Health Insurance
9.1 The State shall continue to provide all the forms and extent of
coverage as defined by the contracts in force on
9.2(a) The Benefits Management Program will continue. Precertification will be required for all inpatient confinements and prior to certain specified surgical or medical procedures, regardless of proposed inpatient or outpatient setting.
o To provide an opportunity for a review of surgical and diagnostic procedures for appropriateness of setting and effectiveness of treatment alternative, precertification will be required for all inpatient elective admissions.
o Precertification will be required prior to maternity admissions in order to highlight appropriate prenatal services and reduce costly and traumatic birthing complications.
o A call to the Benefits Management Program will be required within 48 hours of admission for all emergency or urgent admissions to permit early identification of potential ''case management'' situations.
o Precertification will be required prior to an admission to a skilled nursing facility.
o The
hospital deductible amount imposed for non-compliance with Program requirements
will be $200. Also, this deductible will be fully waived in instances where the
medical record indicates that the patient was unable to make the call. In
instances of non-compliance, a retroactive review of the necessity of services
received shall be performed. For each day deemed inappropriate for an inpatient
setting, a $100 deductible shall be incurred by the enrollee. The $100 per day deductible for inappropriate days will apply to
inpatient days incurred through
o The Prospective Procedure Review Program will screen for the medical necessity of certain specified surgical or diagnostic medical procedures which, based on Empire Plan experience, have been identified as potentially unnecessary or over utilized. The list of procedures will undergo annual evaluation by the Benefits Management Program vendor. As revised and approved by the Joint Committee on Health Benefits, the list will be published and distributed to enrollees prior to implementation.
o The Benefits Management Program will be modified to refine the Prospective Procedure Review requirement to include only Magnetic Resonance Imaging (MRI).
o In order to assure the timely and accurate notification of PS&T Unit employees of these changes, the State and PEF, in conjunction with the vendor, will develop educational materials relating to the Benefits Management Program and oversee the distribution of said materials.
o Enrollees will be required to call the Benefits Management Program for precertification when a listed procedure subject to prospective review is recommended, regardless of setting. Enrollees will be requested to call two weeks before the date of the procedure.
o The Empire Plan's Prospective Procedure Review penalties will apply for failure to comply with the requirements of the Prospective Procedure Review Program regardless of whether the expense is an outpatient hospital or medical program expense.
b. Charges for emergency room care within
72 hours of an accident or within 24 hours of the sudden onset of an illness
(medical emergency) are subject to a
$35 copayment per visit. Effective
January 1, 2005, this Hospital Emergency Room copayment will be $50 for
emergency room services covered by the hospital contract. Effective January 1, 2007, this Hospital
Emergency Room copayment will be $60 for emergency room services covered by the
hospital contract. Charges for other outpatient services
covered by the hospital contract are
subject to a $25 copayment per outpatient visit regardless of the number and
type of services rendered in the hospital outpatient setting. Effective
Hospital outpatient physical therapy visits will be subject to the same copayment in effect for physical therapy visits under the Managed Physical Medicine Program.
c. Effective
Effective January 1, 2005, or as soon as practicable thereafter,
emergency room and other outpatient services covered by the hospital contract
and rendered at a network hospital shall be paid-in-full except for the
appropriate copayment. For emergency room
services rendered at a non-network hospital and covered by the hospital
contract, reimbursement shall be at the billed charges minus the emergency room
copayment. For outpatient services
covered by the hospital contract and rendered at a non-network hospital,
reimbursement shall be at the billed charges minus the enrollee share. The enrollee’s share of the charge for
covered outpatient services shall be the larger of (a) the $75 non-network
hospital copayment, or (b) 10% of billed charges, subject to the separate
annual non-network coinsurance maximum of $1,500 per enrollee, per spouse or
domestic partner, and per dependent children.
