Hospital Program and Medical/Surgical Program Work Together
SEHP is made up of multiple programs that work together to provide you comprehensive coverage. Certain services you receive at a hospital may be covered by the Medical/Surgical Program instead of the Hospital Program.
Call 1-877-769-7447 if you have questions about your coverage.
Benefits Management Program
Call 1-877-769-7447 for precertification.
To receive the maximum benefits under the plan, you must follow the Benefits Management Program requirements.
Some scheduled (nonemergency) diagnostic tests must go through Prospective Procedure Review. They include:
- Magnetic resonance imaging (MRI)
- Magnetic resonance angiography (MRA)
- Computerized tomography (CT) scan
- Positron emission tomography (PET) scan
- Nuclear medicine test
If you do not call the Benefits Management Program and the test or procedure is determined to be not medically necessary, you will be responsible for the entire cost. If you do not call and the test or procedure is later determined to be medically necessary, you will pay up to $250 in costs.
Other services provided by the Benefits Management Program include:
- Coordination of voluntary specialist consultant evaluation
- Outpatient medical case management for coordination of covered services for certain catastrophic and complex cases that may require extended care
Network and Non-Network Coverage
SEHP uses The Empire Plan network for Medical/Surgical coverage. Physicians and providers that are part of the network are also known as “participating providers.”
When you receive covered services from a participating provider, you only pay applicable copayments. Most types of visits to a participating provider are subject to a 15-visit per person annual limit.
There are some exclusions to the 15-visit per person annual limit. They include:
- Preventive care visits are not subject to the 15-visit per person limit.
- Any visit you make to your SUNY Campus Student Health Center (which is not a network provider) does not count toward the 15-visit per person limit. (This does not apply to CUNY SEHP enrollees.)
Speak with your HBA or call the plan at 1-877-769-7447 to confirm.
Non-network coverage applies when:
- You use a physician or provider who is not in The Empire Plan network
- You exceed the 15-visit annual limit
Non-network coverage is limited. Your out-of-pocket costs will be higher. After you pay the deductible amount, the plan pays 80% of the allowable amount for covered services (which may be less than 80% of the entire cost). You are responsible for the balance.
Medical/Surgical Coverage
The Medical/Surgical Program covers a broad range of services, including some services you may receive while in a hospital. Call 1-877-769-7447 or review the SEHP AAG for a full list of benefits under the program.
Some services are covered with no cost to you if you use a network provider. This includes:
- Routine health exams
- Office visits for preventive care
- Certain adult immunizations
- Women’s health care (including certain contraceptives provided in a physician’s office)
- Covered services while you’re an inpatient at a hospital or birthing center
- Covered outpatient services provided in an outpatient department of a hospital
- Prenatal and postnatal office visits included in your provider’s delivery charge
- Well-child care
- Mammogram screening, diagnostic and 3-D mammograms
- Pregnancy termination
- Dialysis
- Chemotherapy
Other services are covered with just the copayment cost if you use a participating provider.
Managed Physical Medicine Program
The Managed Physical Medicine Program is administered by Managed Physical Network (MPN). Through the program, you are covered for:
- Chiropractic treatment
(up to 15 visits per person per calendar year) - Physical therapy
(up to 60 visits per diagnosis, if determined to be medically necessary)
Home Care Advocacy Program (HCAP)
HCAP covers:
- Diabetic equipment and supplies (including insulin pumps)
- Home skilled nursing services
- Durable medical equipment and supplies (other than diabetic equipment and supplies)
You must get preauthorization before you receive services or supplies under HCAP. Call the following numbers to get prior authorization.
| Start HCAP Preauthorization | |
|---|---|
For diabetic equipment and supplies: | Call The Empire Plan Diabetic Supplies Pharmacy at 1-800-321-0591 |
For home skilled nursing services and durable medical equipment and supplies: | Call 1-877-769-7447 Press or say 1 Choose HCAP for prior authorization |
Use network providers to receive maximum benefits.
If you have Medicare as your primary coverage, using a Medicare contract provider will give you maximum benefits. If you are in an area that participates in the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program, you must use a Medicare-approved supplier.