The Empire Plan is a unique health insurance plan designed especially for public employees in New York State. Empire Plan benefits include inpatient and outpatient hospital coverage, medical/surgical coverage, Centers of Excellence for transplants, infertility and cancer, home care services, equipment and supplies, mental health and substance abuse coverage and prescription drug coverage.
Frequently Asked Questions
- What is NYSHIP?
- What is The Empire Plan?
- How many people does NYSHIP cover?
- What are the administrative costs for The Empire Plan?
- What are the employee eligibility rules for The Empire Plan?
- Can retirees of public employers continue Empire Plan coverage, even after they become eligible for Medicare?
- Does The Empire Plan offer a rate structure that includes a reduced premium for Medicare-eligible individuals?
- How are claims coordinated between Medicare and The Empire Plan?
- Why do retirees still need The Empire Plan after they have primary coverage under Medicare?
- How often do benefits change?
- When an employer joins The Empire Plan, what publications are mailed to their employees?
- In addition to the publication mailings, is other customer service provided?
- Are there Empire Plan participating providers in our area? Are Empire Plan participating providers available in other parts of the country?
- As an employer, how do I become a Participating Agency in The Empire Plan?
- What local government employers currently participate in NYSHIPs Empire Plan?
- What are The Empire Plan confidentiality practices?
Q. What is NYSHIP?
A. NYSHIP is the New York State Health Insurance Program a comprehensive health insurance program for New York State public employees comprising The Empire Plan and NYSHIP-approved Health Maintenance Organizations (HMOs). The New York State Department of Civil Service administers NYSHIP. The Empire Plan is available to New York States public employees and employers.
Q. What is The Empire Plan?
A.The Empire Plan is NYSHIPs unique health insurance plan designed exclusively for New York States public employees and employers. The Empire Plan pays for covered hospital services, physicians bills, prescription drugs and other covered medical expenses. Enrollees have the freedom to choose participating providers and pay only a copayment or choose non-participating providers and pay a higher share of the cost.
Q. How many people does NYSHIP cover?
A. NYSHIP protects over 1.2 million State and local government employees, retirees and their families in the United States. NYSHIP is one of the largest employer sponsored group health insurance programs in the United States. Approximately 800 local government employers currently offer NYSHIP's Empire Plan to their employees.
Q. What are the administrative costs for The Empire Plan?
A. The administrative agency fee was eliminated in 2004.
The administrative enrollee fee is based upon annual budget projections and covers the administrative costs that are attributed to Participating Agencies. The 2013 Participating Agency Per Enrollee Fee is $25.32 annually, or $2.11 monthly.
Q. What are the employee eligibility rules for The Empire Plan?
A. The State has established minimum Empire Plan eligibility requirements, but local government employers may adopt modified rules within specific limits. Generally, to be eligible, the employee must:
- Be expected to work at least three months; and
- Work a regular schedule of 20 hours or more a week, or be paid an annual salary at a rate of $2,000 or more per year, or be in one of the following categories:
- A local elected official
- A paid member of a public legislative body
- An elected member of a school board
- An unpaid board member of a public authority with at least six months service as a board member
- Receive your major source of family income from your public employment
Q. Can retirees of public employers continue their Empire Plan coverage, even after they become eligible for Medicare?
A. Most public employers (Participating Agencies) that offer NYSHIPs Empire Plan permit employees who retire and have met certain requirements to continue their coverage after retirement and contribute to the cost. For complete details about eligibility for employees, retirees, spouses and dependents, see the Who Is Eligible? and the Continuing Coverage When You Retire sections of the NYSHIP General Information Book for Participating Agencies.
For retirees and their dependents, NYSHIP requires enrollment in Medicare Parts A and B when first eligible. NYSHIPs Empire Plan pays secondary to Medicare. Participating Agencies are required by law to reimburse Medicare-primary enrollees and dependents for the Part B premiums.
Q. Does The Empire Plan offer a rate structure that includes a reduced premium for Medicare-eligible individuals?
A. Yes. Persons enrolled in The Empire Plan who are eligible for primary coverage under the federal Medicare program are enrolled with either Medprime individual (individual enrolled in Medicare) or Medprime family (family coverage with one or more members enrolled in Medicare) coverage. There are two Medprime family enrollments: family with one Medicare enrollee and family with two or more Medicare enrollees. Under this arrangement, the premium cost for the agencys Medicare-primary enrollees is lower than the cost for active employees. In the aggregate, all Participating Agencies pay the same premium under the Medprime premium structure as they would pay under a traditional two-tier rate structure (individual and family).