Once an enrollee, enrolled spouse or domestic partner, or all dependent
children combined, have met the annual coinsurance maximum, all subsequent
eligible non-network outpatient services for that enrollee, enrolled spouse or
domestic partner, or all dependent children combined, for the balance of the
calendar year will be paid subject to network level copayments. Coincident with the
Once the enrollee, enrolled spouse or domestic partner, or all dependent
children combined have incurred $500 in annual non-network hospital expenses, a
claim may be filed with the Empire Plan medical carrier for reimbursement of
out-of-pocket non-network hospital expenses incurred above the $500 and up to
the balance of the annual Hospital coinsurance maximum amount.
d. The Empire Plan “Centers of Excellence” Programs will continue. A travel allowance for transportation and lodging will be included as part of the Centers of Excellence Program. The Joint Committee on Health Benefits will work with the State and Empire Plan carriers in the ongoing oversight of this benefit.
1. The Centers of Excellence for organ and tissue
transplants will be required to provide pre-transplant evaluation, hospital and
physician services (inpatient and outpatient), transplant procedures, follow-up
care for transplant related services, as determined by the Centers, and any
other services as identified during implementation as part of an all-inclusive
global rate.
2. The
Centers of Excellence for infertility shall offer enhanced benefits to include
treatment of “couples” as long as both partners are covered either as an
enrollee or dependent under the Empire Plan.
The lifetime coverage limit is $25,000.
Effective
3. Effective
e. The Empire Plan shall include medical/surgical coverage through use of participating providers who will accept the Plan's schedule of allowances as payment in full for covered services. Except as noted below, benefits will be paid directly to the provider at 100 percent of the Plan's schedule not subject to deductible, coinsurance, or annual/lifetime maximums.
1. Office visit charges by participating
providers will be subject to a $12
copayment by the enrollee, with the balance of covered scheduled allowances
paid directly to the provider by the Plan. Effective
2. All covered surgical procedures
performed by participating providers during a visit will be subject to a $12 copayment by the enrollee. Effective
3. All covered radiology services performed by participating providers during a visit will be subject to a $12 copayment by the enrollee. Effective January 1, 2005, all covered radiology services performed by participating providers will be subject to a $15 copayment by the enrollee. Effective January 1, 2007, all covered radiology services performed by participating providers will be subject to an $18 copayment by the enrollee.
4. All covered diagnostic/laboratory
services performed by participating providers during a visit will be subject to
a $12 copayment by the enrollee.
Effective January 1, 2005, all covered
diagnostic/laboratory services performed by participating providers will be
subject to a $15 copayment by the enrollee.
Effective January 1, 2007, all covered diagnostic/laboratory services
performed by participating providers will be subject to an $18 copayment by the
enrollee.
5. The office visit, surgery, radiology and diagnostic/laboratory copayment amounts may be applied against the basic medical co-insurance out-of-pocket maximum, however, they will not be considered covered expenses for basic medical.
f. The Empire Plan shall also include basic medical coverage to provide benefits when non-participating providers are used. These benefits will be paid directly to enrollees according to reasonable and customary charges and will be subject to deductible, co-insurance, and calendar year and lifetime maximums.
1. Covered charges for medically appropriate local commercial ambulance transportation will be a covered basic medical expense subject only to the $35 copayment. Volunteer ambulance transportation will continue to be reimbursed for donations at the current rate of $50 for under 50 miles and $75 for 50 miles or over. These amounts are not subject to deductible or coinsurance.
2. Charges for Private Duty Nursing services provided as part of an inpatient stay in a hospital will continue to be covered by the hospital carrier when billed by the hospital. However, these charges will not be reimbursable under the basic medical component of the Empire Plan.
g. Periodic evaluation and adjustment of basic medical Reasonable and Customary charges will be performed according to guidelines established by the basic medical plan insurer.
h. The State agrees to pay 90 percent of the cost of the individual coverage and 75 percent of the cost of dependent coverage, including prescription drug coverage, provided under the Empire Plan.
i. The State agrees to continue to provide alternative Health Maintenance Organization (HMO) coverage. The State agrees to pay 90 percent of the cost of individual coverage and 75 percent of the cost of dependent coverage toward the hospital/medical/mental health and substance abuse component of each HMO, not to exceed 100 percent of its dollar contribution for those components under the Empire Plan. The State agrees to pay 90 percent of the cost of individual prescription drug coverage and 75 percent of dependent prescription drug coverage under each participating HMO.
