SUPPLEMENTThis flyer is a companion document to the Health Insurance Choices for 2022 booklet. It explains your benefits as a NYSHIP enrollee in a negotiating unit that does not have an agreement/award with New York State as of the date this document was printed.Please refer to this document in place of pages 13–23 in Choices for information on your Empire Plan benefits.

For employees of the State of New York who are represented by Council 82 (C-82) and their enrolled dependents, COBRA enrollees

with their NYSHIP benefits and Young Adult Option enrollees

HEALTH INSURANCE

October 2021

New York State Department of Civil Service, Employee Benefits Division, Albany, New York 12239 • www.cs.ny.gov/employee-benefits

CHOICES FOR 2022

Empire Plan benefits are available worldwide, and the Plan gives you the freedom to choose a participating or nonparticipating provider or facility. This section summarizes benefits available under each portion of The Empire Plan as of January 1, 2022.1 You may also visit www.cs.ny.gov/employee-benefits or call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) for additional information on the following programs.

Medical/Surgical ProgramUnitedHealthcareP.O. Box 1600, Kingston, NY 12402-1600

Medical and surgical coverage through:

• Participating Provider Program – The Participating Provider Program network administered by UnitedHealthcare includes over 1.2 million physicians, laboratories and other providers, such as physical therapists, occupational therapists and chiropractors, located throughout the United States. Certain services are subject to a $20 copayment.

• Basic Medical Program – If you use a nonparticipating provider, the Program considers up to 80 percent of usual and customary charges for covered services after the combined annual deductible is met. After the combined annual coinsurance maximum is met, the Plan considers up to 100 percent of usual and customary charges for covered services. See Cost Sharing (beginning on page 4) for additional information.

• Basic Medical Provider Discount Program – If you are Empire Plan primary and use a nonparticipating provider who is part of the Empire Plan MultiPlan group, your out-of-pocket costs may be lower (see page 5).

Home Care Advocacy Program (HCAP) – Benefits for home care, durable medical equipment and certain medical supplies (including diabetic and ostomy supplies), enteral formulas and diabetic shoes are paid in full. (Diabetic shoes have an annual maximum benefit of $500.) Prior authorization is required. Guaranteed access to network benefits nationwide. Limited non-network benefits available (see the Empire Plan Certificate for details).

Managed Physical Medicine Program (MPMP) – Chiropractic treatment, physical therapy and occupational therapy through a network provider are subject to a $20 copayment. Unlimited network benefits when medically necessary. Guaranteed access to network benefits nationwide. Non-network benefits available.

Under the Benefits Management Program, you must call the Medical/Surgical Program for Prospective Procedure Review before an elective (scheduled) magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computerized tomography (CT) scan, positron emission tomography (PET) scan or nuclear medicine test, unless you are having the test as an inpatient in a hospital (see the Empire Plan Certificate for details).

When arranged by the Medical/Surgical Program, a voluntary, paid-in-full specialist consultant evaluation is available. Voluntary outpatient medical case management is available to help coordinate services for catastrophic and complex cases.

Hospital ProgramEmpire BlueCrossNew York State Service Center P.O. Box 1407, Church Street Station New York, NY 10008-1407

The following benefit levels apply for covered services received at a BlueCross and BlueShield Association BlueCard® PPO network hospital:

• Inpatient hospital stays are covered at no cost to you.• Outpatient hospital and emergency care are

subject to network copayments.• Anesthesiology, pathology and radiology provider

charges for covered hospital services are paid in full under the Medical/Surgical Program (if The Empire Plan provides your primary coverage).

• Certain covered outpatient hospital services provided at network hospital extension clinics are subject to outpatient hospital copayments.

• Except as noted above, physician charges received in a hospital setting will be paid in full if the provider is a participating provider under the Medical/Surgical Program. Physician charges for

THE EMPIRE PLAN NYSHIP CODE #001

1 These benefits are subject to medical necessity and to limitations and exclusions described in the Empire Plan Certificate.

