to you.

  5. End Stage Renal Disease. For those eligible for Medicare due to end stage renal disease, whose coordination period began on or after March 1, 1996, NYSHIP will be the primary coverage for the first 30 months of treatment, then Medicare becomes primary. See End stage renal disease in your General Information Book. Benefits under this Plan are reduced to the extent that Medicare benefits could be available to you. Therefore, you must apply for Medicare and have it in effect at the end of the 30-month period to avoid a loss in benefits.

  6. Veterans' Facilities. If you are eligible for primary coverage under Medicare, and you receive treatment in a U.S. Department of Veterans' Affairs facility or other facility of the federal government which is not eligible for payment from Medicare, The Empire Plan will pay as a secondary coverage, not primary coverage. Empire Plan payment will be calculated as if the services were provided by a non-governmental facility and covered under Medicare. You are not responsible for the cost of services in a governmental facility if those expenses would have been covered under Medicare.

Medicare Advantage plans and your Empire Plan coverage

For Medicare-primary Empire Plan enrollees who also enroll in a Medicare Advantage Plan. If you or your dependent enrolls in a Medicare Advantage plan in addition to your Empire Plan coverage, The Empire Plan will not provide benefits for any services available through your HMO or services that would have been covered by your HMO if you had complied with the HMO's requirements for coverage. Covered medical expenses under The Empire Plan are limited to expenses not covered under your Medicare Advantage plan. If your Medicare Advantage plan has a point-of-service option that provides partial coverage for services you receive outside the plan, covered medical expenses under The Empire Plan are limited to the difference between the HMO’s payment and the amount of covered expenses under The Empire Plan.

Termination of Your Empire Plan Hospital Program Coverage

  1. Termination of eligibility. Your coverage under this Plan terminates when you are no longer eligible for NYSHIP coverage. Eligibility for coverage is determined under Regulations of the President of the New York State Civil Service Commission. Refer to the General Information Book for further information concerning eligibility.

  2. Under certain conditions, you may be eligible to continue coverage under this Plan. Refer to the General Information Book for information concerning this eligibility.

    Your coverage will also terminate if you fail to make your premium payments toward the cost of The Empire Plan, if any are required.

  3. Termination of this Plan. If this Plan ends, your coverage will end.

  4. Benefits after termination. If the Hospital Program administrator determines that you are totally disabled from an illness, injury or pregnancy on the date of termination of your coverage, Hospital Program hospitalization and related expense benefits are available while you are totally disabled from that illness, injury or pregnancy for expenses incurred within a period of 90 days after the termination of your coverage, or during a hospital stay that began within that 90 day period.

  5. In no event will you be entitled to receive greater Hospital Program benefits, or Hospital Program benefits for a longer period of time, than you would have been entitled to receive if your coverage had not terminated.

Miscellaneous Provisions

  1. No assignment. You cannot assign any benefits or monies due from the Hospital Program administrator to any person, corporation or other organization. Any assignment by you will be void. Assignment means the transfer to another person or organization of your right to the services provided or your right to collect from the Program administrator for those services.

  2. Your medical records. In order to process your claims, it may be necessary for the Program administrator to obtain your medical records and information from hospitals, skilled nursing facilities, doctors, pharmacists or other practitioners who treated you. When you become covered under this Plan, you automatically give Empire BlueCross BlueShield permission to obtain and use those records and that information for the purposes of payment and administration of health care operations. That permission extends to the physicians and other health care personnel with whom we contract to assist us in administering this Plan and reviewing the medical necessity of services covered under this Plan. If we are unable to obtain the medical records, we have the right to deny payment for that claim. The information will be kept confidential.

  3. Recovery of overpayments and subrogation. In the event that you suffer an injury or illness for which another party may be responsible, such as someone injuring you in an accident or due to medical malpractice, and we pay benefits as a result of that injury or illness, we may subrogated to and may succeed to all rights of recovery against the party responsible for your illness or injury to the reasonable value of any benefits we have paid to the extent permitted by law. This right is limited to the amount of any settlement that represents medical expenses that have been paid. This means we may have the right, as a plaintiff-intervener in an action you may commence, to proceed against the party responsible for your injury or illness to recover the benefits we have paid. However, we shall not exercise our right to bring an independent action if you do not pursue a claim.

  4. Right to develop guidelines. The Hospital Program administrator reserves the right to develop or adopt criteria which set forth in more detail the instances and procedures when they will make payment.

