Chapter V: Health, Dental, Vision, and Flex Spending Accounts

Eligibility
The following employees are eligible for health insurance under the New York State Health Insurance Plan (NYSHIP) coverage for themselves and/or their families (which includes qualified domestic partners).

• Full-time faculty and professional staff;
•  Part-time (non-casual) faculty and professional staff employees who are employed at 50% or higher for professionals and a minimum of 6 credits for faculty.

Effective Date of Coverage
Providing you apply for coverage within the first 30 days of employment, coverage will become effective on the 43rd day of employment.

• NYSHIP Options
• The Empire Plan
  • Blue Cross
  • United Health Care
• HMO - Blue

1. The Empire Plan
   The Empire Plan provides coverage for hospitalization through Blue Cross, and combined medical/surgical and major medical coverage through United HealthCare. You may incur additional costs by utilizing a non-participating provider or receiving unauthorized care. Please refer to the NYSHIP General Information Booklet for detailed plan information.
   
   There is a $100 co-payment for each emergency room visit. This co-payment is waived if you are subsequently admitted to the hospital. There is also a $50 co-payment for each out-patient visit to a hospital, with the exception of visits for chemotherapy, radiation therapy, physical therapy or kidney dialysis. The plan features a network of participating providers (physicians, laboratories, chiropractors and other specialists and establishments). Services rendered by participating providers will generally be paid in full, with the exception of an $25 payment for office visits, covered outpatient surgical procedures, radiology services, and diagnostic laboratory services. The insurance carrier pays the provider directly.
   
   Claims for services by providers who do not participate in the Plan must be submitted using a claim form. Once a deductible is met, major medical will pay 80 percent of reasonable and customary charges. The annual deductible for employees who select non-participating providers is currently $1,250 for the enrollee; $1,250 for enrolled spouse/domestic partner; and $1,250 for all dependent children combined. Thereafter, major medical will pay 80 percent of reasonable and customary charges (adjusted annually), and there is a deductible and coinsurance limits have been met, the plan pays 100 percent of reasonable and customary charges. Covered expenses for mental health and substance abuse, home care advocacy program services and managed physical medicine are excluded in determining the maximum out-of-pocket limit.
   
   NOTE: Please refer to the Choices booklet and Empire Plan Certificate for additional information available at: http://www.cs.ny.gov/ebd/welcome/login.cfm.
    
2. HMO-BLUE (https://www.excellusbcbs.com/) or HMO-MVP
   HMO Blue provides a wide range of health services including hospital benefits, medical and surgical care and preventative care. These services are provided or arranged by a primary care physician whom you select from the HMO participating providers. HMO's have no annual deductible. Referral forms to see network specialists are usually required.
    
3. Cost of Coverage
   Your portion of the premium will be automatically deducted from your bi-weekly salary. The bi-weekly costs for participation in these plans are available here.

You may elect to play your share of health insurance premiums on a pre-tax basis. These costs are subject to change.

If an employee takes leave without pay or is otherwise temporarily removed from the payroll, he or she may pick up the full cost of the health insurance program and thereby continue coverage while off the payroll. Should such leave without pay occur as part of an authorized leave under FMLA, he or she may be entitled to continue coverage by paying the employee share. Arrangements for continued coverage must be made in advance through the Office of Human Resources.

If an employee covered by the Empire Plan is totally disabled, and on authorized leave without pay or unpaid Family and Medical Leave, the requirement that he or she pay a premium may be waived for a period of up to one year. Additional information is available from the Office of Human Resources.

4. How to Enroll
   Complete the appropriate sections of the New York State Health Insurance Transaction form and submit to Office of Human Resources. If you elect an HMO option, you will also need to complete a separate HMO enrollment form.
   
   Proof of eligibility must be provided in order for you and your eligible dependent to enroll in NYSHIP. For enrollee, spouse and child(ren), documentation of the following is required:

• Date of Birth
• Social Security Number
• Date of Marriage/Date of Divorce
  
  The following documentation may also be required:
• Domestic Partner – Completed PS-425 and proof of date of birth
• Adopted child(ren) – proof of adoption
• Stepchild(ren) who do not reside with you – proof of substantial support or legal requirement to pay
• Other Child(ren) – Statement of Dependence PS-457

5. Change of Status
   If an employee wishes to change health insurance coverage as a result of a birth, death, or other change in family status, he or she must submit an application or change to the Office of Human Resources.
   
   Change of Plan Option
   There is an annual transfer period (usually in November/December) during which you can, should you wish, change your option.
    
6. Retirement Coverage
   If you meet specific criteria, you will be eligible to continue individual coverage and that of enrolled dependents during retirement. In general, you must complete at least ten (10) years of eligible service; be at least 55 years of age and have coverage at the time you retire. You may, at your discretion, suspend health insurance coverage after you retire.

