FAQs about the New NYC 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, except participants living outside NY State—primarily pre-Medicare retirees—will have access to the CIGNA provider network effective 1/1/26. See the website for details.
• 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, in late December 2025. 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.

• 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.
• United Healthcare 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 United Healthcare.
• UMR, a United Healthcare company, will process all claims.
• There is a Summary of Benefits and Coverage (SBC) posted here on the plan’s website. 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.
• Those traveling to or living in Puerto Rico will have in-network coverage through the MAPFRE network.

• 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.

• 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. Note that, since the new plan has not yet gone into effect, many providers have not heard about NYCE PPO.
  • EmblemHealth has committed to a larger provider network than they offer under the GHI/Anthem CBP, the EmblemHealth Bridge EmblemHealth will manage the in-network providers for downstate residents living in the 13 downstate NY counties. When you contact your provider in the 13 downstate NY counties about the new plan, ask if they participate in the EmblemHealth Bridge Program if they have not heard about NYCE PPO. Also, refer them to the provider portal on the NYCE PPO website.
  • 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 many providers may not be aware of the new plan until it takes effect in January. Also, 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. Once it is set up, participants will be able to create a digital account on the website: NYCEPPO.com/start and create a HealthSafe ID to facilitate access.
• 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 United Healthcare company which will manage administration of the entire plan.
• Prior authorizations (PAs) will be eliminated for many common procedures like some MRIs and CT scans. (MRIs and CT scans scheduled at “high cost” locations may require PAs, which your provider should handle.) 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. For questions, call 212-501-4444.
• 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.

• 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 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.)
• “Preferred” in network providers include:
  • 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.
• Other In-network providers are referred to as “Participating.”
• 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 out for out-of-network providers.

• 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.
  • The Employee Benefit Program will be updating their health plan rate comparison chart shortly. When they do, it will be posted here. Some plans charge premiums over and above what NYC pays. Review costs and benefits carefully.
  • See health plan descriptions for the other available plans: https://www.nyc.gov/site/olr/health/summaryofplans/health-sbc.page
  • The SBC for the new NYCE PPO plan is here: https://image.mail.umr.com/lib/fe3e15707564067e731772/m/1/d1f016a3-3cd7-4002-b2be-53282221b88b.pdf

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

• 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.

• 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. Note that not all providers will be familiar with the name of the new plan in the beginning.
• Listings of both Emblem and United in-network providers are or will be available on the NYCE PPO website at  www.nyceppo.com or you can call the customer service phone number: 212-501-4444, Monday – Friday, 8 am – 6 pm.

• 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 the 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 who submit a claim for an out-of-network service, you will receive 100% of the Medicare rate for that service, which may be more than in the past. However, provider charges have increased as well.
• There is no out-of-pocket maximum on what you can pay out to out-of-network providers.

• Yes

• 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. Conditions that may qualify for “transition of care” include: pregnancy, cancer treatment, organ transplant patient and being an inpatient as of 1/1/26. Again, consult a nurse about your transition at the customer service number above. You must request approval of transition of care within 60 days before 1/1/26 or 60 days after 1/1/26. You can download a form to request transition of care by going to the website (nyceppo.com) and selecting Form center.

• Residents of Connecticut and New Jersey will be covered by the United provider network. Because the health coverage and claims processing is now integrated, whether you get your care in New York City or out-of-state, the coverage and claims process will be the same.
• For residents of the 13 downstate NY counties who receive care outside of that area, the coverage and claims process will also be the same.

• 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.

• 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.

• Patients will be automatically transferred to the new plan. Reach out to customer service for assistance, if needed.
• Reimbursement will be at 100% of the Medicare rate.
• 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 regardless of where you live), so you can check to see if your current provider is listed.
• There are virtual behavioral health services 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.

• 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 ensure there are no transition problems.

• 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.