§11.1 The State shall continue to provide all the forms and extent of coverage as defined by the contracts in force on March 31, 1991 with the State's health and dental insurance carriers unless specifically modified or replaced pursuant to this Agreement.

§11.2

1. A Effective April 1, 1993, a new Benefits Management Program, Health Call, will replace the current Empire Plan Precertification and Second Surgical Consultation Programs. Precertification will be required for all inpatient confinements and prior to certain specified surgical or medical procedures.

   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 pre-natal 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.

   The hospital deductible amount imposed for non-compliance with Program requirements will be reduced from $250 to $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. For each day deemed inappropriate for an inpatient setting, a $100 deductible shall be incurred by the enrollee.

   The current Empire Plan Second Surgical Consultation Program will be replaced with a program of Prospective Procedure Review. This Program will screen for the medical necessity of certain listed surgical or diagnostic medical procedures which, based on Empire Plan experience, have been identified as potentially unnecessary or overutilized. The list of procedures will undergo annual evaluation by the Benefits Management Program vendor. As revised and approved by the Joint Committee on Health and Dental Benefits, the list will be published and distributed to enrollees prior to implementation.

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

   Current Second Surgical Consultation co-insurance levels will apply for failure to comply with the requirements of the Prospective Procedure Review Program.

   An appeal procedure has been established by the Joint Committee on Health and Dental Benefits and will be utilized during this agreement.

   1. Charges for outpatient services, covered by the hospital contract, including emergency room services, will be subject to a $15 copayment per outpatient visit, for such service received on or after April 1, 1993.

2. 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, co-insurance, or annual and lifetime maximums. Office visit charges by participating providers will be subject to a $5.00 copayment per covered individual.

   All covered surgical procedures rendered during any visit by participating providers will be subject to a $5.00 copayment.

   1. All covered outpatient radiology services rendered during any visit by participating providers will be subject to a $5.00 copayment.

      All covered outpatient laboratory services rendered during any visit by participating providers will be subject to a $5.00 copayment.

      The office visit, office surgery, outpatient radiology and laboratory copayment amounts may be applied against the major medical copayment maximum, however they will not be considered covered expenses for major medical payment.

   2. The State shall require the insurance carriers to continue to actively seek new participating providers in regions that are deficient in the number of participating providers, as determined by the Joint Committee on Health Benefits.

3.  

   1. The Empire Plan shall also include major 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 and co-insurance.
   2. Periodic evaluations and adjustment of Reasonable & Customary (R&C) charges will be performed according to guidelines established by the Major Medical Plan insurer.

4. The ambulatory surgery procedures outlined in the Memorandum of Understanding dated November 8, 1982, will be covered to the same extent as all other covered surgical procedures under both the participating provider and major medical portions of the Empire Plan.

5. The current last quarter carryover provision of the major medical component will be discontinued.

6. Coverage for ambulance services will be provided by major medical solely. Up to $50 of charges for ambulance services, if a covered service under the Blue Cross contract in effect on March 31, 1991, will be provided by major medical without deductible or copayment.

7. Effective April 1, 1993, private duty nursing charges reimbursable under the Blue Cross Hospital component of the Empire Plan will not also be reimbursed under the Major Medical component of the Empire Plan.

8. The State agrees to pay 90 percent of the cost of individual coverage and 75 percent of the cost of dependent coverage provided under the Empire Plan.

9. 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 under each participating HMO. The cost of prescription drug coverage provided by the HMO will be paid in full by the State.

In addition to the basic Empire Plan benefits, the Empire Plan for PBA enrollees shall include:

1. The copayments for outpatient services, covered by the hospital contract, will be waived for persons admitted to the hospital as an inpatient directly from the outpatient setting or for the following covered chronic care outpatient services: chemotherapy, radiation therapy, physical therapy, hemodialysis or any other services that require long-term outpatient visits approved by the Joint Committee.

2. In the event that there is both an office visit charge and office surgery charge by a participating provider in any single visit, the covered individual will be subject to a single $5.00 copayment.

3. Outpatient radiology services and laboratory services rendered during a single visit by the same participating provider will be subject to a single $5.00 copayment.

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

5. Charges by participating providers for professional services for allergen immunotherapy in the prescribing physician's office or institution and chronic care services for chemotherapy, radiation therapy, hemodialysis and any major injuries or diseases that require long term doctor visits approved by the Joint Committee on Health Benefits and will be excluded from the office visit copayment.

