Understanding the Empire Plan

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Understanding the Empire Plan
EMPLOYEE BENEFITS at BINGHAMTON
UNIVERSITY Updated Dec. 2005
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Contract with Carriers
The Empire Plan is a specially-made plan for New
York State employees ... Various insurance
companies (carriers who are otherwise
unaffiliated) have agreed to provide coverage
under the general contract of the Empire Plan
Empire
HOSPITAL Empire Blue Cross Blue Shield
MAJOR MEDICALUnited HealthCare
MENTAL HEALTH SUBSTANCE ABUSE PROGRAMSGHI/
ValueOptions
PRESCRIPTIONSCaremark
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Overview Empire Plan

• Managed care features, but primary/referrals
  not required
• More choice, flexibility, but more
  self-management
• Participating providers co-pays, no deductible
  
• Out of network providers meet deductible,
  partial reimbursement

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2006 New Prescription Carrier
PRESCRIPTIONSEmpire BlueCross Blue Shield/
Caremark

• Replaces Express Scripts
• More information on-line, Choices 2006
• Auto transfer of existing maintenance
  prescriptions, except
• Controlled substances
• Combination drugs
• Billing information
• Same co-pay structure
• Check list for preferred, generic, etc.

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Hospital Coverage
Empire Blue Cross Blue Shield
United HealthCare

• Hospital charges go to Empire Blue Cross/ Blue
  Shield
• Major medical services received in hospital are
  covered by United HealthCare

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Hospital Coverage
HOSPITAL Empire Blue Cross Blue Shield

• Anesthesiology
• Included in hospital billing, covered by United
  HealthCare when using participating hospital
• Network of Hospitals
• 95 of USA hospitals participate
• If not, expenses are covered at non-network
  levels

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Major Medical Coverage (United HealthCare)

• What are major medical charges?
• Your doctors (in or out of hospital)
• Tests and diagnosticians (labs, radiologists,
  blood work, X-rays ...)
• Physical therapy, chiropractic, other special
  services
• Ambulance

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Major Medical Coverage
MAJOR MEDICALUnited HealthCare

• If you use a participating provider
• No annual deductible
• Small copayments
• Less out-of-pocket cost
• Doctor submits your claims
• If you use a NON-participating provider
• Reimbursement is according to BASIC MEDICAL or
  MultiPlan

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Major Medical Coverage using NON-participating
providers

• Reimbursement will be

Basic Medical
MultiPlan
OR
If doctor is out-of network, but participates
with MultiPlan

• Meet annual deductible

• 80 reimbursement ofreasonable
  customaryexpenses (you are responsible for 20
  plus differential)

• Meet annual deductible

• 80 reimbursement is based on discounted
  doctor charges you are only responsible for the
  20 balance

• Submit claims

• Providers office submits claims

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for more MultiPlan details
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Save by using a participating provider
MAJOR MEDICALUnited HealthCare

• Ask the office if they participate with the NYS
  Empire Plan (the carrier is United HealthCare)
• If not, are they a MultiPlan provider?
• Find providers on the web page www.cs.state.ny.us
  (or call 877-769-7447), and always ask the
  doctors office directly if they still participate

Are you a participating provider with the New
York State Empire Plan? ... the major medical
carrier is United HealthCare ...
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Save by using a participating provider
MAJOR MEDICALUnited HealthCare

• When you need lab work or X-rays ...
• Ask if the service your doctor orders will be
  done in a facility that participates with your
  plan (not necessarily so, even if your doctor
  participates)
• Your tests might be analyzed by radiologists or
  diagnosticians that dont have your insurance
  information. If you get bills from these places,
  contact them with your insurance information!

