EmblemHealth Healthy NY Small Businesses App

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                                           Healthy NY Case Submission
                                       Small Businesses (2-50 Employees)


         Eligibility Requirements:
        • Business is located in New York State and has 50 employees or fewer
        • Business did not provide health insurance to its employees in the last 12
        months
        • Employees work 20 or more hours per week
        • Thirty percent of the employees earn $40,000 or less in annual wages
        • Fifty percent of the employees must be enrolled in the Healthy New York
        plan; or, they must have coverage through another source
        • Fifty percent of the Healthy New York plan premium is paid by the
        employer
 

Along with your signed and dated application, be sure to include the following documents listed below.

        Completed Small Group Application and Transaction Form for Group
        Accounts
        Quarterly Combined, Withholding, Wage Reporting and Unemployment
        Insurance Return (NYS 45)
        If you do not have an NYS-45, you may provide a letter from a C.P.A. or
        attorney. The letter must include the company name, tax identification
        number, a list of all employees, the number of hours/week each employee
        works and their salary. Also please submit a copy of filed certificate of
        organization.
        A business check for the first month's premium payable to GHI


Make sure to:
    • Sign all forms where indicated
    • Furnish and sign the BOR letter included with this application
Mail application forms along with the above to:
                                             Vista Health Solutions, Inc.
                                                  Enrollment Dep’t.
                                                    PO Box 337
                                                 Suffern, NY 10901

31 Park Ave., Suffern, NY 10901                       Tel. 8457532320  Fax. 8455101940                          info@nyhealthinsurer.com 
 
                                    Healthy NY Application for Small Businesses
 
 
    Healthy NY Application Instructions
    Individuals and sole proprietors looking to purchase Healthy NY must complete a different application.

    Confidentiality Statement: The information provided on this application will remain confidential and will only
    be disclosed to the staff at health plans and state agencies operating this program.
 
 
    Section A: Small Business Information                        • Your business has a class of employees that you have
                                                                   not offered health insurance to during the last 12
    In this section, we ask how to contact you. Your               months but would now like to cover. The class must
    business must be located in New York State in order            pertain to geographic location or employees’ earnings,
    to participate.                                                method of payment, hours, or job duties.
                                                                  
 
                                                                 Section D: Eligibility Requirements
    Section B: Coverage Options                                   
                                                                 The business must be able to answer “Yes” to each
    1. Benefits                                                  question in Section D to be eligible.
    Healthy NY offers a standardized benefits package,            
    with an optional prescription benefit. Choose if you         Section E: Participation Requirements
    want Healthy NY with a prescription drug benefit              
    or without a prescription drug benefit.                      In order to be eligible, your business must meet the
    Once you choose the benefit option, you will not be able     participation rules concerning employees who will
    to change your selection until your annual recertification   purchase Healthy NY.
    or at the time of a premium rate change.                      
 
                                                                  
                                                                 Section F: Employee Information
    2 . Deductible                                                
                                                                 Please answer the questions in Section F about your
    All plans are subject to an annual deductible. The
                                                                 employees who will be enrolling in Healthy NY.
    deductible amount is the amount you must spend out-of-
                                                                 You do not need to include information about their
    pocket before services are covered. Preventive care can
                                                                 dependents. If necessary, photocopy the chart and
    be accessed prior to meeting the deductible. For 2012,
                                                                 attach additional sheets.
    the deductible is $1,200 for individuals and $2,400 for       
    families. The deductible amount may change annually           
    and we encourage you to visit our website at                 Section G: Certification
    www.healthyny.com for more information.                       
                                                                 The certification must be completed by a duly
                                                                 authorized officer of the business.
                                                                  
    Section C: Insurance Information                              
                                                                  
    Healthy NY is available to small business employers who      Submitting Your Application
    have not provided comprehensive health insurance to their     
    employees or a class of their employees during the last 12   Detach and send your completed application your broker,
    months. If you provided health benefits within the last 12   the HMO or participating insurer selected by your
    months, your business may still qualify if:                  business. To submit this application, please mail it to: Vista
                                                                 Health Solutions, PO Box 337, Suffern, NY 10901.
    • Your business provided only “limited” health
                                                                 Additional documents may be required by the carrier if necessary
      insurance benefits.
                                                                 to complete the application process. If you have any
    • Your business did not contribute more than $50 per         questions, please contact our office at 1-888-215-4045 or
      employee per month towards the premium (or $75 if          845-753-2320. You call also visit www.nyhealthinsurer.com to
      the business is located in Bronx, Kings, Nassau, New       chat with a representative or Email info@nyhealthinsurer.com.
      York, Orange, Putnam, Queens, Richmond, Rockland,
                                                                  
