§39.1 a. The State shall continue to provide all the forms and extent of coverage as defined by the contracts in force on June 30, 1995 with the State's health insurance carriers unless specifically modified by this Agreement.

b. The State will continue coverage for birthing centers, home health care benefits, hospice and skilled nursing facility care as specified in the Memorandum of Understanding dated November 18, 1982.

§39.2 a. The Benefits Management Program, HealthCall, will continue. Precertification will be required for all inpatient confinements and prior to certain specified surgical or medical procedures regardless of proposed inpatient or outpatient setting.

1. 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.

2. Precertification will be required prior to maternity admissions in order to highlight appropriate pre-natal services and reduce costly and traumatic birthing complications.

3. 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.

4. 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.

5. The Prospective Procedure Review 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 over-utilized. The list of procedures will undergo annual evaluation by the Benefits Management Program vendor. As revised and approved by the Joint Committee on Health Benefits, the list will be published and distributed to enrollees prior to implementation.

6. Enrollees will be required to call the Benefits Management Program for precertification when it is recommended they undergo one of the listed procedures, regardless of setting. Enrollees will be requested to call two weeks before the date of the procedure.

7. The Empire Plan's former Second Surgical Consultation co-insurance levels will apply for failure to comply with the requirements of the Prospective Procedure Review Program.

Appeal procedures relating to both the precertification and Prospective Procedure Review Program requirements will also be established by the Joint Committee on Health Benefits.

b.1. Charges for outpatient services, covered by the hospital contract, including emergency room services, will be subject to a $25.00 copayment per outpatient visit, for such services received on or after October 1, 1997. The $25.00 hospital outpatient copayments 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 and hemodialysis.

2. All professional component charges associated with ancillary services billed by the outpatient department of a hospital for emergency care for an accident or for sudden onset of an illness (medical emergency) will be a covered expense. Payment will be made under the participating provider or the basic medical component of the Empire Plan, not subject to deductible or co-insurance, when such services are not otherwise included in the hospital facility charge covered by Blue Cross.

c. Effective September 1, 1991, charges for Private Duty Nursing services in a hospital will not be reimbursed under the Basic Medical component of the Empire Plan.

§39.3 a. 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/lifetime maximums.

b.1. Office visit charges by participating providers will be subject to an $8.00 copayment by the enrollee, with the balance of covered scheduled allowances paid directly to the provider by the Plan.

2. All covered surgical procedures performed by participating providers during a visit will be subject to an $8.00 copayment by the enrollee.

3. All covered radiology services performed by participating providers during a visit will be subject to an $8.00 copayment by the enrollee.

4. All covered diagnostic/laboratory services performed by participating providers during a visit will be subject to an $8.00 copayment by the enrollee.

5. The office visit, surgery, radiology and diagnostic/laboratory copayment amounts may be applied against the basic medical copayment maximum however, they will not be considered covered expenses for basic medical.

c. The Empire Plan shall also include basic medical coverage to provide benefits when nonparticipating providers are used. These benefits will be paid directly to enrollees according to reasonable and customary charges and will be subject to deductible, co-insurance, and calendar year and lifetime maximums.

1. Effective January 1, 1989, the ambulatory surgery procedures outlined in the Memorandum of Understanding dated November 18, 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.

2. Effective October 1, 1997, or thirty days after the execution of the 1995-1999 Collective Bargaining Agreement, if later, Empire Plan coverage for ambulance services, other than when supplied by the admitting hospital, will be provided by basic medical for medically appropriate local professional ambulance transportation subject only to a $35.00 copayment. Volunteer ambulance transportation will continue to be reimbursed for donations at the current rate of $50 for under 50 miles and $75 for 50 miles or more. These amounts are not subject to deductible or coinsurance. Other coverage for ambulance services under basic medical, in effect on June 30, 1995, will also continue.

d.1. The Empire Plan participating provider schedule of allowances and the basic medical reasonable and customary levels will be at least equal to those levels in effect on June 30, 1995.

2. Annual evaluation and adjustment of Reasonable & Customary (R&C) charges will be performed according to guidelines established by the Basic Medical Plan insurer.

e. 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.

f. The State agrees to continue to provide alternative Health Maintenance Organization (HMO) coverage. Effective January 1, 1998, or thirty days after the execution of the 1995-1999 Collective Bargaining Agreement, if later, the State agrees to pay 90 percent of the cost of individual coverage and 75 percent of the cost of dependent coverage toward the hospital/medical/mental health and substance abuse component of each participating HMO not to exceed 100 percent of the dollar contribution for those components under the Empire Plan.

g. Effective September 1, 1991, the State will discontinue the Dual Eligibility Family Option.