9.3 PEF Empire Plan Enhancements
In addition to the basic Empire Plan benefits, the Empire Plan for PS&T Unit enrollees shall include:
a. Effective January 1, 2004 the basic medical component deductible is $295 per enrollee; $295 per enrolled spouse or domestic partner; and $295 per all dependent children. Covered expenses for mental health and/or substance abuse treatment services, physical medicine services, and non-network hospital services are excluded in determining the basic medical component deductible.
b. Effective January 1, 2004, the maximum annual co-insurance out-of-pocket expense under the basic medical component is $1,419 per individual or family. Covered expenses for mental health and/or substance abuse treatment services, physical medicine services, and non-network hospital services are excluded in determining the maximum annual co-insurance limit.
Effective January 1, 2004, and thereafter on each
successive January 1, the deductible and maximum annual co-insurance
out-of-pocket expense will increase by a percentage amount equal to the
percentage increase in the medical care component of the CPI for Urban Wage Earners
and Clerical Workers, all Cities (CPI-W) for the preceding period of July 1 -
June 30.
c. Employees 50 years of age or older and their covered spouses/domestic partners 50 years of age or older will be allowed up to $250 reimbursement once per year toward the cost of a routine physical examination. These benefits shall not be subject to deductible or co-insurance.
d. The newborn routine child care
allowance under the basic medical component shall be $150, not subject to deductible or co-insurance.
e. The annual and lifetime maximum for each covered member under the basic medical component shall be unlimited.
f. Services for examinations and/or purchase of hearing aids shall be a covered basic medical benefit and shall be reimbursed up to a maximum of $1,200 once every four years not subject to deductible or co-insurance. Effective January 1, 2005, the hearing aid reimbursement will be up to a maximum of $1,200, per hearing aid, per ear, once every four years, not subject to deductible or coinsurance. Effective January 1, 2006, the hearing aid reimbursement will be up to a maximum of $1,500 per hearing aid, per ear, once every four years, not subject to deductible or coinsurance. For children 12 years old and under the same benefits can be available after 24 months, when it is demonstrated that a covered child's hearing has changed significantly and the existing hearing aid(s) can no longer compensate for the child's hearing impairment.
g. Office visit charges by participating providers for well child care will be excluded from the office visit copay.
h. Charges by participating providers for professional services for allergy immunization or allergy serum will be excluded from the office visit copayment.
i. Chronic care services for chemotherapy, radiation therapy, or hemodialysis, will be excluded from the office visit copayment.
j. In the event that there is both an office visit charge and an office surgery charge by a participating provider in any single visit, the covered individual will be subject to a single copayment.
k. Outpatient radiology services and diagnostic/laboratory services rendered during a single visit by the same participating provider will be subject to a single copayment.
l. Routine pediatric care, including the cost of all oral and injectable substances for routine preventive pediatric immunizations, shall be a covered benefit under the Empire Plan participating provider component and the basic medical component.
m. Influenza vaccine is included in the list of pediatric immunizations, subject to appropriate protocols, under the participating provider and basic medical components of the Empire Plan.
n. Mastectomy bras prescribed by a physician, including replacements when it is functionally necessary to do so, shall be a covered benefit under the Empire Plan.
o. The Pre-Tax Contribution Program will continue unless modified or exempted by the Federal Tax Code.
p. The Home Care Advocacy Program (HCAP) will continue to provide services in the home for medically necessary private duty nursing, home infusion therapy and durable medical equipment under the participating provider component of the Empire Plan.
Individuals who fail to have medically necessary designated HCAP services and supplies pre-certified by calling HCAP and/or individuals who use a non-network provider will receive reimbursement at 50 percent of the HCAP allowance for all services, equipment and supplies upon satisfying the basic medical annual deductible. In addition, the basic medical out-of-pocket maximum will not apply to HCAP designated services, equipment and supplies. All other HCAP non-network benefit provisions will remain.
