Dental Stipend – Update 2.22.24

The Office of the State Comptroller (OSC) has released Payroll Bulletin 2204 providing information about the payment of the 2023 $400 dental stipend pursuant to the Dental Stipend Side Letter contained in the 2023-2026 PEF/State Agreement. The side letter provides for a $400 payment each fiscal year to eligible PS&T members until the State enters into a new dental services contract. 

EmblemHealth Albany Family Dental Practice Closure

It has been brought to PEFs attention, that as of Wednesday, February 7th, the EmblemHealth Family Dental Practices at the Empire State Plaza Concourse, and 1873 Western Avenue will be permanently closing April 30th, 2024.

This is not a notification stating that EmblemHealth is closing as a whole or that EmblemHealth is no longer the insurance carrier for the State’s dental plan. This is a notification of just the two practices that are closing. Although there is a bidding process in progress, the State’s current Dental Contract remains with EmblemHealth as the insurance carrier, until further notice, if applicable, regarding the outcome of the bidding process.

The State has provided PEF with the following information regarding the closure of these two EmblemHealth Family Dental Practice offices in the Albany area:

  • Letters notifying current patients about the 4/30/24 closures went out at the end of January, early February, giving the required 90 day notice of the closures to patients
  • The letter recommends that patients should start looking for a new dentist and to contact them prior to 4/30/24 to request any important copies of information pertaining to your dental records for your personal files or to give to your new provider
  • The offices have confirmed that they are reviewing all outstanding clinical work and that patients will be scheduled so that all treatment plans already in place will be completed prior to the closing date of 4/30/24

For further information, you may contact the following:

EmblemHealth: 1-800-947-0101

The Department of Civil Service: 1-800-833-4344

Public Employees Federation, Health Benefit Specialist Erika Frasier: 1-800-342-4306 ext.283

New Vision/Dental Eligibility for Dependents to Age 26

New Vision/Dental Eligibility for Dependents to Age 26

In accordance with the 2023-2026 PEF/State Agreement, dependents up to age 26 are eligible for Dental and Vision benefits, regardless of student status.  This is effective January 1, 2024.  The State has advised PEF of the following implementation process that took place prior to January 1, 2024:

  1. The Department of Civil Service (DCS) auto-enrolled eligible dependents for the January 1, 2024 effective date, on November 22, 2023
  2. DCS sent out notices to PEF members advising of dependents who have been automatically enrolled or re-enrolled, starting the week of November 27, 2023.
  3. If a PEF member with an eligible dependent up to age 26 did not receive a notice from 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.
  4. If a PEF member received notification of a dependent that should not have been auto-enrolled during this process, the member will need to reach out directly to the agency Health Benefit Administrator (HBA/HR Department) to have the necessary dis-enrollment paperwork completed to remove the dependent.

PEP Deduction Error:

The Department of Civil Service notified PEF that employees who had a 2023 PEP credit had their health insurance deduction stopped in the December 20, 2023, paycheck in error. It is expected that health insurance deductions will resume on the January 3, 2024, paycheck. There is no impact to employees health insurance coverage.

The Department of Civil Service has also advised that impacted enrollees should expect a regular health insurance deduction, and an additional special health insurance deduction of up to $100. The special health insurance deduction(s) will continue until the total amount of health insurance premium that should have been collected in the December 20, 2023, paycheck has been recouped. This may span multiple paychecks depending on the amount of the employee’s regular premium deduction. For any further questions please contact the Department of Civil Service at 1-800-833- 4344.

COVID-19 Related Changes to Health Benefits:

Health Benefits News

New Change to the NYSHIP Eligibility Waiting Period:
Effective October 1, 2023, the initial waiting period for enrollment for all employees newly hired into a benefits eligible position or who become newly eligible for benefits in the States health insurance programs will now be 28 days, instead of 56 days. Employees who are newly hired into a benefits eligible position or who become newly eligible to enroll in NYSHIP prior to October 1, 2023, must serve the 56-day initial waiting period as applicable to the PEF bargaining unit. For more information, please contact your agency Health Benefits Administrator (HBA).

New Dental Access Enhancement Program, June 2023
Single Case Agreements are now available under the NYSHIP Dental Plan. In an effort to increase access to network benefits available under the NYSHIP Dental Program currently administered by EmblemHealth, the State has advised PEF that members can reduce their out-of-pocket expenses through a Single Case Agreement (SCA).

If no participating providers are available for emergency or routine dental care, EmblemHealth can ensure a dental service is provided at the in-network level of benefits with a non-participating provider through a single case agreement; this applies when clinically appropriate, or to address access issues to dentists and specialists, and approval must be obtained prior to receiving treatment by calling Emblem Customer Service at 1-800-947-0101.

