CWA 1104/GSEU/ContractIndex/Article 6: Health Insurance

From CGEU

6.1 The State will continue the Student Employee Health Plan (SEHP) for hospital, medical, prescription drugs, dental and vision services through The New York State Health Insurance Program (NYSHIP).

The SEHP will consist of two components, network and non-network care. The insurance carrier(s) will maintain the network and will provide other administrative services.

For services to be covered whether in the network or outside the network they must be medically necessary, and cannot be experimental or investigational as determined by the insurance carrier(s).

All network and non-network, non emergency inpatient stays must be pre certified, as well as certain elective outpatient procedures as designated by the insurance carrier(s). In the event of a medical emergency requiring an inpatient admission, the covered individual, or someone acting on the individual's behalf, must contact the plan within 48 hours of the admission. Failure to obtain pre certification of any designated inpatient or outpatient procedure will result in a reimbursement of 50% of allowable expenses after the applicable deductible, if any.

Pre-Certification Requirement Certain outpatient services will require pre-certification. These services include: certain elective outpatient procedures as determined by the insurance carrier; mental health; alcohol and substance abuse; physical therapy; hospice care; home health care and non emergency ambulance services.

6.2 Hospitalization — Network

Inpatient Services Inpatient hospital semi private room and board, services and supplies, including blood and blood plasma will be reimbursed at 80% of allowable expenses after a $200 deductible per admission.

Doctor's in hospital consultations, radiologist's fees, anesthesiologist's fees, surgeon's fees and assistant surgeon's fees (in a hospital where an intern resident or a house staff member is not available) will be covered in full. Effective June 1, 2005, inpatient hospital services obtained at a network hospital will be covered in full after a $200 copayment per admission.

Emergency Services Covered services rendered in the Emergency Room of a hospital will be covered in full subject to a $15.00 copay. Effective June 1, 2005, the copayment will be $25.00. The copayment will be waived if the patient is admitted directly into the hospital from the Emergency Room. Emergency is defined as the sudden onset of symptoms of sufficient severity, including severe pain, that a prudent layperson could reasonably expect the absence of immediate care to put the members life in jeopardy, or cause serious impairment to bodily functions.

Outpatient Services Outpatient hospital services at a network hospital will be subject to an $8.00 copayment. Effective June 1, 2005, the copayment will be $15.00.

6.3 Medical/Surgical — Network

Doctor's Office Visits Doctor's office visits will be provided for the treatment of illness or injury and for designated screening services. Outpatient x-ray, lab and pathology services provided during an office visit will also be covered. The first 15 doctor's office visits provided on a network basis per covered individual, per health insurance contract year will be covered subject to a $8 copayment. Effective June 1, 2005, the copayment will be $10. Outpatient x-ray, lab and pathology services provided during the first 15 visits will be covered in full.

Beginning with the 16th visit per covered individual per health insurance contract year, doctor's office visits and outpatient x-ray, lab and pathology services provided during the visit will be reimbursed at 80% of allowable expenses after the $100 per person annual deductible. Visits by the employee to the Student Health Center will not count toward the 15 visit limit and will not be subject to a copayment, deductible or coinsurance.

Routine Health Exams The plan shall pay up to $60 for a routine physical once every two years for employees under the age of 40, and annually for employees 40 years of age or older, not subject to the office visit copayment or annual 15 visit limit. The Joint Committee on Health Benefits shall discuss the viability of the $60.00 cap throughout the course of the contract.

Outpatient x-ray, lab and pathology screening services provided on a different date from a doctor's office visit or in a different location, other than the Student Health Center, will be subject to an $8.00 copayment for the first 15 occurrences and reimbursed at 80% of allowable expenses after the $100 per person annual deductible beginning with the 16th occurrence. Effective June 1, 2005, the copayment will be $10.00.

Mammograms and Cervical Cytology Screening Coverage for cervical cytology screening once each health insurance contract year will be provided subject to the doctor's office limit and either an $8.00 copayment or deductible and coinsurance. Services for the examination of the Pap smear on a different date or at a different location than the office visit will result in a separate $8.00 copayment or deductible and coinsurance. Effective June 1, 2005, the copayment will be $10.00.

Coverage will be provided for mammographies according to the guidelines outlined below subject to the doctor's office visit limit and an $8.00 copayment or deductible and coinsurance. Effective June 1, 2005, the copayment will be $10.00.

