Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan. 0000019659 00000 n Our health coverage meets the minimum value standard of 60% established by the ACA. Generic drugs may differ in color, size, or shape, but they have the same strength, purity, and quality as the brand-name alternatives. When no PPO provider is available, non-PPO benefits apply. If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, x-rays and scans and hospitalization related to treating the patients condition) if it is not provided by the clinical trial. outpatient care and maternity care, to the nearest facility. Write a short note about what you liked, what to order, or other helpful advice for visitors. %PDF-1.4 % We credential Plan providers according to national standards. Example: When you see your primary care physician you pay a copayment of $50 per office visit, and $10 per office visit for dependent children to age 26, under the Standard Option. You refers to the enrollee and each covered family member. We will then decide within 30 more days. We strongly encourage you to select a personal EmblemHealth, Inc participating doctor who will provide your care within the Plans participating provider network. VP, Pharmacy Services @ ZipDrug Director Of Clinical Services @ Medly, Ranked #701 out of 14,029 for Women's contraceptive drugs and devices including the "morning after pill" as an over-the-counter (OTC) emergency contraceptive drug. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage. PPO benefits apply only when you use a PPO provider. 0000002839 00000 n If you receive care outside our service area, we will pay only for emergency care benefits. You must: a) Write to us within 6 months from the date of our decision; and, b) Send your request to us at: EmblemHealth Customer Service Department, 55 Water St. , New York, NY 10041; and, c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. Under the Standard Option, you must obtain care fromwithin the participating provider network. Ask about any risks or side effects of the medication and what to avoid while taking it. The list is also on our website. Thispolicy helps to protect you from preventable medical errors and improve the quality of care you receive. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate,in the same option of the same plan; or. Contraceptive counseling on an annual basis, Acute care provided in a licensed Article 28 facility or acute care facility that specializes in terminally ill patients,for members diagnosed with advanced cancer with less than sixty (60) days to live.. Voluntary sterilization (e.g., Tubal ligation, Vasectomy). Acupuncture Therapy - Save up to 25% on acupuncture therapy. Care we provide benefits for, as described in this brochure. Note: We only cover GHT when we preauthorize the treatment before you begin treatment. Just present your identification card and pay your copayment, coinsurance, or deductible. Laser Vision Care- Save as much as 25% on laser vision correction. Note: When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in his or her own right. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. $50 copay forfirstvisitonly (for all prenatal and postnatal care). However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. 0000001385 00000 n We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights. 25% coinsurance up to a maximum of $200 perprescription for specialty drugs, $125 brand name listed on the preferred prescription drug formulary, $170 brand name drug not listed on the preferred prescription drug formulary, $45 brand name listed on the preferred prescription drug formulary, $95 brand name drug not listed on the preferred prescription drug formulary. For more information or to make an inquiryabout situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan's customer service representative at the phone number found on your enrollment card, plan brochure, or plan website. FEHB Carriers must have clauses in their in-network (participating) providers agreements. The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time. To make your request, please contact our Customer Service Department by writingEmblemHealth Customer Service, 55 Water Street, New York, NY 10041 calling 877-842-3625. Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise. Part-time or intermittent nursing care by a registered professional nurse(R.N.) Services Provided by a Hospital or Other Facility, and Ambulance Services, Section 5(d). 0000010045 00000 n Plan dentists must provide or arrange your care. For a complete list of Well Women preventive care services go to the Health and Human Services (HHS) website at, To build your personalized list of preventive services go to, Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older, Tetanus-diptheria (Td) booster - once every 10 years, ages 19 and over (except as provided for under Childhood immunizations), Varicella (Chickenpox) - for all persons aged 19-49, Tetanus, Diphtheria and Pertussis (TDAP) - for persons aged 19-64, with a booster every 10 years, Well-child visits, examinations, andother preventive servicesas described in the Bright Future Guidelines provided by the American Academy of Pediatrics.For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to, Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. The amount shown under employee contribution is the maximum you will pay. If you do not agree with our decision, you may ask OPM to review it. Please contact us at the number on the back of your member ID card or visit our website at emblemhealth.com/outofnetwork for more information about what constitutes a surprise bill and what you should do if you think your claim was for a surprise bill.. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment. You may remain in the hospital up to 4 hours after a vaginal delivery and 96 hours after a cesarean delivery. Diagnostic and treatment services for disease or medical conditions affecting hearing, For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or Audiologist, External hearing aids for children to age 26 (See "Orthopedic and Prosthetic devices"), Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery), Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy, External hearing aids for children up to age 26, Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment. 20% of the Plans fee schedule for a participating provider. We will not provide duplicate or year-end statements. 