2 Choices 2022/Active Supplement

covered services received from a non-network provider will be paid in accordance with the Basic Medical portion of the Medical/Surgical Program.

If you are an Empire Plan-primary enrollee,2 you will be subject to 10 percent coinsurance for inpatient stays at a non-network hospital. For outpatient services received at a non-network hospital, you will be subject to the greater of 10 percent coinsurance or $75 per visit. The Empire Plan will begin to cover 100 percent of the billed charges for covered inpatient and outpatient services only after the combined annual coinsurance maximum threshold has been reached.

The Empire Plan will approve network benefits for hospital services received at a non-network facility if:

• Your hospital care is emergency or urgent• No network facility can provide the medically

necessary services• You do not have access to a network facility within

30 miles of your residence• Another insurer or Medicare provides your primary

coverage (pays first)

Preadmission Certification Requirements Under the Benefits Management Program, if The Empire Plan is your primary coverage, you must call the Hospital Program for certification of any of the following inpatient stays:

• Before a scheduled (nonemergency) hospital admission

• Within 48 hours or as soon as reasonably possible after an emergency or urgent hospital admission

• Before admission or transfer to a skilled nursing facility

If you do not follow the preadmission certification requirement for the Hospital Program, you must pay:

• A $200 hospital penalty if it is determined any portion was medically necessary; and

• All charges for any day’s care determined not to be medically necessary.

Voluntary inpatient medical case management is available to help coordinate services for catastrophic and complex cases.

Mental Health and Substance Use ProgramBeacon Health Options, Inc.P.O. Box 1850, Hicksville, NY 11802

The Mental Health and Substance Use (MHSU) Program offers both network and non-network benefits.

Network Benefits(unlimited when medically necessary)

If you call the MHSU Program before you receive services and follow their requirements, you receive:

• Inpatient services, paid in full• Crisis intervention, paid in full for up to three visits

per crisis; after the third visit, the $20 copayment per visit applies

• Outpatient services, including office visits, home-based or telephone counseling and nurse practitioner services, for a $20 copayment per visit

• Intensive Outpatient Program (IOP) with an approved provider for mental health or substance use treatment for a $20 copayment per day

2 If Medicare or another plan provides primary coverage, you receive network benefits for covered services at both network and non-network hospitals.

3Choices 2022/Active Supplement

Non-Network Benefits3

(unlimited when medically necessary)

The following applies if you do NOT follow the requirements for network coverage.

• For Practitioner Services: The MHSU Program will consider up to 80 percent of usual and customary charges for covered outpatient practitioner services after you meet the combined annual deductible per enrollee, per enrolled spouse or domestic partner and per all enrolled dependent children combined. After the combined annual coinsurance maximum is reached, the Program reimburses up to 100 percent of usual and customary charges for covered services (see page 5).

• For Approved Facility Services: You are responsible for 10 percent of covered, billed charges up to the combined annual coinsurance maximum per enrollee, per enrolled spouse or domestic partner and per all enrolled dependent children combined. After the coinsurance maximum is met, the Program pays 100 percent of billed charges for covered services (see page 5).

• Outpatient treatment sessions for family members of an individual being treated for alcohol or substance use are covered for a maximum of 20 visits per year for all family members combined.

Empire Plan Cost SharingPlan ProvidersUnder The Empire Plan, benefits are available for covered services when you use a participating or nonparticipating provider. However, your share of the cost of covered services depends on whether the provider you use participates in the Plan. You receive the maximum plan benefits when you use participating providers. For more information, read Reporting On Network Benefits. You can find this publication at www.cs.ny.gov/employee-benefits or ask your HBA for a copy.

If you use an Empire Plan participating or network provider or facility, you pay a copayment for certain services. Some services are covered at no cost to you. The provider or facility files the claim and is reimbursed by The Empire Plan.

