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HealthBenefits Updated June 3, 2010 - Health Benefits Homepage
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Use a Par Lab to Avoid Unexpected Expenses

United Healthcare’s (UHC’s) network of participating laboratory (par lab) service providers for The Empire Plan Medical Program includes a combination of LabCorp, as the only national provider, plus other local, regional and hospital-owned labs and draw stations. Enrollees who are not familiar with how the Plan works, may find that their out-of-pocket costs for lab services are higher than they expected.

Specimens collected at a physician’s office

As long as your physicians use par labs, you pay a $20 copayment for covered tests. However, you may not always know which lab service provider your physician uses. In most cases, specimens are collected in a physician’s office and picked up by a courier. To minimize your out-of-pocket costs, it is important that you ensure your physician sends your samples to an Empire Plan par provider for testing.

Specimens collected at a hospital-owned lab

In other cases, your physician may write you an order for lab services and allow you to choose where to have the specimen collected. With one exception, you should know that your out-of-pocket cost may be substantially higher if you use a hospital-owned lab. The exception is the list of hospital-owned labs that are subcontracted by LabCorp to serve as LabCorp draw sites. These labs are listed in the directory of Empire Plan par providers with “LCA subcontracted” before the name of the facility.

If you are physically present at the outpatient department of a hospital or at a hospital-owned extension clinic that is not an LCA subcontracted facility, the lab services you receive may be covered under the Empire Plan Hospital Program. As such, benefits will be subject to the Plan’s outpatient hospital services copayment. You will pay a $35 copayment for each visit to a network facility, or the greater of 10 percent of charges or $75 at a non-network facility.

Stellaris Health Network (SHN) Hospital Labs

UHC’s directory of Empire Plan par lab service providers includes the labs based in the following non-network hospitals: Lawrence Hospital Center, Northern Westchester Hospital, Phelps Memorial Hospital Center, and White Plains Hospital Center. These hospital-based labs are included in the directory because you will only pay the Medical Program par provider copayment if your physician sends your sample(s) to one of these hospital labs for testing.

However, if you are physically present at one of these hospitals, then benefits will be subject to the outpatient hospital services copayment. Since these hospitals are currently not in the Hospital Program network, you will pay the greater of 10 percent of charges or a $75 copayment.

List of Par Lab Providers

To find the most current listing of par lab providers in the Medical Program, visit the NYS Department of Civil Service web site at www.cs.state.ny.us. On the home page, click on “Benefit Programs” and follow the instructions to access NYSHIP Online. Then, click on “Find a Provider.” You can also obtain a list of par labs by calling UHC at 1-877-7NYSHIP (1-877-769-7447) and selecting the prompt for United Healthcare.

Results of Dependent Eligibility Audit

During the past year, the Department of Civil Service (DCS) conducted an eligibility audit to verify that any enrollee’s dependents covered under the New York State Health Insurance Program (NYSHIP) meet the state’s definition of an eligible dependent. If they were found to be ineligible, either because the enrollee failed to submit the required documentation or submitted incomplete documentation, DCS terminated the dependent’s coverage. Enrollees received a letter from NYSHIP advising them that coverage had been terminated for their ineligible dependent(s) retroactively to February 1, 2009.

Members who disagree with the ineligible status determination of their dependent(s) may still pursue an appeal through DCS. DCS has established a special call center for this purpose. The toll-free number for the DCS call center is 1-800-409-9059. Before DCS will reinstate coverage, the member will have to provide DCS with the documentation required to prove the dependent’s eligibility.

During the eligibility audit, DCS notified enrollees that any claims paid for a dependent while the dependent was ineligible would be the enrollee’s responsibility to pay. In other words, if a dependent’s coverage was terminated retroactively to 2/1/09, and the dependent’s coverage has not been reinstated, then the enrollee’s health plan will be requesting a refund from the enrollee for any payments made for services performed on or after 2/1/09.

As of 4/14/10, 2,275 covered dependents of PEF-represented enrollees were deemed ineligible. Of these dependents, 1,437 were deemed ineligible because no documentation of eligibility was received, and the documentation for the other 838 dependents was incomplete.

These tables indicate the number of PEF claimants who received refund request letters from the Empire Plan and from GHI Dental.

Regarding the Vision program, an analysis was made of potential recoveries from dependents removed during the eligibility audit and for the Vision program. The cost of recovering exceeded the expected recoveries so no claims recoveries will be pursued under the Vision program.

It appears that a significant portion of the ineligible dependents did not actually have claims paid. Most likely, employees did not ask their Health Benefit Administrators (HBAs) to terminate the coverage of their dependent children between 19 and 25 years old even though they knew their children were no longer eligible. The employees either didn’t submit claims for these children, or the insurers rejected their claims because the employee did not submit full-time student or disabled dependent documentation. The state’s enrollment system automatically terminates coverage when a dependent child reaches age 25.

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Continuing Coverage for Dependents Who Graduate or Leave School

Your unmarried dependent children who are age 19 or over but under age 25 are eligible for coverage in the New York State Health Insurance Program (NYSHIP) if they are full-time students at an accredited secondary or preparatory school, college or other educational institution, and are otherwise not eligible for employer group or military health care coverage (e.g., cadets at U.S. military academies). They continue to be eligible until the earlier of the following dates:

-The end of the third month following the month in which the dependent completes a semester.

