The Empire Plan vs. NYSHIP HMOs
There are two types of health insurance plans available to you under NYSHIP: The Empire Plan and NYSHIP-approved Health Maintenance Organizations (HMOs).
NYSHIP HMOs
NYSHIP HMOs are available in various geographic areas of New York State. Depending on where you live or work, one or several HMO plans will be available to you.
The Empire Plan
The Empire Plan is available to all employees of the State of New York and Participating Employers, regardless of location.
Similarities and Differences
While all NYSHIP plans provide a wide range of hospital, medical/surgical, mental health/substance use and prescription drug coverage, there are some fundamental differences between the two plan types.
| Empire Plan | HMO | |
|---|---|---|
| Plan Type | A self-insured Preferred Provider Organization (PPO) plan with features of a managed care system. | A managed-care system in a specific geographic area that provides comprehensive coverage through a network of providers. |
| Service Area | Benefits for covered services, not just urgent and emergency care, are available worldwide. | Aside from emergencies, coverage for services received outside the service area is limited and at the discretion of the individual HMO. |
| Providers | Enrollees have access to over 1.2 million network providers and facilities throughout the United States and are not required to choose a Primary Care Physician (PCP) or obtain referrals to see specialists. Certain services require preapproval. | Enrollees usually choose a PCP from the HMO's network for routine medical care. It may be necessary to obtain referrals to receive services from certain specialists and hospitals. | Out-of-Pocket Expenses/Cost Sharing | Enrollees usually pay a copayment as a per-visit fee. Benefits for covered services obtained from a nonparticipating provider are subject to a deductible and/or coinsurance. | Enrollees usually pay a copayment as a per-visit fee or coinsurance. HMOs have no annual deductible. Out-of-network benefits not available. |
Frequently Asked Questions
Reviewing responses to Frequently Asked Questions about the two NYSHIP plan types is another way to figure out which one will best meet your needs.
| Question | Empire Plan | HMO |
|---|---|---|
| Will I be covered for medically necessary care I receive away from home? | Yes, coverage is available worldwide. If you use a nonparticipating provider, deductibles, coinsurance and benefit limits may apply. | You are always covered for emergency care. Some HMOs may provide coverage for urgent or routine care outside the service area or for college students away from home. |
| If I am diagnosed with a serious illness, can I see a physician or go to a hospital that specializes in my illness? | Yes. If the doctor you choose participates in The Empire Plan, network benefits will apply for covered services. Your hospital benefits will differ depending on whether you choose a network or non-network hospital. | You should expect to choose a participating physician and a participating hospital. Under certain circumstances, you may be able to receive a referral to a non-network provider but will need to contact your HMO for prior approval. |
| Can I be sure I will not need to pay more than my copayment(s) when I receive medical services? | Your copayment(s) should be your only expense if you receive medically necessary and covered services from a participating provider. | As long as you receive medically necessary and covered services and obtain any required referrals, your copayment(s) or coinsurance should be your only expense. |
| Can I use the hospital of my choice? | Yes. You have coverage worldwide, but you will receive the highest level of benefits at network facilities. | Except in an emergency, you generally do not have coverage at non-network hospitals unless authorized by the HMO. |
| What kind of physical therapy, occupational therapy and chiropractic care is available? | You have guaranteed access to unlimited, medically necessary care. | Coverage is available for a specified number of days/visits each year. |
| What if I need durable medical equipment, medical supplies or home nursing? | Through the Home Care Advocacy Program (HCAP), benefits for home care, durable medical equipment and certain medical supplies (including diabetic and ostomy supplies) and enteral formulas are paid in full. Prior authorization is required. | Benefits are available, vary depending on the HMO and may require a greater percentage of cost sharing. |
Use this checklist to focus your research and ensure that you select the plan that best meets your needs.
Please Note: This page highlights only general differences between The Empire Plan and NYSHIP HMOs. Find additional details in the Health Insurance Choices for 2024 booklet or contact the plans directly with your specific questions.