Recent Health Benefits News

The Empire Plan’s Home Care Advocacy Program (HCAP) provides coverage for home care services, durable medical equipment, and related medical supplies.

HCAP is part of the Empire Plan Medical/Surgical Program, which is administered by United Healthcare. As soon as the provider prescribes home care services, durable medical equipment or medical supplies, call HCAP toll free at 1-877-7-NYSHIP (1-877-769-7447). Press or say 1 for the Medical/Surgical Program, then 3 for HCAP.

An HCAP representative can help enrollees get covered services quickly with paid-in-full benefits (when using an HCAP-approved provider). The HCAP team will arrange or help arrange for care with approved providers in the area, and for ongoing care, will send a letter of confirmation.

There are six main types of equipment and services covered under HCAP when they are medically necessary:

Durable Medical Equipment and Related Supplies covered under HCAP is medical equipment that is for repeated use (not a consumable or disposable item), is used primarily for a medical purpose, is appropriate for use in the home and is generally not useful to a person in the absence of a sickness or injury. Examples of durable medical equipment that can be covered under HCAP includes, but is not limited to, hospital beds, manual wheelchairs and power mobility devices, continuous positive airway pressure (CPAP) devices and accessories, nebulizers, and oxygen equipment. Medical supplies covered under HCAP include diabetic supplies, ostomy supplies and supplies used with covered durable medical equipment, such as oxygen tubing and oxygen masks. Call HCAP prior to receiving durable medical equipment or supplies.

Diabetic and Ostomy Supplies covered under HCAP include glucometers, test strips, lancets, ostomy baseplates and pouches. Supplies must be prescribed by a physician and determined to be medically necessary. For most diabetic supplies, call the Empire Plan Diabetic Supplies Pharmacy at 1-800-321-0591. Insulin pump requests must receive HCAP authorization. For ostomy supplies, call Byram Healthcare Centers at 1-800-354-4054.

Skilled Nursing Services covered under HCAP include nursing in the home where skilled care is provided. Care must be ordered and supervised by a physician. HCAP does not provide custodial care, companionship or assistance with daily living, including care or services provided by a home health aide.

Home Infusion Therapy Services covered under HCAP includes, but is not limited to, the administration of medications or nutritional therapies (prescribed and supervised by a physician) and administered in the home by a nurse.

Communication Devices may be covered under HCAP. The rental or purchase of devices ordered or prescribed by a physician can be covered if a speech-language pathologist determines the patient is unable to communicate through typical means, including speech and writing.

Enteral Formulas covered under HCAP include nutritional replacements taken by mouth or through a feeding tube that provide basic nutrition when food in its usual form is not appropriate or adequate to meet the individual’s nutritional needs. HCAP covers non-prescription enteral formulas for home use when the doctor gives a written order that identifies medical necessity. Prescribed enteral formulas must be proven safe and effective for the diagnosis.

HCAP pre-certification of covered services save enrollees money and there will be no claim forms to fill out. Individuals must call HCAP and set up network providers prior to receiving paid-in-full benefits.

Empire Plan enrollees and dependents requiring HCAP services should call the Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and press or say 1 for the Medical Surgical Program, administered by United Healthcare, then 3 for HCAP. HCAP representatives are available Monday through Friday, 8 a.m. to 4:30 p.m. Eastern time. HCAP voicemail is available 24 hours a day, seven days a week to leave a message at any time.

In an emergency, to get the care or equipment/supplies needed, then call HCAP within 48 hours or as soon as possible. Covered services and items can be certified if HCAP determines that the urgent or emergency services were medically necessary.

The Empire Plan is a unique health insurance plan that continues to be the comprehensive health plan that gives enrollees the freedom to choose whether to receive care from Empire Plan network providers or from non-network providers.

Although not all health care providers participate in the Empire Plan network, Empire Plan enrollees have access to 1.2 million physicians, surgeons, anesthesiologists, mental health specialists, physical therapists, acupuncturists and more.

When accessing health care for yourself or your enrolled dependents, it is important to ensure that you are visiting an Empire Plan network provider. Participating providers save you and the plan money.

• Your out-of-pocket responsibility is usually limited to only a copayment for services covered by network providers
• Network providers will handle many administrative tasks for you, such as submitting claims to the appropriate Empire Plan administrator.

Very IMPORTANT: Confirm network status before scheduling any visit.

The Empire Plan does not require that a participating provider refer you to a participating laboratory, radiologist, specialist or center. It is important to verify before receiving services that a provider is an Empire Plan participating provider.

To get the most out of your plan, confirm with providers ahead of time by asking, “Are you participating and in-network with the specific carrier…United Healthcare, Anthem Blue Cross or Carelon Behavioral Health, for The Empire Plan?”

