ReportJune 2002

FOR EMPLOYEES OF THE STATE OF NEW YORK REPRESENTED BY COUNCIL 82And for their enrolled DependentsAnd for COBRA Enrollees with their Empire Plan Benefits

THE EMPIRE PLAN

1 Asthma Management;Allergy Serum

2 Clinical Referral Line;Subrogation

3 Transplants; Outside the U.S.4 NYSHIP Reminders

NYSHIP General Information Book and Empire Plan CertificateAmendments

Reporting On Asthma

Telephone Cards

5 Empire Plan Reminders6 New Publications7 Your Plan

In This ReportSAVE THISREPORT

SPECIALSECTIONS

IMPORTANTNUMBERS

ManagementAsthma Allergy

Asthma Management ProgramThe Empire Plan now offers theAsthma Management Program, also called Managing for Tomorrow.If you or your dependents havereceived recent treatment forasthma or asthma-relatedrespiratory problems, you may be invited to participate in thisprogram. Participation is voluntary,free of charge and confidential. Ifyou agree to participate, you willreceive information to help youunderstand your condition. You willalso be offered educationalmaterials and other services.

The Asthma Management Programbegan January 1, 2002 and isavailable to Empire Plan enrolleesthrough United HealthCare. Withthe introduction of this newprogram, the Empire Plan nowoffers two disease managementprograms through UnitedHealthCare: the CardiovascularRisk Reduction Program and theAsthma Management Program.

Reporting On AsthmaThis Empire Plan Report includes aspecial insert, Reporting On Asthma. The insert offers information about the chronic disease that affects 17million Americans.

SerumEffective January 1, 2002, youhave no copayment for allergyserum dispensed by an EmpirePlan participating physician to beadministered to you by anotherparty in another setting. TheEmpire Plan will reimburse theprovider directly for the allergyserum according to the networkschedule; you will have noadditional costs.

Before this change, such serum,called “take-away” serum, wasconsidered under the BasicMedical Program, subject todeductible and coinsurance.

We’ve enclosedfour new EmpirePlan telephonenumber cardsfor you andyour familywithin thisReport. If youneed morecards, pleasecontact your agency HealthBenefits Administrator.

New PhoneNumber Cards

HOSPITAL BENEFITSPre-admission certification for hospital(including maternity admission) and skilled nursing facility, if the Empire Plan is primary

Transplants ProgramCall Empire Blue Cross and Blue Shield(Albany area & Alaska) 518-367-0009(NYS & other states) 1-800-342-9815MEDICAL BENEFITSParticipating Provider and Basic Medical Programs Chiropractic treatment and physical therapyCall United HealthCare 1-800-942-4640Pre-authorization of MRI

Home care services, durable medical equipment/suppliesInfertility benefitsCall United HealthCare 1-800-638-9918

THE EMPIRE PLANNew York State Health Insurance Program

Click on Our New Look

NYS OnLine,the healthbenefits sectionof the NewYork StateDepartment of CivilService Web site, has a new look.Go to www.cs.state.ny.us and clickon Employee Benefits. You’ll nowfind faster page response and a site-wide search function. This up-to-date resource for your NYSHIP andEmpire Plan benefits offers recentpublications, a directory of agencyHealth Benefits Administrators’numbers and other importanttelephone numbers. The site meetsuniversal accessibility standardsadopted by New York State forNew York State agency Web sites.If you don’t have computer accessto the Internet, visit your locallibrary. Most libraries havecomputers linked to the Internet.

Dental:

New York State

Employees of:

Retired State/PE Employees

Participating Employers (PE)

© Copyright 2002 and previous years. New York State

Department of Civil Service Employee Benefits Division.

All rights reserved throughout the world

Employee Benefits Division • State of New York Department of Civil Service

The Empire State

Governor Pataki map-NY e-bizNYS Citizen

Guide

New York State

You Should Know...

Choosing a Health Plan?

Meetings & More

Publications

Phone Numbers

About Us / Privacy Policy Awards

Copyright / Disclaimer

Tech Help

Site Map

Super Search

Dental

Vision

Life

Income Protection Plan (IPP)Survivor Benefits

Workers' Compensation

More New York State Government Employee Benefits

New York State Health Insurance Programfor NY State and Local Governments

Are you a public employer thinking of joining NYSHIP?

Empire Plan ProvidersEmpire Plan Pharmacy

Long Term Care

Participating Agencies (PA)

Find the benefit, click on the group. Benefits vary by group.