The Dental Plan’s network team will coordinate care with a non-participating provider when necessary, and the member will only be responsible for the in-network cost for the arranged service. If a provider is not willing to accept direct payment from Emblem as part of the SCA, Emblem guarantees members will be reimbursed for the provider’s billed amount, up to the maximum allowance according to the Certificate of Insurance.

If any members encounter problems with the SCA program, please contact the PEF Health Benefits Administrator at (800) 342-4306, ext. 283.

Please take note: Upcoming July 2023 Empire Plan changes do NOT apply to active PEF members. Read more, here.

NYSHIP General Information Book: https://www.cs.ny.gov/employee-benefits/nyship/shared/publications/general-information-book/2021/ny-gib-2021.pdf

2024 Annual NYSHIP Materials:

Dependent Survivor Coverage in NYSHIP: please see this document.

Recall of Philips CPAP Machines and Medical Devices

Philips has issued a recall for certain sleep apnea machines and ventilators due to potential health risks. For more detailed information about the recall, click here.

Click here for the online registration process that Philips has created to allow you to check if your device is affected by the recall. If your device is being recalled, you should reach out to your physician to determine the most appropriate options for continued treatment. You can also call Philips toll free at 1-877-907-7508 for more information.

For questions about your benefits for medical devices, including CPAP machines, you can also call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Medical/Surgical Program, then the Benefits Management Program to reach the Home Care Advocacy Program (HCAP). Representatives are available from 8:00 a.m. to 4:30 p.m., Monday – Friday, ET.

Thinking of Retiring Soon?

Planning for Retirement Benefits Checklist, is now available. Click on the link to access online or ask you Heath Benefits Administrator for a copy. You can also order a Planning for Retirement Package here.

NYS Benefits

Office of Employee Relations
Department of Civil Service

Employee Assistance Program (EAP): 1-800-822-0244

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 Child Care Centers, and DIRECTIONS: Pre-Retirement Planning.

Flexible Spending Accounts:

Flex Spending Account web site contains information about the available flexible spending accounts or by phone 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 FSA is voluntary – you decide to enroll in any or all of the benefits and choose how much to have taken out of your paycheck to pay for your eligible expenses. There are no fees for employees who participate in these programs. They are funded by the Office of Employee Relations in cooperation with the state public employee unions. The Legislature and Unified Court System also contribute on behalf of their employees.

The Health Care Spending Account (HCSA) is an employee benefit. It helps state employees pay for health-related expenses with tax-free dollars. This includes medical, hospital, laboratory, prescription drug, dental, vision, and hearing expenses that are not reimbursed by your insurance, or other benefit plans.

Before enrolling in the HCSA program, you should consider what your eligible expenses might be. Reviewing your costs from previous years can help. Once you have estimated the amount of your costs, you may then decide how much to contribute to your HCSA. Under federal law, any money that you put into your HCSA must be used for expenses incurred during the plan year in which it was contributed. For the 2022 plan year, the maximum annual contribution allowed is $2,850 and the minimum annual contribution is $100. The maximum contribution may be subject to change annually.

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. For participants who did not re-enroll, carryover funds will be available after the runout period ends. The current IRS carryover limit is $610.

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.

DCAA and Adoption Grace Period: The grace period allows an additional 2.5 months to incur dependent care or 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.

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) by having up to $15,950 withheld from your paycheck on a pre-tax basis.

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

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

EmblemHealth – formly known as GHI — is the state administrated Dental Plan. EmblemHealth Dental Toll Free Customer Service: 1-800-947-0101.

EmblemHealth Albany Family Dental Practice Closure

It has been brought to PEFs attention, that as of Wednesday, February 7th, the EmblemHealth Family Dental Practices at the Empire State Plaza Concourse, and 1873 Western Avenue will be permanently closing April 30th, 2024.

This is not a notification stating that EmblemHealth is closing as a whole or that EmblemHealth is no longer the insurance carrier for the State’s dental plan. This is a notification of just the two practices that are closing. Although there is a bidding process in progress, the State’s current Dental Contract remains with EmblemHealth as the insurance carrier, until further notice, if applicable, regarding the outcome of the bidding process.

