Section XXVIII SelectCare Schedule of Benefits Gold COST-SHARING for Individual Family $600 $1,200 None None Out-of-Pocket Limit Individual Family OFFICE VISITS Primary Care Office Visits (or Home Visits) $4,000 $8,000 for services are not Covered except as for emergency care. Visits (or Home Visits) Referral
PREVENTIVE CARE Well Child Visits and Immunizations* for Adult Annual Physical Examinations* Adult Immunizations* Routine Gynecological /Well Woman Exams* Mammograms, Screening and Diagnostic Imaging for the Detection of Breast Cancer Sterilization Procedures for Women* Vasectomy See Surgical Bone Density Testing* Screening for Prostate Cancer PCP Office
PREVENTIVE CARE for All other preventive services by USPSTF and HRSA *When preventive services are not provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA EMERGENCY CARE Pre-Hospital Emergency Medical (Ambulance ) Non-Emergency Ambulance Emergency Department Copayment waived if Hospital admission Urgent Care Center Use for appropriate service (Primary Care Office Visit; Visit; Diagnostic Radiology ; Laboratory Procedures and Diagnostic Testing) for $150 Copayment after $150 Copayment after $150 Copayment after $60 Copayment after $150 Copayment after $150 Copayment after
PROFESSIONAL SERVICES and OUTPATIENT CARE Advanced Imaging Freestanding Radiology Facility or Office Setting for Performed as Outpatient Hospital Referral Allergy Testing and Treatment PCP Office Referral Ambulatory Surgical Center Facility Fee Anesthesia (all settings) Autologous Blood Banking $100 Copayment after not subject to 20% Coinsurance after
PROFESSIONAL SERVICES and OUTPATIENT CARE Cardiac and Pulmonary Rehabilitation for Performed as Outpatient Hospital Performed as Inpatient Hospital Included as part of inpatient Hospital service Included as part of inpatient Hospital service Chemotherapy PCP Office Performed as Outpatient Hospital Referral Chiropractic Clinical Trials Use for appropriate service Use for appropriate service
PROFESSIONAL SERVICES and OUTPATIENT CARE Diagnostic Testing PCP Office for Referral Performed as Outpatient Hospital Referral Dialysis PCP Office Freestanding Center or Setting Referral Performed as Outpatient Hospital Referral Habilitation (Physical Therapy, Occupational Therapy or Speech Therapy) Home Health Care $30 Copayment after Dialysis performed by Non- Participating Providers is limited to ten (10) visits per calendar year Sixty (60) visits per condition, per Plan Year combined therapies Forty (40) visits per Plan Year
PROFESSIONAL SERVICES and OUTPATIENT CARE Infertility for Use for appropriate service (Office Visit; Diagnostic Radiology ; Surgery; Laboratory and Diagnostic Procedures) Infusion Therapy PCP Office Referral Performed as Outpatient Hospital Referral Home Infusion Therapy Home infusion counts toward home health care visit limits Inpatient Medical Visits $0 Copayment
PROFESSIONAL SERVICES and OUTPATIENT CARE Laboratory Procedures PCP Office for Freestanding Laboratory Facility or Performed as Outpatient Hospital Medications Administered in Office PCP Office Included as part of the PCP office visit Cost- Sharing Included as part of the Specialist office visit
PROFESSIONAL SERVICES and OUTPATIENT CARE Maternity and Newborn Care Prenatal Care Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA for Prenatal Care that is not provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA Use for appropriate service (Primary Care Office Visit; Visit; Diagnostic Radiology ; Laboratory Procedures and Diagnostic Testing) Inpatient Hospital and Birthing Center Physician and Midwife for Delivery $1,000 Copayment after $100 Copayment after One (1) home care visit is Covered at no if mother is discharged from Hospital early Breast Pump Covered for duration of breast feeding Postnatal Care for inpatient services; breast pump
PROFESSIONAL SERVICES and OUTPATIENT CARE Outpatient Hospital Surgery Facility Charge Preadmission Testing Diagnostic Radiology PCP Office for $100 Copayment after $0 Copayment not subject to Freestanding Radiology Facility or Performed as Outpatient Hospital Therapeutic Radiology Freestanding Radiology Facility or Performed as Outpatient Hospital Referral
PROFESSIONAL SERVICES and OUTPATIENT CARE Rehabilitation (Physical Therapy, Occupational Therapy or Speech Therapy) Second Opinions on the Diagnosis of Cancer, Surgery and Other for $30 Copayment after Sixty (60) visits per condition, per Plan Year combined therapies. Speech and physical therapy are only Covered following a Hospital stay or surgery. Referral Second opinions on diagnosis of cancer are Covered at participating for non-participating Specialist when a Referral is obtained.
