po box 1407, church street station new york, ny 10008-1407 www.empireblue.com Dear Prospective Customer: Thank you for inquiring about a Direct Payment HMO and/or an HMO/POS policy with Empire. Direct Payment HMO and HMO/POS contracts provide a wide range of services and have one of the largest networks of doctors and hospitals of any HMO in our service area. As with any HMO, the direct payment HMO policy requires that all medical care be coordinated through your chosen Primary Care Physisicn (PCP) and provides benefits for network services only. The direct payment HMO/POS program makes available to you benefits for both a traditional HMO program for in-network services AND the additional freedom to obtain non-network medical services from the provider of your choice even if the provider does not participate in the HMO provider network. These non-network services have additional cost sharing in the form of deductibles, co-insurance and balance billing by providers. The addition of an Out-of-Plan Benefit Rider is the difference between the HMO and HMO/POS programs. Enclosed you will find: how to obtain a listing of the Hospitals and Facilities, Physicians and Specialists that participate in the Network One Service Region a Direct Pay HMO, POS Premium Rate Sheet; a HMO Direct Payment Application with return envelope. Please review the materials carefully. To enroll in either the HMO or HMO/POS program(s), choose a Primary Care Physician for yourself and for each member of your family. Then complete the application form and return it in the enclosed envelope. Make sure you have indicated the contract of your choice, listed the PCP name and number chosen for each family member and signed your application before returning it. The privacy of your information is important to you, and it s important to Empire. That s why Empire follows strict privacy policies and practices to protect the privacy of the information we collect about you. Therefore, any information or changes to your account can only be granted at your request. If you have any questions, please call our Dedicated Service Area at 1-800- 261-5962, Monday through Friday 8:30 a.m. to 5:00 p.m. (Eastern Standard Time). Sincerely, Jeff Nicola Director of Sales LGL6061X 04/07 Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número de servicio al cliente que aparece al dorso de su tarjeta de identificación o en el folleto de inscripción. Services provided by Empire HealthChoice HMO, Inc., a licensee of the Blue Cross and Blue Shield Association, an Association of independent Blue Cross and Blue Shield Plans.
Highlights of Your Standard Benefits HMO What You Pay HMO/POS (within network) ( Non-Network) after deductible *Doctor s Services Allergy Testing and Treatment $ 15.00/visit $ 10.00/visit 20% Anesthesia $ 15.00/visit $ 10.00/visit 20% Delivery of Child 20% up to $200 $ 10.00 20% Diagnostic Services and Treatments $ 15.00/visit $ 10.00/visit 20% Obstetrical/Gynecological Services $ 15.00/visit $ 10.00/visit 20% Office Visits $ 15.00/visit $ 10.00/visit 20% Pre- and Post-Natal Care No Cost No Cost 20% Radiation Therapy and Chemotherapy $ 15.00/visit $ 10.00/visit 20% Second Surgical Opinions $ 15.00/visit No Cost 0%** Surgical Services (per occurrence) 20% up to $200 $ 10.00/visit 20% X-ray and Laboratory Services $ 15.00/visit $ 10.00/visit 20% Preventive Services No Cost No Cost 20% Hospital Services Inpatient Admission $500.00 No Cost 20% Outpatient Surgery $ 75.00/visit No Cost 20% Ambulance Service No Cost No Cost 20% Emergency Room Care (no admission to hospital) $ 50.00/visit $ 35.00/visit $35.00/visit Hospital Alternatives Skilled Nursing Facility No Cost No Cost 20% Home Health Care (200 visit limit) $ 15.00/visit $ 10.00/visit 20% Hospice Care Inpatient *** $500.00 No Cost 20% Hospice Care Outpatient *** $ 15.00/visit $ 10.00/visit 20% Private Duty Nursing ($5,000 maximum per calendar year, $10,000 lifetime maximum $ 15.00/visit $ 10.00/visit 20% Rehabilitative Services Physical Therapy Inpatient $500.00 No Cost 20% Physical Therapy Outpatient (limited to 90 days per condition, per calendar year) $ 15.00/visit $ 10.00/visit 20% Prescription Drugs Subject to a $100.00 deductible per individual per calendar year. $300.00 deductible per family per calendar year. Retail 34 day supply Generic $ 5.00 $ 5.00 Not Covered Brand Name $ 10.00 $ 10.00 Not Covered Mail Order 90 day supply Generic $ 10.00** $ 10.00** Not Covered Brand Name $ 20.00** $ 20.00** Not Covered (** not subject to deductible) (*** combined benefits of 210 days)
