2007-2011

PROFESSIONAL, SCIENTIFIC

AND

TECHNICAL SERVICES UNIT

AGREEMENT

 

 

Article 9

Health Insurance

 

9.1 The State shall continue to provide all the forms and extent of coverage as defined by the contracts in force on April 1, 2007 with the State's health insurance carriers unless specifically modified by this Agreement.

 

9.2(a) The Benefits Management Program will continue. Precertification will be required for all inpatient confinements and prior to certain specified surgical or medical procedures, regardless of proposed inpatient or outpatient setting.

 

·         To provide an opportunity for a review of surgical and diagnostic procedures for appropriateness of setting and effectiveness of treatment alternative, precertification will be required for all inpatient elective admissions.

·         Precertification will be required prior to maternity admissions in order to highlight appropriate prenatal services and reduce costly and traumatic birthing complications

·         A call to the Benefits Management Program will be required within 48 hours of admission for all emergency or urgent admissions to permit early identification of potential ''case management'' situations.

·         Precertification will be required prior to an admission to a skilled nursing facility.

·         The hospital deductible amount imposed for non-compliance with Program requirements will be $200. Also, this deductible will be fully waived in instances where the medical record indicates that the patient was unable to make the call. In instances of non-compliance, a retroactive review of the necessity of services received shall be performed.  The hospital portion of the Empire Plan will only cover those inpatient days determined by the Benefits Management Program to be medically necessary and/or appropriate for the inpatient setting. 

·         The Prospective Procedure Review Program will screen for the medical necessity of certain specified surgical or diagnostic medical procedures which, based on Empire Plan experience, have been identified as potentially unnecessary or over utilized. The list of procedures will undergo annual evaluation by the Benefits Management Program vendor. As revised and approved by the Joint Committee on Health Benefits, the list will be published and distributed to enrollees prior to implementation.

·         The Benefits Management Program will be modified to refine the Prospective Procedure Review requirement to include only Magnetic Resonance Imaging (MRI). Effective July 1, 2008, or as soon thereafter as practicable, Computerized Axial Tomography (CAT Scans), Positron Emission Tomography (PET scans), Magnetic Resonance Angiography (MRAs) and Nuclear Medicine will be added to the Prospective Procedure Review Program.

·         In order to assure the timely and accurate notification of PS&T Unit employees of these changes, the State and PEF, in conjunction with the vendor, will develop educational materials relating to the Benefits Management Program and oversee the distribution of said materials.

·         Enrollees will be required to call the Benefits Management Program for precertification when a listed procedure subject to prospective review is recommended, regardless of setting. Enrollees will be requested to call two weeks before the date of the procedure.

·         The Empire Plan's Prospective Procedure Review penalties will apply for failure to comply with the requirements of the Prospective Procedure Review Program regardless of whether the expense is an outpatient hospital or medical program expense.

 

(b) Charges for emergency room care within 72 hours of an accident or within 24 hours of the sudden onset of an illness (medical emergency) are subject to a $60 copayment per visit.  Effective January 1, 2010, this Hospital Emergency Room copayment will be $70 for emergency room services covered by the hospital contract.  Charges for other outpatient services covered by the hospital contract are subject to a $35 copayment per outpatient visit regardless of the number and type of services rendered in the hospital outpatient setting.  Effective January 1, 2010, the copayment for other outpatient services covered by the hospital contract, except for outpatient surgery, will be $40.  Effective January 1, 2010, the copayment for hospital outpatient surgery will be $60.  Services provided in a hospital owned or operated . will be paid by the hospital carrier, subject to appropriate copayment.  Enrollees have the right of appeal of copayments not charged in accordance with this provision.  Appeals should be directed to the hospital carrier or to the Health Benefits Administrator. In addition, there will be participating provider copayment for covered services for the treatment of alcohol or substance abuse. The outpatient and emergency room hospital copayments will be waived for persons admitted to the hospital as an inpatient directly from the outpatient setting, for pre-admission testing/pre-surgical testing prior to an inpatient admission or for the following covered chronic care outpatient services: chemotherapy, radiation therapy, or hemodialysis.

Hospital outpatient physical therapy visits will be subject to the same copayment in effect for physical therapy visits under the Managed Physical Medicine Program.

 

(c) Covered inpatient hospital services at a network hospital shall be a paid-in-full benefit.  Covered inpatient hospital services at a non-network hospital shall be reimbursed at 90% of charges, subject to a separate annual non-network coinsurance maximum of $1,500 per enrollee, per spouse or domestic partner, and per dependent children. 

