NYS Benefit information for Medical, Dental, Vision and NYS administrated Flexible Spending Accounts

Annual NYSHIP Option Transfer Materials:
Annual Rate Renewal Memo 2025
NYSHIP Planning for Option Transfer 2025
NYSHIP Active Choices Guide 2025
NYSHIP Active Rates and Deadlines 2025
NYSHIP Direct Pay Rates and Information 2025
NYSHIP at a Glance 2025
Dental and Vision Brochure

Informational Materials and Forms:
NYSHIP General Information Book
NYSHIP Dependent Survivor Coverage
PS-404 Form (PEF does not handle enrollment – this form must be submitted to your Agency Health Benefit Administrator/HR Department/BSC)

PEF Health Benefits Contact Information:
Phone: 518-785-1900 x283
Email: HealthBenefits@pef.org

For information on insurance benefits such as Short- and Long-term Disability, Life Insurance, Accidental Death & Dismemberment Insurance, etc., please visit PEF Membership Benefits.

Health Benefits News

April 2025: Hospital Facility Fee Copayment Waived

We are pleased to announce that due to advocacy by PEF and other unions, facility fee copayments of $50 for visits to a hospital extension clinic will not be charged unless an outpatient service such as radiology or laboratory is performed. Please note that this applies to hospital extension clinic copayments.  Hospital extension clinic facility fees were previously eliminated effective 2/1/2023. You will be responsible for a $25 medical co-payment, but, again, the facility fee copayment will no longer be charged unless outpatient services are provided.  The copayment waiver will be retroactive to January 1, 2025, and all claims will be reprocessed back to January 1, 2025. Members that paid a facility fee copayment will receive a reimbursement check. Please note the following information will be posted within the Spring 2025 Empire Plan Report:

“A hospital extension clinic is a clinic that is owned and operated by a hospital. When you see a physician or receive services at a hospital extension clinic, you are being treated at a hospital-owned facility, even if the location where you receive services is located miles away from the main hospital campus or in your physician’s office. If you go to a hospital extension clinic for an office visit, you can be responsible for a Medical/Surgical Program (professional services) copayment ($25). You will not be responsible for facility fee charges or facility fee copayments. However, if you receive additional services, such as laboratory or radiology, you can also be responsible for a Hospital Program (outpatient facility) copayment ($50).”

 

Rite Aid Closing all Stores June 4, 2025

It has been brought to PEF’s attention that Rite Aid will close all its stores and begin laying off staff June 4, 2025. This will impact any members of The Empire Plan who use Rite Aid pharmacies for prescription drug benefits.

Members can locate in-network pharmacies by signing into Caremark.com. Choose “Plan and Benefits” and then select “Pharmacy Locator.” Members can ask their new pharmacy to request that Rite Aid transfer over their prescriptions. If you have any questions or need assistance locating an in-network pharmacy, please call The Empire Plan at 1-877-769-7447 and select 4 for the Prescription Drug Program.

CVS Caremark – Zepbound

PEF has been notified that CVS Caremark’s coverage for the GLP-1 medication, Zepbound, will be changing effective July 1, 2025. Please be advised that this change does not apply to enrollees under The Empire Plan. Eligible enrollees can still access Zepbound.

Jet Dental Clinics for New York State Dental Plan Enrollees – June 4, 5, and 6, 2025
Jet Dental clinics are coming to the North Country! New York State Dental Plan enrollees and covered dependents can receive preventive dental care, including cleanings, exams and X-rays at locations in your area. You must make an appointment to attend. Any services rendered by Jet Dental are subject to your New York State Dental Plan benefits. If you have questions on what is covered, please contact Anthem Blue Cross at 1-833-821-1949. Jet Dental will bill Anthem directly for covered services.

Wednesday, June 4 & Thursday, June 5, 9 am – 5 pm: SUNY Potsdam, Raymond Hall, 8th Floor, 44 Pierrepont Avenue, Potsdam, NY 13676

Friday, June 6, 9 am – 5 pm: Village of Saranac Lake, 39 Main Street, Saranac Lake, NY 12983

For more information and to sign up, click here. You can also call Jet Dental at 801-430-9262 or email hello@jetdental.com with any questions. A Frequently Asked Questions document is available here.

April 2025 Information About Dental Solutions:
Having Problems Finding an Anthem In-Network Dental Provider or Specialist?

