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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 III: Medical/Surgical Program
CERTIFICATE OF INSURANCE

The Empire Plan includes the Participating Provider Program, the Basic Medical Program, the Home Care Advocacy Program (HCAP), the Managed Physical Medicine Program, Infertility Benefits and the Centers of Excellence for Cancer Program. The following describes these programs.

The Empire Plan was designed to provide you with comprehensive medical care coverage and to do so in such a way as to curb rising health care costs. To receive the highest level of benefits, be sure you understand each of these programs.

Plan Overview

Medical coverage for most services is under the Participating Provider Program and the Basic Medical Program (covering non-participating providers). The following information will give you an overview of how these two parts work to provide benefits for covered services.

If you choose a Participating Provider

You pay only the copayment. (Some services require no copayment.)

If you choose the Basic Medical Program (a Non-Participating Provider)

Before your covered expenses can be reimbursed, you must meet an annual medical deductible. If you have Family coverage, your enrolled spouse/domestic partner must meet an annual deductible. All your enrolled children, combined, must meet an annual deductible. Please do not send claims to the Medical/Surgical Program administrator until the annual deductible is satisfied.

Once the annual deductible is satisfied, submit claims to the Program administrator. The Empire Plan reimburses you 80 percent of the reasonable and customary charges for covered services and supplies or the Scheduled Pharmaceutical Amount for Pharmaceutical Products or the actual billed charges, whichever is less.

You pay the remaining 20 percent (coinsurance) until you and your family meet the coinsurance maximum. You also pay any charges above the reasonable and customary amount.

Note: There are also five special programs under your Medical/Surgical Program coverage: the Home Care Advocacy Program for home care services and durable medical equipment and supplies; the Managed Physical Medicine Program for chiropractic treatment and physical therapy; the Basic Medical Provider Discount Program; the Infertility Benefits Program; the Centers of Excellence for Cancer Program. Special benefits and requirements apply under these programs, as explained in each section.

Participating providers

Participating providers have agreed to accept a schedule of allowances, including any copayment, for their services. When you use a participating provider, you pay the provider your copayment for covered services and Medical/Surgical Program administrator pays the provider in accordance with the schedule of allowances. You do not have to pay the participating provider for remaining charges for covered services or submit a claim form. You sign a claim form, the provider sends it to the Program administrator, and the Program administrator sends you an explanation of benefits form telling you what benefits the participating provider received.

Using participating providers is convenient for you and helps keep the cost of The Empire Plan at a reasonable level.

Basic Medical (Non-participating providers)

The second portion of this Plan is the Basic Medical Program. When you use a non-participating provider, you are responsible for paying the provider's charges, and must submit a claim for benefits due you. You are liable for an annual deductible, for a percentage of covered medical expenses in excess of the deductible, for any charges above the reasonable and customary amount, and for any penalties incurred under the benefits management programs. See How, When and Where to Submit Claims for information on how to submit Basic Medical claims.

The Benefits Management Program requirements apply, if The Empire Plan is primary

Please refer to Section I: The Empire Plan Benefits Management Program. Also refer to the sections of this certificate on HCAP, the Managed Physical Medicine Program, and Infertility Benefits. Make sure you understand the steps you must take for each program in order to receive maximum benefits.

Your benefits under both the Participating Provider Program and the Basic Medical Program can be affected by the requirements of the Benefits Management Program.

Hospital admission

If you have a hospital admission which is covered under this Plan, you must comply with the Pre-Admission Certification requirements. If you do not comply, you will be subject to paying a $200 inpatient deductible if any portion of the hospitalization is determined to be medically necessary. You will be responsible for all charges for any day it is determined that your hospitalization is not medically necessary.

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

If you have Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scans or Nuclear Medicine tests that require Prospective Procedure Review (PPR) you must comply with PPR requirements. If you do not comply you may be subject to paying a higher share of the cost as explained in the Benefits Management Program: Pre-Admission Certification and Prospective Procedure Review. If you do not comply with PPR requirements and the Medical/Surgical Program administrator's review does not confirm that the procedure was medically necessary, you will be responsible for the full charges. Read Section I: The Empire Plan Benefits Management Program section for complete information.

HCAP requirements apply even if Medicare is primary

If you need home nursing services, home infusion therapy enteral formulas and/or durable medical equipment/supplies, you must comply with the requirements of the Home Care Advocacy Program (HCAP), even if Medicare is your primary coverage. When you follow HCAP requirements, you will have a paid-in-full benefit. If you do not comply, non-network benefits will apply for medically necessary services: you must pay for the first 48 hours of private duty nursing per calendar year. You must meet the combined annual deductible and you will be reimbursed up to 50 percent of the HCAP Network Allowance. Read the Home Care Advocacy Program section for complete information.

MPN requirements apply even if Medicare is primary

To receive network benefits, the highest level of benefits for chiropractic treatment or physical therapy, you must comply with the requirements of the Managed Physical Medicine Program, administered by Managed Physical Network, Inc. (MPN). When you choose MPN providers, you pay only a $20 copayment. When you use non-network providers, you pay a much higher share of the cost unless MPN has made arrangements for you because no network providers are available in your area. Under non-network coverage, you are liable for an annual deductible, for a percentage of covered medical expenses in excess of the deductible and for any charges above your maximum annual benefit. Read the Managed Physical Medicine Program section for complete information.

Infertility Benefits requirements apply, even if Medicare is primary

Special benefits and requirements apply for Empire Plan Infertility Benefits. For infertility treatment, you must call the Medical/Surgical Program for prior authorization of certain Qualified Procedures, regardless of provider or where the procedure is performed. The Lifetime Maximum for authorized Qualified Procedures for infertility treatment is $50,000 per covered person under The Empire Plan hospital and medical programs. When care is authorized at a participating Center of Excellence, you have paid-in-full benefits. Read the Infertility Benefits section for complete information.

Meaning of Terms Used

Throughout this certificate, the meaning of these terms is limited to these definitions:

  1. This Plan means the medical expense coverage, described in this plan document (previously provided under Group Policy Nos. 30500-G and 30501-G as of December 31, 2012) and any subsequent amendments, which is self-insured by the New York State Department of Civil Service and for which UnitedHealthcare Insurance Company of New York is the administrative services provider.

  2. The word You as used in this Plan means you, the enrollee, and you, an eligible dependent member of the enrollee's family. Enrollee and Dependent are defined in the NYSHIP General Information Book.

  3. Provider means a practitioner licensed and/or certified and qualified under his/her respective scope of license under applicable state law to perform a covered medical service. Providers include, but are not limited to, Audiologists, Certified Midwives, Chiropractors, Dentists, Licensed Nurse Practitioners, Nurses, Optometrists, Pathologists, Physical Therapists, Physicians or Speech Therapists. Provider also means facilities legally licensed to perform a covered medical service, including but not limited to Convenience Care Clinics, Dialysis Centers, Laboratories and Outpatient Surgical Centers.

  4. Hospital is defined in the Hospital Program section of this book.

  5. Participating Providers are those eligible providers who have an agreement in effect with the Medical/Surgical Program administrator to accept your copayment plus payment directly from the Program administrator, in accordance with The Empire Plan schedule of allowances, as payment-in-full for covered medical services under the Participating Provider Program. Exceptions to payment-in-full under the program are detailed in Section I: The Empire Plan Benefits Management Program and under Infertility Benefits.

  6. Home Care Advocacy Program (HCAP) Providers are those eligible providers who have an agreement in effect with the Medical/Surgical Program administrator to provide home nursing services, home infusion therapy and/or durable medical equipment or supplies under the Home Care Advocacy Program.

  7. Schedule of Allowances means the Medical/Surgical Program administrator's schedule of amounts it will pay to Empire Plan participating providers for covered medical services.

  8. A Non-Participating Provider is one who has not entered into an agreement with the Medical/Surgical Program administrator to accept payment in accordance with the schedule of allowances for covered medical expenses under this Plan. You are responsible for paying a non-participating provider's charges. To receive reimbursement for such charges you must file a claim with the Program administrator. The fees charged by a non-participating provider may exceed the amount reimbursed by the Program administrator.

  9. MPN Network Providers are those eligible providers who have an agreement in effect with Managed Physical Network, Inc. (MPN) to accept your copayment plus the MPN Network Allowance as payment in full for chiropractic treatment and physical therapy under the Managed Physical Medicine Program.

  10. MPN Network Allowance means the amount MPN Network providers have agreed to accept as payment in full for services they render to you, including your copayments, under the Managed Physical Medicine Program.

  11. An MPN Non-Network Provider is one who has not entered into an agreement with Managed Physical Network, Inc. (MPN) to accept payment in accordance with the MPN Network Allowance under the Managed Physical Medicine Program for chiropractic treatment or physical therapy. You are responsible for paying a non-network provider's charge. To receive reimbursement for such charges you must file a claim with the Medical/Surgical Program. The fees charged by a non-network provider may exceed the amount reimbursed by the Medical/Surgical Program administrator.

  12. HCAP Network Allowance means the amount network providers have agreed to accept as payment in full for services they render to you.

  13. HCAP Non-network Allowance means the lower of the following:

    • the amount you actually paid for a medically necessary service, equipment or supply covered under HCAP; or

    • 50 percent of the HCAP network allowance for such service, equipment or supply.

    The HCAP non-network allowance for a home care service, durable medical equipment or supply is determined by the Medical/Surgical Program administrator and applied according to established guidelines. The non-network allowance is used by the Program administrator as a basis for determining the amount of benefits you are entitled to receive under non-network coverage.

  14. An HCAP Non-Network Provider is one who has not entered into an agreement with the Medical/Surgical Program administrator to accept payment in accordance with the HCAP Network Allowance under the Home Care Advocacy Program. You are responsible for paying a non-network provider's charge. To receive reimbursement for such charges you must file a claim with the Program administrator. The fees charged by a non-network provider may exceed the amount reimbursed by the Program administrator.

  15. Medically Necessary or Medical Necessity means the health care services, supplies and Pharmaceutical Products that are determined by the Medical/Surgical Program administrator to be medically appropriate and:

    1. Necessary to meet your basic health needs

    2. Rendered in the least intensive and most appropriate setting for the delivery of the service or supply

    3. Consistent in type, frequency and duration of treatment with scientifically based guidelines of national medical research or health care coverage organizations or government agencies that are accepted by the Medical/Surgical Program administrator

    4. Consistent with the diagnosis of the condition

    5. Required for reasons other than the comfort or convenience of you or your physician or other provider

    6. Demonstrated through prevailing peer-reviewed medical literature to be either:

      1. safe and effective for treating or diagnosing the sickness or condition for which their use is proposed, or,

      2. safe with promising efficacy

        1. for treating life-threatening sickness or condition,

        2. in a clinically-controlled research setting, and

        3. using a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health

    The fact that a physician or other provider has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness or pregnancy does not mean that it is medically necessary as defined above. The definition of medically necessary used in this Certificate relates only to coverage and differs from the way in which a physician or other provider engaged in the practice of medicine may define medically necessary.

  16. Covered Medical Expenses means the covered charges for covered medical services performed or supplies prescribed by a physician or other provider, except as otherwise provided below, due to your sickness, injury or pregnancy. A covered medical expense is incurred on the date the service or supply is received by you. In order for a charge to be a covered medical expense, the service or supply must be provided by a provider as defined in paragraph C above. Charges for a service or supply by a person or facility that is not a provider as defined above are not covered medical expenses.

