NYU Health Care Coverage
Full-time employees make contributions for health care coverage through convenient payroll deductions.
Each fall, during the designated Annual Enrollment Period, you will have an opportunity to make changes to your health care coverage and add or drop dependents. Changes made during Annual Enrollment become effective on January 1 of the following year.
Changes remain in effect for the entire year, unless you experience a qualifying life event that permits you to change your coverage.
A copayment is a flat dollar amount that you pay for specific services each time you use them, such as office visits. Copayments are not part of the annual deductible (if your plan has one), and are not applied to any out-of-pocket maximum. Each NYU health care plan has a schedule of benefits, with specified copayments for covered services.
Yes, when you are eligible for coverage under a NYU medical or dental plan, you may elect to cover your eligible spouse, or registered domestic partner, and/or eligible children. (See also, "Dependent Coverage".)
Generally, you become eligible to enroll for coverage during the NYU initial enrollment period. This period is from your date of hire until 31 days following your date of hire. If you do not enroll during this period, you will have to wait until the next Annual Enrollment Period.
A qualifying life event is a change in your personal life that may impact your eligibility or your dependents' eligibility for benefits. If you are eligible to make changes, you must make the change within 31 days of the date of your qualifying life event. After the 31-day deadline, you will have to wait until the next Annual Enrollment Period to make further changes.
Any changes made must be consistent with the qualifying event experienced. Some changes, e.g., birth, marriage, and divorce, may require proof of the qualifying event.
Examples of qualifying life events are: birth or adoption of a child; marriage; establishing a domestic partnership; divorce; ending a domestic partnership; disability; death; spouse/domestic partner gains or loses coverage; move to an area where current coverage is not available; and retirement.
In-network doctors and hospitals have a negotiated fee agreement with your insurance plan. Each of the plan providers offered by NYU has an extensive roster of in-network providers who are board-certified and rigorously screened.
The out-of-pocket maximum limits the amount you might be expected to pay for medical services each calendar year. This means that once your expenses reach a certain amount after you pay your deductible, covered services will be paid in full by your Plan, at the Reasonable and Customary rate. Out-of-pocket maximums do not apply to services with copays.
The NYU Point-of-Service (POS) Value and POS Advantage plans cover services rendered by both in-network and out-of-network providers and have a different out-of-pocket maximum for each type of service. The Aetna and Oxford HMO Plans cover in-network services only. All other plans have an out-of-pocket maximum for covered services.
If you are enrolled in one of the NYU Point-of-Service Plans, you may choose to use an out-of-network provider and still have a portion of the cost of those services covered by your plan. Note that the fees they charge are not limited by a contracted fee agreement. If you go out of network, any amounts your provider charges that are above Reasonable & Customary rates, are your responsibility and are not credited to your out-of-pocket maximum. (See also, "Explanation of Reasonable & Customary".)
The annual deductible is an amount you must pay before your Plan will pay any benefits. Your annual deductible does not apply to services with copayments, but amounts that you pay toward your annual deductible are credited to your out-of-pocket maximum.
If you are enrolled in one of the NYU Point-of-Service Plans, and you go out of network, any amounts your provider charges that are above Reasonable & Customary rates are your responsibility and are not credited to your annual deductible. (See also, "Explanation of Reasonable & Customary".)
Coinsurance is the percentage of the cost for covered services that are your responsibility. After your deductible limit has been reached, the Plan will pay a stated percentage, based on Reasonable & Customary rates, and you pay the other percentage. Coinsurance is applied to your out-of-pocket maximum.
Prescription Drug Benefits
CVS/Caremark is the administrator of the prescription drug program for all NYU health plans.
The plan covers brand-name prescription drugs. However, brand-name medications have a higher copayment.
Copayment amounts will depend upon whether the prescription that your physician writes is for a generic or a brand name drug. Prescriptions written for a specific brand-name medication will have a higher copayment. There is also a $75 copayment if you use a retail pharmacy for the third or any subsequent refills of maintenance drugs.
Any time the price of the drug is less than the required copayment, you will pay the actual price of the prescription.
You may request a refill of a 90-day prescription through Caremark mail service at day 50. This should eliminate the problem of coordinating the timing of receipt of mail service prescriptions with planned travel.
You may receive as much as a 180-day supply through the Caremark mail order pharmacy. In order to obtain a 180-day supply of a medication, your physician will need to write the prescription for that quantity. You will pay two times the copay you would pay for a 90-day supply.
There is a pharmacy network associated with the Caremark plan. You receive the highest level of benefits when you have your prescription filled at a network pharmacy.
When you use a network pharmacy, any out-of-pocket copayments will automatically be reimbursed through your Health Care FSA (if you have one), up to the FSA amount you have elected.
