EmblemHealth Gold EPO Virtual EPO N PEGDVN001
EmblemHealth Gold EPO Virtual EPO-N PEGDVN001 Coverage Period: Begins on or after 01/01/2021
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services
EmblemHealth : EmblemHealth Gold EPO Virtual-N
Coverage for: Individual/Family
Plan Type: EPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-447-8255. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.emblemhealth.com or call 1-800-447-8255 to request a copy.
Important Questions Answers
Why this Matters:
What is the overall deductible?
Virtual Preferred Provider Tier: $0 Participating Provider Tier: $500 Individual / $1,000 Family in network providers. Does not apply to preventive care.
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Yes. Primary care office visits,
Are there services covered preventive care, prenatal care,
before you meet your
telemedicine, and acupuncture are
deductible?
covered before you meet your
deductible.
This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?
No
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
What is the out-of-pocket For in network providers $7,800
limit for this plan?
Individual / $15,600 Family.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?
Premiums, penalties, balanced-bill charges, and health care this plan doesn't cover.
Even though you pay these expenses, they don't count toward the outofpocket limit.
Will you pay less if you a network provider?
use
Yes. See www.EmblemHealth.com or call 1-800-447-8255 for a list of participating providers.
This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?
No.
You can see the specialist you choose without a referral.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 2016
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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical Event
If you visit a health care provider's office or clinic
If you have a test
What You Will Pay
Services You May Need
Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Primary care visit to treat an injury or illness
$40 co-pay per visit not subject to
deductible
Not covered
Virtual visits available
Specialist visit
$60 co-pay per visit not subject to deductible
Not covered
Preventive care/screening/ immunization
No charge
Not covered
Diagnostic test (x-ray, blood work)
Lab: $0/$60 co-pay per visit not subject to deductible Virtual access available X-ray: After Plan deductible is met, $40/60 co-pay per visit.
Not covered
Imaging (CT/PET scans, After Plan deductible is met,
MRIs)
$60 co-pay per visit
Not covered
*Limitations, Exceptions, & Other Important Information
Primary care visit not subject to Plan deductible.
Specialist visit not subject to Plan deductible.
You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your Plan will pay for.
Prior Approval required for Outpatient Diagnostic Testing and Lab Procedures. Failure to obtain Prior Approval will result in denial of payment or reduced payment.
Prior Approval required. Failure to obtain Prior Approval will result in denial of payment or reduced payment.
* For more information about limitations and exceptions, see the plan or policy document at www.emblemhealth.com.
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Common Medical Event
Services You May Need
What You Will Pay
Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Generic drugs (Tier 1)
If you need drugs to treat your illness or
Preferred brand drugs (Tier 2)
condition
More information about
prescription drug coverage is available at www.EmblemHealth.com.
Non-preferred brand drugs (Tier 3)
Specialty drugs
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center)
Physician/surgeon fees
Retail: $0 co-pay/30 day supply
not subject to deductible
Mail Order: $0 co-pay/90 day Not covered
supply not subject to deductible
Virtual access available
After Plan deductible is met,
Retail: $40 co-pay/30 day supply
Mail Order: $100 co-pay/90 day Not covered
supply
Virtual access available
After Plan deductible is met,
Retail: $80 co-pay/30 day supply
Mail Order: $200 co-pay/90 day Not covered
supply
Virtual access available
Tier 1: $0 co-pay/30 day supply
not subject to deductible
After Plan deductible is met, Tier 2: $40 co-pay/30 day supply
Not covered
Tier 3: $80 co-pay/30 day supply
Virtual access is available
After Plan deductible is met, $350 co-pay per visit
Not covered
After Plan deductible is met, $350 co-pay per visit
Not covered
Emergency room care
If you need immediate Emergency medical
medical attention
transportation
Urgent care
After Plan deductible is met, After Plan deductible is met,
40% coinsurance
40% coinsurance
After Plan deductible is met, After Plan deductible is met,
$350 co-pay per visit
$350 co-pay per visit
$75 co-pay per visit not subject to deductible
Not covered
*Limitations, Exceptions, & Other Important Information
Generic (Tier 1) drugs not subject to Plan deductible. If you have an emergency condition, Prior Approval is not required for a covered prescription drug used to treat a substance use disorder, including a prescription drug to manage opioid withdrawal and/or stabilization and for opioid overdose reversal. Ancillary charges apply, per your Member Contract. Your cost may be higher if you select a brand name drug when a generic medicine is available. This plan has a Preferred Pharamacy Network which excludes CVS.