    The fact that a physician or other provider recommends that a service be provided by a person who is not a provider does not make the charge for that service a covered medical expense, even if the care provided is medically necessary. These services or supplies must be medically necessary as defined in this section. A more detailed description of covered expenses and exclusions follows.

    Covered medical expenses are subject to the Medical/Surgical Program’s reimbursement policy guidelines. The Medical/Surgical Program administrator develops these reimbursement policy guidelines in accordance with one or more of the following methodologies:

    • As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association and/or the Centers for Medicare and Medicaid Services (CMS)

    • As reported by generally recognized professionals or publications

    • As used for Medicare

    • As determined by medical staff and outside medical consultants pursuant to other appropriate sources or determinations that the Medical/Surgical Program administrator accepts

    Following evaluation and validation of certain provider billings (e.g., error, abuse and fraud reviews), the reimbursement policies are applied to provider billings. The Medical/Surgical Program administrator shares the reimbursement policies with participating providers through its provider web site. Participating providers may not bill you for the difference between their schedule of allowances (as may be modified by the reimbursement policies) and the billed charge. However, nonparticipating providers are not subject to this prohibition and they may bill you for any amounts the Medical/Surgical Program administrator does not pay, including amounts that are denied because one of the reimbursement policies does not reimburse (in whole or in part) for the service billed. You may obtain copies of the reimbursement policies for yourself or to share with your nonparticipating provider by going to the web site listed on the Contact Information page for the Medical/Surgical Program or by calling Customer Care at the telephone number on your ID card.

  17. Reasonable and Customary Charge means the lowest of:

    1. the actual charge for a service or supply; or

    2. the usual charge by the physician or other provider for the same or similar service or supply; or

    3. the usual charge of other physicians or other providers in the same or similar geographic area for the same or similar service or supply.

    The determination of the reasonable and customary charge for a service or supply is made by the Medical/Surgical Program administrator. In making the determination of the reasonable and customary charge for a service or supply, the Medical/Surgical Program administrator uses data sources including the benchmarking database maintained by FAIR Health, a nonprofit organization approved by the State of New York.

    You are responsible for any amount billed by a nonparticipating provider that exceeds the reasonable and customary charge, in addition to the annual deductible and coinsurance amounts.

  18. Combined annual deductible means the amount you must pay in total, each calendar year, for covered Basic Medical Program expenses, non-network Home Care Advocacy Program expenses and/or non- network Mental Health and Substance Abuse Program expenses before benefits will be paid under these components of the Plan.

    The Empire Plan combined annual deductible is $1,000 for the enrollee, $1,000 for the enrolled spouse/domestic partner and $1,000 for all dependent children combined. The combined annual deductible must be met before your claims can be reimbursed.

    There is a separate deductible of $250 for the enrollee, $250 for the enrolled spouse/domestic partner and $250 for all dependent children combined for non-network physical medicine office visits under the Managed Physical Medicine Program.

  19. Calendar Year means the period beginning with January 1 and ending with December 31.

  20. Coinsurance means the difference between the reasonable and customary charge or Scheduled Pharmaceutical Amount and the covered percentage under the Basic Medical Portion of the Plan. Coinsurance also means the difference between the network allowance and the covered percentage under the Managed Physical Medicine Program and the Home Care Advocacy Program. You pay the coinsurance.

  21. Covered percentage

    1. Under the Participating Provider Program, the covered percentage is 100 percent of the schedule of allowances, including your copayment.

    2. Under the Basic Medical portion of this Plan, the covered percentage for covered medical expenses is 80 percent of the reasonable and customary charge or the Scheduled Pharmaceutical Amount except:

      1. as provided under Prospective Procedure Review: MRI; under Home Care Advocacy Program; under Guaranteed access for the Managed Physical Medicine Program and under Infertility Benefits; and

      2. The covered percentage becomes 100 percent of the reasonable and customary charge or the Scheduled Pharmaceutical Amount once the combined annual coinsurance maximum is met.

      3. 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.

        The annual deductible does not count toward the coinsurance maximum. Any expenses above the reasonable and customary charge or the Scheduled Pharmaceutical Amount do not count. Expenses under the Home Care Advocacy Program, Managed Physical Medicine Program and the Benefits Management Program do not count toward the coinsurance maximum, nor do any penalties under the Benefits Management Program or the Home Care Advocacy Program.

        Once the coinsurance maximum is met, covered medical expenses will be reimbursed at 100 percent of the reasonable and customary or Scheduled Pharmaceutical Amount, or 100 percent of the billed amount, whichever is less. You will still be responsible for any charges above the reasonable and customary or Scheduled Pharmaceutical Amount and any penalties under the benefits management programs.

    3. For Infertility Benefits, expenses are paid the same as for other medical conditions: the covered percentage for Basic Medical Program services is 80 percent of the reasonable and customary charges. Under the Participating Provider Program, the covered percentage is 100 percent of scheduled allowances after your copayments. However, you have no copayment at an Infertility Center of Excellence. Certain benefits are subject to prior authorization and to a lifetime maximum as indicated in the section titled Infertility Benefits.

  22. Outpatient means that covered medical expenses are incurred in a physician’s or other provider’s office, in the outpatient department of a hospital or in a hospital extension clinic (an outpatient facility that is hospital owned and is not in the same location as the hospital).

  23. Inpatient means covered medical expenses are incurred during confinement for which a room and board charge is made by a hospital.

  24. The Annual Maximum for the Basic Medical portion of this Plan is unlimited.

  25. The Lifetime Maximum for authorized Qualified Procedures for infertility treatment is $50,000 per covered person under The Empire Plan hospital and medical programs.

  26. Emergency Care is care received for an emergency condition. An emergency condition is a medical 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;

    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.

  27. Your Copayment is the first $20 which you are required to pay for certain services by participating providers and MPN Network Providers, or the first $30 in a participating outpatient surgical location.

  28. An Urgent Care Center is a facility staffed by medical professionals that include physicians and nurses, with evening and weekend hours. It provides services for acute and uncomplicated problems without the need for an appointment.

  29. A spell of illness begins when you are admitted as a patient to a hospital, birthing center or skilled nursing facility or receive home health care. When you are no longer a patient or receiving home health care for a period of at least 90 days for the same illness, the spell of illness ends, and benefits are available to you again starting with the date of your new spell of illness.

  30. Nuclear Medicine means a subspecialty of Radiology best used to demonstrate both image and function of a body organ, as well as its anatomy. It has diagnostic capabilities as well as valuable therapeutic applications and uses very small amounts of radioactive substances, or tracers that are attracted to specific organs, bones or tissues, to diagnose or treat disease.

  31. Scheduled Pharmaceutical Amount means:

    For covered Pharmaceutical Products, the lowest of:

    1. the actual charge billed for such covered Pharmaceutical Product or

    2. the average wholesale price of such Pharmaceutical Product as set forth in the Red Book published by Thomson Reuters. The Pharmaceutical Product pricing information is updated annually on October 1st. When Red Book does not have a price for the product, the Medical/Surgical Program administrator uses alternative pricing sources such as RJ Health or an internally developed pharmaceutical pricing resource to determine the average wholesale price for the covered Pharmaceutical Product. The Program administrator will provide specific pricing information to you upon request.

    You are responsible for any amount billed by a non-participating provider which exceeds the Scheduled Pharmaceutical Amount in addition to the annual deductible and coinsurance amounts.

  32. Pharmaceutical Products means FDA-approved prescription Pharmaceutical Products administered by a physician or other provider within the scope of the provider’s license. Pharmaceutical Products do not include pharmaceuticals that are dispensed to you by a licensed pharmacy, which are subject to the provisions of your prescription drug program.

  33. Convenience Care Clinic is a health care clinic located in a fixed location in a retail store, supermarket or pharmacy that treats uncomplicated minor illnesses and provides preventive health care services. It is staffed by medical professionals that include physicians, licensed nurse practitioners, physician assistants and nurses and is designed to provide fast, appointment-free health care services. Only services received at a participating Convenience Care Clinic are covered; services received at a nonparticipating Convenience Care Clinic are not covered.

  34. Preventive Care Services means routine health care that includes screenings, check-ups and patient counseling to prevent illnesses, disease or other health problems. The federal Affordable Care Act (ACA) requires coverage of certain preventive care services received from a participating provider to be paid at 100 percent (not subject to copayment). Preventive care services covered under the ACA include:

    • Items or services with an “A” or “B” rating from the United States Preventive Services Task Force;

    • Immunizations for children, adolescents and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;

    • Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and

    • Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration.

    For further information on preventive care services, see the Empire Plan Preventive Care Coverage Chart at the New York State Department of Civil Service web site (see Contact Information), or visit www.hhs.gov/healthcare/rights/preventive-care or www.hhs.gov/safety/index.html.

  35. Program administrator means the company contracted by the State of New York to administer the Empire Plan Medical/Surgical Program. The Medical/Surgical Program administrator is UnitedHealthcare. 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 Medical/Surgical Program.

Participating Provider Program

The Participating Provider Program of The Empire Plan is described in this portion.

When you use a participating provider, you pay only applicable copayments. Not all services are subject to copayments and you pay a maximum of two copayments per visit for services billed by the same provider:

  • One copayment applies to charges for an office visit and/or office surgery.

  • One copayment applies to charges for laboratory and/or radiology services provided in the same visit. If a laboratory test and/or radiology test is sent to an outside service, an additional copayment(s) will apply.

Except as noted below, your copayment is $20. After you pay any applicable copayments, charges for these services will be paid directly to the participating provider in accordance with the Program’s schedule of allowances.

Your out-of-pocket expenses are lower when you choose participating providers

If the services you receive are for other than preventive care as required by the Patient Protection and Affordable Care Act (PPACA), you pay only your $20 copayment(s) for office visits, home visits, surgical procedures performed during an office visit, radiology services, diagnostic laboratory services and visits to a cardiac rehabilitation center, urgent care center or convenience care clinic when they are covered under the Participating Provider Program. You pay only your $30 copayment for facility charges, including anesthesiology, at a participating outpatient surgical location. There is no cost to you for some services covered under the Participating Provider Program.

Finding Participating Providers

To learn whether a doctor, specialist, laboratory, outpatient surgical location, cardiac rehabilitation center or urgent care center is an Empire Plan participating provider, check with the provider directly or call The Empire Plan and choose the Medical Program or visit NYSHIP Online (see Contact Information).

The Directory also lists physicians in the following areas who are in the UnitedHealthcare Options Preferred Provider Organization (PPO) network and have agreed to participate in The Empire Plan: Arizona; Connecticut; Florida; Maryland; New Jersey; North Carolina; Pennsylvania; South Carolina; Virginia; Washington, D.C.; West Virginia and the greater Chicago area. Ask physicians in these areas if they are in the UnitedHealthcare Options PPO network and tell them you are covered by The Empire Plan. In all other states including New York, and for providers other than physicians in these areas, ask if the provider participates in The Empire Plan.

When you use a participating provider, the Medical/Surgical Program administrator will pay for the covered medical services listed below. You must advise the participating provider of your Empire Plan coverage before you receive services. Benefits are automatically assigned and the Program administrator will pay the participating provider directly in accordance with the schedule of allowances. By using participating providers, you minimize your out-of-pocket expenses.

You have the freedom to choose any participating provider without a referral. However, there is no guarantee a participating provider will always be available to you. The Empire Plan does not require that a participating provider send you to a participating specialist, laboratory, radiologist or center. Ask for a participating provider and ask that samples be sent to a participating laboratory. It is always your responsibility to determine whether a provider is an Empire Plan participating provider.