Even if there are no network providers in your area, you are guaranteed access to network benefits for the following services if you call The Empire Plan at 1-877-769-7447 beforehand to arrange care with an appropriate medical or mental health provider:

• Mental Health and Substance Use (MHSU) Program services

• Managed Physical Medicine Program services (physical therapy, chiropractic care and occupational therapy)

• Home Care Advocacy Program (HCAP) services (including durable medical equipment)

If you use a nonparticipating provider or non-network facility, benefits for covered services are subject to a deductible and/or coinsurance.

2022 Annual Maximum Out-of-Pocket Limit Your maximum out-of-pocket expenses for in-network covered services will be $5,650 for Individual coverage and $11,300 for Family coverage for Hospital, Medical/Surgical and MHSU Programs, combined. Once you reach the limit, you will have no additional copayments.

Combined Annual DeductibleFor Medical/Surgical and MHSU Program services received from a nonparticipating provider or non-network facility, The Empire Plan has a combined annual deductible that must be met before covered services under the Basic Medical Program and non-network expenses under both the HCAP and MHSU Programs can be reimbursed. See the table on page 5 for 2022 combined annual deductible amounts. The Managed Physical Medicine Program has a separate $250 deductible per enrollee, $250 per enrolled spouse/domestic partner and $250 per all dependent children combined that is not included in the combined annual deductible.

After you satisfy the combined annual deductible, The Empire Plan considers 80 percent of the usual and customary charge for the Basic Medical Program and non-network practitioner services for the MHSU Program, 50 percent of the network allowance for covered services for non-network HCAP services and 90 percent of the billed charges for covered services for non-network approved facility services for the

3 You are responsible for ensuring that MHSU Program certification is received for care obtained from a non-network practitioner or facility.

4 Choices 2022/Active Supplement

MHSU Program. You are responsible for the remaining 20 percent coinsurance and all charges in excess of the usual and customary charge for Basic Medical Program and non-network practitioner services, 10 percent for non-network MHSU-approved facility services and the remaining 50 percent of the network allowance for covered, non-network HCAP services.

Combined Annual Coinsurance MaximumThe Empire Plan has a combined annual coinsurance maximum that must be met before covered services under the Basic Medical Program and non-network expenses under the Hospital and MHSU Programs will be fully reimbursed. See the table above for 2022 combined annual coinsurance maximum amounts.

After you reach the combined annual coinsurance maximum, you will be reimbursed up to 100 percent of covered charges under the Hospital Program and 100 percent of the usual and customary charges for services covered under the Basic Medical Program and MHSU Program. You are responsible for paying the provider and will be reimbursed by the Plan for covered charges. You are also responsible for paying all charges in excess of the usual and customary charge.

The combined annual coinsurance maximum will be shared among the Basic Medical Program and non-network coverage under the Hospital Program and MHSU Program. The Managed Physical Medicine Program and HCAP do not have a coinsurance maximum.

Basic Medical Provider Discount ProgramIf you are Empire Plan primary, the Plan also includes a program to reduce your out-of-pocket costs when you use a nonparticipating provider. The Empire Plan Basic Medical Provider Discount Program offers discounts from certain physicians and providers who are not part of The Empire Plan participating provider network. These providers are part of the nationwide MultiPlan group, a provider organization contracted with UnitedHealthcare. Empire Plan Basic Medical Program provisions apply, and you must meet the combined annual deductible.

Providers in the Basic Medical Provider Discount Program accept a discounted fee for covered services. Your 20 percent coinsurance is based on the lower of the discounted fee or the usual and customary charge. Under this Program, the provider submits your claims, and UnitedHealthcare pays The Empire Plan portion of the provider fee directly to the provider if the services qualify for the Basic Medical Provider Discount Program. Your explanation of benefits, which details claims payments, shows the discounted amount applied to billed charges.