q. Effective July 1, 2004, or as soon as possible thereafter, the Empire Plan medical carrier will establish a network of prosthetic and orthotic providers. Prostheses or orthotics obtained through an approved prosthetic/orthotic network provider will be paid under the participating provider component of the Empire Plan, not subject to copayment. For prostheses or orthotics obtained other than through an approved prosthetic/orthotic network provider, reimbursement will be made under the basic medical component of the Empire Plan, subject to deductible and co-insurance.
r. All professional component charges associated with ancillary services billed by the outpatient department of a hospital for emergency care for an accident or for sudden onset of an illness (medical emergency) will be a covered expense. Payment shall be made under the participating provider or the basic medical component of the Empire Plan, not subject to deductible or co-insurance, when such services are not otherwise included in the hospital facility charge covered by the hospital carrier.
s. Effective
January 1, 2005, external mastectomy prostheses will be a covered-in-full
benefit, not subject to deductible or coinsurance. Coverage will be provided by the medical
carrier as follows: Benefits are available for one single/double mastectomy
prosthesis in a calendar year.
Pre-certification through the Home Care Advocacy Program is required for
any single external prosthesis costing $1,000 or more. If a less expensive prosthesis can meet the
individual’s functional needs, benefits will be available for the most
cost-effective alternative.
t. The medical component of the Empire Plan shall include a voluntary 24 hour day/7 day week nurse-line feature to provide both clinical and benefit information through a toll-free phone number. The Joint Committee on Health Benefits will work with the State and Empire Plan carriers in the ongoing oversight of this benefit.
u. The Empire Plan medical component
shall include a voluntary Disease Management Programs. Disease Management covers those illnesses identified to be
chronic, high cost, impact quality of life, and rely considerably on the
patient's compliance with treatment protocols.
The current Disease Management
Programs for Cardiovascular Disease Risk Reduction, Asthma, and Diabetes will
continue. As soon as is reasonably
practicable, at least two additional Disease Management Programs will be
considered for addition, as recommended by an Empire Plan carrier. The Joint Committee on Health Benefits will
work with the State and Empire Plan carriers in the ongoing oversight of this
benefit.
v. The cost of certain injectable adult immunizations shall be a covered expense, subject to copayment(s), under the participating provider portion of the Empire Plan. The list of immunizations shall include Influenza, Pneumococcal, Measles, Mumps, Rubella, Varicella and Tetanus Toxoid, and shall be subject to protocols developed by the medical program insurer.
w. Effective
January 1, 2005, the Empire Plan Basic Medical component will include a Basic
Medical Provider Discount Program. This
benefit is provided as a pilot program which will expire on December 31, 2006,
unless extended by agreement of both parties.
9.4 The Voluntary Catastrophic Medical Case Management component of the Empire Plan's Benefits Management Program will continue. This voluntary program will review cases of
catastrophic illness or injury, provide patients an opportunity for flexibility in Plan benefits,
maximize rate of recovery, and maintain quality of care.
9.5
There shall be a waiting period of fifty-six (56) days after employment before
a new employee shall be eligible for enrollment under the State's Health
Insurance Program, Dental Program and
Vision Care Program.
9.6 a. The State Health Insurance Plan's regulations shall continue to stipulate that the term "employee" means any person in the service of the State as employer whose regular work
schedule is at least half-time per biweekly payroll period.
b. Employees eligible to enroll in the State Health Insurance Program may select individual or individual and dependent (family) coverage. Those eligible and enrolling for family coverage must provide the names of all eligible dependents to the Plan administrator in order for family coverage to become effective. Employees enrolling without eligible dependents, or those who choose not to enroll their eligible dependents, will be provided individual coverage.
c. When more than one family member is eligible to enroll for coverage under the State's Health Insurance Program, there shall be no more than one individual and dependent enrollment permitted in any family unit.
9.7 a. Seasonal employees who are anticipated to be or who are continuously employed on at least a half-time basis for six months, shall be eligible for health insurance coverage subject to the provisions of this Agreement.
b. Where the State establishes a seasonal position for six months or more, the appointee to that position shall not have his/her service intentionally broken solely for the purpose of rendering that employee ineligible for health insurance coverage.
c. Should a seasonal employee, who attained health insurance coverage eligibility, leave the payroll and then be subsequently rehired, the employee shall retain eligibility for health insurance coverage upon rehire, provided the employee was not off the payroll more than three months. The employee may continue his/her health insurance on a full pay basis for the period of time he/she is off the payroll.
