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.
NY15-33
PE15-26
TO: Agency Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: The Empire Plan Annual Maximum Out-of-Pocket, Deductible and Coinsurance Amounts for 2016
DATE: November 30, 2015
The Empire Plan has annual maximum out-of-pocket limits for covered, in-network services/supplies* and combined annual deductible and coinsurance maximum amounts for non-network (Basic Medical Program) services. In 2016, the maximum out-of-pocket limits for covered, in-network services/supplies 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.***
Attached is a chart showing the annual maximum out-of-pocket, deductible and coinsurance maximum amounts for 2016 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.
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* Does not apply to employees represented by 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.
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