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Lab/Radiology Tests

• Empire Blue Cross/Blue Shield pays if
• You go to outpatient area of hospital for tests,
  or a hospital-owned clinic/facility (youll have
  hospital co-pays)
• United HealthCare pays if
• Test is done at doctors office or other
  non-hospital facility (youll have co-pays if
  participating Basic Medical or MediPlan if not
  participating)
• Co-pays are higher when the same test is done in
  a hospital (outpatient basis) than when done in
  an office facility

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Centers of Excellence
MAJOR MEDICALUnited HealthCare

• Cancer Centers of Excellence
• Paid-in-full coverage with no co-pays for
  cancer-related medical received through
  nationwide network (includes Sloan-Kettering,
  Roswell Park, Dana Farber, etc.). Can coordinate
  with local care.
• Travel, lodging, meals reimbursed
• Call 1-866-936-6002, nurse/info
• Transplant Centers
• Infertility Centers

HOSPITAL Empire Blue Cross Blue Shield
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Managed Care Coverage
MUST CALL ! 1-877-7NYSHIP 1-877-769-7447

• Call for network providers and pre-authorizations

• MANAGED PHYSICAL MEDICINE (United HealthCare)
• Chiropractic Treatment and
• Physical Therapy

• VALUEOPTIONS
• (GHI)
• Mental Health and
• Substance Abuse Treatment

HOMECARE ADVOCACY PROGRAM HCAP (United
HealthCare) Home Care Services and/or Durable
Medical Equipment/Supplies
EMPIRE BLUE CROSS BLUE SHIELD

• Before Maternity or Scheduled Hospital
  Admissions
• Within 48 Hours of Emergency/Urgent Hospital
  Admission

UNITED HEALTHCARE

• Before Scheduling an MRI

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Prescription Drug Coverage
Caremark

• Three levels of drug coverage
• Generic
• Preferred Brand-name
• Non-preferred Brand-name
• Mail order will save you money on co-pays
• 90-day prescription will save the cost of one
  co-pay at the pharmacy

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2006 Prescription Drug Co-pays
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Helpful Hints Use Participating Providers When
Possible

• Check first to see if your doctors, hospital,
  facilities, labs, etc. participate with the NYS
  Empire Plan
• If youre using a non-participating provider
• Ask if they participate with MultiPlan
• If not, you can request a pre-determination of
  benefits to see if youll be reimbursed for a
  reasonable and customary fee. Contact

United HealthCare Insurance Company of New
YorkP.O. Box 1600 Kingston, NY 12402-1600
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Helpful HintsCheck and Follow Plan Rules

• Always check requirements for you must call
  situationshospital admissions, MRIs, managed
  care, other major services
• Dont assume! If in doubt about a
  rule/procedure, call the Empire Plan directly

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Helpful Hints Stay Up to Date with Claims

• The NYS Empire Plan carriers web sites help you
  self-manage your plan, and access your claim
  information at any time.

www.cs.state.ny.us (click on Employee Benefits)
www.myuhc.com United HealthCare
www.empireblue.com Empire Blue Cross Blue Shield
www.express-scripts.com (ExpressScripts) until
end of 2005
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Helpful Hints Understand the Explanation of
Benefits
PLAN BENEFITS
REMARK CODE

73
0.00
(73) PLEASE HAVE THE HOSPITAL SEND THESE CHARGES
TO UNITED HEALTHCARE FOR PAYMENT.

• Look for the Remark Code and its explanation
  below.
• If problem/question, call your doctors billing
  office or the insurance company that sent you
  the Explanation of Benefits (United HealthCare,
  Empire Blue Cross Blue Shield, GHI/Value Options)

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Helpful HintsResolve Problems Promptly
If I ignore these bills, maybe theyll go away!

• Be pro-active with any bills and Explanation of
  Benefits you receive. If it doesnt look right,
  ask!Look at your claim on-line, call the Empire
  Plan, or ask your doctors billing office to
  clarify.
• Keep copies of claims youve sent in, at least
  until theyre resolved
• (or, you can print your EOBs from the website)

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Helpful Hints

• Make sure bills are submitted (either by you or
  the hospital/doctors billing office) before
  March 30, 2006 for charges incurred in 2005
• If neither you nor the provider submits the bill
  in time, the insurance carriers do not have to
  reimburse any amount (as stated in Certificates).

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Helpful Hints Plan Ahead, Get Yourself Informed!

• Try thinking of health insurance somewhat like
  car insurance

• understand the carrier agreement (Empire Plan
  General Information Book Certificate)
• follow carrier rules procedures
• shop for health care providers that
  offer reasonable cost with good service
• anticipate deductibles, maintenance costs,
  and other out-of-pocket expenses

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For More Information

• Refer to the Empire Plan General Information Book
  Certificate.Check the web site
  www.cs.state.ny.us

• Read the Empire Reports you receive in the mail.
  Save for future reference.