22690NYMENEBS Rev. 9/14. Benefits that give MTA - NYC Transit members freedom and choice

Transcription

1 22690NYMENEBS Rev. 9/14 Benefits that give MTA - NYC Transit members freedom and choice

2 Benefits that give you freedom and choice For more than 75 years, Empire BlueCross BlueShield (Empire) has provided quality health care benefits coverage and administration to New Yorkers and their families. Empire is proud to serve more than 2.5 million union members in New York. 1 The MTA - NYC Transit health care benefits plans administered by Empire put you in control of your health care. With Empire, MTA NYC Transit members don t need referrals to see a specialist. And if you want to get care from a doctor who isn t in our network, you have the freedom to do that (see the footnote on page 5 of this brochure for out-of-network coverage details). If you are an active employee, you can choose either the Basic Option or the High Option. The High Option provides extra benefits, such as a higher reimbursement for out-of-network care and more coverage for inpatient hospital care. If you have questions, call Empire at between 8:30 a.m. - 8 p.m., Eastern time. Or, visit empireblue.com/mta. Exceptional customer service We listen and respond to our members. When you have a question about your benefits, local Customer Service associates in New York will take your call. We share member feedback with our Customer Service teams to make sure we re always improving our service. Need help with your benefits? If you have any questions, call us at between 8:30 a.m. - 8 p.m., Eastern time. Or visit us online at empireblue.com/mta. Want information on the go? Find the nearest urgent care center or ER. Look for doctors, specialists or pharmacies close to you. Find what you need, no matter where you are. Just download the Empire mobile app to your smartphone from the App Store TM or Google Play. 2

3 High Option gives you more Active employees can buy the High Option, which is the Basic Option (described on page 5) with the following extra benefits: Higher reimbursement when you go out of network for care. Based on the service you receive, Empire will pay more for out-of-network care than under the Basic Option. More coverage for inpatient hospital care 365 days a year (instead of 120 days as in the Basic Option). For details on the dental, vision and dependent coverage, please refer to your open enrollment material. Coverage for Medicare-eligible retirees If you are a Medicare-eligible retiree, Empire will be secondary to Medicare Part A and Part B coverage even if you are not actually enrolled in Medicare. The plan covers: The Part A hospital deductible and coinsurance up to 120 days. The Part B deductible and 20% coinsurance for services covered by Medicare. Easy access to doctors and hospitals With Empire, you can choose from a network of more than 90,000 doctors 2 and 200 hospitals in New York and nearby counties in New Jersey and Connecticut. That s the largest provider network in the New York area. It s not just the number of doctors in our network of independent providers, it s also the excellent service of these doctors that helps set us apart from other health care plans. Empire s network gives you access to most doctors in New York Magazine s list of Best Doctors in New York and most of the best hospitals listed in U.S. News & World Report s America s Best Hospitals. 3 3

4 Network access If you and your covered dependent(s) live in New York (in Empire s 28 counties) you have access to the Empire POS network. If you and your covered dependent(s) live in New Jersey, you have access to the Horizon Managed Care Network. If you live elsewhere, you have access to the BlueCard PPO network. If you re traveling outside your service area, you have access to the BlueCard PPO network for all care, regardless of which network you are enrolled in within your primary service area. No hassles when picking a doctor With Empire s plans, you don t need to go through a gatekeeper to get a referral to see a specialist. You just call to make an appointment directly with the doctor you want to see. While there is no gatekeeper, we believe it s important to have preventive and primary care to keep you healthy. It s also vital to have a relationship with a trusted primary care physician who helps with your preventive health care needs. A primary care physician can also help you manage any acute or chronic (ongoing) condition you have now or may develop in the future. How to search for a provider To see if your current doctor is in the Empire POS network or the Horizon Managed Care Network, go to empireblue.com/mta and follow these steps: 1. Click on the Find a Doctor link. 2. Select Find a Doctor Across the country (National Provider Search). 3. You can search by Provider, Location, and Plan Type. (Be sure to select ALT NET - Alternate Network for Plan Type). If you or a covered family member are enrolled in the PPO network or are enrolled in the POS network and are living or traveling outside of the local Empire service area, you can search for a BlueCard PPO network provider by following these steps: 1. Click on the Find a Doctor link. 2. Select Across the country (National Provider Search). 3. You can search by Provider, Location, and Plan Type. (Be sure to select ALT NET - Alternate Network for Plan Type). If you want to see a doctor who is not in the Empire network, you can do that (see the footnote on page 5 of this brochure for details on out-of-network coverage). You can get care from any licensed provider. However, you will have costs, as noted in the footnote on page 5, and you may need to file a claim with Empire for care received from an out-of-network provider. 4

