Empire Plan RETIREE At A Glance - Human Resources

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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
Hospice CareNetwork CoveragePaid in full when provided by an approvednetwork hospice program as described inthe Empire Plan Certificate.Non-network CoverageThe hospice care services covered under theProgram are the same whether received ina network or non-network hospice program.However, you will be responsible for acoinsurance amount of 10 percent of billedcharges up to the combined annual coinsurancemaximum. When the coinsurance maximum hasbeen satisfied, you will receive network benefits.See page 4.Medical/Surgical Program Benefits for Physician/Provider Services Received ina Hospital Inpatient or Outpatient Setting, Skilled Nursing Facility or HospiceWhen you receive covered services from a physician or other provider in a hospital, skilled nursingfacility or hospice setting and those services are billed by the provider (not the facility), thefollowing Medical/Surgical benefits apply:Participating Provider ProgramPaid-in-full benefits for covered services whenthe provider participates with The Empire Plan.Basic Medical ProgramPaid-in-full benefits for covered radiology,anesthesiology and pathology services receivedwhile in a network facility.In a medical emergency: Paid-in-full benefits for emergency services provided by attendingemergency room physicians and provides who administer or interpret radiological exams, laboratorytests, electrocardiogram exams and/or pathology services. For other non-participating specialtyphysicians or providers, benefits for emergency services are subject to deductible but not coinsurance.All other covered services subject to deductible and coinsurance.Medical/Surgical ProgramBenefits for covered medical/surgical services are available under the Participating ProviderProgram when you use a provider that participates with The Empire Plan or under Basic MedicalProgram when a provider is non-participating. Call The Empire Plan toll free at 1-877-7-NYSHIP(1-877-769-7447) and choose the Medical Program if you have questions about the status of aprovider, Plan coverage, an Explanation of Benefits (E0B) or your benefits. Representatives areavailable Monday through Friday, 8 a.m. to 4:30 p.m. Eastern time. Covered services andsupplies must be medically necessary as defined in the current version of your NYSHIP GeneralInformation Book & Empire Plan Certificate or as amended in subsequent Empire Plan Reports.Participating Provider ProgramYou pay a copayment for office visits, surgicalprocedures performed during an office visit,radiology services and diagnostic laboratoryservices, outpatient surgical location visits,cardiac rehabilitation center visits, urgent carecenter visits and convenience care clinic visits.Basic Medical ProgramCombined Annual Deductible: The combinedannual deductible must be satisfied beforebenefits are payable. See page 4.AAG-NY/PE-RET-1/14-REV 7
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: Hospital ProgramThe Hospital Progra
Page 11 and 12: Reasonable distance from the enroll
Page 13 and 14: Prostheses and Orthotic DevicesPart
Page 15 and 16: Home Care Advocacy Program (HCAP)Ho
Page 17 and 18: Outpatient ServicesNetwork Coverage
Page 19 and 20: • Placing a brand-name drug on Le
Page 21 and 22: Empire Plan Medicare Rx Prescriptio
Page 23 and 24: Prior Authorization ProgramCertain
Page 25 and 26: Contact InformationCall The Empire

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