Empire Plan members · Treated in Encino, Los Angeles

Does NYSHIP Cover Drug Rehab?

Yes. The Empire Plan covers medically necessary substance use treatment, through its Mental Health and Substance Use Program administered by Carelon Behavioral Health. The Certificate states that medically necessary services out of network are also covered. New Spirit Recovery treats NYSHIP members at its residential facility in Encino, Los Angeles, using that benefit.

Call (855) 932-2725 How authorization works

Out of network on every plan · benefits read from your policy on the first call · adults 18+

Other plansCarelonBlue Cross Blue ShieldUMR

NYSHIP

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Who actually pays

What is NYSHIP, and who administers its addiction benefits?

NYSHIP is the New York State Health Insurance Program. The Empire Plan is one benefit option inside it, and the Empire Plan splits administration across four separate companies. Substance use treatment sits with Carelon Behavioral Health, not with the medical or hospital administrator, so that is the company whose determination decides your coverage.

The Empire Plan’s four administrators, and which one governs addiction treatment.
Program	Administered by	Governs your rehab claim
Mental Health and Substance UseThis one	Carelon Behavioral Health, named Beacon Health Options until March 2023	Yes. Precertification, medical necessity and continued-stay review.
Medical and Surgical	UnitedHealthcare	No. A separate program with separate benefits.
Hospital	Anthem Blue Cross	Only where a hospital facility charge applies.
Prescription Drug	CVS Caremark, or SilverScript where Medicare is primary	Medication only, not the treatment stay.

Three names get confused, and it changes who you call.

NYSHIP is the program you enrol in. The Empire Plan is the option inside NYSHIP that carries these benefits. Empire BlueCross BlueShield is a different company again, and it became Anthem Blue Cross Blue Shield in January 2024. A member who calls Anthem about a residential admission has called the hospital administrator, not the one that decides substance use coverage.

New Spirit Recovery opens every Empire Plan request with Carelon rather than with the medical or hospital administrator. Members who call the wrong one first commonly lose several days before the request even reaches a reviewer.

Sources: New York State Department of Civil Service, cs.ny.gov, Empire Plan Certificate. Administrator naming per Anthem provider notices, January 2024.

Levels of care

What levels of addiction treatment does the Empire Plan cover?

The Empire Plan covers detoxification and inpatient rehabilitation when Carelon determines them medically necessary, and outpatient care at a $25 copay per appointment. New Spirit Recovery delivers detox and residential treatment on site in Los Angeles and refers the outpatient levels to providers near the member's home.

How the Empire Plan treats each level, and how New Spirit Recovery delivers it.
Level of care	How the Empire Plan treats it	At New Spirit Recovery
DetoxificationOn site	Covered when medically necessary. Precertification through Carelon.	Delivered on site under 24-hour nursing. Typically 7 to 10 days, extending to 21 where the clinical picture requires it.
Inpatient rehabilitationOn site	Covered when medically necessary. No fixed day limit appears in the Certificate.	Delivered on site in Los Angeles, typically as part of a 35-day programme.
Outpatient treatment	$25 copay per appointment under the Mental Health and Substance Use Program.	Referred to a provider near the member’s home.
Partial hospitalization and intensive outpatient	Separate authorization from an inpatient stay.	Referred to an external provider as part of discharge planning.

Plan figures: New York State Office of Employee Relations, oer.ny.gov, and the Empire Plan Certificate via cs.ny.gov. Facility figures: New Spirit Recovery programme records. Plan benefits and facility practice are stated separately and never combined.

The part that decides everything

How does the Empire Plan authorize addiction treatment?

Coverage turns on a medical necessity determination, not on a day count. The Certificate states that treatment found not medically necessary receives no Empire Plan benefit at all and the member carries the full cost. Calling the Clinical Referral Line before admission is what secures network-level benefits.

Step 1Before admission

Call the Clinical Referral Line first

The Empire Plan publishes a Clinical Referral Line on 1-877-7-NYSHIP, which is 1-877-769-7447. Press 3 for the Mental Health and Substance Use Program, then 3 for enrollee, then 3 again for the Clinical Referral Line.

