Empire Plan RETIREE At A Glance - Human Resources

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Mental Health and Substance Abuse Programto ensure the highest level of benefitsCall The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the MentalHealth and Substance Abuse Program before seeking services from a covered mental health orsubstance abuse provider, including treatment for alcoholism. The ValueOptions Clinical ReferralLine is available 24 hours a day, every day of the year. By following the Program requirements fornetwork coverage, you will receive the highest level of benefits. If you contact the Mental Healthand Substance Abuse Program before you receive services, you have guaranteed access tonetwork benefits.In an emergency, go to the nearest hospital emergency room. You or your designee must call theMental Health and Substance Abuse Program within 48 hours of an admission for emergency careor as soon as reasonably possible.Program requirements apply even if Medicare or another health plan is primary.All benefits apply to treatment determined medically necessary by ValueOptions.Mental Health and Substance Abuse BenefitsNetwork CoverageNo deductiblesNo annual or lifetime benefit maximumsInpatient ServicesNetwork CoverageApproved Facilities: Paid in fullPractitioner Treatment or Consultation:Paid in fullNon-network CoverageThe amount you pay for non-network inpatientand outpatient services counts toward meetingyour combined annual deductible. See page 4for the combined annual deductibles andmaximum coinsurance amounts.Non-network CoverageWhen you use a non-network facility, you willbe responsible for a coinsurance amount of10 percent of billed charges up to the combinedannual coinsurance maximum. Benefits will bepaid at 100 percent after the combinedcoinsurance maximum is met. See page 4.No non-network benefits are available forresidential treatment facilities, halfway housesor group homes.Same as inpatient non-network coverage above.Ambulance ServiceAmbulance service to a hospital where you will be receiving mental health or substance abusetreatment is covered when medically necessary.14AAG-NY/PE-RET-1/14-REV
Outpatient ServicesNetwork CoverageMental Health: $20 copayment per visit withup to three visits per crisis paid in full.Applied Behavioral Analysis Services: There isan annual maximum of 680 hours for AppliedBehavioral Analysis (ABA) services, networkand non-network combined.Substance Abuse: $20 copayment per visit.Hospital Emergency Room: $70 copaymentper visit. The copayment is waived if you areadmitted to the hospital as an inpatient directlyfrom the hospital emergency room.Non-network CoverageAnnual and Lifetime Maximum: Unlimited,except for an annual maximum of 680 hoursfor Applied Behavioral Analysis (ABA) services,network and non-network combined.Combined Annual Deductible: The combinedannual deductible must be satisfied beforebenefits are payable. See page 4.Coinsurance: The Empire Plan pays 80percent of reasonable and customary chargesfor covered services after you meet thecombined annual deductible.Reasonable and Customary Charge: Thelowest of the actual charge, the provider’susual charge or the usual charge within thesame geographic area.Combined Annual Coinsurance Maximum:Once the combined annual coinsurancemaximum is reached, benefits are paid at100 percent of reasonable and customarycharges for covered services. See page 4.Hospital Emergency Room: Same asnetwork benefits.Psychological Testing and Neuropsychological Testing:Network and non-network psychological testing and evaluations will be reviewed for medicalnecessity; only medically necessary services are covered. Therefore, precertification byValueOptions is required before testing or evaluation begins.Neuropsychological network or non-network testing and evaluations will be reviewed for medicalnecessity; only medically necessary services are covered. Therefore, precertification by ValueOptionsis recommended before testing or evaluation begins.Notes: Neuropsychological testing with a medical diagnosis is also covered under theMedical Program. These services will be reviewed by UnitedHealthcare for medical necessity.Precertification by UnitedHealthcare is recommended before testing or evaluation begins.Applied Behavioral Analysis Services: Covered in accordance with New York State law, subjectto 680 hours of service annual cap for network/non-network combined.AAG-NY/PE-RET-1/14-REV 15
Page 1 and 2: UPDATEDJanuary 1, 2014RETIREENew Yo
Page 3 and 4: Quick ReferenceThe Empire Plan is a
Page 5 and 6: Centers of ExcellenceCancer Service
Page 7 and 8: Hospital ProgramThe Hospital Progra
Page 9 and 10: Hospice CareNetwork CoveragePaid in
Page 11 and 12: Reasonable distance from the enroll
Page 13 and 14: Prostheses and Orthotic DevicesPart
Page 15: Home Care Advocacy Program (HCAP)Ho
Page 19 and 20: • Placing a brand-name drug on Le
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Page 25 and 26: Contact InformationCall The Empire

Empire Plan RETIREE At A Glance - Human Resources

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