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HealthBenefits Updated March 9, 2010 - Health Benefits Homepage
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Deadlines Approaching for Flex Spending and Empire Plan Claims

Employees enrolled in the Flex Spending Account for the 2009 plan year have until March 31, 2010 to send in reimbursement claims for eligible expenses incurred under the Health Care Spending Account and the Dependent Care Advantage Account.

Visit the Flex Spending Account web site at www.flexspend.state.ny.us to download a reimbursement claim form or call Fringe Benefits Management Company at 1-800-342-8017 to request one. You can submit your reimbursement claim form and supporting documentation in one of the following three ways:

Mail form to:

Fringe Benefits Management Company Post Office Box 1820 Tallahassee, Florida 32302-1820 or

Fax form to: (800) 743-3271 or

Submit form online at: www.myFBMC.com

If you fax your reimbursement claim form to FBMC or submit it online, do not mail the form as well.

2009 Empire Plan claims due March 31

Empire Plan enrollees take note: Time is running out for filing claims for covered medical services and items received in 2009.

March 31 is the last day to submit your 2009 claims to:

United HealthCare for the Empire Plan Basic Medical Program, the Home Care Advocacy Program (HCAP), and for non-network physical medicine services;

OptumHealth Behavioral Solutions for non-network mental health and substance abuse services; and

Medco for prescriptions filled in 2009 at non-participating pharmacies or without using your Empire Plan Benefit Card.

If the Empire Plan is your secondary insurer, you must submit claims by March 31, or within 90 days after your primary health insurance plan processes your claim, whichever is later. If you are covered under the Empire Plan as both an enrollee and as a dependent, you may submit secondary claims to the Empire Plan for expenses not reimbursed under your primary coverage, such as copayments (including prescription drug copayments), deductibles and coinsurance amounts.

Claims submitted after the deadline will be rejected. The carriers will only reconsider their denial of these claims if you provide documentation indicating it was not reasonably possible for you to meet the deadline (for example, due to illness).

Ask your agency Health Benefits Administrator for claim forms, or call the Empire Plan toll-free telephone number 1-877-7NYSHIP (1-877-769-7447). Or, just download the forms using the NYS Department of Civil Service website, www.cs.state.ny.us.

From the home page, click on “Benefit Programs” and follow the prompts to access NYSHIP Online. Then click on “Using Your Benefits”.

Mail completed claim forms with supporting bills, receipts and, if applicable, a Medicare Summary Notice or statement from your other primary insurer to:

1. United HealthCare
P.O. Box 1600
Kingston, New York 12402-1600

2. OptumHealth Behavioral Solutions
P.O. Box 5190
Kingston, New York 12402-5190

3. The Empire Plan Prescription Drug Program c/o Medco Health Solutions P.O. Box 14711 Lexington, KY 40512

Specialty Pharmacy Program

During negotiations for the 2007-2011 PS&T contract, PEF agreed to the implementation of an Empire Plan Specialty Pharmacy Program in order to help members and their dependents who are taking specialty medications achieve the best possible outcomes from their treatments. By ensuring quality care, with improved clinical outcomes, the Program will also help control the rising cost of specialty medications.

Specialty medications are drugs that are used to treat complex conditions and illnesses, such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis, and rheumatoid arthritis. These drugs usually require special handling, special administration, and intensive patient monitoring. (Medications used to treat diabetes are not considered specialty medications.) For these reasons, not all retail pharmacies are able to dispense specialty medications. Many drug manufacturers will only distribute these medications through designated specialty pharmacies because of the complexity of the medical conditions and the medications being used.

Whether they are administered by a health care professional, self-injected, or taken by mouth, specialty medications require an enhanced level of service. A list of the medications included in the Specialty Pharmacy Program is now available online at the NYS Department of Civil Service website, www.cs.state.ny.us.

