Department of Civil Service

PA96-10

TO: Participating Agency Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: Empire Plan Flyer for enrollees
DATE: October 16, 1996

Empire Plan Flyer

At this time of year we know your employees may call you with questions about their health insurance for next year. The attached flyer is an overview of the Empire Plan which they may find helpful.

We sent you a copy of this flyer in November 1995 with instructions for ordering more, so you may already have a supply on hand. You may continue to distribute copies because benefits described in the flyer remain in effect for 1997.

If you would like to receive more copies now, please use the Publications Supply Request form you currently have. Fill in the quantity you need next to PA-OT-96 and fax the form to the Employee Benefits Division at (518) 457-1311.

If you need a new Supply Request form, please call the Communications Unit at (518) 457-7577.

Coming Next

• We are also developing a more detailed summary of benefits for Participating Agencies. Later this fall we will mail it to your employees and retirees as an insert in an Empire Plan Report. We will send you a surplus supply of the Report and then make the insert available to you as a stand alone piece.
• Next month we will send you a memo about procedures for the annual option transfer period.

If you have any questions about publications, please call Communications at (518) 457-7577.

THE EMPIRE PLAN
New York State Health Insurance Program
Health Insurance For Participating Agency Employees, Retirees, Vestees and Dependent Survivors

Health Insurance You Can Count On

The Empire Plan is a comprehensive health insurance program which provides:

Inpatient and outpatient hospital coverage through Blue Cross. Inpatient hospital care for covered inpatient hospital services are paid in full. A copayment may be required for emergency room and certain other covered outpatient hospital services.

Medical and surgical services through Metropolitan. Choose from a Participating Provider network of approximately 20,000 physicians and other providers located throughout New York State and in many other states. Non-participating provider services are covered under the Basic Medical Program.

Value Behavioral Health network for mental health/substance abuse services. You pay only the copayment when you call VBH and follow their recommendation.

Home Care Advocacy Program (HCAP) for home care services and durable medical equipment/supplies. Services and supplies covered under HCAP are paid in full. Costs vary if you don't use HCAP.

Managed Physical Network (MPN) for chiropractic care and physical therapy.

HealthCall, the Empire Plan's hospital and medical benefits management program, through Intracorp.

Prescription drug coverage administered by CIGNA/ValueRx.

NEW YORK STATE
THE EMPIRE PLAN

Participating Agencies designate one of the Empire Plan's three benefit packages for each group of their employees and retirees who are eligible for coverage under the New York State Health Insurance Program (NYSHIP).

The three Empire Plan options are:

• Core Only
• Core Plus Medical Enhancement
• Core Plus Medical and Psychiatric Enhancements

The benefits under each package are different. Be sure you know which package applies-ask your agency Health Benefits Administrator if you have questions.

The following is a brief list of the benefits available under each portion of the Empire Plan. These benefits are subject to medical necessity and to limitations and exclusions described in the Empire Plan Certificate of Insurance and Empire Plan Reports/Certificate Amendments. Benefits are subject to change- ask your agency or the Empire Plan carriers for up-to-date information.

Blue Cross
(518) 367-0009 (Albany area and Alaska)
1-800-342-9815 (NYS and other states except Alaska)

Your choice of acute care hospitals for medical or surgical admissions is virtually unlimited.

• Inpatient hospital care for medical, surgical and maternity conditions including anesthesia administered by a hospital employee
• Skilled nursing facility care in lieu of hospitalization unless eligible for primary Medicare benefits
• Hospice care
• Outpatient hospital care for:
• Emergency care*
• Surgery*
• Diagnostic radiology and diagnostic laboratory tests*
• Mammography screening*
• Pre-admission testing*
• Administration of Desferal for Cooley's anemia*
• Hemodialysis
• Chemotherapy
• Radiation therapy
• Physical therapy

Blue Cross member hospitals will bill Blue Cross directly. They will require you to pay any copayment due for outpatient services at the time of service. When non-member hospitals ask you for full payment, send the bill to Blue Cross for reimbursement.

* Services marked by an * may be subject to a $25 copayment.

Metropolitan
1-800-942-4640

Metropolitan provides coverage for the following types of services:

• Offlce visits*
• Surgeon's fees when not covered by Blue Cross*
• In-Hospital anesthesia, unless covered by Blue Cross or administered by your doctor*
• Maternity care
• Pediatric care (well-child visits)
• Specialist consultations*
• Durable medical equipment and related supplies, diabetic and ostomy supplies
  • home nursing
  • home infusion therapy
  • certain home health care services when they take the place of hospitalization or care in a skilled nursing facility are paid in full under the Home Care Advocacy Program (HCAP).Costs vary if you don't use HCAP.
• Chiropractic care and physical therapy when you choose a Managed Physical Network, Inc. (MPN) provider. For Core Plus Medical and Psychiatric Enhancements and Core Plus Medical Enhancement, non-network coverage has substantially lower benefits. No out-of-network benefits for Core Only.*
• Diagnostic laboratory and radiology services*
• Podiatry*
• Radiation therapy
• Chemotherapy
• Hemodialysis
• Ambulance service
• Hospital charges upon expiration of Blue Cross benefits

* Outpafient Services marked by an * may be subject to a $10 copayment under tbe Participating Provider Program.