  1. A physician may order a mammography at any time when a medical condition is suspected or known to exist;
  2. At the recommendation of a physician, a mammography will be provided for a covered individual at any age having a prior history of breast cancer or whose mother or sister has a prior history of breast cancer;
  3. Screening will be provided according to the appropriate medical guidelines.
  4. The plan shall cover in full the acquisition, replacement and/or repair of prosthetic breasts in cases of mastectomy due to cancer. The reading of the mammography on a different date or at a different location will result in a separate $8.00 copayment or deductible and coinsurance Effective June 1, 2005, the copayment will be $10.00.

Maternity Care Maternity care (pre-natal and post natal) will be subject to an $8.00 office visit copayment but the 15 visit limit for doctor's office visits will not apply to maternity care. Effective June 1, 2005, the copayment will be $10.00.

Chiropractic Treatment/Physical Therapy Short term outpatient physical therapy and up to 15 chiropractic treatment visits will be subject to an $8.00 copayment per visit. The number of physical therapy visits will be pre certified by the insurance carrier. Effective June 1, 2005, the copayment will be $10.00. These visits will not count toward the 15-visit limit.

Ambulatory Surgical Centers Ambulatory surgical centers are subject to an $8.00 copayment. Effective June 1, 2005, the copayment will increase to $10.00.

Hemodialysis, Chemotherapy and Radiation Therapy Hemodialysis, chemotherapy and radiation therapy will be covered in full. Visits for these services will not count toward the 15-visit limit.

Hospice Care Hospice coverage will be covered in full up to a 210 day maximum.

6.4 Mental Health/Substance Abuse — Network

Inpatient Mental Health Inpatient mental health services will be reimbursed at 80% of allowable expenses after a $200 deductible per admission for a maximum of 30 days per covered individual, per health insurance contract year.

Outpatient Mental Health Care Outpatient mental health visits are reimbursed at 50% coinsurance for visits 1-10, not to exceed $50.00 per visit. Effective June 1, 2005, outpatient mental health visits will be paid in full subject to a $15 copayment for visits 1-10. Visits 11-30 are reimbursed at 50% coinsurance up to $35.00 per visit.

Inpatient Alcohol/Substance Abuse Inpatient alcohol and substance abuse detoxification will be reimbursed at 80% of allowable expenses for a maximum of 7 days per covered individual, per health insurance contract year.

Outpatient Alcohol/Substance Abuse Outpatient alcohol and substance abuse treatment will be covered in full subject to an $8.00 copayment with no limit on the number of visits per health insurance contract year. When multiple visits per week are pre certified, the covered individual will not be required to pay more than two $8.00 copayments per week. Effective June 1, 2005, the copayment will be $10.00.

6.5 Emergency Ambulance Services — Network

Commercial ambulance charges for transportation to the nearest hospital where emergency care can be performed are not subject to deductible or coinsurance. Effective June 1, 2005 medically necessary ambulance services will be subject to a $15 copayment.

6.6 Human Donor Transplants — Network

The plan shall pay for standard human donor transplants including, but not limited to, bone marrow, liver, lung, kidney, heart and cornea, including multiple organ transplants, when medically necessary, subject to appropriate deductibles, coinsurance, copayments and plan maximums.

6.7 Prescription Drug Program — Network

Student Health Center Coverage will be provided for prescription drugs subject to a $3.00 copayment per script at the Student Health Center. Effective June 1, 2005, the copayment will increase to $7.00.

Network Pharmacy A $6.00 copayment per script will apply at a participating pharmacy for a generic drug and a $10 copayment per script will apply at a participating pharmacy for a single source brand name drug. If the covered individual purchases a brand name drug when a generic equivalent is available, the covered individual must pay the $10.00 copayment plus the difference between the cost of the generic and the brand name drug. Prescription drugs will be limited to a 30 day supply.

Effective June 1, 2005, a third level of prescription drugs and prescription copayments will be created to differentiate between preferred brand-name and non-preferred brand-name drugs. The copayment for prescription drugs purchased at a retail pharmacy or the mail service pharmacy for up to a 30-day supply shall be as follows: $5 Generic $15 Preferred Brand $30 Non-Preferred Brand When a brand-name prescription drug is dispensed and a FDA-approved generic equivalent is available, the member will be responsible for the difference in cost between the generic drug and the non-preferred brand-name drug, plus the non-preferred brand-name copayment ($30).

Mail Service Pharmacy The copayment for prescription drugs purchased through the mail service pharmacy for a 31-90 day supply will be as follows: $5 Generic $20 Preferred Brand $55 Non-Preferred Brand When a brand-name prescription drug is dispensed and an FDA-approved generic equivalent is available, the member will be responsible for the difference in cost between the generic drug and the non-preferred brand-name drug, plus the non-preferred brand-name copayment ($55).

