• No pre-existing condition limitation

We will not refuse to cover the treatment of a condition you had before you enrolled in this plan solely because you had the condition before you enrolled.

• Minimum essential coverage (MEC)

Coverage under this plan qualifies as minimum essential coverage.  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.

• Minimum value standard

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

• Where you can get information about enrolling in the FEHB Program

See www.opm.gov/healthcare-insurance  for enrollment information, as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you brochures for other plans and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We don’t determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, you must also contact your employing or retirement office.

• Types of coverage available for you and your family

Self Only coverage is for you alone.  Self Plus One coverage is for you and one eligible family member. Self and Family coverage is for you and one eligible family member, or you your spouse, and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office.  Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family.  You may change your enrollment 31 days before to 60 days after that event.  The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member.  When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form.  Benefits will not be available to your spouse until you are married.  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 employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we.  Please tell us immediately of changes in family member status including your marriage, divorce, annulment, or when your child reaches age 26.  

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) – such as marriage, divorce, or the birth of a child –  outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage.  For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

• Family member coverage

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage if you reside in a state that recognizes common-law marriages) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

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.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

• Children’s Equity Act

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. 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).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM
• 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
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to a Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child.  Contact your employing office for further information.

• When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2021 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2020 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage, (i.e. 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.  You may be billed for services received directly from your provider.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

• When you retire

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

• When FEHB coverage ends

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment; or
• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31^st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60^th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy).

• Upon divorce

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM’s website at  www.opm.gov/healthcare-insurance/healthcare/plan-information.  A carrier may request than an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment. 

• Temporary Continuation of Coverage (TCC)

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Affordable Care Act (ACA) did not eliminate TCC or change The TCC rules. For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn 26, etc. You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

• Converting to individual coverage

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (if you cancelled your coverage or did not pay your premium, you cannot convert),
• You decided not to receive coverage under TCC or the spouse equity law, or
• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions.  When you contact us, we will assist you in obtaining information about health benefits coverage inside and outside the Affordable Care Act's Health Insurance Marketplace in your state.  For assistance in finding coverage, please contact us at 800-HIP-TALK (800-447-8255) or visit our website at www.emblemhealth.com.

• Health Insurance Marketplace

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov.  This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a plan provider, or fill a prescription at a plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-HIP-TALK (800-447-8255) or write to us at HIP Health Plan of New York, 55 Water Street, New York, NY 10041.  You may also request replacement cards through our website: www.emblemhealth.com.

Where you get covered care

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments and deductibles.

• Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is also available on our website at www.emblemhealth.com.

• Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website at www.emblemhealth.com.

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care.

• Primary care

Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the plan, call us. We will help you select a new one.

• Specialty care

Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral.  However, you may see a Plan gynecologist without a referral.

Here are some other things you should know about specialty care:

• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).
• If you are seeing a specialist when you enroll in our plan, talk to your primary care physician. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause;
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
  • reduce our service area and you enroll in another FEHB plan;

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

• Hospital care

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

• If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our plan begins, call our customer service department immediately at 800-HIP-TALK (800-447-8255). 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.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

You need prior plan approval for certain services

Since your primary care physician arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services requiring our Prior Approval.  You are responsible for the cost of any service received without Prior Approval.

• Inpatient hospital admission

Prior Approval is the process by which - prior to your inpatient hospital admission - we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition.

• Other services requiring our Prior Approval

Your primary care physician has authority to refer you for most services.  For certain services, however, your physician must obtain prior approval from us.  Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

The following are services that require prior approval:

• Inpatient non emergency procedures that provide acute, rehabilitation and skilled nursing care. 
• All outpatient invasive and surgical procedures and treatments in a facility or doctor's office.               
• Inpatient treatment of mental illness and substance use disorder, detoxification treatment of substance use disorder, and Rehabilitation treatment of Substance Use Disorder.                             
• Non-routine outpatient treatment of mental illness and substance use disorder, which includes:
  • partial hospitalization;
  • intensive outpatient treatment;
  • ambulatory detoxification treatment;
  • outpatient ECT (electro-convulsive treatment);
  • neuropsychological testing; and
  • psychological testing.                     
• Non emergent transportation.                     
• Home health care.      
• Hospice care.        
• Pre-transplant evaluation and transplant services.        
• Outpatient cardiac and pulmonary rehabilitation.      
• Outpatient diagnostic radiology services.   
• Outpatient physical, occupational and speech therapies.         
• Radiation Oncology.
• Pain management.  
• Sleep studies.
• Advanced molecular diagnostics and genetic testing.
• Hyperbaric oxygen therapy.
• Experimental and/or investigational treatments and procedures.

