Department of Civil Service

NY12-42

TO: New York State Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: Summary of Benefits and Coverage (SBC)
DATE: December 1, 2012

The Patient Protection and Affordable Care Act (PPACA) requires all insurance plans to make available a Summary of Benefits and Coverage (SBC) for employees eligible for benefits and potential enrollees. The Employee Benefits Division will notify current enrollees of the availability of the Summary of Benefits and Coverage and Uniform Glossary online at https://www.cs.ny.gov/sbc/index.cfm via annual mailings, including the rate notification and plan mailings for 2013. Employees who do not have internet access may call 1-877-7-NYSHIP (1-877-769-7447) and select the Medical Program to request a copy of the SBC for The Empire Plan. Employees who need a copy for a NYSHIP HMO should contact the HMO. Empire Plan enrollees will continue to receive the At A Glance publication, which provides a comprehensive summary of benefits for the coming year.

Contents of the Summary of Benefits and Coverage
The Summary of Benefits and Coverage is a simple and standardized four-page comparison tool that is intended to help consumers better understand and compare available health insurance options. There are four main sections – Important Questions, Common Medical Events, Excluded Services & Other Covered Services and Coverage Examples. The Coverage Examples reflect scenarios for Having a Baby and Managing Type II Diabetes. These Coverage Examples are based on presumptions of what services a person may receive over a year of each scenario. The Coverage Examples do not reflect the actual cost to the enrollee.

Some terms in the Summary of Benefits and Coverage appear in bold and are underlined. These terms are defined in the Uniform Glossary, a companion document to the SBC. These definitions are intended to improve consumer understanding of common terms and do not necessarily reflect the plan’s definition of the same term.

While this information may be helpful, employees should refer to other plan material, such as the Choices booklet for more comprehensive coverage and benefit information, prior to making a decision regarding choosing a health plan.

Availability of the Summary of Benefits and Coverage
The Summary of Benefits and Coverage and Uniform Glossary for The Empire Plan and NYSHIP HMOs are available at https://www.cs.ny.gov/sbc/index.cfm. If a new employee does not have internet access, please print the appropriate copy for him/her when you provide the Choices booklet. You may also direct employees to call 1-877-7-NYSHIP (1-877-769-7447) and select the Medical Program to request a copy of the SBC for The Empire Plan. Employees who need a copy for a NYSHIP HMO should contact the HMO.

Distribution of the Summary of Benefits and Coverage
The Employee Benefits Division will notify current enrollees of the availability of the Summary of Benefits and Coverage and Uniform Glossary online at https://www.cs.ny.gov/sbc/index.cfm via annual mailings, including the rate notification and plan mailings for 2013. Information concerning the SBC will be included in future Empire Plan Reports and HMO Reports sent to enrollees. Copies of the SBC will not be mailed to enrollees or agencies.

Important: Employees who are newly eligible for enrollment in NYSHIP must receive a copy of the attached notice at the time you provide NYSHIP enrollment information and no later than the first day the employee is in a benefits eligible position. In addition, the notice must be made available when a previously eligible employee is enrolling in NYSHIP or when an enrollee is seeking an option change outside of the option transfer period, e.g. because of a qualifying event.

Attachment

The New York State Health Insurance Program (NYSHIP) for Employees of New York State

Welcome to the New York State Health Insurance Program (NYSHIP). As a new employee, or an employee newly eligible for health insurance, there are some important things you should know:

• You may select coverage under The Empire Plan or a NYSHIP HMO. Refer to the Choices guide for a comprehensive overview of each option.
• Federal Health Care Reform requires that a Summary of Benefits and Coverage be available for The Empire Plan and each NYSHIP HMO. You may view copies of each at https://www.cs.ny.gov/sbc/index.cfm. Or, if you do not have internet access, you may call 1-877-7-NYSHIP (1-877-769-7447) and choose the Medical Program to request a copy.
• Depending on your agency, your Health Benefits Administrator(s) (or HBA) may be located in your agency’s personnel office or at the OGS Business Service Center. Contact your HBA to make any changes to your health insurance coverage. For example, if you need to add or remove a dependent, update your address, change your health insurance option, or if you have any questions about your coverage, contact your HBA.
• Check https://www.cs.ny.gov/ebd, the New York State Department of Civil Service web site, for updates and information, including new publications, your prescription drug list, benefit changes and to find a participating provider.
• If you enroll in a NYSHIP HMO, you may want to familiarize yourself with their web site and bookmark it for your reference and use.