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NYSHIP Participants

Thank you for your service! The New York State Health Insurance Program (NYSHIP) provides exceptional health insurance coverage for a wide range of NY public employees and their dependents. The program covers various employee and employer groups.
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NYSHIP Covered Services 2025

Medical Massage

Medical Massage

20 annual visits covered
(prescription required)
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Medical Acupuncture

Medical Acupuncture

20 annual visits covered
(NO prescription required)
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How It Works

Initial Consult

Initial Consult

Review of NYSHIP benefits coverage
NYSHIP Consult

Get Approval

Get Approval

Get Doctor or Physician Assistant Approval For Treatment

Receive Treatment

Receive Treatment

Relax, heal and experience the benefits of therapeutic functional wellness.

NYSHIP Covered
Employees And Entities

New York State Employees

  • Executive Branch Employees: Individuals working in departments and agencies under the executive branch of the state government.
  • Legislative Branch Employees: Staff members employed by the New York State Legislature.
  • Judicial Branch Employees: Personnel working within the state's judicial system.
  • State University of New York (SUNY) Employees: Faculty and staff associated with SUNY institutions.
  • City University of New York (CUNY) Employees: Faculty and staff associated with CUNY institutions.
  • Management/Confidential (M/C) Employees: Non-unionized state employees in managerial or confidential positions.

Participating Employers (PEs)

These New York State governmental agencies are maintained and financed from special administrative funds and covered under NYSHIP benefits:

  • Metropolitan Transportation Authority (MTA): Employees of the MTA and its subsidiaries.
  • New York State Thruway Authority: Personnel working for the Thruway Authority.
  • Dormitory Authority of the State of New York (DASNY): Employees involved in financing and constructing facilities for higher education and other institutions.
  • New York State Energy Research and Development Authority (NYSERDA): Staff members working on energy research and policy development.
  • Environmental Facilities Corporation (EFC): Employees managing environmental projects and funding.

Participating Agencies (PAs)

These include local government entities and public organizations participate in NYSHIP:

  • County Governments: Employees of various county administrations within New York State.
  • City Governments: Personnel working for city administrations across the state.
  • Town and Village Governments: Staff members of town and village municipalities.
  • School Districts: Employees, including teachers and administrative staff, of public school districts.
  • Public Libraries: Personnel working in publicly funded libraries.
  • Fire Districts: Employees associated with fire protection and emergency services.
  • Public Utilities: Staff of publicly owned utility companies.
  • Parks and Recreation Departments: Employees managing public parks and recreational facilities.

Other Eligible Groups

  • Retirees: Former employees who continue to be covered by NYSHIP post-retirement.
  • Dependents: Eligible family members of NYSHIP participants, such as spouses and children.
  • Survivors: Dependents of deceased employees who maintained NYSHIP benefits or retirees who may be eligible for continued coverage.

Important Eligibility Considerations

  • Participation can vary based on specific agreements and the nature of employment.
  • For detailed information regarding eligibility, benefits, and enrollment procedures, NYSHIP participants should consult their respective Human Resources departments.

Resources

You can visit the official NYSHIP website or call us and we’ll provide you with the details
NYSHIP Consult
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Got a question?

FAQs

General

NYSHIP covers certain wellness services—like massage or acupuncture—when medically necessary and approved. We’ll guide you through eligibility, paperwork, and next steps so you can access care without the confusion.

The number of sessions depends on your condition and goals. Many people notice improvements after a few treatments, while chronic issues may require ongoing sessions.

Your first session includes a detailed consultation, where we assess your health history and create a personalized care plan. Treatment typically begins during this visit.

Report address/employment status changes promptly; your option to change plans is during the option transfer period or after qualifying events; replacement ID cards are available through the administrator.

  • NYSHIP ID card and photo ID
  • Referral or prior authorization (HMO only)
  • Provider’s NPI, diagnosis code, and itemized bill (for OON claims)
  • Medication list, allergy list, and any relevant test results
  • Acupuncture: Unlimited in-network; capped at 20 visits/year OON.
  • Medical Massage: 20 visits/year total (network + OON combined; MPMP visits excluded).
  • Trigger Point Injections: No numeric cap; covered when medically necessary.
  • Out-of-Network Care: Deductible, coinsurance, reimbursement at 275% of Medicare, plus possible balance billing.

NYSHIP Acupuncture

Yes. Acupuncture is covered when medically necessary, with up to 20 visits covered annually (no prescription required).

Absolutely! Acupuncture works well alongside other therapies such as massage, chiropractic care, or physical therapy for a comprehensive approach to wellness.