If you are having difficulty finding a participating dental provider near your home address, please reach out to the dedicated Anthem NYS Dental Plan toll-free number at 1-833-821-1949 for assistance.
If no in-network providers are available, please request coverage under the “limited access program” in which you can use an approved out-of-network provider and be covered as if using an in-network provider.
Call Anthem Blue Cross about this to get approval before receiving treatment from the out-of-network provider. Subsequent visits to the out-of network provider will need approval as well.
If there are any problems with this, please contact PEF Health Benefits at 518-785-1900 x 283 or HealthBenefits@pef.org.

 

April 2025 Information About Measles and Travel:

The New York State Department of Health has released guidance for travel and measles. The Empire Plan covers the measles, mumps, and rubella (MMR) vaccine with no out-of-pocket cost when you use a network medical provider or for adults at a network vaccine pharmacy. If you are unsure if you are vaccinated, try to find your vaccination records, or consult with your health care provider. Your provider or local health department can help you decide if you need an MMR vaccination.

DOH release: https://www.cs.ny.gov/employee-benefits/nyship/shared/publications/measles-travel-advisory-for-all-new-yorkers.pdf

February 2025 Out-of-Network Dental Reimbursement Update:

PEF has been notified, effective 2/11/25, Anthem will now be sending all reimbursements for out-of-network dental services directly to the member, rather than to the provider. Should you have any questions please contact Anthem directly: 1-833-821-1949.

February 2025 Update: Albany Medical Health System (AMHS) Negotiations with Capital District Physicians Health Plan (CDPHP)

PEF has been advised that negotiations between CDPHP and AMHS have reached a multiyear contract agreement that will prevent any disruption in member care.

Jan. 2025: Update to Periodontal Dental Cleaning Visits with Anthem

Our members were experiencing problems being improperly told there was a limitation of two periodontal cleanings per year. We are happy to report that this has been rectified. If you went for periodontal cleanings between October 1, 2024, and December 16, 2024, and were told you were only eligible for two cleanings and had cleanings completed and were denied coverage, Anthem will be re-processing these claims to be billed correctly.

Anthem anticipates a completion date for the corrections to be done by January 24, 2025.  Claims after December 17, 2024, should be processed correctly.  If you had a claim denied and it isn’t corrected by January 24, 2025, or have any other related issues with this benefit, please reach out directly to Anthem: 1-833-821-1949 or Health Benefits within the PEF Contract Administration Department: 518-785-1900 x283. Additionally, if you paid out-of-pocket for periodontic cleanings during this time period or have claims that were not submitted to Anthem by you or your provider, you may also contact Anthem or the Health Benefits Team for assistance with reimbursement for these periodontal cleanings.

NYS Vision Plan – Visionworks Online Provider

Nov. 20, 2024, 10:00 a.m. – PEF has been notified by the State that all Davis insurance plans are currently disabled from the VisionWorks online website. This appears to be an issue on the VisionWorks side and is not isolated to just the NYS Vision Plan. Davis is currently working with VisionWorks to resolve this, as soon as we have further information, we will update membership.

PEF has been notified by the State of a new enhancement to the New York State Vision Plan – Davis Vision. As a member of the NYS Vision Plan, you are now able to order glasses and contact lenses online through the Visionworks retailer: https://www.visionworks.com/. Once at the website, you will first need to create an account, under the “My Account” tab at the top of the landing page. After you have successfully created your account, you may log in to enter your prescription. Visionworks will then need to verify that your prescription is valid. Verification can be done by uploading a copy of the prescription either within your account portal, email (websupport@visionworks.com), fax (210-201-8445), via online chat, or requesting the prescribing physician be contacted.

Eyeglass orders ship within 10 days of purchase via UPS Ground Service and can take up to 5 days for delivery. As a PEF member you have access to two pairs of eyeglasses through the occupational benefit. In order to receive both the dress pair and occupational pair of glasses you will need to enter two separate transactions. For assistance or more information, please contact Davis Vision: 1 (888) 588-4823

St. Peter’s Health Partners Contract with NYSHIP – The Empire Plan

The Empire Plan’s Medical/Surgical Program administrator, and St. Peter’s Health Partners in New York’s Capital District reached an agreement in October 2024. There is no impact on PEF members enrolled in the NYSHIP Empire Plan.