When you use a non-participating provider, covered benefits are payable under the Basic Medical portion of the Plan, so your out-of-pocket expenses are usually higher.

Guaranteed Access

The Empire Plan will guarantee access to primary care physicians and specialists (listed as follows) in New York or in the counties of Fairfield and Litchfield in Connecticut; Bershire in Massachusetts; Bergen, Hudson, Middlesex, Passaic, Sussex and Union in New Jersey; Bradford, Erie, McKean, Pike, Potter, Susquehanna, Tioga, Warren and Wayne in Pennsylvania; and Addison, Bennington, Chittenden, Grand Isle and Rutland in Vermont, when there is not an Empire Plan participating provider within a reasonable distance from an enrollee's residence (see chart that follows).

To receive network benefits, enrollees must contact the Medical Program prior to receiving services and use one of the providers approved by the Program. You will be responsible for contacting the provider to arrange care. Appointments are subject to provider's availability and the Program does not guarantee that a provider will be available in a specified time period. Guaranteed access applies when The Empire Plan is your primary health insurance coverage (pays benefits first, before any other group plan or Medicare), the enrollee lives in New York State or counties listed in the previous paragraph in Connecticut, Massachusetts, New Jersey, Pennsylvania and Vermont and there is not an Empire Plan participating provider within a reasonable distance from the enrollee's residence.

Reasonable distance from the enrollee's residence is defined by the following mileage standards:

Primary Care

Urban: 8 miles
Suburban: 15 miles
Rural: 25 miles

Specialist

Urban: 15 miles
Suburban: 25 miles
Rural: 50 miles

Within these mileage standards, network benefits are guaranteed for the following primary care physicians and core specialties:

Primary Care Physicians

Family Practice
General Practice
Internal Medicine
Pediatrics
Obstetrics/Gynecology

Specialties

Allergy
Anesthesia
Cardiology
Dermatology
Emergency Medicine
Gastroenterology
General Surgery
Hematology/Oncology
Neurology
Ophthalmology
Orthopedic Surgery
Otolaryngology
Pulmonary Medicine
Radiology
Rheumatology
Urology

What is covered under the Participating Provider Program

Under the Participating Provider Program, covered medical expenses include charges for the following services.

  1. Adult Immunizations – Adult immunizations as recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention are covered, not subject to copayment, when received from a participating provider. Covered adult immunizations include influenza, pneumonia, measles-mumps-rubella (MMR), varicella (chickenpox), tetanus immunizations, Human Papillomavirus (HPV) immunizations (covered for enrollees and dependents age 19 through 26), meningitis immunizations and Herpes Zoster (Shingles) immunizations (paid in full for enrollees and dependents age 60 or older; subject to copayment for enrollees and dependents age 55 through 59).

  2. Breast Pumps – You are covered, not subject to copayment, for purchase of a double-electric breast pump following the birth of your child. This is a network benefit only; you must utilize a Medical/Surgical Program national provider.

  3. Cardiac Rehabilitation Center – If your physician prescribes cardiac rehabilitation, you pay a $20 copayment for each visit to a freestanding cardiac rehabilitation center that has an Empire Plan agreement in effect with the Medical/Surgical Program on the date of your visit. You pay a single copayment for use of the facility and services you receive from nurses and physicians who monitor the program. There is no copayment for visits to a hospital-based cardiac rehabilitation center that has an Empire Plan agreement in effect with the Medical/Surgical Program administrator on the date of your visit.

  4. Chronic Care – You are covered for chronic care services for chemotherapy, radiation therapy and dialysis. There is no copayment for these chronic care services or for related services rendered during the course of chemotherapy, radiation therapy or dialysis.

  5. Contraceptive Drugs and Devices – When the office visit is solely for the purpose of obtaining such drug or device, including contraceptive drugs and devices dispensed by the provider, the visit is covered, not subject to copayment. The costs of FDA-approved contraceptive methods for women, including sterilization, that require physician intervention, are covered and are not subject to a copayment.

  6. Dental Care – You are covered for dental services, subject to copayment, including Pharmaceutical Products and appliances dispensed by a provider:

    • For the correction of damage caused by an accident, provided the services, supplies or Pharmaceutical Products are received within 12 months of the trauma and while you are covered under this Plan.

    • For the correction of damage caused by a medical illness, congenital disease or anomaly for which you are eligible for benefits under this Plan.

    • For charges incurred for temporomandibular joint (TMJ) syndrome for the following conditions that are consistent with the diagnosis of organic pathology of the joint and can be demonstrated by X-ray: degenerative arthritis, osteoarthritis, ankylosis, tumors, infections and traumatic injuries.

    • For TMJ, covered services, supplies, or Pharmaceutical Products include diagnostic exams, X-rays, models and testing, injections of medications and trigger point injections.

  7. Diabetes Education Centers – If you have a diagnosis of diabetes, you are covered for visits for self-management education, subject to an office visit copayment.

  8. Diagnostic Laboratory and Radiology – You are covered for diagnostic laboratory and radiology procedures performed as outpatient services. You are also covered for the separate interpretation of radiology procedures by a radiologist if the radiologist bills separately.

    If both outpatient diagnostic laboratory tests and outpatient radiology procedures are billed by a participating provider during a single visit, only one copayment will apply.

  9. Infertility Treatment – See Infertility Benefits for information regarding benefits for the treatment of infertility.

  10. In-Hospital Anesthesia – You are covered for anesthesia services if such services are performed in connection with in-hospital surgery or maternity care. You are not covered if the anesthesia services are administered by your surgeon, by your surgeon’s assistant or by a hospital employee.

  11. In-Hospital Physician’s or Other Provider’s Visits – You are covered for physician’s or other provider’s visits while an inpatient in a hospital if such visits are not related to surgery. Benefits for visits related to surgery are included in the scheduled amount for the surgery.

    Services provided in the Outpatient Department of a Hospital – There is no copayment for covered outpatient services provided in the outpatient department of a hospital by a participating provider.

  12. Mammograms – In addition to mammograms performed when a medical condition is suspected or known to exist, you are covered for mammograms under these conditions:

    • a single baseline mammogram for covered persons 35 through 39 years of age, subject to copayment;

    • a mammogram every year for covered persons 40 years of age and older, or more frequently upon the recommendation of a physician or other provider. Mammograms performed for routine preventive care are not subject to copayment;

    • upon the recommendation of a physician or other provider, 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. A copayment will apply if the covered person is age 39 or younger.

  13. Mastectomy Bras – Mastectomy bras, including replacements when functionally necessary, are covered when prescribed by a physician. There is no copayment when you use a participating provider.

  14. Maternity Care – You are covered for care related to pregnancy and childbirth. This includes care given before and after childbirth and for complications of pregnancy. The Medical/Surgical Program administrator’s payment of maternity benefits may be made in up to two payments (at reasonable intervals) for covered care and treatment rendered during pregnancy, and a separate payment for the delivery and post-natal care provided.

    Maternity care may be rendered by a physician or other provider such as a licensed or certified midwife. The midwife must be:

    1. licensed or certified to practice midwifery; and

    2. permitted to perform the service under the laws of the state where the services are rendered.

    There is no copayment for prenatal visits, delivery and the six-week check-up after delivery.

  15. Nutritional Counseling/Medical Nutritional Therapy – You are covered when the treatment is medically necessary and the provider is licensed in the state where the service is rendered.

  16. Office and Home Visits – You are covered for office visits and home visits by a physician or other provider for general medical care, diagnostic visits, treatment of illness, allergy desensitization, immunization visits and well-child care. General medical care includes routine and preventive pediatric care and routine and preventive adult care, including gynecologic exams.

    If your participating physician or other provider uses a nonparticipating provider for laboratory testing or interpretation of radiology, that service is covered under Basic Medical Program benefits, subject to deductible and coinsurance.

    There is no copayment for well-child office visits, including routine pediatric examinations, pediatric immunizations and the cost of oral and injectable substances, according to prevailing clinical guidelines.

    There is no copayment for professional services for allergy immunotherapy or allergy serum when billed by a participating provider. If there is an associated office visit, a copayment will apply.

  17. Outpatient Surgical Location – You pay a $30 copayment for facility charges at a freestanding outpatient surgical location that has an Empire Plan agreement in effect with the Medical/Surgical Program on the date of your elective surgery. You pay a single copayment for anesthesiology, radiology and laboratory tests performed at the outpatient surgical location on the same day as the surgery. You pay an additional $30 copayment for pre-operative testing performed on a different day from the surgery. Surgeons’ charges are billed separately and covered under either the Participating Provider or Basic Medical Program provisions.

  18. Pediatric immunizations – Routine well-child care is a paid-in-full benefit. This includes examinations, immunizations and the cost of oral and injectable substances when administered according to pediatric immunization guidelines.

  19. Podiatry – You are covered for the services of a podiatrist except for routine care of the feet, subject to copayment.

  20. Prostheses and Orthotic Devices – You are covered for one prosthesis and/or orthotic device per affected body part meeting an individual’s functional needs. There is no copayment for the prosthesis and/or orthotic device when you use a participating provider. Replacements, when functionally necessary, are also covered. However, an orthotic device used to support, align, prevent or correct deformities or to improve the function of the foot is covered only when it is medically necessary and custom made.

  21. Reconstructive Surgery – You are covered, subject to copayment, for the services of a physician or other provider for the following:

    • Reconstructive surgery to restore or improve a body function when the functional impairment is the direct result of one of the following:

      • Birth defect

      • Sickness

      • Accidental injury

    • Reconstructive breast surgery following a medically necessary mastectomy (including surgery and reconstruction of the remaining breast to produce a symmetrical appearance following the mastectomy).

    • Reconstructive surgery to remove or revise scar tissue if the scar tissue is due to sickness, accidental injury or any other medically necessary surgery.

  22. Second Opinion for Cancer Diagnosis – You pay a $20 copayment for a second medical opinion by an appropriate specialist in the event of a positive or negative diagnosis of cancer or recurrence of cancer or a recommendation of a course of treatment for cancer.

  23. Specialist Consultations – A consultation is more extensive than an office visit. A physician may refer you to a specialist for consultation to have your medical condition evaluated and to obtain professional advice regarding how to proceed with your care.

    You are covered, subject to copayment(s), for one out-of-hospital consultation in each specialty field per calendar year for each condition being treated. You are covered for one in-hospital consultation in each specialty field, per confinement, for each condition being treated.

    You are not covered for consultations in the fields of pathology, roentgenology, or anesthesiology. Exception: consultations by an anesthesiologist, not rendered in conjunction with anesthesia services for surgery, such as office consultations for pain management, are covered when medically necessary.

  24. Speech Therapy – You are covered, subject to copayment, for the services of a speech therapist or speech-language pathologist when:

    1. such services are prescribed and supervised by your physician;

    2. treatment is medically necessary; and

    3. the provider is currently licensed in the state where the service is rendered.

  25. Surgery – You are covered for the services of a physician or other provider for surgery, including post-operative care, whether performed in or out of a hospital, subject to the appropriate copayment.

  26. Urgent Care Center – Services received at an Urgent Care Center that has an Empire Plan agreement in effect with the Medical/Surgical Program on the date of your visit are covered, subject to copayment.

Basic Medical Program

If you incur covered medical expenses and do not use a participating provider, your benefits for most services will be determined under the Basic Medical portion of this Plan. This section describes your coverage under the Basic Medical Program, and how the program works.

Also refer to the sections of this certificate on the Home Care Advocacy Program and Managed Physical Medicine Program. Benefits for certain services are determined under these programs, not under the Basic Medical Program.

