Department of Civil Service

NY07-41

TO: Health Benefit Administrators
FROM: Employee Benefits Division
SUBJECT: Health Benefit Changes for Contract Affected Employees Represented by Council 82 (NU 91)
DATE: September 28, 2007

The following is a summary of health, dental, vision benefits and administrative changes for non-arbitration eligible (those subject to negotiated contract agreement) employees represented by Council 82 (NU 91), for their enrolled dependents and for COBRA enrollees who have these benefits when NYSHIP eligibility is lost.

If you have any questions, please contact your EBD Processor.

Empire Plan Benefit Changes for Contract-Affected Council 82, Security Supervisors Unit Represented Employees

Hospital Component

Effective October 1, 2007:

• Hospital carrier will establish a network of hospitals (hospitals, skilled nursing facilities and hospices) throughout the Untied States.
• There will be a network and non-network benefit structure.
• Network benefits:
• Covered inpatient services will be paid in full;
• Covered outpatient services will be subject to the appropriate copayment;
• Anesthesiology, pathology, and radiology services received at a network hospital will be paid in full less the appropriate copayment regardless of the provider’s participation in the medical component network; and
• Services received at a non-network hospital will be reimbursed at the network level of benefits under the following conditions:
• Emergency outpatient/inpatient treatment;
• Inpatient/outpatient treatment only offered by a non-network hospital;
• Inpatient/outpatient treatment in geographic areas where access to a network hospital exceeds 30 miles; and
• Care provided outside of the United States.
• Non-network benefits
• There is a $1,500 annual coinsurance maximum for non-network hospital charges that cannot be combined with any other Empire Plan coinsurance maximums. A separate annual coinsurance maximum is applied to enrollee claims, spouse/domestic partner, and all dependent children independently;
• Covered inpatient and outpatient services will be reimbursed at 90% of charges or a copayment of $75 whichever is greater until the $1,500 coinsurance maximum is met;
• Upon meeting a coinsurance maximum of $1,500, covered services will be reimbursed at 100% of charges; and
• Once the enrollee, spouse/domestic partner of all dependent children combined have incurred $500 in non-network expenses, a claim may be filed with the medical carrier for coinsurance expenses in excess of $500 up to the balance of the annual coinsurance maximum.
• No payment will be made for inpatient hospital days that are determined to be non-medically necessary by the hospital carrier.
• Services provided in a hospital-owned extension clinic (which would otherwise be covered under the hospital contract if performed in the outpatient department of a hospital), will be covered under the hospital contract.

Medical Component

*  Basic Medical benefits are 80% of the reasonable and customary charges for the item.
** Children age 12 and under are eligible for this benefit every 2 years.

• Effective August 1, 2007, Centers of Excellence will expand to include Cancer Resource Services (CRS):
• Paid in full reimbursement for all services provided at a CRS network facility when care is precertified; and
• Up to $10,000 in travel allowance, paid according to the CRS schedule of travel reimbursements.
• Effective October 1, 2007, Basic Medical Discount Provider Network:
  • Provides a network of additional providers under the Basic Medical portion of the Plan;
  • Upon satisfaction of the Basic Medical deductible, payment will be made directly to the provider with no balance billing to the patient; and
  • This program will terminate on December 31, 2007 unless extended by mutual agreement of both parties.

Managed Mental Health and Substance Abuse

Prescription Drug Component

*  When an FDA approved generic version of the drug is available, patient pays copay PLUS the difference in the brand-name drug and its generic equivalent (with some exceptions) not to exceed the full cost of the drug.

• Prescription drugs dispensed by Skilled Nursing Facilities with on premises pharmacies will be covered as non-network prescription drug claims.

Other Benefit Changes

NYS Vision Program

*  Procedures not covered by the Empire Plan or an HMO

** Coverage includes a preliminary examination, the actual procedure and up to two follow-up visits and is limited to one procedure every five years.  Five year limitation may be waived based on significant vision change due to illness or injury.

NYS Dental Program

Dependent Eligibility

Domestic Partner Eligibility: The proof of residency requirement as well as the financial interdependence requirement for domestic partner eligibility has been reduced from one year to six months.