The State has provided PEF with the following information regarding the closure of these two EmblemHealth Family Dental Practice offices in the Albany area:

  • Letters notifying current patients about the 4/1/24 closures went out at the end of January, early February, giving the required 90 day notice of the closures to patients
  • The letter recommends that patients should start looking for a new dentist and to contact them prior to 4/1/24 to request any important copies of information pertaining to your dental records for your personal files or to give to your new provider
  • The offices have confirmed that they are reviewing all outstanding clinical work and that patients will be scheduled so that all treatment plans already in place will be completed prior to the closing date of 4/1/24

For further information, you may contact the following:

EmblemHealth: 1-800-947-0101

The Department of Civil Service: 1-800-833-4344

Public Employees Federation, Health Benefit Specialist Erika Frasier: 1-800-342-4306 ext.283

New Vision/Dental Eligibility for Dependents to Age 26

In accordance with the 2023-2026 PEF/State Agreement, dependents up to age 26 will be eligible for Dental and Vision benefits, regardless of student status, effective January 1, 2024. PEF continues to work with the State on the enrollment process for these dependents. The State has advised PEF of the following implementation process:

  1. The Department of Civil Service (DCS) will auto-enroll eligible dependents for the January 1, 2024 effective date.  This is expected to be completed in November 2023.
  2. DCS will send out notices to PEF members advising of dependents who have been automatically enrolled or re-enrolled.  Notices are expected to go out in November.
  3. If a PEF member with an eligible dependent up to age 26 has not received a notice from DCS by mid-December (December 15, 2023) 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 for the January 1, 2024, implementation date.  Please do not reach out to your HBA/HR Department prior to December 15 regarding this enrollment.

Please note, the current eligibility rules still apply to dependents until January 1, 2024.  Until January 1, 2024, dependent children ages 19 through 25 are still required to be full-time students to be eligible for Dental and Vision benefits.

New Dental Guaranteed Access Enhancement, June 2023
Single Case Agreements are now available under the NYSHIP Dental Plan. PEF has been working closely with The State and the current NYSHIP Dental Plan administrator, EmblemHealth, in response to concerns of access and availability to network providers. In an effort to increase access to network benefits available under the NYSHIP Dental Program, members can reduce their out-of-pocket expenses through a Single Case Agreement (SCA).

If no participating providers are available for emergency or routine dental care, EmblemHealth can ensure a dental service is provided at the in-network level of benefits with a non-participating provider through a single case agreement; this applies when clinically appropriate, or to address access issues to dentists and specialists, and approval must be obtained prior to receiving treatment by calling Emblem Customer Service at 1-800-947-0101.

The Dental Plan’s network team will coordinate care with a non-participating provider when necessary, and the member will only be responsible for the in-network cost for the arranged service. If a provider is not willing to accept direct payment from Emblem as part of the SCA, Emblem guarantees members will be reimbursed for the provider’s billed amount, up to the maximum allowance according to the Certificate of Insurance.

College-age Students’ Coverage
As of July 1, 2020, enrollees with NYSHIP Vision and Dental Plan coverage will no longer be required to submit a full-time student verification form. All full-time student verification will be obtained through the NYSHIP Dental Plan vendor, Emblem Health (Emblem), and will be considered adequate proof of full-time student status for the NYSHIP Vision Plan.

Dependent children ages 19 through 25 are still required to be a full-time student in order to be eligible for vision benefits. The federal Patient Protection and Affordable Care Act requires insurers to offer children coverage as dependents on their parents’ health insurance plan up to age 26 for medical regardless of student status.

Emblem Health, who is administering the dental program for enrollees NYSHIP, will begin a monthly systematic process of adding and removing dependents ages 19 through 25 based on their full-time student status in the system. All information received from Emblem Health will be used to update the dependent’s vision coverage under Davis Vision.

  • Removing Dependents (after first Friday of each month) Dependents who have not confirmed as full-time student status will be removed from NYBEAS accordingly:
  • No response to Emblem Health Student Verification form 2 months prior to the 19th birthday: Dependent is removed the first of the month following their 19th birthday
  • No response to Emblem Student Verification form for Current Semester: Dependent is removed the first of the month following a 3-month extension beyond the last semester full-time student status was confirmed
  • Re-adding verified dependents (after the first Friday of each month)
    Dependents who have confirmed full-time student status with Emblem Health since the previous monthly update, will be re-added to NYBEAS accordingly:
  • Retroactively: Dependent is re-added retroactive to the date they were originally removed with confirmation of continuous full-time student status.
  • When classes began: Dependent is re-added as of the first day of the month in which classes began. There will be a break in coverage when there is a break in between semesters. (Example: dependent attends Fall semester, but does not return to school again until the following Fall semester)
  • Age 25 removals: EBD will continue the automated process of removing all children from NYSHIP dental and vision effective the first of the month following their 25th birthday.

COBRA Eligibility
Dependents being removed from the file will automatically receive a COBRA application. Deadlines as noted on the application must be adhered to. Please instruct enrollees and/or their dependents to contact EBD at 1-800-833-4344 and select menu options for COBRA.