9.8 Eligible employees in the State Health Insurance Plan may elect to participate in a federally qualified or State certified Health Maintenance Organization which has been approved to participate in the State Health Insurance Program by the Joint Committee on Health Benefits.
If more than one HMO services the same area, the Joint Committee on Health Benefits reserves the right to approve a contract with only one such organization.
9.9 a. Enrollees may change their health insurance option each year throughout the month of November, unless another period is mutually agreed upon by the State and the Joint Committee on Health Benefits. Changes between options will be permitted without regard to the enrollee's age or the number of previous transfers. If rate renewals are not available by the time of the option transfer period, then the option transfer period shall be extended to assure ample time for enrollees to transfer.
b. The State shall provide health insurance comparison information to employees, through State agencies, prior to the beginning of an option transfer period. If the comparison information is delayed for any reason, the transfer period shall be extended for a minimum of 30 calendar days beyond the date the information is distributed to the agencies. Employees transferring plans during a scheduled period but prior to the provision of the comparison data, may elect to further alter or rescind his/her health plan transfer during the remainder of the option transfer period.
9.10 a. Continued health insurance coverage will be provided for the unremarried spouse or domestic partner who has not acquired another domestic partner and other eligible dependents of employees who die in State service under circumstances for which they are eligible for the accidental death benefit or for weekly cash workers' compensation benefits under the conditions prescribed in Section 165 of the Civil Service Law.
b. If an employee is granted a service-connected disability retirement by a retirement or pension plan or system administered and operated by the State of New York, the State will continue the health insurance of that employee on the same basis as any other retiring employee, regardless of the duration of the employee's service with the State.
c. Covered dependent students shall be provided with a three-month extended benefit period upon graduation from a qualified course of study. The benefit extension will begin on the first day of the month following the month in which dependent student coverage would otherwise end and will last for three months or until such time as eligibility would otherwise be lost under existing plan rules.
d. Covered dependents of employees who are activated for military duty as a result of an action declared by the President of the United States or Congress shall continue health insurance coverage with no employee contribution for a period not to exceed 12 months from the date of activation, less any period the employee remains in full pay status. Contribution-free health insurance coverage will end at such time as the employee's active duty is terminated or the employee returns to State employment, whichever occurs first.
9.11 A permanent full-time employee, who loses employment as a result of the abolition of a position on or after April 1, 1977, shall continue to be covered under the State Health Insurance Plan at the same contribution rate as an active employee for one year following such layoff or until re-employment by the State or employment by another employer, whichever first occurs.
9.12 a. The unremarried spouse or domestic partner who has not acquired another domestic partner and otherwise eligible dependent children of an employee, who retires after April 1, 1979 with 10 or more years of active State service and subsequently dies, shall be permitted to continue coverage in the Health Insurance Program with payment at the same contribution rates as required of active employees for the same coverage.
b. The unremarried spouse or domestic partner who has not acquired another domestic partner and otherwise eligible dependent children of an active employee, who dies after April 1, 1979 and who, at the date of death, was vested in the Employees' Retirement System, had 10 or more years of benefits eligible service, who was at least 45 years of age and was within 10 years of the minimum retirement age shall be permitted to continue coverage in the Health Insurance Program with payment at the same contribution rates as required of active employees for the same coverage.
9.13 a. Employees on the payroll and covered by the State Health Insurance Program have the right to retain health insurance coverage after retirement, upon the completion of ten years of State service.
b. Prior to the expiration of this contract, PEF and the State, through the Joint Committee process, shall develop a proposal to modify the manner in which employer contributions to retiree premiums are calculated in order to recognize and underscore the value of the services rendered to the State by its long-term employees.
c. An employee who is eligible to continue health insurance coverage upon retirement and who is entitled to a sick leave credit to be used to defray any employee contribution toward the cost of the premium, may elect an alternative method of applying the basic monthly value of the sick leave credit. The basic monthly value of the sick leave credit shall be calculated according to the procedures in use on March 31, 1991.