You can search for Empire Plan participating network providers online by visiting NYSHIP Online and use The Empire Plan Provider Director , choose your group and plan, if prompted, then select Find a Provider or you can contact The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) and speak with the specific plan administrator (1 Medical Surgical Program, 2 Hospital Program, 3 Mental Health & Substance Use Program, 4 Prescription Drug Program, 5 Empire Plan NurseLine).

Below is a listing of the administrators for The Empire Plan and the program they are responsible for overseeing.

United Healthcare oversees the medical/surgical services (such as office visits and surgery) as well as:

• The Home Care Advocacy Program (HCAP) for covered home care services and durable medical equipment/supplies, including diabetic shoes and enteral formulas.
• The Managed Physical Network (MPN) for chiropractic treatment and physical therapy.
• Centers of Excellence Program for Cancer and Infertility
• Access to acupuncturists under The Empire Plan

Anthem Blue Cross oversees The Empire Plan’s Hospital Program and provides coverage at hospitals worldwide. Anthem Blue Cross also oversees the Empire Plan Center of Excellence Program for Transplants.

Carelon Behavioral Health oversees The Empire Plan’s Mental Health and Substance Use Programs and provides a nationwide network for mental health and substance use treatment, including alcoholism, and the Center of Excellence Program for Substance Use Disorders.

CVS Caremark oversees The Empire Plan’s Prescription Drug Program and includes a nationwide network of participating pharmacies and Mail Order Pharmacy.

Any questions about The Empire Plan network benefits should be addressed to the appropriate administrator at The Empire Plan’s toll-free number at 1-877-7-NYSHIP.

If you meet the qualifications and carry NYSHIP health insurance, whether under The Empire Plan or a NYSHIP HMO, the “General Information Book for NY Active Employees” includes important information regarding NYSHIP eligibility, enrollment options, how changes to employment impact health insurance and enrollee’s associated cost contributions.

A copy of the General Information Book is mailed to all enrollees and can also be found on the Department of Civil Service’s NYSHIP online website.

It is recommended that you keep the General Information Book with important health insurance materials for reference.

The agency health benefits administrator (HBA) or the New York State Business Services Center performs various tasks to assist NYSHIP enrollees. The HBA serves as the employee’s contact for health insurance information and updates. The HBA communicates enrollee health insurance enrollments and updates to the New York State Department of Civil Service so enrollment files are updated timely.

Please note that it is the enrollee’s responsibility to notify the agency HBA/Business Services Center of any changes that may affect your NYSHIP coverage. Civil Service sends reminders to NYSHIP enrollees reinforcing the importance of enrollees to keep their NYSHIP enrollment record up to date, to provide timely notification of address changes and advise if a dependent no longer meets NYSHIP eligibility requirements.

Examples of health insurance updates that an enrollee should contact their agency HBA or NYS Business Services Center:

• Change in your name, mailing address, home address or phone number
• Changes that result in your health insurance coverage type (individual/family)
• Seeking to add or delete an eligible dependent
• A covered dependent loses eligibility
• You get divorced (a copy of the divorce decree must be submitted)
• Employment status changes and/or removal from the payroll
• You are planning to retire or leave state service.

To avoid delays, please ensure changes are made in a timely manner. Questions about specific health insurance plan benefits should be addressed directly with your plan.

The Empire Plan’s “Reporting On” publications are issued periodically by the New York State Department of Civil Service to Empire Plan enrollees and their enrolled dependents.

The publications help describe the benefits available under The Empire Plan. Current publications are on Civil Service’s NYSHIP Online website and include topics such as:

• Mental Health and Substance Use Program: The Empire Plan’s Mental Health and Substance Use Program (MHSU) for network treatment toward the path to recovery.
• Asthma: This report will help provide a better understanding of asthma, its symptoms, treatments and The Empire Plan Asthma Support Program.
• Centers of Excellence: Describes how the Empire Plan’s Centers of Excellence Programs for Cancer, Transplants, Mental Health and Substance Use and Infertility can be used to help your family find peace of mind during a difficult time.
• Diabetes: This report helps provide a better understanding of the disease, risk factors, and describes the important role of the Empire Plan’s HCAP for medically necessary diabetic supplies and diabetic shoes.
• (HCAP) Home Care Advocacy Program: Explains the Empire Plan’s HCAP coverage for covered skilled nursing care, home infusion therapy and durable medical equipment.
• Network Benefits: Discusses the benefits available to Empire Plan enrollees who use network providers. Choosing an Empire Plan network Provider maximizes your benefits and minimizes your out-of-pocket expenses.
• Healthy Babies: Discusses important steps to take before the baby is born. Includes prenatal care, nutrition, postpartum depression and the Empire Plan’s Building Healthy Families Program.

In addition to the above publications, NYSHIP Online includes other topics of interest. Visit NYSHIP Online at www.cs.ny.gov/employee-benefits. Choose your group (active state, then CSEA and Empire Plan). From the main menu, select ‘using your benefits’ and under publications, choose ‘reporting on’ for more information.