  5. Examples of the use of the criteria are to determine whether hospital inpatient care was medically necessary or whether emergency care in the outpatient department of a hospital was necessary. If you have a question about the criteria which apply to a particular benefit, you may contact the Program administrator and you will receive an explanation of these criteria.

  6. Time to sue. You must start any lawsuit against the Hospital Program administrator within two years from the date on which the Program administrator issued the initial notification that benefits were not available.

Filing and Payment of Hospital Program Claims

  1. Identification card. When you receive hospital services, show your Empire Plan Benefit Card. The hospital will contact Empire BlueCross BlueShield for payment. If you receive hospital services outside of New York State, have the hospital submit its bills to the local Blue Cross Plan and instruct the local Blue Cross Plan to refer the bill to Empire BlueCross BlueShield, Code YLS (see Contact Information for more details).

  2. If you are over 65, or otherwise eligible for Medicare, see Payment of Medicare Claims in the If You Qualify for Medicare section for the payment of Medicare claims.

  3. If the hospital does not deal directly with its local Blue Cross Plan:

    • For services in the United States, the bill is payable to the hospital unless you have already paid the bill. Then Empire BlueCross BlueShield will reimburse you.

    • For services outside of the United States, Empire BlueCross BlueShield will pay you directly.

    • Follow the directions below to file your claim:

    • If you receive inpatient or outpatient services at a non-member hospital, ask the hospital to file the claim for you.

    • If the hospital will not file the claim, you should file the claim directly with the local Blue Cross Plan (the Plan in the area where you received services). Send the local Blue Cross Plan an itemized bill showing the services rendered, the dates on which those services were received, the diagnosis, and your Empire Plan identification number. See Contact Information for instructions on where to send the bill. If the bill is for emergency room medical services, you must also include information about the condition or symptoms that led you to seek emergency room treatment.

      The Hospital Program administrator, at its option, will either pay the hospital directly or will reimburse you directly for covered services. The Empire BlueCross BlueShield payment to you is payment in full for covered services, less any applicable copayments or penalties.

    • Hospital Outside of the United States - Send an original itemized hospital bill in English or with a translation if possible, and your Empire Plan identification number to the address listed in the Contact Information section.

    • In order to process your claims according to the guidelines of The Empire Plan, Empire BlueCross BlueShield may require medical records. To expedite the processing of your claim, you may wish to obtain copies of your medical records from the hospital when you are discharged. It would be helpful to have these records translated into English, if possible.

      Payment for these services will be calculated based on the rate of exchange (foreign exchange rate) effective on the date of discharge as listed in the Wall Street Journal.

    • If assistance is needed in the claims filing process, contact The Empire Plan and choose the Hospital Program.

  4. If Empire BlueCross BlueShield denies your claim for benefits. If Empire BlueCross BlueShield denies your claim for benefits for a medical procedure or service on the basis that the medical procedure or service is not medically necessary, benefits will be paid by Empire BlueCross BlueShield for covered hospitalization and related expenses if:

    • Another Empire Plan program administrator has liability for some portion of the expenses for that same medical procedure or service provided to you and has paid benefits in accordance with Empire Plan provisions on your behalf for that medical procedure or service; or

    • Another Empire Plan program administrator has liability for some portion of the expense for that same medical procedure or service proposed for you and has provided to you a written pre-authorization of benefits stating that Empire Plan benefits will be available to you for that medical procedure or service and the procedure or service confirms the documentation submitted for the pre-authorization; and

    • You provide to Empire BlueCross BlueShield proof of payment or pre-authorization of benefits from the other Empire Plan program administrator regarding the availability of Empire Plan benefits to you for that medical procedure or service.

The above provisions will not prevent Empire BlueCross BlueShield from imposing any penalties that apply for failure to comply with The Empire Plan Benefits Management Program requirements. In addition, the above provisions do not apply if another Empire Plan program administrator paid benefits in error or if the expenses are specifically excluded elsewhere in this Certificate.

Utilization Review Guidelines

If we have all the information necessary to make a determination regarding a preadmission or prospective procedure review, we will make a determination and provide notice to you (or your designee) and your provider, by telephone and in writing, within three business days of receipt of the request. If we need additional information, we will request it within three business days. You or your provider will then have 45 calendar days to submit the information. We will make a determination and provide notice to you (or your designee) and your provider, by telephone and in writing, within three business days of the earlier of our receipt of the information or the end of the 45-day time period.