You may have access through The Empire Plan Basic Medical Provider Discount Program (MultiPlan) to non-participating providers who have agreed to discount their charges for covered Basic Medical expenses. Your 20 percent coinsurance may be based on a discounted fee, rather than the reasonable and customary charges, if:

  • The Empire Plan is your primary coverage;
  • you receive covered Basic Medical services from the non-participating provider;
  • the discounted fee is lower than the Basic Medical reasonable and customary allowance; and
  • you have met your combined annual deductible.

You will not be billed for charges in excess of the discounted fee. The provider will submit claims for you and the Medical/Surgical Program administrator will pay the provider directly.

Assignment of benefits to a non-participating provider is not permitted. (Assignments will be made to hospitals and for ambulance services as long as the ambulance service has a contract in effect with the Medical/Surgical Program and to providers in The Empire Plan Basic Medical Provider Discount Program.)

You must meet a deductible and pay 20% coinsurance when you choose non-participating providers

You are responsible for the charges billed by a non-participating provider, and must submit a claim for benefits due. These benefits are calculated based on the following:

  • First, you are liable for the deductible. It is your responsibility.

  • After the deductible, covered medical expenses are considered for payment. The Medical/Surgical Program administrator will reimburse you for 80 percent of the reasonable and customary charges for covered services and supplies or the Scheduled Pharmaceutical Amount, for Pharmaceutical Products, or actual billed charges whichever is less. You pay the balance of 20 percent (coinsurance) and any charges above the reasonable and customary or Scheduled Pharmaceutical Amount. The covered percentage becomes 100 percent of the reasonable and customary charge or the Scheduled Pharmaceutical Amount once each coinsurance amount exceeds the coinsurance maximum in a calendar year.

  • You are responsible for the payment of all deductible and coinsurance amounts payable to a non-participating provider after processing of your Basic Medical claim by the Medical/Surgical Program administrator. Waiver of deductible and co-insurance amounts by a non-participating provider is not permitted under the Basic Medical Program. Prior to receiving services under the Basic Medical benefit you should discuss with your non-participating provider this requirement and your potential "out of pocket" liability. The level of benefits you are entitled to is predicated on meeting all deductible and coinsurance requirements set forth in this Certificate of Insurance. The Plan reserves the right to recover from enrollees benefits paid inconsistent with the provisions of this section of the Certificate of Insurance.

Details of the annual deductible and how it works, and your covered medical expenses, are described on the following pages.

  1. Annual Deductible
  2. The Empire Plan combined annual deductible is $1,000 for the enrollee, $1,000 for the enrolled spouse/domestic partner and $1,000 for all dependent children combined for covered services supplied by nonparticipating providers. The combined annual deductible must be met before your claims can be reimbursed. You must meet the combined annual deductible before your Basic Medical claims can be reimbursed.

    There is a separate deductible of $250 for the enrollee, $250 for the enrolled spouse/domestic partner and $250 for all dependent children combined for non-network physical medicine office visits under the Managed Physical Medicine Program.

    You must meet the combined annual deductible before your Basic Medical claims can be reimbursed.

  3. Coverage

    The Medical/Surgical Program administrator will pay Basic Medical benefits to the extent covered medical expenses in a calendar year exceed the deductible and coinsurance, up to the reasonable and customary charge or the Scheduled Pharmaceutical Amount.

  4. Covered Basic Medical Expenses

    Covered medical expenses under the Basic Medical Program are defined as the reasonable and customary charge for covered medical services performed or supplies prescribed by a physician or other provider or the Scheduled Pharmaceutical Amount for Pharmaceutical Products provided by a physician or other provider, except as otherwise provided below, due to your sickness, injury or pregnancy. These services, supplies and Pharmaceutical Products must be medically necessary as defined under the Meaning of Terms Used in this Certificate. No more than the reasonable and customary charge or the Scheduled Pharmaceutical Amount for medical services, supplies and Pharmaceutical Products will be covered by this Plan.

    Covered medical expenses under the Basic Medical Program are also subject to the definition of covered medical expenses as stated under the Meaning of Terms Used in this Certificate.

What is covered under the Basic Medical Program (non-participating providers)

Under the Basic Medical Program, covered medical expenses include charges for the following services or supplies:

  1. Ambulance Service – Emergency ambulance transportation to the nearest hospital where emergency care can be performed is covered when the service is provided by a licensed ambulance service, and ambulance transportation is required because of an emergency condition. Medically necessary non-emergency transportation is covered if provided by a licensed ambulance service.

    Covered medical expenses for ambulance services include the following:

    1. Local commercial ambulance charges except for the first $35. These amounts are not subject to deductible or coinsurance.

    2. When the enrollee has no obligation to pay, donations up to a maximum of $50 for trips of fewer than 50 miles and up to $75 for trips over 50 miles will be reimbursed for voluntary ambulance services. These amounts are not subject to deductible or coinsurance.

  2. Anesthesiology, Radiology and Pathology – If you receive anesthesia, radiology or pathology services in connection with covered inpatient or outpatient hospital services at an Empire Plan network hospital and The Empire Plan provides your primary coverage, covered charges billed separately by the anesthesiologist, radiologist or pathologist will be paid in full by the Medical/Surgical Program.

  3. Cardiac Rehabilitation Center – Medically necessary visits to a cardiac rehabilitation center are covered when prescribed by a physician.

  4. Dental Care – You are covered for dental services, including Pharmaceutical Products and appliances dispensed by a provider:

    • For the correction of damage caused by an accident, provided the services, supplies or Pharmaceutical Products are received within 12 months of the trauma and while you are covered under this Plan.

    • For the correction of damage caused by a medical illness, congenital disease or anomaly for which you are eligible for benefits under this Plan.

    • For charges incurred for temporomandibular joint (TMJ) syndrome for the following conditions that are consistent with the diagnosis of organic pathology of the joint and can be demonstrated by X-ray: degenerative arthritis, osteoarthritis, ankylosis, tumors, infections and traumatic injuries.

    • For TMJ, covered services, supplies or Pharmaceutical Products include diagnostic exams, X-rays, models and testing, injections of medications and trigger point injections.

  5. Diabetes Education Centers – If you have a diagnosis of diabetes, you are covered for medically necessary visits for self-management, subject to deductible and coinsurance.

  6. Eye Care Following Cataract Surgery – The charges for one pair of prescription eyeglasses or contact lenses and one eye examination are covered medical expenses per affected eye per cataract surgery.

  7. Gynecologic Exams – You are covered for a minimum of two gynecologic exams each year, as well as any services resulting from such exams.

  8. Hearing Aids – Hearing aids, including evaluation, fitting and purchase, are covered up to a total maximum reimbursement of $1,500 per hearing aid per ear, once every four years. Children age 12 years and under are eligible to receive a benefit of up to $1,500 per hearing aid per ear, once every two years when it is demonstrated that a covered child’s hearing has changed significantly and the existing hearing aid(s) can no longer compensate for the child’s hearing loss. These benefits are not subject to deductible or coinsurance.

  9. Hospital Emergency Room – If the Hospital Program administrator determines that you received emergency care in a hospital emergency room, covered charges billed separately by the attending emergency room physician and providers who administer or interpret radiological exams, laboratory tests, electro-cardiograms and/or pathology services, will be paid in full by the Medical/Surgical Program.

    Services provided by other specialty physicians or other providers in a hospital emergency room are considered under the Participating Provider Program if the physician participates in The Empire Plan.

    If the Emergency Services are provided by a nonparticipating provider, the charges will be considered under the Basic Medical Program, subject to deductible but not coinsurance.

  10. Hospitals – Charges for room and board and special services provided to you as an inpatient are covered after Hospital Program benefits have been exhausted.

    Remember: You must comply with the requirements of the hospital and Benefits Management Program for a hospital admission. Refer to the details of how this program works in the Benefits Management Program section of this book.

    If and when it is determined that inpatient care is no longer medically necessary, benefits will cease and notice will be given to the hospital and patient the day before your benefits end.

    The Medical/Surgical Program will provide coverage for services and supplies in connection with Infertility Benefits and Cancer Resource Services whether or not benefits are available under The Empire Plan’s hospital benefits plan.

  11. Infertility Treatment – See Infertility Benefits for information regarding benefits for the treatment of infertility.

  12. Mammograms:

    Part of Routine Preventive Care – You are covered for preventive care mammograms according to the same guidelines that apply under the Participating Provider Program.

    New York State law also provides for an annual mammogram for covered females age 40 and older.

    Part of a Medical Condition – Mammograms are covered when a medical condition is suspected or known to exist; this benefit is subject to deductible and coinsurance.

  13. Mastectomy Bras – When prescribed by a physician or other provider, mastectomy bras, including replacements when functionally necessary, are covered, subject to deductible and coinsurance.

  14. Mastectomy Prostheses – One single or double mastectomy prosthesis per calendar year is covered in full. Any single external mastectomy prosthesis costing $1,000 or more requires prior approval through the Home Care Advocacy Program (HCAP). For a prosthesis requiring approval, if a less expensive prosthesis can meet an individual’s functional needs, benefits will be available for the most cost-effective choice. This benefit is not subject to deductible or coinsurance.

  15. Maternity Care – You are covered for care related to pregnancy and childbirth. This includes care given before and after childbirth and for complications of pregnancy. The Medical/Surgical Program administrator’s payment of maternity benefits may be made in up to two payments (at reasonable intervals) for covered care and treatment rendered during pregnancy, and a separate payment for the delivery and post-natal care provided.

    Maternity care may be rendered by a physician or other provider such as a licensed or certified midwife. The midwife must be:

    1. licensed or certified to practice midwifery; and

    2. permitted to perform the service under the laws of the state where the services are rendered.

  16. Miscellaneous Services and Supplies – The following services are covered under the Basic Medical Program when not covered elsewhere by the Plan:

    1. Diagnostic laboratory procedures and radiology

    2. X-ray or radiation treatments

    3. Oxygen and its administration

    4. Anesthetics and their administration, except when performed by your physician or other provider

    5. Blood transfusions, including the cost of blood and blood products; however, such costs will be covered medical expenses only to the extent that there is evidence, satisfactory to the Medical/Surgical Program, that such supplies could not be obtained without cost

    6. Chemotherapy

    7. Dialysis

    8. Speech therapy

    9. Contraceptive drugs and devices that require injection, insertion or other provider intervention when the drugs/devices are dispensed in a provider’s office

    10. Adult immunizations provided at non-network pharmacies

  17. Modified Solid Food Products – When prescribed by a physician or other provider, modified solid food products (MSFP) are covered up to a total maximum reimbursement of $2,500 per covered person per calendar year. This benefit is not subject to deductible or coinsurance.

    A modified solid food product is a product/food that is low in protein or contains modified protein and is consumed by individuals with certain diseases of amino acid and organic acid metabolism.

  18. Nutritional Counseling/Medical Nutritional Therapy – You are covered when the treatment is medically necessary and the provider is licensed in the state where the service is rendered.

  19. Outpatient Surgical Location – You are covered for medically necessary facility charges at a freestanding outpatient surgical location.

  20. Physicians – Services of physicians and other providers who perform covered medical services are covered.

  21. Podiatrists – Services of duly licensed podiatrists for the treatment of (i) diseases, (ii) injuries and (iii) malformation of the foot are covered, except that those treatments or supplies listed in Items P and Q of the Exclusions segment are not covered medical expenses. See General Provisions: Exclusions.

  22. Prosthesis and Orthotic Devices – One prosthesis and/or orthopedic appliance commonly known as an orthotic device, per affected body part meeting an individual’s functional needs, is covered.

