DOCTORAL STUDENT HEALTH CARE (NYSHIP) FAQ*

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Getting Started

Benefits

Problems / Grievances

Other

Contact Information

Important Documents

GETTING STARTED

NYSHIP is the health insurance made available through the Student Employee Health Plan (SEHP), (see: NYSHIP Summary of Benefits), a component of the New York State Health Insurance Program (NYSHIP) for CUNY graduate and teaching assistant employees and their families.

Eligibility / Enrolling

Am I eligible?
You are eligible if you are:

  • matriculated in a doctoral program at the Graduate Center;
  • employed in one of the following Professional Staff Congress (PSC) titles: Graduate Assistant A, B, or C; Adjunct Instructor; Adjunct Lecturer; Adjunct College Laboratory Technician (CLT); Non-Teaching Adjunct I or II;
  • and earn at least $4,122 per year in one of those titles; or, earn at least $2,061 per semester if employed for just one semester (these figures are subject to change.)

If I am not eligible, can I pay to join the plan?
No, the basic requirements must be met for participation in the plan.

When can I enroll or change my level of coverage?
You may enroll or change your level of coverage during an open enrollment period (usually takes place in November with deductions beginning on the first pay check of the following January) or with the occurrence of a valid qualifying event. Life changes such as certain changes in job status, marriage, the birth of a child or a dependent child graduating or reaching the maximum age of coverage are examples of valid qualifying events.

What if I start in the spring?
Those enrolled in the Spring semester can be covered over the summer if, during the Spring semester, they complete a form that will allow payroll deductions to extend coverage for the summer months. You may contact healthinsuranceinfo@gc.cuny.edu for this form.

What do I need to do to enroll in NYSHIP/SEHP?
Bring the completed NYSHIP enrollment form and required supporting documentation to the Student Affairs office (GC, room 7301). When you are hired or newly eligible, you should receive a packet containing the information and forms you need to enroll for benefits. Your paperwork must be received in Human Resources within 30 days of your initial or qualifying appointment in order to be eligible.

If I am currently employed at a CUNY Community College, am I eligible to enroll in this program?
Yes. You must present your appointment letter to the Student Affairs Office at The Graduate Center by either fax: (212) 817-1621 or email healthinsuranceinfo@gc.cuny.edu in order to initiate the transfer from city to state payroll.

In the event you do not have your appointment letter, please contact the Office of Student Affairs at the Graduate Center immediately at (212) 817-7400.

Graduate Assistants enrolled in the Engineering Program at City College must contact the Human Resources Department at City College at (212) 650-7963.

What if I don’t get my NYSHIP packet?
If you do not receive this information within two weeks of your hiring / eligibility, contact your Benefits Officer or print the enrollment form and list of documents at the Doctoral Student Employee Health Plan on the CUNY University Benefits Office Web site.

Is coverage automatic? Is it mandatory?
No. You must enroll in the program to be covered. Enrolling in this health insurance plan is voluntary.

Can I choose my insurance companies or networks?
No, you must use the companies and networks indicated in the SEHP Benefit Summary.

When does my coverage end?
When you no longer meet the eligibility criteria. Upon termination, you will automatically receive a COBRA package which will provide the opportunity to continue group health insurance. See also NYSHIP Termination Form.

Will coverage continue through out the summer? How do I pay for it?
If you expect to return in September, your coverage will continue through the summer months. If you are an adjunct, you must notify the Graduate Center’s Human Resources department of your anticipated appointment.
Premium contributions will be taken from your last few pay checks prior to summer in order for coverage to continue through the summer months. Therefore, you will see an increase in the amount of your deductions for these pay periods.

How much do I pay for insurance?
For Spring/Fall 2010, the bi-weekly premium is $6.32 for individual student coverage and $47.36 for family coverage (spouses, children and domestic partners).
The premiums are automatically deducted from bi-weekly paychecks.