And Your Out-of-Pocket Costs HMO What You Pay HMO/POS (within network) ( Non-Network) after deductible Alcoholism, Substance Abuse and Mental and Nervous Conditions Mental Health Inpatient Admission (limited to 30 days combined with inpatient detoxification benefit) $500.00 No Cost 0%** Mental Health Outpatient (limited to 30 visits for regular treatment and 3 visits for crisis intervention) 10% 10% 10% Inpatient Detoxification (limited to 30 days combined with inpatient mental health benefit) $500.00 No Cost 0%** Durable Medical Equipment No Cost No Cost 20% Diabetic Equipment and Supplies $ 15.00/item $ 10.00/item 20% Prosthetic and Orthotic Devices Such as prosthetic limbs, artificial eyes and external breast prostheses No Cost No Cost 20% Deductibles Individual per calendar year None None $1,000.00 Family per calendar year None None $2,000.00 Maximum Out-of-Pocket Costs Individual per calendar year $1,500.00 None $3,000.00 Family per calendar year $3,000.00 None $5,000.00 Lifetime Maximum None None None *After the deductible is paid, the coinsurance payable is based on the usual, customary, and reasonable fee or a comparable fee schedule. After deductible and coinsurance requirements are met, your plan will pay 100% of the usual, customary and reasonable fee or 100% of a comparable fee schedule for services covered under the plan. You are always responsible for fees exceeding the usual, customary and reasonable fee or comparable fee schedule. ** not subject to deductible Exclusions The contracts contain exclusions such as coverage for unauthorized or unnecessary medical procedures, and experimental treatments. Please see your contract and member handbook for additional information. This summary of benefits complies with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.
Utilization Management and Case Management Our Utilization Management (UM) services offer a structured program that monitors and evaluates member care and services. The UM clinical team, which is made up of health care professionals who hold active professional licenses and certificates, perform the prior authorization, concurrent and retrospective review processes explained below. The UM team follows criteria to assist in decisions regarding requests for health care and other covered benefits, and complies with specific timeframes to ensure requests are handled in a timely manner. Our case management services help you to better understand and manage your health conditions. Prospective Review / Pre-Admission Review Prospective review (also known as pre-service or pre-admission review) is the process of reviewing a request for a medical procedure or service before it takes place. The review occurs to ensure that: 1) the procedure is medically necessary and 2) the procedure meets your health care plan s specific guidelines prior to being performed. Requests for prospective review may include but are not limited to: inpatient hospitalizations outpatient procedures diagnostic procedures therapy services durable medical equipment Prospective review is required for all elective inpatient admissions and certain outpatient services. The review process evaluates medical necessity and the best level of care and assigns expected length of stay if needed. Concurrent Review Concurrent review is an ongoing evaluation of a member s hospital stay, as well as ongoing extensions of services that may be needed (such as acute care facilities, skilled nursing facilities, acute rehabilitation facilities, and home health care services). The review includes physicians, member-assigned health care professionals (or member authorized representative) and takes place by telephone, electronically and/or onsite. Concurrent review uses pre-set decision criteria in order to approve medical care (deemed to be medically necessary) and assign the right level of care for continued medical treatment. Review decisions are based on the medical information obtained at the time of the review. Concurrent review also helps to coordinate care with behavioral health programs. Retrospective Review The retrospective review process consists of obtaining information to determine medical necessity as it relates to services provided without approval or notice ahead of time (e.g. without pre-service notification). Relevant clinical information is required for the retrospective review process. Review decisions are based only on the medical information the doctor or other provider had at the time the member received medical care. Case Management Case managers are licensed healthcare professionals who work with you to help you understand your benefits and support your health care needs. The case manager works with you and your doctor to help you better understand and manage your health conditions. Services provided by Empire HealthChoice HMO, Inc., a licensee of the Blue Cross and Blue Shield Association, an association of independent BlueCross Blue Shield Plans. NYBR12004XHM 9/10
