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Tri-State Preferred Plan SPD >> Hospital and Medical Benefits
Overview of Eligibile Expenses
 
About the Empire Networks
The Plan provides hospital and medical benefits through Empire BlueCross BlueShield ("Empire"). The Plan offers the Empire Direct Point-of-Service ("Direct POS") network. This network includes over 65,000 doctors and other providers and 150 hospitals in the following two states:
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New York: 29 eastern counties – Albany, Bronx, Clinton, Columbia, Delaware, Dutchess, Essex, Franklin, Fulton, Greene, Kings, Montgomery, Nassau, New York, Orange, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington and Westchester.
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New Jersey: 8 northern counties – Bergen, Essex, Hudson, Middlesex, Monmouth, Passaic, Sussex and Union.
Participants who reside outside the New York and New Jersey counties identified above will receive their hospital and medical benefits through the Empire Preferred Provider Organization ("PPO") network. The PPO allows participants and their dependents to access in-network benefits through providers who participate in the local BlueCross BlueShield plan where the participant resides on the same terms as in-network providers under the Direct POS. (All hospital and medical benefits described in the following sections are identical for the Direct POS and PPO networks.)
When you use a network provider, you will have minimal or no cost for services.
You are also covered when seeing out-of-network doctors, but you will incur substantial charges since the Plan pays 50% of the allowed amount, which is generally less than the amount you are charged. So when you go out-of-network, you pay 50% plus the difference between what you are actually charged and what the Plan recognizes as the allowed amount for that particular service, treatment or supply.
Empire ID Card. This is your passport to quality health care, giving you access to thousands of doctors, surgeons, hospitals and other health care facilities in the network. It also gives you 24-hour phone access to a registered nurse who can help you with your health care decisions. Plus, your Empire ID card can get you discounts on certain non-covered services, such as laser vision correction, health club memberships and Weight Watchers programs.
Nurses Healthline. This is round-the-clock information free to Empire members. When you call, you can either speak to a registered nurse or select from over 1,100 audiotaped messages in English or Spanish on a wide variety of topics. If you do not speak English or Spanish, interpreters are available through the AT&T Language Line. You may find it helpful to speak to a registered nurse when you need help assessing symptoms, deciding whether a trip to the emergency room is necessary or understanding a medical condition, procedure, prescription or diagnosis. You can reach the Nurses Healthline at 1-877-825-5276..
When You Go In-Network
When you use an in-network provider, your expenses are covered at the highest level. In addition, there are no deductibles or co-insurance to pay, and no claims to file or track.
In-network benefits apply only to services and supplies that are both covered by the Plan and provided or authorized by a network provider. The network provider will assess your medical needs and advise you on appropriate care, as well as take care of any necessary tests, pre-certifications or hospital admissions. When you use a doctor, hospital or other provider in-network, the Plan generally pays 100% for most charges, including hospitalization. You will not have to satisfy a deductible — you will pay only a $15 co-payment for doctor visits and certain other services and supplies, such as outpatient physical therapy or chiropractic care.
When You Go Out-of-Network
Care that is not provided by a network provider is considered out-of-network care and, as such, reimbursed at a lower level. If you use out-of-network providers, you must first satisfy the annual deductible before being reimbursed at 50% of the allowed amount. Amounts above the allowed amount are not eligible for reimbursement and are your responsibility to pay, in addition to any deductibles and required co-insurance. If you use an out-of-network provider, ask your provider if he or she will accept Empire's payment as payment in full (excluding your deductible or co-insurance requirements). While many providers will tell you that they take "32BJ" or "Empire" coverage, they may not accept Plan coverage as payment in full. Then they will bill you directly for charges that are over the Plan's allowed amount. In addition to the 50% you pay, you will then be responsible for the excess charges.
Annual deductible. $500 individual or $1,000 family, provided one covered individual in a family has met the individual deductible.
