The Empire Plan vs. HMO

There are two types of plans available through NYSHIP: The Empire Plan and NYSHIP-approved HMOs. Learn about the differences between these plan types so you know which one is right for you. 

NYSHIP offers multiple plan options, and enrollees can choose the option that best suits their needs. Each plan is administered by the New York State Department of Civil Service and offers a wide range of coverage. 

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.

The Empire Plan

The Empire Plan is available to all NYSHIP enrollees. It has worldwide coverage and an extensive list of in-network providers. The Empire Plan is a self-insured preferred provider organization (PPO), which means there are both in-network and out-of-network benefits. Benefits are negotiated by NYS unions.

Health Maintenance Organizations (HMOs)

HMOs are regional plans tied to specific geographic areas. There are multiple NYSHIP-approved HMOs; the counties where you live and work will determine which ones are available to you. HMOs provide comprehensive coverage through a network of providers, but do not offer out-of-network benefits.

Plan Comparison

There are some general key differences between The Empire Plan and NYSHIP-approved HMOs.

You can directly compare NYSHIP plans available to you. Fill in the requested information to create a list of available plans. Then, select the plans you want to compare directly. 

Compare NYSHIP Plans

The Empire Plan vs. NYSHIP HMOs

Service Area

Empire Plan

Worldwide coverage is available for covered services

HMOs

Emergency care away from home is covered. Other services received outside the service area are limited

Participating Providers

Empire Plan

  • Over 1.2 million network providers and facilities throughout the U.S. 
  • Enrollees are not required to choose a Primary Care Physician or obtain referrals to see specialists. 
  • Certain services require preapproval. 

HMOs

  • Participating providers are typically within the HMO's service area. 
  • Enrollees usually choose a Primary Care Physician from the HMO's network. 
  • It may be necessary to obtain referrals. 

Expenses/Cost Sharing

Empire Plan

  • Copayment as a per-visit fee is typical. 
  • Benefits for covered services obtained from a nonparticipating provider are subject to a deductible and/or coinsurance.

HMOs

  • Copayment as a per-visit fee or coinsurance is typical. 
  • There are no out-of-network benefits. 
  • No annual deductible. 

Both plan types provide:

  • Physician services
  • Preventive care services
  • Emergency care
  • Inpatient and outpatient medical/surgical hospital care
  • Telehealth 
  • Laboratory and radiology services
  • Prescription drug coverage
  • Physical, occupational and speech therapy

Exclusions

All plans contain coverage exclusions for certain services and prescription drugs. Workers' Compensation-related expenses and custodial care are generally excluded from coverage. For details on a plan's exclusions, read The Empire Plan Certificate or NYSHIP HMO certificate or check with the plan directly. 

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