HR Policies: 6.8.11
Group Health Insurance Plans, Endowed and Statutory
Subject: Providing Benefits
Number: 6.8.11
Issued: 3/1/82
Revised: 12/23/99
Group Health Care Plans for Endowed Employees
Description
Endowed faculty and staff currently have a choice of three Health
Care plans: 80/20 Plan, Open Choice Plan, or Point of Service
Plan.
80/20 Plan
Under the 80/20 Plan the university pays 80 percent of reasonable and customary eligible medical expenses after satisfaction of the annual deductible. If the amount paid out of a staff member's own pocket for eligible medical expenses reaches the annual out-of-pocket maximum (including the annual deductible) the university pays eligible medical expenses in full for the rest of the calendar year. Certain routine expenses are covered at 80 percent with no deductible.
80/20 Plan claims are adminstered by Aetna Life Insurance Company. Aetna also administers the utilization review programs including mandatory inpatient hospital precertification and case management
Open Choice Plan
The Open Choice Plan is a moderately managed care plan that does not require members to designate a primary care physcian to obtain a referral for specialty care. For each instance of illness or injury, participants may choose whether to use a network provider or a provider who is out of the network.
Open Choice Plan claims are adminstered by Aetna Life Insurance Company. Aetna also administers the utilization review programs including mandatory inpatient hospital precertification and case management
Point of Service (POS) Plan
The Point of Service Plan is a managed care plan that requires members to designate a primary care physician to coordinate all care for themselves and their families. A network of participating providers is used for most health care needs, with a reduced benefit payable if care is not coordinated through the primary care physician.
Point of Service Plan claims are adminstered by Health Now. Health Now also administers the utilization review programs including mandatory inpatient hospital precertification and case management.
Specifics on the 80/20 Plan, Open Choice Plan and Point of Service Plan are detailed in plan summary booklets. These booklets are available, upon request, from the Office of Human Resources, Benefit Services. The Benefit Services staff is available to provide more information and assist you and your family with your health coverage questions.
Termination of Health Care Coverage
Termination of health care coverage will occur when a staff member terminates, if a staff member fails to pay the required premiums, or when a dependent no longer meets the plan definition. Participants have a federally protected right to a temporary extension of coverage under certain circumstances.
Nonduplication of Benefits Payments
Medical costs paid by other sources will not be duplicated. These sources include no-fault insurance, other group health plans, Workers' Compensation, governmental plans, and paid treatment in Veterans Administration facilities.
Group Dental Insurance
Coverage is provided by First Ameritas Life Insurance Corporation of New York. There are two plans: High Option (Plan A) and Low Option (Plan B). Both plans provide comprehensive dental benefits with similar deductibles, waiting periods and annual benefit maximums. The difference between the plans is the reimbursement levels.
Employees who do not enroll when first eligible are subject to a Late Entrant Provision. Only exams and cleanings are covered during the first year of enrollment.
Specifics on the Group Dental Insurance are detailed in the plan summary booklet. This booklet are available, upon request, from the Office of Human Resources, Benefit Services. The Benefit Services staff is available to provide more information and assist you and your family with your health coverage questions.
Termination of Dental Coverage
Termination of dental coverage will occur when a staff member terminates, if a staff member fails to pay the required premiums, or when a dependent no longer meets the plan definition. Participants have a federally protected right to a temporary extension of coverage under certain circumstances.
Nonduplication of Benefits Payments
Medical costs paid by other sources will not be duplicated. These sources include no-fault insurance, other group health plans, Workers' Compensation, governmental plans, and paid treatment in Veterans Administration facilities.
Disclaimer
While every attempt has been made to ensure the accuracy of the
above descriptions, the legal documents, policies, or certificates
pertaining to the benefits prevail in the event of any discrepancy.
These descriptions do not constitute legal documents. The university
reserves the right to alter this or any other employee benefits
program by action of the Board of Trustees.
