SEHP Student Employee Health Plan
AT A GLANCE JANUARY 2020SEHP Student Employee Health PlanFor Graduate Student Employees and for their enrolled Dependents; and forCOBRA Enrollees and Young Adult Option Enrollees with SEHP benefitsThis guide briefly describes the principal New York State HealthInsurance Program (NYSHIP) SEHP benefits. It is not a completedescription and is subject to change. If you have questions abouteligibility, enrollment procedures or the cost of health insurance,contact the Health Benefits Administrator (HBA) on your SUNY campus.CUNY SEHP enrollees with questions may contact their HBA at theCUNY University Benefits Office. If you have questions regardingspecific benefits or claims, contact the appropriate Plan administrator(see page 23).New York State Department of Civil Service, Employee Benefits Division, Albany, NY 12239www.cs.ny.gov/employee-benefits
WHAT’S NEW In-Network Out-of-Pocket Limit – For 2020,the maximum out-of-pocket limit for covered,in-network services under the Plan is 8,150 forIndividual coverage and 16,300 for Familycoverage, split between the Hospital, Medical/Surgical, Mental Health and Substance Abuseand Prescription Drug Programs. See page 3 formore information. 2020 Empire Plan Flexible Formulary Drug List –The annual update lists the most commonlyprescribed generic and brand-name drugs includedin the 2020 Empire Plan Flexible Formulary andnewly excluded drugs with 2020 Empire PlanFlexible Formulary alternatives. Hospice Care Coverage – Effective July 1, 2019,enrollees are eligible for hospice care if thedoctor and hospice medical director certify thatthe covered patient is terminally ill and likely hasless than 12 months to live. HPV Vaccine Coverage – Effective October 1, 2019,enrollees age nine through 45 are covered for thehuman papillomavirus (HPV) 9 immunization at nocost when the vaccine is received from aparticipating provider. Other forms of HPVvaccines continue to be covered through age 26. Infertility Benefits – Effective January 1, 2020,Plan infertility benefits will cover enrollees forthree IVF cycles per lifetime. Additionally, standardfertility preservation services are covered whena medical treatment, such as treatment for cancer(radiation therapy or chemotherapy), will directlyor indirectly lead to infertility. PrEP HIV-Prevention Medication Coverage –Effective January 1, 2020, HIV-preventionmedication for Pre-Exposure Prophylaxis (PrEP)will be covered with no copayment, deductibleor any other out-of-pocket costs for enrolleeswho do not have HIV but are at high risk ofacquiring it. Screening for HIV continues tobe covered with no out-of-pocket costs whenusing a network provider. Modified Solid Food Products Coverage –Effective January 1, 2020, modified solid foodproducts (MSFPs) are no longer subject toa 2,500 total maximum reimbursement percovered person, per year. Modified solid foodproducts are covered when prescribed by aphysician or provider.
Quick ReferenceThe NYSHIP Student Employee Health Plan isa health insurance plan for CUNY and SUNYgraduate and teaching assistant employeesand their families. The Plan has six main parts:Hospital Programadministered by Empire BlueCrossProvides coverage for inpatient and outpatientservices provided by a hospital or birthing center andfor hospice care. Also provides inpatient BenefitsManagement Program services for preadmissioncertification of scheduled hospital admissions or within48 hours after an emergency or urgent admission.Medical/Surgical Programadministered by UnitedHealthcareProvides coverage for medical services, such as officevisits, convenience care clinics, surgery and diagnostictesting under the network and non-network programs.Coverage for chiropractic care and physical therapyis provided through the Managed Physical MedicineProgram. Home care services provided in lieu ofhospitalization and diabetic supplies provided by theHome Care Advocacy Program. Benefits ManagementProgram services for Prospective Procedure Reviewfor MRIs, MRAs, CT scans, PET scans and nuclearmedicine tests.Mental Health and Substance Abuse Programadministered by Beacon Health Options, Inc. Provides coverage for inpatient and outpatient mentalhealth care and substance use care services. Alsoprovides preadmission certification of inpatient andcertain outpatient services, concurrent reviews, casemanagement and discharge planning.Prescription Drug Programadministered by CVS CaremarkProvides coverage for prescription drugs dispensedthrough Empire Plan network pharmacies, the mailservice pharmacy, the specialty pharmacy andnon-network pharmacies.Dental Programadministered by EmblemHealth 1-800-947-0101Provides coverage for dental examinations, cleaningand bitewing X-rays. Also provides discounts onother services.Vision Programadministered by Davis Vision 1-888-588-4823Provides coverage for routine eye examinations,eyeglasses or contact lenses.See Contact Information on page 23.
