Understanding the new city health plan

The Municipal Labor Committee is the union alliance that negotiates health care coverage for New York City public sector workers. On September 30, Mayor Eric Adams announced that the MLC agreed to a new health-care plan that includes an “expansion of coverage without increasing costs for employees, and while simultaneously providing savings of up to $1 billion annually compared to the current plan.”

The PSC, at the direction of the delegate assembly, abstained from voting on whether to approve the new plan due to many outstanding questions about its details. But with the MLC’s vote, the plan is going forward.

The PSC has published this set of frequently asked questions in order to guide members through this new plan.

1. What is the new health plan?

The NYC Employees PPO Plan (NYCE PPO) will replace the GHI/Anthem CBP that covers 70% of active NYC and full-time and part-time CUNY employees and pre-65 retirees and their dependent families. EmblemHealth and UnitedHealthcare will administer the new plan for the City.

• Participants will pay no premiums for 5 years.
• The HIP HMO plan and other health plans which the City offers continue to be available and are unchanged.
• For retirees on Medicare, there is no change to the available supplemental health plans, like Emblem Senior Care.
• Plan participants will have a single health plan ID card which will be mailed out with a welcome package prior to 1/1/26. There will be a single health record information portal, instead of two. The mailing will include information about how to register on the new portal. Be sure your college Benefits Officer has your current address. (Pre-65 retirees can contact the NYC Employees Benefit Program at: [email protected] for address-change forms.)
• If, as expected, the NYCE PPO is approved by the NYC contracting process, it will be implemented 1/1/26. The GHI/Anthem CBP will no longer be offered.
• For 2026, participants in the NYCE PPO are likely to see little change in their coverage from the GHI/Anthem CBP. The City could change the plan design in future years.

2. How is the new plan structured?

• It is a PPO plan, which means participants can choose their providers.
• The City will design the health plan, not the insurers, and will guarantee payment of claims and administrative costs. The plan will be self-insured. (See below.)
• EmblemHealth will manage the provider network and assist participants in the 13 downstate NY counties: NYC, Nassau, Suffolk, Westchester, Rockland, Dutchess, Orange, Putnam, Ulster.
• UnitedHealthcare will manage providers and cover participants in the rest of NY State, New Jersey, Connecticut and other states.
• All mental and behavioral health services will be provided by UnitedHealthcare.
• UMR, a UnitedHealthcare company, will process all claims.
• There is a Summary of Benefits and Coverage (SBC) on the plan’s website: https://image.mail.umr.com/lib/fe3e15707564067e731772/m/1/d1f016a3-3cd7-4002-b2be-53282221b88b.pdf. Because the SBC is in a standardized format, you can use it to compare the NYCE PPO with other plans offered to City workers and pre-65 retirees.

3. What is the role of the unions in developing and approving the new plan?

• Representatives of the Executive Committee of the Municipal Labor Committee (MLC, the coalition of municipal employee unions which negotiates with NYC over health plan benefits) were involved in reviewing the plan design, but most union leaders, including PSC’s, have not been informed of the financial details of the contract between NYC and Emblem/United.
• The MLC had to vote to approve the plan, which they did. (PSC abstained due to incomplete information.) Any future changes in the plan design by NYC must be negotiated with the MLC.

4. How will members’ access to health care be affected by this change?

• Those currently enrolled in the GHI/Anthem CBP will be automatically enrolled in the NYCE PPO effective 1/1/26 unless they choose a different health plan during the Open Enrollment Period, which will run November 1 through November 30, 2025. (See below.)
• Participants will have access to the doctors, clinical providers and hospitals to which they now have access, at least for 2026.
• EmblemHealth has committed to a larger provider network than they offer under the GHI/Anthem CBP, the EmblemHealth Bridge Program. EmblemHealth will manage the in-network providers for downstate residents living in the 13 downstate NY counties.
• UnitedHealthcare’s Choice Plus network has more than 1.6M in-network providers nationally available to people living outside the 13 downstate NY counties – a significant increase. Note that participants living in the 13 downstate NY counties will not have access to United’s network.
• Participants will continue to be able to receive care from out-of-network providers. (See below for reimbursement information.)
• Provider lists are starting to be available on the plan website: https://go.tpa.com/nyceppo.

Note that providers can take themselves out of network at any time, so such lists are not always fully accurate. NYC OLR claims that a large majority of providers will be able to enroll new patients.

