Costs
NYSHIP 2026 deductibles, copays and out-of-pocket limits
For 2026, the in-network out-of-pocket limit is $4,244 individual / $8,487 family under PE and $4,120 / $8,240 under C-82. Both guides list a $1,250 combined non-network deductible and a $3,750 combined annual coinsurance maximum — three separate thresholds that apply to different expenses.
Published by the NYSHIP.rehab editorial resource · Updated
What is the 2026 in-network out-of-pocket limit?
| Program | PE individual | PE family | C-82 individual | C-82 family |
|---|---|---|---|---|
| Hospital, Medical/Surgical and MHSU | $2,750 | $5,510 | $2,670 | $5,350 |
| Prescription Drug Program* | $1,494 | $2,977 | $1,450 | $2,890 |
| Total | $4,244 | $8,487 | $4,120 | $8,240 |
What is the 2026 non-network combined deductible?
Both guides list a combined annual deductible of $1,250 for the enrollee, $1,250 for the enrolled spouse/domestic partner and $1,250 for all dependent children combined (printed p. 2). It must be met before the plan considers non-network outpatient MHSU expenses, Basic Medical Program expenses and certain non-network home care expenses.
What does the $3,750 coinsurance maximum include?
The combined annual coinsurance maximum is $3,750 enrollee / $3,750 spouse or partner / $3,750 all dependent children combined (printed p. 3). Specific expenses count toward it, including:
- Coinsurance for non-network Hospital Program, Basic Medical Program and non-network MHSU coverage
- Copayments to Medical/Surgical participating providers and to MHSU network practitioners
The guide notes that copayments to network facilities do not count toward this maximum. It is also not a cap on the deductible, on charges above the allowed amount, or on care that is not covered.
What MHSU copays apply in 2026?
| Service | Network cost |
|---|---|
| Approved inpatient stay | Paid in full |
| Office visits and outpatient services, including outpatient substance use rehabilitation programs | May have a $25 copayment per visit |
| Emergency department visit | $100 copayment, waived if admitted directly as an inpatient |
| Medically necessary ambulance to an MHSU facility | No cost to you |
How do the three thresholds fit together?
| Threshold | What it applies to | What it does not do |
|---|---|---|
| In-network out-of-pocket limit | Network copays and expenses | Does not limit non-network costs |
| Combined annual deductible ($1,250) | Must be met before certain non-network benefits | Is not a maximum on spending |
| Combined coinsurance maximum ($3,750) | Listed coinsurance and certain copays | Does not cap every out-of-pocket charge |
Put the numbers to work with the rehab cost estimate guide or read how out-of-network care is paid.
Frequently asked questions
Why are the PE and C-82 limits different?
The C-82 guide explains that limits are determined by the amount of the negotiated salary increase from the prior year. Use the guide that matches your enrollment group.
Do these figures apply to NYSHIP HMOs?
No. These figures come from the Empire Plan PE and C-82 At A Glance guides. NYSHIP HMOs and other groups publish their own benefits.
Related guides
- CostsHow much does rehab cost with NYSHIP?Estimate your Empire Plan rehab cost in five steps: network copays, the non-network deductible, coinsurance and balance billing.
- CostsOut-of-network rehab with NYSHIP in 2026How the Empire Plan pays out-of-network substance abuse treatment in 2026: allowed amounts, billed-charge coinsurance, balance bills and luxury rehab.
- CoverageHow Empire Plan rehab coverage works in 2026How The Empire Plan's Mental Health and Substance Use Program covers rehab in 2026: who it applies to, network vs non-network rules, and what to confirm first.
- CoverageOutpatient, PHP and IOP coverage under NYSHIPEmpire Plan coverage for outpatient rehab, PHP, IOP and virtual IOP: the $25 network copay, non-network 80% allowed amount and questions to ask.
Sources and source dates
- The Empire Plan At A Glance — Participating Employers (PE), January 2026 (opens in a new tab) — January 2026 (AAG-PE-1/26). Printed page(s) 2, 3, 11, 12. New York State Department of Civil Service.
- The Empire Plan At A Glance — Council 82 (C-82), January 2026 (opens in a new tab) — January 2026 (AAG-C-82-1/26). Printed page(s) Cover (What's New), 2, 3, 11, 12. New York State Department of Civil Service.
Plan guides are summaries and can change. Your Empire Plan Certificate and Certificate amendments control. This page is general education, not medical, legal or benefits advice. Read our editorial standards.