Cell and tissue labelling 1: Antibodies and fluorophores Choices, choices, choices
HEALTH INSURANCE CHOICES FOR 2022 - cs.ny.gov
Transcript of HEALTH INSURANCE CHOICES FOR 2022 - cs.ny.gov
SUPPLEMENTThis flyer is a companion document to the Health Insurance Choices for 2022 booklet. It explains your benefits as a NYSHIP enrollee in a negotiating unit that does not have an agreement/award with New York State as of the date this document was printed.Please refer to this document in place of pages 13–23 in Choices for information on your Empire Plan benefits.
For employees of the State of New York who are represented by Council 82 (C-82) and their enrolled dependents, COBRA enrollees
with their NYSHIP benefits and Young Adult Option enrollees
HEALTH INSURANCE
October 2021
New York State Department of Civil Service, Employee Benefits Division, Albany, New York 12239 • www.cs.ny.gov/employee-benefits
CHOICES FOR 2022
Empire Plan benefits are available worldwide, and the Plan gives you the freedom to choose a participating or nonparticipating provider or facility. This section summarizes benefits available under each portion of The Empire Plan as of January 1, 2022.1 You may also visit www.cs.ny.gov/employee-benefits or call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) for additional information on the following programs.
Medical/Surgical ProgramUnitedHealthcareP.O. Box 1600, Kingston, NY 12402-1600
Medical and surgical coverage through:
• Participating Provider Program – The Participating Provider Program network administered by UnitedHealthcare includes over 1.2 million physicians, laboratories and other providers, such as physical therapists, occupational therapists and chiropractors, located throughout the United States. Certain services are subject to a $20 copayment.
• Basic Medical Program – If you use a nonparticipating provider, the Program considers up to 80 percent of usual and customary charges for covered services after the combined annual deductible is met. After the combined annual coinsurance maximum is met, the Plan considers up to 100 percent of usual and customary charges for covered services. See Cost Sharing (beginning on page 4) for additional information.
• Basic Medical Provider Discount Program – If you are Empire Plan primary and use a nonparticipating provider who is part of the Empire Plan MultiPlan group, your out-of-pocket costs may be lower (see page 5).
Home Care Advocacy Program (HCAP) – Benefits for home care, durable medical equipment and certain medical supplies (including diabetic and ostomy supplies), enteral formulas and diabetic shoes are paid in full. (Diabetic shoes have an annual maximum benefit of $500.) Prior authorization is required. Guaranteed access to network benefits nationwide. Limited non-network benefits available (see the Empire Plan Certificate for details).
Managed Physical Medicine Program (MPMP) – Chiropractic treatment, physical therapy and occupational therapy through a network provider are subject to a $20 copayment. Unlimited network benefits when medically necessary. Guaranteed access to network benefits nationwide. Non-network benefits available.
Under the Benefits Management Program, you must call the Medical/Surgical Program for Prospective Procedure Review before an elective (scheduled) magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computerized tomography (CT) scan, positron emission tomography (PET) scan or nuclear medicine test, unless you are having the test as an inpatient in a hospital (see the Empire Plan Certificate for details).
When arranged by the Medical/Surgical Program, a voluntary, paid-in-full specialist consultant evaluation is available. Voluntary outpatient medical case management is available to help coordinate services for catastrophic and complex cases.
Hospital ProgramEmpire BlueCrossNew York State Service Center P.O. Box 1407, Church Street Station New York, NY 10008-1407
The following benefit levels apply for covered services received at a BlueCross and BlueShield Association BlueCard® PPO network hospital:
• Inpatient hospital stays are covered at no cost to you.• Outpatient hospital and emergency care are
subject to network copayments.• Anesthesiology, pathology and radiology provider
charges for covered hospital services are paid in full under the Medical/Surgical Program (if The Empire Plan provides your primary coverage).
• Certain covered outpatient hospital services provided at network hospital extension clinics are subject to outpatient hospital copayments.
