The Empire Plan is the primary health benefits option under the New York State Health Insurance Program (NYSHIP), a self-insured preferred provider organization that covers eligible public employees, retirees, and their dependents across New York. You pay less when you use in-network doctors and hospitals, you can go out-of-network at higher cost, and the state, not a commercial insurer, pays the claims. Because the plan is funded directly by New York State and participating public employers, it sits outside the commercial insurance rules the Department of Financial Services applies to private carriers, and it is exempt from ERISA as a governmental plan.1Office of the Law Revision Counsel. 29 US Code 1003 – Coverage Private companies like UnitedHealthcare process claims and manage the network, but they act as administrators, not insurers.2The Empire Plan. The Empire Plan Provider Directory
Who Can Enroll
Eligibility begins with your employer. Nearly 900 public employers participate in NYSHIP, including state agencies, public authorities, county and local governments, school districts, libraries, and fire districts.3NYS Department of Civil Service. Overview – Health Insurance for Local Governments – Participating Agencies – Empire Plan Within those employers, the statewide minimum threshold to qualify is a 20-hour work week or an annual salary of at least $2,000. Participating employers can set stricter requirements but cannot go below those floors, and new employees may face a waiting period of up to six months before coverage starts.4NYS Department of Civil Service. NYSHIP Self-Audit for Participating Agencies Because collective bargaining agreements and civil service rules shape the specifics, two people at the same agency can face different eligibility rules.
You can add a spouse, a domestic partner, and children up to age 26. When a new dependent enters your household through marriage, birth, or adoption, you have 30 days to notify your benefits administrator. Miss that window and you wait until open enrollment or face a late-enrollment waiting period.5NYS Department of Civil Service. General Information Book for Employees, Retirees, Vestees and Dependent Survivors Enrolled in NYSHIP
Retirees, Vestees, and Survivors
Retirees can keep NYSHIP coverage with at least five years of public service if they were enrolled in the plan at retirement. That is the statewide minimum; individual employers may require more.4NYS Department of Civil Service. NYSHIP Self-Audit for Participating Agencies If you leave public employment before retirement but have at least 10 years of eligible service, you may qualify as a vestee, which preserves your right to future NYSHIP coverage. Vestees pay both the employee and employer shares of the premium, so the same plan costs substantially more than it does for active employees. Surviving spouses and dependents of enrollees with 10 or more years of service may also be offered continued coverage.
What You Pay in 2026
Your out-of-pocket cost has three parts: biweekly premium contributions from your paycheck, copays at the point of care, and deductibles or coinsurance if you go out-of-network.
Premiums
Employers must contribute at least 50% of individual coverage costs and 35% of dependent (family) coverage costs.4NYS Department of Civil Service. NYSHIP Self-Audit for Participating Agencies For state employees in 2026, biweekly employee 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 employers set their own rates.
In-Network Copays
The 2026 in-network copay schedule looks like this:6NYS Department of Civil Service. Summary of Benefits and Coverage 2026 – Settled Groups
- Primary care or specialist office visit: $25
- Freestanding urgent care center: $30
- Hospital-owned urgent care center: $50 ($40 for CSEA and UCS bargaining units)
- Emergency room: $100 ($90 for CSEA and UCS), waived if you are admitted as an inpatient
- Outpatient mental health or substance use visit: $25; inpatient treatment has no copay7NYS Department of Civil Service. Choices for 2026 – Empire Plan Comparison
There is no annual deductible for in-network care.
Deductibles and Out-of-Pocket Maximums
Out-of-network care carries a $1,250 annual deductible per enrollee. The same $1,250 applies separately to your spouse or domestic partner, and another $1,250 covers all dependent children combined.8NYS 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. For out-of-network services, the coinsurance maximum is $3,750 per enrollee, per spouse, and per dependent children combined. Your total out-of-pocket costs can exceed that figure because the coinsurance max does not include the deductible or provider charges above the plan’s allowed amount.8NYS Department of Civil Service. Summary of Benefits and Coverage 2026 – Unrepresented
Prescription Drugs
Prescription drugs run on a three-tier formulary. Generics sit at Level 1 with the lowest copay, preferred brand-name drugs at Level 2, and non-preferred brands at Level 3 with the highest copay.9NYS Department of Civil Service. 2026 Empire Plan Advanced Flexible Formulary Preferred Drug List Exact dollar amounts vary by bargaining unit and group. Your plan materials will show your tier copays, or you can call 1-877-7-NYSHIP (1-877-769-7447).
