Page 17 - Work Force February 2016
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                                                                                                                       2016 patient protections for Empire Plan enrollees
The Emergency Medical Services and Surprise Bill law requires The Empire Plan to provide information regarding your out-of-network reimbursement, including
details on referrals, costs and coverage as well as surprise bills.
In early January,
Empire Plan enrollees
were sent the 2016
Empire Plan at
a Glance, which
included the detailed
Disclosures” handout.
Following is a brief
summary of the coverage requirements for Empire Plan enrollees. Detailed questions should be directed to the Empire Plan at 1-877-769-7447.
Understanding the Out-of-Network Referral Mandate
Effective Jan. 1, 2016, due to provisions of the Emergency Medical Services and Surprise Bill law, the Empire Plan is required to provide access to primary care and specialty physicians if there is not one available within a 30-mile radius or 30-minute travel time from your home address.
This requirement applies to Empire Plan-primary enrollees residing in New York State and those states/regions where there is an agreement in effect
for Empire Plan enrollees to use United HealthCare’s PPO
What to do if you feel there is not a provider
accessible to you?
If you or your attending physician feels that the Empire
Plan network does not have a provider
accessible to you who has the appropriate level of training and experience to treat
a condition, you have the right to request an out-of-network referral to a provider who can offer the service(s) required.
• You or your attending physician must first request approval from the appropriate Empire Plan administrator at 1-877-769-7447 to receive consideration for
the service to be paid at an in-
network level.
• The attending physician must
recommend the provider with the specific level of training or experience to meet the health
care needs of the patient.
• If the plan approves the request,
the patient must use the out-of- network provider approved by the plan and covered services will be paid at the in-network benefit level, with only the applicable network co-payment owed.
• The enrollee is responsible for contacting the provider to arrange care.
What if the plan denies the request?
If the plan denies the request, benefits for covered services received from a non-participating provider are available under out-of-network benefit provisions, subject to deductible and co-insurance. You may also have a right to appeal, including an external appeal through the New York State Department of Financial Services (DFS).
Appeal forms are available at extappqa.htm.
What is a surprise bill?
Another provision of the law protects patients from being responsible for paying the full charge for surprise bills from non-participating
doctors. When you receive services from a non-participating doctor at an in-network hospital or ambulatory surgical center, the bill you receive for those services will be a surprise bill if:
• A participating doctor was not available; or
• A participating doctor sends a specimen taken from the patient in the office to a non- participating laboratory or pathologist; or
• A non-participating doctor provided services without your knowledge; or
• Unforeseen medical circumstances arose at the time the health care services were provided.
What is NOT a surprise bill?
If you elect to seek care from an out-of-network provider when an in- network provider is available, any
bills you receive are not considered
to be a surprise bill. If you have questions about whether a bill meets this definition, contact the state Department of Financial Services at 1-800-342-3736 or visit consumer/hprotection.htm.
                                                                                    2016 NYSHIP Dependent Eligibility Verification Project deadlines
As previously reported in The
Work Force, NYSHIP will conduct
a Dependent Eligibility Verification Project in 2016, similar to the audit conducted in 2009, to help ensure that every participant who receives benefits is entitled to them.
In early December, HMS Employer Solutions, the administrator of the verification project, mailed an amnesty letter to all NYSHIP enrollees with family coverage to provide them an opportunity to remove any ineligible dependent(s) without incurring any liability for repayment of claims
paid on their behalf. Enrollees were requested to review the information contained in the letter and report any ineligible dependents directly to HMS, no later than Jan. 29, 2016.
After the Special Amnesty Period ends on Jan. 29, enrollees will be required to provide documentation
of dependent eligibility during a verification phase. Due to the size of the NYSHIP population, this will be conducted in three separate phases, as follows:
etc.): Feb. 29 – April 15, 2016 • New York State retirees and
participating employers (authorities, etc.): May 2 – June 17, 2016
• New York State active employees: July 5 – Aug. 19, 2016.
It is very important that enrollees respond and provide copies of acceptable proofs of eligibility, such as birth certificates or marriage certificates, in a timely manner during the appropriate verification
phase. Dependents of enrollees who fail to respond will be removed from coverage retroactive to Jan. 1, 2016. Additionally, enrollees may be responsible for repaying all health insurance claims for ineligible dependents as early as the date the dependent became ineligible.
Any questions regarding the dependent eligibility verification project can be directed to HMS Employer Solutions at 1-855-884-9475 Monday through Friday, 8 a.m.
– 11 p.m. EST.
Participating agencies (local government, municipalities,
 February 2016
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