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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.

EMPIRE PLAN CERTIFICATE OF INSURANCE

Introduction

The Empire Plan is the result of collective bargaining between the State and unions representing its employees. It has been designed to provide you with a complete health insurance benefits package at the lowest possible cost. A number of features have been included in The Empire Plan to manage costs, for both you and your employer, and to ensure that the health care you receive is that which is the most appropriate for you.

This Certificate of Insurance describes the coverage provided by The Empire Plan. The Plan is administered by the Department of Civil Service and includes the following basic elements of coverage:

  • Hospital and related coverage provided by Empire HealthChoice Assurance, Inc., a licensee of the BlueCross and BlueShield Association, an association of independent BlueCross and BlueShield plans (copayments apply for outpatient hospital certain services);

  • Medical/surgical benefits administered by UnitedHealthcare Insurance Company of New York (UnitedHealthcare) for a modest copayment when you choose participating providers;

  • Basic Medical coverage through UnitedHealthcare when you receive Medical/Surgical coverage from non-participating providers;

  • Benefits Management Program through Empire BlueCross BlueShield for prior authorization of hospital and skilled nursing facility admissions, and through UnitedHealthcare for Prospective Procedure Review of MRI, CT, CAT, PET scans and Nuclear Medicine tests;

  • Home Care Advocacy Program through UnitedHealthcare for home care services, durable medical equipment and certain supplies;

  • Managed Physical Medicine Program through UnitedHealthcare/Managed Physical Network Inc. for chiropractic treatment and physical therapy;

  • Centers of Excellence for Transplants Program through Empire BlueCross BlueShield;

  • Centers of Excellence for Infertility Treatment through UnitedHealthcare;

  • Centers of Excellence for Cancer Treatment through UnitedHealthcare;

  • Mental Health and Substance Abuse Program through ValueOptions; and

  • Prescription drug coverage through CVS/caremark.

You should familiarize yourself with The Empire Plan by reading this certificate so that you will be able to use effectively the benefits it provides. Pay particular attention to the information about The Empire Plan's Benefits Management Program, the Home Care Advocacy Program, the Managed Physical Medicine Program, Transplants Program, Infertility Benefits, the Mental Health and Substance Abuse Program and prior authorization requirements for certain drugs. Designed to control costs and provide you with the most appropriate care, these features have requirements which must be met to obtain full benefits.

Preventive Care Services

The federal Patient Protection and Affordable Care Act (PPACA) provides the following services received from an Empire Plan participating provider or network hospital paid at 100% (not subject to copayment):

  • Evidence-based items or services that have a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force.

  • Recommended immunizations from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

  • With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.

  • With respect to women, such additional preventive care and screenings as are provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

A list of covered preventive services is available at www.healthcare.gov. After opening the page, click on "Learn About Prevention" then on "Read a list of covered services" under the heading "For More Information" at the bottom of the page. You may also receive a printed copy of the list by calling The Empire Plan and choosing the Medical Program.

Copayments, deductibles and coinsurance may apply to services provided during the same visit as the preventive services. For example, if a preventive service is provided during an office visit but the preventive service is not the primary purpose of the visit, any copayment, deductible or coinsurance that would otherwise apply to the office visit will still apply.