Emergency room and other outpatient services covered by the hospital contract and rendered at a network hospital shall be paid-in-full except for the appropriate copayment.  For emergency room services rendered at a non-network hospital and covered by the hospital contract, reimbursement shall be at the billed charges minus the emergency room copayment.  For outpatient services covered by the hospital contract and rendered at a non-network hospital, reimbursement shall be at the billed charges minus the enrollee share.  The enrollee’s share of the charge for covered outpatient services shall be the larger of (a) the $75 non-network hospital copayment, or (b) 10% of billed charges, subject to the separate annual non-network coinsurance maximum of $1,500 per enrollee, per spouse or domestic partner, and per dependent children.  Once an enrollee, enrolled spouse or domestic partner, or all dependent children combined, have met the annual coinsurance maximum, all subsequent eligible non-network outpatient services for that enrollee, enrolled spouse or domestic partner, or all dependent children combined, for the balance of the calendar year will be paid subject to network level copayments.  Inpatient anesthesiology, pathology and radiology services received at a network hospital will become a paid-in-full (less any appropriate copayment) benefit.

Once the enrollee, enrolled spouse or domestic partner, or all dependent children combined have incurred $500 in annual non-network hospital expenses, a claim may be filed with the Empire Plan medical carrier for reimbursement of out-of-pocket non-network hospital expenses incurred above the $500 and up to the balance of the annual Hospital coinsurance maximum amount.  Effective January 1, 2009, once the enrollee, enrolled spouse or domestic partner, or all dependent children combined have incurred $500 in annual non-network hospital expenses, a claim may be filed with the Empire Plan medical carrier for reimbursement of out-of-pocket non-network hospital expenses incurred above the $500 and up to $1,000.  Effective January 1, 2011, the Empire Plan medical carrier will no longer reimburse out-of-pocket non-network hospital expenses.

 

(d) The Empire Plan “Centers of Excellence” Programs will continue. A travel allowance for transportation and lodging will be included as part of the Centers of Excellence Program.  Effective July 1, 2008, the travel allowance for mileage will be consistent with the maximum mileage allowance permitted by the Internal Revenue Service; the meal and lodging allowance in each location will be equal to the rate provided by the Federal government to its employees in such locations.  The Joint Committee on Health Benefits will work with the State and Empire Plan carriers in the ongoing oversight of this benefit.

 

1.         The Centers of Excellence for organ and tissue transplants will be required to provide pre-transplant evaluation, hospital and physician services (inpatient and outpatient), transplant procedures, follow-up care for transplant related services, as determined by the Centers, and any other services as identified during implementation as part of an all-inclusive global rate.

 

2.         The Centers of Excellence for infertility shall offer enhanced benefits to include treatment of “couples” as long as both partners are covered either as an enrollee or dependent under the Empire Plan.  The lifetime coverage limit is $50,000.  Covered services include: patient education and counseling, diagnostic testing, ovulation induction/hormonal therapy, surgery to enhance reproductive capability, artificial insemination and Assisted Reproductive Technology procedures.  Prior authorization may be required for certain procedures.  Exclusions include: experimental procedures, fertility drugs dispensed at a licensed pharmacy, medical and other charges for surrogacy, donor services/compensation in connection with pregnancy.

 

3.         The Centers of Excellence for Cancer Resource Services (CRS) program will provide direct nurse consultations, information and assistance in locating appropriate care centers, connection with cancer experts at CRS Cancer Centers, and paid-in-full reimbursement for all services provided at a CRS Cancer Center.  Effective July 1, 2008, the lifetime maximum for travel and lodging expenses for the CRS program is eliminated.

 

 

(e) The Empire Plan shall include medical/surgical coverage through use of participating providers who will accept the Plan's schedule of allowances as payment in full for covered services. Except as noted below, benefits will be paid directly to the provider at 100 percent of the Plan's schedule not subject to deductible, coinsurance, or annual/lifetime maximums.

 

1.         Office visit charges by participating providers will be subject to an $18 copayment by the enrollee, with the balance of covered scheduled allowances paid directly to the provider by the Plan. Effective July 1, 2009, office visit charges by participating providers will be subject to a $20 copayment by the enrollee. 

 

2.         All covered surgical procedures performed by participating providers during a visit will be subject to a $18 copayment by the enrollee. Effective July 1, 2009, all covered surgical procedures performed by participating providers will be subject to a $20 copayment by the enrollee. 

 

3.         All covered radiology services performed by participating providers during a visit will be subject to a $18 copayment by the enrollee. Effective July 1, 2009, all covered radiology services performed by participating providers will be subject to a $20 copayment by the enrollee. 

 

4.         All covered diagnostic/laboratory services performed by participating providers during a visit will be subject to a $18 copayment by the enrollee. Effective July 1, 2009, all covered diagnostic/laboratory services performed by participating providers will be subject to a $20 copayment by the enrollee.

 

5.         All covered services provided at a participating ambulatory surgery center are subject to a $15 copayment by the enrollee.  Effective July 1, 2008, services provided at a participating ambulatory surgery center will be subject to a $30 copayment by the enrollee.  All anesthesiology, radiology and laboratory tests performed on-site on the day of the surgery shall be included in this single copayment. 

 

6.         The office visit, surgery, radiology and diagnostic/laboratory copayment amounts may be applied against the basic medical co-insurance out-of-pocket maximum, however, they will not be considered covered expenses for basic medical.