How to find a Network One Participating Provider You can locate a network provider in one of two ways: 1. Visit www.empireblue.com to look up providers online and create a customized directory. 2. Request a printed directory by phone, using Empire s Voice Response Unit (VRU). Search for providers online For the most up-to-date listing of providers, visit www.empireblue.com 24 hours a day, 7 days a week: 1. Choose Find a Doctor or Specialist under the Blue Tools sm heading. 2. Click on New York Provider Search and follow the simple instructions. 3. Or click the CUSTOM DIRECTORY on the left of the page to create a directory you can save and print. Order a customized, printed directory by phone To request a printed directory by phone, using Empire s Voice Response Unit (VRU): 1. Call 1-800-261-5962. 2. Press 0 (for information on becoming an Empire member). 3. Press 1 (for a customized directory). 4. Once transferred, press 2 (not an Empire member). 5. Enter and confirm the zip code. 6. Press 6 (listing of the Empire Networks), then press 3 (Network One Plans). 7. Select provider specialty and delivery method (fax or mail). Services provided by Empire HealthChoice HMO, Inc., a licensee of the Blue Cross and Blue Shield Association, Services provided by Empire an association HealthChoice of independent HMO, Inc., a Blue licensee Cross of and the Blue Blue Cross Shield and Plans. Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. NET1X
Your Rights and Responsibilities We are committed to: Recognizing and respecting you as a member. Encouraging your open discussions with your health care professionals and providers. Providing information to help you become an informed health care consumer. Providing access to health benefi ts and our network providers. Sharing our expectations of you as a member. You have the right to: Participate with your health care professionals and providers in making decisions about your health care. Receive the benefits for which you have coverage. Be treated with respect and dignity. Privacy of your personal health information, consistent with state and federal laws, and our policies. Receive information about our organization and services, our network of health care professionals and providers, and your rights and responsibilities. Candidly discuss with your physicians and providers appropriate or medically necessary care for your condition, regardless of cost or benefit coverage. Make recommendations regarding the organization s members rights and responsibilities policies. Voice complaints or appeals about: our organization, any benefit or coverage decisions we (or our designated administrators) make, your coverage, or care provided. Refuse treatment for any condition, illness or disease without jeopardizing future treatment, and be informed by your physician(s) of the medical consequences. Participate in matters of the organization s policy and operations. The member has the right to obtain complete and current information concerning a diagnosis, treatment and prognosis from a physician or other provider in terms that the member can be reasonably expected to understand. When it is not advisable to give such information to the member, the information will be made available to an appropriate person acting on the member s behalf. You have the responsibility to: Choose a participating primary care physician if required by your health benefit plan. Treat all health care professionals and staff with courtesy and respect. Keep scheduled appointments with your doctor, and call the doctor s office if you have a delay or cancellation. Read and understand to the best of your ability all materials concerning your health benefits or ask for help if you need it. Understand your health problems and participate, along with your health care professionals and providers in developing mutually agreed upon treatment goals to the degree possible. Supply, to the extent possible, information that we and/or your health care professionals and providers need in order to provide care. Follow the plans and instructions for care that you have agreed on with your health care professional and provider. Tell your health care professional and provider if you do not understand your treatment plan or what is expected of you. Follow all health benefit plan guidelines, provisions, policies and procedures. Let our Customer Service Department know if you have any changes to your name, address, or family members covered under your policy. Provide us with accurate and complete information needed to administer your health benefit plan, including other health benefit coverage and other insurance benefits you may have in addition to your coverage with us. We are committed to providing quality benefi ts and customer service to our members. Benefi ts and coverage for services provided under the benefi t program are governed by the Subscriber Agreement and not by this Member Rights and Responsibilities statement. Effective Date: 7/31/2008; First Review: March, 2009; Second Review: February, 2010