Anthem Blue Cross – New Dental Plan Administrator, October 1, 2024

The new NYS Dental Plan Administrator, Anthem Blue Cross, went into effect on October 1, 2024. The level of benefit is governed by the collective bargaining agreement, including enhancements achieved during the negotiation of the 2023-2026 PEF/State Agreement. Please refer to the Dental tab for further information.

NYS Benefits

NYS Work-Life Services: (WLS) Programs are joint labor-management programs that benefit New York State employees by enhancing employee wellbeing, increasing productivity, and improving morale in the workplace. The WLS programs include the Employee Assistance Program (EAP), technical assistance and support for the NYS Network Childcare Centers, and DIRECTIONS: Pre-Retirement Planning.

Flex Spending Account: 1-800-358-7202. The Flex Spending Account (FSA) offers three negotiated benefits to state employees – the Dependent Care Advantage Account (DCAA), the Health Care Spending Account (HCSA), and the Adoption Advantage Account. They are types of flexible spending accounts, administered in compliance with Sections 125 and 129 of the Internal Revenue Code, that give you a way to pay your dependent care, health care, or adoption expenses with pre-tax dollars. Enrollment in the FSAs are voluntary. There are no fees associated with any of these programs and you chose the amount of money you would like to contribute from your paycheck.

The Health Care Spending Account (HCSA): is a negotiated employee benefit that provides a tax-free way to help you, as state employee, pay for out-of-pocket health-related expenses. This includes medical, hospital, laboratory, prescription drug, dental, vision, and hearing expenses that are not reimbursed by your insurance, or other benefit plans.

HCSA Carryover:Unused contributions will carryover to the next plan year for you to use. During the plan year runout period (January 1- March 31), the previous year funds may still be used for previous year expenses. Any remaining funds up to the IRS limit from the previous year will then carryover into the current plan year’s account balance – after the runout period end date. During the runout, the new plan year election will be depleted first, then carryover funds will be accessible for reimbursement.

The Dependent Care Advantage Account (DCAA): is a negotiated employee benefit that provides a tax-free way to help you, as state employee, pay for custodial childcare, elder care, or disabled dependent care while you are at work.

Grace Period:The grace period allows an additional 2.5 months to incur dependent care. You can use any funds remaining in your account after the plan year ends to pay for expenses incurred between January 1 to March 15 of the following year. Claims must be submitted by the March 31 deadline.

Adoption Advantage Account: Eligible employees can enroll in a flexible spending account for expenses related to the adoption of an eligible child. Pre-tax payroll deductions contributed to the Adoption Advantage Account can help pay for an adoption that meets the IRS’s definition of a qualified adoption. Although you won’t save on social security taxes, you can save on federal and state taxes (where applicable).

Grace Period:The grace period allows an additional 2.5 months to incur adoption-related expenses. You can use any funds remaining in your account after the plan year ends to pay for expenses incurred between January 1 to March 15 of the following year. Claims must be submitted by the March 31 deadline.

Helpful Links:
Office of Employee Relations
Department of Civil Service
NYS Retirement
Employee Assistance Program (EAP)
Flexible Spending Account Enrollment Book 
Flexible Spending Account Flyer 
Productivity Enhancement Program
Productivity Enhancement Program Form

External links on this web site are provided for your convenience only. PEF does not necessarily endorse these web sites and is NOT responsible for their content.

Empire Plan

April 2025: Hospital Facility Fee Copayment Waived

We are pleased to announce that due to advocacy by PEF and other unions, facility fee copayments of $50 for visits to a hospital extension clinic will not be charged unless an outpatient service such as radiology or laboratory is performed. Please note that this applies to hospital extension clinic copayments.  Hospital extension clinic facility fees were previously eliminated effective 2/1/2023. You will be responsible for a $25 medical co-payment, but, again, the facility fee copayment will no longer be charged unless outpatient services are provided.  The copayment waiver will be retroactive to January 1, 2025, and all claims will be reprocessed back to January 1, 2025. Members that paid a facility fee copayment will receive a reimbursement check. Please note the following information will be posted within the Spring 2025 Empire Plan Report:

“A hospital extension clinic is a clinic that is owned and operated by a hospital. When you see a physician or receive services at a hospital extension clinic, you are being treated at a hospital-owned facility, even if the location where you receive services is located miles away from the main hospital campus or in your physician’s office. If you go to a hospital extension clinic for an office visit, you can be responsible for a Medical/Surgical Program (professional services) copayment ($25). You will not be responsible for facility fee charges or facility fee copayments. However, if you receive additional services, such as laboratory or radiology, you can also be responsible for a Hospital Program (outpatient facility) copayment ($50).”

