Health Insurance and Prescription Drugs

AM I ELIGIBLE?

Part-time professional employees are eligible to receive benefits if they are hired at a rate of $13,870 between July 2, 2010, and July 1, 2011, and are appointed for at least three (3) months. 

Part-time faculty members teaching two or more courses in a semester are eligible for 13 payroll periods of coverage for each semester worked. If teaching two or more courses in consecutive spring and fall semesters, part-time faculty are eligible to receive benefits year round with no breaks in coverage.

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 dependent’s 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 42 days of appointment to avoid any extended waiting period. Coverage will be effective on the 43rd 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 biweekly 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 (IRS), 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 "qualifying event".

HEALTH INSURANCE PLAN CHOICES

EMPIRE PLAN

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


Under the 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 copayment for Level 1 or generic drugs, a $15 copayment for Level 2, preferred brand-name drugs and a $40 copayment 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.

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 responsibility.

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.  Member’s out-of-pocket costs are usually the lowest with this type of plan. 

PRE-TAX CONTRIBUTION PROGRAM

Under the Pre-Tax Contribution Program (PTCP), you may have your share of your health insurance premiums deducted from your gross wages before taxes are withheld.  This program may lower your taxes.

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 42 days of your appointment date to avoid any extended waiting period.