      Suffolk, or Westchester counties).
                                                                  
    • The coverage was offered through Healthy NY.                
                                                                  
                                                                  
                                                                  
                                                                  
                                                                  
                                                                  
                                                                  
                                                                                                             Updated January 2012
 
                                       Healthy NY Application for Small Businesses
 
 
 
        Section A: Small Business Information
 
        Company Name:
 
        Telephone: (          )                                 Fax: (        )
 
        Street Address of Business:
 
        City:                                     State:     Zip:                 County:
 
        Contact Person:                                              Title:
 
        Telephone: (              )                                   Today’s Date:
 
 
 
        Section B: Coverage Options
         
        Healthy NY is available with or without prescription drug coverage. Premiums are higher for the coverage with the
        drug benefit. All Healthy NY coverage options have a deductible of $1,200 for individual coverage ($2,400 for family
        coverage) for 2012. Preventive services are covered before meeting the deductible.
 
                           
 
        Please select your coverage option:
 


                                       Healthy NY            Healthy     NY
                                        with drug coverage          without drug coverage
 
 
 
        Section C: Insurance Information

        You may offer Healthy NY to all of your employees or a class of your employees if you have not offered
        health insurance to them in the last 12 months. Please answer the following questions to assist us in
        determining your eligibility to purchase Healthy NY.
 
 
        1. Within the last 12 months, has your business provided health
           insurance that included both medical and hospital benefits
           (other than Healthy NY) to the class of employees that you are
            looking to cover?                                                                Yes              No
 
 
        2. If the answer to question 1 above is “Yes,” did your business
           contribute more than $50 per employee per month towards
           the premium (or $75 if the business is located in Bronx, Kings,           NA
           Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland,
           Suffolk, or Westchester counties)?                                                Yes              No
 
        If the answer to both questions 1 and 2 above is “Yes,” then your business is not eligible for Healthy NY.
 
                                               Healthy NY Application for Small Businesses
 
 
 
                      Section D: Eligibility Requirements

                      Eligibility requirements were designed to reach those small businesses most in need. Please answer
                      the following questions about your business. Please note that you must be able to check “Yes” to
                      each question in this section in order to be eligible to purchase Healthy NY.
               
                         1. Does your business have 1-50 employees?                                    Yes            No
                         2. Do at least 30% of the employees who will be offered coverage earn
                            annual wages of $40,000* or less?                                          Yes            No
                   
                        3. Will your business contribute at least 50% of the
                           Healthy NY premium on behalf of full-time employees?                        Yes            No
 
                        4. Will your business offer Healthy NY coverage to all
                           employees working 20 hours or more per week
                           who earn annual wages of $40,000* or less?                                  Yes            No
 
 
 
                      Section E: Participation Requirements

                      Please answer these questions about who will be accepting Healthy NY coverage. Please note that you must
                      be able to check “Yes” to each question in this section in order to be eligible to purchase Healthy NY.
 
                      1. Will at least 50% of the class of employees who
                         are offered Healthy NY coverage through your
                         business actually accept enrollment or have health
                         insurance through another source?                                             Yes            No
 
                      2. Will at least one employee earning annual wages
                         of $40,000* or less enroll in Healthy NY?                                     Yes            No
 
 
 
                      Section F: Employee Information
                      1. Employers may offer Healthy NY coverage to their employees’
                         dependents, including spouses, domestic partners, and
                         children. Employers are not required to contribute towards
                         the Healthy NY premium for dependents. Will your business
                         be offering Healthy NY coverage to the dependents of
                         your employees?                                                               Yes            No
 
                      2. Employers may choose to make Healthy NY available
                         to their part-time workers (those who work less than 20
                         hours weekly). You do not have to contribute towards
                         the premiums for part-time workers. Will your business
                         be offering Healthy NY coverage to part-time workers?                         Yes            No
 
 
 