To find a provider in the Empire Plan Basic Medical Provider Discount Program, ask if the provider is an Empire Plan MultiPlan provider or call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447), choose the Medical/Surgical Program and ask a representative for help. You can also go to www.cs.ny.gov/employee-benefits. Select your group and plan, if prompted, and then Find a Provider.

2022 Combined Annual Deductible and Annual Coinsurance Maximum Amounts

Employees who are represented by C-82 Combined Annual Deductible

Combined Annual Coinsurance Maximum

Enrollee $1,000 $3,000

Enrolled spouse/domestic partner $1,000 $3,000

Dependent children combined $1,000 $3,000

5Choices 2022/Active Supplement

Prescription Drug ProgramCVS CaremarkP.O. Box 6590, Lee’s Summit, MO 64064-6590

The Prescription Drug Program does not apply to those who have drug coverage through a union Employee Benefit Fund.

• When you use a network pharmacy, the mail service pharmacy or the designated specialty pharmacy for a 1- to 30-day supply of a covered drug, you pay a $5 copayment for Level 1 or most generic drugs; a $25 copayment for Level 2, preferred drugs or compound drugs; and a $45 copayment for Level 3, certain generic drugs or non-preferred drugs.

• For a 31- to 90-day supply of a covered drug through a network pharmacy, you pay a $10 copayment for Level 1 or most generic drugs; a $50 copayment for Level 2, preferred drugs or compound drugs; and a $90 copayment for Level 3, certain generic drugs or non-preferred drugs.

• For a 31- to 90-day supply of a covered drug through the mail service pharmacy or the designated specialty pharmacy, you pay a $5 copayment for Level 1 or most generic drugs; a $50 copayment for Level 2, preferred drugs or compound drugs; and a $90 copayment for Level 3, certain generic drugs or non-preferred drugs.

• When you fill a prescription for a covered brand- name drug that has a generic equivalent, you pay the Level 3 or non-preferred copayment, plus the difference in cost between the brand-name drug and the generic equivalent (or “ancillary charge”), not to exceed the full retail cost of the drug, unless the brand-name drug has been placed on Level 1 of the Flexible Formulary. Exceptions apply. Please contact the Empire Plan Prescription Drug Program toll free at 1-877-7-NYSHIP (1-877-769-7447) for more information.

• The Empire Plan has a flexible formulary that excludes certain prescription drugs from coverage.

• Prior authorization is required for certain drugs.• Oral chemotherapy drugs for the treatment of

cancer do not require a copayment.• Tamoxifen, raloxifene, anastrozole and exemestane

do not require a copayment when prescribed for the primary prevention of breast cancer. In addition, generic oral contraceptive drugs/devices or brand-name drugs/devices without a generic equivalent (single-source brand-name drugs/devices) do not require a copayment. The copayment waivers for these drugs will only be provided if the drug is filled at a network pharmacy.

• Certain preventive adult vaccines, when administered at a pharmacy that participates in the CVS Caremark National Vaccine Network, do not require a copayment.

• A pharmacist is available 24 hours a day, seven days a week to answer questions about your prescriptions.

• You can use a non-network pharmacy or pay out of pocket at a network pharmacy (instead of using your Empire Plan Benefit Card) and submit a claim form for reimbursement. In almost all cases, you will not be reimbursed the total amount you paid for the prescription, and your out-of-pocket expenses may exceed the usual copayment amount. To reduce your out-of-pocket expenses, use your Empire Plan Benefit Card whenever possible.

See the Empire Plan Certificate or contact the Plan for more information.

6 Choices 2022/Active Supplement

* The annual maximum out-of-pocket limit does not apply to Empire Plan Medicare Rx.

2022 Annual Maximum Out-of-Pocket Limit* Annual maximum out-of-pocket expenses for covered drugs received from a network pharmacy will be $3,050 for Individual coverage and $6,100 for Family coverage. Once you reach the limit, you will have no additional copayments for prescription drugs.