    Replacements, when functionally necessary, are also covered. However, an orthotic device used to support, align, prevent or correct deformities or to improve the function of the foot is covered under the Basic Medical Program only when it is medically necessary and custom made.

  23. Prosthetic wigs are covered up to the $1,500 lifetime benefit maximum when hair loss is long term and due to a medical condition. These conditions include: disease of the endocrine glands, generalized systemic disease, systemic poisons and hair loss due to radiation therapy, chemotherapy treatment or injury to the scalp. This benefit is not subject to deductible or coinsurance.

    Prosthetic wigs are not covered when hair loss is due to male or female pattern baldness.

  24. Reconstructive Surgery – You are covered for reconstructive surgery under the same conditions as the Participating Provider Program.

  25. Routine Health Exams for Active Employees – Routine health exams are covered for you, the active employee, if you are age 50 or older and for your spouse/domestic partner age 50 or older. These benefits are not subject to deductible or coinsurance.

  26. Routine Newborn Child Care – Physician’s or other provider’s services for routine care of a newborn child are covered. These benefits are not subject to deductible or coinsurance.

  27. Routine Pediatric Care – Routine well-child care is covered for children up to age 19, including examinations, immunizations and the cost of oral and injectable substances, according to pediatric care guidelines.

  28. Second Opinion for Cancer Diagnosis – Charges for a second medical opinion by an appropriate specialist in the event of a positive or negative diagnosis of cancer or recurrence of cancer or a recommendation of a course of treatment for cancer are covered in full, minus the $20 copayment you would normally pay for a visit to a participating provider. This benefit is not subject to deductible.

  29. Specialist Consultations – Charges for a consultation with a specialist who is a nonparticipating provider are considered under the Basic Medical Program and are subject to your annual deductible and coinsurance.

    Basic Medical Benefits are available for one out-of-hospital consultation in each specialty field per calendar year for each condition being treated. Basic Medical benefits are available for one in-hospital consultation in each specialty field, per confinement, for each condition being treated.

    You are not covered for consultations in the fields of pathology, roentgenology, or anesthesiology. Exception: Consultations by an anesthesiologist not rendered in conjunction with anesthesia services for surgery, such as office consultation for pain management, are covered when medically necessary.

  30. Surgery – You are covered for the services of a physician or other provider for surgery, including post-operative care, under the Basic Medical Program when not covered elsewhere by the Plan.

    Multiple surgical procedures performed during the same operative session may be subject to a reduction in reimbursement. Multiple surgical procedures shall be reimbursed in an amount not less than the reasonable and customary charge for the most expensive procedure performed. Less expensive procedures shall be reimbursed in an amount at least equal to 50 percent of the reasonable and customary charge for these secondary procedures.

    When you use a participating provider, you are responsible only for any applicable copayment(s).

  31. Urgent Care Center – You are covered for medically necessary visits to and services provided at an urgent care center.

  32. Voluntary Sterilization – Charges for voluntary sterilization are covered medical expenses.

Benefits Management Program: Pre-Admission Certification and Prospective Procedure Review

Please read about The Empire Plan Benefits Management Program in the preceding sections of this book.

You must call the Benefits Management Program, if The Empire Plan is primary

If you do not follow the Benefits Management Program requirements for Pre-Admission Certification or Prospective Procedure Review, the Medical/Surgical Program administrator will review your claim and will apply penalties as explained below.

You must call The Empire Plan and choose the Hospital Program for Pre-Admission Certification before a maternity or scheduled hospital admission and within 48 hours after an emergency or urgent hospital admission.

Pre-Admission Certification: Hospital

If you do not comply with Pre-Admission Certification requirements for hospital admission, a $200 penalty will be applied. You will be responsible for all charges for each day on which it was not medically necessary for you to be an inpatient.

Prospective Procedure Review MRI, MRA, CT, PET and Nuclear Medicine tests

You must call The Empire Plan for Prospective Procedure Review before having an elective (non-emergency) Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine tests unless you are having the test as an inpatient in a hospital.

If you do not call toll-free The Empire Plan before an elective (non-emergency) procedure and the Medical/Surgical Program administrator's review does not confirm that the procedure was medically necessary, you will be responsible for the full charges.

You do not have to call before an emergency procedure. When the Program administrator receives the claim for the procedure and no call was made, it will determine whether the procedure was performed on an emergency basis and whether the procedure was medically necessary.

If you do not call The Empire Plan before a procedure and the Medical/Surgical Program administrator determines that the procedure was performed on a scheduled (nonemergency) basis and that the procedure was medically necessary, you are liable for the payment of the lesser of 50 percent of the scheduled amounts related to the procedure or $250, plus your copayment, under the Participating Provider Program.

Under the Basic Medical Program, you are liable for the lesser of 50 percent of the reasonable and customary charges related to the procedure or $250. In addition, you must meet your combined annual deductible and you must pay the coinsurance and any provider charges above the reasonable and customary amount.

When Benefits Management Program requirements apply

The Benefits Management Program requirements apply when The Empire Plan is your primary health insurance coverage. (The Empire Plan is primary when it is responsible for paying for health benefits first, before any other group plan or HMO is liable for payment.)

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

The Benefits Management Program requirements apply if you live or seek treatment anywhere in the United States, including Alaska and Hawaii.

The Benefits Management Program requirements apply if you will be using your Empire Plan benefits in a medical center or hospital operated by the U. S. Department of Veterans' Affairs.

Home Care Advocacy Program

The Home Care Advocacy Program (HCAP) is The Empire Plan program for home care services, durable medical equipment and certain supplies. HCAP is administered by the Medical/Surgical Program administrator.

Read this section carefully for details on how to use HCAP. If you do not use HCAP, you will pay higher out-of-pocket costs.

Network coverage: Paid-in-full benefit You must call The Empire Plan toll-free at 1-877-7-NYSHIP (1-877-769-7447) and choose UnitedHealthcare even if Medicare is primary

You Must CallYou must call The Empire Plan and choose the Medical Program to arrange for services and you must use an HCAP-approved provider to receive paid-in-full benefits under Network coverage. You must call HCAP even if Medicare or another plan is primary. If you do not call HCAP before receiving services, you will receive the Non-network level of benefits for medically necessary covered services.

If Medicare is your primary coverage and you receive items or services from a Medicare approved supplier, the Empire Plan will pay the balance after Medicare at 100 percent.

Exception: Call the HCAP network provider directly for authorization before receiving diabetic supplies (except insulin pumps and Medijectors) or ostomy supplies. You may contact the HCAP network providers directly at their toll-free numbers. For most diabetic supplies, call the Empire Plan Diabetic Supplies Pharmacy (see Contact Information). (For insulin pumps and Medijectors, you must call HCAP for authorization.) For ostomy supplies, call Byram HealthCare Centers (see Contact Information).

Important Notes:

  • If Medicare is your primary coverage, you must use a Medicare contract provider.

  • The Medicare Durable Medical Equipment and Prosthetic and Orthotics Supplies Competitive Bidding Program: If you are a Medicare prime member living in a competitive bidding area and require mailorder diabetic testing supplies, or any other items covered under the program, you must use a Medicare contract supplier. For information regarding the Competitive Bidding Program or to locate a Medicare contract supplier, please contact Medicare (see Contact Information). If you need additional assistance locating a Medicare contract supplier contact HCAP.

    If you do not use a Medicare contract supplier, your benefits will be reduced in accordance with item G. in the Impact of Medicare on this Plan section.

The following home care services and/or durable medical equipment or supplies are covered under HCAP when prescribed by your doctor and determined to be medically necessary by the Medical/Surgical Program administrator.

  1. HCAP-covered Durable Medical Equipment and Supplies
  2. To be an HCAP-covered expense, the equipment or supplies must be prescribed by your physician, medically necessary as determined by HCAP and covered under The Empire Plan.

    In some cases, HCAP will certify certain durable medical equipment or supplies for an extended period, and you won't have to call each time you need that item.

    Refer to Non-network benefits for coverage of durable medical equipment when you do not use HCAP.

    1. Durable Medical Equipment covered under HCAP is medical equipment which is for repeated use and is not a consumable or disposable item, is used primarily for a medical purpose, is appropriate for use in the home, and is generally not useful to a person in the absence of a sickness or injury. When appropriate, HCAP benefits are provided for the rental or purchase of durable medical equipment.
    2. Examples of durable medical equipment covered under HCAP that may be considered medically necessary when prescribed by your doctor include, but are not limited to: hospital-type beds, equipment needed to increase mobility (such as a wheelchair), respirators or other equipment for the use of oxygen, and monitoring devices. Items not covered under HCAP such as prosthetics, braces (except cervical collars) and splints, will be considered under the Participating Provider Program or the Basic Medical Program.

      Coverage is also provided for any repairs and necessary maintenance not provided for under a manufacturer's warranty or purchase agreement. You will have to call HCAP. HCAP will provide you with the name of an HCAP-approved provider and/or an authorization when necessary.

    3. Medical Supplies - Medical supplies covered under HCAP are diabetic supplies, ostomy supplies and supplies that are an integral part of Durable Medical Equipment such as oxygen tubing and oxygen masks.

    4. Diabetic Supplies - Examples of diabetic supplies include glucometers, test strips, lancets, alcohol swabs and syringes. If you have insulin-dependent diabetes, you are eligible for HCAP benefits for blood testing supplies, including a glucometer. If you have non-insulin-dependent diabetes you may be eligible for blood testing supplies, including a glucometer. To be considered for benefits, you must be managing your diabetes under the direction of a physician, for example through diet, exercise and/or medication.

  3. Skilled Nursing Services in the Home - You are covered for medically necessary visits by nurses from accredited HCAP participating nursing agencies. Care must be prescribed by, and under the supervision of, a physician. Inpatient visits will not be considered a covered expense.

  4. The services rendered must be medically necessary and must require the skills of nursing care when that care is needed to manage medical problems of acutely ill patients. This does not include assistance with daily living, companionship or any other service which can be given by a less skilled person, such as a home health aide.

    Refer to Non-network benefits for coverage of nursing services when you do not use HCAP.

    Refer to your Hospital Program Certificate for coverage of a Maternity Home Care Visit following early discharge after delivery.

  5. Home Infusion Therapy - You are covered for medically necessary intravenous therapy such as chemotherapy and pain management provided by an HCAP participating agency. Care must be prescribed by and under the supervision of a physician. Prescription medications used in therapies such as chemotherapy and pain management and dispensed by a licensed pharmacy are subject to the provisions of your prescription drug program. (See your Section V: Empire Plan Prescription Drug Program.)

  6. Certain other home health care services and prescription drugs are covered under HCAP only when the home care arranged through HCAP takes the place of hospitalization or care in a skilled nursing facility:

    1. Home Health Aides - Home health aide services consist primarily of caring for the patient in conjunction with skilled nursing services. (The Empire Plan does not cover assistance in activities of daily living, called custodial care.)

    2. Physical, Occupational and Speech Therapy - HCAP covers home physical, occupational and speech therapy.

    3. Prescription Drugs - Prescription drugs billed by a Home Care Agency certified under Article 36 of the New York State Public Health Law are covered under HCAP if The Empire Plan would have paid for those items if you were in a hospital or confined in a skilled nursing facility. In all other cases, coverage for prescription drugs dispensed by a licensed pharmacy is under and subject to the provisions of your prescription drug program.

