2019 New York State Health Insurance Program Plan Rates

For CSEA Active State Employees (and Unified Court System Employees)

The State Division of Budget has approved the Empire Plan’s premium rates for 2019 (rates are listed below).  The approval of the rates signals the beginning of the option transfer period for state employees.

New York state active employees have until January 18, 2019 to change their health insurance option or to submit/resubmit documentation to participate in the Opt-Out Program for 2019.  Enrollees wishing to change options or participate in the Opt-Out Program should complete the necessary transaction forms and return them to their health benefits administrator no later than January 18, 2019.

Administration employees, the new health insurance options will begin

December 27, 2018.  The earliest paycheck in which you will see a health insurance deduction change will be the payroll check of December 12, 2018 (Administrative Lag-Exempt) and December 26, 2018 (Administrative Lag)If you change options, because of processing time, most paycheck changes will be made in January and will include retroactive adjustments.

Institution employees, the new health insurance options will begin January 3, 2019 (triple lag employees will begin December 27, 2018).  The earliest paycheck in which you will see a health insurance deduction change will be the payroll check of December 20, 2018 (for Institution Lag-Exempt) and January 3, 2019 (for Institution Lag and Triple Lag).  If you change options, because of processing time, most paycheck changes will be made in January and will include retroactive adjustments.

Enrollees should review health insurance options carefully and see their health benefits administrator to make any changes or with any questions.

2019 NYSHIP Rates for Active State Employees

    2019 Empire Plan Formulary

    New York State has recently released the 2019 Empire Plan Advanced Flexible Formulary drug list for CSEA active State and Court System Empire Plan enrollees.  The creation of the Empire Plan Formulary is an administrative responsibility held by the New York State Department of Civil Service and the Empire Plan Prescription Drug Administrator, CVS Caremark.  During the creation of the formulary, all medications on the formulary (including generics) are evaluated for effectiveness and safety.

    Generics should be considered the first line of prescribing.  If there is no generic available, there may be more than one brand-name drug to treat a condition.  Preferred brand-name drugs are listed within the formulary to help identify products that are clinically appropriate.  Please note that the 2019 Empire Plan Advanced Flexible Formulary is not an all-inclusive list; the formulary includes a list of commonly prescribed drugs covered by therapeutic class, a Quick Reference Drug List with commonly prescribed covered drugs in alphabetic order, a listing of commonly prescribed non-preferred (Level 3) covered drugs and covered preferred drug alternatives, and a listing of excluded drugs along with covered alternatives.  Brand name drugs in this list are in CAPS and generic drugs in lowercase italics.

    During the annual review, drugs can change copayment tiers (resulting in either an increased or decreased copayment) or drugs can be excluded from coverage or re-introduced to coverage if they were previously excluded.

    Empire Plan enrollees who may be negatively impacted by any changes to the Advanced Flexible Formulary will receive a letter with a list of alternative medications from CVS Caremark.

    The Empire Plan offers a medical exception process for non-formulary drugs that are excluded from coverage.  To request a medical exception, you and your physician must first evaluate whether covered drugs on the Advanced Flexible Formulary are appropriate alternatives to your treatment.  After an appropriate trial of formulary alternatives, your physician may submit a letter of medical necessity to CVS Caremark that details the formulary alternative trials and any other clinical documentation supporting medical necessity.  The physician can fax the exception request to CVS Caremark at 1-888-487-9257.  If an exception is approved, the Level 1 copayment will apply for generic drugs and the Level 3 copayment (and ancillary charge, if applicable) will apply for brand-name drugs.

    For specific information regarding your prescription benefit coverage and copay information, please visit https://www.empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447) and select option 4 for the Empire Plan Prescription Drug Program.

      Changing Your Health Insurance Option for 2019?

      Important options to consider for the 2019 plan year:

      • Changing your Pre-Tax Contribution Program (PTCP) election; ends 11/30/18
      • Changing your New York State Health Insurance Program (NYSHIP) option during the Option Transfer Period*
      • Enrolling in the Opt-Out Program*(if eligible)

      *Option transfer dates not available at the time this article went to press

      The Pre-Tax Contribution Program (PTCP) is a voluntary program that employees can choose to participate in when they are first eligible for health insurance benefits.  Employees may also elect to participate or decline participation in PTCP each year during the PTCP Election Period from November 1 through November 30.  Your paycheck shows whether you are enrolled in PTCP; if you are enrolled, your paycheck stub shows “Regular Before-Tax Health” in the Before-Tax deductions section.  If you wish to change your PTCP selection for 2019, complete a NYS Health Insurance Transaction Form (PS-404) and submit it to your Agency Health Benefits Administrator no later than November 30, 2018.