When you use the Participating Provider Program:

You obtain services from a provider who has an agreement in effect with Metropolitan.

You may be required to pay a modest copayment to the provider.

The participating provider submits a claim directly to Metropolitan.

Metropolitan pays the provider directly for all covered services.

When you use the Basic Medical Program:

You obtain services from a non-participating provider.

You submit a claim to Metropolitan.

Metropolitan pays you for covered services, up to the reasonable and customary amount, subject to a deductible and coinsurance as described in the Empire Plan Certificate of Insurance and Empire Plan Reports/Certificate Amendments.

For Core Plus Medical and Psychiatric Enhancements or Core Plus Medical enhancement, you have a $1 million annual and no lifetime dollar maximum on covered benefits under the Basic Medical portion of the Empire Plan.

For Core Only, you have a $100,000 annual and $1 million lifetime maximum under the Basic Medical portion of the Empire Plan.

Medicare Enrollees

Your provider submits the claim to Medicare. In 1995-1996, the Empire Plan will introduce a new claims procedure: Medicare will file directly with Metropolitan for most Empire Plan enrollees. Information will be mailed to your home.

CIGNA/ValueRx
1-800-964-1888

Your Empire Plan Prescription Drug coverage provides the following, subject to the more detailed descriptions in the Empire Plan Certificate.

$10 Copayment

You pay a $10 copayment for generic drugs and for brand-name drugs that have no generic equivalent. For brand- name drugs that have generic equivalents, you pay your $10 copayment plus the difference in cost between the brand-name drug and its equivalent.

Participating Pharmacy

You may use your New York Government Employee Benefit Card to fill your prescriptions for covered medications at any participating pharmacy.

Medicine Through the Mail

You may fill your prescriptions through the mail by using the ValueRx Mail Service. A pharmacist is on call 24-hours a day for emergencies such as questions about dosage, a change in the appearance of medication, or drug interactions.

Non-Participating Pharmacy

If you use a non-participating pharmacy or you do not use your card at a participating pharmacy, you will pay the pharmacy the full cost of the prescription and then submit a claim to ValueRx for partial reimbursement.

Prior Authorization

Prior authorization is required for certain drugs.

HealthCall
1-800-992-1213

HealthCall, the Empire Plan's medical Benefits Management Program, administered by Intracorp, provides:

• Pre-Admission Certification, before a maternity or scheduled hospital admis sion or within 48 hours after an emergency or urgent hospital admission
• Prospective Procedure Review before Magnetic Resonance Imaging (MRI)
• A voluntary paid-in-full Specialist Consultant Evaluation when arranged through HealthCall
• Voluntary Medical Case Management to help coordinate services for serious conditions and High Risk Pregnancy Program

A phone call is required to initiate these programs.

VBH
VALUE BEHAVIORAL HEALTH
1-800-446-3995

The Empire Plan's managed Mental Health and Substance Abuse Program offers comprehensive benefits:

Core Plus Medical and Psychiatric Enhancement:

Mental Health Network Benefits:

• Inpatient: Unlimited benefits when medically necessary
• Outpatient: $15 copayment, unlimited visits when medically necessary
• Crisis Intervention: Up to 3 visits per crisis paid-in-full

Alcohol/Drug Abuse Services Network Benefits:

• Inpatient Rehab: 3 stays per lifetime when medically necessary
• Structured Outpatient Rehab Program: $10 per visit, unlimited when medically necessary

Non-Network Benefits: limited non-network benefits for medically necessary care. $2,000 annual deductible for inpatient care and a $500 annual deductible for outpatient care as described in the Certificate. The plan then pays 50 percent of the network allowance. There are limits on inpatient and outpatient benefits and annual and lifetime maximums if you do not use VBH.

Core Only and Core Plus Medical Enhancement:

Mental Health Network Benefits:

• Inpatient: Up to 30 days per year when medically necessary
• Outpatient: $15 copayment, up to 20 visits per year when medically necessary
• Crisis Intervention: Up to 3 visits per crisis paid-in-full. Visits count toward 20-visit per year maximum

Alcohol/Drug Abuse Services Network Benefits:

• Inpatient Rehab: Up to 30 days per year, 3 stays per lifetime when medically necessary
• Structured Outpatient Rehab Program: $10 per visit, up to 60 visits per year when medically necessary

Non-Network Benefits: If you do not call VBH or do not follow their recommendations, no benefits are available.