Home » Contract Information » Health Benefits

Health Benefits

PEF Logo

6/15/2018
Do You Have a Student Age 19 or Over? You’ll Need to Submit Verification.

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. For the dental plan, EmblemHealth is responsible for determining eligibility as a full-time student. For the vision plan, Davis Vision is responsible for determining eligibility as a full-time student. Before paying a claim, both carriers require the employee to verify that his or her dependent child was a full-time student at the time the child received services. We recommend submitting the forms used to verify student status at the beginning of each semester. The forms are available at: https://www.emblemhealth.com/Members/Forms. and https://www.cs.ny.gov/employee-benefits/nyship/shared/forms/Davis-Vision-Student-Verfication-Form.pdf

The NYS Department of Civil Service recently implemented a new procedure to ensure that the State is not providing dental and vision coverage to dependent children for which the carriers have not received verification of student status. Each month, EmblemHealth and Davis Vision will be providing Civil Service with a list identifying those dependent children age 19 or older, but under age 25, for which the carrier has not received a current student verification form. Civil Service will terminate the dental and vision coverage for these dependents effective the end of the month in which the dependent turned 19, or three months after the most recent semester for which a student verification form was received.

If the dependent’s coverage should not have been terminated because he or she is a full-time student, then the employee will need to submit student verification forms to both EmblemHealth and Davis Vision. The carriers will then notify Civil Service to reinstate coverage. The forms must be submitted within 90 days of the termination to avoid a break (or gap) in the dependent’s coverage. Civil Service will send a letter to the employee when the dependent’s coverage is reinstated.

If you have any questions regarding the student verification forms or the eligibility of your dependent child, please contact the carrier directly. We recommend calling the carriers before scheduling an appointment for a dependent student to confirm that the carrier’s enrollment records indicate the student is eligible. You don’t want your dependent student to arrive at his or her appointment only to find out he or she is no longer covered. The toll-free telephone number for EmblemHealth is 1-800-947-0101. The toll-free telephone number for Davis Vision is 1-888-588-4823.

4/16/2018

College-age Students’ Dental and Vision Coverage May End With School Year

If your child is age 19 or older, but under age 25, and is completing his/her studies in May or June, then he/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 2018 monthly COBRA rates for individual coverage are: $27.55 for dental and $3.37 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.

4/3/2018

Empire Plan Covers New Shingles Vaccine

The Shingrix vaccine has been recommended by the Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control and Prevention (CDC) for the prevention of shingles (herpes zoster) and related complications for those age 50 and older. The Empire Plan must now cover it as a preventive health care service for this age group in accordance with the federal Patient Protection and Affordable Care Act.

Effective April 1, 2018, the Shingrix vaccine will be covered by both the Empire Plan Medical/Surgical Program and by the Prescription Drug Program through the CVS Caremark Vaccine Network. There will be no enrollee copay for the Shingrix vaccine for enrollees age 50 and older when administered by an in-network provider. Any Shingrix vaccine administered prior to April 1, 2018 will be a covered service, but will have an enrollee cost share applied.

The Shingrix vaccine requires two shots to be administered 2-6 months apart, and both shots will be covered as described above. If an enrollee receives the shots at a pharmacy in the CVS Caremark Vaccine Network, a prescription or doctor’s order is not required.

Shingrix is recommended whether or not an individual previously had shingles, and whether or not an individual previously received the Zostavax vaccine. For additional information see https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/recommendations.html.

If you have any questions, please call the Empire Plan toll-free at 1-877-7-NYSHIP (1-877-769-7447) and, depending on the type of provider, press or say 1 for the Medical/Surgical Program or 4 for the Prescription Drug Program.

3/28/2018
Non-network Mental Health, Substance Abuse Claims Can Be Paid Directly to Providers

An Empire Plan enrollee who receives mental health or substance abuse (MHSA) services from a non-network provider may have payments sent directly to the provider, for claims received on or after March 1, 2018. Previously, the MHSA Program prohibited claim payments for non-network providers to be sent directly to the provider, even if an assignment of benefits was indicated on the claim form. All non-network claim payments were required to be paid directly to the member.

The NYS Department of Civil Service has changed this requirement to allow assignment of benefits to non-network providers for claims received on or after March 1 of this year. No adjustments to the assignment of benefits will be made for non-network claims processed prior to March 1, 2018.

Beacon Health Options Inc. (Beacon) is the administrator for The Empire Plan’s Mental Health and Substance Abuse Program. Beacon is sending letters about the change in payment for non-network providers to enrollees who have received services under the non-network portion of the MHSA Program.

If you have already paid a non-network provider for a date of service and have not submitted a claim form to Beacon yet, do not indicate an assignment of benefits on the claim form because that would result in the provider being paid twice for the same date of service. If this does occur it will be your responsibility to recoup money owed to you from the non-network provider.

By receiving MHSA Program services from a non-network provider, your out-of-pocket costs are much higher than they would be if received from a network provider. If you have any questions, or would like to discuss transitioning to a network provider, please contact Beacon’s Customer Service at 1-877-7-NYSHIP (877-769-7447), Option 3 between 8 a.m. and 8 p.m. (EST).

3/23/2018
Submit 2017 Empire Plan Claims by April 30

If the Empire Plan is your primary insurer, April 30, 2018 (120 days after the end of the
calendar year), is the last day to submit your 2017 claims if you have used a non-network provider or non-network pharmacy. If The Empire Plan is your secondary insurer, you must submit claims by April 30, 2018, or within 120 days after your primary health insurance plan processes your claim, whichever is later.

For non-network provider claim forms, you can ask your agency health benefits administrator or find them online at http://www.cs.ny.gov/employee-benefits.. Just follow the prompts there to access NYSHIP Online and select “Forms”. Or, call 1-877-7-NYSHIP (1-877-769-7447) and choose the appropriate program.

Submit completed claim forms with supporting bills, receipts and if applicable, a Medicare summary notice or statement from your other primary plan as follows:

The Empire Plan Basic Medical Program, the Home Care Advocacy Program (HCAP) and non-network physical medicine services:

UnitedHealthcare Insurance Co. of New York
P.O. Box 1600
Kingston, NY 12402-1600
Claims submission fax: 845-336-7716
Online claim submission: https://nyrmo.optummessenger.com/public/opensubmit.

Non-network inpatient and outpatient hospital services:

Empire BlueCross BlueShield
New York State Service Center
P.O. Box 1407, Church Street Station
New York, New York, 10008-1407
Claim submission fax: 888-367-9788

Non-network mental health and substance abuse services:

Beacon Health Options, Inc.
P.O. Box 1800
Latham, NY 12110
Claims submission fax: 855-378-8309
Online claim submission: https://ets.valueoptions.com/OnlineClaimSubmission.

Prescriptions filled in 2017 at non-network pharmacies or without using your Empire Plan Benefit Card:

CVS Caremark
P.O. Box 52136
Phoenix, AZ 85072-2136

2/15/2018
Leave for Cancer Screening

State employees will soon be able to take paid leave for up to four hours without charge to leave credits for screening of all cancers. Previously, Civil Service Law allowed state employees to take paid leave without charge to leave credits specifically for breast and prostate cancer screening. The new provision will take effect on March 18, 2018.

Cancer screening includes physical exams, blood work or other laboratory tests for the detection of cancer. Travel time is included the four-hour cap. Absence beyond the four-hour cap must be charged to leave credits.

Leave for cancer screening is not cumulative and expires at the close of business on the last day of each calendar year.

If you are looking for older news you can click here.