Rite Aid Closing all Stores June 4, 2025

It has been brought to PEFs attention that Rite Aid will close all its stores and begin laying off staff June 4, 2025. This will impact any members of The Empire Plan who use Rite Aid pharmacies for prescription drug benefits.

Members can locate in-network pharmacies by signing into Caremark.com. Choose “Plan and Benefits” and then select “Pharmacy Locator.” Members can ask their new pharmacy to request that Rite Aid transfer over their prescriptions. If you have any questions or need assistance locating an in-network pharmacy, please call The Empire Plan at 1-877-769-7447 and select 4 for the Prescription Drug Program.

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The Empire Plan’s toll-free number: 1-877-7NYSHIP or 1-877-769-7447

Telehealth Coverage https://www.empireblue.com/nys
Telehealth coverage covers telehealth visits with participating providers in the Medical/Surgical Program and the Mental Health and Substance Abuse (MHSA) Program. Enrollees and covered dependents can access care through a video visit with their own doctor or therapist on a smartphone, tablet or personal computer. Telehealth visits are subject to the same enrollee cost sharing as in-person visits.

Virtual Health Care Access with LiveHealth Online (LHO) – With Empire BlueCross’ partnership with LiveHealth Online, enrollees can stay home and have a telephone or video visit with a board-certified doctor or licensed therapist via smartphone, tablet, or personal computer. To get started, go to www.empireblue.com/nys and select the link to LiveHealth Online. Or, call LHO at 1-888-LiveHealth (1-888-548-3432), 24 hours/day, seven days/week.

United HealthCare (UHC) Medical 1-877-769-7447 myuhc.com provides access to claims processed by United HealthCare, the par provider directory and enrollment verification. Register by visiting the web site and clicking on the Register button. Fill in the basic information, including your Group Number: 030500 and choose a User ID. UHC will create a password and mail it to your home.

Basic Medical Provider Discount Program (Multiplan) 1-877-769-7447 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% coinsurance required by Basic Medical. Multiplan has more than 200,000 providers in their network. 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 https://www.cs.ny.gov/employee-benefits. You can also call 1-877-7-NYSHIP and speak to a UHC representative.

Empire Blue Cross and Blue Shield – Hospital 1-877-769-7447 To use the Empire Blue Cross and Blue Shield web site, register in the Member Services window on the site. You will need your personal ID number, which is the first nine digits of your NY Government Employee Benefit Card. Create a personal password, which is combined with a one-time use activation key number and your log-on ID to safeguard the confidentiality of your records. You can check the status of a hospital claim, complete a coordination of benefits form.

Centers of Excellence for Cancer (Cancer Resource Services) 1-877-769-7447 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/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 https://www.myoptumhealthcomplexmedical.com/gateway/public/welcome.jsp

Benefits Management Program Call UHC: 1-877-769-7447 for Prospective Procedure Review. For pre-admission certification (before a scheduled hospital admission; within 48 hours after an emergency or urgent admission; before admission or transfer to a skilled-nursing facility), call Empire Blue Cross Blue Shield at 1-877-769-7447. It is your responsibility to call.

Carelon Health Options (formerly Beacon Health Options) 1-877-769-7447 Mental health & substance abuse services. You can access an online list of providers from the directory in the Civil Service web site at https://www.cs.ny.gov/employee-benefits.

Home Care Advocacy Program 1-877-769-7447 Durable medical equipment, home nursing care, infusion therapy and diabetic shoes. Diabetic supplies 1-888-306-7337. Ostomy supplies 1-800-354-4054.

EPIC Hearing Service 1-866-956-5400 Program that offers nationwide access to hearing services and treatments, including hearing diagnostics and hearing aids.

Centers of Excellence for Infertility 1-877-769-7447 Call for prior authorization of qualified procedures, regardless of provider. Call for information about all services for infertility.