With respect to preadmission or prospective procedure review of urgent claims, if we have all information necessary to make a determination, we will make a determination and provide notice to you (or your designee) and your provider, by telephone and in writing, within 24 hours of receipt of the request. If we need additional information, we will request it within 24 hours. You or your provider will then have 48 hours to submit the information. We will make a determination and provide notice to you and your provider, by telephone and in writing, within 48 hours of the earlier of our receipt of the information or the end of the 48-hour time period.

Concurrent Reviews. Utilization Review decisions for services during the course of care (concurrent reviews) will be made, and notice provided to you (or your designee) and your provider, by telephone and in writing, within one business day of receipt of all information necessary to make a decision. If we need additional information, we will request it within one business day. You or your provider will then have 45 calendar days to submit the information. We will make a determination and provide notice to you (or your designee) and your provider, by telephone and in writing, within one business day of the earlier of our receipt of the information or the end of the 45-day time period.

For concurrent reviews that involve urgent matters, we will make a determination and provide notice to you (or your designee) and your provider within 24 hours of receipt of the request if the request for additional benefits is made at least 24 hours prior to the end of the period to which benefits have been approved. Requests that are not made within this time period will be determined within the timeframes specified previously for preadmission or prospective procedure review of urgent claims.

If we have already approved a course of treatment, we will not reduce or terminate the approved services unless we have given you enough prior notice of the reduction or termination so that you can complete the appeal process before the services are reduced or terminated.

Retrospective Reviews. If we have all information necessary to make a determination regarding a retrospective claim, we will make a determination and provide notice to you (or your designee) and your provider within 30 calendar days of receipt of the claim. If we need additional information, we will request it within 30 calendar days. You or your provider will then have 45 calendar days to submit the information. We will make a determination and provide notice to you and your provider within 15 calendar days of the earlier of our receipt of the information or the end of the 45-day time period.

Notice of Adverse Determination. A notice of adverse determination (notice that a service is not medically necessary or is experimental/investigational) will include the reasons, including clinical rationale, for our determination, date of service, provider name and claim amount (if applicable). The notice will also advise you of your right to appeal our determination, give instructions for requesting a standard or expedited internal appeal and initiating an external appeal. The notice will specify that you may request a copy of the clinical review criteria used to make the determination. The notice will specify additional information, if any, needed for us to review an appeal and an explanation of why the information is necessary. The notice will also refer to the plan provision on which the denial is based. We will send notices of determination to you (or your designee) and, as appropriate, to your health care provider.

Appeals

You or another person acting on your behalf may submit an appeal. If a post service claim (a claim for benefits payment after medical care has been received) or a preservice request for benefits (including a request for benefits that requires notification, precertification or benefit confirmation prior to receiving medical care) is denied in whole or in part, two levels of appeal are available to you. You may submit an appeal by writing to the address listed in the Contact Information section. Or, call The Empire Plan and choose the Hospital Program.

Appeal process

A qualified individual who was not involved in the decision being appealed will be appointed to decide the appeal. If your appeal is related to clinical matters, the review will be done in consultation with the Hospital Program administrator's Medical Director or a health care professional with appropriate expertise who is credentialed by the national accrediting body appropriate to the profession in that field, and who was not involved in the prior determination. The Program administrator may consult with, or seek the participation of, medical experts as part of the appeal resolution process. By filing an appeal, you consent to this referral and the sharing of pertinent hospital claim information. Upon request and free of charge, you have the right to reasonable access to and copies of all documents, records and other information relevant to your claim for benefit. In addition, if any new or additional evidence is relied upon or generated by the Program administrator during the determination of the appeal, it will be provided to you free of charge and sufficiently in advance of the due date of the decision of the appeal.

Level 1 Appeals

A request for review must be directed to the Hospital Program administrator within 180 days after the claim payment date or the date of the notification of denial of benefits. When requesting a review, you should state the reason why you believe the claim determination or precertification improperly reduced or denied your benefits. Also, submit any data or comments to support the appeal of the original determination as well as any data or information requested by the Program administrator. A written acknowledgment of your appeal will be sent to you within 15 days after it is received.

For a first level appeal of a post service claim, a review of the appeal will be done and within 30 days of your request, the Program administrator will provide you with a written decision.

For a first level appeal of a preservice request for benefits, a review of the appeal will be done and within 15 days of your request, the Program administrator will provide you with a written decision.