• Except as noted above, physician charges received in a hospital setting will be paid in full if the provider is a participating provider under the Medical/Surgical Program. Physician charges for
THE EMPIRE PLAN NYSHIP CODE #001
1 These benefits are subject to medical necessity and to limitations and exclusions described in the Empire Plan Certificate.
2 Choices 2022/Active Supplement
covered services received from a non-network provider will be paid in accordance with the Basic Medical portion of the Medical/Surgical Program.
If you are an Empire Plan-primary enrollee,2 you will be subject to 10 percent coinsurance for inpatient stays at a non-network hospital. For outpatient services received at a non-network hospital, you will be subject to the greater of 10 percent coinsurance or $75 per visit. The Empire Plan will begin to cover 100 percent of the billed charges for covered inpatient and outpatient services only after the combined annual coinsurance maximum threshold has been reached.
The Empire Plan will approve network benefits for hospital services received at a non-network facility if:
• Your hospital care is emergency or urgent• No network facility can provide the medically
necessary services• You do not have access to a network facility within
30 miles of your residence• Another insurer or Medicare provides your primary
coverage (pays first)
Preadmission Certification Requirements Under the Benefits Management Program, if The Empire Plan is your primary coverage, you must call the Hospital Program for certification of any of the following inpatient stays:
• Before a scheduled (nonemergency) hospital admission
• Within 48 hours or as soon as reasonably possible after an emergency or urgent hospital admission
• Before admission or transfer to a skilled nursing facility
If you do not follow the preadmission certification requirement for the Hospital Program, you must pay:
• A $200 hospital penalty if it is determined any portion was medically necessary; and
• All charges for any day’s care determined not to be medically necessary.
Voluntary inpatient medical case management is available to help coordinate services for catastrophic and complex cases.
Mental Health and Substance Use ProgramBeacon Health Options, Inc.P.O. Box 1850, Hicksville, NY 11802
The Mental Health and Substance Use (MHSU) Program offers both network and non-network benefits.
Network Benefits(unlimited when medically necessary)
If you call the MHSU Program before you receive services and follow their requirements, you receive:
• Inpatient services, paid in full• Crisis intervention, paid in full for up to three visits
per crisis; after the third visit, the $20 copayment per visit applies
• Outpatient services, including office visits, home-based or telephone counseling and nurse practitioner services, for a $20 copayment per visit
• Intensive Outpatient Program (IOP) with an approved provider for mental health or substance use treatment for a $20 copayment per day
2 If Medicare or another plan provides primary coverage, you receive network benefits for covered services at both network and non-network hospitals.
3Choices 2022/Active Supplement
Non-Network Benefits3
(unlimited when medically necessary)
The following applies if you do NOT follow the requirements for network coverage.
• For Practitioner Services: The MHSU Program will consider up to 80 percent of usual and customary charges for covered outpatient practitioner services after you meet the combined annual deductible per enrollee, per enrolled spouse or domestic partner and per all enrolled dependent children combined. After the combined annual coinsurance maximum is reached, the Program reimburses up to 100 percent of usual and customary charges for covered services (see page 5).
• For Approved Facility Services: You are responsible for 10 percent of covered, billed charges up to the combined annual coinsurance maximum per enrollee, per enrolled spouse or domestic partner and per all enrolled dependent children combined. After the coinsurance maximum is met, the Program pays 100 percent of billed charges for covered services (see page 5).
• Outpatient treatment sessions for family members of an individual being treated for alcohol or substance use are covered for a maximum of 20 visits per year for all family members combined.
Empire Plan Cost SharingPlan ProvidersUnder The Empire Plan, benefits are available for covered services when you use a participating or nonparticipating provider. However, your share of the cost of covered services depends on whether the provider you use participates in the Plan. You receive the maximum plan benefits when you use participating providers. For more information, read Reporting On Network Benefits. You can find this publication at www.cs.ny.gov/employee-benefits or ask your HBA for a copy.