2020 Copayments at a Glance†Medical/SurgicalProgramHospital ProgramMental Healthand SubstanceAbuse ProgramPrescriptionDrug ProgramParticipating Provider Program* 10 copayment – Office visit, office surgery, urgent care center visit,convenience care clinic visit, infertility treatment visit,allergy testing 10 copayment – Diagnostic laboratory tests, radiology (not performedduring an office visit)Chiropractic treatment or physical therapy services(Managed Physical Medicine Program) 10 copayment – Office visit, up to 15 chiropractic visits per personper calendar year; up to 60 physical therapy visitsper diagnosis 10 copayment – Diagnostic laboratory tests or radiology 15 copayment – Surgery, hospital-owned urgent care center visit,diagnostic radiology, diagnostic laboratory tests andbone mineral density screening in the hospital outpatientdepartment of a network hospital or an extension clinic(including outpatient surgical locations) 25 copayment – Emergency department care 200 copayment – Per admission for covered inpatient hospital stays 10 copayment – Per visit for medically necessary physical therapy(following related hospitalization or surgery); up to 60 visits 10 copayment – Office visit to network practitioner* 25 copayment – Emergency department care 200 copayment – Per admission for a covered inpatient mental health orsubstance use detoxification stayUp to a 30-day supply from a participating retail pharmacy, mail service ordesignated specialty pharmacy: 5 copayment – Level 1 or generic drug 25 copayment – Level 2 or preferred brand-name drug 45 copayment – Level 3 or non-preferred brand-name drug31- to 90-day supply through the mail service or designated specialty pharmacy: 5 copayment – Level 1 or generic drug 50 copayment – Level 2 or preferred brand-name drug 90 copayment – Level 3 or non-preferred brand-name drugCertain covered drugs do not require a copayment (see page 16).Dental Program 20 copayment – Participating provider visit 10 copayment – FillingVision Program 10 copayment – Routine eye exam† Preventive care services under the Patient Protection and Affordable Care Act, women’s health care services andcertain other covered services are not subject to copayment.* Office visits to a network practitioner are subject to a 15-visit annual limit per covered individual. For visit 16 andbeyond, non-network coverage applies. Certain covered services are not subject to the 15-visit per person limit.2AAG-SEHP-1/20
Benefits Management ProgramThe Empire Plan Benefits Management Program helps to protect the enrollee and allows the Plan to continueto cover essential treatment for patients by coordinating care and avoiding unnecessary services. The BenefitsManagement Program precertifies inpatient medical admissions and certain procedures, assists with dischargeplanning and provides inpatient and outpatient medical case management. In order to receive maximum benefitsunder the Plan, following the Benefits Management Program requirements — including obtaining precertificationfor certain services — is required when the Student Employee Health Plan is your primary coverage (pays first,before another health plan or Medicare).YOU MUST CALLfor preadmission certificationYou must call the Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Hospital Program(administered by Empire BlueCross): Before a scheduled (nonemergency) hospital admission* Before a maternity hospital admission.* Call as soon as a pregnancy is certain. Within 48 hours, or as soon as reasonably possible, after an emergency or urgent hospital admission*If you do not call and the Hospital Program does not certify the hospitalization, you will be responsible forthe entire cost of care determined not to be medically necessary.* These services are subject to a 200 penalty if the hospitalization is determined to be medically necessary, butnot precertified.Other Benefits Management Program services provided by the Hospital Program include: Concurrent review of hospital inpatient treatment Discharge planning for medically necessary services post-hospitalization Inpatient medical case management for coordination of covered services for certain catastrophicand complex cases that may require extended care The Future Moms Program for early risk identificationYOU MUST CALLfor Prospective Procedure ReviewYou must call the Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Medical/Surgical Program(administered by