Page 17 - September 2017 Work Force

Obtaining access to the Empire Plan PTarticipating Provider Directory
he Empire Plan Participating You can also get a copy of the Provider Program offers a directory by calling The Empire Plan
Help us maintain your EBF records
network of more than 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 than your home zip code, simply write the name of the version you would like on the line provided on the postcard.
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 four to six weeks of your request. In addition, customer
service representatives can provide a personalized directory.
To find an Empire Plan participating
provider online, go to
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.
We all lead busy lives, but it is important your CSEA Employee Benefit Fund (EBF) records for your dental and vision benefits are up to date.
You are responsible for maintaining the accuracy of your enrollment and dependent records. A quick phone call, website visit
or the prompt submission of
forms and supporting enrollment documentation to EBF’s Member Services Department can often prevent eligibility and claim errors for you and your dependents.
Prevent issues with claim payments and eligibility
coverage until age 19. Coverage may continue to age 25 if your dependent is a full-time student. To qualify for continued coverage, the dependent must be enrolled for at least 12 undergraduate or six graduate credit hours in an accredited college or university.
Members must submit the Dependent Student Certification Form annually. EBF makes every effort to ensure all eligible dependents receive this form. If your dependent is eligible for coverage and did not receive a form, you must
complete a form and send it back to EBF. Members must also notify EBF immediately if your dependent no longer meets full-time
DEPENDENT STUDENT CERTIFICATION FORM 2017-2018
MAIL TO: PO Box 516, Latham, New York 12110 OR FAX TO: (518) 786-3658
(800) 323-2732 | WWW.CSEAEBF.COM
Member Name: CSEA EBF ID #: Member Phone #: Member Email:
I certify that my dependent student listed below meets all of the following Irecqeuritriefymtehnattsmfoyrdelpigeinbdileitnyt asstuadednetpleinstdedntbestluodwemnte:ets all of the following
requirements for eligibility as a dependent student:
Student Name: Student Date of Birth:
A. Is the dependent student married?
B. Semester(s) enrolled: Fall 2017  Spring 2018  Both Semesters  C. Is a full-time student in high school or college/university.* Yes  No  D. Expected date of graduation: / /
Yes  No 
CSEA Employee Benefit Fund
Remove Dependent Form
To amend your enrollment record, please complete and sign the form below and return it to the address below.
Your prompt response will ensure that your benefit records are accurate so that claims can be processed without delay. Thank you for your cooperation.
EMPLOYEE INFORMATION (PLEASE PRINSTta)te Zip Code
- M-ember’s Name _____________________________________________________ EBF ID# __________________________________
Mailing Address ______________________________________________________________________________ Apt # ____________
PLEASE PRINT CLEARLY
Student Name School Name School Address School City School Phone
*The dependent child or ward must be enrolled in a minimum of 12 undergraduate or 6 graduate credit hours to be considered full time. Courses must be from a regionally accredited college or university and working toward an Associate’s
City ___________________________________________________________________ State _____________ Zip Code _____________
Degree (e.g., A.A. or A.S.), Bachelor’s Degree (e.g., B.A. or B.S.) or Master’s Degree (e.g., M.A. or M.S.). Technical courses of short duration do not qualify, even if a diploma is awarded.
Daytime Phone # ___________________________________ Email _______________________________________________________
I attest that the information shown above is true and complete. I understand that failure to complete this form may
DEPENDENT TO BE REMOVED
result in a delay, denial or termination of coverage for the above-named dependent. I understand that CSEA Employee
Benefit Fund reserves the right to ask for more information as proof of the above-named dependent’s full-time student
status. Name _______________________________________________________________________________________________________
Address _____________________________________________________________________________________________________
I agree to advise CSEA Employee Benefit Fund promptly of any changes in my child’s dependent student status.
Relationship to Employee ________________________________________________________________________________________
Member’s Signature Date
Reason for Ineligibility Legal Separation/Divorce*
Death Other: ___________________________________
nt to de*fIrfatuhdisansytaintseumraenncteicsotmopraenmy orveothyeorupresrsponufisle,syaonuapmpluicsattipornofvoirdiensaurcaonpcye orfstthaetefmiresnttaonfdclalaimst page of the divorce/separation papers, or a ion or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
letter from an attorney indicating that you are legally separated or divorced, and provide the date this became effective.
Date dependent became ineligible _________________________________________________________________________________
I certify that the above information is correct:
Member’s Signature ___________________________________________________ Date _____________________________________ This form must be fully completed and signed by the CSEA Employee Benefit Fund member. All required documentation must be attached.
CSEA Employee Benefit Fund 1-800-323-2732 www.cseaebf.com
e, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the
MAIL COMPLETED FORM TO
CSEA Employee Benefit Fund PO Box 516
Latham, NY 12110-0516
Any person who knowingly and with inte concerning any materially false informat fraudulent insurance act, which is a crim claims for each such violation.
HealthAlliance of the Hudson Valley, Empire Blue Cross/Blue Shield reach tentative agreement
issues
arise when
there is
inaccurate
dependent
information
on file. It
is very
important
you notify
us with any
changes to
your family
such as marriage, legal separation or divorce, or the birth of a child.
Since the EBF
does not receive
information from your
health insurance carrier, providing these updates to your carrier and EBF is very important. Failure to do so could result in claim payments for an individual after they are no longer eligible. If this were to occur, the member would be put into collections and held responsible for satisfying those debts before future claims can be paid.
Some homework for you: Notify EBF of full-time student status every year
Dependent children are eligible for
Let us know of legal separation or divorce
A member may choose to remove
a spouse upon legal separation if appropriate paperwork is submitted. If you are divorced, your spouse is no longer eligible for
benefits. You must remove your ineligible spouse from both EBF and your health insurance carrier separately.
Updating is easy
You can easily update your records using EBF’s “Enroll Online” feature at cseaebf.com. On our website, you can also find all EBF forms by clicking “Download Forms.” If you prefer, call us at (800) 323-2732 to have forms mailed to you. Please note that in some circumstances, we may ask for more information.
Westchester Medical Center and Empire Blue Cross/Blue Shield recently announced that Empire Blue Cross/Blue Shield (hospital carrier for The Empire Plan) and the HealthAlliance of the Hudson Valley have reached an agreement in which HealthAlliance of the Hudson Valley will once again be considered an Empire Plan participating hospital effective Sept. 1, 2017.
As of that date, services provided by the hospitals to Empire members will resume on an in-network basis. This affects the HealthAlliance Hospitals on Broadway and Mary’s Avenue, both in Kingston.
This is great news as the HealthAlliance of the Hudson Valley has been a non-participating hospital under the Empire Blue Cross/Blue Shield network since June 2016.
student Many status.
September 2017
The Work Force 17