If you use an Empire Plan participating or network provider or facility, you pay a copayment for certain services. Some services are covered at no cost to you. The provider or facility files the claim and is reimbursed by The Empire Plan.
Even if there are no network providers in your area, you are guaranteed access to network benefits for the following services if you call The Empire Plan at 1-877-769-7447 beforehand to arrange care with an appropriate medical or mental health provider:
• Mental Health and Substance Use (MHSU) Program services
• Managed Physical Medicine Program services (physical therapy, chiropractic care and occupational therapy)
• Home Care Advocacy Program (HCAP) services (including durable medical equipment)
If you use a nonparticipating provider or non-network facility, benefits for covered services are subject to a deductible and/or coinsurance.
2022 Annual Maximum Out-of-Pocket Limit Your maximum out-of-pocket expenses for in-network covered services will be $5,650 for Individual coverage and $11,300 for Family coverage for Hospital, Medical/Surgical and MHSU Programs, combined. Once you reach the limit, you will have no additional copayments.
Combined Annual DeductibleFor Medical/Surgical and MHSU Program services received from a nonparticipating provider or non-network facility, The Empire Plan has a combined annual deductible that must be met before covered services under the Basic Medical Program and non-network expenses under both the HCAP and MHSU Programs can be reimbursed. See the table on page 5 for 2022 combined annual deductible amounts. The Managed Physical Medicine Program has a separate $250 deductible per enrollee, $250 per enrolled spouse/domestic partner and $250 per all dependent children combined that is not included in the combined annual deductible.
After you satisfy the combined annual deductible, The Empire Plan considers 80 percent of the usual and customary charge for the Basic Medical Program and non-network practitioner services for the MHSU Program, 50 percent of the network allowance for covered services for non-network HCAP services and 90 percent of the billed charges for covered services for non-network approved facility services for the
3 You are responsible for ensuring that MHSU Program certification is received for care obtained from a non-network practitioner or facility.
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MHSU Program. You are responsible for the remaining 20 percent coinsurance and all charges in excess of the usual and customary charge for Basic Medical Program and non-network practitioner services, 10 percent for non-network MHSU-approved facility services and the remaining 50 percent of the network allowance for covered, non-network HCAP services.
Combined Annual Coinsurance MaximumThe Empire Plan has a combined annual coinsurance maximum that must be met before covered services under the Basic Medical Program and non-network expenses under the Hospital and MHSU Programs will be fully reimbursed. See the table above for 2022 combined annual coinsurance maximum amounts.
After you reach the combined annual coinsurance maximum, you will be reimbursed up to 100 percent of covered charges under the Hospital Program and 100 percent of the usual and customary charges for services covered under the Basic Medical Program and MHSU Program. You are responsible for paying the provider and will be reimbursed by the Plan for covered charges. You are also responsible for paying all charges in excess of the usual and customary charge.
The combined annual coinsurance maximum will be shared among the Basic Medical Program and non-network coverage under the Hospital Program and MHSU Program. The Managed Physical Medicine Program and HCAP do not have a coinsurance maximum.
Basic Medical Provider Discount ProgramIf you are Empire Plan primary, the Plan also includes a program to reduce your out-of-pocket costs when you use a nonparticipating provider. The Empire Plan Basic Medical Provider Discount Program offers discounts from certain physicians and providers who are not part of The Empire Plan participating provider network. These providers are part of the nationwide MultiPlan group, a provider organization contracted with UnitedHealthcare. Empire Plan Basic Medical Program provisions apply, and you must meet the combined annual deductible.
Providers in the Basic Medical Provider Discount Program accept a discounted fee for covered services. Your 20 percent coinsurance is based on the lower of the discounted fee or the usual and customary charge. Under this Program, the provider submits your claims, and UnitedHealthcare pays The Empire Plan portion of the provider fee directly to the provider if the services qualify for the Basic Medical Provider Discount Program. Your explanation of benefits, which details claims payments, shows the discounted amount applied to billed charges.
