The Empire Plan underwent changes on July 1, 2023

The Empire Plan is a health insurance plan for eligible employees in the state of New York. It is the primary plan for the New York State Health Insurance Program (NYSHIP). NYSHIP is administered by the Department of Civil Service.

It is designed to provide enrollees with comprehensive medical care coverage. Patients may choose participating providers to help keep the cost affordable. UnitedHealthcare is the program administrator for the Empire Plan.

The Empire Plan, for New York state employees, underwent significant changes as of July 1, 2023, affecting the following groups:

These Empire Plan changes have impacted service billing and payments. Medical billing companies and providers must comprehend these changes to maintain accurate billing practices and guide patients through their healthcare journeys.

There are no longer multiple copayments per visit to the same practitioner. Instead, a single $25 copayment will apply for all covered services the same practitioner provides on the same date.

This rule covers office visits, surgeries, radiology, and lab services. However, urgent care visits may still involve up to 2 copayments of $30 each. This copayment structure simplifies billing and provides patients with predictable costs.

Medicare rates are now the fee basis for claims from nonparticipating providers. For enrollees, this could mean potential increases in out-of-pocket costs when they opt for a nonparticipating provider. Thus, it would benefit medical billing companies and providers to inform patients about this change and advise them to consider network providers to minimize unexpected costs.

A significant development is the launching of a new site of care program for infusions of infliximab (Remicade®) or an infliximab biosimilar. Empire BlueCross and UnitedHealthcare will assist in transitioning these services from outpatient hospital settings to alternate locations when clinically appropriate. Alternate locations could include freestanding infusion suites, doctors’ offices, or even the patient’s home. 

This move aims to reduce care costs, increase patient convenience, and improve the overall patient experience. No medical/surgical program or prescription drug program copayments are required of patients who use an alternate setting.

In the event of an exception, enrollees can choose to continue in an outpatient hospital setting. Exceptions may apply when moving care out of an outpatient hospital setting is clinically inappropriate, or there is no other setting within 30 miles or 30 minutes of the enrollee’s home. 

Annual visit limits for acupuncture services by nonparticipating providers and massage therapy services also came to the Empire Plan. Coverage is now capped at a maximum of 20 visits per calendar year, irrespective of the number of providers visited. This change highlights the importance of tracking service usage accurately and informing patients about these limits to help them manage their healthcare decisions. 

To ensure providers are reimbursed for care, it is important to verify visits remaining on a patient’s benefit plan. Failure to confirm the visits will result in non-payment and lost revenue.

Lastly, the Empire Plan is launching a new Center of Excellence for Substance Use Disorder Program in partnership with the Hazelden Betty Ford Foundation. This program will provide authorized treatment services at no cost to enrollees of the Empire Plan. This initiative is essential in providing accessible, high-quality care for people with substance use disorders. 

Medical billing providers must familiarize themselves with this program to bill these services accurately. Authorized services include detoxification, residential rehabilitation, partial hospitalization, intensive outpatient care, care coordination for transition back to the community, family treatment and support, and virtual support services. Allowances are also available for patients and up to 2 travel companions towards accommodation, meals, and transportation.

The Empire Plan changes, which became effective on July 1, 2023, signify the evolving landscape of healthcare insurance. These adjustments present opportunities for medical billing providers to enhance patient communication and improve understanding of healthcare costs and service availability. The changes aim to streamline services, promote cost-effectiveness, and enhance patient care.

For medical billing providers, staying informed and proactive in implementing these updates is key to continuing to provide effective service. Medical billing companies can add significant value to healthcare providers by ensuring providers are aware of these changes and implementing strategies to eliminate the risk of losing revenue. 

Keeping an open line of communication is crucial for accurately interpreting and implementing these changes and ensuring optimal service delivery and patient care. Staying informed and embracing these changes will allow medical billing companies to effectively refine and improve their billing practices.

For further inquiries, medical billing companies and providers can call directly at 877-769-7447 (877-7-NYSHIP). Press or say “1” once connected to reach the Medical/Surgical Program, which UnitedHealthcare administers.