Specialty PharmacyCVS Caremark Specialty Pharmacy is the designated pharmacy for The Empire Plan Specialty Pharmacy Program. The Program provides enhanced services to individuals using specialty drugs (such as those used to treat complex conditions and those that require special handling, special administration or intensive patient monitoring). The complete list of specialty drugs included in the Specialty Pharmacy Program is available on NYSHIP Online. Go to www.cs.ny.gov/employee-benefits and choose your group and plan, if prompted. Select Using Your Benefits and then Specialty Pharmacy Drug List.

The Program provides enrollees with enhanced services that include disease and drug education; compliance, side effect and safety management; expedited, scheduled delivery of medications at no additional charge; refill reminder calls; and all necessary supplies (such as needles and syringes) applicable to the medication.

Under the Specialty Pharmacy Program, you are covered for an initial 30-day fill of most specialty medications at a retail pharmacy, but all subsequent fills must be obtained through the designated specialty pharmacy. When CVS Caremark dispenses a specialty medication, the applicable mail service copayment is charged. To get started with CVS Caremark Specialty Pharmacy, request refills or speak to a specialty-trained pharmacist or nurse, call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447). Choose the Prescription Drug Program and ask to speak with Specialty Customer Care.

Medicare-primary enrollees and dependents:If you are Medicare primary or will be in 2022, ask your HBA for a copy of 2022 Choices for Retirees for information about your coverage under Empire Plan Medicare Rx, a Medicare Part D prescription drug program.

Contact The Empire PlanFor additional information or questions on any of the benefits described here, call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and select the applicable program.

Teletypewriter (TTY) NumbersThese numbers are available to callers who use a TTY device because of a disability and are all toll free.

Medical/Surgical ProgramTTY only: .......................................................................1-888-697-9054Hospital ProgramTTY only: ........................................................................1-800-241-6894Mental Health and Substance Use ProgramTTY only: .........................................................................1-855-643-1476Prescription Drug ProgramTTY only: ..........................................................................................................711

The Empire Plan NurseLineSM

For health information and support, call The Empire Plan and press or say 5 for the NurseLineSM.

Registered nurses are available 24 hours a day, seven days a week. All calls are confidential.

7Choices 2022/Active Supplement

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e

can

be p

erfo

rmed

is co

vere

d wh

en th

e se

rvice

is p

rovid

ed b

y a lic

ense

d am

bulan

ce se

rvice

and

the

type

of a

mbu

lance

tran

spor

tatio

n is

requ

ired

beca

use

of an

em

erge

ncy s

ituat

ion.

9Choices 2022/Active Supplement

The

Empi

re P

lan

Bene

fits

Net

wor

k H

ospi

tal B

enef

its1,2

Part

icip

atin

g Pr

ovid

er2

Non

part

icip

atin

g Pr

ovid

er

Appr

oved

Fac

ility

M

enta

l Hea

lth S

ervi

ces

No co

paym

ent

90%

of b

illed

char

ges;

afte

r app

licab

le

coin

sura

nce

max

, cove

red

in fu

ll (se

e pa

ges 4

–5 fo

r det

ails)

Outp

atie

nt D

rug/

Alco

hol

Reha

bilit

atio

n$2

0 pe

r day

to ap

prov

ed

Inte

nsive

Out

patie

nt P

rogr

amAp

plica

ble

annu

al de

duct

ible

, 80

% of

usu

al an

d cu

stom

ary;

afte

r app

licab

le co

insu

ranc

e m

ax,

100%

of u

sual

and

custo

mar

y (se

e pa

ges 4

–5 fo

r det

ails)

Inpa

tient

Dru

g/Al

coho

l Reh

abili

tatio

nNo

copa

ymen

t90

% of

bille

d ch

arge

s; af

ter a

pplic

able

co

insu

ranc

e m

ax, c

over

ed in

full

(see

page

s 4–5

for d

etail

s)

Dura

ble

Med

ical E

quip

men

tNo

copa

ymen

t (HC

AP)

