You may have to pay your copayment, coinsurance, or deductible for any in-person follow-up care or treatment. fH\N,PHtL8#> N endstream endobj startxref 0 %%EOF 49 0 obj <>stream The Empire Plan is the primary health benefits plan for NYSHIP, covering nearly 1.1 million members. Group Coverage Terminated for Non-Payment of Premiums or You Are No Longer Eligible for Coverage. Please use this listing to locate the available NYSHIP options for each county in New York State. -Unified Court System-COBANC. Starting January 15, 2022, health plans must cover at-home over-the-counter COVID-19 diagnostic tests authorized by the U.S. Food and Drug Administration (FDA). If your employer bought your policy in another state, contact your employer for details. 0000006742 00000 n No Premium Payments. 0000006249 00000 n 4. %PDF-1.4 % Providers can get reimbursed for COVID-19 vaccine administration through the U.S. Human Resources & Services Administration COVID-19 Relief Fund Program. Large Group Coverage. Call 1-877-7-NYSHIP (1-877-769-7447) and follow the prompts to notify the appropriate program carrier/vendor as outlined below, or go touhcprovider.com/paan. Telephone Calls and Videos Included in Telehealth. The extended benefits are only available to treat the condition causing your disability. Physical Health Mental Health Mental Health and Substance Use But if they do, you should contact your insurer to let them know you have been charged for PPE and request a refund. A. The Empire Plan is NYSHIP's unique health insurance plan designed exclusively for New York State's public employees and employers. In addition, if you go to an out-of-network New York hospital, you will only be responsible for your in-network copayment, coinsurance, or deductible for inpatient hospital services which follow an emergency room visit. The annual cost for Empire Plan Family coverage ranged from $20,570 to $28,953 during the audit endstream endobj 1537 0 obj <>stream It is not a surprise bill if you signed a written consent that you knew the services were out-of-network and would not be covered by your health plan. %PDF-1.5 % You will need individual coverage. Let your insurer know if you were charged a deductible, copayment, or coinsurance for diagnosis of COVID-19 and request a refund or credit for that payment. NY Coverage. If you have coverage for prescription drugs, and your insurers formulary does not include a prescription drug that your doctor thinks you need, you can use your insurers formulary exception process to request coverage of an off-formulary prescription drug. 0000003440 00000 n The HCSA, which helps state employees pay for health-related expenses with tax-free dollars, will now allow up to $550 of remaining balances from your 2021 HCSA to go toward eligible expenses incurred during the 2022 calendar year. Contact Your Doctor. The recommendations about getting care for coronavirus (COVID-19) are changing rapidly. If you are totally disabled on the date your coverage terminates, your insurer will provide benefits for covered services during a period of total disability for up to 12 months from the date your coverage ends, or until you are no longer disabled, if sooner. 0000006209 00000 n Visit NYSHIP online I have health insurance through my employer. PIA( NYS Police Investigative Unit) If your employer self-funds the coverage, contact your employer for details. Insurers cant deny COVID-19 treatment as not medically necessary. Can I still continue my group health insurance? medically necessary. COBRA and Continuation of Coverage. NYSHIP's Empire Plan has been reimbursing providers at 90% of the usual and customary rate determined by the cost estimate nonprofit FAIR Health for services since 2015 to also prevent balance . CDPHP provides the programs and services you need to get and stay healthy, including personalized activities and challenges, virtual and in-person mental health support, the ability to find a doctor or compare costs for services with just a few clicks, and so much more. If you have Medicaid, Essential Plan, or Child Health Plus, check the Governors website https://www.governor.ny.gov/news/governor-cuomo-announces-new-directive-requiring-new-york-insurers-waive-cost-sharing or the Department of Healths website www.health.ny.gov. Medicare. Group Contract Terminates. The Workers Compensation Board issued Emergency Adoption of Amendments to 12 NYCRR 325-1.8, 329-1.3, 329-4.2, 333.2, and 348.2 (Telemedicine)regarding telemedicine under No-Fault coverage. 