2017 Empire Plan
& HMO Premium Rates/Option Transfer Period
The Empire Plan and HMO premium rates for 2017 have been
finalized by the Department of Civil Service and the Option Transfer Period has
started. Pursuant to the authority established in New York State Insurance Law
§§4235 (j)(1), (2) and (3), Empire Plan premium rates are adjusted annually
based on enrollee utilization and projected costs. These rates are not
negotiated by PEF.
The 2017 Empire Plan rate increases reflect projected cost
increases in all four benefit programs for 2017, as well as 2016 premium levels
which generated a combined $193.5 million loss in the Hospital, Medical, and
Mental Health and Substance Abuse programs, and a $174.2 million gain in the
Prescription Drug program.
Salary Grade 9 and
Salary Grade 10 and
The option transfer period will run through December 16,
2016. If anyone is considering changing health plans, or enrolling in the
opt-out program for 2017, they should act quickly. Deductions for the 2017 plan
year will begin on December 29, 2016 for Administration Lag Payroll employees
and on January 5, 2017 for Institution Lag Payroll employees.
The NYSHIP Rates and Deadlines for 2017 flyer will be mailed
directly to employees’ homes. In the meantime, members can get option transfer
information, including the premium rates, on the Department of Civil Service
web site at https://cs.ny.gov/employee-benefits. Select your group (PEF) if
prompted, and then click on Health Benefits & Option Transfer. Choose Rates
and Health Plan Choices. Employees can also download, print and complete the
PS-404 form required to change health plan options, and then bring it to their
HBA for processing on or before December 16, 2016. Or, employees can change
their option online using MyNYSHIP.
The actual percentage of rate change varies by HMO and
coverage type (Individual vs. Family). The change in the employee deduction for
each HMO can vary due to the impact of the HMO premium “capping” formula. If a
PS&T Unit employee enrolls in an HMO, the State’s dollar contribution for
the non-prescription drug components (i.e., hospital, medical/surgical and
mental health and substance abuse components) of his or her HMO premium will
not exceed the State’s dollar contribution for the non-prescription drug
components of The Empire Plan premium. The enrollee must pay 100% of the
premium amount exceeding the cap.
We ask that you remind all members to review the NYSHIP
Rates & Deadlines for 2017 flyer even if they don’t plan on changing their
health plan option to avoid the potential of an unpleasant surprise in their
first biweekly paycheck with the new deductions.
It is important to look at more than premium rates when
selecting or remaining with an HMO. PEF (and other unions) only negotiate the
benefits and other elements of plan design for the Empire Plan. PEF does not
negotiate the benefits that HMOs provide. HMOs are allowed to change benefit
levels on an annual basis, independent of the negotiated Empire Plan benefits.
For this reason, we always recommend that HMO enrollees review their plan
options carefully each year during the Option Transfer Period. By now, all
members enrolled in an HMO should have received side-by-side comparisons
illustrating any benefit changes their HMOs will implement for plan year 2017.
If you have any questions about the rates, please contact
Deborah Stayman or Lorraine Simpkins in the Contract Administration Department
(x283) at PEF headquarters.
Important Deadlines for 2017 Benefits Choices
November 7, 2016 – Health Care Spending Account (HCSAccount). The HCSAccount could reduce your 2017 income taxes (payable in 2018) by allowing you to set aside pre-tax salary earned in 2017 to pay for health, dental and vision care expenses that are not reimbursed by your health insurance or other benefit plans. Visit www.flexspend.ny.gov to enroll online, or call 1-800-358-7202 for more information or to enroll by telephone. If you are currently enrolled in the HCSAccount, you must re-enroll to continue your participation in 2017.
November 30, 2016- Pre-Tax Contribution Program (PTCP). The PTCP may lower your 2017 income taxes (payable in 2018) by allowing you to pay for your health insurance premiums before taxes are withheld. If you participate in the PTCP, there are limitations on when you can make changes to your health insurance coverage. You can make the following changes only in November each year when there has been no PTCP-qualifying event: 1) Change from Family to Individual coverage while your dependents are still eligible; or 2) Voluntarily cancel your coverage while you’re still eligible for coverage. Also, you can elect to opt-in or opt-out of the PTCP. For more information, see the September 2016 Planning for Option Transfer flyer.
Deadline date to be announced for electing to participate in the Opt-out Program. The Opt-out Program allows eligible employees who have other employer-sponsored group health insurance to opt out of their NYSHIP coverage in exchange for an annual incentive payment. Other coverage cannot be NYSHIP coverage that is the result of your or your spouse’s, domestic partner’s or parent’s employment relationship with New York State, or the result of your own employment with a NYSHIP Participating Agency (PA) or Participating Employer (PE). If you are covered as a dependent on another NYSHIP policy through a PA or PE, you are eligible to receive the Individual incentive payment of $1,000, but not the Family incentive payment of $3,000. If you currently participate in the Opt-out Program, you must re-enroll to continue to receive incentive payments in 2017. The deadline is the same as the deadline for changing health plans. For more information, see the September 2016 Planning for Option Transfer flyer.
Deadline date to be announced for changing health plans. The annual Option Transfer Period will be announced once 2017 premium rates are approved. You will have 30 days from the date your agency receives the rates to change your health plan. Consider your choice carefully. You may not change your health plan after the deadline except in special circumstances. No action is required if you do not wish to change health plans.
Productivity Enhancement Program (PEP). PEP allows eligible employees to exchange previously accrued annual leave and/or personal leave, in return for a credit which reduces their share of New York State Health Insurance Program (NYSHIP) premium on a biweekly basis. The enrollment period for PEP is usually between October and November; however, under the terms of the 2015-2016 PS&T Contract (which expired April 1, 2016), the PEP sunsets (stops) at the end of 2016 for PS&T employees. Extending PEP for 2017 is contingent on ratification of the 2016-2019 PS&T tentative agreement. If the tentative agreement is ratified, then implementation will occur as soon as practicable thereafter. More information will be provided as it becomes available.