Common accident deductible. If two or more family members are injured in the same accident and require medical care, the family must meet only one individual deductible.
Expenses that do not count toward the deductible:
Co-insurance. Once the annual deductible is met, the Plan pays 50% of the allowed amount for eligible out-of-network expenses. You pay the remaining 50%, which is your co-insurance. You also pay any amounts over the allowed amount.
Annual co-insurance maximum. The Plan limits the co-insurance each patient has to pay in a given calendar year to $1,250. The family limit is $2,500. Once one person in the family has paid $1,250 in co-insurance and the rest of the covered family members combined have paid $1,250 more in co-insurance (for a total of $2,500), you have met the family co-insurance maximum for that year. Any eligible expenses submitted for reimbursement after the annual co-insurance maximum is reached are paid at 100% of the allowed amount, You still have to pay any charge above the allowed amount.
The following expenses are not applied toward the out-of-network annual co-insurance maximum:
Coverage When You Are Away from Home
When you are outside of the Direct POS network (see the "About the Empire Networks" section), emergency treatment will be considered in-network; all other services will be considered out-of-network.
Benefit Maximums
For in-network and out-of-network care combined, there is an annual limit of $250,000 and a lifetime limit of $2,500,000 on hospital and medical benefits payable for each covered person. There are also limits on how much (and how often) the Plan will pay for certain expenses, even when they are covered. If there are limits on a particular expense, those limits will be indicated under "Covered Services." (See the "Covered Services" section.)
Conditions for Hospital and Medical Expense Reimbursement
- Charges must be for necessary care. The Plan will pay benefits only for services, supplies and equipment that the Plan considers to be medically necessary.
- Charges must be less than or equal to the allowed amount. The Plan will pay benefits only up to the allowed amount.
- Charges must be incurred while the patient is covered. The Plan will not reimburse any expenses incurred by a person while the person is not covered under the Plan.
Pre-Certification
When you use a network provider, the provider will do the pre-certification for you.
When you use an out-of-network provider, it is your responsibility to have the required services pre-certified. This means that you have to contact the Fund's Health Services Program as shown in the chart below, or make sure that your provider has done so. Failure to pre-certify will result in a financial penalty, which you will be responsible for paying.
Pre-Certification for Medical/Hospital
The following services must be pre-certified
Call 1-866-230-3225
24 hours a day, seven days a week.
How pre-certification works. . The Health Services Program will review the proposed care to certify the length of stay or number of visits (as applicable) and will approve or deny coverage for the procedure based on medical necessity. They will then send you a written statement of approval or denial within three business days after they have received all necessary information. In urgent care situations, the Health Services Program will make its decision within 72 hours after they have received all necessary information (for more information, see the "Health Service Claims" section).
If you do not pre-certify the care (except for outpatient maternity) listed above within the required time frames, benefit payments will be reduced by 50%, up to a maximum $250 reduction for each admission, treatment or procedure. If the Plan determines that the admission or procedure was not medically necessary, no benefits are payable.
To pre-certify behavioral or substance abuse treatment, you must go through our Employee Assistance Program (EAP). See the "Employee Assistance Program" section for more information.
The Health Services Program's Case Management staff can help you and your family explore your options and make the right treatment choices when you are facing a chronic or complicated illness or injury, such as cancer, heart disease, diabetes, or spinal cord and other traumatic injuries.
Covered Services
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The following tables show different types of health care expenses and how they are covered In-network versus Out-of-network.
* Pre-certification required. See footnotes 1, 2 and 3 in the "Footnotes" section. 
* Pre-certification required.See footnotes 4 - 9 in the "Footnotes" section.
* Pre-certification required.
See footnotes 2, 10 and 11 in the "Footnotes" section.
See footnotes 12 and 13 in the "Footnotes" section.
* Pre-certification required.
See footnote 14 in the "Footnotes" section.
