43 | Page
GHI-COMPREHENSIVE BENEFITS PLAN/ANTHEM BLUE CROSS AND BLUE SHIELD HOSPITAL PLAN (GHI-CBP)
GHI-Anthem CBP option consists of two components:
• GHI, an EmblemHealth company, offering benefits for medical/physician services, and
• Anthem Blue Cross and Blue Shield offering benefits for services provided at hospital and
out-patient facilities.
GHI Emblem Health (GHI): You have the freedom to choose any provider worldwide. You can select a
GHI participating provider and not pay any deductibles or coinsurance, or go out-of-network and still
receive coverage, subject to deductibles and coinsurance. GHI’s provider network includes all
medical specialties. When you need specialty care, you select the specialist and make the
appointment. Payment for services will be made directly to the provider - you will not have to file a
claim form when you use a GHI participating provider.
Anthem Blue Cross and Blue Shield (AnthemBCBS): 96% of the nation’s hospitals participate in the
Blue Cross and Blue Shield Association BlueCard® PPO Program network, which provides you with
access to network care across the country, it should be easy to find a participating facility in a
convenient location.
NEW IN 2020
You can now visit Memorial Sloan Kettering Cancer Center (MSK) for cancer treatment and Hospital
for Special Surgery (HSS) for orthopedic treatment, and your hospital inpatient copays will be waived
when you utilize these two nationally recognized hospitals. You must use a doctor who participates
in your GHI-CBP plan and participates with MSK or HSS. If you prefer, you can still go to any hospital
of your choice and your benefits and costs will remain the same as they are today.
At a Glance
Plan Type:
PPO
Geographic Service Area
Nationwide
Does this plan use a network of providers?
GHI: Yes. Visit the website www.emblemhealth.com/city or call 1-800-624-2414 for a list of
participating medical providers.
Anthem Blue Cross and Blue Shield: Yes. Visit the website www.anthem.com/nyc or call
1-800-433-9592 for a list of participating hospital and out-patient facilities.
Do I need a referral to see a specialist?
No
Contact Information
EmblemHealth
55 Water Street
New York, NY 10041
1-800-624-2414
Anthem Blue Cross and Blue Shield
City of New York
Dedicated Service Center
P.O. Box 1407
Church Street Station
New York, NY 10008-3598
1-800-433-9592 (Monday through Friday 8:30 a.m. to 5:30 p.m.)
Web Sites
emblemhealth.com/city
anthem.com/nyc
44 | Page
Plan Features
Cost
What is the overall medical deductible for this
plan?
GHI: In-network: $0
Out-of-network: $200 individual/$500 family
What is the out-of-pocket limit on my
expenses (applies to in-network services
only)?
For 7/01/23 – 6/30/24 the limit is $4,550 individual/$9,100 family.
AnthemBCBS Hospital:
What are the costs for preventive services?
Visit emblemhealth.com/city for a full list of
preventive services.
What are the costs when you visit an
AdvantageCare Physician’s (ACPNY) office?
• ACPNY primary care visit to treat an injury or illness: $0 copay/visit
• ACPNY specialist visit: $0 copay/visit
What are the costs when you visit a health
care provider’s office?
• In-network primary care visit to treat an injury or illness: $15 copay/visit
• ACPNY: $0 copay/visit
• Non-participating provider: After deductible is met 0% coinsurance
• In-network specialist visit: $30 co-pay/visit
• Non-participating provider: After deductible is met 0% coinsurance
• In-network other practitioner office visit: $15 copay/visit
• Non-participating provider: After deductible is met 0% coinsurance
• In-network preventive care/screening/immunization: $0 copay/visit
• Non-participating provider: After deductible is met 0% coinsurance
What are the costs when you use Teladoc?
• Teladoc is an easy, convenient way to access doctors for treatment of non-emergency
conditions, including cold and flu symptoms, respiratory infections, sinus problems,
bronchitis, skin problems, and allergies.
• Your first visit is free. After that, Teladoc visits have a $10 copay.
• Visit Teladoc/Emblemhealth or call 800-835-2362 (800-Teladoc) (TTY: 711) to set up your
account. Once you register, you are just a call or click away from getting treatment.
What are the costs if you have a test?
• In-network diagnostic test (x-ray, blood work): $20 co-pay/visit
• Non-participating provider: After the deductible is met 0% co-insurance
• In-network imaging (CT/PET scans, MRIs): $50 co-pay for Preferred providers, $100 copay
for Non-preferred providers. (Pre-certification required)
• Non-participating provider: After deductible is met 0% co-insurance
What are the costs if you have outpatient
surgery?