Employees selecting the basic sick leave credit may elect to apply up to 100 percent of the calculated basic monthly value of the credit toward defraying the required contribution to the monthly premium during their own lifetime. If employees who elect that method predecease their eligible covered dependents, the dependents may, if eligible, continue to be covered, but must pay the applicable dependent survivor share of the premium.
Employees selecting the alternative method may elect to apply only up to 70 percent of the calculated basic monthly value of the credit toward the monthly premium during their own lifetime. Upon the death of the employee, however, any eligible surviving dependents may also apply up to 70 percent of the basic monthly value of the sick leave credit toward the dependent survivor share of the monthly premium for the duration of the dependents' eligibility. The State has the right to make prospective changes to the percentage of credit to be available under this alternative method for future retirees as required to maintain the cost neutrality of this feature of the Plan.
The selection of the method of sick leave credit application must be made at the time of retirement, and is irrevocable. In the absence of a selection by the employee, the basic method shall be applied.
d. An employee retiring from State service may delay commencement or suspend his/her
retiree health coverage and the use of the employee's sick leave conversion credits indefinitely, provided that the employee applies for the delay or suspension, and furnishes proof of continued coverage under the health care plan of the employee's spouse or domestic partner, or from post retirement employment.
9.14 The Empire Plan's medical care component will continue to offer a comprehensive managed care network benefit for the provision of medically necessary physical medicine services, including physical therapy and chiropractic treatments. Authorized network care will be available, subject only to the Plan's participating provider office visit copayment(s). Unauthorized medically necessary care, at enrollee choice, will also be available, subject to a $250 annual deductible and a maximum payment of 50 percent of the network allowance for the service(s) provided. Maximum benefits for non-network care will be limited to $1,500 in payments per calendar year. Deductible/co-insurance payments will not be applicable to the Plan's annual basic medical deductible/co-insurance maximums.
9.15 Domestic Partners who meet the definition of a partner and can provide acceptable proofs of financial interdependence as outlined in the Affidavit of Domestic Partnership and Affidavit of Financial Interdependence shall continue to be eligible for health care coverage.
9.16 Joint Committee on Health Benefits
a. The State and PEF agree to continue the Joint Committee on Health Benefits.
b. The Joint Committee on Health Benefits shall meet within 14 days after a request to meet has been made by either side.
c. The Joint Committee shall work with appropriate State agencies to review and oversee the various health plans available to employees represented by PEF.
d. The Joint Committee on Health Benefits shall work with appropriate State agencies to monitor future employer and employee health plan cost adjustments.
e. The Joint Committee shall be provided with each carrier rate renewal request upon submission and be briefed in detail periodically on the status of the development of each rate renewal.
f. The State shall require that the insurance carriers for the State Health Insurance Plan submit claims and experience data reports directly to the Joint Committee on Health Benefits in the format and with such frequency as the Committee shall determine.
g. The State shall provide to the PEF designees to the Joint Committee, a quarterly summary of hospital carrier paid claims (number of charges, amount of covered expenses and amount of benefits) by type of service for PS&T Unit enrollees and New York State Actives; New York State Empire Plan Medical Carrier and Prescription Drug Program paid claims (number of charges, amount of covered expenses and amount of benefits) by type of service for PS&T Unit enrollees and New York State Actives; number of enrollees, spouses or domestic partners, and dependents for PS&T Unit enrollees and New York State Actives.
h. The Joint Committee on Health Benefits shall work with appropriate State agencies in an ongoing review of the Medical Flexible Spending Account. The Joint Committee will work with the State to implement a direct debit vehicle to be utilized under the Medical Flexible Spending Account.
i. The Joint Committee on Health Benefits shall work with appropriate State agencies to review the impact of coverage for adult immunizations in the Empire Plan, and to consider additions to the list of immunizations.
j The Joint Committee on Health Benefits shall work with appropriate State agencies to make mutually agreed upon changes in the Plan benefit structure through such initiatives and activities as:
1. The annual HMO Review Process;
2. The ongoing review of the Managed Mental Health and Substance Abuse Care Program;
3. Ongoing review of the Benefits Management Program and an annual review of the list of procedures requiring Prospective Procedure Review;
4. Ongoing review of the Managed Physical Medicine Program;
5. The Joint Committee on Health Benefits will work with the State and Empire Plan hospital and medical carriers on the implementation and ongoing review of the Empire Plan hospital network;
6. The
development and implementation of a program that will allow enrollees to obtain
Laser Vision Correction services at discounted enrollee-pay-all fees through a
network of providers.