Must be dispensed by a Specialty Pharmacy. Written referral required.
Prior Approval required. Failure to obtain Prior Approval will result in denial of payment or reduced payment. Prior Approval required. Failure to obtain Prior Approval will result in denial of payment or reduced payment.
Waived if admitted.
-----None-----
Urgent care not subject to Plan deductible. In network only
* For more information about limitations and exceptions, see the plan or policy document at www.emblemhealth.com.
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Common Medical Event
If you have a hospital stay
If you need mental health, behavioral health, or substance abuse services
If you are pregnant
Services You May Need
What You Will Pay
Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Facility fee (e.g., hospital After Plan deductible is met,
room)
30% coinsurance per admission
Not covered
Physician/surgeon fee
After Plan deductible is met, $350 co-pay per visit
Not covered
Outpatient services
$40 co-pay per visit not subject to deductible
Not covered
Inpatient services
After Plan deductible is met, 30% coinsurance per admission
Not covered
Office visits
No charge
Not covered
Childbirth/delivery professional services
After Plan deductible is met, $350 co-pay per visit
Not covered
Childbirth/delivery facility After Plan deductible is met,
services
30% coinsurance per admission
Not covered
*Limitations, Exceptions, & Other Important Information
Prior Approval required. Failure to obtain Prior Approval will result in denial of payment or reduced payment. However, Prior Approval is not required for emergency admissions. Prior Approval required. Failure to obtain Prior Approval will result in denial of payment or reduced payment.
Unlimited visits. For Substance Abuse care, up to twenty (20) visits per plan year may be used for family counseling. Prior Approval required. Failure to obtain Prior Approval will result in denial of payment or reduced payment. However, Prior Approval is not required for emergency admissions.
Prenatal Care that is not provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA will use the cost sharing for the appropriate service. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Depending on the type of service, a copayment, coinsurance or deductible may apply. Limited to forty-eight (48) hours for natural delivery and ninety-six (96) hours for caesarean delivery. Prior Approval required. Failure to obtain Prior Approval will result in denial of payment or reduced payment.
* For more information about limitations and exceptions, see the plan or policy document at www.emblemhealth.com.
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Common Medical Event
If you need help recovering or have other special health needs
Services You May Need
What You Will Pay
Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Home health care
After Plan deductible is met, $60 co-pay per visit
Not covered
Rehabilitation services Habilitation services
After Plan deductible is met, Outpatient: $40/$60 co-pay per visit Inpatient: 30% coinsurance per admission After Plan deductible is met, Outpatient: $40/$60 co-pay per visit Inpatient: 30% coinsurance per admission
Not covered Not covered
Skilled nursing care
After Plan deductible is met, 30% coinsurance per admission
Not covered
Durable medical equipment
After Plan deductible is met, 20% coinsurance
Not covered
Hospice services
After Plan deductible is met, Outpatient: $60 co-pay per visit Inpatient: 30% coinsurance
Not covered
*Limitations, Exceptions, & Other Important Information
Forty (40) visits per plan year. Home infusion counts toward home health care visit limits. Prior Approval required. Failure to obtain Prior Approval will result in denial of payment or reduced payment.
Inpatient: Sixty (60) days per plan year. Combined therapies. Outpatient: Sixty (60) visits per condition per plan year. Combined therapies. Rehabilitation speech and physical therapy are only covered following a hospital stay or surgery. Prior Approval required. Failure to obtain Prior Approval will result in denial of payment or reduced payment.
