Department of Civil Service

NY94-26
PE94-19
PA94-18

TO: Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: Employees represented by CSEA, C-82, PEF, PBA, UUP. Home Care Advocacy Program and Emergency Room Benefit Changes
DATE: November 28, 1994

This is to inform you of changes to the Empire Plan that have been extended to the following groups effective October 1, 1994:

• Management/Confidential employees in the Executive Branch of the State of New York, CSEA, PEF, C-82, PBA, UUP,
• Legislative employees of the State of New York,
• Unrepresented employees of the Judicial Branch of New York State and Judges and Justices,
• Employees of all Participating Employers and Participating Agencies,
• All retirees, vestees, preferred list and dependent survivors
• All Cobra enrollees with the benefits of the above groups.

These changes were described in the September Empire Plan Reports sent to enrollees and agencies in September.

1. The Empire Plan's Home Care Advocacy Program (HCAP) will provide a paid-in-full benefit for medically necessary home care services and/or durable medical equipment/supplies prescribed by a doctor when the enrollee calls HCAP at 1-800-638-9918 and uses an HCAP-approved provider. Upon receiving the call, Metropolitan will arrange or help the enrollee arrange for care with its nationally contracted vendors. Enrollees who make the call, but subsequently choose to use non-participating providers that HCAP has not approved, will receive existing Basic Medical benefits subject to all current exclusions, deductibles and coinsurance. Failure to make the mandatory call will result in a $250 penalty or 50% of the covered charges, whichever is less.
2. The $15 hospital outpatient co-payment covers use of the emergency room and certain professional services in a medical emergency. Professional services are defined as:

1. Services of the attending emergency room physician;
2. Services of physicians who administer or interpret radiological exams, laboratory tests, electrocardiograms and pathology services.

When billed separately from the hospital charge, these physician charges will be paid in full by Metropolitan upon submission of a claim by the enrollee.

Services of physicians other than those specifically listed in 1 & 2 above and physician/hospital charges for non-emergency use of the emergency room are not included in the paid-in-full benefit but continue to be covered under the Participating Provider Program or Basic Medical Program of the Empire Plan.

The September 1994 Empire Plan Report, which was mailed to enrollees homes, describes these benefits in detail. Please call Program Services if you have any questions. However, enrollees who need specific benefit information should be referred to Metropolitan at 1-800-942-4640.