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GHI-Brooklyn HealthWorks High Deductible
Health Plan (a Healthy NY EPO HDHP)
| Cost Sharing | ||
| Annual Plan Deductible | $1,250 Individual / $2,500 Family for plan year 2013* |
|
| Annual Out-of-Pocket Maximum |
$6,050 Individual / $12,100 Family for plan year 2013* |
|
This is a high deductible plan. With the exception of Well baby and well child care, Adult Preventive Care Services, and Pre-natal care, the deductible must be satisfied before EmblemHealth will provide coverage for covered services. The family deductible amount applies if the policy covers more than one person. The family deductible may be satisfied by one individual family member or by expenses incurred by various family members. However, the entire plan year deductible must be satisfied before services will be covered for any member of the family. Out-of-pocket maximum expenses include the deductible and copayments paid for HNY benefits covered by this plan. Once the out-of-pocket maximum for the plan year is reached, no further copayments will apply and covered benefits will be covered in full. The family out-of-pocket maximum amount applies if the policy covers more than one person.
*Note: The deductible and out-of-pocket amounts are subject to change each year based on Treasury guidelines.
Plan Details
| Inpatient Hospital Services* | In Network | Out of Network |
|---|---|---|
| Hospital Coverage | $500 Copayment per continuous confinement | Not Covered (except for emergency) |
| Skilled Nursing | Not Covered | Not Covered |
| Maternity and Routine Nursery Care | Covered in Full | Not Covered |
| Hospice Care | Not covered | Not Covered |
| Outpatient Hospital Services* | In Network | Out of Network |
| Ambulatory Surgery | $75 Facility Copayment | Not Covered |
| Home Health Care | $20 Copayment – up to 40 post-hospital or post-surgical visits per year | Not Covered |
| Medical Services | In Network | Out of Network |
| Surgical Services | 20% or $200, whichever is less | Not Covered |
| Delivery | 20% or $200, whichever is less | Not Covered |
| Home and Office Visits | $20 Copayment | Not Covered |
| Physical Check-up (every 3 years) | Covered in Full | Not Covered |
| Chiropractic Care | Not Covered | Not Covered |
| Physical Therapy | $20 Copayment – up to 30 post-hospital or post-surgical visits per year | Not Covered |
| Speech Therapy | Not Covered | Not Covered |
| Well-baby and Well-child Care | Covered in Full | Not Covered |
| Lab and Radiology Services | In Network | Out of Network |
| Diagnostic Lab Tests and Radiology Procedures | $20 Copayment | Not Covered |
| Emergency Services | In Network | Out of Network |
| ER Professional Charge | Covered in Full | Allowed charge |
| Emergency Facility Charge (Waived if Admitted) | $50 Copayment per visit | $50 Copayment per visit |
| Mental Health and Chemical Dependency Services* | In Network | Out of Network |
| Inpatient Mental Health | Not Covered | Not Covered |
| Inpatient Chemical Dependency Treatment (Detoxification) | Not Covered | Not Covered |
| Chemical Dependency Treatment (Rehabilitation) | Not Covered | Not Covered |
| Outpatient Chemical Dependency Treatment | Not Covered | Not Covered |
| Outpatient Mental Health | Not Covered | Not Covered |
| Pharmacy (Optional) | In Network | Out of Network |
| Pharmacy |
Retail Copayment: $10 per generic drug per 34-day supply, $20 per brand name drug plus difference in cost between the brand name drug and its generic equivalent per 34-day supply. Mail Order Copayment: $20 per generic drug per 90-day supply, $40 per brand name drug per 90-day supply plus the difference in cost between the brand name drug and its generic equivalent. Benefit Maximum: Unlimited. | Not Covered |
*Services may be subject to Precertification or Pre-authorization.
The benefits described here are only brief highlights of the coverage available. Some benefits may have calendar year limits and/or maximums. The terms, limitations, conditions, and exclusions of the insurance contract and certificate will govern.
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