The Certificate requires that call before treatment begins: to receive the highest level of benefits you must contact the Program first. Most pages about NYSHIP rehab do not mention it at all.

Step 2The determination

Carelon reviews medical necessity

Carelon Behavioral Health applies medical necessity criteria to the request. The Certificate states that services determined not medically necessary receive no Empire Plan benefit at all. The Certificate is blunt about who pays: you will pay the full cost regardless of the provider when services are not certified as medically necessary. The clinical record, not the diagnosis, decides it.

New Spirit Recovery’s clinical team writes and submits that record, so the determination rests on documentation the facility controls rather than on what a member manages to describe over the phone.

Step 3Admission

Authorization is granted in increments

An approved admission is authorized for a period, not for a programme. There is no fixed day count in the Certificate to approve or exhaust. Each continued-stay review either extends the authorization or steps the member down to a less intensive level.

New Spirit Recovery files each of those reviews and tells the member what came back, rather than leaving them to discover a change at discharge.

Step 4Out of network

The benefit crosses the state line

The Certificate states that medically necessary services out of network are also covered. A member in Albany or Long Island can therefore use the Empire Plan toward a facility in California, subject to the same medical necessity test as an in-state admission.

Related coverage

Insurance coverage for drug rehabCoverage detail Carelon Behavioral HealthCoverage detail UMRCoverage detail Blue Cross Blue ShieldCoverage detail

If you or someone else is in immediate danger, call or text 988 for the Suicide and Crisis Lifeline, available 24 hours a day in English and Spanish. For a medical emergency, call 911.

Verify before you travel

How do I check my Empire Plan benefits for rehab?

Call the Empire Plan Clinical Referral Line on 1-877-7-NYSHIP before anything is booked, pressing 3, then 3, then 3. The Certificate states that contacting the Program first is what secures the highest level of benefits your coverage allows.

Ask Carelon four things: whether residential substance use treatment is covered out of network, what your deductible and coinsurance are, whether precertification has been opened, and what the medical necessity criteria are for the level of care being requested. Write down the date and the name of the person who answered.

One line in the Certificate matters more than any other for an out-of-network admission. If you use a non-network provider, it is your responsibility to ensure that provider obtains the required certification. The obligation sits with the member, not the facility.

New Spirit Recovery carries that out on the member’s behalf, submitting the certification and confirming it was accepted, rather than leaving a member to find out at discharge that it never went in.

New Spirit Recovery holds no network contract with Carelon or with any other insurer. Members use the out-of-network benefit the Certificate describes, and the admissions team states what that benefit pays before anyone commits.

What to ask Carelon

Is residential substance use treatment covered out of network on my plan?
Has precertification been opened, and what does it still need?
What is my out-of-network deductible, and how much have I met?
What coinsurance applies after the deductible?
Which medical necessity criteria apply at this level of care?

Members reach the Clinical Referral Line on 1-877-7-NYSHIP, pressing 3 three times. New Spirit Recovery's admissions line is (855) 932-2725. Read more about how admission works.

New York to California

Can a NYSHIP member travel to New Spirit Recovery in Los Angeles?

Yes. The Empire Plan Certificate states that medically necessary services out of network are also covered, and the benefit follows the member rather than the state line. That is the mechanism a NYSHIP member uses to reach a facility in California.

Out-of-network status is what lets New Spirit Recovery admit NYSHIP members from New York. A plan written in Albany, Long Island or Westchester reaches a residential facility in Los Angeles through the same medical necessity test that applies to an in-state admission, which a narrow local network cannot do.

New Spirit Recovery coordinates the travel directly, including flights and transportation from LAX or Burbank. Health plans pay for treatment rather than for the journey to it, so travel cost is quoted before anyone commits.

One limit applies. New Spirit Recovery does not accept Medicare, so a NYSHIP retiree whose Medicare is primary is declined at admission and reaches covered treatment through a Medicare-enrolled facility instead.