Prior approval is required to obtain certain prescription drugs.  These drugs include migraine medications, anti-nausea medications, anti-fungal agents, anti-inflammatory agents, appetite suppressants, hepatitis C medications, fertility medications, growth hormones, leukotriene blocker asthma medications, smoking deterrents, eczema medications, vitamin A-based medications for treatment of cystic acne and other drugs and drug classes listed below.

If the prescription request is approved, the pharmacist will fill your prescription.  If the prescription request is not approved, HIP will not cover the prescription.

The individual prescription drugs listed below require Prior approval.  The drug list below shows each drug by its brand name and generic name.

• Amevive / alefacept
• Enbrel / etanercept
• Humira / adalimumab
• Kineret / anakinra
• Provigil / modafinil
• Regranex / becaplermin
• Somavert / pegvisomant
• Zyvox / linezolid
• Penlac / ciclopirox solution
• Tazorac / tazarotene
• Lidoderm / lidocaine patch
• Orencia / abatacept
• Sutent / sunitinib malate
• Nexavar / sorafenib tosylate
• Xeloda / capecitabine

In addition, prescription drugs in the drug classes listed below are also subject to Prior Approval.

• Antihypertensive agents
• Anti-nausea medications
• Anti-depressant medications
• Anti-fungal agents
• Anti-inflammatory agents
• Appetite suppressants
• Blood pressure medication
• Cholesterol lowering medications
• Diabetic medication
• Eczema medications
• Fertility medications
• GI medications that block acid secretion
• Growth hormones
• Hepatitis C medications
• Leukotriene blocker asthma medications
• Migraine medications
• Narcotics/opioids
• Osteo-arthritis/anti-inflammatory medications
• Vitamin A based medications for treatment of cystic acne

How to request prior approval for an admission or get prior approval for Other services, Prescription drugs, and Specialty drugs

First, your physician, your hospital, you, or your representative, must call us at 888-447-2884 before admission or services requiring prior approval are rendered.

Next, provide the following information:

• enrollee's name and plan identification number;
• patient's name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay.

Prescription Drugs:  If your prescription is for a drug that is subject to Prior approval, your pharmacist will inform you, and you must notify your physician.  Your physician should then contact our Pharmacy Benefits Services Department (PBSD) at 1-866-447-9717.  Our PBSD staff and your physician will decide, based upon our clinical guidelines, whether the prescription is Medically Necessary and Appropriate for your treatment or condition.  If you elect not to contact your physician, HIP will not cover the prescription and you will be responsible for the cost of the drug.

Specialty Pharmacy:  Your physician must call the Specialty Pharmacy Program Provider at 1-800-424-4084 to obtain Prior Approval before the physician can access and administer certain medically necessary and appropriate specialty pharmacy drugs.

• Non-urgent care claims

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior approval.  We will make our decision within 15 days of receipt of the pre-service claim.  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.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

• Urgent care claims

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim.  You will then have up to 48 hours to provide the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

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.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-HIP-TALK (800-447-8255).  You may also call OPM's FEHB 3 at (202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-HIP-TALK (800-447-8255).  If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

• Concurrent care claims

A concurrent care claim involves care provided over a period of time or over a number of treatments.  We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision.  This does not include reduction or termination due to benefit changes or if your enrollment ends.  If we believe a reduction or termination is warranted we will allow you sufficient time to apeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

The Federal Flexible Spending Account Program -- FSAFEDS

• Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket health care expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

• Emergency inpatient admission

If you have an emergency admission 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 hospital must phone us within 48 hours following the day of the emergency admission, even if you have been discharged from the hospital. 