UnitedHealthcare) before receiving the following scheduled (nonemergency) diagnostic tests: Magnetic resonance imaging (MRI)Magnetic resonance angiography (MRA)Computerized tomography (CT) scanPositron emission tomography (PET) scanNuclear medicine testPrecertification is required unless you are having the test as an inpatient in a hospital. If you do not call,you will pay a larger part of the cost. If the test or procedure is determined not to be medically necessary,you will be responsible for the entire cost.Other Benefits Management Program services provided by the Medical/Surgical Program include: Coordination of voluntary specialist consultant evaluation Outpatient medical case management for coordination of covered services for certain catastrophicand complex cases that may require extended careAAG-SEHP-1/203
Out-Of-Pocket CostsIn-Network Out-of-Pocket LimitAs a result of the federal Patient Protection and Affordable Care Act provisions, there is a limit on the amountyou will pay out of pocket for in-network services/supplies received during the plan year.Out-of-Pocket Limit: The amount you pay for network services/supplies is capped at the out-of-pocket limit.Network expenses include copayments you make to providers, facilities and pharmacies (network expensesdo not include premiums, deductibles or coinsurance). Once the out-of-pocket limit is reached, networkbenefits are paid in full.Beginning January 1, 2020, the out-of-pocket limits for in-network expenses are as follows:Individual Coverage 5,300 for in-network expenses incurred underthe Hospital, Medical/Surgical and Mental Healthand Substance Abuse Programs 2,850 for in-network expenses incurred underthe Prescription Drug ProgramFamily Coverage 10,600 for in-network expenses incurred underthe Hospital, Medical/Surgical and Mental Healthand Substance Abuse Programs 5,700 for in-network expenses incurred underthe Prescription Drug ProgramOut-of-Network Combined Annual DeductibleThe combined annual deductible is 100 per covered individual.The combined annual deductible must be met before Basic Medical Program expenses, non-network expensesunder the Home Care Advocacy Program and non-network, outpatient expenses under the Mental Health andSubstance Abuse Program will be considered for reimbursement.Preventive Care ServicesYour benefits include provisions for expanded coverage of preventive health care services required by thefederal Patient Protection and Affordable Care Act (PPACA).When you meet established criteria (such as age, gender and risk factors) for certain preventive care services,those preventive services are provided to you at no cost when you use an Empire Plan participating provider ornetwork facility. See the 2020 Empire Plan Preventive Care Coverage Chart for examples of covered services.For further information on PPACA preventive care services and criteria to receive preventive care servicesat no cost, visit -SEHP-1/20
Hospital ProgramPRESSOR SAY2Call the Plan at 1-877-7-NYSHIP (1-877-769-7447)and press or say 2 to reach the Hospital ProgramThe Hospital Program provides benefits for services provided in a network or non-network inpatient or outpatienthospital setting or hospice setting. Services must be covered and medically necessary. The Medical/SurgicalProgram provides benefits for certain medical and surgical care provided in a hospital setting when it is notcovered by the Hospital Program.Call the Hospital Program for preadmission certification or if you have questions about your benefits, coverageor an Explanation of Benefits statement.Network coverage applies when you receive emergency or urgent services in a non-network hospital, or whenyou use a non-network hospital because you do not have access to a network hospital. Call the Hospital Programto determine if you qualify for network coverage at a non-network hospital based on access.Network CoverageYou pay only applicable copayments for services/supplies provided by a hospital or hospice that is part ofThe Empire Plan network. No deductible or coinsurance applies. Network coverage also applies when thePlan provides coverage that is secondary to other coverage.Non-Network CoverageWhen you use a hospital that is not part of The Empire Plan network, your out-of-pocket costs are higher. Afteryou pay your deductible amount, the Plan pays 80 percent of the allowable amount. You are responsible forthe balance.Allowable amount means the amount you actually paid for covered, medically necessary services or thenetwork allowance as determined by Empire BlueCross.Hospital InpatientYOU MUST CALLfor preadmission certification (see page 3)The Hospital Program provides unlimited days of care for covered medical or surgical care in a hospital, includinginpatient detoxification. An additional copayment is required if the hospitalization occurs more than 90 days aftera previous discharge for the same illness or injury.Network CoverageNon-Network Coverage 200 copayment per person per admission. The Planpays 100 percent of the allowable amount after youpay the copayment. 