 

(f) The Empire Plan shall also include basic medical coverage to provide benefits when non-participating providers are used. These benefits will be paid directly to enrollees according to reasonable and customary charges and will be subject to deductible, co-insurance, and calendar year and lifetime maximums.  Effective July 1, 2008, the reasonable and customary allowance for pharmaceutical products charged to the basic medical component of the Plan will be the lesser of the actual charge for the covered pharmaceutical product or the average price charged by wholesale distributors/pharmaceutical manufacturers to doctors, pharmacies and infusion companies.

 

1.         Covered charges for medically appropriate local commercial ambulance transportation will be a covered basic medical expense subject only to the $35 copayment.  Volunteer ambulance transportation will continue to be reimbursed for donations at the current rate of $50 for under 50 miles and $75 for 50 miles or over. These amounts are not subject to deductible or coinsurance.

 

2.         Charges for Private Duty Nursing services provided as part of an inpatient stay in a hospital will continue to be covered by the hospital carrier when billed by the hospital. However, these charges will not be reimbursable under the basic medical component of the Empire Plan.

 

(g) Periodic evaluation and adjustment of basic medical Reasonable and Customary charges will be performed according to guidelines established by the basic medical plan insurer.

 

(h) The State agrees to pay 90 percent of the cost of the individual coverage and 75 percent of the cost of dependent coverage, including prescription drug coverage, provided under the Empire Plan. 

 

(i) The State agrees to continue to provide alternative Health Maintenance Organization (HMO) coverage. The State agrees to pay 90 percent of the cost of individual coverage and 75 percent of the cost of dependent coverage toward the hospital/medical/mental health and substance abuse component of each HMO, not to exceed 100 percent of its dollar contribution for those components under the Empire Plan. The State agrees to pay 90 percent of the cost of individual prescription drug coverage and 75 percent of dependent prescription drug coverage under each participating HMO.

 

9.3 PEF Empire Plan Enhancements

In addition to the basic Empire Plan benefits, the Empire Plan for PS&T Unit enrollees shall include:

 

a.         Effective January 1, 2008 the basic medical component deductible is $349 per enrollee; $349 per enrolled spouse or domestic partner; and $349 per all dependent children.  Covered expenses for mental health and/or substance abuse treatment services, physical medicine services, and non-network hospital services are excluded in determining the basic medical component deductible.  Effective January 1, 2009, the deductible will increase by a percentage amount equal to the percentage increase in the medical care component of the CPI for Urban Wage Earners and Clerical Workers, all Cities (CPI-W) for the preceding period of July 1 - June 30.

 

b.         Effective January 1, 2008, the maximum annual co-insurance out-of-pocket expense under the basic medical component is $1,676 per individual or family.  Covered expenses for mental health and/or substance abuse treatment services, physical medicine services, and non-network hospital services are excluded in determining the maximum annual co-insurance limit.  Effective January 1, 2009, the maximum annual co-insurance out-of-pocket expense under the basic medical component is $1,000 per enrollee; $1,000 per enrolled spouse or domestic partner; and $1,000 per all dependent children.

 

Each successive January 1, the deductible and maximum annual co-insurance out-of-pocket expense will increase by a percentage amount equal to the percentage increase in the medical care component of the CPI for Urban Wage Earners and Clerical Workers, all Cities (CPI-W) for the preceding period of July 1 - June 30.

 

c.         Employees 50 years of age or older and their covered spouses/domestic partners 50 years of age or older will be allowed up to $250 reimbursement once per year toward the cost of a routine physical examination. These benefits shall not be subject to deductible or co-insurance.

 

d.         The newborn routine child care allowance under the basic medical component shall be $150, not subject to deductible or co-insurance.

 

e.         The annual and lifetime maximum for each covered member under the basic medical component shall be unlimited.

 

f.          Services for examinations and/or purchase of hearing aids shall be a covered basic medical benefit and shall be reimbursed up to a maximum of $1,500 per hearing aid, per ear, once every four years, not subject to deductible or coinsurance.  For children 12 years old and under the same benefits can be available after 24 months, when it is demonstrated that a covered child's hearing has changed significantly and the existing hearing aid(s) can no longer compensate for the child's hearing impairment.

 

g.         Office visit charges by participating providers for well child care will be excluded from the office visit copay.

 

h.         Charges by participating providers for professional services for allergy immunization or allergy serum will be excluded from the office visit copayment.

 

i.          Chronic care services for chemotherapy, radiation therapy, or hemodialysis, will be excluded from the office visit copayment.

 

j.          In the event that there is both an office visit charge and an office surgery charge by a participating provider in any single visit, the covered individual will be subject to a single copayment.

 

k.         Outpatient radiology services and diagnostic/laboratory services rendered during a single visit by the same participating provider will be subject to a single copayment.

 

l.          Routine pediatric care, including the cost of all oral and injectable substances for routine preventive pediatric immunizations, shall be a covered benefit under the Empire Plan participating provider component and the basic medical component.

 

m.        Influenza vaccine is included in the list of pediatric immunizations, subject to appropriate protocols, under the participating provider and basic medical components of the Empire Plan.

