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
LOLA W. BRABHAM
Acting Commissioner
PE18-19
PA18-13
TO: Participating Agency and Participating Employer Health Benefits Administrators
FROM: James DeWan, Director of the Employee Benefits Division (EBD)
SUBJECT: New York State Health Insurance Program (NYSHIP) Benefit Changes for Participating Agencies and Participating Employers effective January 1, 2019
DATE: November 21, 2018
The following information concerns changes to the Empire Plan copayments for Medical, Hospital, and Mental Health and Substance Abuse Services, and to the combined annual deductible and coinsurance maximum amounts for non-network services. These changes were negotiated by State employee unions that settled their collective bargaining contracts with New York State or the Unified Court System and they are being extended to Participating Agencies (PAs) and Participating Employers (PEs). These changes are effective January 1, 2019 and apply to PA and PE enrollees who are active employees, retirees, dependent survivors or COBRA enrollees with Empire Plan Benefits.
Enrollees will receive information concerning these changes in the Empire Plan at a Glance publication that will be mailed to their homes by mid-December. In addition, the updated Summary of Benefits and Coverage (SBC) will be posted online at www.cs.ny.gov/sbc. PA enrollees will receive a postcard notifying them when the updated SBC will be available online. PE enrollees and retirees receive their annual notification of the SBC in the Option Transfer publications.
The following changes are effective January 1, 2019:
|
In-Network Mental Health & Substance Abuse (MHSA) |
Current Copay |
Change Effective 1/1/2019 |
|
Mental Health Professional Office Visit |
$20 |
$25 |
|
Outpatient Substance Use Treatment Visit |
$20 |
$25 |
|
Emergency Department Visit |
$70 |
$100 |
|
In-Network Medical/Surgical |
Current Copay |
Change Effective 1/1/2019 |
|
Office Visit, Office Surgery, Radiology, Diagnostic Laboratory Testing, Physical Therapy, Chiropractic, Occupational Therapy, Convenience Care Clinic Visit |
$20 |
$25 |
|
Non-Hospital Urgent Care Visit |
$20 |
$30 |
|
Non-Hospital Outpatient Surgical Location Visit |
$30 |
$50 |
|
Licensed Ambulance Service |
$35 |
$70 |
|
In-Network Hospital |
Current Copay |
Change Effective 1/1/2019 |
|
Outpatient Physical Therapy |
$20 |
$25 |
|
Urgent Care Visit, Outpatient Services for Diagnostic Radiology and Laboratory Tests |
$40 |
$50 |
|
Outpatient Surgery |
$60 |
$95 |
|
Emergency Department Visit |
$70 |
$100 |
|
Skilled Nursing Facility Days * (Network & Non-Network)
Each day of care in a skilled nursing facility counts as one-half benefit day of care
* Empire Plan primary enrollees/dependents only.
|
Current Benefit Days per Spell of Illness |
Effective 1/1/2019 Benefit Days per Spell of Illness |
|
365 x 2 |
120 x 2 |
|
Non-Network Benefits |
Current Benefit |
Change Effective 1/1/2019 |
|
Combined Annual Deductible, for Basic Medical expenses and non-network expenses under HCAP and MHSA Programs. |
$1,000 Enrollee $1,000 Spouse/DP $1,000 Children (combined) |
$1,250 Enrollee $1,250 Spouse/DP $1,250 Children (combined) |
|
Combined Annual Coinsurance Maximum, for Basic Medical Program and non-network coverage under the Hospital and MHSA Programs. |
$3,000 Enrollee $3,000 Spouse/DP $3,000 Children (combined) |
$3,750 Enrollee $3,750 Spouse/DP $3,750 Children (combined) |
In addition, the 30-day quantity limit for maintenance medications required by “New to You” Program under the Prescription Drug Program will be eliminated as of January 1, 2019.