6. Effective January 1, 1993, the major medical component deductible shall be $188 per enrollee; $188 per enrolled spouse; and $188 per all dependent children combined plus an annual percentage increase effective January 1, 1994, and thereafter on each successive January 1 in an amount equal to the percentage increases in the medical care component of the C.P.I. for Urban Wage Earners and Clerical Workers, All Cites (C.P.I.-W.) for the period July 1 through June 30 of the preceding year. Covered expenses for mental health and/or substance abuse treatment services are excluded in determining the major medical component deductible.

7. Effective January 1, 1993, the major medical component shall pay 80 percent reimbursement of reasonable and customary charge for the first $3,880 of covered expenses in a calendar year, ($776 maximum out-of-pocket expense) then 100 percent of reasonable and customary covered expenses up to the annual and lifetime limits. Covered expenses for mental health and/or substance abuse treatment services are are excluded in determining the maximum annual co-insurance limits.

8. The major medical component annual and lifetime maximum payments per covered person shall be unlimited.

9. Routine pediatric care including all preventive pediatric immunizations, both oral and injectable shall be considered a covered medical expense under the participating provider component and the major medical component.

10. Effective April 1, 1993, the State will discontinue the Dual Eligibility Family Benefit.

11. The newborn care allowance under the major medical component shall be $100, not subject to deductible or coinsurance.

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

13. 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 for an indefinite period of time 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 from post-retirement employment.

    The surviving spouse of a retiree who dies while under a delay or suspension as referred to in Article 11.3M may transfer back to the State Health Insurance Plan on the first of the month coinciding with or following the retiree's death as described in Article 11.6A.

14. The State shall continue to provide for and pay the full premium cost of the Empire Plan Prescription Drug Program. The drug program will cover medically necessary drugs and medicines requiring a physicians prescription and dispensed by a licensed pharmacist.

    Effective April 1, 1993, 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.

    On a case by case basis, when a physician provides sufficient medical justification of the need for a brand-name drug where a generic equivalent is available the Program administrator will review the physician's request and rule on the appropriateness of a waiver of the mandatory generic substitution requirement.

    Effective April 1, 1993, all prescriptions written for supplies of drugs covered under the Prescription Drug Program of greater than 21 days and 1 refill must be filled either at a community pharmacy, designated by the Program as a participating maintenance pharmacy, or at the Program's designated mail service pharmacy.

    Effective April 1, 1993, the copayment will be $5 for brand-name and generic drugs dispensed at either a community pharmacy or the mail service pharmacy.

15. Services for examinations and/or purchase of hearing aids shall be a covered major medical benefit and shall be reimbursed up to a maximum of $150 once every three years.

16. Employees 50 years of age or older shall be allowed reimbursement up to $125 once every two years toward the cost of a routine physical examination. Covered spouses 50 years of age or older shall be allowed reimbursement up to $75 once every two years towards the cost of a routine physical examination. These benefits shall not be subject to deductible or co-insurance.

17. An unmarried child under age 21 is eligible for coverage under a family enrollment.

18. The Empire Plan participating provider schedule of allowances and the major medical reasonable and customary levels will be no less than the levels in effect on March 31, 1991.

19. 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.

    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.

20. The Participating Provider Panel shall include selected Durable Medical Equipment providers who shall offer durable medical equipment at discounted prices.

§11.4 Effective April 1, 1993, the Empire Plan shall 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. 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
  
  • Paid-in-full medically necessary hospitalization services and inpatient physician charges when provided by or arranged through the network;
  • Outpatient care provided by or arranged through the network will be covered subject to a $15 per visit copay;
  • Up to three visits for crisis intervention provided by, or arranged through, the network will be covered without copay.

• Alcohol and Other Substance Abuse Coverage
  
  • Paid in full medically necessary care for hospitalization or alcohol/substance abuse facilities when provided by or arranged through the network;
  • Outpatient care provided by or arranged through the network will be subject to a $5 per visit copay.

• Benefit Maximums
  
  • Annual and lifetime dollar maximums for covered expenses will be at the same level as the major medical annual and lifetime dollar maximums;
  • Medically necessary inpatient alcohol and substance abuse treatment will be limited to three stays per lifetime. However, the managed care vendor will review on an individual, case by case, basis the appropriateness of additional treatment and may approve coverage for such treatment if it can be demonstrated that significant improvement will occur.