Empire Plan
Each of the health insurance options provides prescription drug coverage for covered employees and dependents.

If you elect the Empire Plan, there is a $5 co-payment for all new generic prescriptions and refills purchased at participating pharmacies. The co-payment for preferred brand name drugs is $25. The co-payment for non-preferred brand name is $60. Coverage is through CVS Caremark. Show your New York Employee Benefit Card at the time of purchase.

There is a mandatory generic substitution requirement. If you purchase a brand name drug with a generic equivalent, you will pay the co-payment plus the difference in cost between the brand name and generic drugs.

You can receive up to a 90 day of your covered prescriptions by mail order from CVS Caremark, telephone number 1-877-769-7477, or at a participating pharmacy.

HMOS
Under each of the Health Maintenance Organization options, prescriptions must be filled at a participating pharmacy or via mail order (if available). The co-payments for each of the Health Maintenance Organizations options are available upon request.

Additional Information
Specific information on health plan benefits is provided in these booklets available online.

1. UUP
   The United University Professions (UUP) Benefit Trust Fund provides employees in the Professional Services Negotiating Unit who are eligible for enrollment in the New York State Health Insurance Program with dental benefits (Delta, http://www.deltadentalins.com/uup/] Group #165).

   
   Note: The union benefit fund exists solely to provide benefit coverage to UUP-represented employees. The cost is funded by payments UUP negotiates for, and receives from, the state. Union dues and agency shop fees do not pay for these benefits.

   New employees become eligible for coverage as soon as they complete 42 days of continuous service. Eligible employees who transfer directly from another state agency will become eligible for benefits the day after their previous coverage ends.

2. M/C
   New York State provides M/C employees with a group dental insurance plan, administered by Group Health Incorporated (GHI). The entire cost of the coverage is paid by the State for eligible employees and dependents. The plan covers a broad range of dental work. If an employee chooses to use a participating dentist, all covered fees are paid by the plan. If the employee chooses to use a non-participating dentist, reimbursement is made in accordance with a fee schedule based on a Statewide average. The employee is responsible for any difference between the dentists' fees and the plan's payment schedule. Coverage under this plan is automatic and is subject to certain deductibles. The eligibility requirements for an employee, dependents, and domestic partners are the same as that for the health insurance program.
   
   Coverage under this Plan is effective on the 57^th day of employment.
   
   There is an annual deductible, for all services except Preventative Care, Diagnostic Care and Orthodontics. The deductible is $25.00 per person per calendar year. The total family deductible will not exceed $75.00 per year for all covered family members. The amount of the deductible is based on GHI's schedule, not on the amount charged by the dentist.

1. UUP
   The United University Professions (UUP) Benefit Trust Fund provides employees in the Professional Services Negotiating Unit who are eligible for enrollment in the New York State Health Insurance Program with vision benefits (Davis Vision).
   
   New employees become eligible for coverage as soon as they complete 42 days of continuous service. Eligible employees, who transfer directly from another state agency, will become eligible for benefits the day after their previous coverage ends.
   
   Eligible members and their dependents receive benefits from Davis Vision once every 12 months. The plan allows payment for one pair of eyeglasses without a co-payment (from a select frame assortment) or plan-covered contact lenses with a co-payment. TAKE OUT: Davis Vision will send eligible employees a listing of participating providers. If a member chooses to use a non-participating provider, s/he will be eligible for reimbursement of $10 for the exam and $35 for glasses, frames or contact lenses. Additional benefits (such as scratch coating and upgraded frames) are available to members at a discounted cost.
    
2. M/C
   Eligible M/C employees, their dependents, and their domestic partners are eligible for vision care coverage under the M/C Vision Care Plan (EyeMed). If an employee chooses to use a participating provider for vision care needs for the entire cost of an examination and eye glasses or standard allowance for contact lenses. If the employee chooses a non-participating provider, payment will be made directly to the employee according to a fixed schedule. Plan benefits are available to each covered person once in each 24 month period. All full-time and half-time salaried M/C employees are eligible for coverage. Dependent and domestic partner eligibility is identical to that of the State Health Insurance Program.
   
   An eligible M/C employee must enroll in the M/C VISION CARE PLAN in order to take advantage of the services provided under the plan. Newly eligible employees will automatically receive an enrollment form and plan information at their residence after they have been on the payroll for 56 days.

(https://goer.ny.gov/fsa)

There are two parts to the Flex Spending Account – the Dependent Care Advantage Account (DCA Account) and the new Health Care Spending Account (HCS Account). Both are a type of Flexible Spending Account (FSA). FSAs give you a way to pay for your dependent care or health care expenses with pre-tax dollars. FSAs are voluntary - you decide how much to have taken out of your paycheck and put into your DCA Account and/or HCS Account.

1. Dependent Care Advantage Account
2. Health Care Spending Account