The Empire Plan is the default health insurance option under the New York State Health Insurance Program (NYSHIP), a self-insured PPO covering eligible public employees, retirees, and their dependents. You pay set copays when you use network doctors and hospitals, higher costs if you go out-of-network, and premium contributions deducted from your paycheck or billed directly if you are retired or on continuation coverage.
What the Empire Plan Actually Is
Officially, it is a “self-insured Preferred Provider Organization (PPO) plan with features of a managed care system.”1NYS Department of Civil Service. The Empire Plan vs. NYSHIP HMOs The PPO structure gives you lower costs inside the participating network and partial reimbursement if you go outside it.
Self-insured means New York State, not a commercial insurer, carries the financial risk. The state and participating public employers collect contributions from enrollees and pay medical claims directly from those pooled funds.2NYS Department of Civil Service. Frequently Asked Questions – Health Insurance for Local Governments Private companies still handle the paperwork: UnitedHealthcare processes medical and surgical claims and manages the provider network,3The Empire Plan. The Empire Plan Provider Directory and other contractors run the hospital, prescription drug, and mental health programs. When you call about a claim, you are talking to a contractor, not your insurer. The state pays the bill.
One practical consequence of the self-insured structure: the New York State Department of Financial Services does not regulate the Empire Plan the way it regulates commercial insurers. The Department of Civil Service sets plan policy. That changes where some disputes go, which matters later when you want to appeal a denial.
Who Can Enroll
Eligibility begins with your employer. Nearly 900 public employers participate, including state agencies, public authorities, counties, municipalities, school districts, libraries, and fire districts.4NYS Department of Civil Service. Overview – Health Insurance for Local Governments – Participating Agencies – Empire Plan If your employer does not participate in NYSHIP, you cannot enroll in the Empire Plan.
Within a participating employer, the statewide minimum is a 20-hour work week or an annual salary of at least $2,000. Employers can set stricter rules but cannot drop below those floors, and new hires can face a waiting period of up to six months.5NYS Department of Civil Service. NYSHIP Self-Audit for Participating Agencies Collective bargaining agreements and civil service rules often add specifics, so two people at the same agency can face different terms.
You can cover a spouse, domestic partner, and children up to age 26. When you gain a dependent through marriage, birth, or adoption, you have 30 days to notify your benefits administrator. Miss that window and you wait for open enrollment or face a late-enrollment waiting period.6NYS Department of Civil Service. General Information Book for Employees, Retirees, Vestees and Dependent Survivors Enrolled in NYSHIP
Retirees and Vestees
Retirees can keep NYSHIP coverage if they have at least five years of public service and were enrolled in the plan at retirement. Participating employers may require more than five, but five is the statewide minimum.5NYS Department of Civil Service. NYSHIP Self-Audit for Participating Agencies
If you leave public employment before retirement with at least 10 years of eligible service, you may qualify as a “vestee.” Vestee status preserves your right to future NYSHIP coverage, but you pay both the employee and employer shares of the premium. Surviving spouses and dependents of enrollees with 10 or more years of service can also be offered continued coverage.5NYS Department of Civil Service. NYSHIP Self-Audit for Participating Agencies
What You Pay in 2026
Costs break into three pieces: biweekly premium contributions, copays when you receive care, and deductible plus coinsurance for anything out-of-network.
Premium Contributions
Participating employers must pay at least 50% of individual coverage and 35% of family coverage.5NYS Department of Civil Service. NYSHIP Self-Audit for Participating Agencies For state employees in 2026, biweekly contributions run roughly $66 to $88 for individual coverage and $299 to $355 for family coverage, depending on your salary grade and bargaining unit. Participating employer rates vary.
