Department of Civil Service

PA04-21

TO: Participating Agency Health Benefits Administrators
FROM: Robert W. DuBois, Director, Employee Benefits Division
SUBJECT: NYSHIP Benefit Changes
DATE: November 9, 2004

The following is a summary of negotiated and administratively extended changes in health benefits for NYSHIP enrollees and dependents of Participating Agencies. The changes are effective January 1, 2005 unless otherwise noted.

Empire Plan Hospital Benefit Changes

Hospital Network

The Empire Plan Hospital Benefits Program will now have two levels of benefits - network and non-network - for Plan-primary enrollees. Network benefits apply at hospitals, hospices and skilled nursing facilities that participate in the Blue Cross and Blue Shield Association’s network. Network facilities will be listed in the new Empire Plan directory and on the Department of Civil Service web site.

Network Benefits:
Paid-in-full benefits for inpatient hospital, hospice or skilled nursing facility care at a network facility. Outpatient hospital services and emergency care from a network facility are subject to applicable co-payments. Coverage for inpatient and outpatient care at a network facility includes paid-in-full benefits under the Medical Program for services provided by an anesthesiologist, radiologist or pathologist, even if that provider is not participating in the Empire Plan.

Non-network benefits:
Inpatient care received at a non-network hospital, hospice or skilled nursing facility is subject to 10% coinsurance. Outpatient care received at a non-network facility is subject to 10% coinsurance or $75, whichever is greater.

Maximum Out-of-Pocket Expenses:
The annual coinsurance maximum for services at a non-network facility for either inpatient or outpatient care is $1,500 per enrollee, $1,500 for an enrolled spouse/domestic partner, and $1,500 for all dependent children combined. After $500 of the coinsurance maximum is reached for enrollee, enrolled spouse/domestic partner, or dependent children, the next $1,000 is reimbursable to the enrollee by UnitedHealthcare.

Once coinsurance maximum of $1,500 is reached, benefits for services at a non-network facility are paid at the network level subject to applicable network co-payments.

Network Benefits at a Non-network facility:

The Empire Plan will approve network coverage level at a non-network facility for medically necessary services under the following circumstances:

• When no network facility can provide the medically necessary services.
• When no network facility is available within 30 miles of your residence.
• When the admission is certified by Empire Blue Cross Blue Shield as an emergency or urgent inpatient or outpatient admission.

Changes in Network Hospital Co-payments

• The Network Hospital Outpatient co-payment will be $35.
• The Network Hospital Emergency Room co-payment will be $50. Effective 1/1/07 it will increase to $60.
• The Hospital Outpatient Physical Therapy co-payment will be $15. Effective 1/1/07 it will increase to $18.

Change in Coverage for Hospital Extension Clinics

Coverage for emergency or outpatient hospital services provided at hospital-owned extension clinics will be transferred from the Medical Program to the Hospital Program and subject to hospital outpatient and emergency care co-payment for all groups.

Empire Plan Benefits Management Program

Inpatient Hospital Days for Empire Plan Enrollees - no benefits will be paid for days determined to be not medically necessary.

Empire Plan Medical Benefits

Participating Provider Co-payment

The Participating Provider co-payment will be $15. Effective 1/1/07 it will increase to $18.

Basic Medical Annual Deductible and Coinsurance Maximum

• The Basic Medical Annual Deductible for PA Core will be $550.
• The Basic Medical Annual Deductible for PA Core Plus Enhancements will be $350.
• The Basic Medical Annual Coinsurance Maximum for PA Core will be $2,650.
• The Basic Medical Annual Coinsurance Maximum for PA Core Enhancements will be $1,650.

Allergen Immunotherapy

There will be no co-payment for allergen immunotherapy injections received by a participating provider. If there is an associated office visit, a co-payment will continue to apply.

Hearing Aid Benefit

For PA Core Plus only - The Hearing Aid benefit will be increased for all groups effective 1/1/05 to $1,200.00 per hearing aid/ per ear/ every 4 years. Effective 1/1/06 it will be increased to $1,500.00 per hearing aid/per ear/ every 4 years. Those having met previous maximum are entitled to balance between old and new maximum for covered expenses incurred after 1/1/05. Children 12 years old and under will receive this benefit every 2 years if medically necessary.

External Mastectomy Prostheses

Paid-in-full benefit for one single or double prosthesis per calendar year under Basic Medical Program, not subject to deductible or coinsurance. Pre-certification through HCAP required for any single prosthesis costing $1,000 or more. Coverage limited to most cost-effective prosthesis meeting individual’s functional need.

Infertility Benefits

The lifetime benefit maximum on Qualified Procedures will increase from $25,000 to $50,000 per covered individual. Individuals who have previously reached the $25,000 lifetime benefit maximum will be eligible for up to an additional $25,000 in coverage.

Centers of Excellence for Cancer Program

Effective 10/1/04, payment in full for services at Cancer Resource Service network facilities; $10,000 lifetime travel allowance; telephonic nurse consultations; assistance in locating centers.

Basic Medical Provider Discount Program

Effective 10/1/04 for Empire Plan-primary enrollees only when services are received by a non-Empire Plan provider that is part of the Multiplan network (through UHC), enrollee is eligible for Basic Medical coverage applied to discounted fees. Once the enrollee has met the basic medical deductible, UHC will pay the Multiplan provider directly at 80% of the discounted fee. Enrollees will be responsible for the remaining 20%, and may not be balance-billed by the provider. Services rendered by a provider who participates in the Empire Plan network as well as the Multiplan network will be adjudicated as Participating Provider claims.

Prostheses and Orthotics Network

Paid-in-full coverage for prostheses and orthotic devices obtained through a network of approved suppliers under the Participating Provider Program. Benefit paid up to cost of device meeting individual’s functional need. Devices provided by a non-network provider will be covered under the Basic Medical Program, subject to deductible and coinsurance.

Empire Plan Mental Health and Substance Abuse Benefits

Outpatient Substance Abuse Treatment Co-payment

The Outpatient Substance Abuse Treatment co-payment will be $15. Effective 1/1/07 it will increase to $18.

Outpatient Substance Abuse Treatment Co-payment

The MH/SA Emergency Room co-payment is $50. Effective 1/1/07 it will increase to $60.

Substance Abuse Care Lifetime Maximum

Effective retroactively to 1/1/04, the lifetime maximum for substance abuse care, including alcoholism, is increased to $250,000 for enrollee and $250,000 for each covered dependent.

Empire Plan Prescription Drug Program

The plan will be changing to a 3-level co-payment structure. The new benefit is based on whether the drug is generic, preferred brand-name or non-preferred brand-name. All medically necessary prescription drugs are covered. The new co-payments are indicated on the following chart:

Prescription Drug Co-payment Chart

The Mandatory Generic Substitution and appeals process continues to apply. If a brand-name drug with a generic equivalent is dispensed the enrollee pays the non-preferred brand-name co-payment plus the difference in cost between the brand-name and the generic drug, not to exceed the cost of the drug. If an enrollee’s appeal for a Mandatory Generic Substitution requirement is granted, the enrollee pays the non-preferred brand co-payment only.

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

Eligibility Changes

Domestic Partner Eligibility

The proof of cohabitation requirement as well as the financial interdependence requirement for domestic partner eligibility has been reduced from one year to six months. Additionally, the waiting period for covering a “new” domestic partner has been reduced from two years to one year.

The above noted changes are being announced to enrollees in the October/November 2004 Empire Plan Reports. The reports are being mailed directly to enrollees and will be available on PA-MARKET and NYS OnLine as they become available. In addition, a small supply is being mailed to each HBA. If you have questions, please call your EBD processor.

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