HMOs

Health Maintenance Organizations
The toll-free numbers are for each HMO’s member services department.

Blue Choice 
165 Court St. Rochester, NY 14647
800-462-0108
585-454-4810

Empire BCBS HMO
P.O. Box 11800, Albany, NY
12211-0800
800-453-0113

Capital District Physicians’ Health Plan (CDPHP)
500 Patroon Creek Blvd., Albany, NY 12206-1057
800-777-2273
518-641-3700

Community Blue
1901 Main St., P.O. Box 80 Buffalo, NY, 14240-0080
877-576-6440
716-887-8840

Emblem Health (formerly HIP Health Plan of New York)
55 Water St., New York, NY 10041
877-861-0175

HMO Blue/Utica
Utica Business Park, 12 Rhoads Dr., Utica, NY 13502
800-722-7884

HMO Blue/Central & Southern Tier
333 Butternut Dr., Syracuse, NY, 13214
800-447-6269

Independent Health
511 Farber Lakes Dr., Buffalo, NY 14221
800-501-3439

MVP Health Care
P.O. Box 2207 625 State St., Schenectady, NY 12301-2207
888-687-6277

MVP Rochester
220 Alexander St., Rochester, NY 14607
585-325-3113
800-950-3224

Dental

Jet Dental Clinics for New York State Dental Plan Enrollees – June 4, 5, and 6, 2025
Jet Dental clinics are coming to the North Country! New York State Dental Plan enrollees and covered dependents can receive preventive dental care, including cleanings, exams and X-rays at locations in your area. You must make an appointment to attend. Any services rendered by Jet Dental are subject to your New York State Dental Plan benefits. If you have questions on what is covered, please contact Anthem Blue Cross at 1-833-821-1949. Jet Dental will bill Anthem directly for covered services.

Wednesday, June 4 & Thursday, June 5, 9 am – 5 pm: SUNY Potsdam, Raymond Hall, 8th Floor, 44 Pierrepont Avenue, Potsdam, NY 13676

Friday, June 6, 9 am – 5 pm: Village of Saranac Lake, 39 Main Street, Saranac Lake, NY 12983

For more information and to sign up, click here. You can also call Jet Dental at 801-430-9262 or email hello@jetdental.com with any questions. A Frequently Asked Questions document is available here.

April 2025 Information About Dental Solutions:

Having Problems Finding an Anthem In-Network Dental Provider or Specialist?
If you are having difficulty finding a participating dental provider near your home address, please reach out to the dedicated Anthem NYS Dental Plan toll-free number at 1-833-821-1949 for assistance.
If no in-network providers are available, please request coverage under the “limited access program” in which you can use an approved out-of-network provider and be covered as if using an in-network provider.
Call Anthem Blue Cross about this to get approval before receiving treatment from the out-of-network provider. Subsequent visits to the out-of network provider will need approval as well.
If there are any problems with this, please contact PEF Health Benefits at 518-785-1900 x 283 or HealthBenefits@pef.org.

February 2025 Out-of-Network Dental Reimbursement Update:

PEF has been notified, effective 2/11/25, Anthem will now be sending all reimbursements for out-of-network dental services directly to the member, rather than to the provider. Should you have any questions please contact Anthem directly: 1-833-821-1949.

Jan. 2025: Update to Periodontal Dental Cleaning Visits with Anthem

Our members were experiencing problems being improperly told there was a limitation of two periodontal cleanings per year. We are happy to report that this has been rectified. If you went for periodontal cleanings between October 1, 2024, and December 16, 2024, and were told you were only eligible for two cleanings and had cleanings completed and were denied coverage, Anthem will be re-processing these claims to be billed correctly.

Anthem anticipates a completion date for the corrections to be done by January 24, 2025.  Claims after December 17, 2024, should be processed correctly.  If you had a claim denied and it isn’t corrected by January 24, 2025, or have any other related issues with this benefit, please reach out directly to Anthem: 1-833-821-1949 or Health Benefits within the PEF Contract Administration Department: 518-785-1900 x283. Additionally, if you paid out-of-pocket for periodontic cleanings during this time period or have claims that were not submitted to Anthem by you or your provider, you may also contact Anthem or the Health Benefits Team for assistance with reimbursement for these periodontal cleanings.