For the most up-to-date information on the annual Option Transfer Period, including the 2017 premium rates, visit the NYS Department of Civil Service website at www.cs.ny.gov/employee-benefits. Select your group (PEF) and plan, if prompted, and then select “Health Benefits & Option Transfer”.
Important Update on Dependent Eligibility Verification Audit
Since December 2015, the NYS Department of Civil Service has been conducting a Dependent Eligibility Verification Audit, using a vendor called Health Management Systems, Inc. (HMS). Similar to the audit conducted in 2009, its purpose is to ensure that every person who receives NYSHIP health benefits from the Empire Plan or an HMO is entitled to those benefits.
HMS has completed the Verification Period of the audit for state agency enrollees. Enrollees were required to provide proof of eligibility for those dependents identified by HMS no later than August 19, 2016. A grace period extended this deadline to September 7, 2016. Civil Service will now send a “Notice of Cancellation of Coverage” to enrollees with unverified dependents.
On October 2, 2016, unverified dependents will be removed from NYSHIP coverage retroactive to January 1, 2016. Once coverage is terminated, enrollees may be responsible for repaying all health insurance claims for services the ineligible dependent received on or after January 1, 2016 (or if enrolled after January 1, 2016, for dates of service back to the date coverage started).
A 90-day reinstatement period is available through December 6, 2016. Enrollees who wish to appeal the cancellation of a dependent’s coverage must contact HMS at 1-866-252-0635. This number is available from 8 a.m. to 11 p.m., Monday through Friday. For an appeal to be successful, the enrollee will have to provide the documents required to verify the dependent’s eligibility. Enrollees may fax documentation to 1-877-223-8478 or upload the documentation via www.VerifyOS.com.
Dependents who are determined eligible through HMS based on documentation provided by the December 6, 2016 deadline will be reinstated with no break in coverage. Dependents reinstated after December 6, 2016 will be subject to the waiting period for late enrollees. Coverage for late enrollees does not begin until the first day of the fifth payroll period following the payroll period in which the application for coverage is received.
Upon completion of the audit, Civil Service will terminate the coverage of unverified dependents enrolled in the state-administered dental and vision care plans administered by EmblemHealth and Davis Vision, respectively.
Protect Your Vision During Summer and Holiday Celebrations
Everyone enjoys the sunshine, warm weather and July 4th celebrations with family and friends. It’s important to remember that your eyes need extra protection during these fun times.
Ultraviolet (UV) light can cause short and long-term damage to your eyes. Find out who is most at risk and steps you can take to protect your eyes here.
Fireworks are a traditional part of July 4th celebrations. Yet each year, thousands of people visit emergency rooms for treatment of fireworks-related injuries, with children the most frequent victims. Although sparklers may seem safe, they are the No.1 cause of all fireworks injuries in both adults and children.
Check out more about fireworks and the safest way to enjoy them here.
Have a great summer!
Health Alliance of the Hudson Valley (HAHV) Hospitals
As of May 31, 2016, the contract between Empire BlueCross BlueShield (the hospital administrator for The Empire Plan) and Health Alliance of the Hudson Valley (HAHV) expired. Effective June 1, 2016, the following HAHV facilities are no longer in The Empire Plan network:
- Health Alliance Hospital – Broadway Campus (formerly known as Kingston Hospital)
- Health Alliance Hospital – St. Mary’s Avenue Campus (formerly known as Benedictine Hospital)
- Margaretville Memorial Hospital
Impact on Empire Plan Enrollee Who Uses a Non-Network Hospital
Except for the special circumstances indicated below, all other services provided by HAHV facilities will now be covered on a non-network basis.
- Cases of emergency
- If no in-network hospital exists that can provide the services required
- If a network hospital is not available within a 30 mile radius from the member’s home
- 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|
|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.|
|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.|
|Emergency Services||$70 copay; copay waived if patient admitted directly from ER.|
If an enrollee receives radiology, anesthesiology or pathology services from a physician in connection with inpatient or outpatient hospital services at one of these three (3) hospitals, his or her out-of-pocket costs for these services may be higher as well. UnitedHealthcare (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 are currently receiving services or are scheduled for treatment at HAHV hospitals are encouraged to call The Empire Plan toll-free at 1-877-7-NYSHIP (1-877-769-7447) and select 2 for the Hospital Program. Representatives can also provide assistance in locating an alternative Empire Plan network hospital in the area.
If you have any questions regarding this memo, please contact Lorraine Simpkins at PEF headquarters, 1-800-342-4306, ext. 283, or at gro.f1485027379ep@sn1485027379ikpmi1485027379sl1485027379
Don’t Get Copay Shock When You Refill Your Crestor Prescription
If you or a family member take Crestor, a drug prescribed for high cholesterol, you should know that a generic equivalent became available on 5/2/16.
Unless your doctor has written DAW (Dispense as Written) on your prescription for Crestor, the pharmacy will automatically refill the prescription with the generic.
Once a generic is available in the marketplace, if you continue to use Crestor an ancillary (additional) fee will be charged. You have three options:
1-To fill the generic
2-To continue to fill Crestor and pay the ancillary fee
3-To appeal the ancillary fee (if the appeal is approved you would pay the cost of the brand only which is currently $45 for a 30 day supply, $90 for a 90 day supply)
If you have questions contact the Empire Plan at 1-877-7-NYSHIP (1-877-769-7447), then select option 4 for CVS/caremark.
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.