ManagementAsthma Allergy

I n T h i s R e p o r tSAVE THISREPORT

SPECIALSECTIONS

IMPORTANTNUMBERS

Asthma Management ProgramThe Empire Plan now offers theAsthma Management Program, alsocalled Managing for Tomorrow. If youor your dependents have receivedrecent treatment for asthma orasthma-related respiratory problems,you may be invited to participate inthis program. Participation isvoluntary, free of charge andconfidential. If you agree toparticipate, you will receiveinformation to help you understandyour condition. You will also beoffered educational materials andother services. The Asthma Management Programbegan January 1, 2002 and is availableto Empire Plan enrollees throughUnited HealthCare. With theintroduction of this new program, the Empire Plan now offers twodisease management programsthrough United HealthCare: theCardiovascular Risk ReductionProgram and the AsthmaManagement 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.

The Empire Plan atwww.cs.state.ny.usThe New York State Department of Civil Service Web site atwww.cs.state.ny.us links to information aboutNYSHIP and yourEmpire Planbenefits. Click onEmployee Benefitsfor the 2002version of The Empire Plan At a Glance,a directory of agency Health BenefitsAdministrators and important telephonenumbers. Recent publications are alsoavailable on the site, which meetsuniversal accessibility standards adoptedby New York State for New York Stateagency Web sites. If you don’t havecomputer access to the Internet, visityour local library. Most libraries havecomputers linked to the Internet.

NEW YORK STATE HEALTH INSURANCE PROGRAM (NYSHIP)FOR ACTIVE EMPLOYEES OF PARTICIPATING EMPLOYERSAnd for their enrolled Dependentsand for COBRA Enrollees with their Empire Plan Benefits

J U N E 2 0 0 2

1 Asthma Management; Allergy Serum

2 Clinical Referral Line;Subrogation

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

NYSHIP General InformationBook and Empire PlanCer tificate Amendments

Repor ting On Asthma

Telephone Cards

5 Empire Plan Reminders 6 New Publications7 Your Plan

SerumEffective January 1, 2002, you haveno copayment for allergy serumdispensed by an Empire Planparticipating physician to beadministered to you by another partyin another setting. The Empire Planwill reimburse the provider directlyfor the allergy serum according tothe network schedule; you will haveno additional costs.Before this change, such serum,called “take-away” serum, wasconsidered under the Basic MedicalProgram, subject to deductible andcoinsurance.

NY SOnLineBenefitsEmployee Benefits DivisionState of New York Department of Civil ServiceFind the benefit, click on the group Benefits vary by group

Recent Publications

What’s New

Happenings

Phone Numbers

About Us

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Copyright/DisclaimersNYSHIP for Local Govts.

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P L A NREPORT

We’ve enclosedfour new EmpirePlan telephonenumber cards foryou and yourfamily withinthis Report. Ifyou need 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 BENEFITS

Participating Provider and Basic Medical Programs Chiropractic treatment and physical therapyCall United HealthCare 1-800-942-4640Pre-authorization of MRIHome care services, durable medical equipment/suppliesInfertility benefitsCall United HealthCare 1-800-638-9918

THE EMPIRE PLANNew York State Health Insurance Program

Clinical Referral LineValueOptions

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The Empire Plan Mental Health andSubstance Abuse Program providescomprehensive coverage for mentalhealth and substance abuse care. But before you seek mental health or substance abuse care, including

treatment for alcoholism, you must callValueOptions’ ClinicalReferral Line at

1-800-446-3995. The Clinical ReferralLine is available 24 hours a day, everyday of the year. When you call ValueOptions, select themenu option for referral to a mentalhealth or chemical dependencyprofessional. An experienced mentalhealth and substance abuse clinicianwill be there to help you.The clinician will talk with you and assesswhether you need routine, urgent oremergency care. The clinician will thenprovide you with names and phone

numbers of three network providers. If you do not have access to a networkprovider, the clinician will arrange for you to receive network benefits with anon-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, an appointmentshould be available to you within 24hours of your contacting the provider.

• If you need emergency care,ValueOptions will have a providercall you within 30 minutes or will direct you to an appropriatefacility for treatment.If you feel your need is urgent or anemergency, tell the clinician; theclinician will accept your assessment.If you have any difficulty scheduling an appointment with one of the recommendedproviders, call ValueOptions again at 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 by thePlan when, in fact, these expenses arethe liability of another party. When thePlan pays for these expenses, it mayhave the right to seek repayment fromthe third party legally responsible forthe injury or illness. This recoveryprocess is known as subrogation.

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

accident may be the responsibility of an automobile insurer; expenses foran injury resulting from the wrongfulacts of a third party may be theresponsibility of 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 United HealthCare)have contracted with HealthcareRecoveries, Inc. (HRI) to administercertain recovery efforts. If the EmpirePlan has paid claims on your behalf thatappear to be the liability of a third party,HRI may send you a letter asking forinformation about those claims.

