Home » Contract Information » Health Benefits

Health Benefits

PEF Logo

COVID-19 Related Changes to Health Benefits

United HealthCare has provided a summary of changes to their benefits plan as a result of the COVID-19 pandemic. Click here for a summary.  This information is current as of June 2021 and is subject to change.

New Empire Plan benefits

Effective 10/1/19, the Empire Plan will be extending the age range for coverage of the Gardasil 9 Human Papilloma Virus (HPV) vaccine as a preventive care service for men and women through age 45. The Plan has been covering the Gardasil 9 vaccine as a preventive care service for enrollees ages 9-26. In October 2018, the FDA approved the Gardasil 9 vaccine for expanded use by men and women ages 27–45 years old. Consequently, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommended extending the age range for coverage of the Gardasil 9 vaccine as a preventive service through age 45. This age range extension applies only to the Gardasil 9 vaccine, not to any of the other HPV vaccines. The CDC adopted the ACIP recommendation in June 2019, to be effective by October 1, 2019.Preventive care services required under the Affordable Care Act, which includes the Gardasil 9 HPV vaccine, are covered at no cost share to enrollees when a network provider is used.

Effective 9/16/19, gender reassignment surgery and any other surgeries, services and procedures associated with gender reassignment (including those performed to change an enrollee’s physical appearance to more closely conform secondary sex characteristics to their identified gender) are now covered if a behavioral health provider determines the surgery or procedure is medically necessary.A behavioral health provider, who must be licensed by the state in which they practice and experienced in treating gender dysphoria, must provide a written assessment documenting that the enrollee has a diagnosis of gender dysphoria, the capacity to make a fully informed decision and to consent for treatment, and is 18 years of age or older.Benefits are available under the Participating Provider and Basic Medical programs. While not required, a predetermination review, also known as a preservice claim determination, is available.Coverage for gender dysphoria treatment also includes cross-sex hormone therapy, puberty- suppressing medications and laboratory testing to monitor the safety of hormone therapy.

More information is provided in the Empire Plan Certificate Amendment dated 9/16/19: Gender Dysphoria Amendment

Westchester Medical Center Update

We are pleased to advise you that the Westchester Medical Center Health Network (WMCHN) and Empire BlueCross (the administrator for the Empire Plan Hospital Program) have reached a contract agreement that reinstates the hospital system’s network status retroactive to June 1, 2019. WMCHN includes the following facilities: Bon Secours—Good Samaritan Hospital; Bon Secours—Mercy Community Hospital; Bon Secours—St. Anthony’s Hospital; Mid-Hudson Regional Hospital and Westchester Medical Center.

This means that claims for covered services received at these facilities on or after June 1, 2019, will be processed at the in-network level of benefits subject to any applicable in-network copayment.

Empire Plan enrollees who have any questions should be advised to call The Empire Plan toll-free at 1-877-7-NYSHIP (1-877-769-7447) and select option 2 for the Hospital Program.

Security Incidents Involving Quest Diagnostics and LabCorp

Quest Diagnostics (Quest) and LabCorp recently reported two separate security incidents involving their debt collection vendor, American Medical Collection Agency (AMCA). AMCA, a third-party vendor used for patient debt collection, may have been the victim of a malware-attack, resulting in exposure of certain personal information. This information is reported to include social security numbers and financial data, such as credit card information. Laboratory test results were not included. This issue is limited to only those Quest and LabCorp patients who had a past due balance for lab services that were sent to the collections vendor, AMCA, where the security incident occurred.

Quest and LabCorp have stated they are working closely with AMCA to determine the facts and understand which health plan members are affected. Although these two incidents did not directly involve NYSHIP, the Department of Civil Service will continue to provide updates as additional information becomes available.

Update – Westchester Medical Center Health Network
As of May 31, 2019, the contract between Empire BlueCross BlueShield (the hospital administrator for The Empire Plan) and Westchester Medical Center Health Network (WMC) expired. Effective June 1, 2019, the following WMC facilities are no longer in The Empire Plan network:

    1. • Bon Secours – Good Samaritan Hospital (Suffern, NY)


    1. • Bon Secours – Mercy Community Hospital (Port Jervis, NY)


    1. • Bon Secours – St. Anthony’s Hospital (Warwick, NY)


    1. • Mid- Hudson Regional Hospital (Poughkeepsie, NY)


    • Westchester Medical Center (Valhalla, N.Y)

Impact on Empire Plan Enrollees – Most Coverage Is Now On a Non-Network Basis
Except for the special circumstances listed below, all other services provided by WMC facilities will now be covered on a non-network basis:

    1. • If no in-network hospital is available within 30 miles of your residence


    1. • If no in-network hospital within 30 miles of your residence can provide the covered services you require


    1. • If you need emergency care


    1. • For continuation of care for pregnancy or health risk


    • For any services that were previously preauthorized

Non-Network Hospital Coverage (Empire BCBS)

Type of Service Non-Network Level of Benefits
Outpatient Services Enrollee pays 10% of billed charges or $75 copay, whichever is greater, up to the combined annual coinsurance maximum. Then, the enrollee pays the network level copay, if any.
Inpatient Services Enrollee pays 10% of billed charges up to the combined annual coinsurance maximum of $3,000 for the enrollee, $3,000 for the spouse/domestic partner, and $3,000 for all dependent children combined. The Plan then pays 100% of billed charges.
Emergency Services $70 copay; copay waived if patient admitted directly from ER.