If you use an out-of-network pharmacy, you'll pay 100% of the retail price and will need to submit a claim form. You will be reimbursed for the discounted cost of the prescription - the cost the plan would have paid had you gone to a network pharmacy - less the applicable copay. In most cases, the discounted price will be less than the retail price. You can get a list of network pharmacies from the Caremark website or call 1-800-421-5501.
Maintenance medications are any prescription medications that you need to take on a regular basis for an extended period of time (i.e. three months or more). Maintenance medications should be refilled through Caremark Maintenance Choice Program which gives you the choice of receiving a 90-day supply of maintenance medications through Caremark Mail Service Pharmacy or obtaining it at your local CVS/pharmacy.
In some instances, even though you take a specific medication on a long-term, recurring basis, it may be classified by law as a "controlled substance." Federal and state laws regulate the dispensing of controlled substances and the law may limit the quantity that can be dispensed at one time. It may also prohibit dispensing through the mail. (See also, "What are controlled substances?")
Contact Caremark to determine if your medicine is considered "maintenance."
You should use a Caremark retail pharmacy for immediate and short-term drug needs. Use Caremark's Mail Order Pharmacy for maintenance or long-term medications.
In some instances, even though you take a specific medication on a regular, recurring basis, it may be classified by law as a "controlled substance." Examples of prescriptions that are classified as controlled substances are: Vicodin®, Acetaminophen with codeine and Marinol®, Valium®, Ambien®, Xanax®, Robitussin AC®, and Lomotil®.
Federal and state laws regulate the dispensing of controlled substances and the law may limit the quantity that can be dispensed at one time. It may also prohibit dispensing through the mail.
The plan will not consider controlled substances to be maintenance medications, even if you take them on a regular, ongoing basis. Therefore, you can use your retail pharmacy to obtain these prescriptions. You will not have to pay a penalty co-pay on the third and subsequent refills.
Coordination of Benefits
Coordination of benefits applies when a person is covered under more than one group medical plan. "Other group plans" include any other plan of dental or medical coverage provided by:
- Group insurance or any other arrangement of group coverage for individuals, whether or not the plan is insured; and
- "No-fault" and traditional "fault" auto insurance, including medical payments coverage provided on other than a group basis, to the extent allowed by law
To find out if benefits will be reduced, the provider must first determine which plan pays benefits first.
there are certain rules that determine which plan pays its benefits first. The plan that covers you or your spouse as the employee pays its benefits before the plan that covers you or your spouse as a dependent.
You should each submit your claims to the primary plan first. When you receive payment from the primary plan, you should then submit a claim form and a copy of the explanation of benefits to the secondary payer, for any additional reimbursement.
When the parents of a dependent child are divorced or separated:
-- If there is a court decree which states that the parents will share joint custody of a dependent child, without stating that one of the parents is responsible for the health care expenses of the child, the parent birthday rule applies.
-- If a court decree gives financial responsibility for the child's medical, dental or other health care expenses to one of the parents, the plan covering the child as that parent's dependent determines its benefits before any other plan that covers the child as a dependent.
-- If there is no such court decree, the order of benefits will be determined as follows:
- the plan of the natural parent with whom the child resides;
- the plan of the stepparent with whom the child resides
- the plan of the natural parent with whom the child does not reside, or
- the plan of the stepparent with whom the child does not reside
If an individual has coverage as an active employee or dependent of such employee, and also as a retired or laid-off employee, the plan that covers the individual as an active employee or dependent of such employee is primary.
The benefits of a plan which covers a person under the right of continuation under federal or state laws will be determined after the benefits of any other plan which does not cover the person as a right of continuation.
If the above rules do not establish an order of payment, the plan which has covered the person for the longest time will pay the benefit first.
"Allowable expenses" are the necessary and reasonable health care expenses covered (in whole or in part) under any of your plan(s) (or those of the person for whom you make a claim).
If it is determined that the other plan pays first, the benefits paid under this plan will be reduced. Aetna will calculate this reduced amount as follows: the amount normally reimbursed for covered benefits under this plan, less benefits payable from your other plan(s)
If you are covered as the employee under two separate medical plans, your medical plan that has covered you for the longest time will be the primary plan and will pay its benefits first.
You should submit your claims to the primary plan first. When you get a payment from the primary plan, you should submit your claim and a copy of the explanation of benefits to the secondary payer, for any additional payment.
Except for children of divorced or separated parents, the plan of the parent whose birthday occurs earlier in the calendar year pays first. When both parents' birthdays occur on the same day, the plan that has covered the parent the longest pays first. If the other plan doesn't have the parent birthday rule, the other plan's COB rule applies.