PROFESSIONAL SERVICES and OUTPATIENT CARE Surgical (including Oral Surgery; Reconstructive Breast Surgery; Other Reconstructive and Corrective Surgery; Transplants; and Interruption of Pregnancy) for Inpatient Hospital Surgery Outpatient Hospital Surgery $100 Copayment after $100 Copayment after All transplants must be performed at designated Facilities Surgery Performed at an Ambulatory Surgical Center $100 Copayment after Office Surgery PCP Office
PROFESSIONAL SERVICES and OUTPATIENT CARE Telemedicine Program Provided by a Telemedicine Physician for $0 Copayment not subject to Provided by a Dietitian/Nutritionist ADDITIONAL SERVICES, EQUIPMENT and DEVICES ABA Treatment for Autism Spectrum Disorder $0 Copayment not subject to for Referral Assistive Communication Devices for Autism Spectrum Disorder Diabetic Equipment, Supplies and Self-Management Education Diabetic Equipment, Supplies and Insulin (30-day supply) Diabetic Education Durable Medical Equipment and Braces 20% Coinsurance after
ADDITIONAL SERVICES, EQUIPMENT and DEVICES External Hearing Aids Cochlear Implants Hospice Care Inpatient Outpatient for 20% Coinsurance after 20% Coinsurance after $1,000 Copayment after Single purchase once every three (3) years One (1) per ear per time Covered Two hundred ten (210) days per Plan Year Five (5) visits for family bereavement counseling Medical Supplies Prosthetic Devices External 20% Coinsurance after 20% Coinsurance after One (1) prosthetic device, per limb, per lifetime with coverage for repairs and replacements Internal Included as part of inpatient Hospital Cost- Sharing Unlimited;
INPATIENT SERVICES and FACILITIES Inpatient Hospital for a Continuous Confinement (including an Inpatient Stay for Mastectomy Care, Cardiac and Pulmonary Rehabilitation, and End of Life Care) for $1,000 Copayment after. However, is not for emergency admissions. Observation Stay Skilled Nursing Facility (including Cardiac and Pulmonary Rehabilitation) $150 Copayment after $1,000 Copayment after Two hundred (200) days per Plan Year Inpatient Habilitation (Physical, Speech and Occupational Therapy) Inpatient Rehabilitation (Physical, Speech and Occupational Therapy) $1,000 Copayment after $1,000 Copayment after Sixty (60) days per Plan Year combined therapies Sixty (60) days per Plan Year combined therapies Speech and physical therapy are only Covered following a Hospital stay or surgery
MENTAL HEALTH and SUBSTANCE USE DISORDER SERVICES Inpatient Mental Health Care (for a continuous confinement when in a Hospital) for $1,000 Copayment after. However, is not for emergency admissions. Outpatient Mental Health Care (including Partial Hospitalization and Intensive Outpatient Program ) Inpatient Substance Use (for a continuous confinement when in a Hospital) $1,000 Copayment after. However, is not for emergency admissions or for Participating OASAScertified Facilities. Outpatient Substance Use PRESCRIPTION DRUGS *Certain Prescription Drugs are not subject to Cost- Sharing when provided in accordance with the comprehensive guidelines supported by HRSA or if the item or service has an A or B rating from the USPSTF and obtained at a participating pharmacy. for Unlimited; Up to twenty (20) visits per Plan Year may be used for family counseling
PRESCRIPTION DRUGS Retail Pharmacy 30-day supply Tier 1 for $10 Copayment not subject to Tier 2 $35 Copayment not subject to Tier 3 Mail Order Pharmacy Up to a 90-day supply Tier 1 $70 Copayment not subject to $25 Copayment not subject to Tier 2 $87.50 Copayment not subject to Tier 3 Enteral Formulas Tier 1 $175 Copayment not subject to $10 Copayment not subject to Tier 2 $35 Copayment not subject to Tier 3 $70 Copayment not subject to WELLNESS BENEFITS for Gym Reimbursement Up to $200 per six (6) month period; up to an additional $100 per six (6) month period for Spouse; not subject to Up to $200 per six (6) month period; up to an additional $100 per six (6) month period for Spouse; not subject to Up to $200 per six (6) month period; up to an additional $100 per six (6) month period for Spouse
PEDIATRIC VISION and DENTAL CARE Pediatric Vision Care Exams Lenses and Frames Contact Lenses Pediatric Dental Care Emergency Dental Care for 20% Coinsurance after 20% Coinsurance after One (1) exam per twelve (12) month period; One (1) prescribed lenses and frames per twelve (12) month period Preventive Dental Care One (1) dental exam and cleaning per six (6) month period Routine Dental Care Major Dental Care (Endodontics, Periodontics, Prosthodontics and Oral Surgery) Full mouth x- rays or panoramic x- rays at thirtysix (36) month intervals and bitewing x- rays at six (6) month intervals Orthodontics Major Dental Care and Orthodontics require All in-network requests are the responsibility of Your. You will not be penalized for a s failure to obtain a. However, if services are not Covered under the Certificate, You will be responsible for the full cost of the services.