 

n.         Mastectomy bras prescribed by a physician, including replacements when it is functionally necessary to do so, shall be a covered benefit under the Empire Plan.

 

o.         The Pre-Tax Contribution Program will continue unless modified or exempted by the Federal Tax Code.

 

p.         The Home Care Advocacy Program (HCAP) will continue to provide services in the home for medically necessary private duty nursing, home infusion therapy and durable medical equipment under the participating provider component of the Empire Plan.

 

Individuals who fail to have medically necessary designated HCAP services and supplies pre-certified by calling HCAP and/or individuals who use a non-network provider will receive reimbursement at 50 percent of the HCAP allowance for all services, equipment and supplies upon satisfying the basic medical annual deductible. In addition, the basic medical out-of-pocket maximum will not apply to HCAP designated services, equipment and supplies. All other HCAP non-network benefit provisions will remain.

 

Effective July 1, 2008, the HCAP program will provide coverage for one pair of diabetic shoes per year.  Coverage will be provided as follows: individuals who use a network provider will receive a paid in full benefit up to a maximum of $500 per year; individuals who use a non-network provider will receive reimbursement under the Basic Medical component of the Empire Plan, subject to deductible with the remainder paid at 75 percent of the HCAP network allowance up to a maximum of $500 per year.

 

q.         The Empire Plan medical carrier will continue to have a network of prosthetic and orthotic providers.  Prostheses or orthotics obtained through an approved prosthetic/orthotic network provider will be paid under the participating provider component of the Empire Plan, not subject to copayment.  For prostheses or orthotics obtained other than through an approved prosthetic/orthotic network provider, reimbursement will be made under the basic medical component of the Empire Plan, subject to deductible and co-insurance. 

 

r.          All professional component charges associated with ancillary services billed by the outpatient department of a hospital for emergency care for an accident or for sudden onset of an illness (medical emergency) will be a covered expense. Payment shall be made under the participating provider or the basic medical component of the Empire Plan, not subject to deductible or co-insurance, when such services are not otherwise included in the hospital facility charge covered by the hospital carrier.

 

s.          External mastectomy prostheses are a covered-in-full benefit, not subject to deductible or coinsurance.  Coverage will be provided by the medical carrier as follows: Benefits are available for one single/double mastectomy prosthesis in a calendar year.  Pre-certification through the Home Care Advocacy Program is required for any single external prosthesis costing $1,000 or more.  If a less expensive prosthesis can meet the individual’s functional needs, benefits will be available for the most cost-effective alternative.

 

t.          The medical component of the Empire Plan shall include a voluntary 24 hour day/7 day week nurse-line feature to provide both clinical and benefit information through a toll-free phone number. The Joint Committee on Health Benefits will work with the State and Empire Plan carriers in the ongoing oversight of this benefit.

 

u.          The Empire Plan medical component shall include voluntary Disease Management Programs. Disease Management covers those illnesses identified to be chronic, high cost, impact quality of life, nd rely considerably on the patient's compliance with treatment protocols.  The current Disease Management Programs for Cardiovascular Disease Risk Reduction, Asthma, Congestive Heart Failure, Sleep Apnea, Depression, Chronic Obstructive Pulmonary Disease and Diabetes will continue.  As soon as practicable, additional Disease Management Programs will be created for Chronic Kidney Disease, Eating Disorders and Attention Deficit Hyperactivity Disorder.  Also, as soon as thereafter practicable, the Disease Management Programs will provide benefits for nutritional services where clinically appropriate.  The Joint Committee on Health Benefits will work with the State and Empire Plan carriers in the ongoing oversight of this benefit.

 

v.         The cost of certain injectable adult immunizations shall be a covered expense, subject to copayment(s), under the participating provider portion of the Empire Plan. The list of immunizations shall include Influenza, Pneumococcal, Measles, Mumps, Rubella, Varicella, Tetanus Toxoid, Human Papilloma Virus (HPV), and Meningococcal Meningitis.  Effective July 1, 2008 the list of immunizations shall include Herpes Zoster.  All adult immunizations shall be subject to protocols developed by the medical program insurer. 

 

w.        The Empire Plan Basic Medical component will include a Basic Medical Provider Discount Program.  This benefit is provided as a pilot program which will expire on December 31, 2011 unless extended by agreement of both parties.

 

x.         Effective January 1, 2008, and implemented as soon as practicable following ratification, the basic medical program will provide paid in full benefits for prosthetic wigs subject to a lifetime maximum benefit of $1,500.

 

y.         Effective July 1, 2008 or as soon as thereafter practicable, the Empire Plan medical carrier shall contract with Diabetes Education Centers accredited by the American Diabetes Education Recognition Program.

 

z.         Effective January 1, 2009, the Complementary and Alternative Medicine Program will be discontinued.

 

            9.4 The Voluntary Catastrophic Medical Case Management component of the Empire Plan's Benefits Management Program will continue. This voluntary program will review cases of catastrophic illness or injury, provide patients an opportunity for flexibility in Plan benefits, maximize rate of recovery, and maintain quality of care.

