PEF and NYSCOPBA Health
All full-time employees and part-time employees working at least half time are eligible for health insurance coverage if they are expected to be employed for at least 12 weeks. Coverage is effective on the 57th day of employment if the employee enrolls within the first 56 days. Later enrollment will subject the employee to a 10 week waiting period, unless the employee enrolls within seven days of the loss of other coverage.
Employees may enroll for either individual or family coverage. Eligible family members include a spouse or domestic partner, children under the age of 19 and children under 25 who are full-time students and unmarried. Proof of date of birth must be provided for all persons; a marriage certificate is also necessary if covering a spouse. To enroll a domestic partner you must provide proof of common residency and financial interdependence dating back at least one year; you generally will have to pay taxes on the value of your partner's health insurance coverage.
Employees may enroll in either the Empire Plan, which is available statewide, or choose from 13 health maintenance organizations available in different parts of the state. There is an annual option transfer period (usually November) when employees may transfer to a different plan for the coming year.
The Empire Plan provides coverage through Blue Cross for hospital services; inpatient services are covered in full. Medical and surgical coverage is provided through United HealthCare. Enrollees may visit a participating provider for a $10 co-payment; the basic medical program provides reimbursement for services rendered by a non-participating provider (after a $295 annual deductible is met, the plan reimburses 80% of reasonable and customary expenses). The prescription drug co-payment is $5 generic, $15 brand-name.
The State pays 90% of the cost of individual coverage in the Empire Plan and 75% of the additional cost for dependent coverage. For HMOs the State pays the same percentage or 100% of its cost for the Empire Plan, whichever is less. Employees may choose to have their contributions on a pre-tax basis.