NON-NETWORK BENEFIT

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

• 30 inpatient days and 30 outpatient visits maximum per year for mental health treatment;
• Inpatient and outpatient reimbursement will be no greater than 50 percent of the in-network discounted fees;
• Inpatient deductible will be $2000 per year and the outpatient deductible will be $500 per year;
• No out of pocket maximum;
• Maximum dollar limit for medically necessary care provided by non-network providers for covered expenses will be $50,000 per calendar year and $100,000 lifetime;
• Medically necessary inpatient alcohol and substance abuse treatment will be limited to one stay per year and three stays per lifetime. There will be a maximum of 30 outpatient visits approved per calendar year.

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

§11.5 There shall be a waiting period of 42 days after employment before a new employee shall be eligible for enrollment under the State's health insurance program.

1. When more than one family member is eligible to enroll for coverage under the State's health insurance plan, there shall be no more than one individual and dependent enrollment permitted in any family unit.

2. Employees eligible to enroll in the State Health Insurance Program may select individual or individual and dependent coverage (family). 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.

§11.6

1. The unremarried spouse of an employee, who retires after April 1, 1988, with ten 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, i.e., 10 percent for the cost of individual coverage and 25 percent of the cost of dependent coverage.

2. The unremarried spouse of an active employee, who dies after April 1, 1988 and who, at the date of death was vested in the Employee's Retirement System and within ten years of his/her first date of eligibility for retirement shall be permitted to continue coverage in the health insurance program with payment at the same contribution rates as required of active employees.

§11.7

1. 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. Employees 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.

   1. If the rate renewals are not available by the time of the open transfer period, then the open transfer period shall be extended to assure ample time for employees to transfer.

§11.8 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.

§11.9 The State shall provide health insurance comparison information to employees, through State agencies, prior to the beginning of an open 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 their health plan transfer during the remainder of the open transfer period.

1. The State and PBA agree to continue a Joint Committee on Health Benefits. The Committee shall consist of at least 3 representatives selected by PBA and 3 representatives selected by the State.

2. The State shall seek the appropriation of funds by the Legislature to support committee initiatives and to carry out the administrative responsibilities of the Joint Committee in an amount equivalent to: 1992-93: $7,800; 1993-94: $7,800; 1994-95: $7,800.

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

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

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

6. 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.

7. 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 and Dental Benefits in the format and with such frequency as the Committee shall determine.

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

   1. The annual HMO Review Process;
   2. The development and implementation of the Managed Mental Health and Substance Abuse Care Program;
   3. The development and implementation of a Program for Managed Medical Care through a panel of preferred hospital and/or medical care providers;
   4. The implementation of the new Benefits Management Program, Health Call, and an annual review of the list of procedures requiring Prospective Procedure Review.

9. In recognition of the recommendations provided by the Study, the State will work to develop a program for managed medical care through the establishment of a panel of preferred hospital and medical care providers. The Joint Committee on Health and Dental Benefits will work with the State in the implementation of this benefit. This shall include development of a mutually agreed upon program design including benefit levels and active participation in the selection of the vendor.

The State shall continue to provide for and pay the full cost for the vision care plan in effect as of March 31, 1991. In addition, the plan shall provide a $70 allowance for the cost of eye examination and contact lenses. The plan shall also provide the complete selection of frames available to other participants in the plan including the frame selections designated as standard, supplemental and designer/metal. The State shall provide toll free telephone service for insurance information and assistance to employees and dependents on vision care insurance matters.

Effective April 1, 1993, dependents under 19 years of age will be eligible to receive Vision Care benefits every 12 months.

The State shall continue to pay for the full premium of the dental insurance plan. Effective April 1, 1993, the State shall provide benefits through the GHI type "Preferred" Dental Plan. The Preferred Dental Plan shall reimburse 100 percent for participating providers and 80 percent for non-participating providers of the GHDI's schedule of allowances. There shall be no individual or family deductible under the Preferred Plan.

§11.13 The State of New York and PBA agree that they shall continue the contract to provide for an employee benefit fund for the term of this Agreement, to be administered by PBA to provide certain benefits for full time annual salaried members of the Trooper Unit.

On or about April 1, 1991, April 1, 1992, April 1, 1993 and April 1, 1994, the Employer shall deposit in the employee benefit fund an amount equal to $9 for each full time annual salaried member of the Trooper Unit. For the purposes of determining the amount to be deposited in accordance with this section, the number of members shall be determined to be the number of full time annual salaried members in the Trooper Unit on the payroll on the first day of the month immediately preceding the date the deposit is to be made.

§11.14 With regard to the issue of smoking in the workplace, the State and PBA agree to work towards a smoke free environment by addressing the issue through discussions that will ensure work location input.