Coverage is limited to 20 visits per calendar year total across all OON providers. These visits are subject to your OON deductible and coinsurance. Reimbursement is based on 275% of Medicare (effective 1/1/2024), and you may also be balance-billed above the plan’s allowed amount.

NYSHIP Medical Massage

Yes. Medical massage is covered under the Basic Medical Program.

Coverage is capped at 20 visits per member per calendar year, across both in-network and OON providers combined. Physical Therapy (PT), Occupational Therapy (OT), and Chiropractic visits under the Managed Physical Medicine Program (MPMP) do not count toward this 20-visit cap.

NYSHIP Trigger Point Injections

Yes. TPIs are covered under the Medical/Surgical Program.

There is no numeric cap. Coverage depends on medical necessity and utilization review.

  • CPT 20552 covers injections into 1–2 muscles.
  • CPT 20553 covers injections into 3+ muscles.
  • All injections in the same muscle group are counted as one service per session.
  • Drug costs are billed separately, typically under HCPCS J-codes.

Yes. A physician office typically results in the lowest out-of-pocket cost. Hospital or Ambulatory Surgical Center (ASC) services may include facility fees, and OON costs can be significantly higher.

Out-Of-Network Claims

Yes—Empire Plan members commonly use out-of-network benefits. Reimbursement is based on the plan’s allowed amounts after your deductible/coinsurance

Submit an Empire Plan claim form with the following:

  • Itemized bill
  • Diagnosis code
  • Provider’s NPI
  • Assignment of Benefits (AOB), if you want direct provider payment

Claims must generally be filed within 120 days after the end of the calendar year in which the service occurred. Extensions may be available.

Yes, we will work with NYSHIP to submit claims on your behalf

Yes. Since Jan 1, 2024, you may sign Assignment of Benefits (AOB) so the plan can pay a non-participating provider directly.

We have you covered and will help with this or you can start with the plan’s internal appeal. If upheld, you usually have 4 months to request an external appeal with NY DFS (medical necessity denials, etc.). Empire Plan members have Article 49 external review rights. We will work with all our clients so that they receive benefits they are entitled to.

Review your group’s Summary of Benefits & Coverage (SBC) and the latest Empire Plan Special Reports/Certificate Amendments posted each year.

  • In-Network: Deductibles, copays, and coinsurance apply, capped by the in-network OOP maximum.
  • Out-of-Network: A separate OON coinsurance cap applies. You may also be balance-billed above the plan’s allowed amount.

NYSHIP publishes in-network OOP maximums and separate OON coinsurance caps   each year; see your 2025 SBC for specifics.

They apply in emergencies, or when you are treated by an OON provider at an in-network hospital or ASC without proper notice. They do not apply if you voluntarily choose an OON provider in their private office.

NYSHIP Empire Plan vs. HMO

They apply in emergencies, or when you are treated by an OON provider at an in-network hospital or ASC without proper notice. They do not apply if you voluntarily choose an OON provider in their private office.

FeatureEmpire PlanHMO
Network AccessNationwideRegion Only
Specialist ReferralsNot RequiredPCP Referral Required
OON CoverageYes (deductible, coinsurance, possible balance billing)No, except emergencies

Check your ID card and log into NYSHIP Online for your group’s “Summary of Benefits & Coverage (SBC)” and current booklets.

Amounts vary by bargaining unit and year; your SBC shows the copays (e.g., many office/telehealth visits are a flat copay under Empire Plan) and your annual in-network OOP maximum.

  • Empire Plan (PPO): No referral needed to see in-network specialists.
  • HMOs: Usually require a PCP and referrals for specialty care (varies by HMO).

Empire Plan’s Benefits Management Program requires pre-approval for advanced imaging (MRI/CT/PET/MRA/nuclear), selected procedures, and certain home care/DME via HCAP. HMOs also require pre-approval for specific services.

OON care is subject to deductible/coinsurance and you may be billed above what the plan pays (balance billing). Surprise-bill protections apply in specific scenarios at in-network facilities or emergencies.

ACA-mandated preventive services (annual physicals, vaccines, certain screenings) are typically $0 in-network; see your SBC for details.

In-network and out of network medical massages are covered (usual copays apply); review your SBC and carrier rules for any pre-admission review.

  • Empire Plan: Managed Physical Medicine Program (MPMP) provides unlimited medically necessary in-network PT/OT/chiro; OON has separate cost-share rules.
  • HMOs: Often have annual visit caps (varies by HMO).

Rules for who pays first and how to enroll when becoming Medicare-primary are outlined in the General Information Book; HMOs enroll Medicare-primary members into the plan’s Medicare Advantage option.

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