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Health Insurance
Health Benefits Department  

This Department is responsible for the coordination and oversight of all negotiated health benefit arrangements. Primary objectives include the development, enhancement and expansion of all health related benefits provided to our members.

The Health Benefits Department acts as a resource for all Divisions of CSEA (State, Local Government and Private Sector) by providing direct assistance and support to Region and Headquarters staff, local and unit officers, and the rank & file membership.

The CSEA-NYS Joint Committee on Health Benefits, pursuant to Article 9 of the State Contract, is primarily responsible for the oversight and administration of the New York Sate Health Insurance Program (NYSHIP). The NYSHIP program includes the Empire Plan and Health Maintenance Organizations located throughout the State.

The CSEA Health Benefits Department can be reached at 518-785-4774 or 1-800-286-5242(JCHB) or by E-mail: healthben@cseainc.org

The following listing is the current staff available to you; as staff/services are expanded we will update you accordingly:

Laura Balogh
Interim Director Health
Benefits Department
 

Dawn Dugan
Deputy Director
Health Benefits Department

Joint Committee on Health Benefits Staff

James Carron
Communications Associate

Scott Futia
Health Benefits Associate

Local Government Private Sector Staff

Margaret Gannon
Health Benefits Specialist

Margaret Lloyd
Health Benefits Specialist

Kimberly Switts
Health Benefits Specialist

Support Staff

Sandra Leith
Office Manager

Michene Smith
Secretary III

Contact us at:

CSEA Health Benefits Department
1 Lear Jet Lane, Suite 4
Latham, NY 12110

(518) 785-4774
(800) 286-5242
Fax: (518) 785-4974

E-Mail: healthben@cseainc.org
 

The Empire Plan

Informational Assistance

The following directory of telephone numbers and addresses will help Empire Plan enrollees and their dependents obtain information and assistance regarding their benefits.

NYS Health Insurance Program: All questions concerning the health insurance program should first be directed to your Agency Personnel Office, or

NYS Department of Civil Service Employee Benefits Division
5th Floor Alfred E. Smith Office Bldg. 80 South Swan Street
Albany, NY 12239

Albany area: (518) 457-5754 or (518) 457-5784
Toll-free: 1-800-833-4344

or on the web at: www.cs.state.ny.us

 Hospital Claims:  All hospital admissions, pre-certification, concurrent reviews of hospital and skilled nursing facility, discharge planning, inpatient complex medical case management and high risk pregnancy program must call Empire Blue Cross and Blue Shield.

Empire Blue Cross and Blue Shield
 NYS Service Center (Code YLS)
Box 1407 - Church Street Station
New York, NY 10008-1407

Within/Outside NYS: 1-877-7NYSHIP (1-877-769-7447)

www.empireblue.com

Contact Empire Blue Cross and Blue Shield for information regarding The Organ Centers of Excellence Transplants Program.

Medical/Surgical/Basic Medical Claims: United Health Care will take over the Benefits Management Program's responsibilities for outpatient medical case management, prospective procedure review (for MRIs) and voluntary specialist consultant evaluation. Enrollees MUST contact United Health Care prior to receiving any elective (non-emergency) Magnetic Resonance Imaging.  

United HealthCare Service Corp.
Administrator for MetLife
P.O. Box 1600
Kingston, NY 12402-0600  

Within/Outside NYS: 1-877-7NYSHIP (1-877-769-7447)

www.mvuhc.com (to check on claim status)

Infertility Benefits: Certain infertility procedures, called Qualified Procedures, are covered under the Empire Plan, ONLY if you receive prior authorization. You MUST call for prior authorization, regardless of the provider of service. Call for information on Qualified Procedures for infertility benefits and Centers of Excellence.

United HealthCare/Infertility 1-877-7NYSHIP (1-877-769-7447)

NurseLine: For health information, advice and education 24 hours a day, 7 days a week. Call the Empire Plan NurseLine at:

Empire Plan NurseLine: 1-877-7NYSHIP (1-877-769-7447)

Managed Physical Medicine Program (MPMP): This Program provides coverage for medically necessary chiropractic treatment and physical therapy services. If you do not use MPN network providers, you will receive significantly lower level of benefits. The MPMP is insured by United HealthCare and administered by Managed Physical Network, Inc. (MPN).

Managed Physical Medicine Program: 1-877-7NYSHIP (1-877-769-7447)

Empire Plan enrollees are eligible to receive a 25% discount (enrollee pay program) from a network of acupuncturists, massage therapists, and nutritionists. Contact American Complementary Care Network/MPN, which oversees the provider network for a listing of providers or to nominate a provider.