50%

of n

etwo

rk al

lowa

nce

(se

e th

e Em

pire

Pla

n Ce

rtific

ate)

Pros

thet

ics

No co

paym

ent14

Basic

Med

ical3,

14 $

1,500

lifet

ime

max

imum

ben

efit

for p

rosth

etic

wigs

no

t sub

ject t

o de

ducti

ble o

r coin

sura

nce

Orth

otic

Devi

ces

No co

paym

ent14

Basic

Med

ical3,

14

Reha

bilit

ativ

e Ca

re

(not

cove

red

in a

skille

d nu

rsin

g fa

cility

if M

edica

re p

rimar

y)

No co

paym

ent a

s an

inpa

tient

; $2

0 pe

r visi

t for

out

patie

nt p

hysic

al th

erap

y fol

lowi

ng re

lated

surg

ery

or h

ospi

taliz

atio

n15

Phys

ical o

r occ

upat

iona

l the

rapy

$2

0 pe

r visi

t (M

PMP)

Spee

ch th

erap

y $20

per

visit

$250

annu

al de

duct

ible

, 50

% of

net

work

allo

wanc

e (M

PMP)

Basic

Med

ical3

Diab

etic

Supp

lies

No co

paym

ent (

HCAP

)50

% of

net

work

allo

wanc

e (se

e th

e Em

pire

Pla

n Ce

rtific

ate)

Insu

lin a

nd O

ral A

gent

s(co

vere

d un

der t

he P

resc

riptio

n Dr

ug

Prog

ram

, sub

ject

to d

rug

copa

ymen

t)

Diab

etic

Shoe

s$5

00 an

nual

max

imum

ben

efit

75%

of n

etwo

rk al

lowa

nce

up to

an

annu

al m

axim

um b

enef

it of

$50

0

(see

the

Empi

re P

lan

Certi

ficat

e)

Hosp

ice

No co

paym

ent,

no lim

it 10

% of

bille

d ch

arge

s up

to th

e co

mbin

ed

annu

al co

insur

ance

max

imum

10 Choices 2022/Active Supplement

Bene

fits

Net

wor

k H

ospi

tal B

enef

its1,2

Part

icip

atin

g Pr

ovid

er2

Non

part

icip

atin

g Pr

ovid

er

Skill

ed N

ursin

g Fa

cility

16,17

No co

paym

ent

10%

of b

illed

char

ges u

p to

the

com

bined

an

nual

coins

uran

ce m

axim

um

Pres

crip

tion

Drug

s (se

e pa

ges 6

–7):

Sp

ecial

ty D

rugs

(see

pag

e 7)

Addi

tiona

l Ben

efits

:

Dent

al (p

reve

ntive

) No

t cov

ered

No

t cov

ered

Vi

sion

(rout

ine

only)

No

t cov

ered

Not c

over

ed

Hear

ing

Aids

No

net

work

ben

efit.

Se

e no

npar

ticip

atin

g pr

ovid

er.

Up to

$1,5

00 p

er ai

d pe

r ear

eve

ry

4 ye

ars (

ever

y 2 ye

ars f

or ch

ildre

n)

if m

edica

lly n

eces

sary

An

nual

Out-o

f-Poc

ket M

axim

umIn

divid

ual c

over

age:

$3,

050

for t

he P

resc

riptio

n Dr

ug P

rogr

am.17

$5,6

50 sh

ared

max

imum

for t

he H

ospi

tal, M

edica

l/Sur

gica

l and

M

enta

l Hea

lth/S

ubsta

nce

Use

Prog

ram

s.Fa

mily

cove

rage

: $6,

100

for t

he P

resc

riptio

n Dr

ug P

rogr

am.17

$1

1,300

shar

ed m

axim

um fo

r the

Hos

pita

l, Med

ical/S

urgi

cal a

nd

Men

tal H

ealth

/Sub

stanc

e Us

e Pr

ogra

ms.

