New PBANYS and NYSCOPBA employees who are eligible have the opportunity to participate in the New York State Health Insurance Program (NYSHIP) which is one of the largest group health insurance programs in the United States. NYSHIP provides valuable medical benefits for you and your eligible dependents through two different options: The Empire Plan with some managed care features, or health care from a participating Health Maintenance Organization (HMO). Both options provide medical and surgical care, hospital expense benefits, mental health and substance abuse benefits and prescription drug coverage. There are no pre-existing condition exclusions.
Am I eligible?
Full-time employees are eligible for health benefits if they are employed for at least three (3) months. Part-time employees who work at least half-time (.50 FTE) are eligible to receive benefits if they are appointed for at least three (3) months.
Are my dependents eligible for coverage?
You may enroll for either individual or family coverage. Eligible dependents include a spouse or domestic partner and children under the age of 26. If you wish to carry family coverage, copies of the following documents are needed to support your dependent’s eligibility: marriage certificate for a spouse, proof of current financial interdependence if married for more than one year, proof of residency and financial interdependence for a domestic partnership. Copies of birth certificate(s) and social security card(s) will also be required prior to enrolling all dependents.
When will my coverage be effective?
If you wish to enroll for health insurance/prescription coverage, you must select a plan within the first 28 days of appointment to avoid any extended waiting period. Coverage will be effective on the 29th day of employment.
What is the cost of coverage?
New York State pays a significant portion of the premium for yourself and your dependents. You pay the balance which is deducted from your paycheck on a bi-weekly basis. There are two types of coverage that you may purchase: individual or family. For current rates, visit health insurance.
One of the decisions you will need to make when enrolling for health insurance is whether or not to participate in the Pre-Tax Contribution Program (PTCP). Under PTCP, your health insurance premiums are deducted from your pay before taxes are taken out. This lowers your taxable income and gives you more spendable income. Under Internal Revenue Rules (IR), if you participate in PTCP, you cannot change your health insurance deduction once the amount is set for the tax year unless you have a "qualifying event".
Health Insurance Plan Choices
Empire Plan
Membership in the New York State Empire Plan allows you to seek medical services from any doctor, hospital, or health care provider that you wish. Hospital and related benefit coverage is provided through Empire Blue Cross and Blue Shield. Major medical/surgical benefits, provided by United HealthCare, are available through participating and non-participating providers. Participating providers, which are paid directly by the insurance company, have agreed to accept the negotiated usual, customary and reasonable (UCR) fees as payment for services. You are responsible for a co-payment: $25 for office visits, diagnostic/therapeutic services, and rehabilitative care. Fees for services received through non-participating providers may be higher than the UCR rates and are subject to an annual deductible. Once your annual deductible is met, reimbursement is 80% of reasonable and customary expenses. Claims for services from providers who do not participate in the plan are submitted using a claim form.
Empire Plan Participating Providers
CVS/Caremark Prescription Drug Plan 1-877-769-7447
Under the Empire Plan prescription drug plan, you can have your prescriptions filled at any network pharmacy or the mail service pharmacy. This plan uses a flexible formulary and for up to a 30-day supply of a covered drug, you pay a $5 co-payment for Level 1 or generic drugs, a $30 co-payment for Level 2, preferred brand-name drugs and a $60 co-payment for Level 3 or non-preferred brand-name drugs.
The network of participating pharmacies includes many of the major chains as well as several independent pharmacies.
Health Maintenance Organizations
HMOs are managed health delivery systems organized to deliver health care services in a specific geographic area. An HMO provides a predetermined set of benefits through a network of selected physicians, laboratories and hospitals for a prepaid premium. Except for emergency services, you and your enrolled dependents must receive services from your primary care physician (which you select at the time of enrollment) or at health centers or hospitals affiliated with the HMO unless you have made other arrangements with your HMO. Medically necessary visits to specialists are covered when authorized by your primary care physician. If you select services outside your HMO network, payment for these services will generally be your responsibility.
All HMOs charge a small co-payment for certain services, usually in the form of a per-visit fee. HMOs have no annual deductibles and rarely, if ever, are claim forms required. Member’s out-of-pocket costs are usually the lowest with this type of plan.
Blue Cross Blue Shield of WNY
Independent Health
How do I enroll?
Please indicate your intention to participate or not to participate in a health insurance plan on the Benefits Election Form. To enroll, please complete the Health Insurance Transaction Form (PS-404) online or provided in your orientation packet and return it to the Employee Benefits Office, Cleveland Hall 403, within 28 days of your appointment date to avoid any extended waiting period.
If you are currently covered under an employer-sponsored group insurance plan through other employment of your own, or a plan that your spouse, domestic partner, or parent has as a result of his or her employment, you may qualify for the Opt-Out Program. This program allows eligible employees to opt out of health insurance coverage through Buffalo State in exchange for an incentive payment. To participate in the Opt-Out Program, you must complete the Health Insurance Transaction Form (PS-404) and the Opt-Out Attestation Form (PS-409) no later than the first date of your eligibility for health insurance benefits.
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