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
PAEX14-27
TO: Health Benefits Administrators of Participating Agencies with The Excelsior Plan
FROM: Employee Benefits Division
SUBJECT: Excelsior Plan Annual Maximum Out-of-Pocket, Deductible and Coinsurance Maximum Amounts for 2015
DATE: October 23, 2014
The Excelsior 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 Medical/Surgical Program, Home Care Advocacy Program (deductible only) and outpatient expenses for the Mental Health and Substance Abuse Program.
Below is a chart showing the annual maximum out-of-pocket, deductible and coinsurance maximum amounts for 2015. Please distribute or post this chart within your office. Click here to download a copy of the chart.
2015 Excelsior 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 |
2015 Excelsior Plan Combined Annual Deductible and Coinsurance Maximum Amounts for Non-Network (Basic Medical Program) Services*
| 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) |
|---|---|
| $1,250 | $4,000 |
* Under The Excelsior Plan, each deductible and maximum coinsurance amount is combined among the Medical/Surgical Program, Home Care Advocacy Program (deductible only) and outpatient expenses for the Mental Health and Substance Abuse Program.
Note: You have no deductible or coinsurance when you use the Participating Provider Program.