EmblemHealth Pharmacy Services: (877) 793-6253, 24 hours a day, 7 days a week Clinical Pharmacy Services (Providers) EmblemHealth: (877) 362-5670, Monday through Friday, 8 a.m. to 6 p.m. Express Scripts, Inc. (ESI): (home delivery for all plan members except for state and federal employees and retirees with GHI coverage) This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program; if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren). Tous les tarifs rgionaux disponibles sur les sites TER, Achetez en ligne tous vos billets et abonnements sur ce site. Sometimes these providers bill us directly. at The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. If you are enrolled in our Standard Option, you have access to covered care only from within our network participating providers under our Exclusive Provider Organization (EPO). 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. EmblemHealth will determine reimbursement for emergency services from non-participating providers based on a lesser of 100% of the 90th percentile of FAIR Health Prevailing Healthcare Charges System for Emergency Professional charges and Emergency Admission Professional Charges or the provider's billed charge. We strongly encourage you to select a doctor within the Emblemhealth network who will provide your care. Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided for up to 32 sessions. Our allowance may not cover the full charges and you will owe that portion of the charges that exceeds our payment. The Secretary of Health and Human Services has identified counties where at least 10 percent of the population is literate only in certain non-English languages. 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. Covered services will include the use of electronic information and communication technologies by a provider to deliver covered services to you while your location is different than your providers location. You may also call FEHB 2 at (202) 606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. 1) Have FEHB coverage on your own as an active employee, 2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant, 3) Have FEHB through your spouse who is an active employee, 4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above. Medically necessary services are services; supplies or equipment provided by a hospitalor covered provider of the health care services that the carrier determines: The fact that a covered provider has prescribed, recommended, or approved a service, supply or equipment does not, in itself, make it medically necessary. The network for this Plan will be expanded to the EmblemHealth, Inc. Bridge Network. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. (See page 45). Our right of reimbursement is not subject to reduction based on attorney fees or costs under the "common fund" doctrine and is fully enforceable regardless of whether you are "made whole" or fully compensated for the full amount of damaged claimed. We will not cover care that you receive from non-network (non-participating) providers. For more information on patient safety, please visit: Preventable Healthcare Acquired Conditions ("Never Event"), When you enter the hospital for treatment of one medical problem, youdo notexpect to leave with additional injuries, infections or other serious conditions that occur during the course of your stay. Get the results of any test or procedure. 0000010220 00000 n For approved inpatientadmissions, you are responsible for the applicable hospital admission copay (see inpatient hospital benefits). The non-PPO benefits are the standard benefits of this Plan. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call. Drugsfor which a prescription is required by Federal law of the United States, FDA approved prescription drugs and devices for birth control, Drugsto treatsexual dysfunction (with Prior authorization), Disposable needles and syringes needed for the administration of covered medication, Intravenous fluids and medications for home use through our Participating Provider network for home infusion therapy, Nutritional supplements for the treatment of phenylketonuria, branched chain ketonuria, galactosemia, and homocystinuria. 0000007359 00000 n Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits. Save copies of all medical bills, including those you accumulate to satisfy a deductible. Arthur Naliboff Director, Pharmacy Compliance and Audit at EmblemHealth New York, New York, United States 67 connections When we are the primary payor, we process the claim first. By choosing an EAN pharmacy, you could see smaller copays. Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest. hb``b``mg`a`R Bl@q +Z0 KFe|592 GGXQ^+ ie 312(,``esz@xC?cWl These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. Alternative benefits are subject to our ongoing review. Benefits on this page are not part of the FEHB contract. However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare. 0000034312 00000 n Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants). Understand both the generic and brand names of your medication. breast prostheses and surgical bras and replacements (see Prosthetic devices). Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise. Our service area is: New York City (the Boroughs of Manhattan, Brooklyn, Bronx, Queens, and Staten Island) all of Nassau, Suffolk, Rockland, Westchester Broome, Cayuga, Chemung, Columbia, Cortland, Delaware, Dutchess, Franklin, Greene, Hamilton, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Orange, Oswego, Otsego, Putnam, St. Lawrence, Schuyler, Steuben, Sullivan, Tioga, Tompkins, Ulster, New Jersey counties of Bergen, Essex, Hudson, Middlesex, Monmouth, Morris, Passaic, Somerset, Sussex and Union. If you purchase Medicare Part B, your provider is in our network and participates in Medicare, then we waive some costs because Medicare will be the primary payor. Let only the appropriate medical professionals review your medical record or recommend services. 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. 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. Coverage that utilizes a network(s) of providers and uses provider selection standards, utilization management, and quality assessment techniques to complement negotiated fee reductions as an effective strategy for long-term health care costs savings. For urgent care claims, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent. Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures. A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure; Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms; Copies of all letters you sent to us about the claim; Copies of all letters we sent to you about the claim; Your daytime phone number and the best time to call; and. FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. EOC VIP RX CH Making remote or global hires? Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals, Section 5(b). For a complete list of QLEs, visit the FEHB website at, www.opm.gov/healthcare-insurance//lifeevents. If you joined at any other time during the year, your employing office will tell you the effective date of coverage. You may be responsible to pay for certain services and charges. Although we may list a specific service as a benefit, we will not cover it unlessit is medically necessary to prevent, diagnose, or treat your illness, disease, injury or condition. If you have any questions, please call EmblemHealth Pharmacy Services toll free at 1.877.444.7097, Monday through Sunday, 8:00 a.m. to 8:00 p.m. (TTY/TDD: 711). %PDF-1.4 % Finally, if you qualify for coverage under another group health plan (such as your spouses plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage. family counseling under the direction of a doctor. Not covered: Elective care or non-emergency care. Note: You are the only person who has a right to file a disputed claim with OPM. See Section 5(c) for charges associated with a facility (i.e. Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefit. $10 per visitfor children (under age 26), This benefit is administered byEyeMed-www.eyemed.com, Nothing for services provided by participating opticians, optometrists and vision centers, Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes, includingthe routine treatment of corns, calluses, and bunions, and the partial removal of toenails. Your ID card will indicate the EmblemHealth network for your coverage. You may get information about us, our networks, and our providers. You must live or work in our geographic service area to enroll. Especially note the times and conditions when your medication should and should not be taken. Our EPO offers a network of participating providers and uses provider selection standards, utilization management, and quality assessment techniques to complement negotiated fee reductions as an effective strategy for long term cost savings. Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual limits when received from a network provider. 5 visitors have checked in at Emblem Health Pharmacy Services. Bills and receipts should be itemized and show: Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills. A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. 0000056147 00000 n Choose a doctor with whom you feel comfortable talking. If you have an emergencyadmission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospitalmust telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. Children with or eligible for employer-provided health insurance Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday. at Make sure you understand what will happen if you need surgery. When you are enrolled in Original Medicare along with this plan, you still need to follow the rules in this brochure for us to cover your care. 90 days after the date of our letter upholding our initial decision; or, 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or. In addition to providing comprehensive health care services for illness and injury, we emphasize preventive benefits such as routine office visits, physicals, immunizations, and well-baby care. Nothing for counseling for up to two quit attempts per year. For more about these services, visit www.emblemhealth.com/goodhealth. Make sure that you review the benefits that are available under the option in which you are enrolled. H\@. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC. The out-of-pocket limits for these Plans may differ from the IRS limit, but cannot exceed that amount. To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium. We will cooperate with OPM so they can quickly review your claim on appeal. Please contact us for a copy of our most recent provider directory or visit us online atwww.emblemhealth.com/federalfor the most up-to-date information on our provider network. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. Please seeSection 5(f) Prescription Drug benefits for information on growth hormone.. However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your express consent. A surprise bill is an unexpected bill you receive from a nonparticipating health care provider, facility, or air ambulance service for healthcare. 4. 0000049101 00000 n Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter. Read the label and patient package insert when you get your medication, including all warnings and instructions. Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice. Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies. Any costs associated with the professional charge (i.e., physicians, etc.) You should ask your physicianor pharmacist whether a generic version of your medications is available. If you are aparticipant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial. These are private health care choices (like HMOs and regional PPOs) in some areas of the country. Emblem Health. Generic drugs may differ in color, size, or shape, but they have the same strength, purity, and quality as the brand-name alternatives. Precertify your hospital stay, or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or. The need for these services must result from an accidental injury caused by external means and services must be completed within one year. 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. Your email address, if you would like to receive OPM's decision via email. Contact your doctor or pharmacist if you have any questions. Note: To receive this benefit a prescription from a doctor must be presented to the pharmacy. Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. If you would like to purchase health insurance through the ACA's HealthInsurance Marketplace, please visit www.HealthCare.gov. 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.. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. Self Plus One coverage is for the enrollee and one eligible family member. 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. Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals, Section 5(c). If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. If you have already met yourprior plans catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. (See page 86.). You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC). It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Professional ambulanceservice to or from a hospitalfor medically necessaryservices. Prior approval/authorizations must be renewed periodically. 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. These costs are generally covered by the clinical trials.This plan does not cover these costs. 0000014455 00000 n It also helps prevent you from taking a medication to which you are allergic. Definitions of Terms We Use in This Brochure, Summary of Benefits for the Standard Option of the EmblemHealth Plan - 2022, 2022 Rate Information for EmblemHealth Plan, Except for necessary technical terms, we use common words. Some FEHB Plans already cover dental and vision services. Voluntary family planningservices for men, limited to: Diagnosis and treatment of infertility, except as shown in Not covered. Noverbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at, Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. We will ask you to submit information that establishes that the GHT is medically necessary.Ask us to authorize GHT before you begin treatment. If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. We will only cover GHT services and related services and supplies that we determine are medically necessary. Surprise bills can happen when you receive emergency care when you have little or no say in the facility or provider from whom you receive care.
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