To find a provider in the Empire Plan Basic Medical Provider Discount Program, ask if the provider is an Empire Plan MultiPlan provider or call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447), choose the Medical/Surgical Program and ask a representative for help. You can also go to www.cs.ny.gov/employee-benefits. Select your group and plan, if prompted, and then Find a Provider.
2022 Combined Annual Deductible and Annual Coinsurance Maximum Amounts
Employees who are represented by C-82 Combined Annual Deductible
Combined Annual Coinsurance Maximum
Enrollee $1,000 $3,000
Enrolled spouse/domestic partner $1,000 $3,000
Dependent children combined $1,000 $3,000
5Choices 2022/Active Supplement
Prescription Drug ProgramCVS CaremarkP.O. Box 6590, Lee’s Summit, MO 64064-6590
The Prescription Drug Program does not apply to those who have drug coverage through a union Employee Benefit Fund.
• When you use a network pharmacy, the mail service pharmacy or the designated specialty pharmacy for a 1- to 30-day supply of a covered drug, you pay a $5 copayment for Level 1 or most generic drugs; a $25 copayment for Level 2, preferred drugs or compound drugs; and a $45 copayment for Level 3, certain generic drugs or non-preferred drugs.
• For a 31- to 90-day supply of a covered drug through a network pharmacy, you pay a $10 copayment for Level 1 or most generic drugs; a $50 copayment for Level 2, preferred drugs or compound drugs; and a $90 copayment for Level 3, certain generic drugs or non-preferred drugs.
• For a 31- to 90-day supply of a covered drug through the mail service pharmacy or the designated specialty pharmacy, you pay a $5 copayment for Level 1 or most generic drugs; a $50 copayment for Level 2, preferred drugs or compound drugs; and a $90 copayment for Level 3, certain generic drugs or non-preferred drugs.
• When you fill a prescription for a covered brand- name drug that has a generic equivalent, you pay the Level 3 or non-preferred copayment, plus the difference in cost between the brand-name drug and the generic equivalent (or “ancillary charge”), not to exceed the full retail cost of the drug, unless the brand-name drug has been placed on Level 1 of the Flexible Formulary. Exceptions apply. Please contact the Empire Plan Prescription Drug Program toll free at 1-877-7-NYSHIP (1-877-769-7447) for more information.
• The Empire Plan has a flexible formulary that excludes certain prescription drugs from coverage.
• Prior authorization is required for certain drugs.• Oral chemotherapy drugs for the treatment of
cancer do not require a copayment.• Tamoxifen, raloxifene, anastrozole and exemestane
do not require a copayment when prescribed for the primary prevention of breast cancer. In addition, generic oral contraceptive drugs/devices or brand-name drugs/devices without a generic equivalent (single-source brand-name drugs/devices) do not require a copayment. The copayment waivers for these drugs will only be provided if the drug is filled at a network pharmacy.
• Certain preventive adult vaccines, when administered at a pharmacy that participates in the CVS Caremark National Vaccine Network, do not require a copayment.
• A pharmacist is available 24 hours a day, seven days a week to answer questions about your prescriptions.
• You can use a non-network pharmacy or pay out of pocket at a network pharmacy (instead of using your Empire Plan Benefit Card) and submit a claim form for reimbursement. In almost all cases, you will not be reimbursed the total amount you paid for the prescription, and your out-of-pocket expenses may exceed the usual copayment amount. To reduce your out-of-pocket expenses, use your Empire Plan Benefit Card whenever possible.
See the Empire Plan Certificate or contact the Plan for more information.
6 Choices 2022/Active Supplement
* The annual maximum out-of-pocket limit does not apply to Empire Plan Medicare Rx.
2022 Annual Maximum Out-of-Pocket Limit* Annual maximum out-of-pocket expenses for covered drugs received from a network pharmacy will be $3,050 for Individual coverage and $6,100 for Family coverage. Once you reach the limit, you will have no additional copayments for prescription drugs.