• The customer support phone number for the NYCE PPO is 212-501-4444, Monday – Friday, 8 am – 6 pm.
• There will also be a customer service portal on the plan website for both plans. Access should be available before the Open Enrollment Period.
• Participants can make appointments with specialists directly, no referral or primary care provider needed.
• Providers will be able to verify your plan eligibility through a UMR provider portal about which they will be notified. UMR is a UnitedHealthcare company, which will manage administration of the entire plan.
• Prior authorizations (PAs) will be eliminated for many common procedures like MRIs and CT scans. PAs will be required for expensive procedures, emerging technologies, PT, OT, speech therapy, and other high-cost services. The full list will be available in the SPD, which will be published before 1/1/2026.
• The City, Emblem, United and the MLC have agreed to establish a committee that will meet monthly to review how well the plan is working, including satisfaction with claims processing and data collection.
• Because PSC representatives were not permitted to review the financial elements of the contract between NYC and Emblem/United, including cost-reduction targets, the union cannot know whether NYC will seek to change the plan design in 2027 or subsequent years, thereby potentially limiting members’ health-care access.

Note that, as the plan sponsor, NYC can restructure the plan at any time, if they are not seeing expected savings. The MLC unions must be informed of and approve any changes NYC proposes to make.

5. Will participants’ costs increase?

• Participants will pay no premiums during the 5 years of the contract.
• For in-network health care, costs should not change much in 2026. The MLC chart from August 2025, comparing the proposed and current plans: 389a2dd9-aa06-4eb1-be85-58bbc1a7596b indicates there will be no change in co-payments or deductibles in 2026 from the GHI/Anthem CBP plan. (Changes in plan design in future years could result in increases.)
• Emblem’s Advantage Care Physicians Network clinics and Health & Hospitals (NYC’s public hospital system) facilities will charge $0 co-pays.
• Memorial Sloan Kettering (MSK) and the Hospital for Special Surgery (HSS) will remain in the network for 2026, as now, continuing to charge $0 co-pays for hospital services. Note that numerous doctors at those facilities are not in network, so they may charge out-of-network fees for non-emergency services.
• For 2026, annual deductibles remain like the GHI/Anthem CBP. For in-network health care, there is no annual deductible, except for durable medical equipment. For out-of-network care, the annual deductible (what you must pay out before any reimbursement) remains $200 per individual and $500 for a family.
• One change is the out-of-pocket maximum on what you pay for covered (in-network) services. (The maximum does not include the amount you pay out-of-network providers.) Under the GHI/Anthem CBP plan there was one maximum for GHI and one maximum for Anthem. In this plan, the two amounts have been added together, so the in-network, out-of-pocket limit, after the annual deductible, is $7,150 per individual and $14,300 per family. It will likely take longer before you hit that maximum in any year. There is no maximum on what you pay for out-of-network providers.

6. What if I do not want to be automatically enrolled in the new plan?

• The current plan, Emblem/Anthem CBP, will no longer exist.
• There will be an Open Enrollment Period during the month of November 2025, during which participants may choose to enroll in a different NYC-supported health plan.
• See the NYC OLR health plan comparison chart, which will be posted when available. A number of the plans charge premiums to employees, over and above what NYC pays. Review costs and benefits carefully.
• See available health plan descriptions to be posted when available.

7. If I am currently enrolled in a NYC health plan other than the GHI/Anthem CBP plan, can I enroll in this new plan?

• Yes, you can choose to enroll in the NYCE PPO during the November Open Enrollment Period, to take effect 1/1/26.

8. Do preventive services still have $0 co-pay like the old plan?

• Yes, the $0 co-pay for preventive services is required under the ACA. It is not up to the plan sponsor or insurer to change that.

9. How do I find out if my current providers are in-network for the new plan?

• The City and the MLC claim that current in-network providers will remain in-network for 2026, but providers can choose to leave at any time, so it is a good idea to check with your provider in advance if they are still in-network.
• Listings of both Emblem and United in-network providers are or will be available on the NYCE PPO website: https://go.tpa.com/nyceppo, or you can call the customer service phone number listed above.

10. What will the new plans, Emblem or United, reimburse me if I go to an out-of-network provider?

• As with the current GHI/Anthem CBP plan, if you go to an out-of-network provider, either you pay the full provider charge and submit a claim and the plan will reimburse you a fixed, pre-set amount regardless of what the provider charges, or the provider will submit a claim and you will pay the difference between what the plan reimburses the provider and the full charge.
• Provider reimbursement rates are now generally consistent with Medicare reimbursement rates, which for Emblem is an increase. For those in the 13 downstate NY counties, you may receive a larger reimbursement than in the past. However, provider charges have increased as well.
• There is no out-of-pocket maximum on what you can pay to out-of-network providers.