Text Version

EPR-C-82-02-12

Clinical Referral LineValueOptions

The Empire Plan Mental Health andSubstance Abuse Program providescomprehensive coverage for mentalhealth and substance abuse care. But

before you seek mentalhealth or substanceabuse care, includingtreatment for alcoholism,

you must call ValueOptions’ ClinicalReferral Line at 1-800-446-3995. TheClinical Referral Line is available 24hours a day, every day of the year.

When you call ValueOptions, selectthe menu option for referral to amental health or chemical dependencyprofessional. An experienced mentalhealth and substance abuse clinicianwill be there to help you.

The clinician will talk with you andassess whether you need routine,urgent or emergency care. If you feelyour need is urgent or an emergency,tell the clinician; the clinician willaccept your assessment.

The clinician will then provide youwith names and phone numbers ofthree network providers. If you donot have access to a networkprovider, the clinician will arrange foryou to receive network benefits witha non-network provider in your area.

• If the need is routine, anappointment should be available toyou within seven days of yourcontacting the provider.

• If the need is urgent, anappointment should be availableto you within 24 hours of yourcontacting the provider.

• If you need emergency care,ValueOptions will have aprovider call you within 30minutes or will direct you to anappropriate facility for treatment.

If you have any difficultyscheduling an appointment withone of the recommendedproviders, call ValueOptions againat 1-800-446-3995. A referral lineclinician will be there to help you.

In a life-threatening situation, go to the nearest hospitalemergency room for treatment.

You must call ValueOptions within48 hours after an emergencyhospitalization to ensure maximumbenefits for any inpatient days inexcess of those required to provideemergency services.

The Empire Planand Subrogation

What is subrogation?Sometimes, claims for health careservices are submitted to the EmpirePlan for reimbursement and paid bythe Plan when, in fact, theseexpenses are the liability of anotherparty. When the Plan pays for theseexpenses, it may have the right toseek repayment from the third partylegally responsible for the injury orillness. This recovery process isknown as subrogation.

What are examples of third party liability?Expenses resulting from work-relatedinjuries and illnesses are usually theresponsibility of Workers’Compensation insurance; expensesfor injuries resulting from a motor

vehicle accident may be theresponsibility of an automobileinsurer; expenses for an injuryresulting from the wrongful acts of athird party may be the responsibilityof another insurer.

What is HRI? In the past, each Empire Plan carriermanaged subrogation individually.Now, the Empire Plan hospital andmedical carriers (Empire Blue Crossand Blue Shield and UnitedHealthCare) have contracted withHealthcare Recoveries, Inc. (HRI) to administer certain recovery efforts.If the Empire Plan has paid claims onyour behalf that appear to be theliability of a third party, HRI maysend you a letter asking forinformation about those claims.

What if I receive a letter from HRI? If you receive a letter from HRI,please respond as directed. Even if you think no other party isresponsible for your claim, pleaseprovide the requested information.HRI needs the information todetermine the Empire Plan’s liability.

Why should I contact HRI?When you answer your letter fromHRI, you may be helping the EmpirePlan recover monies that are theliability of another party. Thisprocess is one way the Empire Plankeeps your health insurancepremiums as reasonable as possible.

YOU MUST

CALL

EPR-C-82-02-1 3

for Transplants ProgramCenters of Excellence

Outside the U.S.The Empire Plan

The Empire Plan Centers of Excellence for Transplants Programoffers a paid-in-full benefit for thefollowing types of transplants: bonemarrow (inpatient and outpatient),peripheral stem cell, cord blood stemcell, heart, heart-lung, kidney, liver,lung, kidney-pancreas. Reimbursementfor travel expenses related to a coveredtransplant may also be available toProgram participants. Participation inthe Program is voluntary.

The enhanced benefits under theProgram are available only when youare enrolled in the TransplantsProgram, the Empire Plan is yourprimary coverage and your transplantservices are pre-authorized by EmpireBlue Cross and Blue Shield.

You must call Empire BlueCross and Blue Shield at518-367-0009 (Albanyarea and Alaska) or

1-800-342-9815 (NYS and other statesexcept Alaska) for pre-authorization of the covered services.

If you do not use the TransplantsProgram, you are still eligible forEmpire Plan benefits for yourmedically necessary transplant. Youmust call Empire Blue Cross and BlueShield at 518-367-0009 or 1-800-342-9815 for pre-admission certificationof admission for transplants. And,you will have to pay any applicabledeductible, coinsurance, copaymentsand non-covered charges.

If you choose to use a non-participating provider for transplant services, your out-of-pocket expenses may besubstantial. Therefore, it is advisable torequest a pre-determination of benefitsfrom both Empire Blue Cross and BlueShield and United HealthCare.

