Empire Plan RETIREE At A Glance - Human Resources

Hospital Outpatient, continuedNetwork CoverageNon-network CoveragePaid-in-full benefits for bone mineral densitytests, colonoscopies, mammograms, pap smears,proctosigmoidoscopy and sigmoidoscopyscreenings considered preventive as required bythe Patient Protection and Affordable Care Act.Paid-in-full benefits for preadmission and/orpresurgical testing prior to an inpatientadmission, chemotherapy, radiology,anesthesiology, pathology or dialysis.$20 copayment for medically necessary physicaltherapy following a related hospitalization orrelated inpatient or outpatient surgery. (Refer toyour Empire Plan Certificate for other conditionsof coverage.)Medically necessary physical therapy is covered under the Managed Physical Medicine Programwhen not covered under the Hospital Program. (See Medical/Surgical Program coverage.)Emergency room services, including use of thefacility for emergency care and services of theattending emergency room physician andproviders who administer or interpretlaboratory tests and electrocardiogram servicesare subject to one copayment of $70 per visitwhen billed by the hospital. The copayment iswaived if you are admitted as an inpatientdirectly from the emergency room.Network coverage applies to non-networkhospital emergency room services.Note: Emergency services provided in the hospital and billed by a physician or provider: Paid-in-fullbenefits for attending emergency room physician and providers who administer or interpret radiologicalexams, laboratory tests, electrocardiogram exams, and/or pathology services. This benefit applies tothe Participating Provider Program and the Basic Medical Program. For other participating specialtyphysicians, benefits will be paid in full. For other non-participating specialty physicians, benefits willbe considered under the Basic Medical Program subject to deductible but not coinsurance.Skilled Nursing Facility Care • Semi-private roomfor preadmission certification (see page 2)Benefits are subject to the requirements of the Empire Plan’s Benefits Management Program.The Empire Plan does not provide Skilled Nursing Facility benefits, even for short-term rehabilitativecare, for Retirees, Vestees, and Dependent Survivors or their dependents who are eligible forprimary benefits from Medicare.Network CoverageSkilled nursing facility services covered underthe Program are covered in an approvednetwork facility when medically necessary inplace of hospitalization. Refer to the NYSHIPGeneral Information Book & Empire PlanCertificate regarding the number of days ofskilled nursing facility care for which coverageis provided and other conditions of coverage.Non-network CoverageThe skilled nursing facility services covered underthe Program are the same whether received in anetwork or non-network facility. However, youwill be responsible for a coinsurance amount of10 percent of billed charges up to the combinedannual coinsurance maximum. When thecoinsurance maximum has been satisfied, youwill receive network benefits. See page 4.6AAG-NY/PE-RET-1/14-REV