Benefits

Dental Plan Administrator Change, October 1, 2024

The NYS Dental Plan Administrator will change from EmblemHealth to Anthem, effective October 1, 2024. The level of benefit is governed by the collective bargaining agreement, including enhancements achieved during the negotiation of the 2019-2023 PEF/State Agreement, such as a higher annual maximum allowance of $3,000 per person, an increase to $3,000 for the orthodontic lifetime maximum per child, inclusion of a $600 implant allowance, and long overdue coverage for precious/upgraded metal fillings. These previously negotiated enhanced contractual benefits will continue.

The Department of Civil Service plans to send out the following mailings to NYSHIP dental plan enrollees:

NYS Dental Plan Administrator Change Letter
In July, the Department of Civil Service will mail this letter to enrollees’ homes. This letter will explain the change to Anthem and will highlight how enrollees can access and search the applicable Anthem Blue Cross network of dental providers.

Anthem Blue Cross NYS Dental Plan Benefit Documents and Benefit Card
In September, enrollees will receive a welcome letter from Anthem Blue Cross, which will include their new benefit card along with information on how to access benefit information and documents online through a secure member portal.

Dental providers interested in joining the Anthem NYSHIP network can call 1-866-947-9398 to speak to a designated Anthem representative. As PEF receives further information, we will update membership.

Dental Stipend

Pursuant to the Dental Stipend Side Letter contained in the 2023-2026 PEF/State Agreement. The side letter provides for a $400 payment each fiscal year to eligible PS&T members until the State enters into a new dental services contract. There will be a total of two $400 payments, as The State will be entering into a new dental services contract October 1, 2024.

First Dental Stipend: To be eligible, employees must have been in the PS&T unit and enrolled in the NYSHIP Dental Plan having completed the applicable waiting period on July 28, 2023.
Administration Payroll: check dated March 13, 2024.
Institution Payroll: check dated March 21, 2024.

Second Dental Stipend: To be eligible, employees must have been in the PS&T unit on April 1, 2024, and enrolled in the NYSHIP Dental Plan having completed the 28-day waiting period on or before April 1, 2024.
Administration Payroll: check dated May 22, 2024.
Institution Payroll: check dated May 30, 2024.

For seasonal and temporary employees who are employed or are expected to be employed for at least six months, the agencies must submit information to OSC, and it is possible that payments for these members may be processed in later checks.

NYS Work-Life Services: (WLS) Programs are joint labor-management programs that benefit New York State employees by enhancing employee wellbeing, increasing productivity, and improving morale in the workplace. The WLS programs include the Employee Assistance Program (EAP), technical assistance and support for the NYS Network Childcare Centers, and DIRECTIONS: Pre-Retirement Planning.

Flex Spending Account: 1-800-358-7202. The Flex Spending Account (FSA) offers three negotiated benefits to state employees – the Dependent Care Advantage Account (DCAA), the Health Care Spending Account (HCSA), and the Adoption Advantage Account. They are types of flexible spending accounts, administered in compliance with Sections 125 and 129 of the Internal Revenue Code, that give you a way to pay your dependent care, health care, or adoption expenses with pre-tax dollars. Enrollment in the FSAs are voluntary. There are no fees associated with any of these programs and you chose the amount of money you would like to contribute from your paycheck.

The Health Care Spending Account (HCSA): is a negotiated employee benefit that provides a tax-free way to help you, as state employee, pay for out-of-pocket health-related expenses. This includes medical, hospital, laboratory, prescription drug, dental, vision, and hearing expenses that are not reimbursed by your insurance, or other benefit plans.

• HCSA Carryover:Unused contributions will carryover to the next plan year for you to use. During the plan year runout period (January 1- March 31), the previous year funds may still be used for previous year expenses. Any remaining funds up to the IRS limit from the previous year will then carryover into the current plan year’s account balance – after the runout period end date. During the runout, the new plan year election will be depleted first, then carryover funds will be accessible for reimbursement.

The Dependent Care Advantage Account (DCAA): is a negotiated employee benefit that provides a tax-free way to help you, as state employee, pay for custodial childcare, elder care, or disabled dependent care while you are at work.

• Grace Period:The grace period allows an additional 2.5 months to incur dependent care. You can use any funds remaining in your account after the plan year ends to pay for expenses incurred between January 1 to March 15 of the following year. Claims must be submitted by the March 31 deadline.

