Update – Westchester Medical Center Health Network
As of May 31, 2019, the contract between Empire BlueCross BlueShield (the hospital administrator for The Empire Plan) and Westchester Medical Center Health Network (WMC) expired. Effective June 1, 2019, the following WMC facilities are no longer in The Empire Plan network:
• Bon Secours – Good Samaritan Hospital (Suffern, NY)
• Bon Secours – Mercy Community Hospital (Port Jervis, NY)
• Bon Secours – St. Anthony’s Hospital (Warwick, NY)
• Mid- Hudson Regional Hospital (Poughkeepsie, NY)
• Westchester Medical Center (Valhalla, N.Y)
Impact on Empire Plan Enrollees – Most Coverage Is Now On a Non-Network Basis
Except for the special circumstances listed below, all other services provided by WMC facilities will now be covered on a non-network basis:
• If no in-network hospital is available within 30 miles of your residence
• If no in-network hospital within 30 miles of your residence can provide the covered services you require
• If you need emergency care
• For continuation of care for pregnancy or health risk
• For any services that were previously preauthorized
Non-Network Hospital Coverage (Empire BCBS)
|Type of Service||Non-Network Level of Benefits|
|Outpatient Services||Enrollee pays 10% of billed charges or $75 copay, whichever is greater, up to the combined annual coinsurance maximum. Then, the enrollee pays the network level copay, if any.|
|Inpatient Services||Enrollee pays 10% of billed charges up to the combined annual coinsurance maximum of $3,000 for the enrollee, $3,000 for the spouse/domestic partner, and $3,000 for all dependent children combined. The Plan then pays 100% of billed charges.|
|Emergency Services||$70 copay; copay waived if patient admitted directly from ER.|
Radiology, Anesthesiology and Pathology Physician Services (UnitedHealthcare)
If an enrollee receives radiology, anesthesiology or pathology services from a physician in connection with inpatient or outpatient hospital services at one of the non-network WMC facilities, his or her out-of-pocket costs for these services may be higher as well. United Healthcare (UHC) will provide benefits for these services based on the physician’s participation status. If the physician is not an Empire Plan participating provider, UHC will reimburse the enrollee under the Basic Medical portion of the Plan subject to the out-of-network combined annual deductible of $1,000 for the enrollee, $1,000 for the spouse/domestic partner, and $1,000 for all dependent children combined, and paid at 80% up to the Reasonable and Customary Charge.
Enrollees who have questions or need assistance in identifying an alternative facility should be advised to call Empire BCBS toll-free at 1-800-495-9323, Monday through Friday, between the hours of 8:30am and 5:00pm
Westchester Medical Center Health Network Termination
If an agreement with Empire Blue Cross Blue Shield is not reached by June 1, 2019, the Westchester Medical Center Health Network will no longer be in-network.
Westchester Medical Center Health Network consists of the following facilities: Bon Secours – Good Samaritan Hospital; Bon Secours – Mercy Community Hospital; Bon Secours – St. Anthony’s Hospital; Mid- Hudson Regional Hospital; and Westchester Medical Center.
Under these circumstances, Westchester Medical Center Health Network will only provide the following in-network services:
1) Cases of emergency;
2) If no in-network hospital exists that can provide the services required;
3) If a network hospital is not available within a 30-mile radius from your home;
4) For continuation of care for pregnancy or health risk;
5) For any services that were previously preauthorized.
If you choose to use Westchester Medical Center Health Network, all other services will be covered on an out-of-network basis. You will be responsible for paying ten percent (10%) of the billed charges for covered services, up to the annual coinsurance maximum amount.
To find an alternate network hospital or learn more, call 1-877-7-NYSHIP (1-877-769-7447) and select option 2.
Revised Empire Plan Certificate Books\
The NYS Department of Civil Service recently mailed the January 1, 2018 Empire Plan Certificate book to the homes of all active PEF-represented state employees enrolled in the Empire Plan. The updated Certificate book, which describes the coverage provided by the Empire Plan, is also posted on the Civil Service Employee Benefits Division website, NYSHIP Online. Go to www.cs.ny.gov/employee-benefits, select your group (PEF) and plan, if prompted, and then select Health Benefits & Option Transfer.
The 2018 Certificate book replaces your 2014 Empire Plan Certificate book and all Empire Plan Reports/Certificate Amendments updating the 2014 book. The 2018 Certificate includes all of the changes to the Empire Plan since publication of the 2014 Empire Plan Certificate book and January 1, 2018. When PEF ratifies a successor contract, Civil Service will update the Certificate book to include any negotiated benefit changes.
Civil Service will also be mailing a revised Empire Plan Certificate for New York State Retirees to retirees in the near future. The retiree Certificate book will be dated January 1, 2019.