Insurance Cards

Is the expiration date printed on my health insurance card the actual date on which my benefits will end?
Insurance cards are reissued every year and are effective September 1 thru August 31. If you continue to be eligible for benefits, you will automatically receive a new card.

I lost my insurance card. Who do I contact?
Replacement cards may be ordered online at www.cs.state.ny.us/mynyship

What cards do I have to show my doctor to get coverage?
Your cards are mailed three to four weeks after the enrollment forms are processed. Students receive three cards: one for hospital / medical benefits, one for dental, and one for vision.

Crucial Information: what you really, REALLY need to know

The plan has six main parts, which can make it a little confusing. This will help:

If you need inpatient or outpatient hospital care, your provider is:

Empire BlueCross BlueShield

Provides coverage for inpatient and outpatient services provided by a hospital or birthing center and for hospice care. Also provides inpatient Benefits Management Program services for preadmission certification of scheduled hospital admissions or within 48 hours after an emergency or urgent admission. Services provided by Empire HealthChoice Assurance, Inc., a licensee of the BlueCross and BlueShield Association, an association of independent BlueCross and BlueShield plans.

If you need to go to the doctor, get tests or surgery, go to a chiropractor or do physical therapy, your provider is:

UnitedHealthcare

Provides coverage for medical services, such as office visits, surgery and diagnostic testing under the network and non-network programs.

Coverage for chiropractic care and physical therapy is provided through the Managed Physical Medicine Program. Home care services provided in lieu of hospitalization and diabetic supplies provided by the Home Care Advocacy Program (HCAP). Benefits Management Program services for Prospective Procedure Review for MRI, MRA, CT, PET, and Nuclear Medicine tests.

If you need inpatient and outpatient mental health or substance abuse services, your provider is:

UnitedHealthcare, administered by OptumHealth Behavioral Solution (OptumHealth)

If you need prescription drugs, your provider is:

UnitedHealthcare / Medco

UnitedHealthcare partners with Medco Health Solutions, Inc. (Medco) for services including the retail pharmacy network and mail pharmacy services. Provides coverage for prescription drugs, oral contraceptives and diaphragms through network pharmacies, the Medco Pharmacy (mail service) and non-network pharmacies.

If you need a teeth cleaning, dental exam or filling, your provider is:

GHI, (800) 947-0101

Also provides discounts on other services.

If you need an eye exam, eyeglasses or contact lenses, your provider is:

EyeMed, (877) 226-1412

Pre-approval is required for coverage of some services (for more information, see Benefits):

  • Before a scheduled (non-emergency) hospital admission
  • Before a maternity hospital admission
  • Within 48 hours after an emergency or urgent hospital admission
  • (Non-emergency) Magnetic Resonance Imaging (MRI), and for a Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) or a Nuclear Medicine test
  • Diabetic equipment, supplies and home care services

Are there any co-pays for medical treatments, hospitalization or prescription drugs? What are they?
Yes:

  • $200 for each hospital inpatient admission
  • $15 per hospital outpatient visit
  • $25 for hospital emergency room
  • $10 for doctor’s office visits
  • $10 for physical therapy and chiropractic visits
  • $10 for mental health and substance abuse outpatient visits
  • for prescription drugs:
    • a $5/$15/$30 for up to a 30-day supply
    • $5/$20/$55 for up to a 90-day supply

BENEFITS

Benefit Basics

What does the plan cover?

  • Medical / hospitalization
  • Pharmacy / Prescription drugs
  • Mental health/substance abuse
  • Dental
  • Vision

What doesn’t the plan cover?