h. Effective October 1, 1997, or thirty days after the execution of the 1995-1999 Collective Bargaining Agreement, if later, the Empire Plan's medical care component will be modified to offer a comprehensive managed care network benefit for the provision of medically necessary physical medicine services, including physical therapy and chiropractic treatments. Authorized network care will be available, subject only to the Plan's participating provider $8 office visit copayment(s). Unauthorized non-network medically necessary care, at enrollee choice, will also be available, subject however, to a $250 annual deductible per enrollee, $250 annual deductible per spouse and $250 for one or all dependent children and a maximum payment of 50 percent of the network allowance for the service(s) provided. Maximum benefits for non-network care will be limited to $1,500 in payments per person, per calendar year. Deductible/coinsurance payments will not be applicable to the Plan's annual basic medical deductible/coinsurance maximums. The Joint Committee on Health Benefits will work with the State on the implementation of this benefit for UUP represented employees.

i. Effective October 1, 1997, or thirty days after the execution of the 1995-99 Collective Bargaining Agreement, if later, there will be a modification to the non-network benefit provided under the Home Care Advocacy Program (HCAP). As of that date, individuals who fail to have medically necessary designated HCAP services and supplies precertified by calling HCAP and/or individuals who use a non-network provider will be subject to the following provisions: where nursing services are rendered, the first 48 hours of nursing care will not be a covered expense; and services (including nursing services), equipment and supplies will be subject to the annual basic medical deductible ($226 in 1997) and reimbursed at 50 percent of the HCAP network allowance. The basic medical out-of-pocket maximum will not apply to HCAP designated services, equipment and supplies.

§39.4 UUP Empire Plan Enhancements. In addition to the basic Empire Plan benefits, the Empire Plan for UUP employees shall include:

a. Effective January 1, 1992, the major medical component deductible shall be $161 per enrollee; $161 per enrolled spouse; and $161 per all dependent children. Effective January 1, 1992, and thereafter on each successive January 1, the annual deductible will increase by a percentage amount equal to the percentage increase in the medical care component of the CPI for Urban Wage Earners and Clerical Workers, All Cities (CPI-W) for the period July 1 through June 30 of the preceding year. Covered expenses for mental health and substance abuse treatment services and for physical medicine services are excluded in determining the basic medical component deductible.

b. Effective January 1, 1998, the maximum enrollee co-insurance out-of-pocket expense under the basic medical component shall be $1,500 per individual or family in any year. Effective January 1, 1999, and each successive January 1, the maximum annual co-insurance out-of-pocket expense will increase by a percentage amount equal to the percentage increase in the medical care component of the CPI for Urban Wage Earners and Clerical Workers, All Cities (CPI-W.) for the period July 1 through June 30 of the preceding year. Covered expenses for mental health and substance abuse treatment services Home Care Advocacy Program services (HCAP) and managed physical medicine services are excluded in determining the $1,500 maximum copayment limit.

c. The routine newborn child care allowance under the basic medical component shall be $100, not subject to deductible or co-insurance.

d. Effective September 1, 1991, the annual and lifetime maximum for each covered member under the basic medical component shall be unlimited.

e. Effective October 1, 1997, or thirty days after the execution of the 1995-99 Collective Bargaining Agreement, if later, services for examinations and/or purchase of hearing aids shall be a covered basic medical benefit and shall be reimbursed up to a maximum of $600 in any 48 month period, not subject to deductible or co-insurance. For children 12 years old or under, the same benefits can be available after 24 months when it is demonstrated that a covered child's hearing has changed significantly and the existing hearing aid(s) can no longer compensate for the child's hearing impairment.

f. Effective October 1, 1997, or thirty days after the execution of the 1995-99 Collective Bargaining Agreement if later, employees 50 years of age or older shall be allowed reimbursement up to $250 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 $250 once every two years towards the cost of a routine physical examination. These benefits shall not be subject to deductible or co-insurance.

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

h. Charges by participating providers for professional services for allergen immunotherapy in the prescribing physician's office or institution, chemotherapy, radiation therapy, or hemodialysis, will be excluded from the office visit copayment.

i. In the event that there is both an office visit charge and an office surgery charge by a participating provider in any single visit, the covered individual will be subject to a single $8.00 copayment.

j. Outpatient radiology services and diagnostic/laboratory services rendered during a single visit by the same participating provider will be subject to a single $8.00 copayment.

k. The cost of oral and injectable substances for routine preventive pediatric care, including the cost of all oral and injectable substances for routine pediatric immunizations shall be a covered benefit under the Empire Plan. Routine pediatric care, including well child office visits, physical examinations and pediatric immunizations, for children up to age 19 will be covered under the basic medical component, subject to deductible and coinsurance.

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

m. The provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) as amended, will continue.

n. The Participating Provider Panel shall be expanded to include, but not be limited to, selected Durable Medical Equipment Providers who shall offer durable medical equipment at discounted prices.

o. Effective October 1, 1997, or thirty days after the execution of the Collective Bargaining Agreement if later, mastectomy brassieres prescribed by a physician, including replacements when it is functionally necessary to do so, shall be a covered benefit under the Empire Plan.

p. Domestic Partners who meet the definition of a partner and can provide acceptable proofs of financial interdependence as outlined in the Affidavit of Domestic Partnership and Affidavit of Financial Interdependence shall continue to be eligible for health care coverage.