7. Ongoing review of Prospective Procedure Review (PPR) requirements and role/responsibility of medical providers in PPR process;
8. Review of the Infertility Centers of Excellence program as utilization information becomes available from the medical program vendor;
9. Review of the program to provide an annual vision care benefit for enrollees who demonstrate a vision loss resulting from a medical condition;
10. In cooperation with the New York State Health Insurance Program (NYSHIP) management, attempt to develop a "report card" which will include objective quality data to assist employees in selecting the health benefit plan that best meets the needs of the employees and their dependents.
11. The Joint Committee on Health Benefits
will review the impact of Domestic Partner coverage under the New York State
Health Insurance Program (NYSHIP), including the appropriateness of the existing
waiting periods.
12. The Joint Committee on Health Benefits will review the alternative medicine program that allows Empire Plan enrollees to obtain non-covered treatments or services at discounted enrollee-pay-all fees through a network of providers.
13. The Joint Committee on Health Benefits will work with the State and medical carrier to develop an enhanced network of urgent care facilities.
k. The
PEF Joint Committee on Health Benefits will work with the State to conduct an
extensive analysis of the current New York State Health Insurance Program
(NYSHIP) prescription drug benefit designs (Empire Plan and HMOs) and
associated costs.
l. The State shall seek appropriations of funds by the Legislature in the amount of $350,000 for fiscal years 2003-04, 2004-05, 2005-06, and 2006-2007 to support Committee initiatives and to carry out the administrative responsibilities of the Joint Committee during the term of this Agreement.
9.17 The program for managed care of mental health services and alcohol and other substance abuse treatment shall continue. The Joint Committee on Health Benefits will work with the State on the ongoing review of this program.
The Empire Plan shall continue to provide comprehensive coverage for medically necessary mental health and substance abuse treatment services through a managed care network of preferred mental health and substance abuse care providers. As soon as is reasonably practicable, the providers will be included in all lists of Empire Plan providers, including on-line directories. In addition to the in-network care, limited non-network care will be available.
Benefits shall be as follows:
IN-NETWORK
BENEFIT
Mental
Health Coverage
Medically necessary care rendered outside of the network will be subject to the following provisions:
Expenses applied against the deductible and copay levels indicated above will not apply against any deductible or copay levels or maximums under the basic medical portion of the Plan.
9.18 Appropriate descriptive material relating to any changes in benefits as a result of this Agreement shall be distributed to each State agency for internal distribution to enrollees prior to the effective date of the change in benefit. The State shall also take all steps necessary to provide revised health insurance booklets to every enrollee as soon as practically possible.
9.19 The State shall provide toll-free telephone service at the Department of Civil Service Health Insurance Section for information and assistance to employees and dependents on health insurance matters.
9.20a. A permanent full-time employee who is removed from the payroll due to an accepted work related injury or occupational condition shall remain covered under the State Health Insurance Plan and shall be treated as described in Section 13.3(h) of this Agreement.
b. A permanent full-time employee who is removed from the payroll due to a controverted work related injury or occupational condition will have the right to apply for a health insurance premium waiver. The appropriate agency will be responsible to inform the employee of his/her right to apply for the waiver prior to the employee meeting the eligibility requirements for the waiver of premium.
9.21 The confidentiality of individual subscriber claims shall not be violated. Except as required to conduct financial and claims processing audits of carriers and coordination of benefit provisions, specific individual claims data, reports or summaries shall not be released by the carrier to any party without the written consent of the individual, insured employee or covered dependent.
9.22 Eligible PS&T Unit employees enrolled in the Empire Plan will be provided with prescription drug coverage through the Empire Plan Prescription Drug Program. The benefits provided shall consist of the following:
The Prescription Drug Program will cover medically necessary drugs requiring a physician's prescription and dispensed by a licensed pharmacist.
