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On the road with The Empire Plan

You’re taking your family on a trip this summer, or your child is going off to college this fall, or you’ve finally retired and plan to spend winters in Florida. In any of these situations and more, it’s good to know The Empire Plan is there wherever you or your family goes.

Before you go, however, plan ahead. Do you have your doctors’ phone numbers and your benefit card? Do you have enough of your maintenance medications? If you are Medicare primary, do you also have your Empire Plan Medicare Rx Card? And don’t forget to pack On the Road with The Empire Plan. This informative booklet has important phone numbers and information you or a family member may need while away from home.

Empire Plan coverage is available worldwide and not just for emergencies. Most parts of The Empire Plan have two levels of benefits known as network and non-network. If you use an Empire Plan participating (or network) provider, you will receive medically necessary covered services and supplies at little or no cost and have no claim forms to fill out. If you use a nonparticipating (or non-network) provider, medically necessary services and/or supplies are covered, but deductibles, coinsurance and benefit limits may apply.

The Empire Plan Medical/Surgical Program has network providers in many states, and the Hospital Program, Prescription Drug Program and Medicare Rx have nationwide networks. The Empire Plan Mental Health and Substance Abuse Program, the Home Care Advocacy Program (HCAP) and the Managed Physical Medicine Program guarantee access to network benefits nationwide if you call to make the necessary arrangements before you receive services. The toll-free number is 877-7-NYSHIP or 877-769-7447.

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In the event you or a family member needs medical care while away from home, be prepared. Request the booklet On the Road with The Empire Plan from your agency health benefits administrator, usually located in your personnel office or the Business Services Center.

If you are a retiree, contact the Employee Benefits Division of the NYS Department of Civil Service at 518-457-5754 or 800-833-4344. It can also be found online at www.cs.ny.gov/employee-benefits. Select your group and plan to get to the NYSHIP Online homepage. Select “Using Your Benefits” and then “Publications.”


Empire Plan enrollees: Hold on to your new Empire Plan Certificate book

empire-plan300x170The state Department of Civil Service recently mailed the January 1, 2018, Empire Plan Certificate book to the homes of all active PEF-represented state employees enrolled in the Empire Plan. The updated book, which describes the coverage provided by the Empire Plan, is also posted on the Civil Service Employee Benefits Division website, NYSHIP Online. Go to www.cs.ny.gov/employee-benefits, select your group (PEF) and plan, if prompted, and then select Health Benefits & Option Transfer.

The 2018 Certificate book replaces your 2014 Empire Plan Certificate book and all Empire Plan Reports/Certificate Amendments updating the 2014 book. The 2018 Certificate includes all of the changes to the Empire Plan since publication of the 2014 Empire Plan Certificate book and January 1, 2018. When PEF ratifies a successor contract, DCS will update the certificate book to include any negotiated benefit changes.

You should save this book and all subsequent Empire Plan Reports/Certificate Amendments you receive in the mail. New certificate books are not issued every year. It is important that you read and keep this book and any future Empire Plan Reports/Certificate Amendments that update this book and inform you of important changes to your Empire Plan coverage.


WMC Health Network hospitals lost Empire Plan in-network coverage June 1

By SHERRY HALBROOK

Westchester Medical Center Health Network lost its participating provider status in the state’s Empire Plan provider network effective June 1, because no agreement between the medical center and Empire BlueCross BlueShield, which administers the Empire Plan, was reached.

The Governor’s Office of Employee Relations notified PEF in April that no agreement had been reached yet and that this group of hospitals could drop out of the network June 1, if continuing negotiations proved unproductive. No agreement was reached

Westchester Medical Center Health Network (WMC) includes:

  • Bon Secours – Good Samaritan Hospital;
  • Bon Secours – Mercy Community Hospital;
  • Bon Secours – St. Anthony’s Hospital;
  • Mid-Hudson Regional Hospital; and
  • Westchester Medical Center.

It is always to your advantage as an enrollee to seek health care from participating providers when possible. Many other hospitals are participating providers in the lower Hudson and downstate regions.

Most coverage of services at the WMC facilities will now be on a non-network basis. That means you will be responsible for paying 10 percent of the billed charges for covered services, up to your annual coinsurance maximum amount that is listed in your Empire Plan At a Glance publication for 2019.

However, the Empire Plan will continue to cover as in-network the following services provided by the WMC Health Network hospitals:

  • Cases of emergency;
  • Services that no in-network hospital within 30 miles of the enrollee can provide;
  • Continuation of care for pregnancy or health risk; and
  • Services that were previously preauthorized.

Since the WMC Health Network will no longer be paid directly by the Empire Plan, WMC Network hospitals could:

  • Refuse to provide you with non-emergency services, or elective treatment;
  • Transfer you to another hospital after stabilizing your emergency condition;
  • Require you to pay up front before the hospital provides services to you;
  • Require you to sign a guarantee of payment (that could include an outline of a payment schedule, as well as any interest that could be charged on an outstanding balance) before providing services to you; and/or
  • Bill you directly, making you responsible for filing claims with Empire BlueCross BlueShield for reimbursement.

If you are an enrollee and have questions or need help identifying an alternative facility, call the Empire Plan BCBS at 800-495-9323 weekdays between 8:30 a.m. and 5 p.m. to discuss your options.


See the complete PEF Health Benefits page here.

 

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