Anthem Blue Cross – New Dental Plan Administrator, October 1, 2024

The new NYS Dental Plan Administrator, Anthem Blue Cross, went into effect on October 1, 2024. The level of benefit is governed by the collective bargaining agreement, including enhancements achieved during the negotiation of the 2019-2023 PEF/State Agreement, such as:

    • a higher annual maximum allowance of $3,000 per person
    • an increase to $3,000 for the orthodontic lifetime maximum per child
    • inclusion of a $600 implant allowance
    • long overdue coverage for precious/upgraded metal fillings

These previously negotiated enhanced contractual benefits will continue.

Anthem NYS Dental Plan Customer Service: 1-833-821-1949
Anthem Out-of-Network Claims: OON Claims Form

Use Anthem’s find-a-provider tool: Select “New York State Dental Plan” under Search for a Dental Provider. You will be directed to the XPO Dental Complete network where you can search for providers by address, doctor name or specialty type.

Dental providers interested in joining the Anthem NYSHIP network can call 1-866-947-9398 to speak to a designated Anthem representative.

Useful Dental Links:

Anthem Dental FAQ
American Association of Orthodontists
American Dental Association
American Academy of Periodontology
American Academy of Pediatric Dentistry

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EmblemHealth Customer Service – Dental Administrator prior to October 1, 2024: 1-800-947-0101

EmblemHealth (prior to 10/1/2024):
NYS Dental Plan Certificate of Insurance
NYS Dental Plan Certificate of Insurance – PEF Attachment
NYS Dental Plan Certificate of Insurance – PEF Rider Attachment
EmblemHealth Out-of-Network Claims: (OON Claims Form)
EmblemHealth Dental Claims
PO Box 2838
New York, NY, 10116-2838

Vision

NYS Vision Plan – Visionworks Online Provider

Nov. 20, 2024, 10:00 a.m. – PEF has been notified by the State that all Davis insurance plans are currently disabled from the VisionWorks online website. This appears to be an issue on the VisionWorks side and is not isolated to just the NYS Vision Plan. Davis is currently working with VisionWorks to resolve this, as soon as we have further information, we will update membership.

PEF has been notified by the State of a new enhancement to the New York State Vision Plan – Davis Vision. As a member of the NYS Vision Plan, you are now able to order glasses and contact lenses online through the Visionworks retailer: https://www.visionworks.com/. Once at the website, you will first need to create an account, under the “My Account” tab at the top of the landing page. After you have successfully created your account, you may log in to enter your prescription. Visionworks will then need to verify that your prescription is valid. Verification can be done by uploading a copy of the prescription either within your account portal, email (websupport@visionworks.com), fax (210-201-8445), via online chat, or requesting the prescribing physician be contacted.

Eyeglass orders ship within 10 days of purchase via UPS Ground Service and can take up to 5 days for delivery. As a PEF member you have access to two pairs of eyeglasses through the occupational benefit. In order to receive both the dress pair and occupational pair of glasses you will need to enter two separate transactions. For assistance or more information, please contact Davis Vision: 1 (888) 588-4823

New Vision/Dental Eligibility for Dependents to Age 26

Effective January 1, 2024, in accordance with the 2023-2026 PEF/State Agreement, dependents up to age 26 are now eligible for Dental and Vision benefits, regardless of student status. Coverage will end the first of the month following their 26th birthday.

  • If a PEF member with an eligible dependent up to age 26 did not receive a notice in November 2023 from Dept. of Civil Service (DCS) that the dependent was auto enrolled, then the member will need to reach out directly to the agency Health Benefit Administrator (HBA/HR Department) to complete the necessary enrollment paperwork.
  • If a PEF member received notification of a dependent that should not have been auto enrolledduring this process, the member will need to reach out directly to the agency Health Benefit
  • COBRA Eligibility: Dependents being removed will automatically receive a COBRA application from DCS. Deadlines noted on the application must be adhered to. For more information contact DCS at 1-800-833-4344 and select the COBRA prompt.

Davis Vision: 1-888-588-4823

Out-of-Network Claims: (OON Claims Form)
Davis Vision, Vision Care Processing Unit
P. O. BOX 152 LATHAM,
NEW YORK, 12110

Useful Vision Links:
American Optometric Association
NYS Vision Certificate Book 
Davis Vision

FAQ

How do I obtain a new or replacement ID Card?