American Complementary Care Network/MPN 1-877-7NYSHIP (1-877-769-7447)

or on the web at www.empireplancam.com

Home Care Advocacy Proqram (HCAP): All visiting and private duty nursing, home infusion therapy and durable medical equipment (insulin pumps and medijectors) must be pre-certified through HCAP which is administered by United HealthCare. Enrollees requiring diabetic supplies or ostomy supplies can contact the supplier directly or contact HCAP.

Home Care Advocacy Program: 1-877-7NYSHIP (1-877-769-7447)

(enrollees requiring diabetic supplies (except insulin pumps and medijectors can contact National Diabetic Pharmacies at 1-888-306-7337)

(enrollees requiring ostomy supplies can contact Byram HealthCare at 1-800-354-4054).

Mental Health and Substance Abuse Services: Call ValueOptions (Administrator for GHI) Before beginning any treatment for mental health or substance abuse, including alcoholism. If you do not follow ValueOptions requirements, you will receive significantly lower level of benefits.

ValueOptions: 1-877-7NYSHIP (1-877-769-7447)

Prescription Drugs: You must call for prior authorization for certain drugs. Call The Empire Plan Prescription Drug program at 1-877-7NYSHIP (1-877-769-7447) 0.

Prior Authorization, Written Appeals and General Correspondence

The Empire Plan
Prescription Drug Program
P.O. Box 11826
Albany, NY 12211

Caremark Mail Service

Caremark
P.O. Box 3223
Wilkes-Barre, PA 18773-3223

 

Medicare: Information can be obtained through your local Social Security office listed in your telephone directory under "United States Government" or contact: 1-800-772-1213.

CSEA/NYS Joint Committee on Health Benefits: The primary objective of the Joint Committee on Health Benefits is to ensure that the health insurance provided to CSEA members as a result of state contractual negotiations is implemented, administered, adjudicated and rated fairly and properly. For assistance in resolving ongoing enrollment and/or claims disputes or if you have questions regarding the state contractual agreement (Article 9) please contact:

CSEA-JCHB
One Lear Jet Lane, Suite 4
Latham, NY 1211 0

Albany area: (518) 785-4774 Within NYS: 1-800-286-JCHB (5242)

CSEA Joint Committee on Health Benefits

 

CSEA was successful in negotiating a greater involvement in the design, implementation and ongoing administration of The Empire Plan by enhancing the role of the CSEA-NYS Joint Committee on Health Benefits.

The Committee convenes on a scheduled basis and can meet on an emergency basis within fourteen days, when required. Full-time Committee support staffs perform daily activities and administrative tasks. Funds for the support staff are provided by the State pursuant to Article 9 .26(b) of the agreements.  

Committee Appointees are:

William Curtin – OSU
Thomas Moylan – ASU
Lori Nilsson – ISU

The primary objective of the Joint Committee on Health Benefits is to ensure that the health insurance provided to CSEA members as a result of the state contractual negotiations is implemented, administered, adjudicated and rated fairly and properly. While the Committee is a result of State contracts, it will always weigh the direct and indirect implications, Committee decisions or actions will have on political subdivisions. A secondary objective of the Committee will be to serve as a vehicle for CSEA to develop its own agenda for successor agreements via its ability to access and utilize shared experience data and retain consulting actuaries.

Major tasks and responsibilities the Committee is charged with are found in Article 9.26 of the agreement and summarized as follows:

  1. Oversee administration of New York State Health Insurance Program for State employees.
  2. Oversee and assist in revision and distribution of health insurance certificates, reports, updates and brochures.
  3. Assist CSEA membership in claims/enrollment problems.
  4. Study subscriber complaints and take corrective action as required.
  5. Review and analyze HMO requests for inclusion or expansion in the New York State Health Insurance Program.
  6. Monitor and assist in recruitment of Empire Plan Participating providers; assist in development and distribution of participating provider directories.
  7. Monitor schedule of allowances to maximize provider participation.
  8. Participate in the Empire Plan rate renewal process.
  9. Monitor claims data base and utilization and experience reports.
  10. Oversee/monitor Health Insurance Training Program for agency Health Benefits Administrators.
  11. Oversee/monitor the Benefits Management Program consisting of: Pre-Admission Certification, Concurrent Review, Discharge Planning, Medical Case Management and Prospective Procedure Review (Second Surgical Opinion).
  12. Oversee/monitor Blue Cross and Blue Shield (Empire HealthChoice) and Centers of Excellence for Organ Transplants.
  13. Oversee/monitor United HealthCare and Centers of Excellence for Infertility.
  14. Establish/oversee/monitor the Complementary Alternative Medicine Program discount program for Empire Plan enrollees.
  15. Oversee/monitor the voluntary Disease Management Programs administered under the Empire Plan.
  16. Oversee/monitor the Home Care Advocacy Program (HCAP)
  17. Oversee/monitor the Managed Physical Medicine Program for physical therapy and chiropractic treatment.
  18. Oversee/monitor the Optum Empire Plan NurseLine and the ongoing review of services.
  19. Oversee/monitor the ValueOptions Mental Health and Substance Abuse Program.
  20. Oversee/monitor the NYSHIP Prescription Drug Programs.
  21. Administration of the Video Tape Library Program and other JCHB wellness resources which can be used for educational purposes on health, wellness and self-care topics; these wellness resources can be used at employee health fairs, information days, Employee Assistance Program functions or membership meetings. Review and analyze proposals to modify the manner in which employer contributions to retiree premiums are calculated.
  22. Assist in the expansion of ambulatory surgical centers in bordering states and in those states where retirees commonly reside.
  23. The Joint Committee shall study and address other issues and concerns brought to the attention of the Committee that impact the accessibility, quality and costs of health care for employees covered by this agreement.
  24. Review and analyze proposals to modify the manner in which employer contributions to retiree premiums are calculated.
  25. Assist in the expansion of ambulatory surgical centers in bordering states and in those states where retirees commonly reside.
  26. Oversee/monitor the enrollment/participation requirements for the Medical Flexible Spending Account.
  27. The Joint Committee shall study and address other issues and concerns brought to the attention of the Committee that impact the accessibility, quality and costs of health care for employees covered by this agreement.