If the determination is upheld, the Program administrator's written response will cite the specific Plan provision(s) upon which the denial is based and will include both of the following:

  • Detailed reasons for the determination regarding the appeal. If the case involves a clinical matter, the clinical rationale for the determination will be given.

  • Notification of your right to a further review.

Level 2 Appeals

If, as a result of the Level 1 review, the original determination of benefits is upheld by the Hospital Program administrator, in whole or in part, you can request a Level 2 review. This request should be directed either in writing or by telephone to the Program administrator within 60 days after you receive notice of the Level 1 appeal determination. When requesting the Level 2 review, you should state the reasons you believe the benefit reduction or denial was improperly upheld and include any information requested by the Program administrator along with any additional data, questions or comments deemed appropriate.

For a second level appeal of a post service claim, a review of the appeal will be done and within 30 days of your request, the Program administrator will provide you with a written decision.

For a second level appeal of a preservice request for benefits, a review of the appeal will be done and within 15 days of your request, the Program administrator will provide you with a written decision.

If the determination is upheld, the Program administrator's written response will cite the specific Plan provision(s) upon which the denial is based and will provide detailed reasons for the determination regarding the appeal. If the case involves a clinical matter, the clinical rationale for the determination will be given.

Appeals involving urgent situations: If an appeal involves a situation in which a delay in treatment could significantly increase the risk to your health, or the ability to regain maximum function, or cause severe pain, the appeal will be resolved and you will be notified of the determination in no more than 72 hours following receipt of the appeal. Notice of the determination will be made directly to the person filing the appeal (you or the person acting on your behalf).

If you are unable to resolve a problem with an Empire Plan program administrator, you may contact the Consumer Assistance Unit of the New York State Department of Financial Services at the address listed in the Contact Information section.

External Appeals

Your right to an External Appeal

Under certain circumstances, you have a right to an external appeal of a denial of coverage. Specifically, if the Hospital Program administrator has denied coverage on the basis that the service is not medically necessary or is an experimental or investigational treatment, you or your representative may appeal for review of that decision by an External Appeal Agent, an independent entity certified by the New York State Department of Financial Services to conduct such appeals.

Your right to appeal a determination that a service is not medically necessary

If you have been denied coverage on the basis that the service is not medically necessary, you may appeal for review by an External Appeal Agent if you satisfy the following two criteria:

  1. The service, procedure or treatment must otherwise be a Covered Service under the Policy; and

  2. You must have received a final adverse determination through the internal appeal process described previously and if any new or additional information regarding the service or procedure was presented for consideration, the Hospital Program administrator must have upheld the denial or you must both agree in writing to waive any internal appeal.

Your right to appeal a determination that a service is experimental or investigational

If you have been denied coverage on the basis that the service is an experimental or investigational treatment, you must satisfy the following two criteria:

  1. The service must otherwise be a Covered Service under the Policy; and

  2. You must have received a final adverse determination through the internal appeal process described previously and if any new or additional information regarding the service or procedure was presented for consideration, the Hospital Program administrator must have upheld the denial or you must both agree in writing to waive any internal appeal.

Your attending physician must certify that you have a condition/disease whereby 1) standard health services or procedures have been ineffective or would be medically inappropriate, or 2) for which there does not exist a more beneficial standard health service or procedure covered by the health care plan, or 3) for which there exists a clinical trial or rare disease treatment.

In addition, your attending physician must have recommended one of the following:

  1. A service, procedure or treatment that two documents from available medical and scientific evidence indicate is likely to be more beneficial to you than any standard Covered Service (only certain documents will be considered in support of this recommendation. Your attending physician should contact the New York State Department of Financial Services (see Contact Information) to obtain current information about what documents will be considered acceptable); or

  2. A clinical trial for which you are eligible (only certain clinical trials can be considered).

For the purposes of this section, your attending physician must be a licensed, board-certified or board-eligible physician qualified to practice in the area appropriate to treat your condition or disease.

Your right to appeal that a service should be covered since it is considered a rare disease is defined as a condition:

  • That is currently or has been subject to a research study by the National Institutes of Health Rare Diseases Clinical Research Network or affects fewer than 200,000 United States residents per year; and

  • For which there are no standard health services or procedures covered by the health care plan that are more clinically beneficial than the requested service or treatment.