• AnthemBCBS: Facility fee:
In-network: 20% coinsurance of allowed amount to a maximum of $200 per
person per calendar year.
Out-of-Network provider: $500 deductible per person per visit and 20%
coinsurance per person and balance billing.
• GHI: Physician/surgeon fees:
In-network: Covered
Non-participating provider: After deductible is met 0% co-insurance
You must call NYC Healthline 1-800- 521-9574 for pre-certification.
What are the costs if you need immediate
medical attention?
• AnthemBCBS: Emergency room services:
In-network: $150 copay/visit; Co-pay waived if admitted.
Out-of-network: $150 copay/visit; Co-pay waived if admitted
• GHI: Emergency medical transportation:
In-network: Not covered
Out-of-network: 100% of the 80% percentile of Fair Health
• GHI: Urgent Care:
In-network: $50 copay/visit Preferred $100 copay/visit Non-preferred
Non-participating provider: After the deductible is met 0% co-insurance
What are the costs if you have a hospital stay?
• GHI: Physician/surgeon fees:
In-network: Covered
Non-participating provider: After the deductible is met 0% co-insurance
• ANTHEM: Facility fee (e.g., hospital room):
In-network (e.g., hospital room): $300 per person up to $750 maximum individual co-
pay per calendar year.
45 | Page
Out-of-network: $500 per person up to $1,250 in a calendar year. After the individual
co-payment is met, Anthem will pay 80% of the allowed amount and you will be
charged 20% co-insurance and balance billing.
You must call NYC Healthline 1-800- 521-9574 for approval. If there is no call, claim is subject
to a penalty of $250 per day up to a maximum of $500. There has to be a gap of 90 days
between admissions before the 365 days will renew.
What are the costs if you are pregnant?
• GHI: Prenatal and postnatal care:
In-network: No charge
Out-of-Network: After the deductible is met 0% co-insurance
• GHI: Delivery and inpatient physician/surgeon services:
In-network: No charge
Out-of Network: After the deductible is met 0% co-insurance
• ANTHEM: Delivery and all inpatient services:
In-network: $300 per person up to $750 maximum deductible.
Out-of-network: $500 per person up to $1,250 maximum deductible. Doesn’t apply to
copayments.
You must call NYC Healthline 1-800- 521-9574 for approval. If there is no call, claim is subject
to a penalty of $250 per day up to a maximum of $500.
WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• GHI: In-network: $15 co-pay/visit
Out-of-Network: After the deductible is met 0% coinsurance.
Mental/Behavioral health
Inpatient services
• GHI: In-network: $300 co-pay per admission
Out-of-Network: $500 co-pay per admission/$1,250 maximum per calendar year.
*20% to max of $2,000 per person per calendar year.
Substance abuse
Outpatient services
• GHI: In-network: $15 co-pay/visit
Out-of-network: After the deductible is met 0% coinsurance.
Substance abuse
Inpatient services
• GHI: In-network: $300 co-pay per admission
Out-of-Network: $500 co-pay per admission/ $1,250 maximum per calendar year
*20% to max of $2,000 per person per calendar year.
WHAT ARE THE COSTS IF YOU NEED HELP RECOVERING OR HAVE OTHER SPECIAL HEALTH NEEDS?
Service
Cost
Home health care
• GHI:
− In-network: No charge
− Out-of-Network: $50 deductible per episode; 20% coinsurance
− 200 visits per member per year
− Pre-certification required
Skilled nursing care
• ANTHEM:
− In-network: $300 deductible per admission, up to a maximum of $750 per person
per calendar year
− Out-of-network: $500 deductible per person per visit and 20% co-insurance per
person and balance billing.
− Coverage is limited to 90 days annual max.
Durable medical equipment (DME)
•
GHI:
− In-network: $100 deductible
− Out-of-network: $100 deductible; 50% of usual and customary charge
− Pre-certification required on items greater than $2,000
−
You must call NYC Healthline 1-800- 521-9574 for approval.
Hospice service
• ANTHEM:
− In-network: No charge
− Out-of-Network: No charge
− Coverage is limited to 210 days lifetime max.
46 | Page
OPTIONAL RIDER – PRESCRIPTION DRUGS PROVIDED THROUGH GHI-EMBLEMHEALTH
WHAT IS THE COST IF YOU NEED DRUGS TO TREAT YOUR ILLNESS OR CONDITION?
Retail
Mail Order: Smart90 Program
Generic drugs
Retail - 30 days supply - 2 fills;
20% co-insurance with min charge of $5 or
actual cost, if less.
Mandatory mail order –90 day supply; $12.50 co-pay.
Prescriptions will not be filled at retail after 2 fills. The
90 day supply can be obtained through Express Scripts
or participating Duane Reade or Walgreens.