You should save this book and all subsequent Empire Plan Reports/Certificate Amendments you receive in the mail. New Certificate books are not issued every year. It is important that you read and keep this book and any future Empire Plan Reports/Certificate Amendments that update this book and inform you of important changes to your Empire Plan coverage.
On the Road with The Empire Plan
You’re taking your family on a trip this summer…your child is going off to college this fall… you’ve finally retired and plan to spend winters in Florida… it’s good to know that The Empire Plan is there wherever you or your family goes. Before you go, however, plan ahead. Do you have your doctors’ phone numbers and your benefit card? Do you have enough of your maintenance medications? If you are Medicare primary, do you also have your Empire Plan Medicare Rx Card? And, don’t forget to pack On the Road with The Empire Plan. This informative booklet has important phone numbers and information you or a family member may need while away from home.
Empire Plan coverage is available worldwide and not just for emergencies. Most parts of The Empire Plan have two levels of benefits known as network and non-network. If you use an Empire Plan participating (or network) provider, you will receive medically necessary covered services and supplies at little or no cost and have no claim forms to fill out. If you use a nonparticipating (or non-network) provider, medically necessary services and/or supplies are covered, but deductibles, coinsurance and benefit limits may apply.
The Empire Plan Medical/Surgical Program has network providers in many states, and the Hospital Program, Prescription Drug Program and Medicare Rx have nationwide networks. The Empire Plan Mental Health and Substance Abuse Program, the Home Care Advocacy Program (HCAP) and the Managed Physical Medicine Program guarantee access to network benefits nationwide if you call to make the necessary arrangements before you receive services. The toll-free number is 1-877-7-NYSHIP or 1-877-769-7447.
In the event you or a family member needs medical care while away from home, be prepared. Request the booklet On the Road with The Empire Plan from your agency health benefits administrator, usually located in your Personnel Office or the Business Services Center. If you are a retiree, contact the Employee Benefits Division of the NYS Department of Civil Service at (518) 457-5754 or 1-800-833-4344. It can also be found online at www.cs.ny.gov/employee-benefits. Select your group and plan to get to the NYSHIP Online homepage. Select Using Your Benefits and then Publications.
College-age Students’ Dental, Vision Coverage May End with School Year
If your child is age 19 or older, but under age 25, and is completing his or her studies in May or June, then he or she may lose eligibility for coverage as a dependent child under your dental and vision plans.
You must notify your state agency’s health benefits administrator of your child’s change in student status, and you should request information about how to continue their dental and vision coverage.
The federal Patient Protection and Affordable Care Act requires insurers to offer children coverage as dependents on their parents’ health insurance plan up to age 26, but that only applies to medical care, not dental or vision care.
When coverage ends
Under the EmblemHealth (formerly GHI) Preferred Dental Plan and the NYS Vision Plan, your unmarried dependent children age 19 or older, but under age 25, are eligible for coverage if they are full-time students. They continue to be eligible until the first of the following dates:
- • The end of the third month following the month in which they completed the semester as a full-time student;
• The end of the month in which attendance at school ends, if the semester is not completed and proof of the last day of attendance for the semester is provided, or the end of the third month following the month that the last semester was completed, whichever is later;
• The starting date of the semester if the semester is not completed and no proof of attendance is provided, or the end of the third month following the month that the last semester was completed, whichever is later;
• The end of the third month following the month in which they complete course requirements for graduation; or
• The end of the month in which they reach age 25.
How to extend coverage
The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) requires most employers sponsoring group health plans to offer employees and their covered dependents the opportunity for temporary “continuation coverage” at group rates in certain instances where coverage under the employer-sponsored plan would otherwise end.
The dental and vision care benefits your dependent may continue are the same benefits you receive as an active employee. COBRA requires that your child have the opportunity to continue coverage for up to 36 months. The cost of COBRA coverage is the full premium (both the employer and employee shares) plus a 2 percent administrative fee. The 2019 monthly COBRA rates for individual coverage are: $23.41 for dental and $3.16 for vision.
Under COBRA, the employee or dependent is responsible for informing the Employee Benefits Division (EBD) of the state Department of Civil Service (DCS) within 60 days of when the dependent loses eligibility. If you do not notify EBD within that time, regardless of the reason, the dependent will not be entitled to COBRA continuation coverage.
For more information about COBRA continuation coverage, visit the DCS web site at www.cs.ny.gov/employee-benefits.. Follow the prompts to NYSHIP Online, and then select Other Benefits to access the Dental Plan Certificate Book and NYS Vision Plan Book, or you may call the DCS at 518-457-5754 or 1-800-833-4344.
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