Copays and Deductibles
In-network copays in 2026:7NYS Department of Civil Service. Summary of Benefits and Coverage 2026 – Settled Groups
- Primary care or specialist visit: $25
- Freestanding urgent care center: $30
- Hospital-owned urgent care center: $50 ($40 for CSEA and UCS)
- Emergency room: $100 ($90 for CSEA and UCS), waived if admitted
- Mental health or substance use outpatient visit: $25 in-network; no copay for inpatient treatment8NYS Department of Civil Service. Choices for 2026 – Empire Plan Comparison
There is no annual deductible for in-network care. Out-of-network services carry a $1,250 annual deductible per enrollee, with a separate $1,250 for your spouse or domestic partner and another $1,250 covering all dependent children combined.9NYS Department of Civil Service. Summary of Benefits and Coverage 2026 – Unrepresented
The 2026 in-network out-of-pocket maximum is $4,244 for an individual and $8,487 for a family. Out-of-network coinsurance caps at $3,750 per enrollee, spouse, and dependent children combined, but your actual out-of-pocket can run higher because that cap does not include the deductible or any provider charges above the plan’s allowed amount.9NYS Department of Civil Service. Summary of Benefits and Coverage 2026 – Unrepresented
Prescription Drugs
The plan uses a three-tier formulary: generics at Level 1, preferred brand-name drugs at Level 2, and non-preferred brands at Level 3 with the highest copay.10NYS Department of Civil Service. 2026 Empire Plan Advanced Flexible Formulary Preferred Drug List Exact copay amounts at each tier vary by bargaining unit and group. Check your plan materials or call 1-877-7-NYSHIP (1-877-769-7447).
In-Network vs. Out-of-Network
This is where enrollees get surprised. In-network, you pay the flat copay and nothing more for most covered services, because the provider has agreed to accept the plan’s negotiated rate as full payment. No balance billing.
Out-of-network, you pay the deductible first, then 20% coinsurance on the plan’s allowed amount, and potentially the full difference between what the provider charges and what the plan considers allowed.7NYS Department of Civil Service. Summary of Benefits and Coverage 2026 – Settled Groups The plan sets its allowed amount using FAIR Health data at the 80th percentile of usual and customary rates for your geographic area.11NYS Department of Civil Service. Out-of-Network Reimbursement Disclosures If your provider charges above that benchmark, the excess is on you. You can estimate ahead of time at fairhealthconsumer.org.
Medicare and Working Spouse Rules
For active employees and their dependents, the Empire Plan pays before Medicare regardless of age. Once you retire or otherwise become Medicare-primary, Medicare pays first and the Empire Plan covers remaining eligible expenses as secondary.12NYS Department of Civil Service. Medicare and NYSHIP
NYSHIP requires you and your dependents to enroll in both Medicare Part A and Part B as soon as you become eligible for primary Medicare coverage. Skip it, and the Empire Plan will not pay for services Medicare would have covered, leaving you responsible for the hospital and medical bills yourself.12NYS Department of Civil Service. Medicare and NYSHIP Civil Service Law also requires reimbursement of the Part B premium once you or a dependent becomes Medicare-primary.5NYS Department of Civil Service. NYSHIP Self-Audit for Participating Agencies You do not need a separate Medicare Part D plan; the Empire Plan’s prescription benefit is separate from Part D.
If your spouse has access to group health insurance through their own employer and declines it, a working spouse surcharge applies. In 2026 the monthly surcharge runs $150 to $190 depending on which types of coverage your spouse turned down. It does not apply if the spouse’s employer does not offer group health coverage at all.
If a Claim Gets Denied
Start with the explanation of benefits. It states the reason, and some denials are just missing information or coding errors that get fixed with a call.
You have 180 days from receiving the denial to file an internal appeal with the third-party administrator for that benefit. Submit medical records, a letter from your provider, or any evidence that the service meets the plan’s coverage criteria. If the plan upholds the denial, your notice should spell out further options.
Some denials qualify for an external appeal through the New York State Department of Financial Services: denials based on medical necessity, denials of experimental or investigational treatment, and denials involving an out-of-network referral where the plan proposed an in-network alternative.13Department of Financial Services. New York State External Appeal Application You have four months from the final internal decision to file. DFS assigns the case to an independent review organization, and that decision is binding.14Department of Financial Services. New York State External Appeal
Keeping Coverage After You Leave
If you lose eligibility because of job loss, a cut in hours, or another qualifying event, COBRA lets you stay on the Empire Plan temporarily by paying the full premium yourself. In 2026, monthly COBRA rates (including the 2% administrative fee) are $1,218.73 for individual coverage and $3,129.19 for family coverage.15NYS Department of Civil Service. NYSHIP Rates and Information for 2026 The jump reflects the full cost your employer previously subsidized, plus the surcharge.
Employees who leave before retirement with at least five years of service should check whether they qualify for vestee status, which preserves the right to re-enroll in NYSHIP later. Vestees pay both the employee and employer shares, but the coverage itself is the same Empire Plan active employees receive.