Adoption Advantage Account: Eligible employees can enroll in a flexible spending account for expenses related to the adoption of an eligible child. Pre-tax payroll deductions contributed to the Adoption Advantage Account can help pay for an adoption that meets the IRS’s definition of a qualified adoption. Although you won’t save on social security taxes, you can save on federal and state taxes (where applicable).

• Grace Period:The grace period allows an additional 2.5 months to incur adoption-related expenses. You can use any funds remaining in your account after the plan year ends to pay for expenses incurred between January 1 to March 15 of the following year. Claims must be submitted by the March 31 deadline.

Helpful Links:
Office of Employee Relations
Department of Civil Service
NYS Retirement
Employee Assistance Program (EAP)

External links on this web site are provided for your convenience only. PEF does not necessarily endorse these web sites and is NOT responsible for their content.

The Empire Plan’s toll-free number: 1-877-7NYSHIP or 1-877-769-7447

Telehealth Coverage https://www.empireblue.com/nys
Telehealth coverage covers telehealth visits with participating providers in the Medical/Surgical Program and the Mental Health and Substance Abuse (MHSA) Program. Enrollees and covered dependents can access care through a video visit with their own doctor or therapist on a smartphone, tablet or personal computer. Telehealth visits are subject to the same enrollee cost sharing as in-person visits.

Virtual Health Care Access with LiveHealth Online (LHO) – With Empire BlueCross’ partnership with LiveHealth Online, enrollees can stay home and have a telephone or video visit with a board-certified doctor or licensed therapist via smartphone, tablet, or personal computer. To get started, go to www.empireblue.com/nys and select the link to LiveHealth Online. Or, call LHO at 1-888-LiveHealth (1-888-548-3432), 24 hours/day, seven days/week.

United HealthCare (UHC) Medical 1-877-769-7447 myuhc.com provides access to claims processed by United HealthCare, the par provider directory and enrollment verification. Register by visiting the web site and clicking on the Register button. Fill in the basic information, including your Group Number: 030500 and choose a User ID. UHC will create a password and mail it to your home.

Basic Medical Provider Discount Program (Multiplan) 1-877-769-7447 When you use non-par physicians who are affiliated with Multiplan, you will receive discounts on the provider’s usual fees. You still must satisfy the annual deductible and 20% coinsurance required by Basic Medical. Multiplan has more than 200,000 providers in their network. Be sure to confirm the provider’s participation before receiving services. You can access an online list of Multiplan providers from the directory in the Civil Service web site at https://www.cs.ny.gov/employee-benefits. You can also call 1-877-7-NYSHIP and speak to a UHC representative.

Empire Blue Cross and Blue Shield – Hospital 1-877-769-7447 To use the Empire Blue Cross and Blue Shield web site, register in the Member Services window on the site. You will need your personal ID number, which is the first nine digits of your NY Government Employee Benefit Card. Create a personal password, which is combined with a one-time use activation key number and your log-on ID to safeguard the confidentiality of your records. You can check the status of a hospital claim, complete a coordination of benefits form.

Centers of Excellence for Cancer (Cancer Resource Services) 1-877-769-7447 This program provides paid-in-full coverage for cancer-related expenses received through a nationwide network known as Cancer Resource Services (CRS). CRS is staffed by experienced cancer nurses, who can explain treatment options and help you choose the best physician/cancer center for a specific type of cancer. The CRS network includes many of the nation’s leading cancer centers, such as Roswell Park Cancer Institute, Memorial Sloan Kettering Cancer Center and Dana-Farber Cancer Institute. Reimbursement for travel expenses is available. For more information call toll-free 1-866-936-6002 from 8 a.m. to 8 p.m., Monday – Friday, or visit the CRS web site at https://www.myoptumhealthcomplexmedical.com/gateway/public/welcome.jsp

Benefits Management Program Call UHC: 1-877-769-7447 for Prospective Procedure Review. For pre-admission certification (before a scheduled hospital admission; within 48 hours after an emergency or urgent admission; before admission or transfer to a skilled-nursing facility), call Empire Blue Cross Blue Shield at 1-877-769-7447. It is your responsibility to call.

Carelon Health Options (formerly Beacon Health Options) 1-877-769-7447 Mental health & substance abuse services. You can access an online list of providers from the directory in the Civil Service web site at https://www.cs.ny.gov/employee-benefits.