                      * Updated annually
                                Healthy NY Application for Small Businesses
    Section F: Employee Information (continued)
    Complete the following information for each employee who is applying for coverage.
    Please photocopy and attach additional sheets, if needed
 
                                                                                 
           Employee Name                   Male or       Social Security            Is this employee
                                           Female           Number                      eligible for
            (First, MI, Last)
                                                                                         Medicare?
                                                                                       (Yes or No)

                                                                                 
                                                                                         NO
                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 

                                                                                 
                             Healthy NY Application for Small Businesses
 
 
    Section G: Certification
 
 
    By signing this certification of eligibility, I certify under penalty of perjury that all statements contained in
    this certification are true and accurate to the best of my knowledge. I further certify that I am duly
    authorized to execute this certification on behalf of the business.
 
 
    I understand that any person who knowingly and with the intent to defraud any insurance company or
    other person files an application for insurance or statement of claim containing any materially
    false information, or conceals for the purpose of misleading, information concerning any fact material
    thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty
    not to exceed five thousand dollars and the stated value of the claim for each such violation.
 
 
 
    Print name of person completing certification            Signature
 
 
 
    Title                                                    Date
 
 
    If a broker assisted you with completing this application, please include:
 
 
  Vista Health Solutions                     LB-1033148                       Vista Health Solutions
    Broker’s Name                           License #                         Company
 
 
  31 Park Avenue, Suffern, NY 10901                       845-753-2320            info@nyhealthinsurer.com
    Address                                              Phone                    E-mail
 
 
 
 



 
 
 
 
IMPORTANT INFORMATION ABOUT PRE-EXISTING CONDITIONS
 
    A pre-existing condition is any physical or mental condition for which medical advice, diagnosis, care,
    or treatment was recommended or received within the six-month period ending on the first day of your
    coverage under a new contract. Pregnancy is not a pre-existing condition in small group contracts. If
    you have employees with pre-existing conditions at the time they enroll in Healthy NY, the policy will
    exclude coverage for those conditions for up to 12 months. However, this 12-month period may be
    reduced or eliminated if those employees are enrolling in Healthy NY within 63 days of the termination
    of other health insurance coverage. There are no pre-existing condition exclusions for anyone under 19.
    Advise your employees to review their Healthy NY certificate or to contact the health plan for a full
    explanation of what constitutes a pre-existing condition and how this restriction may affect them.
 
    The 12-month exclusion period mentioned above is shorter if you have been determined to be eligible
    Under the Federal Trade Adjustment Act of 2002. Please notify your HMO.
Attn EmblemHealth:

                    (the “Group”) Hereby designates the broker with BROKER
CODE 599F to be listed as the Broker/Consultant(s) of Record (the”BOR”) for the
Group. Further, the Group authorizes EmblemHealth to send all quotes, policies
and notices to the BOR. The Group hereby acknowledges and agrees that notice to
the BOR is notice to the Group.

This BOR designation shall remain in effect until it is expressly terminated by the
Group in writing.



        Broker Name                  Address             Tax ID         Commission

Vista Health Solutions, Inc.    31 Park Avenue        20-4850104          100%
                               Suffern, NY 10901




X
Signature



Print Name



Title



Date
                                                                         TransacTion Form For group accounTs
                                                                                      TO BE COMPLETED FOR EACH EMPLOYEE APPLYING FOR COVERAGE

 I. SUBSCRIBER INFORMATION
 Last Name                                                                                     First Name                                            M.I.              Sex             Social Security Number
                                                                                                                                                                                                           -                                   -
 Street Address                                                                                Apt.                    City                                                                                             State                ZIP Code

 Were you ever a member of EmblemHealth?                    Marital Status:                 Birth Date:               Telephone #:                         E-Mail Address: ______________________________________________
     NO    YES                                               Single        Married          Mo. Day         Yr.       Home: (_____) ______________________
 If YES, member ID ______________________                    Domestic Partner                                         Work: (_____) ______________________   “Go PaPErlESS” and save trees (see back of application)*

