In 2020, COBRA costs $2,387.58 for NYSHIP family coverage and $1,031.85 for NYSHIP individual coverage. NYSHIP is not charging the administrative fee in 2020. See rate sheet for HMO premiums. Dental coverage is through Healthplex and the COBRA cost is $47.69. Optical coverage is through Davis Vision and the COBRA cost is $9.38.

notify their enrollees of 2020 rates. The rate flyer announces the option-change deadline and dates that changes in health insurance payroll deductions will occur. You will have 30 days from the date your agency receives rate information to submit any changes. Your HBA can help if you have questions. COBRA and Young Adult Option enrollees 2020 Monthly COBRA Rates PLAN COST Empire Individual (001) Family (001) $810.21 $2,031.92 HMO-Blue Individual (072) Family (072) $819.50 $1/993.76 MVP Individual (330) Family (330) $876.01 $2,031.28 DENTAL PEF & M/C Individual Family $24.14 $67.96 VISION PEF & M/C Individual Family $4.06 $9.23 11/2019 In 2020, COBRA costs $2,387.58 for NYSHIP family coverage and $1,031.85 for NYSHIP individual coverage. NYSHIP is not charging the administrative fee in 2020. See rate sheet for HMO premiums. Dental coverage is through Healthplex and the COBRA cost is $47.69. Optical coverage is through Davis Vision and the COBRA cost is $9.38. Leave Without Pay, COBRA and Young Adult Option enrollees will be notified of their rates separately. These rates reflect the monthly cost for NYSHIP retiree coverage. Rates for retirees do not reflect sick leave credits. (See page 3 for information on how sick leave credit impacts your premium.) Retirement prior to 1/1/83 NYSHIP MONTHLY 2019 RATES. To enroll in an HMO or to remain enrolled in your current HMO, you must live or work† in the HMO’s NYSHIP service area. If you reside outside New York State, your only NYSHIP option is The Empire Plan. If you move into an area served by a NYSHIP HMO, you will be eligible to change your option to an HMO at that time.

A. Enroll in NYSHIP Coverage: Choose options 1 or 2 and complete box 3. 1. I understand that I will receive an application for COBRA continuation of Dental 

2020 Monthly COBRA Rates PLAN COST Empire Individual (001) Family (001) $810.21 $2,031.92 HMO-Blue Individual (072) Family (072) $819.50 $1/993.76 MVP Individual (330) Family (330) $876.01 $2,031.28 DENTAL PEF & M/C Individual Family $24.14 $67.96 VISION PEF & M/C Individual Family $4.06 $9.23 11/2019 In 2020, COBRA costs $2,387.58 for NYSHIP family coverage and $1,031.85 for NYSHIP individual coverage. NYSHIP is not charging the administrative fee in 2020. See rate sheet for HMO premiums. Dental coverage is through Healthplex and the COBRA cost is $47.69. Optical coverage is through Davis Vision and the COBRA cost is $9.38. Leave Without Pay, COBRA and Young Adult Option enrollees will be notified of their rates separately. These rates reflect the monthly cost for NYSHIP retiree coverage. Rates for retirees do not reflect sick leave credits. (See page 3 for information on how sick leave credit impacts your premium.) Retirement prior to 1/1/83 NYSHIP MONTHLY 2019 RATES. To enroll in an HMO or to remain enrolled in your current HMO, you must live or work† in the HMO’s NYSHIP service area. If you reside outside New York State, your only NYSHIP option is The Empire Plan. If you move into an area served by a NYSHIP HMO, you will be eligible to change your option to an HMO at that time. The Empire Plan Mental Health and Substance Abuse Program, the Home Care Advocacy Program (HCAP) and the Managed Physical Medicine Program guarantee access to network benefits nationwide if you call to make the necessary arrangements before you receive services. The toll-free number is 1-877-7-NYSHIP or 1-877-769-7447.

You are responsible for paying the full premium for your plan and coverage. The premium levels indicated on the back of this page reflect 102% of the current rate (because these rates are subject to change, you should check with the plan to determine the premium at the time of your COBRA enrollment).