200 copayment per person per admission. The Planpays 80 percent of the allowable amount after you paythe copayment. You are responsible for the balance.Maternity care: First 48 hours of hospitalization formother and newborn after any delivery other than acesarean section, or first 96 hours following a cesareansection, are presumed medically necessary andcovered at the same copayment and coverage levelas other inpatient admissions. If you choose earlydischarge following delivery, you may request onepaid-in-full home care visit.Maternity care: First 48 hours of hospitalization formother and newborn after any delivery other thana cesarean section, or first 96 hours following acesarean section, are presumed medically necessary.The plan pays 80 percent of the allowable amountafter you pay the copayment. You are responsiblefor the balance.AAG-SEHP-1/205
Hospital OutpatientIf you are admitted as an inpatient directly from the emergency department or another outpatient department,the emergency or outpatient department copayment is waived, and only the inpatient copayment applies.Emergency DepartmentNetwork CoverageNon-Network CoverageYou pay one 25 copayment per visit to an emergencydepartment, including use of the facility for emergencycare, services of the attending emergency departmentphysician, services of providers who administeror interpret radiological exams, laboratory tests,electrocardiogram and pathology services.Network coverage applies to emergency servicesreceived in a non-network hospital.Emergency is defined as a medical condition with symptoms of sufficient severity, including severe pain,that a prudent layperson could reasonably expect the absence of immediate care to put the person’s life injeopardy or cause serious impairment of bodily functions.Outpatient DepartmentServices covered in a network hospital outpatient department or extension clinic are the same services coveredwhen received in a non-network facility.Network CoverageNon-Network CoverageYou pay one 15 copayment per visit for outpatientsurgery, diagnostic radiology, diagnostic laboratorytests and bone mineral density screening.The Plan pays 80 percent of allowable amount afteryou meet the combined 100 annual deductible(per covered individual).You pay one 15 copayment per visit to a hospitaloutpatient urgent care facility.The following services are paid in full whendesignated preventive according to the PatientProtection and Affordable Care Act: Bone mineral density testsColonoscopiesMammograms*Pap smearsProctosigmoidoscopy screeningsSigmoidoscopy screenings* Screening, diagnostic and 3-D mammograms are paidin full under New York State law.Physical therapy following a related hospitalization orrelated inpatient or outpatient surgery is subject to a 10 copayment per visit. Up to 60 medically necessaryvisits are covered under network coverage.Physical therapy covered under the non-networkbenefit is subject to a separate combined 100deductible for physical therapy and chiropracticcare (see page 12).Medically necessary physical therapy is covered under the Managed Physical Medicine Program when notcovered under the Hospital Program (see page 12).6AAG-SEHP-1/20
