Contact Your Doctor. Welcome to The Empire Plan's Online Participating Provider Directory. What if I am uninsured? Can I get these tests reimbursed by insurance? Your premium may not be more than 102% of the group premium. Check NYSHIP . The Empire Plan is NYSHIP's unique health insurance plan designed exclusively for New York State's public employees and employers. The annual Option Transfer Period for State employees will begin Thursday, December 1, 2022, and end Friday, December 30, 2022. 0000000016 00000 n Providers can visit the HRSA website for more information about this program. No. 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. For more information on the amounts of financial assistance available to you, please visit the NY State of Health: The Official Health Plan Marketplace. Empire Plan participants are given NYSHIP ID cards by the State of New York Department of Civil Service, the Empire Plan policyholder. hV]k1+ 6 Follow KR2 Medical Billing on WordPress.com, MVP Health Plans: reimbursement of sick E&M codes billed w/preventative codes -05/01/23. With Anthem, you have access to both on-exchange and off-exchange health insurance plans. Your insurer will notify you of the right to buy a conversion policy. What if there isnt a prescription drug on my insurers formulary? The CSEA Health Benefits Department can be reached at 518-785-4774 or 1-800-286-5242(JCHB) or by email at healthben@cseainc.org. Empire Plan Copayments 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. Diagnosis. | 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. Student Employee Health Plan will still continue to have a $10 Office Visit co-pay, 3. You are covered for medically necessary emergency services in hospitals. You will need individual coverage. Empire Plan General Information Book 0000017166 00000 n NYSHIP plan. You should not be charged if you receive the vaccine from an out-of-network provider during the federal Public Health Emergency. 0000002098 00000 n 0000035031 00000 n %PDF-1.7 % Let your insurer know if you were charged for a COVID-19 vaccine and request a refund for that payment. Contact your insurer. Up to $600 per plan year for going to the gym, taking paid digital classes, or for youth sports fees. U|nL(.deiLGL:<391#V@(&h&5&4,SJcJ+f_2:2US>V5M`S3h(M6, u'!:;=#NYC(>_jvV5y Check the CMS website to find out if the federal Public Health Emergency is still active. You are only responsible for your in-network copayment, coinsurance, or deductible. You are only responsible for your in-network deductible, copayment, or coinsurance. This does not apply to Medicare-primary Empire Plan enrollees and their covered dependents. Group Contract Terminates. 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. 1. See Consumer Frequently Asked Questions: COBRA Coverage for more information. If Covered at Your Providers Office. What happens if I lose my job? Already registered with our Producer Appointment Tool? Apply for coverage through NY State of Health by phone at 855-355-5777, or directly to insurers. Current versions of NYSHIP ID cards are displayed on the following page. If you are feeling sick, use telehealth services before going to the doctor's office, urgent care or the emergency room. 0000006209 00000 n Special Enrollment Period. Learn more about decision timeframes under Appealing Decisions by HMOs and Insurers. My name is Kate Patskovska, CPB. Learn more about the protections for surprise bills. trailer <]/Prev 69751/XRefStm 1182>> startxref 0 %%EOF 551 0 obj <>stream 0000037637 00000 n Table of Contents show Are mental illnesses covered by insurance? 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. Balance billing refers to the additional bill that an out-of-network medical provider can send to a patient, in addition to the person's normal cost-sharing and the payments (if any) made by their health plan. 0000006769 00000 n Retirees: Under current rules, retirees contribute to the cost of health benefits at the same rate they contributed as employees. No action is necessary for those State employees who are currently enrolled and continue to qualify for the Opt-Out Program. 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. -Council 82 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 Wx endstream endobj 99 0 obj <>stream Do I have to pay my deductible, copayment, or coinsurance for diagnosis or treatment of COVID-19 if I have a high deductible health plan (HDHP) with a health savings account (HSA)? You have 60 days to apply for this coverage. 0000035395 00000 n View All Posts, Your email address will not be published. Totally disabled generally means that you cant engage in any work or other gainful activity due to injury or disease. Discount medications, a pharmacy app, and so much more. Where do I go for more information about at-home COVID-19 tests? 0000028757 00000 n 0000001247 00000 n You must ask your insurer for approval before you see the out-of-network provider. . NY Insurance Coverage. If you choose to enroll in a Medicare PDP or Medicare Advantage Plan outside of NYSHIP, your Empire Plan coverage will end and you will be disenrolled from all Empire Plan health insurance coverage, including medical/surgical, hospital, mental health/substance use and . 