How an Empire Plan admission from New York runs

Clinical Referral Line called first, to secure network-level benefits
Benefits read from your policy on the first call to New Spirit Recovery
Clinical assessment by phone to establish the level of care
Precertification submitted to Carelon, not to a California administrator
Flights and airport transportation coordinated by New Spirit Recovery
Discharge planning that names outpatient providers in New York

Available on site: medical detox, residential treatment and dual diagnosis care at a drug rehab in Los Angeles serving adults 18 and over.

Check your Empire Plan benefits with New Spirit Recovery

Ten minutes and a member ID is all it takes. Someone answers at any hour, including this one.

(855) 932-2725 How coverage works

Questions NYSHIP members ask

NYSHIP and rehab, answered

Are NYSHIP and the Empire Plan the same thing?

No. NYSHIP is the New York State Health Insurance Program, the umbrella that state and participating employees enrol in. The Empire Plan is one option inside NYSHIP, and it is the option that carries the Mental Health and Substance Use Program.

Does the Empire Plan cover drug rehab and addiction treatment?

Yes. Empire Plan drug rehab coverage includes medically necessary withdrawal management and residential care. NYSHIP addiction treatment is administered separately from the medical benefit, by the Mental Health and Substance Use Program.

Is there a 30-day limit on NYSHIP rehab coverage?

No. The Empire Plan Certificate ties inpatient substance use coverage to medical necessity and states no fixed number of days. Pages that quote a 30-day cap are describing a limit the Certificate does not contain.

Who administers Empire Plan substance use benefits?

Carelon Behavioral Health, which was named Beacon Health Options until March 2023. The Empire Plan splits administration four ways, and Carelon handles mental health and substance use separately from the medical and hospital programs.

Does NYSHIP cover rehab outside New York?

Yes. The Empire Plan Certificate states that medically necessary services out of network are also covered, and the benefit follows the member rather than the state. That is the mechanism a NYSHIP member uses to reach a California facility.

What happens if NYSHIP decides treatment is not medically necessary?

The Certificate is explicit: if treatment is determined not medically necessary, you receive no Empire Plan benefits and you are responsible for the full cost of care. This is why the medical necessity review matters more than the coverage percentage.

Is the Empire Plan the same as Anthem Blue Cross?

No, although Anthem administers one part of it. Empire BlueCross BlueShield became Anthem Blue Cross Blue Shield in January 2024, and that company is a separate insurer from The Empire Plan, which is a NYSHIP benefit option.

Does New Spirit Recovery accept NYSHIP?

New Spirit Recovery is an out-of-network facility and holds no network contract with any insurer, including the Empire Plan's administrators. Members use their out-of-network benefit. The admissions team reads that benefit from your policy on the first call.

Can a NYSHIP retiree on Medicare come to New Spirit Recovery?

No. New Spirit Recovery does not accept Medicare, and a plan with Medicare as the primary payer is declined at admission. NYSHIP members whose Medicare is primary reach covered treatment through a Medicare-enrolled facility.

How do I find a rehab that accepts NYSHIP in Los Angeles?

Call the Empire Plan's Mental Health and Substance Use Program first, because doing so secures the highest level of benefits. NYSHIP drug rehab and NYSHIP alcohol rehab requests both route through that programme rather than the medical carrier.

Who wrote and reviewed this page

Written by Dr. Patrick Lockwood

Clinical Psychologist at New Spirit Recovery. Dr. Lockwood works with clients through detox and residential treatment.

Reviewed by Sean O'Neill, MS, LMFT

Clinical Director at New Spirit Recovery. Sean oversees the clinical documentation that supports every authorization request.

Empire Plan benefits described on this page are sourced to New York State's own published documents at cs.ny.gov and oer.ny.gov. Benefit amounts on any individual policy are verified by the New Spirit Recovery admissions team. This page explains how the plan works and does not state what any specific policy will pay.

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