• Maternity care

Claims for maternity care are broken down into claim payments for medical services received throughout all three trimesters of pregnancy, hospital services for delivery, and postpartum care.  Maternity care in an outpatient setting applies to pre and postpartum care in a doctor's office or other outpatient setting.  Delivery claims apply to inpatient admissions for birthing services (vaginal delivery/c-section).  Inpatient admissions for maternity care do not require prior authorization.

• If your treatment needs to be extended

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have a pre-service claim and you do not agree with our decision regarding prior approval of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.

• To reconsider a non-urgent care claim

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to:

1. Precertify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or

2. Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

3. Write to you and maintain our denial.

• To reconsider an urgent care claim

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.  We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

Cost-sharing

Cost-sharing  is the general term used to refer to your out-of-pocket costs (e.g., deductible and copayments) for the covered care you receive.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

In the High Option plan, when you see your primary care physician, you pay a copayment of $30 per office visit. When you see a specialist, you pay a copayment of $50 per office visit.

In the Standard Option plan, when you see your primary care physician, you pay a copayment of $30 per office visit. When you see a specialist, you pay a copayment of $75 per office visit.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them.  Copayments do not count toward any deductible. 

• We do not have a calendar year deductible for the High Option.
• The calendar year deductible is $3,000 per person under Standard Option. Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $3,000 under Standard Option. Under Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $6,000 under the Standard Option.  Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $6,000 under the Standard Option.
• There is also an annual $100 deductible for brand name prescription drugs under the High Option and an annual $300 deductible for brand name prescription drugs under the Standard Option.

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan.  If you change plans at another time during the year, you must begin a new deductible under your new plan.

Your catastrophic protection out-of-pocket maximum

After your (in network) out-of-pocket expenses, for the High Option plan, including any applicable deductibles and copayments total $6,850 for Self Only, or $13,700 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost sharing listed under Self Only of $6,850 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

After your (in network) out-of-pocket expenses, for the Standard Option plan, including any applicable deductibles and copayments total $8,550 for Self Only, or $17,100 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost sharing listed under Self Only of $8,550 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

High Option example scenario:  Your plan has a $6,850 Self Only maximum out-of-pocket limit and a $13,700 Self Plus One or Self and Family maximum out-of-pocket limit.   If you or one of your eligible family members has out-of-pocket qualified medical expenses of $6,850 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan.  With a Self and Family enrollment out-of-pocket maximum of $13,700, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $6,850 for the calendar year before their qualified medical expenses will begin to be covered in full. 

However, copayments if applicable for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments for these services:

• Routine foot care 

• Vision care services 

• Expenses for services and supplies that exceed the stated maximum dollar or day limit 

• Expenses from utilizing out-of-network providers

Be sure to keep accurate records and receipt of your copayments to ensure the plan's calculation of your out-of-pocket maximum is reflected accurately.

Carryover

If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan.  If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan.  If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan.  Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

• High Option

• $30 copay for primary care physicians.
• $30 copay for mental health and substance abuse providers.
• $50 copay for specialists.
• $50 deductible for durable medical equipment (DME).
• $50 deductible for orthopedic and prosthetic devices.
• $100 brand name prescription drug calendar year deductible per individual.
• $0 copay for dependent children to age 26 for the following services:
  • primary care physician office visits
  • specialist physician office visits
  • home health care
  • x-rays and diagnostic & lab tests
  • outpatient treatment of mental illness
  • outpatient rehabilitation treatment of substance use disorders
  • chiropractic services
  • outpatient speech, occupational and physical therapy

• Standard Option

• $30 copay for primary care physicians, not subject to deductible.
• $30 copay for mental health and substance abuse providers, not subject to deductible.
• $75 copay for specialists, after deductible.
• $100 deductible for durable medical equipment (DME). 
• $300 brand name prescription deductible.
• $3,000 calendar year deductible per individual; $6,000 calendar year deductible per family.

Prior Approval

To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following network authorization processes:

Routine outpatient mental health and substance use disorder services do not require prior authorization. For mental health and substance use disorder services that do require prior authorization, including those identified in Section 3, above, regarding “Other services requiring our Prior Approval,” call 888-447-2526 for authorization and help in selecting a provider. A trained professional will assess your treatment needs and assist you in obtaining treatment with a participating provider. You do not need a referral from your primary care physician for mental health and substance use services.

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

24-Hour Nurse Advice Line

For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-877-444-7988 and talk with a registered nurse who will discuss treatment options and answer your health questions.