                                                                                                                                                                           Subscriber Employment Status: ___________________________________
 Young Adult Coverage:          26 And Under — Family           26 - 29 — Single      Parent ID: __________________________________________________
                                                                                                                                                                             Applicant working at least 20 hours per week
                                           Primary Care Physician Name: (Not required for EPo/PPo members)                                                  oB/GYN Selection Name: (optional)
 Disabled?         NO       YES            ____________________________________________________________________                                              ____________________________________________________________________
                                           ID Number: ___________________________________________________________                                           ID Number: ___________________________________________________________
 Prior Health Insurance Information:          are you covered by any other health insurance or Medicare?                                                                   Check one:                  Status:                         Transfer:
 Carrier Name: ______________________________    NO        YES If YES, indicate:                                                                                             New Enrollment              Add Dependent                    To Another Carrier
 Coverage Begin Date: ____ / ____ / ____      Insurance Co. Name: _________________________________________                                                                  Reinstatement               Remove Dep.                      EmblemHealth Group Change:
                                              Insurance Co. Telephone #: (_____) _____________ Type of Coverage: ______________                                              Termination                 Address Change                   From: _________________
 Coverage End Date: ____ / ____ / ____
                                                                                                                                                                             Change to Ind.              Name Change                      To: ___________________
                                              Policy #: ____________________________________ Effective Date: ____ / ____ / ____
 II. ENROLLMENT INFORMATION — If you are enrollIng your spouse/Dp anD/or chIlDren, please lIst each one below — see electIon of coverage for elIgIbIlIty
            last Name (if different)                          First Name                    Social Security Number                   Sex relationship               Birth Date            ✓ if         Primary Care Physician                      oB/GYN Selection
                                                                                                                                                                 Mo. Day         Yr.    Disabled          Name/ID Number                           Name/ID Number
                                                                                                                                                                                                        (Not required for EPo/PPo members)              (optional)

 DEPENDENT                                                                                                                                       Spouse
                                                                                                  -               -                              DP
                                                                                                                                                 Child
 Current/Prior Health Insurance Information:       Carrier Name: ____________________________________________________ Coverage Begin Date: ____ / ____ / ____ Coverage End Date: ____ / ____ / ____
 DEPENDENT
                                                                                                  -               -                              Child

 Current/Prior Health Insurance Information:       Carrier Name: ____________________________________________________ Coverage Begin Date: ____ / ____ / ____ Coverage End Date: ____ / ____ / ____
 DEPENDENT
                                                                                                  -               -                              Child

 Current/Prior Health Insurance Information:       Carrier Name: ____________________________________________________ Coverage Begin Date: ____ / ____ / ____ Coverage End Date: ____ / ____ / ____
Note: A birth/marriage certificate or 1040 Form will be required for spouse/dependents with different last name.