Please refer to your Empire PlanCertificate for more information aboutbenefits for transplant services.

Organ DonationFor a free brochure on organdonation and a donor card, call the Coalition on Donation at 1-888-90-SHARE (1-888-907-4273).

For more information about organdonation, visit the U.S. Departmentof Health and Human Services Web site at www.organdonor.gov.

What should you do if you needhealth care while traveling or livingoutside the United States?

Here are some suggestions:

• Ask the American Embassy fornames of reliable, English-speakingdoctors.

• After you receive services, ask forcopies of your medical records inEnglish, if possible.

• Get an itemized receipt when youpay your bill(s).

• Submit the records to theappropriate Empire Plan carrier.

You have paid-in-full benefits formedically necessary covered servicesprovided in an inpatient hospitalsetting. Pre-admission certificationis not required when you arehospitalized or admitted to askilled nursing facility outsidethe United States.

Carriers will consider other claims for payment under non-network coverage.

Please see your Empire PlanCertificate for carrier addresses

and information to help you file claims.

If you need more information, checkour Web site at www.cs.state.ny.us.Click on Employee Benefits. Or,when you’re outside the UnitedStates where the Empire Plan toll-free numbers do not work, youmay call the Employee BenefitsDivision at 518-457-5754. EmployeeBenefits representatives are availableMonday through Friday, 9 am to 3 pm Eastern time.

Medicare CoverageIf you are Medicare-primary,remember that you have noMedicare coverage outside theUnited States. The Empire Plan isprimary until you return. Save yourhealth care records and send them tothe Empire Plan carriers.

If you are living permanently outsidethe United States, you must notifythe Employee Benefits Division inwriting. The State will discontinueyour Medicare Part B reimbursement,and the Empire Plan will provide yourprimary health insurance coverage.

YOU MUST

CALL

EPR-C-82-02-14Report continued on page 5

Full-Time Student EligibilityYour unmarried dependent childrenare eligible for NYSHIP coverage ifthey are:

• age 19 or over but under age 25,and

• full-time students at an accreditedsecondary, preparatory or tradeschool, college or othereducational institution, and

• otherwise not eligible foremployer group coverage.

They continue to be eligible until theend of the third month following themonth in which they complete courserequirements for graduation, or theyreach age 25, whichever occurs first.

If your dependent loses NYSHIPeligibility, you have 60 days from thedate coverage ends to apply forcontinuation of coverage underCOBRA. You must send a writtenrequest to the Employee BenefitsDivision within that 60-day period.And, remember to notify your agencyHealth Benefits Administrator.

Please see your NYSHIP GeneralInformation Book for more informationabout dependent eligibility forNYSHIP coverage and COBRA.

Continuing Coverage in RetirementWhen you retire, you may continuecoverage for yourself and youreligible dependents if you meetcertain eligibility requirements. Aminimum service period is one ofthese requirements. You must havecompleted a minimum service periodas determined by the date on whichyou last entered State service.

If you were last hired before April 1,1975, you must have had at least fiveyears of benefits-eligible Stateservice or at least five years ofcombined benefits-eligible servicewith the State and one or moreParticipating Employers orParticipating Agencies.

If you were last hired on or after April 1, 1975, you must have had atleast 10 years of benefits-eligibleState service or at least 10 years ofcombined benefits-eligible servicewith the State and one or moreParticipating Employers orParticipating Agencies.

See your NYSHIP General InformationBook for information about less thanfull-time employment andemployment by a ParticipatingEmployer or a Participating Agency.

Your NYSHIP General InformationBook explains eligibility for retireecoverage. In addition to completing the minimum service period, youmust satisfy requirements for retiringas a member of a State retirementsystem and be enrolled in the NewYork State Health InsuranceProgram. See your Book for moreinformation.

Information in Another Language The New York State Health InsuranceProgram offers Language LineServices (LLS), an over-the-phonelanguage translation service forenrollees who call the EmployeeBenefits Division.

If you understand another languagebetter than English and would likeanswers to your health insurancequestions in another language, youmay call the Employee BenefitsDivision and use LLS. You may callon your own or ask someone elseacting on your behalf to call for you.

Here’s how LLS works:

1. Call the Employee Benefits Division at 518-457-5754 (Albany area) or 1-800-833-4344 (U.S., Canada, Puerto Rico, Virgin Islands).Employee Benefits representativesare available Monday throughFriday, 9 am to 3 pm.

2. The representative will call aninterpreter to translate for you.In most cases, the interpreter isavailable within 30 seconds.