Not a

vaila

ble

Ou

t-of-A

rea B

enef

itBe

nefit

s for

cove

red

serv

ices a

re av

ailab

le w

orld

wide

.

24-h

our N

urse

LineSM

for h

ealth

info

rmat

ion

and

supp

ort a

t 1-8

77-7

-NYS

HIP

(1-87

7-76

9-74

47);

pres

s or s

ay 5

.

Volu

ntar

y dise

ase

man

agem

ent p

rogr

ams a

vaila

ble

for c

ondi

tions

such

as as

thm

a, at

tent

ion

defic

it hy

pera

ctivi

ty d

isord

er (A

DHD)

, car

diov

ascu

lar d

iseas

e (C

AD),

ch

roni

c kid

ney d

iseas

e (C

KD),

chro

nic o

bstru

ctive

pul

mon

ary d

iseas

e (C

OPD)

, con

gesti

ve h

eart

failu

re, d

epre

ssio

n, d

iabet

es an

d ea

ting

diso

rder

s.

Diab

etes

edu

catio

n ce

nter

s for

enr

olle

es w

ho h

ave

a diag

nosis

of d

iabet

es.

For m

ore

info

rmat

ion

rega

rdin

g co

vere

d va

ccin

es, t

ests

and

scre

enin

gs, s

ee th

e Em

pire

Pla

n Pr

even

tive

Care

Cov

erag

e Gu

ide

on N

YSHI

P On

line

unde

r Pub

licat

ions

or

visit

www

.hhs

.gov

/hea

lthca

re/ri

ghts/

prev

entiv

e-ca

re.

1 I

npat

ient

stay

s at n

etwo

rk h

ospi

tals

are

paid

in fu

ll. Pr

ovid

er ch

arge

s are

co

vere

d un

der t

he M

edica

l/Sur

gica

l Pro

gram

. Non

-net

work

hos

pita

l cov

erag

e pr

ovid

ed su

bjec

t to

coin

sura

nce

(see

page

s 2–3

). 2

Cop

aym

ent w

aived

for p

reve

ntive

serv

ices u

nder

the

PPAC

A.

See

www.

hhs.g

ov/h

ealth

care

/righ

ts/pr

even

tive-

care

or N

YSHI

P On

line

fo

r det

ails.

Diag

nosti

c ser

vices

requ

ire p

lan co

paym

ent o

r coi

nsur

ance

. 3

See

Cos

t Sha

ring

(beg

inni

ng o

n pa

ge 4

) for

Bas

ic M

edica

l info

rmat

ion.

14 B

enef

it pa

id u

p to

cost

of d

evice

mee

ting

indi

vidua

l’s fu

nctio

nal n

eed.

15 P

hysic

al th

erap

y mus

t beg

in w

ithin

six m

onth

s of t

he re

lated

surg

ery o

r ho

spita

lizat

ion

and

be co

mpl

eted

with

in 3

65 d

ays o

f the

relat

ed su

rger

y or

hos

pita

lizat

ion.

16 U

p to

365

ben

efit

days

; Ben

efits

Man

agem

ent P

rogr

am p

rovis

ions

appl

y. 17

Doe

s not

appl

y to

Med

icare

-prim

ary e

nrol

lees

.

11Choices 2022/Active Supplement

It is the policy of the New York State Department of Civil Service to provide reasonable accommodation to ensure effective communication of information in benefits publications to individuals with disabilities. These publications are also available on NYSHIP Online at www.cs.ny.gov/employee-benefits. Visit NYSHIP Online for timely information that meets universal accessibility standards adopted by New York State for NYS agency websites. If you need an auxiliary aid or service to make benefits information available to you, please contact your Health Benefits Administrator. COBRA and Young Adult Option enrollees, contact the Employee Benefits Division.

Health Insurance Choices was printed using recycled paper and environmentally sensitive inks. Choices 2022/Active Supplement NY1398

2022 Health Insurance Choices Supplement – October 2021