Group Health Care Plans for Contract College Employees
Eligibility
Full-time and part-time staff are eligible to enroll if their employment is
expected to continue for at least three months. New enrollees are subject to
a waiting period before their coverage is effective.
Description
The New York State Employees' Health Insurance Program offers two
different coverage options to staff of the statutory colleges: The
Empire Plan and the Health Maintenance Organization (HMO) Option.
The Empire Plan
There are three components of this coverage:
Hospitalization (Blue Cross)
- Covered expenses include charges for up to 365 days of care per spell of illness in a semiprivate room.
- Emergency room for accidental injuries or medical emergencies.
- Emergency room, laboratory and x-rays are subject to a copay unless admitted.
- Pre-admission certification provision requires that all nonemergency inpatient stays be approved prior to admission. Staff must call 1-800-992-1213 in advance (within 48 hours for emergency admission) to avoid payment of a deductible and copays for any inpatient days not considered medically necessary.
Medical/Surgical (Metropolitan Life)
- Charges for office visits at participating providers for well-child visits, chemotherapy, hemodialysis, radiation therapy are covered at no cost to staff and eligible dependents. Other office visits are subject to a copay.
Charges at nonparticipating providers are reimbursed at 80 percent after the deductible has been satisfied. Once a staff member reaches the annual out-of-pocket maximum for eligible medical expenses, the plan will pay 100 percent of any additional eligible expenses incurred in the same calendar year.(The deductible is not included in the out-of-pocket maximum.)
- Mandatory prospective procedure review provision applies to selected surgical and diagnostic procedures. See plan booklet for details.
- Ambulatory surgery is required for certain procedures. See plan booklet for details.
- Paid in full benefits are available for mental health, substance abuse, and home care services and equipment you may require at home. Precertification and use of participating providers is required.
- Mandatory Generic Substitution Requirement
- Participants pay a copay for each prescription filled through participating pharmacies.
- Using the mail-order service or participating pharmacy, participants may obtain up to a 90-day supply, of maintenance medications. Participants must pay a copay for each prescription or refill.
- Prior approval needed for some drugs.
Prescription Drugs
The Health Maintenance Organization (HMO) Option
This option is only available to staff who reside or work in an
area of New York State served by a Health Maintenance Organization.
A complete listing of available HMOs may be obtained from departmental
central employee representatives (CER). Services which are covered
must be rendered by a primary care physician who is a member of
the HMO. This type of program provides prepaid medical services,
rather than reimbursement toward the direct cost of health care
services. Employees share the cost of coverage with New York State.
Dental Insurance
Coverage is provided by Group Health Incorporated (GHI). Benefits
are paid according to a schedule of allowable charges and are subject
to a $25 annual deductible (maximum $75 per family). Coverage is
effective on the first day of the month following the completion
of six full consecutive months of service. New York State provides
this coverage at no cost to staff and dependents.
Dependent Coverage
Employees may enroll in single or family coverages for both health
and dental. Under family coverage, eligible dependents include:
- Legal spouse; partner (same or opposite sex).
- Unmarried children under age 19.
- Unmarried children up to age 25 who are enrolled as full-time students and receive more than half of their support from the staff member.
- Children include your natural children, legally adopted children, and step-children. Other children who reside permanently with you in your household, and who are dependent on you, are also eligible.
Procedure
Employees should contact their statutory hiring departments for
the appropriate forms to enroll in any of these plans, change coverage
or change health insurance options.
A change of health insurance option can only be made once a year, during the month of November. Changes of coverage or options may be subject to waiting periods, or qualifying events, according to the plan provisions.
Disclaimer
While every attempt has been made to ensure the accuracy of the
above statements, the legal documents, policies, or certificates
pertaining to this benefit prevail in the event of any discrepancy.
This description does not constitute a legal document.
Contact the local hr representative or Benefit Services in the Office of Human Resources (607) 255-3936 for more information.