Home Care Advocacy Program 1-877-769-7447 Durable medical equipment, home nursing care, infusion therapy and diabetic shoes. Diabetic supplies 1-888-306-7337. Ostomy supplies 1-800-354-4054.

EPIC Hearing Service 1-866-956-5400 Program that offers nationwide access to hearing services and treatments, including hearing diagnostics and hearing aids.

Centers of Excellence for Infertility 1-877-769-7447 Call for prior authorization of qualified procedures, regardless of provider. Call for information about all services for infertility.

Health Maintenance Organizations
The toll-free numbers are for each HMO’s member services department.

Blue Choice 
165 Court St. Rochester, NY 14647
800-462-0108
585-454-4810

Empire BCBS HMO
P.O. Box 11800, Albany, NY
12211-0800
800-453-0113

Capital District Physicians’ Health Plan (CDPHP)
500 Patroon Creek Blvd., Albany, NY 12206-1057
800-777-2273
518-641-3700

Community Blue
1901 Main St., P.O. Box 80 Buffalo, NY, 14240-0080
877-576-6440
716-887-8840

Emblem Health (formerly HIP Health Plan of New York)
55 Water St., New York, NY 10041
877-861-0175

HMO Blue/Utica
Utica Business Park, 12 Rhoads Dr., Utica, NY 13502
800-722-7884

HMO Blue/Central & Southern Tier
333 Butternut Dr., Syracuse, NY, 13214
800-447-6269

Independent Health
511 Farber Lakes Dr., Buffalo, NY 14221
800-501-3439

MVP Health Care
P.O. Box 2207 625 State St., Schenectady, NY 12301-2207
888-687-6277

MVP Rochester
220 Alexander St., Rochester, NY 14607
585-325-3113
800-950-3224

Dental Plan Administrator Change, October 1, 2024

The NYS Dental Plan Administrator will change from EmblemHealth to Anthem, effective October 1, 2024. The level of benefit is governed by the collective bargaining agreement, including enhancements achieved during the negotiation of the 2019-2023 PEF/State Agreement, such as a higher annual maximum allowance of $3,000 per person, an increase to $3,000 for the orthodontic lifetime maximum per child, inclusion of a $600 implant allowance, and long overdue coverage for precious/upgraded metal fillings. These previously negotiated enhanced contractual benefits will continue.

The Department of Civil Service plans to send out the following mailings to NYSHIP dental plan enrollees:

NYS Dental Plan Administrator Change Letter
In July, the Department of Civil Service will mail this letter to enrollees’ homes. This letter will explain the change to Anthem and will highlight how enrollees can access and search the applicable Anthem Blue Cross network of dental providers.

Anthem Blue Cross NYS Dental Plan Benefit Documents and Benefit Card
In September, enrollees will receive a welcome letter from Anthem Blue Cross, which will include their new benefit card along with information on how to access benefit information and documents online through a secure member portal.

Dental providers interested in joining the Anthem NYSHIP network can call 1-866-947-9398 to speak to a designated Anthem representative. As PEF receives further information, we will update membership.

Dental Stipend
Pursuant to the Dental Stipend Side Letter contained in the 2023-2026 PEF/State Agreement. The side letter provides for a $400 payment each fiscal year to eligible PS&T members until the State enters into a new dental services contract. There will be a total of two $400 payments, as The State will be entering into a new dental services contract October 1, 2024.

First Dental Stipend: To be eligible, employees must have been in the PS&T unit and enrolled in the NYSHIP Dental Plan having completed the applicable waiting period on July 28, 2023.
Administration Payroll: check dated March 13, 2024.
Institution Payroll: check dated March 21, 2024.

Second Dental Stipend: To be eligible, employees must have been in the PS&T unit on April 1, 2024, and enrolled in the NYSHIP Dental Plan having completed the 28-day waiting period on or before April 1, 2024.
Administration Payroll: check dated May 22, 2024.
Institution Payroll: check dated May 30, 2024.

For seasonal and temporary employees who are employed or are expected to be employed for at least six months, the agencies must submit information to OSC, and it is possible that payments for these members may be processed in later checks.

EmblemHealth Albany Family Dental Practice Closure
It has been brought to PEFs attention, that as of Wednesday, February 7^th, the EmblemHealth Family Dental Practices at the Empire State Plaza Concourse, and 1873 Western Avenue will be permanently closing April 30^th, 2024. This is not a notification stating that EmblemHealth is closing as a whole. This is a notification of just the two practices that are closing. For further information, you may contact the following: EmblemHealth: 1-800-947-0101 or The Department of Civil Service: 1-800-833-4344.

