New PEF 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.
Full-time PEF employees are eligible for health
benefits if they are employed for at least three (3) months.
AM I ELIGIBLE?
Part-time PEF 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 dependentís 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 56 days of appointment to avoid any extended
waiting period. Coverage will be effective on the 57th
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.
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
HEALTH INSURANCE PLAN CHOICES
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: $20 for office visits, diagnostic/therapeutic services,
and rehabilitative care; $70 per emergency room visit. 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
ESI/Medco Prescription Drug Plan 1-877-769-7447
Empire Plan Prescription Drug Program, 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 $25 co-payment for Level
2, preferred brand-name drugs and a $45 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.
Blue Cross Blue Shield of WNY
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
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. Memberís out-of-pocket costs are usually the
lowest with this type of plan.
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 Enrollment Form (PS-404) online or provided in your
orientation packet and return it to the Employee
Benefits Office, Cleveland Hall 410, within 56 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
Health Insurance Enrollment Form
(PS-404) and the Opt-Out
Attestation Form (PS-409) no later than the first date of your eligibility
for health insurance benefits.