ATTENTION: If you speak other languages, language assistance services, free of charge, are available to you. Call 1-877- 411-3625 (TTY/TDD: 711). Español (Spanish) ATENCIÓN: Si usted habla español, tiene a su disposición, gratis, servicios de ayuda para idiomas. Llame al 1-877- 411-3625 (TTY/TDD: 711). 中文 (Traditional Chinese) 注意 : 如果您講中文, 我們免費提供相關的語言協助服務 請致電 1-877- 411-3625 (TTY/TDD: 711) Pусский (Russian) ВНИМАНИЕ! Если Вы говорите на русском языке, Вам доступны бесплатные услуги переводчика. Звоните по тел. 1-877- 411-3625 (служба текстового телефона, TTY/TDD: 711). Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis èd nan lang gratis ki disponib pou ou. Rele nimewo 1-877- 411-3625 (TTY/TDD: 711). 한국어 (Korean) 주의 : 귀하가한국어를사용하는경우, 귀하에게언어지원서비스가무료로제공됩니다. 1-877- 411-3625 (TTY/TDD: 711) 로전화하십시오. Italiano (Italian) ATTENZIONE: Sono disponibili servizi gratuiti di assistenza linguistica in italiano. Chiamare il numero 1-877- 411-3625 (TTY/TDD: 711). שידיא (Yiddish) (Yiddish) אידיש טפור.ךייא ראפ ןעמוקאב וצ אד ןענייז,זיירפ ןייק ןהא,סעסיוורעס ףליה ךארפש,שידיא טדער ריא ביוא :גנוטכא אכטונג: אויב איר רעדט אידיש, שפראך הילף סערוויסעס, אהן קיין פרייז, זיינען דא צו באקומען פאר אייך. רופט <X-XXX-XXX-XXXX> (TTY/TDD: <XXX>)..(TTY/TDD:.(TTY/TDD: <XXX>) <X-XXX-XXX-XXXX> 711)1-877- 411-3625 ব ল (Bengali) দ ষ ট আকর ষণ করছ : আপন যদ ব ল ভ ষ হন, আপন র জন য ব ন ম ল য ভ ষ স ক র ন ত পর ষ ব র ব যবস থ থ কব <X-XXX-XXX-XXXX> নম বর (TTY/TDD: <XXX>) ফ ন কর ন :, 1-xxx-xxx-xxxx 1-877- 411-3625 (TTY/TDD: 711) Polski (Polish) UWAGA: Dla osób mówiących po polsku dostępna jest bezpłatna pomoc językowa. Proszę zadzwonić pod numer 1-877- 411-3625 (TTY/TDD: 711). (ARABIC) (Arabic) ةيبرعلا مقرلاب لصتا, اناجم ةيوغللا ةدعاسملا تامدخ كل رفوتت ةيبرعلا ةغللا ملكتت تنك اذإ :هابتنالا ىجري وأ جى لانتبا : كن تتكل <X-XXX-XXX-XXXX> ب تت ف ل خ ا ساع مجانا, تص بال ق 411-3625 -1-877 (TTY/TDD: 711) Y0026_126476 Accepted 8/29/16 Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Company, LLC are EmblemHealth companies. EmblemHealth Company, LLC provides administrative services to the EmblemHealth companies.
Français (French) ATTENTION : si vous parlez français, une assistance d interprétation gratuite est à votre disposition. Veuillez composer le 1-877- 411-3625 (Sourds et malentendants : 711). ودرا( Urdu ) ںیہ بایتسد تفم تامدخ یک ددم قلعتم ےس نابز ےیل ےک پآ وت ںیہ ےتلوب ودرا پآ رگا :ںید ہجوت ) 1-877- 411-3625 : کے سے کی ںیرک لاک رپ (< XXX >:یڈ یڈ یٹ /یئاو یٹ یٹ) <X-XXX-XXX-XXXX> (<XXX>: 711 / Tagalog (Tagalog) NANANAWAGAN NG PANSIN: Kung nagsasalita ka ng Tagalog, mayroon kang magagamit na mga serbisyo para sa tulong sa wika nang walang bayad. Tawagan ang 1-877- 411-3625 (TTY/TDD: 711). Ελληνικά (Greek) ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, δωρεάν. Καλέστε 1-877- 411-3625 (για άτομα με προβλήματα ακοής/tty/tdd: 711). Shqip (Albanian) VINI RE: Nëse flisni Shqip, shërbimi i asistencës për gjuhën do të jetë në dispozicionin tuaj, pa pagesë. Telefononi 1-877- 411-3625 (Shërbimi i teletekstit TTY/TDD: 711). Notice of Nondiscrimination Policy EmblemHealth complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. EmblemHealth does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. EmblemHealth: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact 1-877- 411-3625. If you believe that EmblemHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with EmblemHealth Grievance and Appeals Department, PO Box 2844, New York, NY 10116, or call 1-877- 411-3625. (Dial 711 for TTY/ TDD services.) You can file a grievance in person, by mail or by phone. If you need help filing a grievance, EmblemHealth s Grievance and Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human, Office of Civil Rights electronically through the Office of Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at U.S. Department of Health and Human, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201; 1-800-368-1019, (dial 1-800-537-7697 for TTY services). Complaint forms are available at hhs.gov/ocr/office/file/index.html. Y0026_126477 NM