EmblemHealth Participating Providers: For information benefits and to obtain the names of participating dentists in your area, refer to the Directory of Participating Dentists, Customer Service at 1-800-947-0101, or visit GHI website.

EmblemHealth Non-Participating Provider Reimbursement Schedulehttps://www.cs.ny.gov/employee-benefits/nyship/group/1/10/3/dental/12.cfm

For more information about dental health and dentistry, use the links below:
American Association of Orthodontists
American Dental Association
American Academy of Periodontology
American Academy of Pediatric Dentistry

Vision

New Vision/Dental Eligibility for Dependents to Age 26

In accordance with the 2023-2026 PEF/State Agreement, dependents up to age 26 will be eligible for Dental and Vision benefits, regardless of student status, effective January 1, 2024. PEF continues to work with the State on the enrollment process for these dependents. The State has advised PEF of the following implementation process:

  1. The Department of Civil Service (DCS) will auto-enroll eligible dependents for the January 1, 2024 effective date.  This is expected to be completed in November 2023.
  2. DCS will send out notices to PEF members advising of dependents who have been automatically enrolled or re-enrolled.  Notices are expected to go out in November.
  3. If a PEF member with an eligible dependent up to age 26 has not received a notice from DCS by mid-December (December 15, 2023) 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 for the January 1, 2024, implementation date.  Please do not reach out to your HBA/HR Department prior to December 15 regarding this enrollment.

Please note, the current eligibility rules still apply to dependents until January 1, 2024.  Until January 1, 2024, dependent children ages 19 through 25 are still required to be full-time students to be eligible for Dental and Vision benefits.

The Davis Vision Care Customer Service Toll free phone number: 1-888-588-4823

Davis Vision online portal: https://idoc.davisvision.com/DavisVision.Member/Home/Index?id=$PPL2932&grp=XE9&subgrp=999&plan=98X

You can access the Davis Vision web site from the Department of Civil Service website: https://www.cs.ny.gov/employee-benefits/nyship/group/1/10/vision/index.cfm

If prompted, choose your group and plan, then select Other Benefits and then Vision Benefits. Follow the links to the Davis Vision website.

Out-of-Network Claims Address:
Davis Vision, Vision Care Processing Unit, and P. O. BOX 152 LATHAM, NEW YORK, 12110

For more information about vision and eye care use the links below:

American Optometric Association Eye and vision problems

College-age Students’ Coverage

Effective July 1, 2020, enrollees with NYSHIP Vision and Dental Plan coverage will no longer be required to submit a full-time student verification form. All full-time student verification will be obtained through the NYSHIP Dental Plan vendor, Emblem Health (Emblem), and will be considered adequate proof of full-time student status for the NYSHIP Vision Plan.

Dependent children ages 19 through 25 are still required to be a full-time student in order to be eligible for vision benefits. The federal Patient Protection and Affordable Care Act requires insurers to offer children coverage as dependents on their parents’ health insurance plan up to age 26 for medical regardless of student status.

Emblem Health, who is administering the dental program for enrollees NYSHIP, will begin a monthly systematic process of adding and removing dependents ages 19 through 25 based on their full-time student status in the system. All information received from Emblem Health will be used to update the dependent’s vision coverage under Davis Vision.

  • Removing Dependents(after first Friday of each month) Dependents who have not confirmed as full-time student status will be removed from NYBEAS accordingly:
  • No response to Emblem Health Student Verification form 2 months prior to the 19th birthday:Dependent is removed the first of the month following their 19th birthday
  • No response to Emblem Student Verification form for Current Semester:Dependent is removed the first of the month following a 3-month extension beyond the last semester full-time student status was confirmed
  • Re-adding verified dependents(after the first Friday of each month)
    Dependents who have confirmed full-time student status with Emblem Health since the previous monthly update, will be re-added to NYBEAS accordingly:
  • Retroactively:Dependent is re-added retroactive to the date they were originally removed with confirmation of continuous full-time student status.
  • When classes began:Dependent is re-added as of the first day of the month in which classes began. There will be a break in coverage when there is a break in between semesters. (Example: dependent attends Fall semester, but does not return to school again until the following Fall semester)
  • Age 25 removals: EBD will continue the automated process of removing all children from NYSHIP dental and vision effective the first of the month following their 25th birthday.

COBRA Eligibility
Dependents being removed from the file will automatically receive a COBRA application. Deadlines as noted on the application must be adhered to. Please instruct enrollees and/or their dependents to contact EBD at 1-800-833-4344 and select menu options for COBRA.

 

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.