247 39 Mental Health and Substance Use Disorder Benefits, Section 5(h). If you or a family member moves, you do not have to wait until Open Season to change plans. Ward, semiprivate, or intensive care accommodations; Operating, recovery, maternity, and other treatment rooms, Administration of blood and blood products, Blood or blood plasma, if not donated or replaced, Dressings, splints, casts, and sterile tray services, Medical supplies and equipment, including oxygen, Anesthetics, including nurse anesthetist services, Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home, Operating, recovery, and other treatment rooms, Administration of blood, blood plasma, and other biologicals, Dressings, casts, and sterile tray services, Diagnostic laboratory tests, X-rays, and pathology services. The benefits in this brochure are effective January 1. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial. If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8. You can also contact us to request that we mail a copy to you. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits. Vitamins and Natural Supplements - Order online and save 45%. Officeof Personnel Managementhas implemented the Federal Employees Health Benefits Childrens Equity Act of 2000. Contact your doctor or pharmacist if you have any questions. We will cover dental care for accidental injury only as indicated within the benefits description. All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. Covered services must be provided in the state in which the practitioner is licensed or certified. If you want more information about us, call (877) 842-3625, or write to EmblemHealth, 55 Water St., New York, NY 10043. 0000009863 00000 n Please contact your Tribal Benefits Officer for exact rates. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage. Surgery to correct a condition caused by injury or illness if: the condition produced a major effect on the members appearance and; the condition can reasonably be expected to be corrected by such surgery. 0000026595 00000 n We will not pay more than our allowance. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected. Standard Option alsooffers the following unique features: Important things you should keep in mind about these benefits: $10per office visit for children (under age26), All charges for non-participating providers. If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts. You must use participating providers under the Standard Option coverage. $150 copayment for outpatient hospital or ambulatoryfacility and $50copaymentfordiagnostic labs, x-rays, and pathology. For information and assistance 24 hours a day, 7 days a week, access our automated telephone AnswerLine at 1-877-842-3625. Call EmblemHealth Managed Care at least 10 days before the hospitaladmission to pre-certify coverage and for details on how to use this program. Your medical and claims records are confidential. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. Up to 60 visits per condition if significant improvement can be expected for the services of each of the following: Note: We only cover therapy when a physician orders the care. Federal law prevents the pharmacy from accepting unused medications. ZipDrug, Director of Clinical Relations at Medly Pharmacy We will make diligent efforts to recover benefit payments we made in error but in good faith. Your health plan must comply with the NSA protections that hold you harmless from unexpected bills. We do not waive any costs if the Original Medicare Plan is your primary payor. If your claim was for services from a non-participating provider, the claim may be for a surprise bill, giving you protection from out-of-pocket costs in excess of what you would have paid in-network for the services. 030r5= ?x s @-a\1hSN)+Ua`&r!#\T]Z ` - endstream endobj 284 0 obj <>/Filter/FlateDecode/Index[42 205]/Length 30/Size 247/Type/XRef/W[1 1 1]>>stream Note: Thereis a limit of 4 visits per calendar year. All charges for non-participating providers. 0000000016 00000 n It also helps prevent you from taking a medication to which you are allergic. Wellness and Other Special Features, Non-FEHB benefits available to Plan members, Section 6. Please remember that we do not make decisions about plan eligibility issues. 0000011322 00000 n Understand both the generic and brand names of your medication. What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire; When the next Open Season for enrollment begins. All charges for a non-participating provider, Nothing for chemotherapy and radiation provided in a participating facility, Note: Prior Approval Required, see Section 3, Skilled nursing facility (SNF) care is limited to 30 days per calendar year and includes the following:. Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition. Noverbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. Your facility will file on the UB-04 form. With the exception of durable medical equipment, thereis no calendar year deductible. This brochure describes the benefits of EmblemHealth, Inc. under contract (CS 1056) between EmblemHealth, Inc. and the United States Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. at $10 pervisitfor children (under age 26). 0000005557 00000 n Clinic for urgent healthcare. These centers are recognized leaders in their respective specialties and their services are available to you at no out-of-pocket expense. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services. For a complete list of QLEs, visit the FEHB website at, www.opm.gov/healthcare-insurance//lifeevents. Prior approval/authorizations must be renewed periodically. We will cooperate with OPM so they can quickly review your claim on appeal. Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness. For covered services you receive byproviders and hospitals outside the United States and Puerto Rico, send a completed HCFA 1500 Claim Form and the itemized bills to: EmblemHealth PO Box 3000 New York, NY 10116-3000. For certain services, you or your physician must obtain prior approval from us. 0000014455 00000 n Annuitants coverage and premiums begin on January 1. Non-Degree Course Work, Finance and Financial Management Services, Viral Shah's Professional Skills Radar We may identify medically appropriate alternatives toregular contract benefitsas a less costly alternative. Please review the following table it illustrates your cost share if you are enrolled in Medicare Part B. For information on suspending your FEHB enrollment, contact your retirement office. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect. If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim tolet you know what informationwe need to complete our review of the claim. Also read the General exclusions in Section 6; they apply to the benefits in the following subsections. Contact us or, if we drop out of the Program, contact your new plan. Jacqueline Marie Director, Pharmacy Vendor Operations at EmblemHealth New York, New York, United States 129 connections $200 per hospital emergency room visit and charges that exceed the Plans emergency fee schedule. We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification. View Viral Shah's business profile as Senior Director, Clinical Product Strategy at Medly Pharmacy. Your ID card will indicate the EmblemHealth network for your coverage. Speech therapy services that help a person keep, learn or improve skills and functioning for daily living. including: services or programs that help maintain or prevent deterioration in cognitive function. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. Patients name, date of birth, address, phone number and relationship to enrollee, Name and address of person or company providing the service or supply, Dates that services or supplies were furnished. You will not be billed for inpatient services related to treatment of specific hospital acquired conditions or for inpatient services needed to correct Never Events, if you use Emblemhealth providers. Choose a doctor with whom you feel comfortable talking. The non-PPO benefits are the standard benefits of this Plan. or a home healthaide under the supervision of a registered professional nurse, Medical supplies which serve a specific therapeutic or diagnosticpurpose, Other medically necessary services or supplies that would have been provided by a hospital if the subscriber were still hospitalized, Manipulation of the spine and extremities, Adjustment procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application. Note: We cover Habilitation Services in the outpatient department of a Facility or in a Health Care Professionals office. 3 services are provided at Emblemhealth Pharmacy. 0000049101 00000 n Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay. Professional ambulanceservice to or from a hospitalfor medically necessaryservices. For orthopedic and prosthetic devices, oxygen and other covered durable medical equipment you pay $100 calendar year deductible per individual. Call 800-MEDICARE 800-633-4227, TTY 877-486-2048. Theservices listed below are for the charges billed by a physician or other healthcare professional for your surgical care. This is a smaller network that is available in addition to the larger ESI network of pharmacies you can choose from that are included in your EmblemHealth FEHB plan. Standard Option Plan Serving: New York City plus most New York Counties, and Northern New Jersey. Insertion of internal prostethic devices. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. All stages of breast reconstruction surgery following a mastectomy, such as: surgeryto produce a symmetrical appearance on the other breast; treatment of any physical complications, such as lymphedemas; or. Go to Over-the-Counter Items. Section 9 has additional information on costs related to clinical trials. Door-to-door prescription delivery service. admission to pre-certify coverage and for details on how to use this program. Coinsurance is the percentage of our allowance that you must pay for your care. You may call OPM'sFEHB 2at (202) 606-3818 between 8 a.m. and 5 p.m. Eastern Time. myelogenous) leukemia, Advanced Hodgkins lymphoma with recurrence, Advanced Myeloproliferative Disorders (MPDs), Advanced non-Hodgkins lymphoma with recurrence, Chronic Lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), Marrow Failure and Related Disorders (i.e. Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. Here are some examples. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. By law, you have the right to access your protected health information (PHI). We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. Covered professional providers are medical practitioners who perform covered services when acting within the scope of their license or certification under applicable state law and who furnish, bill, or are paid for their health care services in the normal course of business. A participating EmblemHealth provider must provide your follow-up care. In most instances they will serve as evidence of your claim. Contact your carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a dependent when there is already family Coverage. An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug administration; or is a drug trial that is exempt from the requirement of an investigational new drug application. This plan recognizes that transsexual, transgender, and gender-nonconforming members require health care delivered by healthcare providers experienced in transgender health. Married children Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday. For more about these services, visit www.emblemhealth.com/goodhealth. We may delay processing or deny benefits for your claim if you do not respond. Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. We use the latest and greatest technology available to provide the best possible web experience.Please enable JavaScript in your browser settings to continue. Failure to comply with pre - admission review or the concurrent review will result in the following reductions in health benefit reimbursment: $125 per day to a maximum of $250 per confinment as long as we determine thatthe inpatient admissionor service was medically necessary. 4. This policy does not apply toservices that you receive at non-participating hospitals. We do not cover these costs. The IRS limits out-of-pocket expenses for covered services obtained from participating providers, including deductibles and copayments, to no more than $7,000 for Self-Only enrollment, or $14,000 for a Self Plus One or Self and Family. Anthem, Inc.) A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts: Urgent care claims usually involve Pre-service claims and not Post-service claims. Making remote or global hires? If another health plan is your primary payor, you must send a copy of the explanation of benefits (EOB) form you received from your primary payor (such as the MedicareSummary Notice (MSN)) with your claim.

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