InfertilityNetwork CoverageNon-Network CoverageThe following services provided in the inpatient oroutpatient departments of a hospital are covered:artificial/intra-uterine insemination; three in vitrofertilization cycles per lifetime; fertility preservationwhen a medical treatment will directly or indirectlylead to infertility; inpatient and/or outpatient surgicalor medical procedures performed in the hospital,which would correct malfunction, disease ordysfunction resulting in infertility and associateddiagnostic tests and procedures including, but notlimited to, those described in New York State InsuranceLaw as set forth in Chapter 82 of the Laws of 2002.Outpatient infertility treatment: The Plan pays80 percent of the allowable amount after youmeet the combined 100 annual deductible.Hospice CareInpatient infertility treatment: The Plan pays80 percent of the allowable amount after youpay the 200 copayment.Network CoverageNon-Network CoverageCare provided by a licensed hospice program is paidin full for up to 210 days.The Plan pays up to 100 percent of allowable amountfor up to 210 days for care provided by a licensedhospice program.Medical/Surgical ProgramPRESSOR SAY1Call the Plan at 1-877-7-NYSHIP (1-877-769-7447)and press or say 1 to reach the Medical/Surgical ProgramThe Medical/Surgical Program provides benefits for medically necessary, covered services received from aphysician or other practitioner licensed to provide medical/surgical services. It also covers services receivedfrom facilities not covered under the Hospital Program, such as outpatient surgical centers, imaging centers,laboratories, urgent care centers and convenience care clinics. Call the Medical/Surgical Program if you havequestions about the status of a provider, Plan coverage or your benefits.Network CoverageNetwork coverage applies when you use a physician or provider who participates in The Empire Plan network.When you receive covered services from a participating provider, you pay only applicable copayments.Women’s health care services, many preventive care services and certain other covered services are paidin full (see pages 8-11).The Plan does not guarantee that network providers
2 AAG-SEHP-1/20 2020 Copayments at a Glance† Medical/Surgical Program Participating Provider Program* 10 copayment – Office visit, office surgery, urgent care center visit, convenience care clinic visit, infer
units are identified in Exhibit II.C, DCS/NYSIF Prescription Drug Program Copayment Matrix, as well as the other groups that participate in The Empire Plan, the Excelsior Plan, and the SEHP. The Empire Plan also provides benefits to members of the SEHP through the various Empire Plan
Fisher Engineering P.O. Box 529 Rockland, Maine 04841 Table Of Contents . 11 1 2 8611 Vehicle Harness - 7-Pin (Belt Drive) 1 8275 Vehicle Harness - 9-Pin (SEHP) 1 8276 Vehicle Harness - 12-Pin (SEHP/Belt Drive) 1 3 8612 Snowplow Harness Kit - 7-Pin (Belt Drive) 1
Employee or an employee's dependent becomes entitled to coverage under Medicare, or the employee or employee's dependent loses eligibility for coverage under Medicare. No No Yes Yes Yes Employee's or dependent's current health plan becomes una vailable because the employee or dependent is no longer eligible for a Health Savings Account (HSA).
Rater: I met with the employee and discussed this Performance Plan. Rater’s Signature (Signs first, immediately after discussing plan with employee) Performance Plan Section 5: Signatures Employee: I was given the opportunity to discuss the content of this Performance Plan with my Rater.I understand that I will receive an appraisal at the end of this appraisal cycle.
Dec 27, 2020 · The effective date of contractual employee terminations should be the last day of work Procedure: 1. Search for the employee. Tip: To find an employee Type the employee name or employee ID in the Search field. Then, click the Search icon, OR Find the employee in their
834 Other long-term employee benefits are all employee benefits other than short-term employee benefits, post-employment benefits and termination benefits. Termination benefits are employee benefits provided in exchange for the termination of an employee's employment as a result of either: (a) an entity's decision to terminate an employee's employment before the normal retirement
To add a new employee, click Add Employee and fill in the Employee profile shown below. To submit the new employee's profile click the Add Employee button at the bottom of the screen. When viewing an individual employee's record you can see the employee's Profile, Account Summary, Enrollments, Contributions, Claims, Payments, and Status.
language classes (and be honest, did you actually learn all that much in there?). There are now many different online lessons and tutorials to help you become proficient in the language of your choice. FluentU stands out among language learning websites, thanks to the huge range of learning opportunities it provides. 5 The Complete Guide to Foreign Language Immersion. FluentU takes real-world .