      During the Option Transfer Period (date not available at press time), you may change your New York State Health Insurance Program (NYSHIP) health insurance option for the next plan year to one of the following:

      • The Empire Plan
      • A NYSHIP Health Maintenance Organization (HMO)
      • The Opt-Out Program (if eligible)

      In 2019, NYSHIP will continue to offer the Opt-Out Program, which allows eligible CSEA active employees who have other employer-sponsored group health insurance to opt out of their NYSHIP coverage in exchange for an incentive payment.  If you currently participate in the Opt-Out Program and wish to continue receiving incentive payments in 2019, you must re-elect the Opt-Out Program during the Option Transfer Period.

      Please see your Agency Health Benefits Administrator for specific details, plan requirements and deadlines.

        Save on 2019 Health Insurance Costs

        Enrollees should start thinking about their expenses for next year.  Do you currently participate in the Flex Spending Account?  Do you currently participate in the Productivity Enhancement Program (PEP)?   If you don’t, now is the ideal time to obtain additional information about these cost-saving benefits as enrollment begins in October (enrollment is time-sensitive) and ends in November).

        The Flex Spending Account is a negotiated employee benefit for State employees.  There are two parts to the FSA; the Health Care Spending Account (HCSAccount) (medical, hospital, laboratory, prescription, dental, vision, hearing expenses, etc. not reimbursed by insurance or benefit plan) and the Dependent Care Advantage Account (DCAAccount) (childcare, eldercare or disabled dependent care, required for an employee or spouse to work).  Both are types of flexible spending accounts that give you a way to pay for your health care expenses or dependent care with pre-tax dollars.  Enrollment in the flexible spending account is voluntary – you decide how much to have taken out of your paycheck

        For more detailed information regarding the Flexible Spending Account programs, including eligibility, enrolling online and calculating your out-of-pocket expenses, please visit www.flexspend.ny.gov or call 1-800-358-7202.

        Another program that helps to save enrollees money is the Productivity Enhancement Program (PEP).  PEP allows eligible full and part-time State employees to exchange previously accrued vacation leave and/or personal leave, in return for a biweekly credit, which reduces their share of the New York State Health Insurance Program (NYSHIP) premium.

        Eligible CSEA active State members can receive up to a $600 credit (approx. $23 biweekly) or $1,200 credit (approx. $46 biweekly), determined by salary grade and number of days forfeited.

        Review the Planning for Option Transfer documentation and contact your Health Benefits Administrator, usually located in your personnel office, or, if applicable, the Business Service Center if you have questions or to confirm your eligibility for this benefit.


          Obtaining Access to the Empire Plan Participating Provider Directory

          The Empire Plan Participating Provider Program offers a network of over 275,000 physicians, laboratories and other providers located throughout New York and in many other states.

          Each year the Empire Plan sends postcards to all Empire Plan enrollees across the United States and Puerto Rico so that the enrollee may elect to have a printed directory for The Empire Plan Medical/Surgical Program mailed to them.

          You can obtain a printed directory by returning the participating provider request postcard you receive in the mail.  If you would like to receive a directory from a different state or region other than your home zip code, simply write the name of the version you would like on the line provided on the postcard.  You can also get a copy of the directory by calling The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and using option 1 for the Medical Program.  A directory will be mailed within 4-6 weeks of your request.  In addition, customer service representatives can provide a personalized directory.

          To find an Empire Plan participating provider online, go to www.cs.ny.gov/employee-benefits. If prompted, choose your group and plan, and select Find a Provider.  You can choose from one of the following programs:  Hospital, Medical/Surgical, Mental Health and Substance Abuse or Prescription Drug.

          Both Enrollees and the Plan save when participating providers are used.  You pay only the applicable copayment for most covered services.

            Enrolled in the Empire Plan? Make Sure Student’s Shots Are Up To Date

            Is your child off to college this fall? If you’ve made a checklist of items to pack and things to take care of before he or she goes, you may want to add just one more item – make sure their shots are up to date.

            Growing research has found that some groups of college students may be at a higher risk of contracting bacterial meningitis, and that risk can be minimized by means of a quick injection.