    4. Laboratory Services - HCAP covers laboratory services provided by or on behalf of the home care agency.

  7. Enteral Formulas - You are covered for enteral Formulas under HCAP. The enteral formula must be prescribed by your physician and medically necessary as determined by HCAP. The prescribed enteral formula must be considered safe and effective for the diagnosis.

  8. Enteral formulas are nutritional replacements taken by mouth or through a feeding tube. These formulas provide basic nutrition intended to be used when food in its usual form is not appropriate or adequate to meet the individual's nutritional needs.

  9. Diabetic Shoes - You are covered for one pair of medically necessary custom molded or depth shoes per calendar year if you have a diagnosis of diabetes and diabetic foot disease; diabetic shoes have been prescribed by your provider; and the shoes are fitted and furnished by a qualified pedorthist, orthotist, prosthetist or podiatrist. Shoes ordered by mail or from the internet are not eligible for benefits.
  10. Network coverage - If you use an HCAP-approved provider for medically necessary diabetic shoes you receive a paid-in-full benefit up to a maximum annual benefit of $500 per year. You must make a pre-notification call to HCAP to receive paid-in-full network benefits.

    Non-network coverage - If you do not use an HCAP-approved provider for medically necessary diabetic shoes Basic Medical benefits apply subject to deductible with any remaining covered charges covered at 75 percent of the network allowance with a maximum annual benefit of $500.

Coverage ends under HCAP for these services when the home care being provided is no longer taking the place of hospitalization or care in a skilled nursing facility. After HCAP coverage ends, coverage for these services is subject to the provisions of the Participating Provider and Basic Medical Programs. For physical therapy, benefits will be under the Managed Physical Medicine Program.

When do requirements apply?

HCAP requirements apply:

  • Whenever you seek Empire Plan coverage for home care services and/or HCAP-covered durable medical equipment or supplies.
  • Nationwide. You must call HCAP if you live or seek treatment anywhere in the United States.

After you call

Once you call, HCAP will determine to what extent your home care services and/or durable medical equipment or supplies are medically necessary. You will be advised by telephone what services and supplies are precertified and for how long. For ongoing care, the Medical/Surgical Program administrator will also send you a letter of confirmation.

Your benefits and responsibilities under HCAP

The following describes your benefits and responsibilities under HCAP.

Network coverage: When you call HCAP and use an HCAP provider

You have a paid-in-full benefit under Network coverage when:

  1. You call HCAP before you receive home care services and/or HCAP-covered durable medical equipment or supplies; and

  2. The Medical/Surgical Program administrator precertifies your home care and/or equipment or supplies as medically necessary; and

  3. The Program administrator makes or helps you make arrangements with an HCAP-approved provider for covered services and/or equipment or supplies.

When you follow these steps, you will have no claim forms and no out-of-pocket cost, no copayment, no deductible and no exclusion for the first 48 hours of private duty nursing.

Non-network coverage: If you do not call or if you call HCAP but do not use an HCAP provider

You will receive Non-network benefits if:

  1. You do not call HCAP before you receive home care services and/or HCAP-covered durable medical equipment or supplies; or

  2. You call HCAP before you receive home care services and/or HCAP-covered durable medical equipment or supplies; and the Medical/Surgical Program administrator precertifies your home care and/or equipment or supplies as medically necessary; but you use a non-participating provider that HCAP has not approved for covered services and/or equipment or supplies.

Non-network benefits

If you do not call HCAP for precertification before receiving home care services, durable medical equipment or supplies and/or if you choose to use a non-network provider, you will pay a much higher share of the cost.

48 hour exclusion for nursing care: You are responsible for the cost of the first 48 hours of nursing care per calendar year. This is not a covered expense and will not be applied toward your combined annual deductible.

The Empire Plan combined annual deductible for covered services supplied by nonparticipating providers is $1,000 for the enrollee, $1,000 for the enrolled spouse/domestic partner and $1,000 for all dependent children combined. The combined annual deductible must be met before your claims can be reimbursed.

There is a separate deductible of $250 for the enrollee, $250 for the enrolled spouse/domestic partner and $250 for all dependent children combined for non-network physical medicine office visits under the Managed Physical Medicine Program.

You must satisfy the combined annual deductible before non-network benefits will be paid for HCAP-covered services, equipment or supplies. The amount applied toward satisfaction of the combined annual deductible for non-network HCAP-covered services, equipment and supplies will be the lower of the following:

  • The amount you actually paid for a medically necessary service, equipment or supplies covered under HCAP; or

  • The network allowance for such service, equipment or supply.

Non-network Benefits: After you have satisfied the combined annual deductible, submit a claim to the Medical/Surgical Program administrator. You will be reimbursed for medically necessary HCAP-covered home care services, durable medical equipment or supplies up to a maximum of 50 percent of the network allowance. You are responsible for any amounts in excess of 50 percent of the network allowance. The combined annual coinsurance maximum does not apply to HCAP.

Note: Non-network benefits apply to all charges if you don't use HCAP, except that Basic Medical benefits apply to durable medical equipment or supplies that are less than $100 in total and are dispensed by your doctor during an office visit.

Who calls?

If you cannot call HCAP, others may make the call for you: a member of your family or household, your doctor or a member of your doctor's staff, the hospital, the Benefits Management Program Case Manager or the Benefits Management Program discharge unit. But you are responsible for seeing that the call is made.

Call anytime

Call anytime. When your doctor prescribes home care services, durable medical equipment and certain supplies, call The Empire Plan and choose the Medical Program before you receive services.

In an emergency or urgent situation, obtain necessary care. Then, you are advised to call HCAP within 48 hours after receiving emergency care or receiving durable medical equipment/supplies. If it is not reasonably possible to call within 48 hours, call HCAP as soon as possible. If HCAP determines that the urgent or emergency care was medically necessary, covered services and/or items will be certified.

Remember, call The Empire Plan and choose the Medical Program before you receive home care services and/or durable medical equipment or supplies. And call if you have any questions.

More about HCAP

If you are admitted to the hospital - If you are receiving home care and then are admitted to the hospital, you must before your hospital admission and within 48 hours after an emergency or urgent hospital admission.

Hospice care - HCAP requirements do not apply to hospice care. Refer to Hospice Care in your Hospital Program Certificate for hospice care coverage.

Medical necessity - If the Medical/Surgical Program administrator determines that you have received home care services and/or durable medical equipment or supplies that were not medically necessary, you must pay the full cost. When HCAP makes or helps you make the arrangements, you're assured that services and equipment or supplies are medically necessary and covered under The Empire Plan.

60-day deadline to appeal

HCAP Appeals - All HCAP appeals are handled directly through HCAP. Submit a written appeal within 60 days of denial of benefits or services to the Medical/Surgical Program administrator (see Contact Information) or call The Empire Plan and choose the Medical Program.

For information on Medical/Surgical Program claims appeals, see How, When and Where to Submit Claims.

Managed Physical Medicine Program

The Managed Physical Medicine Program is administered by Managed Physical Network, Inc. (MPN).

Coverage for chiropractic treatment and physical therapy

Please read this section carefully. You will receive network benefits, the highest level of benefits, when you use MPN network providers for medically necessary chiropractic treatment and physical therapy. You will receive a significantly lower level of benefits when you choose non-network providers.

The Empire Plan Managed Physical Medicine Program covers medically necessary services typically performed by a chiropractor or physical therapist. Other providers, such as osteopaths and occupational therapists, may also provide these services. The provider must be licensed to perform such services in the state where the service is received. Physical therapy must be prescribed by a doctor.

When requirements apply

Managed Physical Medicine Program benefits and responsibilities apply to you and your enrolled dependents whenever you seek coverage for physical therapy or chiropractic treatment, even if you have Medicare or other health insurance coverage as well.

You must follow program requirements if you seek treatment anywhere in the United States, including Alaska and Hawaii.

Refer to your Hospital Program certificate for coverage of physical therapy in a hospital and in the outpatient department of a hospital following related hospitalization or surgery.

Refer to Home Care Advocacy Program for coverage of physical therapy at home in lieu of hospitalization or care in a skilled nursing facility.

Network benefits

You pay a $20 copayment for each office visit for chiropractic treatment or physical therapy when you choose an MPN network provider. You pay an additional $20 copayment for related radiology and diagnostic laboratory services billed by the MPN network provider. If an MPN network provider bills for radiology and diagnostic laboratory services performed during a single office visit, only one copayment for both radiology and diagnostic laboratory services will apply.

Copayments when you use a network provider

You do not need to call MPN before your visit. Your MPN provider will be responsible for certifying the medical necessity of your care. Charges for all certified services will be paid in full except for your copayments. You do not have to pay more than your copayments to a network provider unless you have agreed in writing in advance to pay for non-covered services.

How to find a network provider

You may contact a provider of chiropractic treatment or physical therapy directly and ask if the provider is in the MPN network. Or, you may call The Empire Plan and choose the Medical Program. MPN providers are also listed in The Empire Plan Participating Provider Directory.

Guaranteed access

What if there are no MPN providers in your area? You are guaranteed that network benefits will be available to you under the Managed Physical Medicine Program. Call The Empire Plan and choose the Medical Program. MPN will make arrangements for you to receive medically necessary chiropractic treatment or physical therapy, and you will pay only your $20 copayments for each visit. But, you must call first and you must use the provider with whom MPN has arranged your care.

Non-network benefits

If you receive chiropractic treatment or physical therapy from a non-network provider when MPN has not made arrangements for you, you will pay a much higher share of the cost.

Deductible and coinsurance apply

Deductible applies. For non-network physical medicine office visits, you must meet the Managed Physical Medicine Program annual deductible of $250. Your spouse/domestic partner must meet the $250 annual deductible, and all your enrolled children, combined, must meet the $250 annual deductible. The amount applied toward satisfaction of the deductible will be the amount you actually paid for medically necessary services covered under the Managed Physical Medicine Program or the MPN network allowance for such services, whichever is less. This deductible is separate from other Plan deductibles.

Coinsurance applies. After you meet your deductible, submit a claim to UnitedHealthcare. You will be reimbursed up to a maximum of 50 percent of the network allowance for medically necessary services.

Your $250 deductible and amounts applied to coinsurance under the Managed Physical Medicine Program do not count toward your combined annual deductible and coinsurance maximum. If MPN determines that the non-network care you received was not medically necessary, you will not receive any Empire Plan benefits, and you will be responsible for the full cost of care.

Other services

Charges by a non-network provider for other medically necessary services such as radiology and diagnostic laboratory tests are covered under the Basic Medical Program, subject to the combined annual deductible and Basic Medical coinsurance maximum.

Questions?

If you have questions about your coverage for chiropractic treatment or physical therapy, call The Empire Plan and choose the Medical Program and select the Managed Physical Medicine Program from the automated telephone system menu.

Appeals: 60-day deadline

In order to appeal MPN's determination, submit a written appeal within 60 days to Managed Physical Network, Inc. (see Contact Information). For information on Medical/Surgical Program administrator claims appeal, see Appeals.

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.

By using participating providers, you minimize your out-of-pocket costs. Benefits for Qualified Procedures are not payable if they are not pre-authorized by the Medical/Surgical Program administrator.

What is covered

Covered Services and Supplies include but are not limited to: Patient Education/Program Orientation; Diagnostic Testing; Ovulation Induction/Hormonal Therapy; Artificial/Intra-Uterine Insemination; and Surgery to enhance reproductive capability.

The Medical/Surgical Program administrator 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.

