Department of Civil Service

PA00-16

TO: Participating Agency Health Benefit Administrators
FROM: Employee Benefits Division
SUBJECT: New York State Health Insurance Program (NYSHIP)/Empire Plan Benefit Changes
DATE: September 29, 2000

The following is a summary of Empire Plan benefit changes for Participating Agency Employees. These benefits also apply to enrolled dependents and COBRA enrollees with PA benefits.

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

Effective January 1, 2000

Adult Immunizations

Influenza, pneumonia, measles, mumps, rubella, varicella and tetanus are covered under the Participating Provider Program subject to applicable copayment.

Benefits After Termination

If you or a dependent is totally disabled on the date Empire Plan coverage ends, Empire Plan benefits for that disability will be covered until the day the enrollee or dependent is no longer totally disabled or 90 days after coverage ended, whichever is earlier.

Emergency Room Care

There is a $35 copayment for each visit to the emergency room of a hospital for emergency care.

The Empire Plan NurseLine_sm

You may call the Empire Plan NurseLine_sm at 1-800-439-3435 toll-free to talk to a Registered Nurse. The Empire Plan NurseLine_sm provides health and medical information, education and support by Registered Nurses, 24 hours a day, 365 days a year - at no cost to the enrollee or dependents.

Hearing Aids

ALL GROUPS EXCEPT "CORE ONLY"

The maximum is increased to $800 every four years for adults and $800 every two years for children when medically necessary. Employees who had already received the previous maximum benefit after January 1, 2000, are eligible for the increased amount if their expenses exceeded the previous maximum. They should contact UHC for an adjustment.

Home Care Advocacy Program (HCAP)

Non-network reimbursement maximum is reduced to 50 percent of the network allowance if you do not follow HCAP requirements.

Infertility Treatment

Paid-in-full benefits at Centers of Excellence. Pre-authorization requirement and lifetime maximum of $25,000 per covered person for certain qualified procedures.

Newborn Child Care

Basic Medical maximum allowance increased to $100 for Core Only, increased to $150 for all other groups, not subject to deductible or coinsurance.

Pediatric Immunizations

Influenza vaccine, when provided in accordance with pediatric guidelines, is covered under Participating Provider Program with no copayment and Basic Medical Program subject to deductible and coinsurance.

Physical Therapy

There is a $10 copayment for a physical therapy visit in the hospital outpatient department when covered by Blue Cross.

Prescription Drug Copay

There is a $5 copayment for a generic drug, $15 copayment for a brand-name drug without a generic equivalent, $15 copayment plus difference in cost for brand-name with generic equivalent.

Prospective Procedure Review

Enrollees must call the Benefits Management Program at 1-800-992-1213 before an elective MRI is performed in any outpatient setting, now including a hospital outpatient department.

Skilled Nursing Facility

Enrollees must call the Benefits Management Program at 1-800-992-1213 before admission or transfer to a skilled nursing facility.

Effective May 1, 2000

Graduating Students

Graduating students age 19 or over, but under age 25, are eligible for three months of continued coverage following the end of the month in which they complete course requirements for graduation. The enrollee must be able to provide verification of the dependent's graduation. After the three-month extension ends, the graduated dependent student may apply for COBRA or direct-pay conversion coverage.

Effective July 1, 2000

Arizona, North Carolina and South Carolina Provider Networks Expand

Empire Plan enrollees can now use physicians in UnitedHealthcare's Preferred Provider Organization (PPO) network in these states. The number of Empire Plan participating providers has grown by 5,300 in Arizona, 11,300 in North Carolina and 4,700 in South Carolina.

Centers of Excellence for Organ Transplants

Centers of Excellence will be available under hospital contract for organ transplants. Participation is voluntary. Enrollees receiving medically necessary transplants at designated Centers of Excellence will have paid-in-full coverage for evaluation, procedure and up to 12 months of follow-up at the Center, as well as case management services by Empire Blue Cross. There will be a pre-authorization requirement for certain organ and tissue transplants performed at a Centers of Excellence. Travel and lodging costs for the patient and a companion will also be covered under specified conditions. Additional information on this benefit will be provided shortly.

Military Leave (optional)

Employees called to active duty by a declaration of the President of the United States or an Act of Congress will be eligible for up to 12 months of dependent coverage at no employee cost. This does not apply to COBRA enrollees.

Pre-Admission Testing

No copayment for hospital outpatient pre-admission testing and/or pre-surgical testing prior to inpatient admissions.

Effective September 1, 2000

Prescription Drug Coverage

Prevnar will be covered as part of the routine pediatric series under both the participating and non-participating portions of the Empire Plan, subject to appropriate medical protocols for age and frequency.

Effective January 1, 2001

Hearing Aids

ALL GROUPS EXCEPT "CORE ONLY"

The maximum is increased to $1000 every four years for adults and $1000 every two years for children when medically necessary.

Routine Health Exams

ALL GROUPS EXCEPT "CORE ONLY"

Basic Medical allowance increased to $250 per calendar year for an active employee age 50 or older and $250 per calendar year for an active employee's spouse/domestic partner age 50 or older.

Effective January 1, 2002

Hearing Aids

ALL GROUPS EXCEPT "CORE ONLY"

The maximum is increased to $1200 every four years for adults and $1200 every two years for children when medically necessary.

Effective January 1, 2003

$12 Copayment

The following copayments will be changed to $12:

Hospital Outpatient Department Services for Physical Therapy

Services by Empire Plan Participating Providers for an Office Visit, Office Surgery, Radiology service, Diagnostic Laboratory service, Cardiac Rehabilitation Center visit and Urgent Care Center visit

Services by Managed Physical Network (MPN) Providers for an Office Visit, Radiology and Diagnostic Laboratory service

Services by Mental Health and Substance Abuse Network Providers When You Are Referred by ValueOptions for a Visit to an Outpatient Substance Abuse Treatment Program (Mental Health per visit copayment remains at $15)