Specialty PharmacyCVS Caremark Specialty Pharmacy is the designated pharmacy for The Empire Plan Specialty Pharmacy Program. The Program provides enhanced services to individuals using specialty drugs (such as those used to treat complex conditions and those that require special handling, special administration or intensive patient monitoring). The complete list of specialty drugs included in the Specialty Pharmacy Program is available on NYSHIP Online. Go to www.cs.ny.gov/employee-benefits and choose your group and plan, if prompted. Select Using Your Benefits and then Specialty Pharmacy Drug List.
The Program provides enrollees with enhanced services that include disease and drug education; compliance, side effect and safety management; expedited, scheduled delivery of medications at no additional charge; refill reminder calls; and all necessary supplies (such as needles and syringes) applicable to the medication.
Under the Specialty Pharmacy Program, you are covered for an initial 30-day fill of most specialty medications at a retail pharmacy, but all subsequent fills must be obtained through the designated specialty pharmacy. When CVS Caremark dispenses a specialty medication, the applicable mail service copayment is charged. To get started with CVS Caremark Specialty Pharmacy, request refills or speak to a specialty-trained pharmacist or nurse, call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447). Choose the Prescription Drug Program and ask to speak with Specialty Customer Care.
Medicare-primary enrollees and dependents:If you are Medicare primary or will be in 2022, ask your HBA for a copy of 2022 Choices for Retirees for information about your coverage under Empire Plan Medicare Rx, a Medicare Part D prescription drug program.
Contact The Empire PlanFor additional information or questions on any of the benefits described here, call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and select the applicable program.
Teletypewriter (TTY) NumbersThese numbers are available to callers who use a TTY device because of a disability and are all toll free.
Medical/Surgical ProgramTTY only: .......................................................................1-888-697-9054Hospital ProgramTTY only: ........................................................................1-800-241-6894Mental Health and Substance Use ProgramTTY only: .........................................................................1-855-643-1476Prescription Drug ProgramTTY only: ..........................................................................................................711
The Empire Plan NurseLineSM
For health information and support, call The Empire Plan and press or say 5 for the NurseLineSM.
Registered nurses are available 24 hours a day, seven days a week. All calls are confidential.
7Choices 2022/Active Supplement
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8 Choices 2022/Active Supplement
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Am
bulan
ce tr
ansp
orta
tion
to th
e ne
ares
t hos
pita
l whe
re e
mer
genc
y car
e
can
be p
erfo
rmed
is co
vere
d wh
en th
e se
rvice
is p
rovid
ed b
y a lic
ense
d am
bulan
ce se
rvice
and
the
type