0000022947 00000 n Telehealth services keep you safer and those around you safer. The hbbd```b``Z "@$fb"elW0{= fW`{$ However, your insurer may require telehealth services to be provided by an in-network provider. 0000045658 00000 n 0000006649 00000 n Can my insurer cancel or refuse to renew my insurance policy if I get COVID-19? Formulary Appeal. Please note there are two sets of rates. 3V7 |F B endstream endobj 11 0 obj <> endobj 12 0 obj <> endobj 13 0 obj <>stream Steps to getting contracted plus plan information, Phone numbers and links for connecting with us, List of contracted, high-quality independent lab providers, Update, verify and attest to your practice's demographic data, Provider search for doctors, clinics and facilities, plus dental and behavioral health, Policies for most plan types, plus protocols, guidelines and credentialing information, Specifically for Commercial and Medicare Advantage (MA) products, Pharmacy resources, tools, and references, Updates and getting started with our range of tools and programs, Reports and programs for operational efficiency and member support, Resources and support to prepare for and deliver care by telehealth, Tools, references and guides for supporting your practice, Log in for our suite of tools to assist you in caring for your patients. TTY users should call 711. 1. active State employees (and Unified Court System). Empire members receive the COVID-19 vaccine at no cost. Surprise Bill If You Are Referred By Your Doctor. 0000018183 00000 n How do I get an at-home over-the-counter COVID-19 test? Student Employee Health Plan will still continue to have a $10 Office Visit co-pay, 3. 0000048148 00000 n No. May a participating provider charge me a fee for personal protective equipment (PPE) used during my visit? Check the NY Department of Healths website on Coronavirus information for the most up-to-date information on what you should do. I am an Independent Medical Biller CPB (AAPC) and an owner of KR2 Medical Billing. Our licensed agents can help you determine if you are eligible for financial help and find . Your doctor or health care provider may need to write your prescription a certain way so that the pharmacy can fill a 90-day supply. Contact your insurer. 0000015114 00000 n Need More Information? 0000011846 00000 n If Covered at Your Providers Office. Your employer or its benefit administrator must tell you about your right to continue health insurance coverage. 0000028757 00000 n 0000005663 00000 n With the new year (2020) around the corner The Empire Plan NYSHIP has released a list of more employee groups that will be affected by the office visit co-pay changes. Each household can order four tests. The open enrollment period to request participation in these programs ends December 12, 2022. If you have Medicare, check with the Centers for Medicare & Medicaid Services (CMS) at (800) MEDICARE, the Medicare Rights Center at (800) 333-4114, www.medicare.gov, or the CMS fact sheet because different protections will apply. You are only responsible for your in-network copayment, coinsurance, or deductible. If you are totally disabled on the date your individual health insurance policy terminates, your insurer will continue to pay for covered services for up to 12 months, or until you are no longer disabled, if sooner. However, you can get coverage through the NY State of Health: The Official Health Plan Marketplace. This does not apply to Medicare-primary Empire Plan enrollees and their covered dependents. No Preauthorization. Complete healthy activities and challenges. Medicaid, Essential Plan, and Child Health Plus. See the 2023 State NYSHIP Enrollee Biweekly Premium Contributions See NYS Department of Civil Services NYSHIP Rates and Deadlines publication The annual Option Transfer Period for State employees will begin Thursday, December 1, 2022, and end Friday, December 30, 2022 . Resources and support when you need it most. Information on medication coverage. You have 60 days to apply for this coverage. 2&pqA8@BV)yS,yQX>,OFJx=uNT@4T>BD"5A 1 Effective 01/01/2020 the following employee groups will have a $25 office visit co-pay: 0000012693 00000 n For specific formulary updates check here, Side-by-side comparison and highlights of benefits of the plan, Side-by-side comparison and highlights of benefits of the plan with drug coverage, How you and the plan would share the cost for covered health care services, How you and the plan would share the cost for covered health care services with drug coverage. This page is available in other languages. Demographic Data Self-Identification Form, Office Visit, Office Surgery, Radiology, Diagnostic Laboratory Tests, Free-standing Cardiac Rehabilitation Center