 

            9.5 There shall be a waiting period of fifty-six (56) days after employment before a new employee shall be eligible for enrollment under the State's Health Insurance Program, Dental Program and Vision Care Program.

 

9.6 (a) The State Health Insurance Plan's regulations shall continue to stipulate that the term "employee" means any person in the service of the State as employer whose regular work schedule is at least half-time per biweekly payroll period.

 

(b) Employees eligible to enroll in the State Health Insurance Program may select individual or individual and dependent (family) coverage. Those eligible and enrolling for family coverage must provide the names of all eligible dependents to the Plan administrator in order for family coverage to become effective. Employees enrolling without eligible dependents, or those who choose not to enroll their eligible dependents, will be provided individual coverage.

 

(c) When more than one family member is eligible to enroll for coverage under the State's Health Insurance Program, there shall be no more than one individual and dependent enrollment permitted in any family unit.

 

9.7 (a) Seasonal employees who are anticipated to be or who are continuously employed on at least a half-time basis for six months, shall be eligible for health insurance coverage subject to the provisions of this Agreement.

 

(b) Where the State establishes a seasonal position for six months or more, the appointee to that position shall not have his/her service intentionally broken solely for the purpose of rendering that employee ineligible for health insurance coverage.

 

(c) Should a seasonal employee, who attained health insurance coverage eligibility, leave the payroll and then be subsequently rehired, the employee shall retain eligibility for health insurance coverage upon rehire, provided the employee was not off the payroll more than three months. The employee may continue his/her health insurance on a full pay basis for the period of time he/she is off the payroll.

 

9.8 Eligible employees in the State Health Insurance Plan may elect to participate in a federally qualified or State certified Health Maintenance Organization which has been approved to participate in the State Health Insurance Program by the Joint Committee on Health Benefits.

 

If more than one HMO services the same area, the Joint Committee on Health Benefits reserves the right to approve a contract with only one such organization.

 

9.9 (a) Enrollees may change their health insurance option each year throughout the month of November, unless another period is mutually agreed upon by the State and the Joint Committee on Health Benefits. Changes between options will be permitted without regard to the enrollee's age or the number of previous transfers. If rate renewals are not available by the time of the option transfer period, then the option transfer period shall be extended to assure ample time for enrollees to transfer.

 

(b) The State shall provide health insurance comparison information to employees, through State agencies, prior to the beginning of an option transfer period. If the comparison information is delayed for any reason, the transfer period shall be extended for a minimum of 30 calendar days beyond the date the information is distributed to the agencies. Employees transferring plans during a scheduled period but prior to the provision of the comparison data, may elect to further alter or rescind his/her health plan transfer during the remainder of the option transfer period.

 

9.10 (a) Continued health insurance coverage will be provided for the unremarried spouse or domestic partner who has not acquired another domestic partner and other eligible dependents of employees who die in State service under circumstances for which they are eligible for the accidental death benefit or for weekly cash workers' compensation benefits under the conditions prescribed in Section 165 of the Civil Service Law.

 

(b) If an employee is granted a service-connected disability retirement by a retirement or pension plan or system administered and operated by the State of New York, the State will continue the health insurance of that employee on the same basis as any other retiring employee, regardless of the duration of the employee's service with the State.

 

(c) Covered dependent students shall be provided with a three-month extended benefit period upon graduation from a qualified course of study.  Effective July 1, 2008, covered dependent students shall be provided with a three-month extended benefit period upon completion of each semester of study. The benefit extension will begin on the first day of the month following the month in which dependent student coverage would otherwise end and will last for three months or until such time as eligibility would otherwise be lost under existing plan rules.

(d) Covered dependents of employees who are activated for military duty as a result of an action declared by the President of the United States or Congress shall continue health insurance coverage with no employee contribution for a period not to exceed 12 months from the date of activation, less any period the employee remains in full pay status. Contribution-free health insurance coverage will end at such time as the employee's active duty is terminated or the employee returns to State employment, whichever occurs first.

 

9.11 A permanent full-time employee, who loses employment as a result of the abolition of a position on or after April 1, 1977, shall continue to be covered under the State Health Insurance Plan at the same contribution rate as an active employee for one year following such layoff or until re-employment by the State or employment by another employer, whichever first occurs.

 

9.12 (a) The unremarried spouse or domestic partner who has not acquired another domestic partner and otherwise eligible dependent children of an employee, who retires after April 1, 1979 with 10 or more years of active State service and subsequently dies, shall be permitted to continue coverage in the Health Insurance Program with payment at the same contribution rates as required of active employees for the same coverage.

 

(b) The unremarried spouse or domestic partner who has not acquired another domestic partner and otherwise eligible dependent children of an active employee, who dies after April 1, 1979 and who, at the date of death, was vested in the Employees' Retirement System, had 10 or more years of benefits eligible service, who was at least 45 years of age and was within 10 years of the minimum retirement age shall be permitted to continue coverage in the Health Insurance Program with payment at the same contribution rates as required of active employees for the same coverage.