Remember to call the Health Services Program at 1-866-230-3225 within the first three months of pregnancy to be covered for prenatal vitamins through a special program established under the Plan's pharmacy program (see the "Prescription Drugs" section for information).
* Pre-certification required.
See footnotes 15, 16 and 17 in the "Footnotes" section.
Excluded Hospital and Medical Expenses
The following expenses are not covered under the hospital or medical coverage. However, some of these expenses are covered under your EAP, prescription drug, vision or dental coverages. Check the other sections of this booklet to see if an expense not paid under hospital/medical is covered elsewhere under the Plan.
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expenses incurred before the patient's coverage began or after the patient's coverage ended
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treatment that is not medically necessary
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cosmetic treatment
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technology, treatments, procedures, drugs, biological products or medical devices that in Empire's judgment are experimental, investigative, obsolete or ineffective. Also excluded is any hospitalization in connection with experimental or investigational treatments.
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expenses for the diagnosis or treatment of infertility
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assisted reproductive technologies, including, but not limited to, in-vitro fertilization, artificial insemination, gamete and zygote intrafallopian tube transfer and intracytoplasmic sperm injection
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surgery and/or non-surgical treatment for gender change
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reversal of sterilization
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travel expenses, except as specified
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psychological testing for educational purposes for children or adults
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common first-aid supplies such as adhesive tape, gauze, antiseptics, ace bandages, and surgical appliances that are stock items, such as braces, elastic supports, semi-rigid cervical collars or surgical shoes
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expenses for acupressure, prayer, religious healing including services, and naturopathic, naprapathic, or homeopathic services or supplies
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expenses for memberships in or visits to health clubs, exercise programs, gymnasiums or other physical fitness facilities
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operating room fees for surgery, surgical trays and sterile packs done in a non-state-licensed facility including the doctor's office
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orthotics for routine foot care (including dispensing of surgical shoe(s) and pre- and post-operative X-ray(s)
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routine hearing exams
the following specific preventive care services:
- screening tests done at your place of work at no cost to you
- free screening services offered by a government health department
- tests done by a mobile screening unit, unless a doctor not affiliated with the mobile unit prescribes the tests
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the following specific emergency services:
- use of the emergency room to treat routine ailments because you have no regular doctor or because it is late at night (and the need for treatment does not meet the Plan's definition of emergency – see the "Glossary")
- use of the emergency room for follow-up visits
- ambulette, except for home health care services
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the following specific maternity care services:
- days in hospital that are not medically necessary (beyond the 48-hour/96-hour stays required by law)
- private room (If you use a private room, you pay the difference between the cost for the private room and a semi-private room. The additional cost does not count toward your deductible or co-insurance.)
- out-of-network birthing center facilities
- private-duty nursing
- expenses for pre-planned home delivery of a child
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the following specific inpatient hospital care expenses:
- private-duty nursing
- private room (If you use a private room, you pay the difference between the cost for the private room and a semi-private room. The additional cost does not count toward your deductible or co-insurance.)
