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College-age Students’ Dental, Vision Coverage May End with School Year

If your child is age 19 or over, but not yet 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 his/her 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.

Under the EmblemHealth (formerly GHI) Preferred Dental Plan and the NYS Vision Plan, your unmarried dependent children age 19 or over, 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.

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 2016 monthly COBRA rates for individual coverage are:  $28.63 for dental and $3.53 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 website at https://www.cs.ny.gov/employee-benefits.  Follow the prompts to NYSHIP Online, and then click on Health Benefits & Option Transfer. Choose NYSHIP General Information Book.  You may also call the Employee Benefits Division of the NYS Department of Civil Service at 518-457-5754 or 1-800-833-4344.


Center of Excellence for Infertility Program – Facility Changes

The Empire Plan’s Center of Excellence (COE) for Infertility Program is partnering with UnitedHealthcare’s Optum Infertility Centers of Excellence network. This change is occurring in order to use Optum’s expertise and to ensure that Plan members continue to have a network of Centers with proven experience and successful outcomes. Benefits will remain the same; however, some facilities in the COE network will change. Please note that as of June 1, 2016, CNY Fertility (locations in Albany and Syracuse, NY) and Reproductive Specialists of New York (located in Mineola, NY) will no longer be part of the COE Program.

Effective June 1, the following facilities will be part of the new COE network:

  • Boston IVF, the Albany Center (Albany)
  • Columbia University for Women’s Reproductive Care (New York)
  • Cornell Center for Reproductive Medicine and Fertility (New York)
  • Genesis Fertility and Reproductive Medicine (Brooklyn)
  • Infertility and IVF Medical Associates of Western NY (Snyder)
  • Long Island IVF (Lake Success, Melville, Port Jefferson)
  • New York University Fertility Center (New York)
  • Reproductive Medicine Associates of Connecticut (Norwalk, CT)
  • Reproductive Medicine Associates of New York (New York)
  • Strong Fertility Center (Rochester)

If you are currently receiving infertility services from a facility that will no longer participate in The Empire Plan COE network, UnitedHealthcare mailed a letter on March 25, 2016 with more information about your specific situation. For certain services, COE-level benefits will continue to be issued until completion of services. If you remain with CNY or Reproductive Specialists of New York after completion of those services, you will be responsible for copayments and the travel and lodging benefit will no longer apply.

If you have questions regarding this change or its impact on any infertility related services you already have in progress or planned, please call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447), press or say 1 for Medical Program, and then choose Benefits Management Program.

New Immunization Requirements for Students in New York State

Beginning September 1, 2016, students entering seventh and 12th grades in New York State schools must be vaccinated against meningococcal disease, a severe bacterial infection that can lead to meningitis. The new law requires immunizations for children at ages 11 or 12 and again at 16 years of age or older. The meningococcal vaccine is covered in full, without a copayment, when administered by an Empire Plan Participating Provider. For more information about the meningococcal vaccine, call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) and press or say 1 for the Medical Program.

Empire Plan Claims Deadlines

If The Empire Plan is your primary coverage, April 30, 2016 (120 days after the end of the calendar year), is the last day to submit your 2015 claims if you have used a nonparticipating provider or out-of-network pharmacy. If The Empire Plan is your secondary coverage, you must submit claims by April 30, 2016, or within 120 days after your primary health insurance plan processes your claim, whichever is later.

You may submit claims later if it was not reasonably possible to meet the deadlines (for example, due to illness); however, you must provide documentation.

Nonparticipating and non-network claim forms are available on the NYS Department of Civil Service website.  Go to https://www.cs.ny.gov/employee-benefits and follow the prompts to access NYSHIP Online.  From the homepage, select Forms.  You can also call The Empire Plan toll-free number, 1-877-7-NYSHIP (1-877-769-7447) and choose the appropriate program.

File claim forms for/to the following:

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:  nyrmo.optummessenger.com/public/opensubmit

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:  ets.valueoptions.com/OnlineClaimSumission

Prescriptions filled in 2015 at non-network pharmacies or without using your Empire Plan Benefit Card:


P.O. Box 52136

Phoenix, AZ 85072-2136

Mail completed claim forms with supporting bills, receipts and if applicable, a Medicare summary notice or statement from your other primary plan by April 30, 2016.

What is IRS Form 1095-C?

In order to comply with Federal Health Care Reform provisions, the State of New York is required to send IRS tax form 1095-C to all full-time employees, enrollees in The Empire Plan or NYSHIP HMOs, as well as retirees who are not enrolled in Medicare. View the form here. Watch your mail in mid-February for a notice from NYSHIP about the form with additional information.

Note: If you are enrolled in a NYSHIP HMO, you may receive a 1095-C from NYSHIP and a 1095-B from your HMO.

The Empire Plan Reporting On Prenatal Care describes benefits for enrollees who are expecting a child, offers helpful maternity information and guidelines for during and after pregnancy, including The Empire Plan’s Future Moms Program. (Link Here)

New Empire Plan Reporting On Publications

The December 2015 Empire Plan Reporting On publications describe benefits for enrollees with asthma, special surgery needs, or those trying to quit smoking.

Reporting on Asthma  (asthma pdf) discusses the causes and symptoms of asthma, how to avoid asthma triggers, The Empire Plan’s Asthma Management Program and Home Care Advocacy Program (HCAP), types of asthma drugs and smoking cessation benefits.

Reporting on Center of Excellence Programs (centers of excellence pdf) discusses The Empire Plan Centers of Excellence Programs for cancer, transplants and infertility. The Programs offer paid-in-full coverage, including a travel allowance, as well as access to a select group of providers who are recognized as leaders in their fields.

Reporting on Smoking Cessation (smoking cessation pdf) explains the health risks of smoking, tips on how to quit, the e-cigarette trend and information on the smoking cessation treatments covered by The Empire Plan.

Click on the links to read them online, or contact your Health Benefits Administrator (HBA) for a printed copy.

2016 Productivity Enhancement Program Extended to PEF Enrollees            PEF and New York State have reached agreement on extending the Productivity Enhancement Program (PEP) for 2016 to eligible PEF enrollees. To elect PEP for 2016, you must apply by January 8, 2016. The attached notice (PEP 2016 HBA Memo and attachments.pdf) explains the application process and credit amounts available. Contact your Health Benefits Administrator (HBA) located in your Personnel Office if you have any questions or want to request an application.

NYSHIP Dependent Eligibility Audit
Beginning in December 2015, the Department of Civil Service (DCS) will conduct a Dependent Eligibility Verification Project (DEVP), similar to the eligibility audit conducted in 2009, to help ensure that every participant who receives benefits through the New York State Health Insurance Program (NYSHIP) is entitled to those benefits. A key component of the audit is an amnesty period. The 2015-16 New York State budget provides legislation for a special amnesty period which will protect employees and retirees who voluntarily identify ineligible dependents during the amnesty period.
Click here for more information.

Productivity Enhancement Program (PEP) Extension for 2016

On December 2, 2015, PEF and New York State reached agreement on a Memorandum of Understanding (MOU) that restores the Productivity Enhancement Program (PEP) for 2016. Under the PEP, eligible full-time and part-time employees may forfeit previously accrued annual and/or personal leave in return for a credit that reduces their state health insurance premium contribution. The PEP credit of either $500 or $1,000 is divided by 26 paychecks and applied on a biweekly basis. Click here to view PDF.

The Memo from the Department of Civil Service can be seen here:   http://www.cs.ny.gov/attendance_leave/pb15-03.pdf

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