Department of Civil Service

SEHP12-09

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. Empire Plan enrollees will continue to receive the SEHP Summary of Benefits publication, which provides a comprehensive overview 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 SEHP Summary of Benefits 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 enrollment material. You may also direct employees to call 1-877-7-NYSHIP (1-877-769-7447) and select the Medical Program to request a copy.

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. Copies of the SBC will not be mailed to enrollees or agencies.

Important: Employees who are newly eligible for enrollment in SEHP must receive a copy of the attached notice at the time you provide SEHP 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 SEHP or when an enrollee is seeking an option change outside of the open enrollment period, e.g. because of a qualifying event.

Attachment

The New York State Health Insurance Program (NYSHIP) for the Student Employee Health Plan (SEHP)

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:

• The Student Employee Health Plan (SEHP) provides medical, hospital, mental health and substance abuse, prescription drug and dental/vision benefits.
• Federal Health Care Reform requires that a Summary of Benefits and Coverage be available for the Student Employee Health Plan. You may view a copy of the Summary of Benefits and Coverage for the Student Employee Health Plan 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.
• Your Health Benefits Administrator (HBA) — usually located in your agency’s personnel office — is the person you should contact to make any changes to your health insurance coverage. For example, if you need to add or remove a dependent, update your address 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.