5 MTA - NYC Transit Basic Option for active employees and non-medicare-eligible retirees* Type of inpatient care When you get care from a network provider, Empire will cover: Hospital stay Emergency room/facility visit In-hospital anesthesia In-hospital medical care Treatment for mental and nervous disorders Alcohol/substance abuse detox Physical therapy Organ transplant Up to 120 days per stay after you pay a $50 deductible per stay (maximum of $240 per contract each calendar year) with a $50 inpatient deductible (maximum of $240 per contract each calendar year) with a $50 inpatient deductible (maximum of $240 per contract each calendar year) Up to 30 days per person each calendar year, with $50 inpatient deductible (maximum of $240 per contract each calendar year) Home health care Hospice care Surgery Up to 200 visits per person each calendar year Up to 210 visits per lifetime Type of office/home/outpatient care Home/office/outpatient visits Laboratory tests and X-rays Annual physical exam Outpatient surgery Well-child care (up to age 19) Chiropractic care** Speech/language therapy (up to 16 visits per year)** Allergy treatment (up to 16 visits per year)** Physical therapy (up to 8 visits per year)** Mental health When you get care from a network provider, you pay: $0 copay *Details on out-of-network coverage: Members are reimbursed for out-of-network covered services based on the out-of-network Type D-3 schedule of allowances and the Extended Medical Benefit (EMB). Reimbursement under EMB is subject to a $100 per-person, per-calendar-year deductible and 80% of the allowed charge. You must pay any difference between the out-of-network reimbursement and the provider s charge. For facility-based services, the out-of-network allowed amount will be based on average county rate. For additional details, please refer to your Summary Plan Description (SPD). **Covered in accordance with the terms of the plan. 5

6 Connect to healthy living starting at empireblue.com/mta The empireblue.com/mta website lets you see your benefits through a secure site that is passwordprotected. Our website gives you freedom and flexibility to: Search for doctors, hospitals and other health care professionals. Access claims information, such as your Explanation of Benefits. View benefits information, including deductibles and coinsurance. Create your health record, where you can store information about doctor visits, treatments, prescriptions and more. Our health and wellness programs can help you be healthier and feel better Whether you need support to stay healthy, manage an ongoing condition or need special care for complex health needs, our health and wellness programs give you the resources, guidance and support to help improve your health. Our health and wellness programs offer a total health solution that includes: 24/7 NurseLine Our 24/7 NurseLine puts you in touch with qualified registered nurses to help you make informed decisions about the right care for you and your family. Nurses can help you decide how to handle a medical issue and answer your questions. Can the problem be treated at home? Do you need to see your doctor? Or should you head straight to the emergency room? To get answers any time of the day or night, you can call the 24/7 NurseLine toll free. Future Moms If you re pregnant, our goal is for you to have a safe delivery and a healthy baby! An experienced obstetrical nurse will check to see if you may have a high-risk pregnancy and, if needed, start a plan to help you. Our Future Moms program offers 24/7 access through a toll-free phone number to a dedicated obstetrical nurse during your pregnancy. The nurse works closely with the expectant mother and her OB/GYN s care plan to help support the birth of a healthy baby. There is also support after the birth to provide help for common needs for new parents. ComplexCare 6 ComplexCare covers medical needs beyond chronic conditions. It covers more urgent medical needs, such as for an upcoming surgery, guidance during a longer treatment or as a resource for care options. The Comprehensive Care Management Team includes registered nurses, pharmacists, dietitians, exercise physiologists, respiratory therapists and social workers. They will work with you to help you improve your health.

7 SpecialOffers SM With SpecialOffers, you can get many discounts on fitness center memberships, weight management programs, eyeglasses, LASIK vision correction, hearing aids, dental products, medications, and family and home products. To learn more about these offers, go to empireblue.com/mta and select SpecialOffers. SpecialOffers includes discounts for: Jenny Craig, Weight Watchers and Lindora weight-loss programs Smoking cessation, stress management, alcohol management and other self-help programs Prescription glasses, sunglasses and lens options at thousands of providers nationwide Health, beauty, wellness and personal care products A wide variety of dietary supplements and other wellness products Vendors and offers are subject to change without prior notice. Empire does not endorse and is not responsible for the products, services or information provided by the Special Offers vendors. Arrangements and discounts were negotiated between each vendor and Empire for the benefit of our members. 7

8 Questions about your options? Call Empire at or visit empireblue.com/mta. Information provided is a summary of benefits available and is subject to the terms, conditions, limitations and exclusions set forth in the Summary Plan Description (SPD). 1 Internal data, Data from February 2012 ProAccess Database by HealthConnect Systems, including providers in 28 eastern and southeastern counties of New York and 10 bordering counties of New Jersey and Connecticut. Numbers represent site count. New Jersey counties: Bergen, Essex, Hudson, Middlesex, Monmouth, Passaic, Sussex and Union. Connecticut counties: Fairfield and Litchfield. 3 Based on lists in New York Magazine s June 2011 issue and searches of competitors websites provided by third-party vendor NetMinder/The Ignition Group, 09/2011. Vendors and offers are subject to change without prior notice. Empire does not endorse and is not responsible for the products, services or information provided by the SpecialOffers vendors. Arrangements and discounts were negotiated between each vendor and Empire for the benefit of our members. Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.