What if I receive a letter from HRI? If you receive a letter from HRI, pleaserespond as directed. Even if you thinkno other party is responsible for yourclaim, please provide the requestedinformation. HRI needs the informationto determine the Empire Plan’s liability.

Why should I contact HRI?When you answer your letter from HRI,you may be helping the Empire Planrecover monies that are the liability ofanother party. This process is one waythe Empire Plan keeps your healthinsurance premiums as reasonable aspossible.

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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. 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 Blue Cross and BlueShield at 518-367-0009(Albany area and Alaska)

or 1-800-342-9815 (NYS and other statesexcept Alaska) for pre-authorization ofthe covered services.If you do not use the TransplantsProgram, you are still eligible forEmpire Plan benefits for your medicallynecessary transplant. You must callEmpire Blue Cross and Blue Shield at518-367-0009 or 1-800-342-9815 forpre-admission certification of admissionfor transplants. And, you will have to payany applicable deductible, coinsurance,copayments and non-covered charges.

If you choose to use a non-participatingprovider for transplant services, yourout-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 Website at www.organdonor.gov.

What should you do if you need healthcare while traveling or livingoutside the United States?

Here are some suggestions:• Ask the American Embassy for names

of reliable, English-speaking doctors.• After you receive services, ask for

copies of your medical records inEnglish, if possible.

• Get a receipt when you pay yourbill(s).

• Submit the records to theappropriate Empire Plan carrier.

You have paid-in-full benefits formedically necessary covered servicesprovided in an inpatient hospital

setting. Pre-admission certification is not required when you arehospitalized or admitted to a skilled nursing facility outside the United States.Carriers will consider other claims for payment under non-network coverage. Please

see your Empire Plan Certificatefor 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, whenyou’re outside the United States wherethe Empire Plan toll-free numbers donot work, you may call the EmployeeBenefits Division at 518-457-5754.Employee Benefits representatives areavailable Monday through Friday, 9 amto 3 pm Eastern time.

Medicare CoverageIf you are Medicare-primary, rememberthat you have no Medicare coverageoutside the United States. The EmpirePlan is primary until you return. Saveyour health care records and send themto the Empire Plan carriers.If you are living permanently outsidethe United States, you must notify theEmployee Benefits Division in writing.The State or your ParticipatingEmployer will discontinue yourMedicare Part B reimbursement, andthe Empire Plan will provide yourprimary health insurance coverage.

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Full-Time Student EligibilityYour unmarried dependent children areeligible for NYSHIP coverage if they are:

• age 19 or over but under age 25, and• full-time students at an accredited

secondary, preparatory or tradeschool, college or other educationalinstitution, and

• otherwise not eligible for employergroup 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, your dependent may beentitled to continue coverage underCOBRA. Ask your agency HealthBenefits Administrator about COBRAand the 60-day application deadline.Please see your NYSHIP GeneralInformation Book for more informationabout dependent eligibility for NYSHIPcoverage.

Continuing Coverage in RetirementAsk your Participating Employer ifyour class (group) of employees iseligible to continue health insurance in retirement.

If your group is eligible, when youretire, you may continue coverage foryourself and your eligible dependents ifyou meet certain eligibilityrequirements. A minimum serviceperiod is one of these requirements. You must have had at least five years ofservice, not necessarily continuous,with your agency from which you areretiring, subject to the following:• Your agency may elect

administratively or through collectivenegotiations to establish a servicerequirement greater than five yearsfor purposes of determining eligibilityfor retirement for all employees or aclass or category of employees whosemost recent date of employment withthe employer is after April 1, 1975.

• If you had less service than thatestablished by your agency forcoverage in retirement, your agencymay elect administratively or throughcollective negotiations to provide forcontinuation of coverage inretirement for all employees or aclass or category of employees whohave met the applicable period ofrequired service with one or morepublic employers, provided you haveserved a minimum of one year withyour agency.

• If your agency elects to provideretiree coverage, it will do so for allemployees or all employees in a classor category who meet the conditionsspecified. Your agency may electadministratively or through collectivenegotiations to establish as ineligiblefor coverage all employees or a classor category of employees whose mostrecent date of employment with theemployer is after April 1, 1977.

See your NYSHIP General InformationBook for information about less thanfull-time employment.Your NYSHIP General InformationBook explains eligibility for retireecoverage. In addition to completing the minimum service period, you mustsatisfy requirements for retiring as amember of a State retirement systemand be enrolled in the New York StateHealth Insurance Program. See yourBook for more information.

Information in Another Language The New York State Health InsuranceProgram offers Language Line Services(LLS), an over-the-phone languagetranslation service for enrollees whocall the Employee Benefits Division.If you understand another languagebetter than English and would likeanswers to your health insurancequestions in another language, you maycall the Employee Benefits Division anduse LLS. You may call on your own orask someone else acting on your behalfto 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 representatives are available Monday through Friday,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 call begins for you, the representative and the interpreter.

