Summary of Benefits and Coverage: What this Covers & What ...
嚜燙ummary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Coverage Period: 07/01/2021每 06/30/2022
Empire Blue Cross Blue Shield Health Plans:
Coverage for: Individual + Family | Plan Type: PPO
City of New York Hospital Only Plan GHI - CBP Hospital
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, . 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 sbc-glossary/ or call (800)
433-9592 to request a copy.
Important Questions
What is the overall
deductible?
Are there services
covered before you
meet your deductible?
Are there other
deductibles for
specific services?
What is the out-ofpocket limit for this
plan?
Answers
$0.
Why This Matters:
See the Common Medical Events chart below for your costs for services this plan covers.
No.
You will have to meet the deductible before the plan pays for any services.
No.
You don't have to meet deductibles for specific services.
$2,600/individual or
$5,200/family for In-Network
Providers.
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?
Will you pay less if
you use a network
provider?
Premiums, balance-billing
charges, and health care this
plan doesn't cover.
Yes, National PPO. See
nyc or
call (800) 433-9592 for a list of
network providers.
Even though you pay these expenses, they don＊t count toward the out-of-pocket limit.
Do you need a referral
to see a specialist?
No.
You can see the specialist you choose without a referral.
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.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
NY/L/F/CityofNYGHICBPHospital-PPO/NA/OW5CI/NA/07-21
Page 1 of "
Common
Medical Event
If you visit a
health care
provider＊s office
or clinic
If you have a test
If you need drugs
to treat your
illness or
condition
More information
about prescription
drug coverage is
available at
[insert].
If you have
outpatient surgery
If you need
immediate
medical attention
If you have a
hospital stay
Services You May Need
Primary care visit to treat an
injury or illness
Specialist visit
What You Will Pay
Out-of-Network
In-Network Provider
Provider
(You will pay the least)
(You will pay the most)
Limitations, Exceptions, & Other
Important Information
Not covered
Not covered
No coverage for Primary care visit
Not covered
Not covered
Not covered
Not covered
No coverage for Specialist visit
No coverage for Preventative care 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.
Not covered
Not covered
No coverage for Diagnostic test
Not covered
Not covered
Not covered
Not covered
No coverage for Imaging
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
20% coinsurance up to
$200 maximum /benefit
period
$500/visit then 20%
coinsurance
Physician/surgeon fees
Not covered
Not covered
Emergency room care
$150/visit
Covered as In-Network
Not covered
Not covered
Not covered
$300/admission up to
$750 maximum /benefit
period
Not covered
Preventive care/screening/
immunization
Diagnostic test (x-ray, blood
work)
Imaging (CT/PET scans, MRIs)
Tier 1 - Typically Generic
Tier 2 - Typically Preferred /
Brand
Tier 3 - Typically Non-Preferred
/ Specialty Drugs
Tier 4 - Typically Specialty
(brand and generic)
Facility fee (e.g., ambulatory
surgery center)
Emergency medical
transportation
Urgent care
Facility fee (e.g., hospital room)
Physician/surgeon fees
Not covered
$500/admission then 20%
coinsurance
Not covered
Carved out to another vendor
--------none-------No coverage for Physician/surgeon
fees
Copay waived if admitted within 24
hours.
No coverage for Emergency medical
transportation
No coverage for Urgent care
--------none-------No coverage for Physician/surgeon
fees
* For more information about limitations and exceptions, see plan or policy document at .
Page 2 of "
Common
Medical Event
If you need
mental health,
behavioral health,
or substance
abuse services
If you are
pregnant
Services You May Need
Outpatient services
Inpatient services
Not covered
Not covered
Office visits
Childbirth/delivery professional
services
Not covered
Not covered
Not covered
Not covered
Childbirth/delivery facility
services
Home health care
Rehabilitation services
Habilitation services
If you need help
recovering or have
Skilled nursing care
other special
health needs
If your child
needs dental or
eye care
What You Will Pay
Out-of-Network
In-Network Provider
Provider
(You will pay the least)
(You will pay the most)
Office Visit
Office Visit
Not covered
Not covered
Other Outpatient
Other Outpatient
Not covered
Not covered
$300/admission up to
$750 maximum /benefit
period
Not covered
Not covered
Not covered
$500/admission then 20%
coinsurance
Not covered
Not covered
Not covered
$300/admission up to
$750 maximum /benefit
period
$500/admission then 20%
coinsurance
Durable medical equipment
Not covered
Not covered
Hospice services
Children＊s eye exam
Children＊s glasses
Children＊s dental check-up
No charge
Not covered
Not covered
Not covered
No charge
Not covered
Not covered
Not covered
Limitations, Exceptions, & Other
Important Information
Office Visit
No coverage for Behavioral Health
Other Outpatient
No coverage for Behavioral Health
No coverage for Behavioral Health -------none-------No Coverage for Childbirth/delivery
professional services Maternity care
may include tests and services
described elsewhere in the SBC (i.e.
ultrasound).
No coverage for Home Health care
*See Therapy Services section
90 days limit/benefit period. NYC
Health line may substitute benefits if
medically appropriate. 2 ? outpatient
visits=1 day.
*See Durable Medical Equipment
Section
210 days limit/lifetime.
*See Vision Services section
*See Dental Services section
* For more information about limitations and exceptions, see plan or policy document at .
Page 3 of "
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.)
? Acupuncture
? Chiropractic care
? Cosmetic surgery
? Dental care (adult)
? Dental Check-up
? Diagnostic test - Lab Office
? Diagnostic test- X-Ray Office
? Durable Medical Equipment
? Emergency medical transportation
? Eye exams for a child
? Glasses for a child
? Habilitation services
? Hearing aids
? Home Health care
? Imaging
? Infertility treatment
? Long- term care
? Maternity
? Mental / Behavioral Health - Inpatient
? Mental / Behavioral Health - Office Visit
? Mental / Behavioral Health - Outpatient
? Preventative care
? Primary Care
? Private-duty nursing
? Rehabilitation services
? Routine eye care (adult)
? Routine foot care unless you have been
diagnosed with diabetes.
? Specialist visit
? Surgeon Fee - Inpatient
? Surgeon Fee - Outpatient
? Tier 1 - Typically Generic
? Tier 2 - Typically Preferred / Brand
? Tier 3 - Typically Non-Preferred / Specialty
Drugs
? Tier 4 - Typically Specialty (brand and generic) ? Urgent care
? Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn＊t a complete list. Please see your plan document.)
? Bariatric surgery
? Most coverage provided outside the United
States. See
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, One State Street, New York, NY 10004-1511, (800) 342-3736, (212) 480-6400, (518) 474-6600.
Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, 1-877-267-2323 x61565, iio.. 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 or call 1-800-318-2596.
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 rights, 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:
ATTN: Grievances and Appeals, P.O. Box 1407, Church Street Station, New York, NY 10008-1407
Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, 1-877-267-2323 x61565, iio.
New York State Department of Financial Services, One State Street, New York, NY 10004-1511, (800) 342-3736, (212) 480-6400, (518) 474-6600
* For more information about limitations and exceptions, see plan or policy document at .
Page 4 of "
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare,
Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the
premium tax credit.
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.
每每每每每每每每每每每 To see examples of how this plan might cover costs for a sample medical situation, see the next section. 每每每每每每每每每每每每每每每每
* For more information about limitations and exceptions, see plan or policy document at .
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