Services for deaf and hearing impaired

The phone number for the hearing impaired is 888- HIP-4TDD (888-447-4833).

Travel benefit/services overseas

Please contact customer service at:  (800) 447-8255

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Providers must file form CMS-1500, Health Insurance Claim Form. Your facility will file the UB-04 form. For claims questions and assistance, contact us at 800-HIP-TALK (800-447-8255), or at our website at www.emblemhealth.com.

When you must file a claim – such as for services you received outside the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:  HIP Health Insurance Plan of New York

                                         55 Water Street

                                         New York, New York 10041

Prescription drugs

Under normal circumstances, you do not have to file claims for your prescription drugs. Please call 800-HIP-TALK (800-447-8255) for specific instructions and a claim form.

Submit your claims to:  HIP Health Insurance Plan of New York

                                         55 Water Street

                                         New York, New York 10041

Other supplies or services

Submit your claims to:   HIP Health Insurance Plan of New York

                                          55 Water Street

                                          New York, New York 10041

We will notify you of our decision within 30 days after we receive your post-service claim.  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 before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

Notice Requirements

If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the health care provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: HIP Health Plan of New York, 55 Water Street, 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

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

e) Include your email address, if you would like to receive our decision via email.  Please note that by giving us your email, we may be able to provide our decision more quickly.

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.  We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date.  However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration.  You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or  

b) Write to you and maintain our denial, or

c) Ask you or your provider for more information

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

3

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 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
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street, NW, Washington, DC 20415-3630. 

Send OPM the following information:

• 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; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM’s decision via email.  Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note:  If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note:  You are the only person who has a right to file a disputed claim with OPM.  Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.  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.

Note:  The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control. 

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied preauthorization or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays health care expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines.  For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.emblemhealth.com.

When we are the primary payor, we will pay the benefits described in this brochure.

• TRICARE and CHAMPVA

TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled veterans and their eligible dependents. IF TRICARE or CHAMPVA and this plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

• Workers' compensation

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or 
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

• Medicaid

When you have this plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

When other Government agencies are responsible for your care

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage.

If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party’s insurance policies, your own insurance policies, or a workers’ compensation program or policy, you must reimburse us out of that payment. Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness. However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned. 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 damages claimed.

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.

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.

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 health plan covers care for clinical trials according to the definitions listed below and as stated on specific pages of this brochure:

• Routine care costs - costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient's cancer, whether the patient is in a clinical trial or is receiving standard therapy.  This plan covers costs for routine care.
• Extra care costs - Costs related to taking part in a clinical trial such as additional tests that a patient may need as  part of the trial, but not as part of the patient's routine care.  This plan does not cover these costs.
• 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.  This plan does not cover these costs.  

When you have Medicare

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

• The Original Medicare Plan (Part A or Part B)

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

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.  This is true whether or not they accept Medicare.

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.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-HIP-TALK (800-447-8255) or see our website at www.emblemhealth.com.

We do not waive any costs if the Original Medicare Plan is your primary payor.

Please review the following table, it illustrates your cost share if you are enrolled in Medicare Part B.  Medicare will be primary for all Medicare eligible services.  Members must use providers who accept Medicare's assignment.

Benefit Description - Calendar Year Deductible

High Option You Pay without Medicare: $0

Standard Option You Pay without Medicare: $3,000 per person/ $6,000 per family

High Option You Pay with Medicare Part B: $0

Standard Option You Pay with Medicare Part B: $3,000 per person/ $6,000 per family

Benefit Description - Out of Pocket Maximum

High Option You Pay without Medicare: $6,850 for Self Only/ $13,700 Family

Standard Option You Pay without Medicare: $8,550 for Self Only/ $17,100 Family

High Option You Pay with Medicare Part B: $6,850 for Self Only/ $13,700 Family

Standard Option You Pay with Medicare Part B: $8,550 for Self Only/ $17,100 Family

Benefit Description - Part B Premium Reimbursement Offered

High Option You Pay without Medicare: N/A

Standard Option You Pay without Medicare: N/A

High Option You Pay with Medicare Part B: N/A

Standard Option You Pay with Medicare Part B: N/A

Benefit Description - Primary Care Physician

High Option You Pay without Medicare:$30 Copay - Adult; $0 Copay - Children to age 26