Call The Empire Plan and choose the Medical Program for prior authorization for Qualified Procedures

You Must CallCertain procedures, called Qualified Procedures, are covered under The Empire Plan only if you call The Empire Plan in advance and receive prior authorization. Qualified Procedures are specialized procedures that facilitate a pregnancy but do not treat the cause of the infertility. If the Medical/Surgical Program administrator authorizes benefits, the following Qualified Procedures 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, processing and banking of sperm or inseminated eggs. This includes expenses associated with cryopreservation (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 $25,000 per covered individual. This maximum applies to all covered hospital, medical, travel, lodging and meal expenses that are associated with Qualified Procedures.

Infertility Centers of Excellence

Centers of Excellence

Infertility Centers of Excellence are a select group of participating providers recognized by the Medical/Surgical Program as leaders in reproductive medical technology and infertility procedures and contracted by the Program administrator to be Infertility Centers of Excellence. These centers are available to provide to you the listed Covered Services and Supplies and Qualified Procedures. If the Program administrator pre-authorizes infertility treatment at an Infertility Center of Excellence, benefits are payable in full, subject to the maximum lifetime benefit. No copayments will be applied for services provided at the Center of Excellence. Copayments may apply for certain services required by the Center of Excellence and received outside the Center, for example laboratory or pathology tests.

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. (If you have prescription drug coverage through a union Employee Benefit Fund, check with that 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 for Cancer Program

The Centers of Excellence for Cancer Program provides paid-in-full coverage for cancer-related expenses received through a nationwide network known as Cancer Resource Services (CRS). If you choose to participate in the Centers of Excellence for Cancer 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 one of the CRS Centers of Excellence. You will also have access to health care nurse consultants who will answer your cancer-related questions and help you understand your cancer diagnosis. Participation in the Centers of Excellence for Cancer Program is voluntary, but the enhanced benefits under the Program are available only when you have enrolled with the Cancer Resource Services and notified your case manager before obtaining services.

Centers of Excellence. Facilities covered under the Centers of Excellence for Cancer Program include some of the best cancer centers in the United States. For a current list of Centers of Excellence for Cancer, call The Empire Plan, select the Medical Program and then choose the number for Cancer Resource Services.

What is covered? You receive paid-in-full benefits for the following services:

  • Inpatient and outpatient hospital and physician care related to the cancer treatment and provided by one of the CRS-contracted Centers of Excellence.

  • Cancer clinical trials and related treatment and services. Such treatment and services must be recommended and provided by a physician in a cancer center. The cancer center must be a participating facility in the Cancer Resource Services network at the time the treatment or service is given.

Enrollment. To receive the paid-in-full benefit and the travel benefit, you must call The Empire Plan. Choose the Medical Program and then choose Cancer Resource Services to enroll in the Program.

Other benefits still available. The Centers of Excellence for Cancer Program is voluntary. If you choose not to enroll in the Program, you are still eligible for Empire Plan benefits for your covered cancer treatment. Covered medical/surgical services may be available under the Participating Provider Program or the Basic Medical Program through the Medical/Surgical Program. Covered hospital services may be available through the Hospital Program. You also will have to comply with the requirements of The Empire Plan Benefits Management Program and will have to pay any applicable deductible, coinsurance and copayments.

Centers of Excellence Travel Allowance

When you enroll in the Centers of Excellence for Cancer 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. The Travel Allowance will be applied toward the $50,000 maximum lifetime benefit for Infertility Benefits.

Medical/Surgical Program General Provisions

Exclusions

Charges for the following services, supplies and/or Pharmaceutical Products are not covered medical expenses:

  1. Services, supplies or Pharmaceutical Products which you received before you were covered under this Plan.

  2. Services, supplies or Pharmaceutical Products which are not medically necessary as defined under Meaning of Terms Used in this Certificate.

  3. Federal legend drugs and insulin dispensed by a licensed pharmacy.

  4. Eyeglasses or contact lenses or exams to prescribe or fit them, except as described in the list of covered medical expenses outlined in the Basic Medical Program section.

  5. Dental services, supplies and/or Pharmaceutical Products provided by a dentist will not be covered, except as described in the list of covered medical expenses outlined in the Participating Provider and Basic Medical Program sections. In addition, extractions, dental caries, periodontics (including but not limited to gingivitis, periodontitis and periodontosis) or the correction of impactions will not be covered.

  6. Services, supplies and/or Pharmaceutical Products for the administration of anesthesia if the charges for surgery are not covered under this Plan.

  7. Services, supplies or Pharmaceutical Products to the extent they are not covered by the Hospital Program due to non-compliance with the requirements of The Empire Plan for inpatient admission, the mandatory Prospective Procedure Review or for inpatient diagnostic testing.

  8. Services or Pharmaceutical Products deemed Experimental, Investigational or Unproven are not covered under this Plan. However, the Medical/Surgical Program administrator may deem an Experimental, Investigational or Unproven Service or Pharmaceutical Product is covered under this Plan for treating a life threatening sickness or condition if:

    1. it is determined by the Program administrator that the Experimental, Investigational or Unproven Service at the time of the determination:

      • is proved to be safe with promising efficacy; and

      • is provided in a clinically controlled research setting; and

      • uses a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health; or

    2. Empire Plan benefits have been paid or approved by another Empire Plan program administrator for the item or service based on a determination that the service or item is covered under The Empire Plan.

    3. Experimental, Investigational or Unproven Services or Pharmaceutical Products shall also be covered when approved by an External Appeal Agent in accordance with an external appeal. For external appeal provisions, see External Appeals under Miscellaneous Provisions. If the External Appeal Agent approves coverage of an Experimental. Investigational or Unproven treatment that is part of a clinical trial, only the costs of services required to provide treatment to you according to the design of the trial will be covered. Coverage will not be provided for the costs of investigational drugs or devices, the costs of non-health care services or Pharmaceutical Products, 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.

  9. If routine services are provided by both a nurse midwife and doctor, only one provider will be paid for these services or Pharmaceutical Products.

  10. Services, supplies or Pharmaceutical Products received because of an occupational injury or an occupational sickness which entitles you to benefits under a workers' compensation or occupational disease law.

  11. Services, supplies or Pharmaceutical Products to the extent they are covered under a mandatory motor vehicle liability law which requires that benefits be provided for personal injury without regard to fault.

  12. Services or Pharmaceutical Products provided in a veteran's facility or other services or Pharmaceutical Products 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 or Pharmaceutical Products 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.

  13. Services, supplies and/or Pharmaceutical Products received by you for which no charge would have been made in the absence of coverage under The Empire Plan.

  14. Services, supplies and/or Pharmaceutical Products for which you are not required to pay.

  15. Services, supplies and/or Pharmaceutical Products received as a result of an injury or sickness due to an act of war, whether declared or undeclared, or a warlike action in time of peace, which occurs after December 5, 1957.

  16. Orthopedic shoes and other supportive devices, and services or Pharmaceutical Products for treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions, except  open cutting operations.

  17. Services, supplies and/or Pharmaceutical Products, including cutting or removal, for treatment of corns, calluses, or toenails, except care which is medically necessary due to metabolic disease diagnosed by a doctor.

  18. Services, supplies and/or Pharmaceutical Products rendered for convalescent care, custodial care, sanitarium-type care, rest cures, and services, supplies or Pharmaceutical Products rendered in a place of rest, a place for the aged, a place for drug addicts, a place for alcoholics, a nursing home or in an educational facility except as otherwise specifically covered under this Plan.

  19. Services, supplies and/or Pharmaceutical Products for which you receive payment or are reimbursed as a result of legal action or settlement, other than from an insurance plan under an individual policy issued to you.

  20. Cosmetic or reconstructive surgery or treatment. Surgery or treatment primarily to change appearance is not covered under this Plan. Refer to What is covered under the Participating Provider Program and What is covered under the Basic Medical Program for limited coverage of reconstructive surgery.

  21. Services or Pharmaceutical Products rendered for medical summaries and medical invoice preparations.

  22. Services, supplies and/or Pharmaceutical Products rendered in conjunction with weight reduction programs, unless the patient is morbidly obese and treatment is in a physician's office. Dietary food supplements or vitamins are not covered medical expenses.

  23. Expenses for private duty nursing services or Pharmaceutical Products while you are an inpatient.

  24. Expenses for mental health or substance abuse services or Pharmaceutical Products and supplies, including alcoholism.

  25. Services or Pharmaceutical Products furnished on a referral prohibited by the Public Health Law section governing business practices and health services or Pharmaceutical Products.

  26. Services, supplies and/or Pharmaceutical Products which are provided by your father, mother, brother, sister, spouse/domestic partner or children.

Coordination of Benefits

  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 payment under The Empire Plan and under another plan is not more than the reasonable and customary charge for a service or the Scheduled Pharmaceutical Amount for Pharmaceutical Products covered under both group plans.

  2. Definitions

    1. Plan means a plan which provides benefits or services for or by reason of 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 to other commercial coverage, 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 reasonable and customary charge for the service or the Scheduled Pharmaceutical Amount or Pharmaceutical Product you receive. The amount payable under The Empire Plan plus the amount payable under the primary plan will sometimes be less than 100 percent of the allowable expense due to annual deductible and coinsurance requirements. If The Empire Plan is secondary to Medicare, the amount payable will be determined as denoted below in the section entitled Impact of Medicare on This Plan.

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. There is a further condition which applies under the Participating Provider Program. When either Medicare or a plan other than this Plan pays first, and if for any reason the total sum reimbursed by the other plan and this Plan is less than the amount billed the other plan, the participating provider may not charge the balance to you.

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.

Impact of Medicare on this Plan

Definitions

  1. Medicare means the Health Insurance for the Aged and Disabled Provisions of the Social Security Act of the United States as it is now and as it may be amended.

  2. Primary Payor means the plan that will determine the medical benefits which will be payable to you first.

  3. Secondary Payor means a plan that will determine your medical benefits after the primary payor.

  4. Active Employee refers to the status of you, the enrollee, prior to your retirement and other than when you are disabled.

  5. Retired Employee means you, the enrollee, upon retirement under the conditions set forth in the General Information Book.

  6. You will be considered disabled if you are eligible for Medicare due to your disability.

  7. You will be considered to have end stage renal disease if you have permanent kidney failure.

Coverage

When you are eligible for primary coverage under Medicare, the benefits under this Plan will change.

Please refer to the General Information Book for information on when you must enroll for Medicare and when Medicare becomes your primary coverage. If you or your dependent is eligible for primary Medicare coverage - even if you or your dependent fails to enroll - your covered medical expenses will be reduced by the amount that could be covered under Medicare, and the Medical/Surgical Program will consider the balance for payment, subject to copayment, deductible and coinsurance.

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 in the last paragraph of this section below.

After you have exhausted your 365 benefit days under Medicare and the Empire Plan Hospital Program, you may use either your Basic Medical coverage under the Medical/Surgical Program or your Medicare Reserve Days.

  1. Retired Employees and/or their Dependents - If you or your dependents are eligible for primary coverage under Medicare - even if you or they fail to enroll - your covered medical expenses will be reduced by the amount that would have been paid by Medicare, and the Medical/Surgical Program administrator will consider the balance for payment, subject to copayment, deductible and coinsurance.

  2. When Medicare pays primary, covered expenses will be based on Medicare's limiting charge, as established under federal, or in some cases, state regulations rather than the Participating Provider Scheduled Allowances, the Reasonable and Customary Charge or the Scheduled Pharmaceutical Amount as defined in the Meaning of Terms Used.

    No benefits will be paid for services, supplies or pharmaceutical products provided by a skilled nursing facility.