§39.5 Eligible employees in the State Health Insurance Program 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. If more than one HMO services the same area, the Joint Committee on Health Benefits reserves the right to approve a contract with only one such organization deemed to be a quality, cost-effective option. The Joint Committee on Health Benefits will work with the State through the HMO Workgroup to identify and mutually agree upon appropriate incentives for HMO alternatives to become more competitive in quality of care provided and efficient in cost to payers.

§39.6 Enrollees 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. Changes between options will be permitted without regard to the enrollee's age or the number of previous transfers. If rate renewals are not available by the time of the option transfer period, then the option transfer period shall be extended to assure ample time for enrollees to transfer.

§39.7 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.

§39.8 The State shall provide health insurance comparison information to employees, throughout 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.

§39.9 There shall be a waiting period of forty-two (42) days after employment before a new employee shall be eligible for enrollment under the State's Health Insurance Program. Effective with the 1991-1992 academic year, the 42-day waiting period for otherwise eligible newly-hired academic employees placed on the State payroll effective September 1, will begin as of the employee's actual first day of professional obligation but in no event before August 15.

§39.10 a. 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.

b. 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.

c. Effective July 1, 1991, 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.

d. Effective October 1, 1997, or thirty days after the execution of the 1995-99 Collective Bargaining Agreement, if later, 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 indefinitely, 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 the first paragraph of Article 39.11(d) may transfer back to the State Health Insurance Plan on the first of any month coinciding with or following the retiree's death as described below.

The unremarried spouse of an employee who retired with 10 or more years of active state service, or with a combination of service with the State or a Participating State Employer or Participating Agency or any political subdivision, and subsequently dies, shall be permitted to continue coverage in the health insurance program at the same contribution as active employees.

§39.11 Effective May 9, 1996, eligible UUP employees enrolled in the New York State Health Insurance Program (NYSHIP) will be provided with prescription drug coverage either through the Empire Plan Prescription Drug Program or a Health Maintenance Organization. For those enrolled in the Empire Plan, the benefits provided will be the same benefits as those provided to Management/Confidential employees enrolled in the Empire Plan Prescription Drug Program. The State agrees to pay 90 percent of the cost of individual coverage and 75 percent of the cost of dependent prescription drug coverage under the Empire Plan and Health Maintenance Organizations, effective May 9, 1996.

§39.12 Eligibility

a. All employees with full-time appointments shall be eligible to receive the benefits contained in Article 39.

b. All part-time employees who received the benefits provided for under Article 39 any time during the period commencing January 1, 1988, and ending on the close of business June 30, 1988, shall continue to be eligible to receive such benefits for so long as they are consecutively reemployed in the same capacity at the same college. In the event of a break in consecutive service for such employees, eligibility for the benefits provided for under Article 39 shall be determined pursuant to paragraphs (c) or (d) below as applicable.

c. Part-time academic employees who teach two or more courses in any one semester shall be eligible to receive the benefits contained in Article 39 during that semester. (Excluding those employees deemed to be casual pursuant to the resolution of IP Charge U-5724.)

d. Part-time academic employees whose professional obligations, as determined by the College President, are primarily other than teaching classes shall be eligible to receive the benefits contained in Article 39 in accordance with the compensation requirements for part-time professional employees as specified in 39.12 (e). (Excluding those employees deemed to be casual pursuant to the resolution of IP charge U-5724.)

e. Part-time professional employees shall be eligible to receive benefits if they are employed at a salary rate which would yield a total compensation of $9,851 or more between July 1, 1995 and June 30, 1996; $9,851 or more between July 1, 1996, and June 30, 1997; $9,851 or more between July 1, 1997 and June 30, 1998; $10,196 or more between July 1, 1998, and June 30, 1999. (Excluding those employees deemed to be casual pursuant to the resolution of IP Charge U-5724.)

f. Part-time employees who are not otherwise eligible for health insurance shall continue, during the term of this Agreement, to be permitted to participate on a full premium cost basis by the employee, in the State Health Insurance Program.

§39.13 The confidentiality of individual subscriber claims shall not be violated. Except as required to conduct financial and claims processing audits of carriers and coordination of benefit provisions, specific individual claims data, reports or summaries shall not be released by the carrier to any party without the written consent of the individual insured employee or covered dependent.

§39.14 The program for managed care of psychiatric services and alcohol and other substance abuse treatment will continue. The Joint Committee on Health Benefits will work with the State on the ongoing review of this program.

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 an $8.00 per visit copay.

Benefit Maximums

• Annual and lifetime dollar maximums for covered expenses will be at the same level as the basic 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 $2,000 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 basic medical portion of the Plan.