Radiology, Anesthesiology and Pathology Physician Services (UnitedHealthcare)

If an enrollee receives radiology, anesthesiology or pathology services from a physician in connection with inpatient or outpatient hospital services at one of the non-network WMC facilities, his or her out-of-pocket costs for these services may be higher as well. United Healthcare (UHC) will provide benefits for these services based on the physician’s participation status. If the physician is not an Empire Plan participating provider, UHC will reimburse the enrollee under the Basic Medical portion of the Plan subject to the out-of-network combined annual deductible of $1,000 for the enrollee, $1,000 for the spouse/domestic partner, and $1,000 for all dependent children combined, and paid at 80% up to the Reasonable and Customary Charge.

Additional Information

Enrollees who have questions or need assistance in identifying an alternative facility should be advised to call Empire BCBS toll-free at 1-800-495-9323, Monday through Friday, between the hours of 8:30am and 5:00pm

Westchester Medical Center Health Network Termination

If an agreement with Empire Blue Cross Blue Shield is not reached by June 1, 2019, the Westchester Medical Center Health Network will no longer be in-network.
Westchester Medical Center Health Network consists of the following facilities: Bon Secours – Good Samaritan Hospital; Bon Secours – Mercy Community Hospital; Bon Secours – St. Anthony’s Hospital; Mid- Hudson Regional Hospital; and Westchester Medical Center.
Under these circumstances, Westchester Medical Center Health Network will only provide the following in-network services:

    1. 1) Cases of emergency;


    1. 2) If no in-network hospital exists that can provide the services required;


    1. 3) If a network hospital is not available within a 30-mile radius from your home;


    1. 4) For continuation of care for pregnancy or health risk;


    5) For any services that were previously preauthorized.

If you choose to use Westchester Medical Center Health Network, all other services will be covered on an out-of-network basis. You will be responsible for paying ten percent (10%) of the billed charges for covered services, up to the annual coinsurance maximum amount.
To find an alternate network hospital or learn more, call 1-877-7-NYSHIP (1-877-769-7447) and select option 2.

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

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

Civil Service will also be mailing a revised Empire Plan Certificate for New York State Retirees to retirees in the near future. The retiree Certificate book will be dated January 1, 2019.

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

On the Road with The Empire Plan

You’re taking your family on a trip this summer…your child is going off to college this fall… you’ve finally retired and plan to spend winters in Florida… it’s good to know that The Empire Plan is there wherever you or your family goes. Before you go, however, plan ahead. Do you have your doctors’ phone numbers and your benefit card? Do you have enough of your maintenance medications? If you are Medicare primary, do you also have your Empire Plan Medicare Rx Card? And, don’t forget to pack On the Road with The Empire Plan. This informative booklet has important phone numbers and information you or a family member may need while away from home.

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

The Empire Plan Medical/Surgical Program has network providers in many states, and the Hospital Program, Prescription Drug Program and Medicare Rx have nationwide networks. The Empire Plan Mental Health and Substance Abuse Program, the Home Care Advocacy Program (HCAP) and the Managed Physical Medicine Program guarantee access to network benefits nationwide if you call to make the necessary arrangements before you receive services. The toll-free number is 1-877-7-NYSHIP or 1-877-769-7447.

In the event you or a family member needs medical care while away from home, be prepared. Request the booklet On the Road with The Empire Plan from your agency health benefits administrator, usually located in your Personnel Office or the Business Services Center. If you are a retiree, contact the Employee Benefits Division of the NYS Department of Civil Service at (518) 457-5754 or 1-800-833-4344. It can also be found online at www.cs.ny.gov/employee-benefits. Select your group and plan to get to the NYSHIP Online homepage. Select Using Your Benefits and then Publications.

College-age Students’ Dental, Vision Coverage May End with School Year

If your child is age 19 or older, but under age 25, and is completing his or her studies in May or June, then he or she may lose eligibility for coverage as a dependent child under your dental and vision plans.

You must notify your state agency’s health benefits administrator of your child’s change in student status, and you should request information about how to continue their dental and vision coverage.

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, but that only applies to medical care, not dental or vision care.

When coverage ends

Under the EmblemHealth (formerly GHI) Preferred Dental Plan and the NYS Vision Plan, your unmarried dependent children age 19 or older, but under age 25, are eligible for coverage if they are full-time students. They continue to be eligible until the first of the following dates:

    1. • The end of the third month following the month in which they completed the semester as a full-time student;

• The end of the month in which attendance at school ends, if the semester is not completed and proof of the last day of attendance for the semester is provided, or the end of the third month following the month that the last semester was completed, whichever is later;

• The starting date of the semester if the semester is not completed and no proof of attendance is provided, or the end of the third month following the month that the last semester was completed, whichever is later;

• The end of the third month following the month in which they complete course requirements for graduation; or

• The end of the month in which they reach age 25.

How to extend coverage

The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) requires most employers sponsoring group health plans to offer employees and their covered dependents the opportunity for temporary “continuation coverage” at group rates in certain instances where coverage under the employer-sponsored plan would otherwise end.

The dental and vision care benefits your dependent may continue are the same benefits you receive as an active employee. COBRA requires that your child have the opportunity to continue coverage for up to 36 months. The cost of COBRA coverage is the full premium (both the employer and employee shares) plus a 2 percent administrative fee. The 2019 monthly COBRA rates for individual coverage are: $23.41 for dental and $3.16 for vision.

Under COBRA, the employee or dependent is responsible for informing the Employee Benefits Division (EBD) of the state Department of Civil Service (DCS) within 60 days of when the dependent loses eligibility. If you do not notify EBD within that time, regardless of the reason, the dependent will not be entitled to COBRA continuation coverage.

For more information about COBRA continuation coverage, visit the DCS web site at www.cs.ny.gov/employee-benefits.. Follow the prompts to NYSHIP Online, and then select Other Benefits to access the Dental Plan Certificate Book and NYS Vision Plan Book, or you may call the DCS at 518-457-5754 or 1-800-833-4344.

If you are looking for older news you can click here.