Preferred brand drugs
Retail - 30 days supply - 2 fills;
40% co-insurance with min charge of $25
or actual cost, if less.
Mandatory mail order - 90 day supply; $50 co-pay.
Prescriptions will not be filled at retail after 2 fills.
Prior authorization is required for certain brand name
medications. The 90 day supply can be obtained
through Express Scripts or participating Duane Reade or
Walgreens.
Non-preferred brand drugs
Retail - 30 days supply - 2 fills;
50% co-insurance with min charge of $40
or actual cost if less
Mandatory mail order - 90 day supply; $75 co-pay.
Prescriptions will not be filled at retail after 2 fills. The
90 day supply can be obtained through Express Scripts
or participating Duane Reade or Walgreens.
Specialty drugs*
Covered (cost based on above categories)
Must be dispensed by the Specialty Pharmacy Program
Provider. Pre-certification required contact NYC
Healthline at 1-800-521-9574.
*Must be dispensed by a Specialty Pharmacy.
OPTIONAL RIDER – ENHANCED SCHEDULE FOR OUT-OF-NETWORK MEDICAL/PHYSICIAN SERVICES PROVIDED
THROUGH GHI-EMBLEM HEALTH
Enhanced schedule increases the reimbursement of the basic program's non-participating provider fee schedule, on average,
by 75%.
GHI-EMBLEM: NON-PARTICIPATING (OUT-OF-NETWORK) PROVIDER BENEFITS:
Payment for services provided by out-of-network providers is made directly to you under the NYC Non-Participating Provider
Schedule of Allowable Charges (Schedule). The reimbursement rates (allowed amounts) in the Schedule are not related to usual and
customary rates or to what the provider may charge but are set at a fixed amount based on GHI's 1983 reimbursement rates. Most
of the reimbursement rates have not increased since that time and will likely be less (and in many instances substantially less) than
the fee charged by the out of- network provider. You will be responsible for any difference between the provider’s fee and the
amount of the reimbursement; therefore, you may have a substantial out-of-pocket expense.
Once a member, if you intend to use an out-of-network provider, you can call GHI-Emblem Customer Service with the medical
procedure code/s (CPT Code) of the service(s) you anticipate receiving to find out what you would be reimbursed.
Below are some examples of what you would typically pay out of pocket if you were to receive care or services from an out-of-
network provider.
Typical Out-of-Pocket Costs for Receiving Care from Out-of-Network Providers:
Established Patient Office Visit (typically 15 minutes) CPT Code 99213
Estimated Charge for a Doctor in Manhattan
$225.00
Reimbursement Under the Schedule
- $ 33.36
Member Out-of-Pocket Responsibility
$191.64
Routine Maternity Care and Delivery CPT Code 59400
Estimated Charge for a Doctor in Manhattan
$9,040.00
Reimbursement Under the Schedule
-$1,379.00
Member Out-of-Pocket Responsibility
$7,661.00
Total Hip Replacement Surgery CPT Code 27130
47 | Page
Estimated Charge for a Doctor in Manhattan
$20,099.95
Reimbursement under the Schedule
- $ 3,011.00
Member Out-of-Pocket Responsibility
$17,088.95
Please note that deductibles may apply and that you could be eligible for additional reimbursement if your catastrophic coverage
kicks in or you have purchased the Enhanced Non-Participating Provider Schedule, an Optional Rider benefit that provides lower out-
of-pocket costs for some surgical and in-hospital services from out-of-network doctors.
Effective for services received on or after April 1, 2015, GHI-EmblemHealth has set up new protections to ensure that — in the
following circumstances — members won't be responsible for costs other than the in-network cost-sharing (in-network copay,
coinsurance and/or deductible) that applies under the plan. These two cases are:
• If you receive out-of-network emergency services in a hospital in the State of New York
• If you receive a non-emergency "surprise bill" for out-of-network services rendered in the State of New York
You will not be responsible for the costs of "emergency services" you receive in a hospital, other than any in-network cost-sharing
(in-network copay, coinsurance and/or deductible) that applies to such services under your plan.
You will not be responsible for the costs of "surprise bills" for out-of-network services, other than any in-network cost-sharing (in-
network copay, coinsurance and/or deductible) that applies under your plan. For more information on what is “surprise bill”, please
call or visit the EmblemHealth website.
Please refer to the GHI-CBP Basic Plan, GHI-CBP with Enhanced Schedule and Prescription Drugs and Anthem Blue Cross and Blue
Shield (companion to GHI-CBP medical coverage) for additional information and to see what this plan covers and any cost-sharing
responsibilities.
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.