- diagnostic inpatient stays, unless connected with specific symptoms that if not treated on an inpatient basis could result in serious bodily harm or risk to life
- any part of a hospital stay that is primarily custodial
- elective cosmetic surgery18 or any related hospital expenses or treatment of any related complications
- hospital services received in clinic settings that do not meet Empire's definition of a hospital or other covered facility
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the following specific outpatient hospital care expenses:
- certain same-day surgeries not pre-certified as medically necessary by the Health Services Program
- routine medical care, including (but not limited to) inoculation, vaccination, drug administration or injection, excluding chemotherapy
- collection or storage of your own blood, blood products, semen or bone marrow
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the following specific equipment:
- air conditioners or purifiers
- humidifiers or de-humidifiers
- exercise equipment
- swimming pools
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skilled nursing facility care that primarily:
- gives assistance with daily living activities
- is for rest or for the aged
- is convalescent care
- is sanitarium-type care, or
- is a rest cure
the following specific home health care services:
- custodial services, including bathing, feeding, changing or other services that do not require skilled care
- out-of-network home infusion therapy
the following specific physical, occupational, speech or vision therapy services:
- therapy to maintain or prevent deterioration of the patient's current physical abilities
- treatment for developmental delay, including speech therapy
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the following specific vision care services:
- expenses for surgical correction of refractive error or refractive keratoplasty procedures including, but not limited to, radial keratotomy (RK), photo-refractive keratotomy (PRK) and laser in situ keratomileusis 21 (LASIK) and its variants
- eyeglasses, contact lenses and the examination for their fitting except following cataract surgery. However, see the "Vision Care Benefits" section to find out how eyeglasses and contact lenses may be covered under the vision program
- routine vision care (see the "Vision Care Benefits" section for coverage information)
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the following services that may be covered elsewhere under the Plan:
- dental treatment, except surgical removal of impacted teeth or treatment of sound natural teeth injured by accident if treated within 12 months of the injury; however, see the "Dental Benefits" section
- all prescription drugs and over-the-counter drugs, self- administered injectables, vitamins, vitamin therapy, appetite suppressants, or any other type of medication, unless specifically indicated. However, see the "Prescription Drug Benefits" section to find out how prescription drug expenses may be covered.
-behavioral health care services, including inpatient and outpatient behavioral care, as well as inpatient and outpatient substance
treatment (detoxification and rehabilitation). However, see the Employee Assistance Program ("EAP") section to find out how these expenses are covered.
- services of a nutritionist and nutritional therapy or counseling, except as provided in Footnote 17
- contraceptive devices (see the "Prescription Drug Benefits" section to find out how oral contraceptives may be covered under the prescription drug program)
- a skilled nursing facility that primarily treats drug addiction or alcoholism (see the Employee Assistance Program ("EAP") section to find out how drug addiction or alcoholism may be covered)
- false teeth (not covered under medical/hospital, but may be covered under dental – see the "Dental Benefits" section)
- the following miscellaneous health care services and expenses:
- services performed in nursing or convalescent homes; institutions primarily for rest or for the aged; rehabilitation facilities (except for physical therapy); spas; sanitariums; or infirmaries at schools, colleges or camps
-injury or sickness that arises out of any occupation or employment for wage or profit for which there is Workers’ Compensation or occupational disease law coverage
(for information about subrogation of benefits, see "Subrogation and Reimbursement" section)
- injury or sickness that arises out of any act of war (declared or undeclared) or military service of any country
- injury or sickness that arises out of a criminal act by the covered person, or an intentionally self-inflicted injury that is not the result of mental illness
- expenses for services or supplies for which a covered person receives payment or reimbursement from casualty insurance or as a result of legal action, or expenses for which the covered person has already been reimbursed by another party who was responsible because of negligence or other tort or wrongful act of that party (for information about subrogation of benefits, see the "Subrogation and Reimbursement" section)
- expenses reimbursable under the "no-fault" provisions of a state law
- services covered under government programs, except under Medicare, Medicaid or where otherwise noted
- any hospital care received outside of the U.S. that is not emergency care
- government hospital services, except specific services covered under a special agreement between Empire and a governmental hospital or services in United States Veterans’ Administration or Department of Defense hospitals for conditions not related to military service
- treatment or care for temporomandibular disorder or temporomandibular joint disorder (TMJ) syndrome
- services such as laboratory, X-ray and imaging, and pharmacy services from a facility in which the referring doctor or his or her immediate family member has a financial interest or relationship
- services given by an unlicensed provider or performed outside the scope of the provider's license
- charges for services a relative provides
- charges that exceed the maximum allowed amount for that service or supply
- services performed at home, except for those services specifically noted in this booklet as covered either at home or in an emergency
- services usually given without charge, even if charges are billed
- services performed by hospital or institutional staff that are billed separately from other hospital or institutional services, except as otherwise specified in this booklet.
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