The Specialty Pharmacy Program will benefit members in a number of ways. Members using a specialty medication will have a one-on-one relationship with a specialty-trained nurse who can help them manage their health condition, provide information about their specialty medication, and teach them how to use their specialty medication. If the prescribing physician determines the specialty medication must be administered by a nurse, the member’s specialty-trained nurse will help him or her arrange for nursing services through the Home Care Advocacy Program. For more detailed information on how the Program will benefit members, see the Frequently Asked Questions (FAQ).

Under the Specialty Pharmacy Program, most specialty medications will only be covered at the in-network (or highest) level of benefits when dispensed by Accredo, the Empire Plan’s Designated Specialty Pharmacy. On or after April 1, 2010, only one fill of a prescription for a specialty medication dispensed by a pharmacy other than Accredo will be covered at the usual copayment amount. Enrollees will have to get subsequent refills of the specialty medication from Accredo to avoid significant out-of-pocket costs.

Refills Dispensed by Accredo

When an enrollee orders a covered specialty medication through Accredo, his or her out-of-pocket cost will be limited to the applicable mail-order copayment. For up to a 30-day supply, the copay amount is $5 for a generic, $15 for a preferred brand name drug and $40 for a non-preferred brand name drug. For a 31 – 90 day supply the copay amount is $5.00 for generic, $20 for preferred brand name drug, and $65 for a non-preferred brand-name drug. There are no additional costs for shipping and handling or for necessary supplies such as needles and syringes.

Refills Dispensed by a Pharmacy Other than Accredo

Enrollees will be responsible for paying the full cost of their specialty medication for refills dispensed by a pharmacy other than Accredo. The enrollee will then have to file a claim for partial reimbursement. An enrollee’s out-of-pocket cost will be significantly higher than the mail-order copayment amount he or she would have paid if Accredo dispensed the medication.

Enrollee Notification Letters

On 2/19/10, United Healthcare (the insurer for the Prescription Drug Program) began sending letters to those enrollees who are already using one or more specialty medications. The letters are being sent in two phases as follows:

The letter to enrollees who currently use Accredo for their specialty medication will be mailed between 2/19/10 and 2/23/10. Current Accredo users will not have to change pharmacies. According to GOER, United Healthcare has identified 241 PEF-represented enrollees (employees and covered dependents) who currently use Accredo.

The letter to enrollees who currently use a pharmacy other than Accredo for their specialty medication will be mailed between 2/25/10 and 2/26/10. The letter will notify them that Accredo will be the Empire Plan’s exclusive provider for specialty medications, and they will have to transition to Accredo to avoid significant out-of-pocket costs. According to GOER, United Healthcare has identified 1,052 PEF-represented enrollees (employees and covered dependents) who will have to transition to Accredo.

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Continuing Coverage for Dependents Who Graduate or Leave School

Your unmarried dependent children who are age 19 or over but under age 25 are eligible for coverage in the New York State Health Insurance Program (NYSHIP) if they are full-time students at an accredited secondary or preparatory school, college or other educational institution, and are otherwise not eligible for employer group or military health care coverage (e.g., cadets at U.S. military academies). They continue to be eligible until the earlier of the following dates:

-The end of the third month following the month in which the dependent completes a semester.

-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 day they reach age 25.

Continuing Coverage in NYSHIP

If your child is no longer eligible, you must act quickly to continue his or her coverage without interruption. You may continue NYSHIP coverage in one of the following two ways:

Continue coverage in NYSHIP under COBRA, or
Continue coverage in NYSHIP under the “Young Adult Option”

According to information on the NYS Insurance Department web site, it may be better for your child to exhaust COBRA continuation coverage before enrolling in the “Young Adult Option”. This is because if your child has “Young Adult Option” coverage and either 1) you lose eligibility for NYSHIP coverage, or 2) your child no longer meets the requirements for the “Young Adult Option”, then your child’s “Young Adult Option” coverage will terminate and he or she will no longer have the right to elect COBRA continuation coverage. However, if your child continues coverage in NYSHIP under COBRA, and you later lose eligibility for NYSHIP coverage, your child’s COBRA coverage would still be available.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

A federal law, known as COBRA, requires that most employers sponsoring group health plans offer employees and their covered dependents the opportunity for a temporary extension of health care coverage called "continuation coverage" at group rates in certain instances where coverage under the program would otherwise end. The health care benefits your dependent may continue are the same benefits you receive as an active employee enrolled in NYSHIP. There is also no change in benefits when your dependent enrolls in COBRA. 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 share) plus a two percent administrative fee. The 2010 monthly rate for Empire Plan COBRA coverage is $509.95.

