The Empire Plan vs. HMO

Welcome to the New York State Health Insurance Program, or NYSHIP.

As a New York State employee, you have several choices when it comes to selecting a health insurance plan for yourself and family. We will break down what these options mean: 

What is The Empire Plan?

The Empire plan is a health insurance plan offered by NYSHIP for New York State public employees and their employers. This is a self-insured, preferred provider organizations plan, where benefits are negotiated by collective bargaining. 

Over 80% of NYSHIP employees are enrolled in The Empire Plan. The plan covers a wide range of medical expenses, including: 

• Inpatient and outpatient hospital services 
• Medical and surgical care 
• Centers of excellence for transplants, infertility and cancer 
• Home care services 
• Equipment and supplies 
• Mental health and substance use coverage 
• Prescription drugs 

The Empire plan has four programs: 

• A hospital program administered by Anthem Blue Cross, 
• A medical program administered by United Healthcare,
• A mental health and substance use program administered by Carelon Behavioral Health
• and a drug program administered by CVS Caremark. 

Features of the plan include: 

• Worldwide benefits for covered services, not just urgent and Emergency Care 
• Access to over 1.2 million Network providers and Facilities throughout the United States 
• Enrollees are not required to choose a primary care physician or obtain referrals to see Specialists
• Co-payments as a per visit fee. 

Benefits for covered Services obtained from a non-participating provider are available and subject to a deductible and/or co-insurance. 

What is a health maintenance organization or HMO? 

NYSHIP-approved HMOs are available in various geographic areas of New York State. Depending on where you live or work, one or several HMO plans will be available to you.

Benefits in an HMO are not negotiated through collective bargaining. Features of HMOs include: 

• Comprehensive coverage through a network of providers in a specific geographic region 
• Aside from emergencies, coverage for services received outside the service area is limited and at the discretion of the individual HMO
• Enrollees usually choose a primary care provider from the HMO's network for routine medical care. It may be necessary to obtain referrals to receive services from certain specialists and hospitals.
• Copayments as a per visit fee, or coinsurance. HMOs have no annual deductible. Out-of-network benefits are not available. 

Selecting a health insurance plan is an important and personal decision. Here are some questions to ask yourself as you are selecting a plan: 

• What is the premium?
•  What choice of providers do I have? 
• Are the providers and facilities I currently use considered in- or out-of-network?
• Is the medicine I currently take covered?
• What will happen if I need care while away from home?
• Is there a deductible?
• What is the annual out-of-pocket maximum?
• Are there any benefit limitations?

For more information on the plans available to you, explore health benefit options on the NYSHIP website or contact your health benefits administrator or HBA.