Visit, Convenience Care Clinic Visit, Non-hospital Outpatient Surgical Locations, Office Visit, Radiology, Diagnostic Laboratory Tests, Urgent Care Center Visit, Outpatient Services for Diagnostic Radiology and Diagnostic Laboratory Tests in a network Hospital or Hospital Extension Clinic, Visit to Outpatient Substance Use Treatment Program, Level 2 Drugs, Preferred Drugs or Compound Drugs, Oral chemotherapy drugs, when prescribed for the treatment of cancer, Generic oral contraceptive drugs and devices or brand-name contraceptive drugs/devices without a generic equivalent (single-source brand-name drugs/devices), with up to a 12-month supply of contraceptives at one time without an initial 3-month supply, Tamoxifen, raloxifene, anastrozole and exemestane when prescribed for women age 35 and over for the primary prevention of breast cancer, Pre-Exposure Prophylaxis (PrEP), when prescribed for enrollees who are at high risk of acquiring HIV, Certain preventive adult vaccines when administered by a licensed pharmacist at a pharmacy that participates in the CVS Caremark national vaccine network, Certain prescription and over-the-counter medications*** that are recommended for preventive services without cost sharing and have in effect a rating of A or B in the current recommendations of the U.S. Preventive Services Task Force (USPSTF). 0000008973 00000 n For further information, visit www.hhs . 0000001247 00000 n In addition, individuals who received unemployment benefits in 2021 may be eligible for free health insurance coverage through the NY State of Health: The Official Health Plan Marketplace. Empire is the largest health insurer in New York supporting more than four million members and more than 38,000 business, union and small employers in New York. ]?e_2Xehb!LIP3F'NrZ(n7y% | Albany, New York 12206, 2023 New York HMO Benefit Summary Rx Plans, 2022 - 2023 Benefit Changes for HMO plans, 2022 - 2023 Benefit Changes for HMO Rx Plans, 2023 Summary of Benefits and Coverage Rx Plans, 2022 New York HMO Benefit Summary Rx Plans, 2021 - 2022 Benefit Changes for HMO plans, 2021 - 2022 Benefit Changes for HMO Rx Plans, 2022 Summary of Benefits and Coverage Rx Plans. Can I get these tests reimbursed by insurance? 0000007858 00000 n 2. Learn more about decision timeframes under Appealing Decisions by HMOs and Insurers. Empire Plan General Information Book Group Coverage Terminated for Loss of Employment. $0 Copay for Kids 0000007365 00000 n What if my participating provider charges me for PPE? If you are covered as a dependent on someone elses health insurance, and you lose your coverage because you no longer qualify as a dependent (for example, due to divorce, age limit for dependent children, or death of the insured), you have your own right to continue your coverage. If you are feeling sick, use telehealth services before going to the doctor's office, urgent care or the emergency room. 0000004766 00000 n Diagnosis. View All Posts, Your email address will not be published. 0000004634 00000 n \\mu?qk<6IO{=%U,"+o[_")S\pI.B'{ld3[l%&x ^B/K%x 5BMY4QQQQ^qg_=:zv#R_W+J}R_W+**tz&?Z9sPA9s0s ";}6Mq,u3-]v8./+ ] endstream endobj 97 0 obj <> endobj 98 0 obj <>stream Q: What are my health insurance choices? You can quickly compare health plan options and apply for assistance that could lower the cost of health coverage. Can I use telemedicine under No-Fault automobile insurance? The following represents the 2023 biweekly premium contributions for CSEA active state employees (and Unified Court System). Medicaid, Essential Plan, or Child Health Plus Coverage. ** Certain covered drugs do not require a copayment when using a Network Pharmacy: *** When available over-the-counter, USPSTF A and B rated medications require a prescription order to process without cost sharing. All Empire Plan and HMO enrollees and dependents are eligible for this benefit. Because of a loss of income, New Yorkers may also be eligible for Medicaid, the Essential Plan, subsidized Qualified Health Plans or Child Health Plus. s;wt2@&6udHHof 2I2=0u$$Q2Z#vODcX8\(#dCOi. NYSHIP Online Guidelines for Web Navigation. hb```b``ea`e`f`@ +zR&I\O7. trailer <<12B93CD34FFF4FD69C1E3B4B131900F6>]/Prev 56307>> startxref 0 %%EOF 36 0 obj <>stream Call 1-877-7-NYSHIP (1-877-769-7447) and follow the prompts to notify the appropriate program carrier/vendor as outlined below, . p JxfID04!9x\0Rx(0|J OY We require advance notification of the procedures and services listed in the chart below. Healthcare Provider Administrative Guides and Manuals The following links provide information including, but not limited to, prior authorization, processing claims, protocol, contact information and resources. Physical therapy services. All Rights Reserved | Capital District Physicians' Health Plan, Inc. | 500 Patroon Creek Blvd. The second set reflects 2023 biweekly rates for CSEA-represented state employees who are Grade 10 and above. 