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
NY18-33
TO: NYS Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: January 1, 2019 Empire Plan Benefit Changes for NY Retirees
DATE: November 27, 2018
The following information concerns changes to The Empire Plan copayments for Medical/Surgical, Hospital, and Mental Health and Substance Abuse program services, and to the combined annual deductible and coinsurance maximum amounts for non-network services. These changes were negotiated by certain State employee unions and they are being extended to all NYS agency retirees, vestees, dependent survivors and enrollees covered under preferred list provisions, effective January 1, 2019.
Affected 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) is posted online at www.cs.ny.gov/sbc/retiree. Please provide these materials to any enrollee who is planning to retire. You may also order a Quick Order package for such individuals after mid-December as it will include the 2019 At A Glance.
The following changes are effective January 1, 2019:
|
In-Network Medical/Surgical |
Current Copay |
New Copay 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 |
New Copay 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 and Non-Network)
Each day of care in a skilled nursing facility counts as
* 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 |
|
In-Network Mental Health & Substance Abuse (MHSA) |
Current Copay |
New Copay Effective 1/1/2019 |
|
Mental Health Professional Office Visit |
$20 |
$25 |
|
Outpatient Substance Use Treatment Visit |
$20 |
$25 |
|
Emergency Department Visit |
$70 |
$100 |
|
Non-Network Benefits |
Current Benefit |
New Benefit 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 the “New to You” Program under the Prescription Drug Program will be eliminated as of January 1, 2019.