200 days per plan year. Prior Approval required. Failure to obtain Prior Approval will result in denial of payment or reduced payment. One (1) external prosthetic device per limb per lifetime. No orthotics. Prior Approval required. Failure to obtain Prior Approval will result in denial of payment or reduced payment. 210 days per plan year. Five (5) visits for family bereavement counseling. Prior Approval required. Failure to obtain Prior Approval will result in denial of payment or reduced payment.
* For more information about limitations and exceptions, see the plan or policy document at www.emblemhealth.com.
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Common Medical Event
If your child needs dental or eye care
Services You May Need
What You Will Pay
Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Children's eye exam No charge
Not covered
Children's glasses
20% coinsurance not subject to deductible
Not covered
Children's dental checkup
$40 co-pay per visit not subject to deductible
Not covered
*Limitations, Exceptions, & Other Important Information
Children's eye exam not subject to Plan deductible. One (1) exam per twelve (12)month period Children's glasses not subject to Plan deductible. One (1) prescribed lenses and frames per twelve (12)-month period Children's dental check-up not subject to Plan deductible. One (1) dental exam & cleaning per six (6)-month period. Full mouth X-rays or panoramic X-rays at thirty-six (36)-month intervals and bitewing X-rays at six (6)-month intervals.
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
· Cosmetic surgery · Dental care
· Long-term care · Most coverage provided outside the United States · Non-emergency care when traveling outside the U.S.
· Private-duty nursing · Routine foot care · Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)
· Acupuncture · Bariatric surgery (Prior Approval required) · Chiropractic care
· Hearing aids (Prior Approval required) · Infertility treatment (Prior Approval required)
· Routine eye care
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: New York State Department of Financial Services at 1-800-342-3736 or www.dfs.ny.gov/, U.S. Department of Health and Human Services at 1-877-2672323 x1565 or www.cciio.cms.gov, U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/contactEBSA/consumerassistance.html or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596 or NY State of Health Marketplace at 1-855-355-5777 or www.nystateofhealth.ny.gov..
* For more information about limitations and exceptions, see the plan or policy document at www.emblemhealth.com.
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Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your right, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:
EmblemHealth By Phone: Please call the number on your ID card. In writing: EmblemHealth Grievance and Appeals Department P.O. Box 2801 New York, NY 10116-2807 Website: www.emblemhealth.com
For EPO Coverage New York State Department of Health By Phone: 1-800-206-8125 In writing: New York State Department of Health Office of Health Insurance Programs Bureau of Consumer Services Complaint Unit Corning Tower OCP Room 1607 Albany, NY 12237 Email: managedcarecomplaint@health.ny.gov Website: www.health.ny.gov
For All Coverage Types New York State Department of Financial Services By Phone: 1-800-342-3736 In writing: New York State Department of Financial Services Consumer Assistance Unit One Commerce Plaza Albany, NY 12257 Website: www.dfs.ny.gov
Consumer Assistance Program New York State Consumer Assistance Program By Phone: 1-888-614-5400 In writing: Community Health Advocates 633 Third Avenue, 10th Floor New York, NY 10017 Email: cha@cssny.org Website: www.communityhealthadvocates.org
For Group Coverage: U.S. Department of Labor Employee Benefits Security Administration at 1-866-444-EBSA (3272) Website: www.dol.gov/ebsa/healthreform
Does this plan provide Minimum Essential Coverage? Yes If you don't have Minimum Essential Coverage for a month, you'll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.
Does this plan meet the Minimum Value Standards? Yes If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
* For more information about limitations and exceptions, see the plan or policy document at www.emblemhealth.com.
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Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-447-8255 Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-447-8255
Chinese (): 1-800-447-8255 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-447-8255 To see examples of how this plan might cover costs for a sample medical situation, see the next section.
* For more information about limitations and exceptions, see the plan or policy document at www.emblemhealth.com.
