Health Insurance eligibility requirements and coverage effective dates vary by employee type.
Eligible CSEA, UUP, M/C, PEF, NYSCOPBA and PBANYS employees have a choice of one of five options: a preferred provider organization or one of four health maintenance organizations. All plans cover pre-existing conditions.
Graduate and Teaching Assistants are eligible for the Student Employee Health Plan (SEHP) as employees represented by the Graduate Student Employees Union (GSEU).
Preferred Provider Organization
NYS Empire Plan
The Empire Plan covers hospitalization through Blue Cross, surgical/medical care through United HealthCare, mental health/substance abuse treatment through Optum Health Behavioral Solutions, and prescription drugs through Medco. Empire Plan enrollees are not required to designate primary care providers or to obtain written referrals for specialists. Generally, services rendered by participating providers are paid in full with the exception of modest co-payments. The insurance carrier pays the provider directly.
Claims for services from providers who do not participate in the plan must be submitted under the Basic Medical Program. The enrollee is responsible for paying all charges and will receive any reimbursements directly from United HealthCare. Once a deductible is met, Basic Medical will reimburse 80% of reasonable and customary charges to a prescribed maximum. The program pays 100% of reasonable and customary expenses after the coinsurance maximum limit is met.
The Empire Plan includes “managed care” components for certain services, such as hospital and skilled nursing facility admissions, mental health and substance abuse treatment, home health care and durable medical goods, and chiropractic/physical therapy. Benefits may be substantially reduced if members go outside the network or do not call for pre-approval.
Health Maintenance Organizations (HMOs)
1. Capital District Physicians' Health Plan (http://www.cdphp.com)
2. HIP (www.emblemhealth.com)
3. MVP Health Plan (http://www.joinmvp.com)
All HMOs provide comprehensive hospital, medical/surgical, mental health/substance abuse, and prescription drug coverage. Generally, enrollees are required to select a primary care provider within the HMO’s network. Enrollees go to their primary provider for health care or referrals to specialists. The HMO pays providers in full except for modest co-payments. The providers take care of claims and paperwork.
Pre-tax Contribution Program
Health insurance contributions are deducted from payroll checks on a pre-tax basis if an employee elects in writing to participate in the Pre-Tax Contribution Program (PTCP).