0000000936 00000 n What if I am uninsured? You will need to submit claim forms and pay a higher share of the cost if you choose a non-participating provider or non-network provider. Your health plan must cover eight tests per month for each individual covered by your plan. 0000009571 00000 n Empire Plan Medicare Rx Phone Numbers and Website Members or non-members, please call The Empire Plan toll free at 1-877-769-7447 and select option 4 for the prescription drug program. Your insurer must cover your telehealth service for mental health or substance use disorder treatment if the service would have been covered if you went to your providers office or facility. Its a surprise bill if, during your in-network doctors office visit, an out-of-network provider treats you, or your doctor takes a specimen from you (for example, blood) and sends it to an out-of-network laboratory, or when referrals are required under your plan and your doctor refers you to an out-of-network provider. Totally disabled generally means that you cant engage in any work or other gainful activity due to injury or disease. 0000028277 00000 n Already registered with our Producer Appointment Tool? You should contact your health plan to find out whether there are locations in your area where you can obtain tests at no cost, or whether you will need to purchase a test and then request reimbursement. Generally, if you are the employee or covered dependent, you must pay the cost of continued health insurance. The annual Option Transfer Period for State employees will begin Thursday, December 1, 2022, and end Friday, December 30, 2022. 520 0 obj <> endobj xref Medicare-primary NYSHIP HMO enrollees will be enrolled in the HMO's Medicare Advantage Plan. 0000008482 00000 n This is the time to choose the health insurance option you want for 2023. If you are unable to resolve the issue after contacting your insurer, file a complaint with DFS. 0000001530 00000 n Welcome to The Empire Plan's Online Participating Provider Directory. Is financial assistance available under the ARP? Additional information can be obtained from agency health benefit administrators. 0000025965 00000 n Your email address will not be published. 0000000016 00000 n 10 0 obj <> endobj 34 0 obj <>/Filter/FlateDecode/ID[<86EB1CA19EF6E70937AF6BC307A1554F><2873B45CADCD41A996A8C339CED1C956>]/Index[10 40]/Info 9 0 R/Length 108/Prev 121154/Root 11 0 R/Size 50/Type/XRef/W[1 3 1]>>stream 0000035031 00000 n Check out our available positions. |m34# |nd)|`lF5U|{h#?82 #C?$cqYPlYoLeIP8u?tlzB2Sv>Rx#y>b Z=cT?Xaocz'y_~S;]Xn$Y#Tp'}[6!t Because of a loss of income, New Yorkers may also be eligible for Medicaid, the Essential Plan, subsidized Qualified Health Plans or Child Health Plus. See the 2022 Empire Plan Preventive Care Coverage Guide for a list of covered services. H]@IKf?0lR]~$4#*-FPjzp>9}z['0<> Q/*,/?w@ vn/`n&&G0e:cN_'~F5SoxSs"EO0^+J Who pays the premium if I lose my job and I continue my health insurance through my former employer? 0000000916 00000 n hb``c``d```YLWY0&I36p0p? If you have a question, call 1-877-7-NYSHIP (1-877-769-7447) toll free and select the appropriate program from the menu. Also, you are only responsible for your in-network copayment, coinsurance, or deductible for emergency services. You will not have to pay your copayment, coinsurance, deductible, or any other charges, including a charge for an office visit or a facility fee, for a COVID-19 vaccine or its administration. Wx endstream endobj 99 0 obj <>stream 2022 State NYSHIP Enrollee Biweekly Premium Contributions . If you lose your insurance coverage and you are totally disabled (including as a result of COVID-19), you have the following protections if you meet the requirements below. B_/BgSD2E&t9(rPA"e9(r0`lp6:glp6:gn?T|i4c9R~? An out-of-network provider treated you at an in-network hospital or ambulatory surgical facility before January 1, 2022. The No Surprises Act provides broad consumer protections against "surprise" balance billing as of 2022. Its a surprise bill if an out-of-network provider treats you and an in-network provider was not available, or you had unforeseen services, or you didnt know the provider was out-of-network. You should check with your provider to see if your provider offers telehealth services. State enrollees wishing to change options or to