            As Empire Plan enrollees and their eligible dependents gear up for another fall semester, the CSEA Health Benefits Department would like to remind those in charge of “PLANNING” that the Empire Plans’ vaccination and immunization benefit was enhanced to include the meningitis vaccine for dependent children.

            Enrollees who have questions about whether their child has received the meningitis vaccination should contact their doctor’s office.

            If you would like to learn more about the Empire Plans’ vaccination and immunization benefit, including the meningitis vaccine, please contact United HealthCare, the Empire Plan’s medical/surgical provider, at 1-877-7NYSHIP (1-877-769-7447).


              South Nassau Communities Hospital and Empire BlueCross BlueShield Reach Agreement

              South Nassau Communities Hospital and Empire BlueCross BlueShield (hospital administrator for the Empire Plan) announced that they have reached a contract agreement in which South Nassau Communities Hospital will continue as a participating hospital under the Empire Plan.

              This is great news considering the difficult negotiations leading up to the new agreement that will run until 2020. There will be no disruption of in-network service for members.


                The Empire Plan Covers Shingrix Vaccine for Prevention of Shingles

                The Centers for Disease Control (CDC) recently approved Shingrix as a recommended vaccine for (Shingles) herpes zoster.  The Shingrix vaccine has also been recommended by the Advisory Committee on Immunization Practices (ACIP) for the prevention of herpes zoster and related complications for those age 50 and older and is therefore required to be covered as a preventive service for this age group.


                Effective April 1, 2018, the Shingrix vaccine will be covered by both the Empire Plan Medical/Surgical Program and by the Prescription Drug Program through the CVS Caremark Vaccine Network. There will be no enrollee cost share for the Shingrix vaccine for enrollees age 50 and older when administered by an in-network provider.  Any Shingrix vaccine that was administered prior to April 1, 2018 will be a covered service but will have enrollee cost share applied.


                Please be aware that the Shingrix vaccine requires two shots to be administered and both Shingrix shots will be covered as described above.

                  Assignment of Benefits for Non-Network MHSA Services

                  Beacon Health Options (Beacon) is the administrator for The Empire Plan’s Mental Health and Substance Abuse Program (MHSA).  Until recently, the Empire Plan prohibited claim payments for non-network MHSA from being sent directly to a provider.  All non-network claim payments were paid directly to the member and the member was required to send payment to the provider of service.  This resulted in numerous problems for enrollees and providers of service.  The NYS Department of Civil Service recently reviewed and revised this policy and will allow assignment of benefits to non-network MHSA claims processed on or after March 1, 2018.  Beacon Health sent a letter explaining this change to enrollees who obtained services under the non-network portion of the MHSA Program.


                  If you have already paid a non-network provider for a date of service and have not submitted a claim form to Beacon yet, do not indicate an assignment of benefits on the claim form. This will result in the provider being paid twice for the same date of service. If this does occur it will be your responsibility to recoup money owed to you from the non-network provider.


                  By receiving MHSA Program services from a non-network provider your out-of-pocket costs are much higher.  If you have any questions or would like to discuss transitioning to a network provider, please contact Beacon’s Customer Service at 1-877-7-NYSHIP (877-769-7447), Option 3 between 8 AM and 8 PM (EST).



                    New Medicare Cards Coming Soon

                    To help protect your identity, Medicare will begin mailing new cards to everyone who receives Medicare benefits.  Medicare and Medicaid Services (CMS) has been directed to remove Social Security Numbers (SSN) from all Medicare cards by April 2019.  A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on new Medicare cards.  Beginning in April 2018, CMS will start mailing the replacement Medicare cards with the MBI to existing Medicare enrollees.


                    Each MBI is a unique, randomly-generated, 11-character number made up only of numbers and uppercase letters.  The characters are “non-intelligent,” which means they don’t have any hidden or special meaning.  The new MBI will help protect private health care and financial information and will be coordinated with the Social Security administration and health care providers.  The Department of Civil Service, administrator of the New York State Health Insurance Program, is looking at any impact the new MBI numbers will have for NYSHIP enrollees and will communicate any new information in future periodicals.


                    Medicare enrollees may start using their new Medicare cards and MBIs as soon as they get them.


                    For additional information call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048.  You can also visit the CMS website for additional information on the distribution of new cards; https://www.medicare.gov/forms-help-and-resources/your-medicare-card.html