 

9.13 (a) Employees on the payroll and covered by the State Health Insurance Program have the right to retain health insurance coverage after retirement, upon the completion of ten years of State service.

 

(b) Prior to the expiration of this contract, PEF and the State, through the Joint Committee process, shall develop a proposal to modify the manner in which employer contributions to retiree premiums are calculated in order to recognize and underscore the value of the services rendered to the State by its long-term employees.

 

(c) An employee who is eligible to continue health insurance coverage upon retirement and who is entitled to a sick leave credit to be used to defray any employee contribution toward the cost of the premium, may elect an alternative method of applying the basic monthly value of the sick leave credit. The basic monthly value of the sick leave credit shall be calculated according to the procedures in use on March 31, 1991.

Employees selecting the basic sick leave credit may elect to apply up to 100 percent of the calculated basic monthly value of the credit toward defraying the required contribution to the monthly premium during their own lifetime. If employees who elect that method predecease their eligible covered dependents, the dependents may, if eligible, continue to be covered, but must pay the applicable dependent survivor share of the premium.

Employees selecting the alternative method may elect to apply only up to 70 percent of the calculated basic monthly value of the credit toward the monthly premium during their own lifetime. Upon the death of the employee, however, any eligible surviving dependents may also apply up to 70 percent of the basic monthly value of the sick leave credit toward the dependent survivor share of the monthly premium for the duration of the dependents' eligibility. The State has the right to make prospective changes to the percentage of credit to be available under this alternative method for future retirees as required to maintain the cost neutrality of this feature of the Plan.

The selection of the method of sick leave credit application must be made at the time of retirement, and is irrevocable. In the absence of a selection by the employee, the basic method shall be applied.

 

(d) An employee retiring from State service may delay commencement or suspend his/her retiree health coverage and the use of the employee's sick leave conversion credits indefinitely, provided that the employee applies for the delay or suspension, and furnishes proof of continued coverage under the health care plan of the employee's spouse or domestic partner, or from post retirement employment.

 

9.14 The Empire Plan's medical care component will continue to offer a comprehensive managed care network benefit for the provision of medically necessary physical medicine services, including physical therapy and chiropractic treatments. Authorized network care will be available, subject only to the Plan's participating provider office visit copayment(s). Unauthorized medically necessary care, at enrollee choice, will also be available, subject to a $250 annual deductible and a maximum payment of 50 percent of the network allowance for the service(s) provided. Maximum benefits for non-network care will be limited to $1,500 in payments per calendar year. Deductible/co-insurance payments will not be applicable to the Plan's annual basic medical deductible/co-insurance maximums.

 

9.15 Domestic Partners who meet the definition of a partner and can provide acceptable proofs of financial interdependence as outlined in the Affidavit of Domestic Partnership and Affidavit of Financial Interdependence shall continue to be eligible for health care coverage.

 

9.16 Joint Committee on Health Benefits

a.         The State and PEF agree to continue the Joint Committee on Health Benefits.

b.         The Joint Committee on Health Benefits shall meet within 14 days after a request to meet has been made by either side.

c.         The Joint Committee shall work with appropriate State agencies to review and oversee the various health plans available to employees represented by PEF.

d.         The Joint Committee on Health Benefits shall work with appropriate State agencies to monitor future employer and employee health plan cost adjustments.

e.         The Joint Committee shall be provided with each carrier rate renewal request upon submission and be briefed in detail periodically on the status of the development of each rate renewal.

f.          The State shall require that the insurance carriers for the State Health Insurance Plan submit claims and experience data reports directly to the Joint Committee on Health Benefits in the format and with such frequency as the Committee shall determine.

g.         The State shall provide to the PEF designees to the Joint Committee, a quarterly summary of hospital carrier paid claims (number of charges, amount of covered expenses and amount of benefits) by type of service for PS&T Unit enrollees and New York State Actives; New York State Empire Plan Medical Carrier and Prescription Drug Program paid claims (number of charges, amount of covered expenses and amount of benefits) by type of service for PS&T Unit enrollees and New York State Actives; number of enrollees, spouses or domestic partners, and dependents for PS&T Unit enrollees and New York State Actives.

h.         The Joint Committee on Health Benefits shall work with appropriate State agencies in an ongoing review of the Medical Flexible Spending Account.  The Joint Committee will work with the State to implement a direct debit vehicle to be utilized under the Medical Flexible Spending Account. 

i.          The Joint Committee on Health Benefits shall work with appropriate State agencies to review the impact of coverage for adult immunizations in the Empire Plan, and to consider additions to the list of immunizations.

j           The Joint Committee on Health Benefits shall work with appropriate State agencies to make mutually agreed upon changes in the Plan benefit structure through such initiatives and activities as:

1.         The annual HMO Review Process;

2.         The ongoing review of the Managed Mental Health and Substance Abuse Care Program;

3.         Ongoing review of the Benefits Management Program and an annual review of the list of procedures requiring Prospective Procedure Review;

4.         Ongoing review of the Managed Physical Medicine Program;

5.         The Joint Committee on Health Benefits will work with the State and Empire Plan hospital and medical carriers on the ongoing review of the Empire Plan hospital network and the network of participating providers.