of a
mbu
lance
tran
spor
tatio
n is
requ
ired
beca
use
of an
em
erge
ncy s
ituat
ion.
9Choices 2022/Active Supplement
The
Empi
re P
lan
Bene
fits
Net
wor
k H
ospi
tal B
enef
its1,2
Part
icip
atin
g Pr
ovid
er2
Non
part
icip
atin
g Pr
ovid
er
Appr
oved
Fac
ility
M
enta
l Hea
lth S
ervi
ces
No co
paym
ent
90%
of b
illed
char
ges;
afte
r app
licab
le
coin
sura
nce
max
, cove
red
in fu
ll (se
e pa
ges 4
–5 fo
r det
ails)
Outp
atie
nt D
rug/
Alco
hol
Reha
bilit
atio
n$2
0 pe
r day
to ap
prov
ed
Inte
nsive
Out
patie
nt P
rogr
amAp
plica
ble
annu
al de
duct
ible
, 80
% of
usu
al an
d cu
stom
ary;
afte
r app
licab
le co
insu
ranc
e m
ax,
100%
of u
sual
and
custo
mar
y (se
e pa
ges 4
–5 fo
r det
ails)
Inpa
tient
Dru
g/Al
coho
l Reh
abili
tatio
nNo
copa
ymen
t90
% of
bille
d ch
arge
s; af
ter a
pplic
able
co
insu
ranc
e m
ax, c
over
ed in
full
(see
page
s 4–5
for d
etail
s)
Dura
ble
Med
ical E
quip
men
tNo
copa
ymen
t (HC
AP)
50%
of n
etwo
rk al
lowa
nce
(se
e th
e Em
pire
Pla
n Ce
rtific
ate)
Pros
thet
ics
No co
paym
ent14
Basic
Med
ical3,
14 $
1,500
lifet
ime
max
imum
ben
efit
for p
rosth
etic
wigs
no
t sub
ject t
o de
ducti
ble o
r coin
sura
nce
Orth
otic
Devi
ces
No co
paym
ent14
Basic
Med
ical3,
14
Reha
bilit
ativ
e Ca
re
(not
cove
red
in a
skille
d nu
rsin
g fa
cility
if M
edica
re p
rimar
y)
No co
paym
ent a
s an
inpa
tient
; $2
0 pe
r visi
t for
out
patie
nt p
hysic
al th
erap
y fol
lowi
ng re
lated
surg
ery
or h
ospi
taliz
atio
n15
Phys
ical o
r occ
upat
iona
l the
rapy
$2
0 pe
r visi
t (M
PMP)
Spee
ch th
erap
y $20
per
visit
$250
annu
al de
duct
ible
, 50
% of
net
work
allo
wanc
e (M
PMP)
Basic
Med
ical3
Diab
etic
Supp
lies
No co
paym
ent (
HCAP
)50
% of
net
work
allo
wanc
e (se
e th
e Em
pire
Pla
n Ce
rtific
ate)
Insu
lin a
nd O
ral A
gent
s(co
vere
d un
der t
he P
resc
riptio
n Dr
ug
Prog
ram
, sub
ject
to d
rug
copa
ymen
t)
Diab
etic
Shoe
s$5
00 an
nual
max
imum
ben
efit
75%
of n
etwo
rk al
lowa
nce
up to
an
annu
al m
axim
um b
enef
it of
$50
0
(see
the
Empi
re P
lan
Certi
ficat
e)
Hosp
ice
No co
paym
ent,
no lim
it 10
% of
bille
d ch
arge
s up
to th
e co
mbin
ed
annu
al co
insur
ance
max
imum
10 Choices 2022/Active Supplement
Bene
fits
Net
wor
k H
ospi
tal B
enef
its1,2
Part
icip
atin
g Pr
ovid
er2
Non
part
icip
atin
g Pr
ovid
er
Skill
ed N
ursin
g Fa
cility
16,17
No co
paym
ent
10%
of b
illed
char
ges u
p to
the
com
bined
an
nual
coins
uran
ce m
axim
um
Pres
crip
tion
Drug
s (se
e pa
ges 6
–7):
Sp
ecial
ty D
rugs
(see
pag
e 7)
Addi
tiona
l Ben
efits
:
Dent
al (p
reve
ntive
) No
t cov
ered
No
t cov
ered
Vi
sion
(rout
ine
only)
No
t cov
ered
Not c
over
ed
Hear
ing
Aids
No
net
work
ben
efit.
Se
e no
npar
ticip
atin
g pr
ovid
er.
Up to
$1,5
00 p
er ai
d pe
r ear
eve
ry
4 ye
ars (
ever
y 2 ye
ars f
or ch
ildre
n)
if m
edica
lly n
eces
sary
An
nual
Out-o
f-Poc
ket M
axim
umIn
divid
ual c
over
age:
$3,
050
for t
he P
resc
riptio
n Dr
ug P
rogr
am.17
$5,6
50 sh
ared
max
imum
for t
he H
ospi
tal, M
edica
l/Sur
gica
l and
M
enta
l Hea
lth/S
ubsta
nce
Use
Prog
ram
s.Fa
mily
cove
rage
: $6,
100
for t
he P
resc
riptio
n Dr
ug P
rogr
am.17
$1
1,300
shar
ed m
axim
um fo
r the
Hos
pita
l, Med
ical/S
urgi
cal a
nd
Men
tal H
ealth
/Sub
stanc
e Us
e Pr
ogra
ms.