3. The interpreter translates for youand for the representative.

LLS interpreters are trained in over-the-phone translation skills. Theygive accurate, objective translations.All calls are strictly confidential.

RemindersNew York State Health Insurance Program

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New Numbers for the BenefitsManagement ProgramYou 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 United HealthCare at 1-800-638-9918:

• Before having an elective (scheduled)Magnetic Resonance Imaging (MRI)unless you are having the test as aninpatient in a hospital

You may also call United HealthCare at1-800-638-9918 to request a voluntaryspecialist consultant evaluation for anyscheduled procedure.The Benefits Management Programrequirements also apply when you or your enrolled dependents have primarycoverage through an HMO withsecondary coverage under the Empire Plan, and you choose not to use the HMO.If you will be admitted to a medicalcenter or hospital operated by the U.S.Department of Veterans’ Affairs, and willbe using your Empire Plan benefits, youmust comply with the BenefitsManagement Program requirements.Empire Blue Cross and Blue Shield and 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 theaccurate and up-to-date informationneeded to complete your claim forms.Participating and non-participating ornon-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 MailThe following does not apply if you haveprescription drug coverage through aunion Employee Benefit Fund.

Do you take any prescriptionmedications on a long-term basis? If so,you can order your covered prescriptiondrugs by mail from the Empire PlanPrescription Drug Program mail servicepharmacy, Express Scripts Mail Service.You can order up to a 90-day supply of your prescriptions, shipped to yourhome. For mail service pharmacy order 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, or onlineat the Express Scripts Web site,www.express-scripts.com. Choose theMail Service Prescriptions Refill page.When your order is placed online, you’llknow right away if your refill has beenapproved. And, you can check the statusof your order.If you prefer, you still may fill yourprescription at an Empire Plan/ExpressScripts participating pharmacy or, at ahigher cost to you, at a non-participatingpharmacy.Please see your Empire Plan Certificatefor more information about the EmpirePlan Prescription Drug Program.

The Empire Plan NurseLineSMThe Empire Plan NurseLine offersenrollees health information and advice24 hours a day, seven days a week.Whether you want more informationabout a recent diagnosis or arewondering how to stay healthy, you cancall 1-800-439-3435 toll-free to talk withan experienced registered nurse or toreach the Empire Plan NurseLine’sHealth Information Library. For recordedmessages on more than 1,000 topics,enter PIN number 335 and a four-digittopic code from the Empire PlanNurseLine brochure you received in themail. 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 ofmedical treatment. In anemergency admission, thecondition requires immediateinpatient medical attention, andany delay in receiving treatmentwould be harmful to the patient.The patient does not have to beadmitted via the emergency roomto be considered an emergencyadmission.

Urgent AdmissionUrgent admissions involve medicalconditions or acute trauma suchthat inpatient medical attention,while not immediately essential,should be provided very early inorder to prevent possible loss orimpairment of life, limb or bodyfunction.

Report continued from page 4

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We’ve also prepared twopublications to help youplan for retirement. TheNovember 2001Planning forRetirement(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 Health InsuranceProgram benefits.

If you’re thinking aboutretirement, ask your agency Health BenefitsAdministrator for copies of these importantpublications. Or check the New York StateDepartment of Civil ServiceWeb site, www.cs.state.ny.us.Click on Employee Benefits,then on Recent Publications.

PublicationsNew

We’ve updated two of ourReporting On publications –Reporting OnNetwork Benefitsand ReportingOn HealthyBabies. Youragency HealthBenefitsAdministratornow has copiesavailable. You’llalso find thesepublications onthe New York State Department of CivilService Web site, www.cs.state.ny.us.Click on Employee Benefits, then onRecent Publications.

Reporting OnNetwork Benefits(January 2002) detailsEmpire Plan networkcoverage. ReportingOn Healthy Babies(March 2002) offersinformation for mothersand their babies.Your agency HealthBenefits Administratoralso has a supply of the

new publication, Reporting OnAsthma, included in this Report, ifyou’d like another copy.

Reporting On

Thinking about Retirement

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 Web site,www.cs.state.ny.us. Click on EmployeeBenefits, then on Recent Publications.

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. TheEmployee Benefits Division administers theNew York State Health Insurance Program(NYSHIP). NYSHIP provides your healthinsurance benefits through the Empire Plan.

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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-PE-02-1

ADDRESS SERVICE REQUESTED

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

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Information for the Enrollee, Enrolled Spouse/Domestic Partner and Other Enrolled Dependents

PE Empire Plan Report – June 2002

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is the Empire PlanYour Plan

The New York State HealthInsurance Program (NYSHIP)provides your healthinsurance benefits throughthe EmpirePlan. TheEmpirePlan isdesigned especially for New York’spublic employees and their families.

In New York State, the EmpireState, you’ll hear the word“Empire” again and again, evenlinked to other health plans. Thecorrect name of your healthinsurance plan is the EmpirePlan. The correct name meanscorrect benefits. Tell yourprovider that you’re in theEmpire Plan for New Yorkgovernment employees.