A three-way conference callbegins for you, the representativeand the interpreter.

3. The interpreter translates for you and for the representative.LLS interpreters are trained in over-the-phone translation skills.They give accurate, objectivetranslations. All calls are strictlyconfidential.

RemindersNew York State Health Insurance Program

EPR-C-82-02-15

Report continued from page 4

New Numbers for theBenefits ManagementProgramYou now have new telephone numbersto call for the Empire Plan BenefitsManagement Program. Your EmpirePlan benefits have not changed as aresult of the numbers change.

If the Empire Plan is your primary coverage,you must call EmpireBlue Cross and Blue

Shield at 518-367-0009 (Albany areaand Alaska) or 1-800-342-9815 (NYSand other states except Alaska):

• Before a maternity or scheduledhospital admission

• Within 48 hours after an emergencyor an urgent hospital admission

• Before admission or transfer to askilled nursing facility

If the Empire Plan is your primary coverage,you must call UnitedHealthCare at 1-800-638-9918:

• Before having an elective(scheduled) Magnetic ResonanceImaging (MRI) unless you arehaving the test as an inpatient in a hospital

You may also call United HealthCareat 1-800-638-9918 to request avoluntary specialist consultantevaluation for any scheduled procedure.

The Benefits Management Programrequirements also apply when you oryour enrolled dependents haveprimary coverage through an HMOwith secondary coverage under theEmpire Plan, and you choose not touse the HMO.

If you will be admitted to a medicalcenter or hospital operated by theU.S. Department of Veterans’ Affairs,and will be using your Empire Planbenefits, you must comply with theBenefits Management Programrequirements.

Empire Blue Cross and Blue Shieldand United HealthCare replacedIntracorp as administrators of theEmpire Plan Benefits ManagementProgram, effective January 1, 2002.Please see your Empire Plan Certificateand Empire Plan Reports for moreinformation about the Empire PlanBenefits Management Program.

Your Up-To-Date InformationBe sure your provider has the accurateand up-to-date information needed to complete your claim forms.Participating and non-participating or non-network providers need yourname, address and Empire Planidentification number to completeclaim forms. Non-participating andnon-network providers also need yoursignature. If information is missing orincorrect, payment for services may bedelayed or denied.

Prescriptions by MailDo you take any prescriptionmedications on a long-term basis? If so, you can order your coveredprescription drugs by mail from theEmpire Plan Prescription DrugProgram mail service pharmacy,Express Scripts Mail Service.

You can order up to a 90-day supply of your prescriptions, shipped to yourhome. For mail service pharmacyorder forms, call Express Scripts at 1-800-964-1888 toll-free, 24 hours aday, seven days a week.

Once your prescription is on file at theExpress Scripts Mail Service, you canorder refills by mail, by phone oronline at the Express Scripts Web site,www.express-scripts.com. Choose theMail Service Prescriptions Refill page.When your order is placed online,you’ll know right away if your refill hasbeen approved. And, you can checkthe status of your order.

If you prefer, you still may fill your prescription at an EmpirePlan/Express Scripts participatingpharmacy or, at a higher cost to you,at a non-participating pharmacy.

Please see your Empire Plan Certificatefor more information about the EmpirePlan Prescription Drug Program.

The Empire Plan NurseLineSM

The Empire Plan NurseLine offersenrollees health information andadvice 24 hours a day, seven days aweek. Whether you want moreinformation about a recent diagnosisor are wondering how to stay healthy,you can call 1-800-439-3435 toll-freeto talk with an experienced registerednurse or to reach the Empire PlanNurseLine’s Health InformationLibrary. For recorded messages onmore than 1,000 topics, enter PINnumber 335 and a four-digit topiccode from the Empire Plan NurseLinebrochure you received in the mail. If you need a brochure, ask theNurseLine nurse to send you one.

Empire Plan Reminders

Emergency AdmissionEmergency admissions involvemedical conditions or acutetrauma such that life, limb or thebody function of the patientdepends on the immediacy ofinpatient medical treatment. Inan emergency admission, thecondition requires immediatemedical attention, and any delayin receiving treatment would beharmful to the patient. Thepatient does not have to beadmitted via the emergencyroom to be considered anemergency admission.

Urgent AdmissionUrgent admissions involvemedical conditions or acutetrauma such that inpatient medicalattention, while not immediatelyessential, should be provided veryearly in order to prevent possibleloss or impairment of life, limb orbody function.