Answer: You must contact the carrier directly. They will be able to issue a new and/or replacement ID card, along with giving you, your personal ID information via phone if available. You may also contact your Agency’s Health Benefits Administrator (HBA) normally located within the HR/Personnel Office. Please keep in mind PEF as a Union does not have access to this information and is unable to obtain your personal ID information or issue ID Cards.

Where can I locate Health Benefits informational packets including The NYSHIP General Handbook and claims forms?

Answer: All of these materials are located via NYSHIP Online or from your Agency’s Health Benefits Administrator (HBA)

Why am I and/or my dependent being denied services or being told we are inactive?

Answer: Your Agency’s Health Benefits Administrator (HBA) normally located within the HR/Personnel Office is responsible for ensuring your enrollment records are accurate and fully up-to-date in the State’s system NYBEAS. Your HBA is responsible for making any necessary corrections and/or changes. Please keep in mind PEF as a Union does not have access to this information and is unable to make these changes to personal profiles.

How do I find out whether a service or item is covered under my plan?

Answer: General benefit information is in the plan’s benefit booklet or member handbook. To obtain more specific benefit information, the plan’s member or customer service department should be contacted. Empire Plan enrollees who want to know beforehand how much United HealthCare (UHC) will pay for a medical service or item may submit a Pre-determination Request form.

Appeal Process Q&A:

What recourse do I have if I disagree with a determination made by my HMO or Empire Plan insurer?

Answer: Each health care plan offered to PEF members has an appeal procedure. When an HMO or Empire Plan insurer has determined a medical service or item isn’t covered, in whole or in part, a review of the determination may be requested using this procedure. Details on how to file an appeal are in the plan’s benefit booklet or member handbook.

What can I do if I’m not satisfied with the outcome achieved through the plan’s appeal procedure?

Answer: Members who wish to pursue their appeal further should contact the PEF Joint Committee on Health Benefits (JCHB). They  will conduct an investigation of the complaint that includes contacting the HMO or Empire Plan insurer to obtain an explanation of the determination. She will then report her findings to the PEF JCHB. If the PEF JCHB decides the response is inconsistent with their understanding of Article 9 of the PEF/NYS contract, or the health plan’s contract with the State, they will present the appeal to management for resolution. If management upholds the plan’s determination, the PEF JCHB, in consultation with PEF’s Contract Administration Department, will determine whether or not to file a contract grievance.

What can I do if I’m not satisfied with the outcome achieved through the JCHB’s appeal process?

Answer: The member can file an external appeal, which is described in the following Q&A. In addition, at any point a member may contact one of the three state agencies that oversee health insurers and HMOs. These agencies are the NYS Department of Financial Services (DFS), the NYS Department of Health (DOH), and the Office of the Attorney General.

For problems related to the payment of benefits, members may contact the Consumer Services Bureau of the NYS DFS at 1-800-342-3736. DFS assures that an insurer’s actions are in accordance with NYS Insurance Law; DFS rules and regulations; and contractual provisions.

HMO enrollees who are unable to get the care they need, or who are dissatisfied with the quality of care they are receiving, may contact the DOH Managed Care Hotline at 1-800-206-8125. DOH is responsible for the authorization and regulation of HMOs in the state, and assures the delivery, continuity, accessibility and quality of health care services are satisfactory.

For problems where you think a law has been broken or fraud might be involved, members may contact the Attorney General’s Health Care Bureau at 1-800-771-7755.

Finally, a member may wish to file a lawsuit against the HMO or insurer when all other attempts to resolve the matter have failed.

How does the external appeals process work?

Answer: The external appeals process is for all health-care services denied on the grounds that the service is not medically necessary. There is also an external review process for patients with life-threatening or disabling conditions who want to participate in clinical trials, use off-label drugs, or use experimental or investigational procedures or treatments when such services are denied on the basis that they are experimental or investigative.

To be eligible for an external appeal, you must first exhaust the health plan’s internal review process. The law permits plans to charge patients up to $50 for an external appeal, but they must give the money back to you if you win the appeal. Randomly assigned agents certified by the state will do the external reviews. These agents are required to make a determination on an appeal within 30 days or three days for emergency cases. Your health plan will send you more information on the external appeals process. You can find a summary of the law through the NYS Department of Financial Services web site.