11. Will Teledoc (video health care provider access) continue to be available?

• Yes

12. What if I have hospital services scheduled for 2026? Will I be affected by the changes in hospital coverage? What should I do to be confident I am covered?

• According to the NYCE PPO website, for scheduled or continuing services after 1/1/26 with in-network providers, existing prior authorizations (PAs) will be transferred and honored. Call the customer service number 212-501-4444 to speak to a nurse about transition.
• For new medical services starting after 1/1/26 (even if you already have an appointment), doctors can submit PA requests after 12/1/25. Call customer service if you are not sure what is applicable.
• If you are using an out-of-network doctor and/or facility and are under active treatment for a continuing condition, you may qualify for “transition of care” coverage for up to 90 days after 1/1/26. Again, consult a nurse about your transition at the customer service number above.

13. What are the approved networks for New Jersey and Connecticut? Are they linked to UnitedHealthcare or to Emblem?

• QualCare in New Jersey and Connecticare Choice in Connecticut are considered in-network and part of UnitedHealthcare Choice Plus. However, these plans are also listed as part of Emblem’s Bridge Program so clarity is needed. We need to clarify how residents of NJ and CT who receive health services in NYC are covered and how residents who live in but go outside the 13 downstate NY counties for health care are covered.

14. What is being done to ensure that providers stay in the Emblem network?

• Health-care providers can choose to leave the network any time, which is why network lists are never completely accurate. It is best to confirm a doctor’s or clinic’s in-network status directly.
• Emblem is updating its provider reimbursements, which in most cases will mean increases to Medicare reimbursement rates.

15. What about hospitals?

• The plan administrators claim that participants will have access to all major national hospital networks, but greater clarity is needed.
• In Emblem’s downstate 13 NY counties, access includes all the hospitals that are currently covered in the GHI CBP, including (but not limited to) – at least for 2026 – NYU Langone, Northwell Health, New York-Presbyterian, Mount Sinai and Montefiore, as well as MSK & HSS.
• There will be no “tiering” of hospitals in 2026 in the NYCE PPO plan.

16. The mental/behavioral health providers, like Beacon, in the Emblem/Anthem CBP plan will not be part of the new plan. How will patients in those programs be transitioned to UnitedHealthcare’s mental/behavioral health providers?

• That information is not yet available.
• On the plan website, there is a section to identify United’s in-network mental/behavioral health providers by zip code and service type (which for these services applies to everyone), so you can check to see if your current provider is listed.

17. The optional rider for an enhanced reimbursement schedule for out-of-network services will no longer be offered. Will the PSC-CUNY Welfare Fund’s extended benefit coverage still be available?

• Because the Welfare Fund’s extended benefit coverage is directly linked to the optional rider, that coverage will not be applicable after 12/31/25.

18. What, if any, changes will the new health plan mean for prescription drugs?

• No change to drugs paid for through the PSC-CUNY Welfare Fund (other than the annual formulary update), which are most of the Rx drugs PSC members use.
• For 2026, no change to chemotherapy and infusion drugs paid for through the PICA program and provided by Express Scripts, Inc (ESI).
• Certain drugs, primarily diabetes medication and birth control, are paid for through the health plan under NY State and ACA mandates. There will be a change in the pharmacy benefit manager (PBM) through which members order and receive these drugs. Starting 1/1/26, the PBM will be Prime Therapeutics, replacing ESI. Currently active prescriptions will all be transferred to Prime Therapeutics for you. According to the plan’s website, 90-day mail order will be available. Plan to refill prescriptions as early as possible to insure there are no transition problems.

19. What difference will it make that this health plan is “self-insured”?

• NYC will save a modest amount of money on taxes it pays now.
• The City will design the health coverage, subject to MLC approval, not the insurance companies. PSC is concerned that, if the City does not save the amount of money it has targeted, the plan design could change every year.
• The City, not the insurers, guarantees payment of claims and administrative costs.
• The NYCE PPO must follow NY State and federal mandates regarding benefit coverage, including:
  • Mental health benefit parity (with physical health benefits)
  • NYS preventive care standards
  • Coverage for autism spectrum diagnosis and treatment
  • Medically necessary infertility treatments
  • NYS Rx drug formulary and access rules
  • Gender-affirming surgery for participants aged 18+.

The plan must also follow consumer protection laws, including grievance and appeal processes.

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Published: December 11, 2025