Q. How are claims coordinated between Medicare and The Empire Plan?
A. The Empire Plan participates in the Medicare crossover process by which Medicare, as primary insurer, automatically forwards claims to The Empire Plan insurance carriers for secondary payment.
For more detailed information, refer to our publication, Medicare and NYSHIP - May 2022 and to the Medicare section of our Empire Plan Participating Agency General Information Book.
Q. Why do retirees still need The Empire Plan after they have primary coverage under Medicare?
A. It is the combination of Medicare coverage plus The Empire Plan that protects enrollees. The Empire Plan becomes secondary and The Empire Plan premium is reduced. The Empire Plan covers the Medicare Part A hospital deductible ($1,132 per hospital stay of one to 60 days in 2011; amount may change yearly) as well as some other medical expenses Medicare does not cover. For example, prescription drugs and hearing aids are not covered under Medicare Part A or Part B, but The Empire Plan for Empire Plan Participating Agencies provides benefits for prescription drugs provides a generous allowance for hearing aids. And, while Medicare does not pay for medical services outside the U.S., Empire Plan benefits are available worldwide.
For more detailed information, refer to our publication, Medicare and NYSHIP - May 2022.
Q. How often do benefits change?
A. The State negotiates NYSHIP health insurance benefits with State employee unions every three or four years. The President of the Civil Service Commission can and usually does extend negotiated benefit changes administratively to unrepresented groups such as Participating Agencies. Occasionally, a benefit change is introduced gradually over the course of time. Policies and benefits may also be affected by State and federal legislation and court decisions. The New York State Department of Civil Service Employee Benefits Division provides quarterly reports to employers and mails Empire Plan information directly to enrollees.
Q. When an employer joins The Empire Plan, what publications are mailed to employees?
A. In addition to detailed benefits information, materials range from benefits newsletters to provider directories. There are also specialized publications on topics such as the management of certain illnesses, diabetes and asthma for example, and helpful guides to the Employee Benefits Division website. A complete package of current publications can be ordered by the Agency Health Benefits Administrator for a direct mailing to the home of a new hire or new enrollee. Since 1995, the Department of Civil Service has won 209 awards recognizing excellence in health communications effectiveness.
Q. In addition to the publication mailings, is other customer service provided?
A. Regional meetings are held to provide Participating Agency health benefit administrators with the opportunity to ask questions, get updates on Empire Plan activities and meet other Participating Agency representatives.
Comprehensive Empire Plan Quarterly Experience Reports are mailed to Participating Agency employers. The reports provide projected Empire Plan experience based on claims paid through the previous quarter and projected premium rates. The reports explain the basis for the projection.
Training on NYBEAS (the NYSHIP enrollment system) for health benefits administrators of new Participating Agencies is offered at the Department of Civil Service offices in small group settings or on a one-on-one basis. HBAs can also access training videos on HBA Online. From the home page, select E-Learning and then choose from a series of tutorials on how to use NYBEAS.
Q. Are there Empire Plan participating providers in our area? Are Empire Plan participating providers available in other parts of the country?
A. The Empire Plan has over 15,000 network hospitals, skilled nursing facilities and hospice care facilities nationwide. The Empire Plan offers over 190,000 participating providers nationwide. For medical, mental health and other providers, see the Participating Provider Directory. The Empire Plan Prescription Drug Program has more than 50,000 participating pharmacies nationwide as well as a mail service pharmacy.
Q. As an employer, how do I become a Participating Agency in The Empire Plan?
A. NYSHIP requires your governing body to pass a formal resolution to join The Empire Plan. Call the Employee Benefits Division of the NYS Department of Civil Service, at 518-485-1771 for details.
Q. What local government employers currently participate in NYSHIP's Empire Plan?
A. Approximately 800 local government employers offer NYSHIP's Empire Plan to their employees.
Q. What are The Empire Plan confidentiality practices?
A. Under the federal privacy regulations relating to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), health plans such as The Empire Plan are required to protect the confidentiality of Protected Health Information (PHI). PHI is individually identifiable health information related to your physical and mental health or condition, health care services provided to you, or payments made for your care, which is created or received by a health plan, a health care clearinghouse, or a health care provider that electronically transmits such information. Details are outlined in the New York State Health Insurance Program (NYSHIP) Notice of Privacy Practices, effective beginning April 14, 2003.