Important Reminder For Empire Plan Enrollers

(LabCorp Continues As Participating Lab)

Quest Diagnostics will no longer be a participating provider of laboratory services with United HealthCare under the Empire Plan Medical Program as of January 1, 2007.

Beginning January 1, 2007, Laboratory Corporation of America (LabCorp) is the national participating provider of laboratory services for the Empire Medical Program.  In addition to LabCorp, other regional and local laboratory providers will participate in the Empire Plan.

To find an Empire Plan participating laboratory, call the Empire Plan toll free at 1-877-NYSHIP (1-877-769-7447); select United HealthCare (option 1) and then select the option for Plan Benefits (option 1).  Or visit the Empire Plans' laboratory locator website at www.empireplanlablocator.com

Attention Empire Plan Enrollees

A Reminder About the Depression Management Program

The Depression Management Program began on October 1, 2006 and is available to all CSEA represented NYS Empire Plan enrollees.  ValueOptions the Empire Plans mental health and substance abuse program provider is the administrator of this program.

If you or your dependents have received recent treatment for depression, you may be invited to participate in this program.  Participation is voluntary, free of charge and confidential.  If you agree to participate, you will receive information to help you understand your condition.  You will also be offered educational materials and other services.

If you have questions about depression or if you or a dependent would like to see a provider, call The Empire Plan toll free at 1-877-7NYSHIP (1-877-769-7447) and choose ValueOptions.

Empire Plan Enrollees

New Coverage for HPV Vaccine

The Empire Plan covers vaccinations and immunizations in accordance with recommendations by the Centers for Disease Control (CDC) and the American Academy of Pediatrics (AAP).

The NYS Insurance Department recently added a requirement for health plans to offer pediatric immunization coverage for immunizations recommended by the Advisory Committee on Immunization Practices (ACIP).

The ACIP has endorsed Gardasil, the new vaccine for prevention of the human papillomavirus (HPV) in females ages 9 to 26.

Effective June 29, 2006 and after, the (HPV) vaccine will become a covered immunization under the Empire Plan for the following categories of young girls/adults.

Dependent females up to the age of 19 will be eligible to receive the HPV vaccine under the pediatric immunization benefit, either through a.participating provider or from a non­participating provider (basic medical coverage - subject to deductible and coinsurance) of the Empire Plan.

Eligible females ages 19 to 26 will be eligible to receive the HPV vaccine under the adult immunization benefit, which is through a participating provider ONLY.

United HealthCare will review their claims history and reconsider HPV vaccine claims retro to June 29, 2006. If eligible females have received the vaccine after June 29, 2006 and you are not sure if the claim was submitted to the Empire Plan, contact your provider's office.

Empire Plan Enrollees

Do You Know the Value of Your Drug Coverage?

True or False ... Thousands of New Yorkers with insurance lack adequate coverage for prescription drugs and must buy them at full price. According to the New York State Attorney General's prescription drug website ... TRUE!

CSEA negotiates with the State of New York to ensure adequate drug coverage is provided to our membership even as the cost of prescription drugs continues to be one of the fastest growing components in the overall cost of health care.

Today, over 80 percent of individuals covered by health insurance use their prescription drug benefit at least once a year and the average number of prescriptions filled by each person covered under the plan exceeds 11 per year.

