Changes to The Empire Plan enrollee benefits, effective July 1

Effective July 1, 2024, there are changes to certain enrollee benefits for some groups enrolled in The Empire Plan. 

These changes affect the following groups:

• District Council 37 (DC37)
• New York State Correctional Officers PBA (NYSCOPBA)

Elimination of multiple participating provider copayments per visit

The $25 participating provider copayment amount remains the same, with multiple copayments for the same provider and same visit eliminated. Just 1 copayment of $25 is required for all covered office visits, office surgery, radiology and/or laboratory services received by the same enrollee from the same provider on the same date of service. Please note that up to 2 copayments of $30 (for a total of $60) may apply for services at an urgent care center.

Change in maximum allowed amount for non-participating providers

Claims from non-participating providers will use Medicare rates as the fee basis. This means enrollees may have greater out-of-pocket costs when using a non-participating provider. Please refer enrollees to providers in The Empire Plan network whenever appropriate. Using network providers will help your patients avoid added costs and help them pay only a copayment for covered services.

New Site of Care program for infusions when The Empire Plan is primary coverage

The Empire Plan hospital carrier, Anthem Blue Cross will review the setting for infusion services under The Empire Plan Hospital Program and, if clinically appropriate, work with you, your patient and UnitedHealthcare to transition those services from an outpatient hospital setting to a new location. Alternate settings include freestanding infusion suites, a doctor’s office or the patient’s home. There are no Medical/Surgical Program or Prescription Drug Program copayments when patients use an alternate setting.

Enrollees may choose to continue infusion services in an outpatient hospital setting when clinically appropriate, or when there is no alternate setting available within 30 minutes or 30 miles of their home. Benefits for covered infusion services in an outpatient hospital setting are unchanged.

Visit limit added for out-of-network acupuncture services

Coverage is available for a maximum of 20 visits per calendar year for acupuncture services by non-participating providers. This is a combined total for all non-participating providers, regardless of how many non-participating providers are visited. The 2024 visit maximum does not include visits prior to July 1, 2024.

Visit limit added for massage therapy services

Coverage is available for a maximum of 20 visits per calendar year for massage therapy services. This is a combined total for all massage therapy visits, regardless of how many providers are visited. The 2024 visit maximum does not include visits prior to July 1, 2024.

A new substance use disorder program

The Empire Plan Mental Health and Substance Use Program, administered by Carelon Behavioral Health, will include a new Center of Excellence for Substance Use Disorder Program in partnership with the Hazelden Betty Ford Foundation. The program provides authorized treatment at no cost to Empire Plan enrollees. 

When authorized, covered services include:

• Detoxification
• Residential rehabilitation
• Partial hospitalization
• Intensive outpatient care
• Care coordination for transition back to community
• Family treatment and support
• Virtual support services

Detoxification facilities are available in California, Minnesota and Oregon. Outpatient services are available in California, Florida, Illinois, Minnesota, New York, Oregon and Washington. Travel, lodging and meal allowances are available for members and up to 2 travel companions.

Questions?

Call 877-769-7447 (877-7-NYSHIP) and press or say “1” to reach the Medical/Surgical Program, administered by UnitedHealthcare.