Generic Appeal Effective June 1, 2005, the generic appeal process will be available to SEHP enrollees.

Prescription Drug Benefit Maximum The maximum prescription drug benefit will be $2,500 per person, per health insurance contract year. Bargaining Unit members shall also be given the option to purchase either generic or brand name drugs by mail order where available. Oral contraceptives and diaphragms, when dispensed through a licensed pharmacy, will be covered subject to the appropriate prescription drug copayment.

6.8 Vision Care Benefit — Network

Routine eye care refraction will be provided to each covered individual once in every two years subject to an $8.00 copayment. Effective June 1, 2005, the copayment will be $10 for routine eye care refraction.

Effective June 1, 2005, select frames and lenses offered by a participating provider will be paid in full. Covered individual may select Plan contact lenses (daily-wear, disposable or planned replacement) instead of eyeglasses. Benefits are available to covered individual, covered individual spouse or domestic partner and covered dependents age 19 or under once in any 24-month period. The paid-in-full eyeglass/contact lens benefit is only available at the time and place of an eye exam. This benefit cannot be split.

6.9 Dental Care Benefit — Network

Dental examinations including cleaning and bitewing X-rays will be available to covered individuals twice each year subject to a $20.00 copayment. The insurance carrier will establish an adequate network of dental providers to provide these services along with a discount on all other dental procedures. Effective June 1, 2005, coverage will be provided for two fillings per year for an additional $10 copayment per filling.

6.10 Non-Network Benefits

Non-Network benefits will be provided when:

  1. When covered individuals do not elect to use a network provider, or
  2. A network provider is not available to provide the service.

6.11 Hospitalization — Non-Network

Inpatient hospital semi private room and board, services and supplies will be reimbursed at 80% of allowable expenses after a $200 deductible per admission.

6.12 Medical/Surgical — Non-Network

Fees for inpatient doctor's visits, radiologist's fees, anesthesiologists, surgeons or assistant surgeons (in a hospital where an intern resident or a house staff member is not available) during an inpatient confinement will be reimbursed at 80% of allowable expenses after the $200 deductible per admission.

6.13 Emergency Services — Non-Network

Emergency services will be covered in full subject to the $15.00 copayment. Effective June 1, 2005, the copayment will be $25.00.

6.14 Outpatient Services — Non-Network

The following outpatient services will be reimbursed at 80% of allowable expenses after a $100 per person outpatient deductible, per health insurance contract year:

  1. Doctor's office visits for the treatment of illness or injury,
  2. Hospital outpatient facility charges,
  3. Outpatient surgeon's, anesthesiologist's and radiologist's charges, x-ray, lab and pathology services,
  4. Outpatient specialty care,
  5. Maternity care except that the visit limit for doctor's office (pre and post natal) visits will not apply,
  6. Annual cytology screening,
  7. mammography screening subject to the guidelines for coverage as outlined in Article 6.3 above, and
  8. Chemotherapy, hemodialysis and radiation therapy.

Pre-certification Requirement — Non-Network Certain outpatient services will require pre certification. These services include: elective outpatient services as defined by the insurance carrier, mental health, alcohol and substance abuse services, physical therapy, hospice care, home health care and non emergency ambulance services.

6.15 Chiropractic Treatment/Physical Therapy — Non-Network

Short-term physical therapy and chiropractic treatment will be reimbursed up to 80% after a separate $100 deductible.

6.16 Prescription Drug Program — Non-Network

If a covered individual purchases prescription drugs from a non-network pharmacy, the covered individual must remit payment to the pharmacy and submit for reimbursement to the insurance carrier. If the covered individual purchases a generic drug, the Plan will reimburse the individual up to the standard reimbursement rate for network pharmacies less a $6.00 copayment. If the covered individual purchases a single source brand name drug, the Plan will reimburse the individual up to the standard reimbursement rate for network pharmacies less a $10.00 copayment. If the covered individual purchases a brand name drug when a generic equivalent is available, the Plan will reimburse the individual up to the standard reimbursement rate for the generic drug for network pharmacies less a $10.00 copayment. Prescription drugs will be limited to a 30 day supply. The maximum prescription drug benefit will be $2,500 per covered individual, per health insurance contract year. Bargaining Unit members shall also be given the option to purchase either generic or brand name drugs by mail order where available. Oral contraceptives and diaphragms, when dispensed through a licensed pharmacy, will be covered subject to the appropriate prescription drug copayment. Effective June 1, 2005, if a covered individual does not use a network pharmacy, the covered individual must submit a claim to the Pharmacy Benefits Manager. If a covered individual's prescription was filled with a generic drug or a preferred brand name or a non-preferred brand name drug with no generic equivalent, the covered individual will be reimbursed up to the amount the program would reimburse a network pharmacy for that prescription. If the covered individual's prescription was filled with a preferred brand name or a non-preferred brand name drug that has a generic equivalent, the covered individual will be reimbursed up to the amount the program would reimburse a network pharmacy for filling the prescription with the drug's generic equivalent.