-The end of the month in which attendance at school ends if the semester is not completed and proof of the last day of attendance for the semester is provided, or the end of the third month following the month that the last semester was completed, whichever is later.

-The starting date of the semester if the semester is not completed and no proof of attendance is provided, or the end of the third month following the month that the last semester was completed, whichever is later.

-The end of the third month following the month in which they complete course requirements for graduation; or

-The day they reach age 25.

Continuing Coverage in NYSHIP

If your child is no longer eligible, you must act quickly to continue his or her coverage without interruption. You may continue NYSHIP coverage in one of the following two ways:

Continue coverage in NYSHIP under COBRA, or
Continue coverage in NYSHIP under the “Young Adult Option”

According to information on the NYS Insurance Department web site, it may be better for your child to exhaust COBRA continuation coverage before enrolling in the “Young Adult Option”. This is because if your child has “Young Adult Option” coverage and either 1) you lose eligibility for NYSHIP coverage, or 2) your child no longer meets the requirements for the “Young Adult Option”, then your child’s “Young Adult Option” coverage will terminate and he or she will no longer have the right to elect COBRA continuation coverage. However, if your child continues coverage in NYSHIP under COBRA, and you later lose eligibility for NYSHIP coverage, your child’s COBRA coverage would still be available.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

A federal law, known as COBRA, requires that most employers sponsoring group health plans offer employees and their covered dependents the opportunity for a temporary extension of health care coverage called "continuation coverage" at group rates in certain instances where coverage under the program would otherwise end. The health care benefits your dependent may continue are the same benefits you receive as an active employee enrolled in NYSHIP. There is also no change in benefits when your dependent enrolls in COBRA. COBRA requires that your child have the opportunity to continue coverage for up to 36 months. The cost of COBRA coverage is the full premium (both the employer and employee share) plus a two percent administrative fee. The 2010 monthly rate for Empire Plan COBRA coverage is $509.95.

Under provisions of COBRA, the employee or dependent is responsible for informing the Employee Benefits Division (EBD) of the NYS Department of Civil Service of a child's losing NYSHIP eligibility within 60 days from the date coverage ends. If you do not notify EBD within the required 60-day period, regardless of the reason, the dependent will not be entitled to COBRA continuation coverage.

For enrollment instructions, visit the NYS Department of Civil Service website at: http://www.cs.state.ny.us. On the Civil Service home page, select “Benefit Programs” and then follow the instructions to access NYSHIP Online. Click on “Health Benefits & Option Transfer” and then, “NYSHIP General Information Book.” Scroll down to “COBRA: Continuation of Coverage”.

“Young Adult Option”

New York State’s “Age 29” law allows young adults through age 29 to purchase an individual policy through a parent's group health insurance policy under the "Young Adult Option". Only health insurance coverage is available; dental and vision coverage are not included. Under the law, the young adult's coverage is subject to all terms of the group policy; however, premiums are paid in full by the young adult or his/her parent. The cost is the full cost of individual coverage for the NYSHIP option selected. The 2010 monthly rate for Empire Plan “Young Adult Option” coverage is $499.07.

For enrollment instructions, frequently asked questions (FAQs) about the “Young Adult Option”, and 2010 monthly rates for all NYSHIP options, visit the NYS Department of Civil Service website at: http://www.cs.state.ny.us. On the Civil Service home page, select “Benefit Programs” and then follow the instructions to access NYSHIP Online. Click on “What’s New” and scroll down to “Young Adult Option Coverage.”

Other Coverage Options

If these two options are unaffordable, other ways of continuing coverage that differs from NYSHIP coverage and is not administered by the NYS Department of Civil Service include the following:

Convert to direct-pay contracts, or
Enroll in Family Health Plus or Healthy New York

Direct-Pay Contracts

Dependent children losing eligibility are entitled to convert to direct-pay contracts after their NYSHIP coverage ends. The benefit package and the premium costs for direct-pay conversion contracts differ from what your child had under NYSHIP.

Written notice of conversion privileges will not be sent to children who lose their status as eligible dependents. You or your child must apply for direct-pay conversion contracts directly to The Empire Plan carriers or, if enrolled in a NYSHIP HMO, the HMO.

For more information on changing to direct-pay conversion contracts, visit the NYS Department of Civil Service website at: http://www.cs.state.ny.us. On the Civil Service home page, select “Benefit Programs” and then follow the instructions to access NYSHIP Online. Click on “Health Benefits & Option Transfer” and then, “NYSHIP General Information Book.” Scroll down to “Changing from NYSHIP to a Direct-Pay Conversion Contract”.

Family Health Plus or Healthy New York

Family Health Plus is a New York State public health insurance program for adults who are aged 19 to 64 who have income too high to qualify for Medicaid. Family Health Plus provides comprehensive coverage, including prevention, primary care, hospitalization, prescriptions and other services. There are minimal copayments for some Family Health Plus services. Health care is provided through participating managed care plans in your area. For more information on Family Health Plus, visit their website: http://www.health.state.ny.-us/nysdoh/fhplus/.

If your dependent is not eligible to enroll in Family Health Plus, then he or she may be eligible for Healthy NY, another New York State public health insurance program. For more information on Healthy NY, call 1-866-HEALTHYNY or visit their website: http://www.ins.state.ny.us/-website2/hny/english/hny.htm.