Under provisions of COBRA, the employee or dependent is responsible for informing the Employee Benefits Division (EBD) of the NYS Department of Civil Service of a child's losing NYSHIP eligibility within 60 days from the date coverage ends. If you do not notify EBD within the required 60-day period, regardless of the reason, the dependent will not be entitled to COBRA continuation coverage.

For enrollment instructions, visit the NYS Department of Civil Service website at: http://www.cs.state.ny.us. On the Civil Service home page, select “Benefit Programs” and then follow the instructions to access NYSHIP Online. Click on “Health Benefits & Option Transfer” and then, “NYSHIP General Information Book.” Scroll down to “COBRA: Continuation of Coverage”.

“Young Adult Option”

New York State’s “Age 29” law allows young adults through age 29 to purchase an individual policy through a parent's group health insurance policy under the "Young Adult Option". Only health insurance coverage is available; dental and vision coverage are not included. Under the law, the young adult's coverage is subject to all terms of the group policy; however, premiums are paid in full by the young adult or his/her parent. The cost is the full cost of individual coverage for the NYSHIP option selected. The 2010 monthly rate for Empire Plan “Young Adult Option” coverage is $499.07.

For enrollment instructions, frequently asked questions (FAQs) about the “Young Adult Option”, and 2010 monthly rates for all NYSHIP options, visit the NYS Department of Civil Service website at: http://www.cs.state.ny.us. On the Civil Service home page, select “Benefit Programs” and then follow the instructions to access NYSHIP Online. Click on “What’s New” and scroll down to “Young Adult Option Coverage.”

Other Coverage Options

If these two options are unaffordable, other ways of continuing coverage that differs from NYSHIP coverage and is not administered by the NYS Department of Civil Service include the following:

Convert to direct-pay contracts, or
Enroll in Family Health Plus or Healthy New York

Direct-Pay Contracts

Dependent children losing eligibility are entitled to convert to direct-pay contracts after their NYSHIP coverage ends. The benefit package and the premium costs for direct-pay conversion contracts differ from what your child had under NYSHIP.

Written notice of conversion privileges will not be sent to children who lose their status as eligible dependents. You or your child must apply for direct-pay conversion contracts directly to The Empire Plan carriers or, if enrolled in a NYSHIP HMO, the HMO.

For more information on changing to direct-pay conversion contracts, visit the NYS Department of Civil Service website at: http://www.cs.state.ny.us. On the Civil Service home page, select “Benefit Programs” and then follow the instructions to access NYSHIP Online. Click on “Health Benefits & Option Transfer” and then, “NYSHIP General Information Book.” Scroll down to “Changing from NYSHIP to a Direct-Pay Conversion Contract”.

Family Health Plus or Healthy New York

Family Health Plus is a New York State public health insurance program for adults who are aged 19 to 64 who have income too high to qualify for Medicaid. Family Health Plus provides comprehensive coverage, including prevention, primary care, hospitalization, prescriptions and other services. There are minimal copayments for some Family Health Plus services. Health care is provided through participating managed care plans in your area. For more information on Family Health Plus, visit their website: http://www.health.state.ny.-us/nysdoh/fhplus/.

If your dependent is not eligible to enroll in Family Health Plus, then he or she may be eligible for Healthy NY, another New York State public health insurance program. For more information on Healthy NY, call 1-866-HEALTHYNY or visit their website: http://www.ins.state.ny.us/-website2/hny/english/hny.htm.