Letters notifying current patients about the 4/30/24 closures went out at the end of January, early February, giving the required 90-day notice of the closures to patients. The letter recommends that patients should start looking for a new dentist and to contact them prior to 4/30/24 to request any important copies of information pertaining to your dental records for your personal files or to give to your new provider. The offices have confirmed that they are reviewing all outstanding clinical work and that patients will be scheduled so that all treatment plans already in place will be completed prior to the closing date of 4/30/24.

New Vision/Dental Eligibility for Dependents to Age 26
Effective January 1, 2024, in accordance with the 2023-2026 PEF/State Agreement, dependents up to age 26 are now eligible for Dental and Vision benefits, regardless of student status. Coverage will end the first of the month following their 26^th birthday.

• If a PEF member with an eligible dependent up to age 26 did not receive a notice in November 2023 from Dept. of Civil Service (DCS) that the dependent was auto enrolled, then the member will need to reach out directly to the agency Health Benefit Administrator (HBA/HR Department) to complete the necessary enrollment paperwork.
• If a PEF member received notification of a dependent that should not have been auto enrolledduring this process, the member will need to reach out directly to the agency Health Benefit
• COBRA Eligibility: Dependents being removed will automatically receive a COBRA application from DCS. Deadlines noted on the application must be adhered to. For more information contact DCS at 1-800-833-4344 and select the COBRA prompt.

Emblemhealth Dental Access Enhancement Program, Single Case Agreement
Single Case Agreements are now available under the NYSHIP Dental Plan. In an effort to increase access to network benefits available under the NYSHIP Dental Program currently administered by EmblemHealth, the State has advised PEF that members can reduce their out-of-pocket expenses through a Single Case Agreement (SCA).

If no participating providers are available for emergency or routine dental care, EmblemHealth can ensure a dental service is provided at the in-network level of benefits with a non-participating provider through a single case agreement; this applies when clinically appropriate, or to address access issues to dentists and specialists, and approval must be obtained prior to receiving treatment by calling Emblem Customer Service at 1-800-947-0101.

The Dental Plan’s network team will coordinate care with a non-participating provider when necessary, and the member will only be responsible for the in-network cost for the arranged service. If a provider is not willing to accept direct payment from Emblem as part of the SCA, Emblem guarantees members will be reimbursed for the provider’s billed amount, up to the maximum allowance according to the Certificate of Insurance.

If any members encounter problems with the SCA program, please contact the PEF Health Benefits Administrator at (800) 342-4306, ext. 283.

EmblemHealth Customer Service: 1-800-947-0101

Out-of-Network Claims: (OON Claims Form)
EmblemHealth Dental Claims
PO Box 2838
New York, NY, 10116-2838

Useful Dental Links:
NYS Dental Plan Certificate of Insurance
NYS Dental Plan Certificate of Insurance – PEF Attachment
NYS Dental Plan Certificate of Insurance – PEF Rider Attachment

American Association of Orthodontists
American Dental Association
American Academy of Periodontology
American Academy of Pediatric Dentistry

New Vision/Dental Eligibility for Dependents to Age 26

Effective January 1, 2024, in accordance with the 2023-2026 PEF/State Agreement, dependents up to age 26 are now eligible for Dental and Vision benefits, regardless of student status. Coverage will end the first of the month following their 26^th birthday.

• If a PEF member with an eligible dependent up to age 26 did not receive a notice in November 2023 from Dept. of Civil Service (DCS) that the dependent was auto enrolled, then the member will need to reach out directly to the agency Health Benefit Administrator (HBA/HR Department) to complete the necessary enrollment paperwork.
• If a PEF member received notification of a dependent that should not have been auto enrolledduring this process, the member will need to reach out directly to the agency Health Benefit
• COBRA Eligibility: Dependents being removed will automatically receive a COBRA application from DCS. Deadlines noted on the application must be adhered to. For more information contact DCS at 1-800-833-4344 and select the COBRA prompt.

Davis Vision: 1-888-588-4823

Out-of-Network Claims: (OON Claims Form)
Davis Vision, Vision Care Processing Unit
P. O. BOX 152 LATHAM,
NEW YORK, 12110

Useful Vision Links:
American Optometric Association
NYS Vision Certificate Book 
Davis Vision

How do I obtain a new or replacement ID Card?