6.17 Mental Health/Substance Abuse — Non-Network

Inpatient Mental Health Inpatient mental health stays will be reimbursed at 80% of allowable expenses after a $200 deductible per admission for a maximum of 30 days per covered individual, per health insurance contract year.

Outpatient Mental Health Outpatient mental health visits will be reimbursed at $25 per visit to a maximum of 30 visits per covered individual, per health insurance contract year.

Inpatient Alcohol/Substance Abuse Inpatient alcohol and substance abuse detoxification will be reimbursed for a maximum of 7 days at 80% of allowable expenses after a $200 deductible per admission.

Outpatient Alcohol/Substance Abuse Outpatient alcohol and substance abuse visits will be reimbursed in an amount equal to the network allowance minus an $8.00 copayment to a maximum of 60 visits per health insurance contract year. Effective June 1, 2005, the copayment will be $10.00.

6.18 Hospice Care — Non-Network

Hospice care will be reimbursed at 100% of allowable expenses up to 210 days per health insurance contract year.

6.19 Ambulance Service — Non-Network

Commercial ambulance charges for transportation to the nearest hospital where emergency care can be performed are not subject to deductible or coinsurance. Effective June 1, 2005, medically necessary ambulance services will be subject to a $15 copayment.

6.20 SEHP Maximum Benefits

The maximum plan benefit for covered employees for the diagnosis and treatment of intercollegiate sports injuries will be $500 per covered employee, per health insurance contract year.

The maximum plan benefit per covered individual for network and non-network services combined shall be $350,000 per health insurance contract year, of which the maximum plan benefit for non-network services shall be $100,000 per health insurance contract year.

6.21 Eligibility

Employees eligible for an employer contribution under the SEHP will be those who work at least one half an assistantship AND are employed at a stipend that would yield a total compensation of:

   * $3,800 or more between July 1, 2003 and June 30, 2004
   * $3,895 or more between July 1, 2004 and June 30, 2005
   * $4,002 or more between July 1, 2005 and June 30, 2006
   * $4,122 or more between July 1, 2006 and June 30, 2007

Employees who work at least one half an assistantship but are hired mid year will be eligible if they earn a stipend that would yield a total compensation equal to or more than the amounts indicated above when annualized over each respective July 1 through June 30 beginning July 1, 2003.

The dependents of an eligible employee are also eligible. An eligible dependent is a spouse, including a legally separated spouse, or an unmarried child under the age of 19. Child means a natural child, legally adopted child including a child in the waiting period prior to finalization of adoption and a dependent stepchild. Other children who reside permanently with the employee in his/her household who are chiefly dependent on the employee and for whom the employee has assumed legal responsibility, in place of the parent, are also eligible.

6.22 Domestic Partnerships

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 Interdependency shall be eligible for coverage under the SEHP.

6.23 Summer Health Insurance

Eligible employees who are employed in the spring semester and are expected to return in the subsequent fall semester, will be eligible for an employer contribution during the intervening summer. The employee's department must verify that the employee is expected to return.

Arrangements will be made to collect the employee portion of the health insurance contribution for the summer from the eligible employee prior to the end of the spring semester.

6.24 SUNY Visa Holders

SUNY J1 Visa holders must enroll for coverage under the State University of New York Medical Insurance Program for International Students and Scholars subject to the coverage requirements of federal regulations. The State University of New York may waive this requirement to enroll if the J1 Visa holder provides proof of other coverage that, in the State University's judgment, meets or exceeds the federal requirements.

SUNY F1 Visa holders who meet the eligibility requirement for an employer contribution must enroll in the SEHP. The State University may waive this requirement to enroll if the F1 Visa holder can show proof of other coverage that, in the State University's judgment, meets or exceeds the coverage provided by the SEHP.

6.25 Enrollment

The State University will designate an open enrollment period of 45 days each academic year.