As part of the external appeal process for rare diseases, a physician other than the member's treating physician, must certify in writing that the condition is a rare disease. The certifying physician must be a licensed, board-certified or board-eligible physician specializing in the appropriate area of practice to treat the rare disease. The physician's certification must provide either that the rare disease:

  • Is or has been subject to a research study by the National Institutes of Health Rare Diseases Clinical Research Network; or

  • Affects fewer than 200,000 United States residents per year.

The certification is to rely on medical and scientific evidence to support the requested service or procedure (if such evidence exists) and must include a statement that, based on the physician's credible experience, there is no standard treatment that will be more clinically beneficial to the member. The statement must also indicate that the requested service or procedure is likely to benefit the member in the treatment of their rare disease and that the benefit outweighs the risks of the service or procedure.

The External Appeal process: If, through the internal appeal process described previously, you have received a final adverse determination upholding a denial of coverage on the basis that the service is not medically necessary or is an experimental or investigational treatment, you have four months from receipt of such notice to file a written request for an external appeal. If you and the Hospital Program administrator have agreed in writing to waive any internal appeal, you have four months from receipt of such waiver to file a written request for an external appeal. The Program administrator will provide an external appeal application with the final adverse determination issued through the Program's internal appeal process described previously or its written waiver of an internal appeal. You may also request an external appeal application from the New York State Department of Financial Services (see Contact Information). Submit the completed application to the Department of Financial Services at the address indicated on the application. If you satisfy the criteria for an external appeal, the Department of Financial Services will forward the request to a certified External Appeal Agent.

You will have an opportunity to submit additional documentation with your request. If the External Appeal Agent determines that the information you submit represents a material change from the information on which the Hospital Program administrator based its denial, the External Appeal Agent will share this information with the Program administrator in order for it to exercise its right to reconsider its decision. If the Program administrator chooses to exercise this right, it will have three business days to amend or confirm its decision. Please note that in the case of an expedited appeal (described in the following), the Program administrator does not have a right to reconsider its decision.

In general, the External Appeal Agent must make a decision within 30 days of receipt of your completed application. The External Appeal Agent may request additional information from you, your physician or the Program administrator. If the External Appeal Agent requests additional information, it will have five additional business days to make its decision. The External Appeal Agent must notify you in writing of its decision within two business days.

If your attending physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to your health, you may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 72 hours of receipt of your completed application. Immediately after reaching a decision, the External Appeal Agent must try to notify you and the Program administrator by telephone or facsimile of that decision. The External Appeal Agent must also notify you in writing of its decision. If the External Appeal Agent overturns the Program administrator's decision that a service is not medically necessary or approves coverage of an experimental or investigational treatment, the Program administrator will provide coverage subject to the other terms and conditions of the Policy. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, the Program administrator will only cover the costs of services required to provide treatment to you according to the design of the trial. The Program administrator shall not be responsible for the costs of investigational drugs or devices, the costs of nonhealth-care services, the costs of managing research, or costs that would not be covered under the Policy for nonexperimental or noninvestigational treatments provided in such clinical trial.

The External Appeal Agent's decision is binding on both you and the Program administrator. The External Appeal Agent's decision is admissible in any court proceeding.

You will be charged a fee of $25 for each external appeal, and the annual limit on filing fees for any claimant within a single year will not exceed $75. The external appeal application will instruct you on the manner in which you must submit the fee. The Program administrator will also waive the fee if it is determined that paying the fee would pose a hardship to you. If the External Appeal Agent overturns the denial of coverage, the fee shall be refunded to you.

Your responsibilities in filing an External Appeal

It is YOUR RESPONSIBILITY to initiate the external appeal process. You may initiate the external appeal process by filing a completed application with the New York State Department of Financial Services. If the requested service has already been provided to you, your physician may file an external appeal application on your behalf, but only if you have consented to this in writing.

Four-month External Appeal deadline

Under New York State law, your completed request for external appeal must be received by the Department of Financial Services within four months (with an additional eight days allowed for mailing) of the date of the Final Notice of Adverse Determination of the first level appeal or the date upon which you receive a written waiver of any internal appeal. The Hospital Program administrator has no authority to grant an extension of this deadline.

Where to Get More Detailed Information

If this book does not answer the questions you may have about your Empire Plan Hospital Program coverage, contact your Health Benefits Administrator (HBA). If your HBA is unable to answer your questions about your coverage, then contact the Hospital Program (see the Contact Information section) or call The Empire Plan.

If you are unable to obtain the information you need, or if you are a retired State employee, you may get in touch with contact the New York State Department of Civil Service (see Contact Information).