  • expenses in excess of $100,000 (non-network benefits); in excess of $350,000 (network and non-network combined); and prescription drugs in excess of $3,000 (network and nonnetwork combined)
  • care that is not medically necessary
  • experimental or investigative procedures
  • custodial care
  • cosmetic surgery
  • routine foot care
  • sex change
  • durable medical equipment and supplies unless provided under the Home Care Advocacy Program (HCAP)
  • prosthetics (except breast prostheses, which are paid in full)
  • orthotics
  • TMJ treatment (except when caused by a medical condition)
  • hearing aids
  • weight loss treatment (except for otherwise covered medical care and prescription drugs for treatment of morbid obesity)
  • adult immunizations (except as part of a covered routine physical)
  • skilled nursing facility care including rehabilitation
  • allergy extracts and injections
  • inpatient alcohol and substance abuse rehabilitation
  • psychological testing and evaluation and outpatient psychiatric second opinion
  • drugs furnished solely for the purpose of improving appearance rather than physical function or control of organic disease
  • reversal of sterilization; assisted reproductive technology and other infertility services (except artificial/intra-uterine insemination and other services for which coverage is mandated by New York State Insurance Law)
  • cloning
  • cardiac rehabilitation;occupational therapy
  • speech therapy

How do I find a physician or hospital in network?
A listing of participating physicians and hospitals can be found at:
www.empireplanproviders.com.

What do I have to show my doctor to get coverage?
Your insurance cards, which are mailed 3 – 4 weeks after the enrollment forms are processed. Students receive one card for hospital / medical benefits, one for dental, and one for vision.

Are there any co-pays for medical treatments, hospitalization or prescription drugs? What are they?
Yes:

  • $200 for each hospital inpatient admission
  • $15 per hospital outpatient visit
  • $25 for hospital emergency room
  • $10 for doctor’s office visits
  • $10 for physical therapy and chiropractic visits
  • $10 for mental health and substance abuse outpatient visits
  • for prescription drugs:
    • a $5/$15/$30 for up to a 30-day supply
    • $5/$20/$55 for up to a 90-day supply

Do I have to use a participating pharmacy?
For a 30-day supply, you can choose a participating or non-participating pharmacy (or the mail service pharmacy). If you use a participating pharmacy, you will be responsible for a co-payment. If you use a non-participating pharmacy, you must pay for the prescription and submit a claim for reimbursement.

To fill a prescription for a 90-day supply, you must use the mail service pharmacy.

What is the mail service pharmacy?
You can order prescriptions through the mail with Medco.

What are my dental benefits?

  • routine dental care – dental examinations, cleaning, bitewing X- Rays
  • up to two fillings per 12-month period

How do I find a participating dentist and/or information regarding my dental plan?
You may link to the GHI website by accessing www.cs.state.ny.us. Choose Benefit Programs, then NYSHIP Online, and choose your group, if prompted. Select Other Benefits, then Dental; or you may call (800) 947-0101. Also, check out the GHI brochure.

What are my vision care benefits?

  • routine vision care – including routine eye exams (once in any 24-month period)
  • eye glasses or contact lenses offered by a participating provider

Where can I find more information about my coverage and benefits?
Information concerning coverage and benefits can be found at NYSHIP online.

Can I purchase additional coverage?
No. You are not able to purchase additional coverage under the NYSHIP.

Do certain medical treatments require approval beforehand?
YES. Pre-approval is required for:

  • Before a scheduled (non-emergency) hospital admission
  • Before a maternity hospital admission
  • Within 48 hours after an emergency or urgent hospital admission
  • (Non-emergency) Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) or a Nuclear Medicine test
  • Diabetic equipment, supplies and home care services

Before a scheduled (non-emergency) hospital admission, a maternity hospital admission, or within 28 hours of an emergency or urgent hospital admission for you or your covered dependents, you must call: (877) 769-7447 and choose Empire BlueCross BlueShield. If you do not call, or if Empire BlueCross BlueShield does not certify the hospitalization, the Plan pays up to 50 percent of allowable amount after your $200 copayment.

For a scheduled MRI or for mental health/substance treatment, call (877) 769-7447 and choose UnitedHealthcare for prior authorization before having a scheduled (non-emergency) Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) or a Nuclear Medicine test (unless you are having the test as an inpatient in a hospital). If you do not call, you will pay a large part of the cost. If the test is determined not to be medically necessary, you will be responsible for the entire cost.