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This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is having a baby
(9 months of in-network pre-natal care and a hospital delivery)
n The plan's overall deductible $500
n Specialist (cost sharing)
$60
n Hospital (facility) cost sharing $0
n Other cost sharing
This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)
Total Example Cost
$12,800
In the example, Peg would pay: Cost Sharing
Deductibles Copayments Coinsurance
What isn't covered Limits or exclusions The total Peg would pay is
$500 $1,160 $3,406
$60 $4,976
Managing Joe's type 2 diabetes
(a year of routine in-network care of a wellcontrolled condition)
n The plan's overall deductible $500
n Specialist (cost sharing)
$60
n Hospital (facility) cost sharing $0
n Other cost sharing
This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)
Total Example Cost
$7,400
In the example, Joe would pay: Cost Sharing
Deductibles Copayments Coinsurance
What isn't covered Limits or exclusions The total Joe would pay is
$500 $2,440
$346
$55 $3,191
Mia's Simple Fracture
(in-network emergency room visit and follow up care)
n The plan's overall deductible $500
n Specialist (cost sharing)
$60
n Hospital (facility) cost sharing $0
n Other cost sharing
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)
Total Example Cost
$1,900
In the example, Mia would pay: Cost Sharing
Deductibles Copayments Co-insurance
What isn't covered Limits or exclusions The total Mia would pay is
$500 $1,680
$18
$2,048
The plan would be responsible for the other costs of these EXAMPLE covered services.
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ATTENTION: Language assistance services, free of charge, are available to you. Call 1-877-411-3625 (TTY/TDD: 711).
Español (Spanish) ATENCIÓN: Usted tiene a su disposición, gratis, servicios de ayuda para idiomas. Llame al 1-877-411-3625 (TTY/TDD: 711).
(Traditional Chinese) 1-877-411-3625 (TTY/TDD: 711)
P (Russian) ! . . 1-877-411-3625 ( TTY/TDD: 711).
Kreyòl Ayisyen (Haitian Creole) ATANSYON: Gen sèvis èd nan lang gratis ki disponib pou ou. Rele nimewo 1-877-411-3625 (TTY/TDD: 711).
(Korean) : . 1-877-411-3625(TTY/TDD: 711) .
Italiano (Italian) ATTENZIONE: sono disponibili servizi gratuiti di assistenza linguistica. Chiami il numero 1-877-411-3625 (TTY/TDD: 711).
(Yiddish) 1-877-411-3625 . , , :
.(TTY/TDD: 711)
(Bengali) : 1-877-411-3625 (TTY/TDD: 711)
Polski (Polish) UWAGA: dostpna jest bezplatna pomoc jzykowa. Prosimy zadzwoni pod numer 1-877-411-3625 (TTY/TDD: 711).
(Arabic) .(TTY/TDD: 711) 1-877-411-3625 :
Français (French) ATTENTION : une assistance d'interprétation gratuite est à votre disposition. Veuillez composer le 1-877-411-3625 (TTY/TDD : 711).
Health Insurance Plan of Greater New York (HIP), EmblemHealth Insurance Company, EmblemHealth Plan, Inc. and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.
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(Urdu) )TTY/TDD: 711( 1-877- 411-3625 :
Tagalog (Tagalog) NANANAWAGAN NG PANSIN: Mayroon kang magagamit na mga serbisyo para sa tulong sa wika nang walang bayad. Tawagan ang 1-877-411-3625 (TTY/TDD: 711).
(Greek) : , . 1-877-411-3625 ( (TTY/TDD): 711).
Shqip (Albanian) VINI RE: Shërbime ndihmore për gjuhën, falas, janë në dispozicionin tuaj. Telefononi në 1-877-411-3625 (TTY/TDD: 711).
NOTICE OF NONDISCRIMINATION POLICY
EmblemHealth complies with 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 help Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose first language is not English, such as: Qualified interpreters Information written in other languages
If you need these services, please call member services at 1-877-411-3625 (TTY/TDD: 711).
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 member services at 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 Services, 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 Services, 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.
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