0000005866 00000 n You are not responsible for paying premiums during an extension of benefits. Empire Plan supplement - 2022 Administrative Guide expand_more. But if they do, you should contact your insurer to let them know you have been charged for PPE and request a refund. Is the test for COVID-19 antibodies covered by my insurance? 0000005145 00000 n If approved, Level 3 copayment applies and ancillary fee is waived. When you visit a participating provider, the provider should not charge you for PPE used during a visit. If your insurer upholds a denial of coverage for treatment, you have the right to appeal to the Department of Financial Services. You should contact your health plan to find out where you can obtain over-the-counter COVID-19 tests at no cost or whether you will need to submit a claim for reimbursement after you purchase a test. 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. Effective 01/01/2020- Excelsior Plan members will have the office visit co-pay of $35. Treatment. Self-Funded Coverage. 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. 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. 0000048148 00000 n If Covered at Your Providers Office. Contact your insurer for more information about your rights if you are disabled and lose your coverage. 0000004228 00000 n You will not have to pay your copayment, coinsurance, or deductible even if you have a HDHP, since vaccines are preventive services which are not subject to the deductible or other cost-sharing. 6[A'`L Will I have to pay to get the COVID-19 vaccine? In-Network Cost-Sharing. COBRA and Continuation of Coverage. 0000002948 00000 n NYSHIP Claims and Administrative Forms, Copyright 2020 | CSEA Local 1000, AFSCME, AFL-CIO, See the 2023 State NYSHIP Enrollee Biweekly Premium Contributions, See NYS Department of Civil Services NYSHIP Rates and Deadlines publication, Health Insurance Transaction Form PS-404, Health Insurance Affordability and Accountability Act EBD-543. The office visit $20 co-pay will still apply to the following employee groups: Yes. An out-of-network provider treated you at an in-network hospital or ambulatory surgical facility before January 1, 2022. May a participating provider charge me a fee for personal protective equipment (PPE) used during my visit? For more information regarding coverage of at-home COVID-19 tests, visit the CMS At-Home Over-The-Counter COVID-19 Test website. If your participating provider requires you to sign a consent form and you pay charges for PPE, you should contact your insurer to request a refund. No Premium Payments. The No Surprises Act provides broad consumer protections against "surprise" balance billing as of 2022. Your insurer must protect you from surprise bills, including those for treatment of COVID-19. Do I have to pay for the COVID-19 vaccine if I go to a provider who is not a participating provider under my NY insurance policy? The hospital stay or surgery must be to treat the condition causing your disability. Depending on where you purchase the test, you may get the test at the point of sale for free, or you may have to pay for the test up-front and submit a claim to your insurer for reimbursement. Physical Health Mental Health Mental Health and Substance Use Medicaid, Essential Plan, and Child Health Plus. 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. A: Most County employees choose to enroll in the "Empire Plan" offered thru NYSHIP. See the 2023 State NYSHIP Enrollee Biweekly Premium Contributions MQxh ! 0000035149 00000 n 0000001139 00000 n If you need documentation of your need to isolate for school or work, you can fill out an Affirmation of Isolation Form instead of getting an Order of Isolation from the state or county Department of Health. Medicare. 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. Group Coverage Terminated for Non-Payment of Premiums or You Are No Longer Eligible for Coverage. Out-of-State Coverage. 0000001530 00000 n Flex Spending Account and Productivity Enhancement Program: As a reminder, the Flex Spending Account and the Productivity Enhancement Program are two negotiated employee benefits for state employees that offers a way for participants to save money on health care and dependent care expenses. You are not responsible for any deductible, copayment, or coinsurance for the COVID-19 diagnostic test. 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) . Things to Know About Empire Plan Medicare Rx Hours of Operation You can call us 24 hours a day, 7 days a week. (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. Referrals; ID cards; Prior authorization and notification requirements; . The Empire Plan pays for covered hospital services, physicians' bills, prescription drugs and other covered medical expenses. How do I get free at-home over-the-counter COVID-19 tests? 