Empire Plan enrollees have until April 30, 2025 (120 days after the end of the calendar year) to submit medical expenses incurred during the 2024 plan year.

Network hospitals, providers and pharmacies will submit claims directly to the appropriate insurance carrier on your behalf when provided with all necessary information.

If you have a non-network claim submission, make sure you complete the requested subscriber information on the appropriate claim form, include the original billing or receipt (if requested), sign and return the claim form.

Claim submission for Empire Plan Basic Medical Program, the Home Care Advocacy Program (HCAP) and for non-network physical therapy or chiropractic services:

 United Healthcare
P.O. Box 1600
Kingston, NY 12402-1600
Claims submission fax (845) 336-7716

Claim form: https://www.cs.ny.gov/forms/UHC_3875.pdf

Claim submission for Empire Plan non-network inpatient or outpatient hospital services:
 Anthem Blue Cross – NYS Service Center
P.O. Box 1407 – Church Street Station
New York, NY 10008-1407

Claims submission fax: 866-829-2395

Plan info and online claim form: https://www.empireblue.com/nys/resources-forms

Claim submission for Empire Plan non-network mental health and substance use services:

 
Carelon Behavioral Health
P.O. Box 1850
Hicksville, NY 11802

Claims submission fax: 855-378- 8309

Claim form: https://www.cs.ny.gov/forms/cms1500-MHSA.pdf

Claim submission for Empire Plan prescriptions filled at non-participating pharmacies or at participating pharmacies without using your New York Government Employee Benefit Card use:

CVS/Caremark
 P.O. Box 52136
Phoenix, AZ 85072-2136

Claim form: https://www.cs.ny.gov/forms/CVSCM_Claim-Form_commercial.pdf

Call the Empire Plan directly at 1-877-7-NYSHIP (1-877-769-7447) with any questions about claims submission.

If you are an Executive Branch state employee and have been thinking of retiring, New York State’s Pre-Retirement Planning Webinars provide important information, such as how to maintain your NYSHIP health insurance in retirement.

The DIRECTIONS: Pre-Retirement Planning was developed to assist eligible New York State employees in planning for one of the most challenging and exciting periods in life – retirement. New York State offers its Executive Branch employees pre-retirement planning information through both online resources and DIRECTIONS: Pre-Retirement Planning webinars.

The webinars are for employees who are eligible to retire within five years. Supervisory approval is required for employees to attend webinars during their normal weekday. The currently scheduled webinars for February and March 2025 will be held on Webex.

The DIRECTIONS: Pre-Retirement Planning Tuesday webinars include two speakers that will cover an overview, NYS Deferred Compensation Plan and NYS State and Local Retirement.

Feb. 18, 2025, 9 a.m. – noon

March 18, 2025, 9 a.m. – noon

The DIRECTIONS: Pre-Retirement Planning Wednesday webinars include two speakers that will cover an overview, Social Security and NYSHIP (health insurance & Medicare).

Feb, 19, 2025, 9 a.m. – noon

March 19, 2025, 9 a.m. – noon

Employees have the option to select which days to attend, and do not need to attend consecutive days in the same month. They may opt to attend the Tuesday webinars in one month and the Wednesday webinars another month.

Every agency has an assigned DIRECTIONS: Pre-Retirement Planning liaison who can provide more information about the webinars.

Visit https://oer.ny.gov/directions-pre-retirement-planning-information for more information or the webinar registration page at https://oer.ny.gov/are-you-interested-attending-webinar.

DIRECTIONS: Pre-Retirement Planning is sponsored by the Office of Employee Relations and the Office of the State Comptroller, with funding for CSEA-represented state employees provided by the CSEA/NYS collective bargaining agreement.

NYSHIP retiree health care

Being aware of your rights and responsibilities as an enrollee in NYSHIP (New York State Health Insurance Program) is important, especially when considering retirement. You will want to verify eligibility to maintain NYSHIP coverage as a retiree. Additionally, it is important to know the rules and requirements that impact your NYSHIP coverage, such as enrollment in Medicare and if you are eligible for sick leave credit to help offset your retiree health insurance premium.

NYSHIP (New York State Health Insurance Program) is administered by the NYS Department of Civil Service Employee Benefits Division.

If you are thinking about retiring, visit NYS Civil Service’s web page for important information and order a Planning for Retirement Package which includes a Planning for Retirement booklet, and a Benefits Checklist. These materials will help you navigate the retirement process, make important decisions and prepare questions for meeting with your agency health benefits administrator about retirement.

Please visit the NYS Department of Civil Service’s webpage for additional information.

https://www.cs.ny.gov/employee-benefits/nyship/shared/retirement-prep/index.cfm

Specific questions regarding your NYSHIP eligibility can be directed to your agency health benefits administrator or the Department of Civil Service at 1-800-833-4344 or 518-457-5754.