Effective July 1, 2023, enrollee benefits for the following groups in The Empire Plan are changing:
The $25 participating provider copayment amount remains the same, with multiple copayments for the same provider and same visit eliminated. Just 1 copayment of $25 is required for all covered office visits, office surgery, radiology and/or laboratory services received by the same enrollee from the same provider on the same date of service. Please note that up to 2 copayments of $30 (for a total of $60) may apply for services at an urgent care center.
Claims from nonparticipating providers will use Medicare rates as the fee basis. This means enrollees may have greater out-of-pocket costs when using a nonparticipating provider. In accordance with your contract, please refer enrollees to providers in The Empire Plan network when appropriate. Using network providers will help your patients avoid added costs and pay only a copayment for covered services.
If an enrollee receives infusion services for infliximab (Remicade®) or an infliximab biosimilar and The Empire Plan is the enrollee’s primary coverage, Empire BlueCross will review the setting for those services under The Empire Plan Hospital Program. If clinically appropriate, Empire BlueCross and UnitedHealthcare will work with you and your patient to transition those services from an outpatient hospital setting to a new location. Alternate settings include freestanding infusion suites, a doctor’s office or the patient’s home. There are no Medical/Surgical Program or Prescription Drug Program copayments when patients use an alternate setting. Enrollees may choose to continue infusion services in an outpatient hospital setting when clinically appropriate or when there is no alternate setting available within 30 minutes or 30 miles of their home. Benefits for covered infusion services in an outpatient hospital setting are unchanged.
Coverage is available for a maximum of 20 visits per calendar year for acupuncture services by nonparticipating providers. This is a combined total for all nonparticipating providers, regardless of how many nonparticipating providers are visited. The 2023 visit maximum does not include visits prior to July 1, 2023.
Coverage is available for a maximum of 20 visits per calendar year for massage therapy services. This is a combined total for all massage therapy visits, regardless of how many providers are visited. The 2023 visit maximum does not include visits prior to July 1, 2023.
The Empire Plan Mental Health and Substance Use Program, administered by Carelon Behavioral Health, will include a new Center of Excellence for Substance Use Disorder Program in partnership with the nationally recognized Hazelden Betty Ford Foundation. The program provides authorized treatment services at no cost to The Empire Plan enrollees. Detoxification facilities are available in California, Minnesota and Oregon, and outpatient services are available in California, Florida, Illinois, Minnesota, New York, Oregon and Washington. When authorized, covered services include detoxification, residential rehabilitation, partial hospitalization, intensive outpatient care, care coordination for transition back to community, family treatment and support, and virtual support services. Travel, lodging and meal allowances are also available for patients and up to 2 travel companions.
Call 877-769-7447 (877-7-NYSHIP) and press or say “1” to reach the Medical/Surgical Program, administered by UnitedHealthcare.