enroll in the Opt-Out Program should submit the necessary paperwork to their agency health benefits administrator no later than the Option Transfer Period deadline of December 30, 2022. Retirees: Under current rules, retirees contribute to the cost of health benefits at the same rate they contributed as employees. If Covered at Your Providers Office. hV]k1+ 6 The Department of Civil Service (Civil Service) is responsible for administering NYSHIP and determines NYSHIP's administrative policies and procedures. U|nL(.deiLGL:<391#V@(&h&5&4,SJcJ+f_2:2US>V5M`S3h(M6, u'!:;=#NYC(>_jvV5y Will my NY health insurance policy cover a COVID-19 diagnostic test ordered by a health care provider even if I am not showing symptoms of COVID-19 and have not had any exposure to a person with the virus? NY Insurance Coverage. Prior versions also remain in circulation. Behavioral Health Program, (except administration of enteral formula through a tube for patients whose primary coverage is Medicare), 2023 UnitedHealthcare | All Rights Reserved, Healthcare Provider Administrative Guides and Manuals, Prior authorization and notification requirements, Empire Plan supplement - 2022 Administrative Guide, Sign in to the UnitedHealthcare Provider Portal, Health plans, policies, protocols and guides, The UnitedHealthcare Provider Portal resources, Empire Plan Durable Medical Equipment (DME) Notification List for Members with Primary Empire Plan Coverage, UnitedHealthcare Benefits Management Program, Managed Physical Network, Inc. (MPN) Managed Physical Medicine Program, UnitedHealthcare Home Care Advocacy Program, Empire BlueCross Benefits Management Program, Beacon Health Options, Inc. Behavioral Health Program, Empire Blue Cross Blue Shield Benefits Management Program, Diabetic shoes (when the Empire Plan is primary coverage), DME items listed on the DME Notification List atuhcprovider.com/priorauth > Advanced Notification and Plan Requirement Resources > Empire Plan Notification Lists >. You should read your policy to learn the specific definition that applies to you. In general, depending on the program, members are responsible for either notifying Empire Plan program vendors of certain services or for using network care providers for these services. If you lost your employer coverage, you have a separate special enrollment period to buy health insurance coverage though the Marketplace for 60 days after your loss. If you are experiencing symptoms, if possible, you should call ahead to your health care provider or local health department before seeking treatment in person. $0 cost-share for primary care visits for children 18 and younger. New for 2023! NYSHIP plan. You are only responsible for your in-network deductible, copayment, or coinsurance. The form is not required for services provided on or after January 1, 2022 at an in-network hospital or ambulatory surgical facility, but it is recommended. 0000003709 00000 n See your Empire Plan Certificates and Empire Plan Reports for details, including preadmission and prior authorization requirements, services that do not require copayments and limitations. With the new year (2020) around the corner The Empire Plan NYSHIP has released a list of more employee groups that will be affected by the office visit co-pay changes. For more information on the amounts of financial assistance available to you, please visit the NY State of Health: The Official Health Plan Marketplace. 0000006769 00000 n 1-877-7-NYSHIP, press option 3 for the mental health/ substance use program, you will receive another set of . 2021 NYSHIP Benefit Plan Comparison . Health insurers must cover diagnostic testing for COVID-19 when ordered by a licensed or authorized health care provider regardless of whether you have symptoms or may have been exposed to the virus. If The Empire Plan is primary for you or your covered dependents, you must call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Medical/Surgical Program (administered by UnitedHealthcare) . You have at least 60 days to elect to continue your coverage from the later of (1) the date your coverage terminates or (2) the date you are sent notice of your right to continue your coverage. These emergency regulations apply to all No-Fault automobile insurance claims with a date of service between March 16, 2020, through July 10, 2023. Empire Plan participants are given NYSHIP ID cards by the State of New York Department of Civil Service, the Empire Plan policyholder. %PDF-1.4 % This notification list may be modified. If there isnt an in-network provider with the training and experience to meet your health care