Mandatory Generic Substitution will be required for all brand-name multi-source prescription drugs (a brand-name drug with a generic equivalent) covered by the Prescription Drug Program.
When a brand-name multi-source drug
is dispensed, the Program will reimburse the pharmacy (or enrollee) for the
cost of the drug's generic equivalent. The enrollee is responsible for the cost
difference between the brand-name drug and its generic equivalent, plus the
copayment. Effective January 1, 2005,
the enrollee will be responsible for the cost difference between the non-preferred
brand name drug and its generic equivalent, plus the copayment for the
non-preferred brand name drug.
The copayment is $5 for up to a 90 day supply of generic drugs dispensed at either the community pharmacy or the mail service pharmacy.
The copayment is $15 for up to a 90 day supply of brand-name drugs dispensed at either the community pharmacy or the mail service pharmacy.
Effective January 1,
2005, the prescription drug program will be modified as follows:
·
A third tier of prescription drugs will be created to differentiate
between preferred and non-preferred brand-name drugs.
·
The
copayment for up to a thirty-day supply at either the retail or mail service
pharmacy, will be $5 for generic drugs, $15 for preferred brand name drugs, and
$30 for non-preferred brand name drugs.
·
The
copayment for a 31 to 90 day supply at the retail pharmacy will be $10 for
generic drugs, $30 for preferred brand name drugs, and $60 for non-preferred
brand-name drugs.
· The copayment for a 31 to 90 day supply at the mail service pharmacy will be $5 for generic drugs, $20 for preferred brand-name drugs, and $55 for non-preferred brand-name drugs.
Prescription drugs will be dispensed through either the preferred provider community pharmacy network (retail pharmacy), or the mail service pharmacy.
Coverage will be provided under the Empire Plan Prescription Drug Program for prescription vitamins, contraceptive drugs, and contraceptive devices purchased at a pharmacy.
9.23 Eligible PS&T Unit employees enrolled in a Health Maintenance Organization participating in the State Health Insurance Plan will be provided with prescription drug coverage through the HMO in which they are enrolled.
9.24 Eligible PS&T Unit employees will be provided with Dental Plan coverage at the same level of benefits in effect on April 1, 2003, except as modified below:
a. The Dental Plan will cover sealants for dependents under age 14 at the same level of benefits in effect for managerial/confidential employees.
b. The maximum annual benefit per person for covered participating and non-participating services, including orthodontia, is $1,800. Effective January 1, 2006 the maximum annual benefit per person shall be $2,300.
c. Anesthesia
(not including topical, e.g., novocaine) administered in a dentist office shall
be a covered benefit under the participating and non-participating components
of the Dental Plan. The allowance for non-participating providers will be
subject to the out-of-network differentials.
Effective
9.25 Eligible PS&T Unit employees will be provided with the
PEF Vision Care Plan at the same level of benefits, including Occupational
Vision coverage, in effect on
a. Covered dependents under 19 years of age shall be eligible to receive vision care benefits once in any 12-month period.
b. If new lenses are required due to vision changes resulting from a medical condition for which the individual is under the care of a physician, vision care benefits, including an examination, new lenses and, if appropriate, new frames, shall be available sooner than once every 24 months, but not sooner than 12 months from the last use of vision care benefits, upon written documentation by an ophthalmologist that the medical condition has caused a vision loss that requires a new prescription. Documentation of the vision loss must be provided in writing by the ophthalmologist each time a new prescription is needed sooner than the standard 24-month interval. An individual who requires new lenses due to vision changes resulting from a medical condition, and who otherwise qualifies for Occupational Vision coverage, will be eligible to receive Occupational Vision benefits in accordance with the terms and conditions contained in this paragraph. The Joint Committee on Health Benefits shall work with the Vision Care Plan vendor to establish and confirm the eligibility rules and application procedures for this vision care enhancement.
9.26 The Medical Flexible Spending Account (MFSA) shall continue. The PEF Joint Committee on Health Benefits shall work with the State in the ongoing review of the MFSA.
Effective