  3. Active Employees and/or their Dependents - This Plan will automatically be the primary payor for active enrolled employees, regardless of age, and for the employee's enrolled dependents (except for a domestic partner eligible for Medicare due to age) unless end stage renal disease provisions apply. Medicare will be the secondary payor. As the primary payor, the Medical/Surgical Program administrator will pay benefits for covered medical expenses under this Plan; as secondary payor, Medicare's benefits will be available to the extent they are not paid under this Plan or under the plan of any other primary payor.

  4. The only way you can choose Medicare as the primary payor is by canceling this Plan; if you do so, there will be no further coverage for you under this Plan.

    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.

  5. 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.

  6. 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 insurer for the first 30 months of treatment, then Medicare becomes primary. See End stage renal disease in the 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.

  7. Veterans' Facilities. Where services are provided in a U.S. Department of Veterans' Affairs facility or other facility of the federal government, benefits under this Plan are determined as if the services were provided by a non-governmental facility and covered under Medicare. The Medicare amount payable will be subtracted from this Plan's benefits. The Medicare amount payable is the amount that would be payable to a Medicare eligible person covered under Medicare. You are not responsible for the cost of services in a governmental facility that would have been covered under Medicare in a non-governmental facility.

  8. If you or your dependents are eligible and enrolled for coverage under Medicare and receive services from a health care provider who has elected to opt-out of Medicare, or whose services are otherwise not covered under Medicare due to failure to follow applicable Medicare program guidelines, we will estimate the Medicare benefit that would have been payable and subtract that amount from the allowable expenses under this Plan.

  9. If Medicare is your primary plan and you live in an area that participates in the Medicare Durable Medical Equipment, Prosthetics and Orthotics Supply Competitive Bidding Program and use equipment or supplies included in the program (or get the items while visiting one of these areas), you must use a Medicare contract supplier. If you live in these areas (or get these items while visiting them) and don't use a Medicare contract supplier, Medicare will not pay for the item and your Empire Plan benefits will be reduced by the amount Medicare would have paid if you had used a contract provider. In order to maximize your benefits, it is important for you to know if you're in an area that is affected by this Medicare program. For more information you can contact Medicare (see Contact Information). If you need additional assistance locating a Medicare contract supplier contact HCAP.

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.

How, When and Where to Submit Claims

How

  1. If you go to a participating provider, MPN Network provider, HCAP-approved provider or a Basic Medical Discount Program Provider, all you have to do is ensure that the provider has accurate and up-to-date personal information – name, address, health insurance identification number and signature – needed to complete the claim form. The provider fills out the form and sends it directly to the Medical/Surgical Program administrator. The claim forms are in each provider's office.

  2. If you use a non-participating provider or a provider that is not in the MPN Network or is not HCAP-approved, claims may be submitted at any time after the appropriate annual deductible has been satisfied but not later than 90 days (120 days – for claims incurred in Calendar Year 2010 or later) after the end of the calendar year in which covered medical expenses were incurred or 90 days (120 days – for claims incurred in Calendar Year 2010 or later) after Medicare or another plan processes your claim. However, you may submit claims later if it was not reasonably possible for you to meet this deadline (for example, due to your illness); you must provide documentation.

  3. You may obtain a claim form from your agency Health Benefits Administrator or the Medical/Surgical Program administrator (see Contact Information) or on NYSHIP Online (click on Forms and select the Medical/Surgical Program and then the applicable form).

    Have the doctor or other provider fill in all the information asked for on the claim form and sign it. If the form is not filled out by the provider and bills are submitted, they must include all the information asked for on the claim form. Missing information will delay processing.

    If the Hospital Program paid part of the costs, the "Statement of Payment" sent to you by the Hospital Program administrator must be enclosed with the claim.

    If Medicare is primary, a "Medicare Summary Notice" (or "Explanation of Medicare Benefits") must be submitted with the completed claim form or detailed bills for all items to receive benefits in excess of the Medicare payment. Make and keep a duplicate copy of the Medicare Summary Notice and other documents for your records.

Remember - If Medicare provides primary coverage, your provider must submit bills to Medicare first.

When

  1. If you use a participating provider, MPN Network provider, HCAP-approved provider or a Basic Medical Discount Program Provider, your provider will submit a claim to the Medical/Surgical Program administrator.

  2. If you use a non-participating provider or a provider that is not in the MPN Network or is not HCAP-approved, claims may be submitted at any time after the appropriate annual deductible has been satisfied but not later than 90 days (120 days – for claims incurred in Calendar Year 2010 or later) after the end of the calendar year in which covered medical expenses were incurred or 90 days (120 days – for claims incurred in Calendar Year 2010 or later) after Medicare or another plan processes your claim. However, you may submit claims later if it was not reasonably possible for you to meet this deadline (for example, due to your illness); you must provide documentation.

Where

Completed claim forms with supporting bills, receipts, "Statement of Payment" from the Hospital Program administrator and Medicare Summary Notice should be sent to the address listed in the Contact Information section.

Fraud

Any person who intentionally defrauds an insurance company by filing a claim which contains false or misleading information or conceals information which is necessary to properly evaluate a claim has committed a crime.

Verification of claim information

The Medical/Surgical Program administrator has the right to request from hospitals, doctors or other providers any information that is necessary for the proper handling of claims. This information is kept confidential.

Claim inquiries

When you have a question about your claim, you may call The Empire Plan and choose the Medical Program.

If you do not speak English or are hearing-impaired or speech-impaired you can receive assistance. Contact The Empire Plan and choose the Medical Program. They can direct you on how to get further help through a language translation line or TTY (Text Telephone).

Claim determinations

Claim determinations will be made within 30 days after receipt of the necessary information.

Denial of claim

If the Medical/Surgical Program administrator 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 in accordance with Empire Plan provisions will be paid under the Participating Provider or Basic Medical Program for covered expenses if:

  • Another Empire Plan program administrator has liability for some portion of the expense 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 the Medical/Surgical Program administrator proof of payment or pre-authorization of benefits from the other Empire Plan carrier regarding the availability of Empire Plan benefits to you for that medical procedure or service.

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.

Right to Convert to an Individual Policy

Right to convert

After you have been covered under this Plan as an enrollee for at least three months and your coverage ends because:

  1. your employment ends,

  2. you are no longer in a class that remains eligible for coverage under this Plan,

  3. COBRA continuation period ends, or

  4. this Plan ends, you may have the right to convert to an individual policy, issued by the Medical/Surgical Program administrator, providing hospital, surgical and medical coverage for you and your dependents.

If your coverage under this Plan ends for any cause stated above, the proper form with which to apply for conversion will be sent to you.

When applying for a conversion policy, proof that you are insurable is not required by the Program administrator.

Deadlines apply

Your application for conversion to an individual policy and the first premium must be submitted to the Medical/Surgical Program administrator within:

  1. 45 days from the date your coverage ends, if written notice of the right to convert is given to you within 15 days after that date;

  2. 45 days from the date you receive written notice of the right to convert, if that notice is given more than 15 days but less than 90 days after your coverage ends; or

  3. 90 days from the date your coverage ends, if no written notice of the right to convert is given.

The Program administrator will not issue a conversion policy if coverage ends because you fail to remit the required cost for coverage continuation under COBRA; or if, on the date your coverage ends, you are eligible for similar types of benefits under any other group plan or program and those benefits, together with the converted policy would, according to the Program administrator's standards, result in more insurance than is needed or in duplicate benefits; nor will such a policy be issued if you are eligible for Medicare due to age or if your coverage ends because you fail to make a required payment to its cost. If you are under age 65 and eligible for Medicare due to disability, you are eligible for a direct-pay policy unless you have coverage which would duplicate the conversion coverage.

Your dependents may apply for an individual policy under the same conditions if they do so within 45 days after coverage ends because COBRA coverage ends, or because of your death or because they no longer qualify as dependents.

Your dependents should request the proper conversion form by writing to the Medical/Surgical Program administrator (see Contact Information).

Please refer to the General Information Book for details on how you may continue coverage under COBRA after termination.

Miscellaneous Provisions

Confined on effective date of coverage

If you become covered under this Plan and on that date are confined in a hospital or similar facility for care or treatment or are confined at home under the care of a doctor for a sickness, injury or pregnancy, your Empire Plan benefits will be coordinated with any benefits payable through your former health insurance plan. Empire Plan benefits will be payable only to the extent that they exceed benefits payable through your former health insurance plan.

Benefits after termination of coverage

If you are totally disabled on the date coverage ends on your account, the Medical/Surgical Program administrator will pay benefits for covered medical expenses for that total disability, on the same basis as if coverage had continued without change, until the day you are no longer totally disabled or 90 days after the day your coverage ended, whichever is earlier. Call The Empire Plan and choose the Medical Program if you need more information about benefits after termination of coverage.

Total Disability and Totally Disabled mean that because of a sickness or injury you, the enrollee, cannot do your job or your dependent cannot do his or her usual duties.

Confined on date of change of options

Option means your choice of either The Empire Plan or a Health Maintenance Organization (HMO).

If, on the effective date of transfer without break from one option to the other, you are confined in a hospital or similar facility or confined at home under the care of a doctor:

  1. if the transfer is out of The Empire Plan, and you are confined on the day coverage ends, benefits are payable as set forth above under Benefits After Termination of Coverage; and

  2. if the transfer is into The Empire Plan, benefits are payable to the extent they exceed or are not paid through your former HMO.

Termination of coverage

  1. Coverage will end when you are no longer eligible to participate in this Plan. Refer to the General Information Book.

  2. If this Plan ends, your coverage will end.

  3. Coverage on account of a dependent will end on the date that dependent ceases to be a dependent as defined in the General Information Book.

  4. If a payment which is required by the State of New York to the cost of coverage is not made, the coverage will end on the last day of the period for which a payment required by the State was made.

If coverage ends, any claim which is incurred before your coverage ends, for any reason, will not be affected; also see Benefits After Termination of Coverage.

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 be 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.

Time limits on starting lawsuits

Lawsuits to obtain benefits may not be started less than 60 days or more than two years following the date you receive written notice that benefits have been denied.

Inquiries

If you have any questions regarding your claim or the availability of benefits under this Plan, you should call the Medical Program.

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.

If we receive a request for coverage of home health care services following an inpatient hospital admission, we will notify you (or your designee) and your provider of our decision by telephone and in writing within one business day of receipt of all necessary information; or, when the day subsequent to the request falls on a weekend or holiday, within 72 hours of receipt of all necessary information.

When we receive a request for home health care services and all necessary information prior to your discharge from an inpatient hospital admission, we will not deny coverage for home health care services, either on the basis of medical necessity or for failure to obtain prior authorization, while our decision on the request is pending.

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 or calling the Medical/Surgical Program administrator (see Contact Information).

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 Medical/Surgical Program'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 Medical/Surgical Program 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 medical 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 Medical/Surgical 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, UnitedHealthcare 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 Medical/Surgical 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 Medical/Surgical 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 (see Contact Information).

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 Medical/Surgical 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 an Immediate External Appeal

If we fail to adhere to the utilization review requirements described in your Certificate, you will be deemed to have exhausted the internal claims and appeals process and may initiate an external appeal as described in your Certificate.

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 Medical/Surgical 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 Medical/Surgical 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 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 Medical/Surgical 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 its 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 Medical/Surgical Program administrator based its denial, the External Appeal Agent will share this information with the Medical/Surgical 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 UnitedHealthcare'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 parties. 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 fee may also be waived if it is determined that paying it 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 Medical/Surgical Program administrator has no authority to grant an extension of this deadline.