Answer: You must contact the carrier directly. They will be able to issue a new and/or replacement ID card, along with giving you, your personal ID information via phone if available. You may also contact your Agency’s Health Benefits Administrator (HBA) normally located within the HR/Personnel Office. Please keep in mind PEF as a Union does not have access to this information and is unable to obtain your personal ID information or issue ID Cards.

Where can I locate Health Benefits informational packets including The NYSHIP General Handbook and claims forms?

Answer: All of these materials are located via NYSHIP Online or from your Agency’s Health Benefits Administrator (HBA)

Why am I and/or my dependent being denied services or being told we are inactive?

Answer: Your Agency’s Health Benefits Administrator (HBA) normally located within the HR/Personnel Office is responsible for ensuring your enrollment records are accurate and fully up-to-date in the State’s system NYBEAS. Your HBA is responsible for making any necessary corrections and/or changes. Please keep in mind PEF as a Union does not have access to this information and is unable to make these changes to personal profiles.

How do I find out whether a service or item is covered under my plan?

Answer: General benefit information is in the plan’s benefit booklet or member handbook. To obtain more specific benefit information, the plan’s member or customer service department should be contacted. Empire Plan enrollees who want to know beforehand how much United HealthCare (UHC) will pay for a medical service or item may submit a Pre-determination Request form.

Appeal Process Q&A:

What recourse do I have if I disagree with a determination made by my HMO or Empire Plan insurer?

Answer: Each health care plan offered to PEF members has an appeal procedure. When an HMO or Empire Plan insurer has determined a medical service or item isn’t covered, in whole or in part, a review of the determination may be requested using this procedure. Details on how to file an appeal are in the plan’s benefit booklet or member handbook.

What can I do if I’m not satisfied with the outcome achieved through the plan’s appeal procedure?

Answer: Members who wish to pursue their appeal further should contact the PEF Joint Committee on Health Benefits (JCHB). They  will conduct an investigation of the complaint that includes contacting the HMO or Empire Plan insurer to obtain an explanation of the determination. She will then report her findings to the PEF JCHB. If the PEF JCHB decides the response is inconsistent with their understanding of Article 9 of the PEF/NYS contract, or the health plan’s contract with the State, they will present the appeal to management for resolution. If management upholds the plan’s determination, the PEF JCHB, in consultation with PEF’s Contract Administration Department, will determine whether or not to file a contract grievance.

What can I do if I’m not satisfied with the outcome achieved through the JCHB’s appeal process?

Answer: The member can file an external appeal, which is described in the following Q&A. In addition, at any point a member may contact one of the three state agencies that oversee health insurers and HMOs. These agencies are the NYS Department of Financial Services (DFS), the NYS Department of Health (DOH), and the Office of the Attorney General.

For problems related to the payment of benefits, members may contact the Consumer Services Bureau of the NYS DFS at 1-800-342-3736. DFS assures that an insurer’s actions are in accordance with NYS Insurance Law; DFS rules and regulations; and contractual provisions.

HMO enrollees who are unable to get the care they need, or who are dissatisfied with the quality of care they are receiving, may contact the DOH Managed Care Hotline at 1-800-206-8125. DOH is responsible for the authorization and regulation of HMOs in the state, and assures the delivery, continuity, accessibility and quality of health care services are satisfactory.

For problems where you think a law has been broken or fraud might be involved, members may contact the Attorney General’s Health Care Bureau at 1-800-771-7755.

Finally, a member may wish to file a lawsuit against the HMO or insurer when all other attempts to resolve the matter have failed.

How does the external appeals process work?

Answer: The external appeals process is for all health-care services denied on the grounds that the service is not medically necessary. There is also an external review process for patients with life-threatening or disabling conditions who want to participate in clinical trials, use off-label drugs, or use experimental or investigational procedures or treatments when such services are denied on the basis that they are experimental or investigative.

To be eligible for an external appeal, you must first exhaust the health plan’s internal review process. The law permits plans to charge patients up to $50 for an external appeal, but they must give the money back to you if you win the appeal. Randomly assigned agents certified by the state will do the external reviews. These agents are required to make a determination on an appeal within 30 days or three days for emergency cases. Your health plan will send you more information on the external appeals process. You can find a summary of the law through the NYS Department of Financial Services web site.