An eligible employee may enroll himself/herself and any eligible dependents during the open enrollment period or within 45 days of the employee's first becoming eligible. Dependents not enrolled at the time of the employee's enrollment may be enrolled within 30 days of a qualifying event (ex: marriage, birth, entry into the country, involuntary loss of prior coverage).

If an eligible employee fails to enroll himself/herself and eligible dependents as provided in Article 6.21, the employee may enroll himself/herself and eligible dependents at any time, subject to a 30 day waiting period.

Domestic students at campuses where enrollment for health insurance coverage is not mandated by the campus may enroll in the SEHP if they meet the eligibility requirements for an employer contribution. Domestic students at campuses where enrollment for health insurance coverage is mandated by the campus, must enroll in the SEHP during the open enrollment or within 45 days of first becoming eligible as described in Article 6.21. If they meet the eligibility requirements for an employer contribution and are not otherwise eligible to have the coverage requirement waived. Failure to either obtain a health insurance waiver or to enroll in the SEHP in a timely manner as described in Article 6.21 may result in the employee being automatically enrolled in the mandatory student health insurance program provided by the campus. The cost of the coverage provided by the campus would be paid for entirely by the student.

Domestic students at campuses where enrollment for health insurance coverage is mandated by the campus may be enrolled in the mandatory student health insurance program provided by the campus if they do not enroll in the SEHP within the appropriate timeframes described in Article 6.21. Late enrollment in the SEHP as provided in Article 6.21 does not entitle them to withdraw from the mandatory insurance program except at times designated by the campus.

6.26 Employer Contribution

The State will contribute:

   * 90% of the cost of individual coverage for domestic students and SUNY F1 Visa holders, and
   * 75% of the additional cost of dependent coverage for the eligible dependents of domestic students and SUNY F1 Visa holders.

For SUNY J1 Visa holders enrolled in the State University of New York Medical Insurance Program for International Students and Scholars, the State will contribute:

   * 90% of the cost of individual coverage under the State University of New York Medical Insurance Program for International Students and Scholars, or a dollar amount equal to what the State would contribute under the SEHP for individual coverage, whichever is less, and
   * For eligible dependents, 75% of the additional cost of their coverage under the State University of New York Medical Insurance Program for International Students and Scholars, or a dollar amount equal to what the State would contribute for dependent coverage under the SEHP, whichever is less.

The State's contribution will be applied toward the cost of hospital, medical, prescription drug, dental and vision coverage as defined under the SEHP. This contribution, however, will not be applied toward the cost of evacuation/repatriation coverage or any hospital, medical, prescription drug, dental and vision coverage in excess of that provided by SEHP.

Failure of the employee to make employee contributions as required (example, through regular payroll deductions or in advance for coverage during the summer, or on a direct pay basis when required) will result in termination of coverage that cannot be reinstated until a subsequent, designated open enrollment period.

Eligible employees may make their employee contributions on a pre tax basis subject to the limitations and restrictions of federal regulations governing plans provided under Section 125 of the Internal Revenue Code.

6.27 Joint Committee on Health Benefits

The State and GSEU agree to establish a Joint Committee on Health Benefits relating to the Student Employee Health Plan (SEHP). The Committee shall consist of no more than five representatives selected by GSEU and no more than five representatives selected by the State. Both parties shall prepare and present a list of the permanent members of the Joint Committee.

The Joint Committee on Health Benefits for the SEHP shall meet within 14 days, or as soon as practicable, after a request has been made in writing by either side. Within three working days of this written request to meet, the entity making such request shall submit a written agenda for the proposed meeting to the Joint Committee members.

The Joint Committee shall work with appropriate State agencies to review and oversee various aspects of the SEHP. The review shall include:

  1.

     The review of access to providers and coverage under the SEHP.
  2.

     The review and development, in conjunction with the carrier, of communications such as the handbook and the certificate of insurance for the SEHP.
  3.

     The study of recurring subscriber complaints and recommendation for the resolution of those complaints.
  4.

     The Joint Committee on Health Benefits for the SEHP shall establish methods and procedures for review of disputed medical claims.
  5.

     The Joint Committee shall request administrative and technical assistance from appropriate State agencies and/or other sources deemed necessary and approved by the Joint Committee.
  6.

     The Joint Committee shall be provided with the carriers' rate renewal request and shall be briefed on the status of the development of such rate renewal.
  7.

     The Joint Committee shall work with appropriate State agencies to monitor future employer and employee SEHP cost adjustments.
  8.

     The Joint Committee will work with appropriate State agencies to make mutually agreed upon changes to the SEHP.