In-Network vs. Out-of-Network Costs
This is where most enrollees are caught off guard. In-network providers have agreed to accept the plan’s negotiated rates as full payment, so your cost is limited to the copay on your plan documents. Balance billing does not happen with in-network care.
Out-of-network is a different picture. You pay the annual deductible first, then 20% coinsurance on the plan’s allowed amount, and potentially the full difference between what your provider charges and what the plan considers allowed.6NYS Department of Civil Service. Summary of Benefits and Coverage 2026 – Settled Groups The plan sets that allowed amount using FAIR Health data at the 80th percentile of usual and customary rates for your geographic area.10NYS Department of Civil Service. Out-of-Network Reimbursement Disclosures If your out-of-network provider charges more than that benchmark, you owe the excess on top of the coinsurance. You can check estimated charges for your area at fairhealthconsumer.org before scheduling care.
Coordinating With Medicare and a Spouse’s Plan
When you have coverage from another plan alongside the Empire Plan, standard coordination of benefits rules decide which one pays first. If the Empire Plan is primary, it processes the claim first and the other plan picks up eligible balances. If the Empire Plan is secondary, it covers what the primary plan does not, up to its own allowed amounts.
Medicare
For active employees and their dependents, the Empire Plan pays first regardless of age. Once you retire or otherwise become Medicare-primary, the order flips: Medicare pays first, and the Empire Plan becomes secondary.11NYS Department of Civil Service. Medicare and NYSHIP
NYSHIP requires you and any Medicare-eligible dependents to enroll in Medicare Part A and Part B as soon as Medicare becomes your primary coverage. Skip that step and the Empire Plan will not cover services Medicare would have paid, leaving you on the hook for hospital and medical bills. Civil Service Law also requires reimbursement of the Medicare Part B premium once a NYSHIP enrollee or dependent becomes Medicare-primary.4NYS Department of Civil Service. NYSHIP Self-Audit for Participating Agencies Empire Plan prescription drug benefits are separate from Medicare Part D, so you do not need a stand-alone Part D plan while you have Empire Plan coverage.
Working Spouse Surcharge
If your spouse has access to group health insurance through their own employer and turns it down, a working spouse surcharge applies to your Empire Plan premium. For 2026, the monthly surcharge runs from $150 to $190 depending on the types of coverage your spouse declined. It does not apply if your spouse’s employer does not offer group health coverage.
Appealing a Denied Claim
When a claim is denied, the explanation of benefits will state the reason. Read it before appealing; some denials come from missing information or a coding error and can be resolved without a formal appeal.
You have 180 days from receiving a denial to file an internal appeal. You can submit medical records, a letter from your provider, or other evidence that the service meets the plan’s coverage criteria. The administrator responsible for that benefit category reviews the appeal and, if the denial stands, notifies you of your remaining options.
Some denials qualify for external appeal through the New York State Department of Financial Services: coverage denied as not medically necessary, denied as experimental or investigational, or denied for an out-of-network referral when the plan proposed an in-network alternative.12Department of Financial Services. New York State External Appeal Application You must file within four months of the final internal appeal decision. DFS assigns the case to an independent review organization whose decision is binding on the plan.13Department of Financial Services. New York State External Appeal
Keeping Coverage After You Leave
Losing NYSHIP eligibility from a job loss, a cut in hours, or another qualifying event does not have to mean losing health insurance right away.
COBRA lets you stay on the Empire Plan by paying the full premium yourself. For 2026, monthly COBRA premiums (which include a 2% administrative fee) are $1,218.73 for individual coverage and $3,129.19 for family coverage.14NYS Department of Civil Service. NYSHIP Rates and Information for 2026 Those numbers reflect the full cost your employer used to subsidize, plus the administrative surcharge.
If you do not elect COBRA, or your COBRA period ends, you may be able to convert to an individual health insurance policy. The conversion application has to be submitted within 60 days of the date your NYSHIP coverage ends.
Employees leaving before retirement with at least five years of service should also check whether they qualify for vestee status. Vestees pay both the employee and employer shares of the premium, but they preserve the right to re-enroll in Empire Plan coverage later.