9 If the enrollee's doctor believes a brand-name drug is medically necessary, the enrollee may appeal the mandatory generic substitution. What if there isnt an in-network provider who can treat me? Learn how you can get the most out of your health insurance benefits. 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. The 2022 open enrollment period is extended during the Public Health Emergency for COVID-19. You also have the right to buy individual coverage through the insurer that provided your group coverage, known as a conversion policy. Contact Your Provider. 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. If you test positive for COVID-19, you have to isolate in accordance with Department of Health guidelines. What if I want more than a 30-day supply of my prescription? If you have a question, call 1-877-7-NYSHIP (1-877-769-7447) toll free and select the appropriate program from the menu. Need More Information? Your Empire Plan participating provider has a participating provider agreement in effect with UnitedHealthcare or MPN; submits claims directly to UnitedHealthcare for covered services or supplies you receive; and accepts your copayment plus UnitedHealthcare's payment as payment in full for covered services and supplies. Yes. hb``c``d```YLWY0&I36p0p? document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Enter your email address to follow this blog and receive notifications of new posts by email. Please refer to the following list: 1. Your employer or its benefit administrator must tell you about your right to continue health insurance coverage. Call 1-877-7-NYSHIP (1-877-769-7447) and follow the prompts to notify the appropriate program carrier/vendor as outlined below, . You will not have to pay your copayment, coinsurance, or deductible when you get a laboratory test to diagnose COVID-19 at other labs either. Many insurance policies cover a 90-day supply of prescription drugs if you use their mail order pharmacy. The extended benefits are only available to treat the condition causing your disability. Medicaid, Essential Plan, or Child Health Plus Coverage. 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. What benefits will my NY health insurance policy cover? Please note there are two sets of rates. Y0001_GRP_3926_2022_M_NYSHIP_9482_2632_811 2022 Summary of Benefits . 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. My job was terminated because my employer went out of business. Information on medication coverage. 1-877-7-NYSHIP, press option 3 for the mental health/ substance use program, you will receive another set of . Your insurer cant cancel or non-renew your policy because you get sick, including if you are diagnosed with COVID-19. Up to $600 per plan year for going to the gym, taking paid digital classes, or for youth sports fees. Telephone Calls and Videos Included in Telehealth. Will my NY health insurance policy cover a COVID-19 diagnostic test ordered by a health care provider even if I am not showing symptoms of COVID-19 and have not had any exposure to a person with the virus? g 9B#SRa/P~u$Av(?m. The COVID-19 oral/nasal swab test can be done through public health laboratories, including New York States Wadsworth Center and the federal Centers for Disease Control and Prevention (CDC), and there is no charge to you. 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. Your insurer must make a decision within the time required by law. 0000009571 00000 n 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. Prior versions also remain in circulation. Your insurer cannot require you to get preauthorization before you receive emergency care. If you have individual or group health insurance coverage that you or your employer bought in New York, including through the NY State of Health Marketplace or the New York State Health Insurance Program (NYSHIP) for public employees, COVID-19 vaccines are covered. Check the NY Department of Healths website on Coronavirus information for the most up-to-date information on what you should do. medically necessary. 0000000916 00000 n 0000005663 00000 n 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. >I,q%/0kYz[ad.-5-w6OB;n?/F:1R! What happens if I lose my health insurance when I am sick? Diagnosis. Cancellation Not Permitted. NY Coverage. All Rights Reserved | Capital District Physicians' Health Plan, Inc. | 500 Patroon Creek Blvd. 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 >. If you are totally disabled on the date your coverage terminates, your insurer will provide benefits for a hospital stay beginning, or surgery performed, within 31 days from the date your coverage ends, or until you are no longer disabled, if sooner. 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. fH\N,PHtL8#> N endstream endobj startxref 0 %%EOF 49 0 obj <>stream If your insurer denies any other treatment as not medically necessary, or as experimental or investigational, you can appeal the denial with your insurer. If you are unable to resolve the issue after contacting your insurer, file a complaint with DFS. 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. No. 0000019830 00000 n
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