Contract College Health Plans. Please Note: Improvements to the EmblemHealth Dental Plan effective June 1, 2019. NYSHIP COBRA Request (pdf) The rate of pay must be greater than zero and the appointment does not need to be indefinite. A person appointed to a courtesy position without pay may be eligible for endowed health and dental if Our Employer Projections & Rates (EPR) application allows you to view your 2021 projection (the contribution amount that may be due to NYSLRS by February 1, 2021), review the rates for your specific retirement plans, and access other important information. You must meet three eligibility requirements to continue NYSHIP coverage for yourself and Your agency reports your rate of pay and unused sick leave balance to the Employee Benefits Division (EBD) of the Department of Civil Service, and EBD calculates the monthly actuarial coverage is available through COBRA or through the group dental

The YAO provides coverage to children of NYSHIP enrollees up to age 30. The 2019 monthly COBRA rates for individual coverage are: $23.41 for dental and 

2020 Monthly COBRA Rates PLAN COST Empire Individual (001) Family (001) $810.21 $2,031.92 HMO-Blue Individual (072) Family (072) $819.50 $1/993.76 MVP Individual (330) Family (330) $876.01 $2,031.28 DENTAL PEF & M/C Individual Family $24.14 $67.96 VISION PEF & M/C Individual Family $4.06 $9.23 11/2019 In 2020, COBRA costs $2,387.58 for NYSHIP family coverage and $1,031.85 for NYSHIP individual coverage. NYSHIP is not charging the administrative fee in 2020. See rate sheet for HMO premiums. Dental coverage is through Healthplex and the COBRA cost is $47.69. Optical coverage is through Davis Vision and the COBRA cost is $9.38. Leave Without Pay, COBRA and Young Adult Option enrollees will be notified of their rates separately. These rates reflect the monthly cost for NYSHIP retiree coverage. Rates for retirees do not reflect sick leave credits. (See page 3 for information on how sick leave credit impacts your premium.) Retirement prior to 1/1/83 NYSHIP MONTHLY 2019 RATES. To enroll in an HMO or to remain enrolled in your current HMO, you must live or work† in the HMO’s NYSHIP service area. If you reside outside New York State, your only NYSHIP option is The Empire Plan. If you move into an area served by a NYSHIP HMO, you will be eligible to change your option to an HMO at that time. The Empire Plan Mental Health and Substance Abuse Program, the Home Care Advocacy Program (HCAP) and the Managed Physical Medicine Program guarantee access to network benefits nationwide if you call to make the necessary arrangements before you receive services. The toll-free number is 1-877-7-NYSHIP or 1-877-769-7447. Welcome to NYSHIP Online, where you will find information on the New York State Health Insurance Program for State and Local Government for active employees. If you are a retiree, please visit NYSHIP Online for Retirees. In order to provide you with targeted information about your benefits, you will need to select your group (negotiating unit You are responsible for paying the full premium for your plan and coverage. The premium levels indicated on the back of this page reflect 102% of the current rate (because these rates are subject to change, you should check with the plan to determine the premium at the time of your COBRA enrollment).

2020 COBRA Dental and Vision Monthly Rates Individual Family Dental $24.14 $67.96 Vision $4.06 $9.23 These rates do not apply to dental and vision coverage under Union Benefit

The YAO provides coverage to children of NYSHIP enrollees up to age 30. The 2019 monthly COBRA rates for individual coverage are: $23.41 for dental and  NYSHIP is the statewide insurance program for NYS government employees and employees may continue dental/vision coverage under COBRA through their  health insurance for all persons eligible for COBRA or state continuation (“mini- COBRA”) coverage up to a total of 36 months of coverage. For more information  pension, you may continue your NYSHIP coverage under retiree provisions if you COBRA coverage expires, you should receive a Direct. Pay Dental Plan  Sponsors of group health plans will be required to make dependent coverage available to children up Loss of Employer Coverage and COBRA considerations. A. Enroll in NYSHIP Coverage: Choose options 1 or 2 and complete box 3. 1. I understand that I will receive an application for COBRA continuation of Dental  Is an employer required to offer COBRA to terminating employees or their dependents?

2020 COBRA Dental and Vision Monthly Rates Individual Family Dental $24.14 $67.96 Vision $4.06 $9.23 These rates do not apply to dental and vision coverage under Union Benefit An employer can impose new rates with the start of the next determination period. The determination period applies only to federal COBRA regulations and not to state continuation. There are limited times when the employer is permitted to change the premiums for COBRA QBs during the determination period. Exceptions to the 12 month Rule NYSHIP options. • NYSHIP Rates & Information for Retirees of New York State provides information about service areas and premium rates of all NYSHIP options. • The Medicare & NYSHIP booklet explains how NYSHIP and Medicare work together to provide health benefits. There is also a companion video for this booklet on our website. • Welcome You must call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and choose the Medical Program for preauthorization and a list of Qualified Procedures before receiving services. Paid-in-full benefit is available subject to the lifetime maximum of $50,000 per covered person for Qualified Contract College Health Plans. Please Note: Improvements to the EmblemHealth Dental Plan effective June 1, 2019. NYSHIP COBRA Request (pdf) The rate of pay must be greater than zero and the appointment does not need to be indefinite. A person appointed to a courtesy position without pay may be eligible for endowed health and dental if