In an effort to provide enrollees with the "true" value of prescription drug coverage, the following is a list of commonly prescribed brand name drugs:

  Employee Cost Plan Cost  
Medication Type Purchased At Day Supply 90 Day Co-pay Amount Annual Co-pay 90 Day Script Cost Annual Cost Annual Enrollee Savings
Osteoporosis Mail Order 90 $20 $80 $450 $1801 $1721
Retail Pharmacy 90 $30 $120 $482 $1928 $1808
High Blood Pressure Mail Order 90 $20 $80 $164 $655 $575
Retail Pharmacy 90 $30 $120 $171 $685 $565
Alzheimer's Mail Order 90 $20 $80 $378 $1512 $1432
Retail Pharmacy 90 $30 $120 $404 $1615 $1495
Infertility Mail Order 90 $20 $80 $1204 $4817 $4737
Retail Pharmacy 90 $30 $120 $1300 $5199 $5079

While many CSEA state enrollees have probably seen an increase in their out-of-pocket expense for prescription drugs as a result of co-payments, your health insurance plan continues to pay most of the cost of your prescription drugs.

To keep your out-of-pocket costs for prescription drugs as low as possible, let your doctor know that your co-payments are lower when you use generics and/or preferred brand-name drugs. Ask if there are alternative prescription drugs that may be right for you.

New York State Alters Domestic Partner Policy

The CSEA Health Benefits Department would like to inform enrollees of a recent change to the Department of Civil Service's policy regarding the eligibility of spouses for coverage under the New York State Health Insurance Program (NYSHIP).

Effective May 1, 2007, the New York State Department of Civil Service will alter its prior policy and afford recognition to any same-sex marriage that is legal in the jurisdiction where it was performed, for purposes of providing spousal benefits eligibility in NYSHIP.

At this time, a same-sex marriage from the following jurisdictions will be recognized if it is legal in the jurisdiction itself: The State of Massachusetts, Canada (including a11 of its provinces), Spain, South Africa, the Netherlands, and Belgium. Please note that the laws governing the legality of same-sex marriages in these jurisdictions vary. In general, NYSHIP will assume, absent any indication to the contrary, that the possession of a marriage certificate from the jurisdiction is proof that the marriage is legally recognized there.

Civil unions continue to be acceptable as part of proof requirements for domestic partner coverage. The offering of coverage for domestic partners will continue to be discretionary for PAs and PEs.

To help implement this change, there will be a special enrollment period from May 1, 2007 through May 31, 2007 during which enrollees may enroll same-sex spouses in NYSHIP without regard to the usual enrollment effective date rules. During the special enrollment period, the effective date of the spouse's coverage will be May 1, 2007 if a legal marriage took place prior to this date and the enrollee requests that effective date. Applications submitted during the special enrollment period for marriages that occur after May 1, 2007 will be effective on the date of the marriage. Applications signed after May 31, 2007 will be subject to the usual effective date rules used for spouse eligibility due to marriage.

Although these dependents are recognized as spouses by NYSHIP, enrollees may still be subject to imputed income for the value of the benefits provided to the spouse, if the spouse does not meet the qualifications as a dependent under IRS Code Section 152.

Any questions regarding this change in policy or the recognition of a marriage for NYSHIP purposes should be directed to your agency's Health Benefits Administrator, usually located in the personnel office.

Attention Empire Plan Enrollees

A Reminder About Mastectomy and Reconstructive 5 Surgery Benefits

The CSEA Health Benefits Department would like to remind enrollees that The Empire Plan covers inpatient hospital care for lymph node dissection, lumpectomy and mastectomy for treatment of breast cancer for as long as the physician and patient determine hospitalization is medically necessary.

The Plan covers all stages of reconstructive breast surgery following mastectomy, including surgery of the other breast to produce a symmetrical appearance.

The Plan also covers treatment for complications of mastectomy, including lymphedema. Prostheses and mastectomy bras are covered.

If you have questions about your coverage for implants, breast forms or other prostheses related to breast cancer treatment call United HealthCare, the Empire Plans medical/ surgical provider, toll free at 1-877-7-NYSHIP (1-877-769-7447) or you contact your agency health benefit administrator, usually located in the personnel office.

Empire Plan Benefits Management Program requirements apply. See your Empire Plan Certificate and Empire Plan Reports.

Attention Empire Plan Enrollees

A Reminder about NurseLine Services

The CSEA Health Benefits Department would like to remind enrollees that the Empire Plan NurseLine offers health and well­being information 24 hours a day. This service is provided to CSEA represented NYS Empire Plan enrollees and their eligible dependents.

Nurses can help answer questions and provide education and support for a wide variety of health related concerns such as; managing diabetes, controlling high blood pressure, understanding cancer and living with asthma. ,

Get answers to health questions, learn about possible treatment options and even gain a better understanding of a medical diagnosis or health condition by contacting the Empire Plan NurseLine toll free at 1-877-7-NYSHIP (1-877-769-7447).