6.         The development and implementation of a program that will allow enrollees to obtain Laser Vision Correction services at discounted enrollee-pay-all fees through a network of providers.

7.         Ongoing review of Prospective Procedure Review (PPR) requirements and role/responsibility of medical providers in PPR process;

8.         Review of the Infertility Centers of Excellence program as utilization information becomes available from the medical program vendor;

9.         Review of the program to provide an annual vision care benefit for enrollees who demonstrate a vision loss resulting from a medical condition;

10.       In cooperation with the New York State Health Insurance Program (NYSHIP) management, attempt to develop a "report card" which will include objective quality data to assist employees in selecting the health benefit plan that best meets the needs of the employees and their dependents.

11.       The Joint Committee on Health Benefits will review the impact of Domestic Partner coverage under the New York State Health Insurance Program (NYSHIP), including the appropriateness of the existing waiting periods.

12.       The Joint Committee on Health Benefits will review the utilization of durable medical equipment provided by the Home Care Advocacy Program.

13.       The Joint Committee on Health Benefits will work with the State and medical carrier to develop an enhanced network of urgent care facilities.

14.       The Joint Committee on Health Benefits will work with the State and medical carrier to determine the feasibility of developing a network of hearing aid providers.

15.       The Joint Committee on Health Benefits will work with the State to explore the implementation of additional Centers of Excellence Programs to include, but not be limited to Centers of      Excellence for Bariatric Surgery.  Nutritional counseling will be available when clinically appropriate.

16.       The Joint Committee on Health Benefits will explore the possibility of a copayment waiver program for office visits and prescription drugs when related to chronic conditions.

 

k.                 The PEF Joint Committee on Health Benefits will work with the State to conduct an extensive analysis of the current New York State Health Insurance Program (NYSHIP) prescription drug benefit designs (Empire Plan and HMOs) and associated costs. 

 

l.                    The State shall seek appropriations of funds by the Legislature in the amount of $500,000 for fiscal year 2007-08, $500,000 for fiscal year 2008-09, $500,000 for fiscal year 2009-2010 and $500,000 for fiscal year 2010-2011 to support Committee initiatives and to carry out the administrative responsibilities of the Joint Committee during the term of this Agreement. 

 

9.17             The program for managed care of mental health services and alcohol and other substance abuse treatment shall continue. The Joint Committee on Health Benefits will work with the State on the ongoing review of this program.

 

        The Empire Plan shall continue to provide comprehensive coverage for medically necessary mental health and substance abuse treatment services through a managed care network of preferred mental health and substance abuse care providers.  The providers will be included in all lists of Empire Plan providers, including on-line directories.  In addition to the in-network care, limited non-network care will be available

 

Benefits shall be as follows:

 

IN-NETWORK BENEFIT

 

Mental Health Coverage

Alcohol and Other Substance Abuse Coverage

Benefit Maximums

NON-NETWORK BENEFIT

 

Medically necessary care rendered outside of the network will be subject to the following provisions:

 

 

Expenses applied against the deductible, coinsurance and/or copay levels indicated above will not apply against any deductible, coinsurance, copay levels or maximums under the basic medical portion of the Plan.

 

9.18 Appropriate descriptive material relating to any changes in benefits as a result of this Agreement shall be distributed to each State agency for internal distribution to enrollees prior to the effective date of the change in benefit. The State shall also take all steps necessary to provide revised health insurance booklets to every enrollee as soon as practically possible.

 

9.19 The State shall provide toll-free telephone service at the Department of Civil Service Health Insurance Section for information and assistance to employees and dependents on health insurance matters.

 

9.20 (a) A permanent full-time employee who is removed from the payroll due to an accepted work related injury or occupational condition shall remain covered under the State Health Insurance Plan and shall be treated as described in Section 13.3(h) of this Agreement. 

 

(b) A permanent full-time employee who is removed from the payroll due to a controverted work related injury or occupational condition will have the right to apply for a health insurance premium waiver. The appropriate agency will be responsible to inform the employee of his/her right to apply for the waiver prior to the employee meeting the eligibility requirements for the waiver of premium.

 

9.21 The confidentiality of individual subscriber claims shall not be violated. Except as required to conduct financial and claims processing audits of carriers and coordination of benefit provisions, specific individual claims data, reports or summaries shall not be released by the carrier to any party without the written consent of the individual, insured employee or covered dependent.

 

9.22 Eligible PS&T Unit employees enrolled in the Empire Plan will be provided with prescription drug coverage through the Empire Plan Prescription Drug Program. The benefits provided shall consist of the following:

 

The Prescription Drug Program will cover medically necessary drugs requiring a physician's prescription and dispensed by a licensed pharmacist.

 

Mandatory Generic Substitution will be required for all brand-name multi-source prescription drugs (a brand-name drug with a generic equivalent) covered by the Prescription Drug Program.