Standard Option You Pay without Medicare: $30 copay, not subject to deductible

High Option You Pay with Medicare Part B: $30 Copay - Adult; $0 Copay - Children to age 26

Standard Option You Pay with Medicare Part B: $30 copay, not subject to deductible

Benefit Description - Specialist

High Option You Pay without Medicare: $50 copay/$0 child copay

Standard Option You Pay without Medicare: $75 copay, after deductible

High Option You Pay with Medicare Part B: $50 copay/$0 child copay

Standard Option You Pay with Medicare Part B: $75 copay, after deductible

Benefit Description - Inpatient Hosptial

High Option You Pay without Medicare: $100 copay per admission

Standard Option You Pay without Medicare: $250 copay per admission, after deductible

High Option You Pay with Medicare Part B: $100 copay per admission

Standard Option You Pay with Medicare Part B: $250 copay per admission, after deductible

Benefit Description - Outpatient Surgery - Hosptial

High Option You Pay without Medicare: $150 copay per visit

Standard Option You Pay without Medicare: $150 copay per visit, after deductible

High Option You Pay with Medicare Part B: $150 copay per visit

Standard Option You Pay with Medicare Part B: $150 copay per visit, after deductible

Benefit Description - Incentives Offered

High Option You Pay without Medicare: N/A

Standard Option You Pay without Medicare: N/A

High Option You Pay with Medicare Part B: N/A

Standard Option You Pay with Medicare Part B: N/A

You can find more information about how our plan coordinates benefits with Medicare in"Medicare And Other Health Benefits: Your Guide to Who Pays First" at www.Medicare.gov

• Tell us about your Medicare coverage

• Medicare Advantage Prime (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY 877-486-2048), or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and our Medicare Advantage plan: You may enroll in our Medicare Advantage plan and also remain enrolled in our High Option FEHB plan only.  In this case, we do waive some cost-sharing for your FEHB coverage.

This Plan and another plan’s Medicare Advantage plan: For High Option only, you may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). 

However, we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium (OPM does not contribute to your Medicare Advantage plan premium).  For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

• Medicare prescription drug coverage (Part D)

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 (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application. 

• Routine care costs - costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy.
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care.
• Research care 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.

Copayment

See Section 4, page 22.

Cost-sharing

See Section 4, page 22.

Custodial care

Deductible

See Section 4, page 22.

A "Covered Appliance" is one of the following items which is prescribed by your plan physician, dispensed by a plan provider and approved by HIP.  HIP maintains a list of Covered Appliances that contains items in each of the categories listed below.  This list is prepared by HIP and periodically reviewed and modified.  HIP will determine whether a Covered Appliance should be customized, rented, purchased or repaired.

1. Durable Medical Equipment, which is:  
   A.  Primarily and customarily used to serve a medical purpose;  
   B.  Generally not useful to a person in the absence of illness or injury; 
   C.  Appropriate for use in the home; 
   D.  Medically necessary for the care and treatment of the member's illness or injury.
2. Prosthetic devices which replace all or part of an internal body organ or external limb.  However, dental prosthetics needed due to an accidental injury to sound natural teeth if the service is provided within twelve (12) months of the accident and necessary in treatment due to congenital disease or anomaly will be covered.
3. Orthopedic devices which are required for the treatment of injuries or disorders of the skeletal system and associated muscles, joints and ligaments.

Experimental or investigational service means any evaluation, treatment, services therapy, or device which involves the application, administration or use, of procedures, techniques, equipment, supplies, products, remedies, vaccines, biological products, drugs, pharmaceuticals, or chemical compounds, as determined solely by the plan:

1. Such evaluation, treatment, therapy, or device cannot be lawfully marketed without approval of the United States Food and Drug Administration or the New York Department of Health and Rehabilitative Services, and approval for marketing has not, in fact, been given at the time such is furnished to the covered person; 
2. Reliable evidence, as determined by the plan, shows that such evaluation, treatment, therapy, or device (a) is the subject of an ongoing Phase I or II clinical investigation, or experimental or research arm of a Phase III clinical investigation, or under study to determine: maximum tolerated dosage(s), toxicity, safety, efficacy, or efficacy as compared without the standard means for treatment or diagnosis of the condition in question; or (b) has not been proven safe and effective for the treatment of the condition in question, as evidenced in the most recently published medical literature in the United States, Canada or Great Britain, using generally accepted scientific, medical or public health methodologies or statistical practices; or (c) is not the standard evaluation, treatment, therapy or device utilized by practicing physicians in treating other patients with the same or similar condition; 
3. There is no consensus among practicing physicians that the evaluation, treatment, therapy or device is safe or effective for the treatment in question; or
4. The consensus of opinion among experts is that further studies, research, or clinical investigations are necessary to determine maximum tolerated dosage(s), toxicity, safety, efficacy or efficacy as compared with the standard means for treatment or diagnosis of the condition in question.

Group health coverage

An organization such as your employer arranged for your coverage under this contract. The member’s group has chosen to engage HIP to make arrangements through which medical services and hospital services will be delivered in accordance with the terms and conditions of the certificate of coverage.

Plan allowance

Plan allowance is the amount we use to determine our payment for covered services. Plans determine their allowances in different ways. We determine our allowance as follows:

For participating providers, the Plan allowance is the fee schedule or negotiated rate that HIP HMO uses as payment in full for covered services rendered by participating providers. 

Urgent care claims

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:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims.   We will determine whether or not a claim is an urgent care claim by applying the judgement of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 800-HIP-TALK (800-447-8255).  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Medical services provided by physicians:  Diagnostic and treatment services provided in the office

Office visit copay: $30 primary care; $50 specialist; $0 dependent children to age 26

27

Services provided by a hospital:  Inpatient

$100 per admission copay

56

 Services provided by a hospital: Outpatient

$150 per visit

57

Emergency benefits:  In-area

$250 per visit

59

Emergency benefits:  Out-of-area

$250 per visit

60

Mental health and substance use disorder treatment:

Regular cost-sharing

61-63

 Prescription drugs: Retail pharmacy (up to a 30-day supply)

$25 for generic formulary drugs
$50 for brand name formulary drugs
$100 for non-formulary drugs
$200 for specialty drugs

65

 Prescription drugs: Mail order (up to a 90-day supply)

No mail order on non-formulary or specialty drugs

$37.50 for generic formulary drugs or
$75 for brand name formulary drugs

65

Dental care:

Nothing for Pediatric Dental

Adult Dental: $5 for one exam; $10 for one prophylaxis (cleaning)

68-69

Vision care:

$50 per visit

38-39

Special features:  

Flexible benefits option, 24-Hour Nurse Advice Line, Services for deaf and hearing impaired, Travel benefit/services overseas.

70

Protection against catastrophic costs (out-of-pocket maximum):

$6,850 for Self Only

$13,700 for Self Plus One and Self and Family

22-23

 Medical services provided by physicians: Diagnostic and treatment services provided in the office

Office visit copay: $30 primary care; $75 specialist, after deductible

27

 Services provided by a hospital: Inpatient

$250 copay per admission, after deductible

56

Services provided by a hospital:  Outpatient

$150 per visit, after deductible

57

 Emergency benefits: In-area

$250 per visit, after deductible

59

 Emergency benefits: Out-of-area

$250 per visit, after deductible

60

Mental health and substance use disorder treatment:

Regular cost-sharing

61-63

 Prescription drugs: Retail pharmacy (up to a 30-day supply)

$25 for generic formulary drugs
$50 for brand name formulary drugs
$100 for non-formulary drugs
$200 for specialty drugs

65

 Prescription drugs: Mail order (up to a 90-day supply)

No mail order on non-formulary or specialty drugs

$38 for generic formulary drugs, or
$75 for brand name formulary drugs

65

Dental care:

Nothing for Pediatric Dental (Covered for children age 19 and under)

No benefit for Adult Dental

68-69

Vision care:

$50 per office visit, after deductible

38-39

Special features: 

Flexible benefits option, 24-Hour Nurse Advance Line, Services for deaf and hearing impaired, Travel benefit/services overseas.

70

Protection against catastrophic costs (out-of-pocket maximum):

$8,550 for Self Only

$17,100 Self Plus One or Self and Family

22-23