For treatment for mental health or substance abuse, including alcoholism, you must be approved for coverage: call (877) 769-7447 and choose OptumHealth (administrator for UnitedHealthcare) OptumHealth’s Clinical Referral Line is available 24 hours a day, every day of the year.

In an emergency, OptumHealth will either arrange for an appropriate provider to call you back (usually within 30 minutes) or direct you to an appropriate facility for treatment. In a life-threatening situation, go to the emergency room. If you are admitted as an inpatient, you or someone acting on your behalf should call OptumHealth within 48 hours or as soon as reasonably possible after an emergency mental health or substance abuse hospitalization.

Diabetic equipment, supplies and home care services: call the Plan toll free at (877) 769-7447 and choose UnitedHealthcare’s Home Care Advocacy Program (HCAP) for prior authorization. Home care services are not covered unless precertified. If precertified, Plan pays 80 percent of allowable amount after you meet the annual deductible.

Program requirements apply even if another health insurance plan (including Medicare) is primary. Only treatment determined medically necessary by OptumHealth is covered.

For more information on required pre-approval, click HERE.

Are there any maximum benefits of which I should be aware?
Yes. The annual maximum for prescription drugs, network and non-network combined is: $3,000.
The Annual BenefitMaximums for all other NYSHIP SEHP coverage, except prescription drugs: non-network benefits: $100,000 / all benefits (network and non-network combined): $350,000
All services must be medically necessary. “Allowable amount” means the amount you actually paid for medically necessary services covered under SEHP, or the network allowance as determined by the carriers, whichever is lower.

Family Benefits

Am I able to add my domestic partner to coverage?
Yes. Please contact the University Benefits Office at (212) 794-5342 for additional information. See also Domestic Partner Coverage Form and Application for Domestic Partnership and Statement of Financial Interdependence.

How much is family coverage?
For Spring/Fall 2010, the bi-weekly premium is $47.36 for family coverage (spouses, children and domestic partners).
The premiums are automatically deducted from bi-weekly paychecks.

Can my dependents be covered on my plan?
Yes. Family coverage is available through this plan. See also Dependent Tax Affidavit.

How much is routine Well-Child Care?
Network Coverage: Paid-in-full benefit for children up to age 19, including examinations and immunizations administered pursuant to pediatric guidelines. Well-child care visits do not count toward the 15-visit per person limit.
Non-Network Coverage: Plan pays 100 percent of allowable amount. This benefit is not subject to deductible or coinsurance.

PROBLEMS / GRIEVANCES

What if my health insurance deduction from my paycheck is incorrect or not being deducted at all?
You should contact the University Benefits Office at (212) 794-5342, which serves as your Health Benefits Administrator, to report incorrect or missing health insurance deductions.

I lost my insurance card. Who do I contact?
Replacement cards may be ordered online at www.cs.state.ny.us/mynyship.

OTHER

What if I am an international student?
Students who plan to take on CUNY employment need to make sure that they have Social Security numbers. This is a necessary precondition to students obtaining employment. International students who currently have Taxpayer Identification Numbers (TINS) should contact the Office of Human Resources for guidance on how to proceed.

If I am an Adjunct currently enrolled in a health plan provided by the PSC-CUNY Welfare Fund, am I eligible to participate in this program?
If you are eligible to receive NYSHIP coverage, you will no longer be eligible to receive Adjunct health insurance coverage through the PSC-CUNY Welfare Fund. To retain health insurance coverage you must enroll for NYSHIP coverage.

*Please note: we are not representatives or consultants with NYSHIP or SEHP; we do our best to keep this FAQ updated. If you find a discrepancy, we would be grateful if you’d email us at theadjunctproject@gmail.com.

There may be some differences in the enrolling process depending on your title: GTF (Enhanced / Chancellor’s Fellow), Adjunct, Graduate Assistant A, B, or C; Adjunct Instructor; Adjunct Lecturer; Adjunct College Laboratory Technician (CLT); Non-Teaching Adjunct I or II.