 

When a brand-name multi-source drug is dispensed, the Program will reimburse the pharmacy (or enrollee) for the cost of the drug's generic equivalent. The enrollee is responsible for the cost difference between the brand-name drug and its generic equivalent, plus the copayment.  The enrollee is responsible for the cost difference between the non-preferred brand name drug and its generic equivalent, plus the copayment for the non-preferred brand name drug.

 

·         The copayment for up to a thirty-day supply at either the retail or mail service pharmacy, will be $5 for generic drugs, $15 for preferred brand name drugs, and $30 for non-preferred brand name drugs. Effective July 1, 2008, the copayment for up to a thirty-day supply of non-preferred brand name drugs will be $40.

 

·         The copayment for a 31 to 90 day supply at the retail pharmacy will be $10 for generic drugs, $30 for preferred brand name drugs, and $60 for non-preferred brand-name drugs.  Effective July 1, 2008, the copayment for a 31-90 day supply of non-preferred brand name drugs at a retail pharmacy will be $70.

 

·         The copayment for a 31 to 90 day supply at the mail service pharmacy will be $5 for generic drugs, $20 for preferred brand-name drugs, and $55 for non-preferred brand-name drugs.  Effective July 1, 2008, the copayment for a 31-90 day supply of non-preferred brand name drugs at the mail service pharmacy will be $65.

 

 

Prescription drugs will be dispensed through either the preferred provider community pharmacy network (retail pharmacy), or the mail service pharmacy.

 

Coverage will be provided under the Empire Plan Prescription Drug Program for prescription vitamins, contraceptive drugs, and contraceptive devices purchased at a pharmacy. 

 

Effective July 1, 2008, or as soon thereafter as practicable, “new to you” prescriptions will be limited to a 30-day initial supply at retail/mail prior to a 31-90 supply being filled.  The initial prescription will be filled for a 30-day supply (subject to the appropriate 30-day copayment).  If the original prescription is written for over a 30-day supply, the enrollee can receive the remaining supply of the prescription up to 90 days.  The balance of the appropriate 31-90 day copayment will be applied.

 

9.23 Eligible PS&T Unit employees enrolled in a Health Maintenance Organization participating in the State Health Insurance Plan will be provided with prescription drug coverage through the HMO in which they are enrolled.

 

9.24 Eligible PS&T Unit employees will be provided with Dental Plan coverage at the same level of benefits in effect on April 1, 2003, except as modified below:

 

a.         The Dental Plan will cover sealants for dependents under age 14 at the same level of benefits in effect for managerial/confidential employees.

b.         The maximum annual benefit per person for covered participating and non-participating services, including orthodontia, is $2,300.  

c.         Anesthesia (not including topical, e.g., novocaine) administered in a dentist office shall be a covered benefit under the participating and non-participating components of the Dental Plan.  There is no out of network differential.  Local or topical anesthetic (e.g., novocaine) is included in the allowance for the procedure being performed and continues to remain covered.

 

9.25 (a)  Eligible PS&T Unit employees will be provided with the PEF Vision Care Plan at the same level of benefits, including Occupational Vision coverage, in effect on April 1, 2003 for managerial/confidential employees.  Effective January 1, 2009, PS&T Unit employees will be provided with the PEF Vision Care Plan at the same level of benefits, including Occupational Vision Coverage in effect on April 2, 2007 for managerial/confidential employees, except as modified below.

Effective July 1, 2008, or as soon as practicable thereafter, eligible employees and dependents will have 90-days from the date of the vision exam to purchase eyewear from a participating provider.

 

(b) Covered dependents under 19 years of age shall be eligible to receive vision care benefits once in any 12-month period.

 

(c) Effective January 1, 2009, under the Medical Exception Program, an individual with a medical condition that may impact vision refraction shall, if referred by his or her physician caring for that condition, qualify for an annual examination of their vision.  If new lenses are required due to vision changes resulting from a medical condition for which the individual is under the care of a physician, new lenses and, if appropriate, new frames, shall be available sooner than once every 24 months, but not sooner than 12 months from the last use of vision care benefits, upon written documentation that the medical condition has caused a vision loss that requires a new prescription. Documentation of the vision loss must be provided in writing each time a new prescription is needed sooner than the standard 24-month interval. An individual who requires new lenses due to vision changes resulting from a medical condition, and who otherwise qualifies for Occupational Vision coverage, will be eligible to receive Occupational Vision benefits in accordance with the terms and conditions contained in this paragraph. The Joint Committee on Health Benefits shall work with the Vision Care Plan vendor to establish and confirm the eligibility rules and application procedures for this vision care enhancement.

 

(d)  The state will continue to provide access to a network of providers to obtain Laser Vision Correction services at discounted enrollee-pay-all fees.

 

9.26 The Medical Flexible Spending Account (MFSA) shall continue. The PEF Joint Committee on Health Benefits shall work with the State in the ongoing review of the MFSA.  Eligible expenses under the Medical Flexible Spending Account will include over-the-counter medications according to guidelines developed by the Medical Flexible Spending Account Administrator.