Not a
vaila
ble
Ou
t-of-A
rea B
enef
itBe
nefit
s for
cove
red
serv
ices a
re av
ailab
le w
orld
wide
.
24-h
our N
urse
LineSM
for h
ealth
info
rmat
ion
and
supp
ort a
t 1-8
77-7
-NYS
HIP
(1-87
7-76
9-74
47);
pres
s or s
ay 5
.
Volu
ntar
y dise
ase
man
agem
ent p
rogr
ams a
vaila
ble
for c
ondi
tions
such
as as
thm
a, at
tent
ion
defic
it hy
pera
ctivi
ty d
isord
er (A
DHD)
, car
diov
ascu
lar d
iseas
e (C
AD),
ch
roni
c kid
ney d
iseas
e (C
KD),
chro
nic o
bstru
ctive
pul
mon
ary d
iseas
e (C
OPD)
, con
gesti
ve h
eart
failu
re, d
epre
ssio
n, d
iabet
es an
d ea
ting
diso
rder
s.
Diab
etes
edu
catio
n ce
nter
s for
enr
olle
es w
ho h
ave
a diag
nosis
of d
iabet
es.
For m
ore
info
rmat
ion
rega
rdin
g co
vere
d va
ccin
es, t
ests
and
scre
enin
gs, s
ee th
e Em
pire
Pla
n Pr
even
tive
Care
Cov
erag
e Gu
ide
on N
YSHI
P On
line
unde
r Pub
licat
ions
or
visit
www
.hhs
.gov
/hea
lthca
re/ri
ghts/
prev
entiv
e-ca
re.
1 I
npat
ient
stay
s at n
etwo
rk h
ospi
tals
are
paid
in fu
ll. Pr
ovid
er ch
arge
s are
co
vere
d un
der t
he M
edica
l/Sur
gica
l Pro
gram
. Non
-net
work
hos
pita
l cov
erag
e pr
ovid
ed su
bjec
t to
coin
sura
nce
(see
page
s 2–3
). 2
Cop
aym
ent w
aived
for p
reve
ntive
serv
ices u
nder
the
PPAC
A.
See
www.
hhs.g
ov/h
ealth
care
/righ
ts/pr
even
tive-
care
or N
YSHI
P On
line
fo
r det
ails.
Diag
nosti
c ser
vices
requ
ire p
lan co
paym
ent o
r coi
nsur
ance
. 3
See
Cos
t Sha
ring
(beg
inni
ng o
n pa
ge 4
) for
Bas
ic M
edica
l info
rmat
ion.
14 B
enef
it pa
id u
p to
cost
of d
evice
mee
ting
indi
vidua
l’s fu
nctio
nal n
eed.
15 P
hysic
al th
erap
y mus
t beg
in w
ithin
six m
onth
s of t
he re
lated
surg
ery o
r ho
spita
lizat
ion
and
be co
mpl
eted
with
in 3
65 d
ays o
f the
relat
ed su
rger
y or
hos
pita
lizat
ion.
16 U
p to
365
ben
efit
days
; Ben
efits
Man
agem
ent P
rogr
am p
rovis
ions
appl
y. 17
Doe
s not
appl
y to
Med
icare
-prim
ary e
nrol
lees
.
11Choices 2022/Active Supplement
It is the policy of the New York State Department of Civil Service to provide reasonable accommodation to ensure effective communication of information in benefits publications to individuals with disabilities. These publications are also available on NYSHIP Online at www.cs.ny.gov/employee-benefits. Visit NYSHIP Online for timely information that meets universal accessibility standards adopted by New York State for NYS agency websites. If you need an auxiliary aid or service to make benefits information available to you, please contact your Health Benefits Administrator. COBRA and Young Adult Option enrollees, contact the Employee Benefits Division.
Health Insurance Choices was printed using recycled paper and environmentally sensitive inks. Choices 2022/Active Supplement NY1398
2022 Health Insurance Choices Supplement – October 2021