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.
ANDREW M. CUOMO
GOVERNOR
DEPARTMENT OF CIVIL SERVICE
ALBANY, NEW YORK 12239
www.cs.ny.gov
JERRY BOONE
COMMISSIONER
NY14-31
PE14-28
TO: Health Benefits Administrators of New York State and Participating Employers
FROM: Employee Benefits Division
SUBJECT: Empire Plan Annual Maximum Out-of-Pocket, Deductible and Coinsurance Maximum Amounts for 2015
DATE: October 23, 2014
The Empire Plan has annual maximum out-of-pocket limits for covered, in-network services* and combined annual deductible and coinsurance maximum amounts for non-network (Basic Medical Program) services. In 2015, the maximum out-of-pocket limits for covered, in-network services will be split between the Prescription Drug Program** and the Hospital, Medical/Surgical and Mental Health and Substance Abuse Programs, combined. The combined annual deductible and coinsurance maximum amounts for non-network (Basic Medical Program) services will be shared among the Hospital, Medical/Surgical and Mental Health and Substance Abuse Programs***.
Below is a chart showing the annual maximum out-of-pocket, deductible and coinsurance maximum amounts for 2015 by employee group. Please distribute or post this chart within your agency. You may also want to prepare a posting specific to your agency. If you are a Health Benefits Administrator in an agency with regional offices, please distribute notices to the regional locations as well. Click here to download a copy of the chart.
* Does not apply to employees represented by PBA-S, PBA-T and PIA.
** Does not apply to Medicare-primary enrollees.
*** Each deductible and maximum coinsurance amount is combined among the Hospital Program (coinsurance only), Home Care Advocacy Program (deductible only), Medical/Surgical Program and Mental Health and Substance Abuse Program.
Please note: There is a separate deductible for non-network services in the Managed Physical Medicine Program.
2015 Empire Plan Maximum Out-of-Pocket Limits for In-Network Services*
| Coverage Type | Prescription Drug Program** | Hospital, Medical/Surgical and Mental Health and Substance Abuse Programs Combined | Total |
|---|---|---|---|
| Individual Coverage | $2,300 | $4,300 | $6,600 |
| Family Coverage | $4,600 | $8,600 | $13,200 |
* Does not apply to employees represented by PBA-S, PBA-T and PIA.
** Does not apply to Medicare-primary enrollees.
2015 Empire Plan Combined Annual Deductible and Coinsurance Maximum Amounts for Non-Network (Basic Medical Program) Services*
| Employee Group | Combined Annual Deductible* (per enrollee; per spouse or domestic partner; per all dependent children combined) | Combined Coinsurance Maximum* (per enrollee; per spouse or domestic partner; per all dependent children combined) |
|---|---|---|
| Executive Branch Employee Groups | ||
| APSU | $1,000 | $3,000 |
| Council 82 | $1,000 | $3,000 |
| CSEA | $1,000/$500** | $3,000/$1,500** |
| DC-37 | $1,000/$500** | $3,000/$1,500** |
| M/C | $1,000/$500** | $3,000/$1,500** |
| NYSCOPBA | $1,000/$500** | $3,000/$1,500** |
| PEF | $1,000/$500** | $3,000/$1,500** |
| PBA - Troopers & Supervisors | $437 CPI*** | $962 CPI*** |
| PIA | $437 CPI*** | $962 CPI*** |
| UUP | $1,000/$500**** | $3,000/$1,500**** |
| Other Employee Groups | ||
| Legislature | $1,000/$500** | $3,000/$1,500** |
| Participating Employers | $1,000 | $3,000 |
| Retirees, Vestees, Dependent Survivors and Preferred List | $1,000 | $3,000 |
| Unified Court System Employees | $1,000/$500** | $3,000/$1,500** |
* Each deductible and maximum coinsurance amount is combined among the Hospital Program (coinsurance only), Home Care Advocacy Program (deductible only), Medical/Surgical Program and Mental Health and Substance Abuse Program.
Please note: There is a separate deductible for non-network services in the Managed Physical Medicine Program.
** The annual deductible for calendar year 2015 will be reduced to $500 and the coinsurance maximum will be reduced to $1,500 for CSEA, DC-37, M/C; Legislature, NYSCOPBA, PEF and employees of the Unified Court System in (or equated to) Salary Grade 6 or below on January 1, 2015. This reduction is not available to Judges and Justices.
*** These changes reflect the 2.5% increase in the medical care component of the Consumer Price Index for Urban Wage Earners and Clerical Workers, all Cities (C.P.I.-W.) for the period July 1, 2013 through June 30, 2014.
**** The annual deductible for calendar year 2015 will be reduced to $500 and the coinsurance maximum will be reduced to $1,500 for UUP-represented employees whose annual salary is $35,005 and below.
Note: You have no deductible or coinsurance when you use The Empire Plan Participating Provider Program.