YOU MUST

CALL

YOU MUST

CALL

EPR-C-82-02-1 6

We’ve also prepared twopublications to help youplan for retirement. TheNovember2001 Planningfor Retirement(which replacesthe September2000 version)explains healthinsurancedecisions andanswers benefitquestions. TheJune 2002 WhatNYS Retirees Need to Know AboutMedicare and NYSHIP tells you when retirees must enroll in Medicareand how Medicare enrollment affectsyour New York State HealthInsurance Program benefits.

If you’re thinking about retirement, askyour agency HealthBenefits Administrator for copies of theseimportant publications. Or check the New YorkState Department of Civil Service Web site,www.cs.state.ny.us. Click on Employee Benefits,then on Publications.

PublicationsNew

We’ve updated two of ourReporting On publications –Reporting OnNetwork Benefits,and ReportingOn HealthyBabies. Youragency HealthBenefitsAdministratornow has copiesavailable. You’llalso find thesepublications onthe New YorkState Department of Civil ServiceWeb site, www.cs.state.ny.us. Click on Employee Benefits, then on Publications.

Reporting OnNetwork Benefits(January 2002)details Empire Plannetwork coverage.Reporting On HealthyBabies (March 2002)offers information formothers and theirbabies.

Your agency HealthBenefits Administrator

also has a supply of the newpublication, Reporting On

Asthma, included in this Report, if you’d like another copy.

Reporting On

Thinking about RetirementPre-Retirement SeminarsThe New York State Departmentof Civil Service cooperates with the NYS Employees’Retirement System and the NYS Office for the Aging inpresenting pre-retirementseminars. A representative fromthe Employee Benefits Divisionwill explain the New York StateHealth Insurance Program andyour choices before you leavethe payroll. Call your personneloffice for the seminar scheduleand to reserve your place.

You can also check the schedule on the New York StateDepartment of Civil ServiceWeb site, www.cs.state.ny.us.Click on Employee Benefits,then on Meetings & More.

On the Road with the Empire PlanYour agency Health BenefitsAdministrator has a supply of the 2002 version ofOn the Road withthe Empire Plan. This handy bookletprovides information and telephonenumbers you’ll need when you’retraveling or when your child is away at school.

Ask your agency Health BenefitsAdministrator for your copy. Or, look for On the Road with the Empire Plan on the New York StateDepartment of Civil Service Website, www.cs.state.ny.us. Click onEmployee Benefits, then onPublications.

EPR-C-82-02-17

It is the policy of the State of New York Department of Civil Service to provide reasonable accommodation to ensure effective communication ofinformation in benefits publications to individuals with disabilities. These publications are also available on the Department of Civil Service Web site(www.cs.state.ny.us). Click on Employee Benefits for timely information that meets universal accessibility standards adopted by New York State for NYS Agency Web sites. If you need an auxiliary aid or service to make benefits information available to you, please contact your agency HealthBenefits Administrator. COBRA Enrollees: Contact the Employee Benefits Division at 518-457-5754 (Albany area) or 1-800-833-4344 (U.S., Canada,Puerto Rico, Virgin Islands).

EPR-C-82-02-1

ADDRESS SERVICE REQUESTED

State of New York Department of Civil ServiceEmployee Benefits DivisionThe State CampusAlbany, New York 12239www.cs.state.ny.us

SAVE THIS DOCUMENT

Information for the Enrollee, Enrolled Spouse/ DomesticPartner and Other Enrolled Dependents

C-82 Empire Plan Report – June 2002

This Report was printed using recycled paper and environmentally sensitive inks.

State of New York Department of Civil Service Employee Benefits Division

The State CampusAlbany, New York 12239

518-457-5754 (Albany area)1-800-833-4344

(U.S., Canada, Puerto Rico, Virgin Islands)www.cs.state.ny.us

The Empire Plan Report is published by theEmployee Benefits Division of the State ofNew York Department of Civil Service.The Employee Benefits Divisionadministers the New York State HealthInsurance Program (NYSHIP). NYSHIPprovides your health insurance benefitsthrough the Empire Plan.

PRSRT STDU.S. Postage Paid

Utica NYPermit No. 320

is the Empire PlanYour Plan

The New York State HealthInsurance Program(NYSHIP) provides yourhealth insurance benefitsthrough theEmpire Plan. TheEmpirePlan isdesigned especially for New York’s public employees andtheir families by the State andemployee unions.

In New York State, theEmpire State, you’ll hear theword “Empire” again andagain, even linked to otherhealth plans. The correctname of your health insuranceplan is the Empire Plan. Thecorrect name means correctbenefits. Tell your provideryou’re in the Empire Plan forNew York governmentemployees.