Highlights of Empire Plan Changes

The following new Empire Plan benefits became effective on October 1, 2004:

Basic Medical Provider Discount Program - Offered through Multiplan. When you use non-par physicians who are affiliated with Multiplan, you will receive discounts on the provider’s usual fees. You still must satisfy the annual deductible and 20 percent coinsurance required by Basic Medical, but you cannot be balance billed for amounts exceeding the discounted fee. Plus, the provider submits the claim for you.

Multiplan has more than 200,000 providers in their network. Please be sure to confirm the provider’s participation before receiving services. You can access an online list of Multiplan providers from the directory in the Civil Service web site at www.cs.state.ny.us or at www.myuhc.com. You can also call the Kingston Service Center at 1-877-7-NYSHIP and speak to a United HealthCare representative.

Centers of Excellence for Cancer Program – This program provides paid-in-full coverage for cancer-related expenses received through a nationwide network known as Cancer Resource Services (CRS). CRS is staffed by experienced cancer nurses who can explain treatment options and help you choose the best physician and cancer center for a specific type of cancer. The CRS network includes many of the nation’s leading cancer centers, such as Roswell Park Cancer Institute, Memorial Sloan Kettering Cancer Center and Dana-Farber Cancer Institute. Reimbursement for travel expenses is available. For more information call toll-free 1-866-936-6002 from 8 a.m. to 8 p.m., Monday – Friday, or visit the CRS web site at www.urncrs.com. 

The following Empire Plan changes will take effect on January 1, 2005:

Prescription Drug Program – The Program will include generic, preferred brand-name and non-preferred brand-name drugs. Your copayment amount will depend on the drug, the quantity prescribed and where you fill your prescription.

A list of the most commonly prescribed generic and preferred brand-name drugs is posted at www.pef.org. Click on Contract ’03, then click on ’03-’07 PS&T Contract Text, and scroll up to on Express Scripts National Preferred Formulary. You can also call Express Scripts at 1-800-964-1888 for more information.

If your prescription is written for a brand-name drug that has a generic equivalent, the Empire Plan continues to cover only the cost of the drug’s generic equivalent. If your prescription is written for a brand-name drug with a generic equivalent, you pay the non-preferred brand-name copay plus the difference in cost between the brand-name and generic drug, not to exceed the full cost of the drug. Certain drugs are excluded from this requirement. In that case you will be responsible for the applicable preferred brand-name or non-preferred brand-name copayment.

If you are unable to use a generic drug for medical reasons, you can appeal the generic substitution requirement. Call 1-800-964-1888 for information about the appeal process.

Network and Non-Network Hospital Benefits

The Empire Plan will have two levels of hospital benefits: network and non-network. Network benefits apply when you use hospitals, hospices and skilled nursing facilities (SNFs) that participate in the Blue Cross and Blue Shield Association’s national network. Every acute care general hospital in New York State and over 90 percent of hospitals nationwide are in the network.

You continue to receive paid-in-full benefits for inpatient hospital, hospice or SNF care at a network facility. Outpatient hospital services from a network hospital are subject to applicable copayments.

A list of network hospitals, hospices and SNFs is available on the Civil Service web site at www.cs.state.ny.us. You can also call the Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) and choose Empire Blue Cross Blue Shield for more information.

Non-network benefits apply if you, your enrolled spouse/domestic partner or your dependent child chooses to use a non-network hospital, hospice or SNF for non-emergency inpatient care. The Empire Plan will reimburse you for 90 percent of the charges, and you pay the remaining 10 percent of charges until you have reached a coinsurance maximum of $1,500. You, your enrolled spouse/domestic partner and all your dependent children combined each have an annual coinsurance maximum. You are responsible for full payment to the facility. For outpatient care, you pay 10 percent or $75, whichever is greater, up to the annual coinsurance maximum.

The annual coinsurance maximum (out-of-pocket costs) for services at a non-network facility for either inpatient or outpatient care is $1,500 for the enrollee, $1,500 for an enrolled spouse/domestic partner, and $1,500 for all dependent children combined. Once your out-of-pocket expenses go over $1,500 for the non-network inpatient and outpatient care, the Empire Plan pays 100 percent of non-network charges, subject to applicable outpatient network level copayment(s).

Reimbursement of Coinsurance Maximum through United HealthCare

After you have paid $500 out-of-pocket for yourself, $500 for your enrolled spouse/domestic partner or $500 for all enrolled dependent children, you may file a claim with United HealthCare for reimbursement of the next $1,000 in coinsurance. Send a copy of your Empire Blue Cross Blue Shield Explanation of Benefits showing you have paid $500 out-of-pocket costs along with the completed claim form to United HealthCare, P.O. Box 1600, Kingston, NY 12402-1600. 

Network Benefits at a Non-Network Facility

If you receive medically necessary covered services at a non-network facility when a network facility is available, the Empire Plan provides non-network coverage. However, the Plan will approve network coverage under the following circumstances:

• When no network facility can provide medically necessary services;

• When no network facility is available within 30 miles of your residence;

• When inpatient or outpatient services are certified by Empire Blue Cross Blue Shield as emergency or urgent care.

• When you are outside the United States.

Emergency or urgent care provided at a non-network facility is not subject to the annual coinsurance. Payment for medically necessary covered emergency or urgent services received in a non-network hospital is made directly to you. You pay the emergency room copayment.

Hospital Extension Clinics

Effective 1/1/05, the Empire Plan will cover charges, including facility charges, for certain hospital services provided in a remote location of a network hospital. This coverage applies to network hospital owned and operated on-site facilities and facilities not physically located in the hospital building, including ambulatory surgical centers. The hospital must bill for the service as part of the hospital’s charges.

Coverage for Non-Medically Necessary Days

Effective 1/1/05, the Empire Plan will not pay for any inpatient hospital charges for a day that is determined to be not medically necessary. You have a right to an expedited appeal of this decision while you are in the hospital. You also have a right to an external appeal pursuant to the guidelines of the NYS Insurance Department.

Prosthetic and Orthotic Devices

Effective 1/1/05, the Empire Plan will include a nationwide network of participating prosthetic and orthotic providers including participating providers (i.e. podiatrists). When you use a par provider, you have a paid-in-full benefit, with no copayment, for prostheses and orthotics. Prosthetic and orthotic devices from non-network providers are covered under the Basic Medical Program. For more information call United HealthCare toll-free at 1-877-7-NYSHIP (1-877-769-7447).

Hearing Aids

Beginning 1/1/05, under the Basic Medical Program, coverage for hearing aids including evaluation, fitting and purchase, increases up to a total maximum reimbursement of $1,200 per hearing aid, per ear. Previously, the maximum was $1,200 for both ears. For children age 12 years and under, the increased benefit is available once in any two-year period for each ear when the child’s hearing has changed and the existing hearing aid(s) no longer fills the need.

External Mastectomy Prostheses

Effective 1/1/05, one single or double external mastectomy prosthesis per calendar year is covered in full under the Basic Medical Program. There is no deductible, coinsurance or copayment required. Any single external mastectomy prosthesis costing $1,000 or more requires approval through the Home Care Advocacy Program (HCAP). Call HCAP toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose United HealthCare before you purchase the prosthesis. 

Infertility Benefits Maximum

Beginning 1/1/05, the lifetime maximum for certain infertility benefits, called Qualified Procedures, increases to $50,000 per individual. This effectively doubles the previous limit of $25,000.