needs, you can go to an out-of-network provider at your in-network cost-sharing. Things to Know About Empire Plan Medicare Rx Hours of Operation You can call us 24 hours a day, 7 days a week. Learn more about the protections for surprise bills. COVID-19 vaccines are covered by Medicaid, Essential Plan, and Child Health Plus. If you are enrolled through the NY State of Health: The Official Health Plan Marketplace you will have lower premiums through 2022 due to the ARP regardless of your income. There is no generic appeal under the Excelsior Plan. For a minor, totally disabled generally means that the minor cant, due to injury or disease, engage in substantially all of the normal activities of a person of that age who is in good health. Will I have to pay my deductible, copayment, or coinsurance for a COVID-19 vaccine under my NY insurance policy? Pharmacy app allows you to view medication costs, search for potential savings, and more. Required fields are marked *. The New York State Health Insurance Program (NYSHIP) offers you the choice of The Empire Plan or a NYSHIP-approved Health Maintenance Organization (HMO) serving the area where you live or work. Apply for coverage through NY State of Healthby phone at 855-355-5777, or directly to insurers. Learn more about decision timeframes under Appealing Decisions by HMOs and Insurers. No action is necessary for those State employees who are currently enrolled and continue to qualify for the Opt-Out Program. Cancellation Not Permitted. Will I have to pay my deductible, copayment, or coinsurance for diagnosis or treatment of COVID-19 under my NY insurance policy? What do I do if I test positive for COVID-19 using an at-home over-the-counter COVID-19 test? ycBQ^]}jE k@oI b"h,QM]GuiU.UeY=8Z?>-/bNriO] Will I have to pay to get the COVID-19 vaccine? 0000001139 00000 n Y0001_GRP_3926_2022_M_NYSHIP_9482_2632_811 2022 Summary of Benefits . trailer <]/Prev 69751/XRefStm 1182>> startxref 0 %%EOF 551 0 obj <>stream NYSHIP will again offer the Opt-Out Program in 2023, which will allow eligible employees who have employer sponsored group health insurance, to opt out of their NYSHIP coverage in exchange for an incentive payment. What if there isnt an in-network provider who can treat me? For more information, visit the Department of Healths website. For more detailed information, a Membership Certificate is available for your review upon request. Yes. . NF1101 2022 NYSHIP Plan Comparison You are not responsible for paying premiums during an extension of benefits. 0000019830 00000 n 6[A'`L The NY State of Health: The Official Health Plan Marketplace has several options for coverage, which could provide you with lower-cost or no-cost coverage depending on your income. Ask your employer whether your large group plan is grandfathered.). Your insurer must protect you from surprise bills, including those for treatment of COVID-19. 0000003482 00000 n APSU The testing is covered regardless of whether it is performed in-network or out-of-network. 0000005866 00000 n In-Network Cost-Sharing. Plan Name: NYSHIP Plan Effective Date: January 1, 2022 Benefits In-Network Additional Information Rehabilitation Services Chiropractic Services $20 copay / visit Physical - Occupational - Speech Therapies $20 copay / visit Up to 20 visits per contract year combined Cardiac Rehabilitation $20 copay / visit Up to 36 visits per event 6 31 You must ask your insurer for approval before you see the out-of-network provider. 0000007764 00000 n Check the CMS website to find out if the federal Public Health Emergency is still active. If approved, Level 3 copayment applies and ancillary fee is waived. Learn how to file an External Appeal. Learn how to file an External Appeal. Your insurer cant cancel or non-renew your policy because you get sick, including if you are diagnosed with COVID-19. (Please note that grandfathered large group plans are not required to cover vaccines for persons aged 19 or older, though federal law prohibits providers from billing you for the COVID-19 vaccine or its administration. Medicaid, Essential Plan, or Child Health Plus coverage. If you go to an emergency room at an out-of-network hospital, your insurer is required to cover your care until you are stabilized, and after that, you may need to transfer to an in-network hospital for the rest of your care. Need access to the UnitedHealthcare Provider Portal? What if my participating provider requires me to sign a consent form to agree to pay PPE charges to receive services? Health insurance policies typically cover the following services that you may need: Lab Tests - Public Lab.