 Your signature is required to process this form. Your signature attests that you have read the reverse side of this form.
 applicant must sign here: ______________________________________________________                                                  Date: _____ / _____ / _____
 III. EMPLOYER INFORMATION — thIs sectIon to be completeD by employer/contractor group
 Name of Group:                                                                                Group Number:                          EmblemHealth     GHI     GHI HMO     HIP                           Type of            Individual                   Family
                                                                                                                                   Plan Name: ________________________________________                   Coverage:          Employee & Spouse/DP         Employee & Child
 Requested Effective Date:                                                                     Hire Date:                          Waiting Period:                     Date Submitted:                   Approved By: (Group Plan Administrator)
 Medical: ____ / ____ / ____            Dental: ____ / ____ / ____
 Instructions to Benefit Administrators or Group Representatives: For groups with 50 employees or fewer, you MUST complete Section A on the reverse side of this form. Required documentation MUST be attached to this Transaction Form to be processed.
16-1613 12/11
elecTion oF coverage
Pre-existing conditions will not be covered during the first 12 months of enrollment in the EmblemHealth CompreHealth program or during the first 11 months of enrollment in the EmblemHealth EPo, EmblemHealth
PPo, EmblemHealth ConsumerDirect PPo or EmblemHealth ConsumerDirect EPo plans. For policies issued or renewed after September 23, 2010, pre-existing condition limitations will be waived for enrollees
under age 19. a pre-existing condition is a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice of treatment was recommended or received during the six-
month period prior to your enrollment date. EmblemHealth will credit the time you were covered by prior creditable health insurance coverage toward the 12-month or 11-month period, as long as the break in cov-
erage between the prior coverage and your EmblemHealth coverage does not exceed 63 days, exclusive of any waiting periods. If requested, you or your group must provide EmblemHealth with information about
your pre-existing conditions and/or previous coverage. You have the right to request a Certificate of Creditable Coverage from your prior health plan. If needed, EmblemHealth will help you get such a certificate
from your prior plan.
a large group (51 or more eligible employees) may elect to cover pre-existing conditions from the start of your EmblemHealth coverage. In such a case, your EmblemHealth policy will not contain a
pre-existing condition limitation or it will state that the pre-existing condition limitation does not apply.
Please call EmblemHealth at 1-877-842-3625 for more information about a pre-existing condition limitation.
                                                                                                      IMPorTaNT INForMaTIoN
1. The subscriber must complete sections I and II. The group plan administrator must complete section III and if for a small group (50 employees or fewer), provide all necessary documentation.
2. All transactions are subject to EmblemHealth’s retroactive policy (30 days for small groups, 90 days for large groups).
3. For policies issued or renewed after September 23, 2010, dependent children may stay on or be added to a parent’s policy until age 26 (end of birthday month), regardless of student status, as part of federal health reform. The premium
   will be billed at the applicable coverage tier and, other than the basic enrollment form, nothing else is required. Most employer groups cannot limit dependent coverage eligibility even if the qualified dependent has access to his or
   her own employer-based coverage. Only standard GHI and HIP HMO Direct Pay, Healthy New York and GHI large groups have the possibility of restrictions for adding dependents up to age 26. As part of New York State’s “age 29” law,
   eligible young adults through age 29 (up to 30th birthday) may continue or obtain coverage through a parent’s group policy.
4. Failure to complete any part of this form (e.g., group number, reason for submission, certificate number, signature, etc.) will require EmblemHealth to return this transaction form to the employer group plan administrator and may delay the
   requested effective date of coverage.
Effective September 23, 2010, federal health reform may require changes to your coverage, depending on your plan. Get more information at www.emblemhealthreform.com.
* By electing “Go Paperless,” you will receive claim statements and some other EmblemHealth letters by e-mail instead of paper mail. You will be able to view your Explanation of Benefits (EoBs) under the
  Claims section of the EmblemHealth Web site. Your enrollment in the “Go Paperless” option will continue as long as your account remains active, or until you choose to discontinue this option.

 SECTIoN a                                                                                      DOCUMENTATION BASED ON GROUP SIZE
 (To be completed by
 Benefits Administrator)                                                               Group Type (Check one)
                                                                                                                                               Sole Proprietorship                   association of                    Small Group —
              aCTIoN                                                                                                                           or one-Subscriber                     Two or More                        less than 50
            Check (4)one                           Qualifying Event                           Documentation required                                 Group                            Employees                          Employees
    Add Subscriber                        New Hire or Change in Plan              For eligible employees who work more than 20 hours                Not Eligible
                                                                                  weekly, provide a recent Copy of NYS45 showing this
                                                                                  subscriber as an employee or provide copy of payroll
                                                                                  documentation reflecting the date, employee’s name
                                                                                  and Social Security #, or the employee’s current-year
                                                                                  W4 form.
    Add Spouse                            Marriage                                If last name is different
                                                                                      Marriage Certificate
                                                                                      1040 Form
    Add Dependent                         Birth                                   If last name is different
                                                                                      Birth Certificate
                                          Adoption                                    Formal Adoption Papers
                                                                                      Court Approved Guardianship Papers
    Add Spouse                            Loss of Coverage                        Certificate of Creditable Coverage
    Add Dependent
    Add Domestic Partner                  Domestic Partnership                    Declaration of Cohabitation & Financial                           Not Eligible                       Not Eligible
                                                                                  Interdependence form
                                     Note: No retroactive Enrollments will be allowed. Members must be enrolled within 30 days from the Qualifying Event/next billing date.
                    Effective September 23, 2010, federal health reform may require changes to your coverage, depending on your plan. Get more information at www.emblemhealthreform.com.
group Health incorporated (gHi), gHi Hmo select, inc. (gHi Hmo), Hip Health plan of new York (Hip), Hip insurance company of new York and emblemHealth services company, llc are emblemHealth companies. emblemHealth
services company, llc provides administrative services to the emblemHealth companies.
Summary of Benefits
GHI HealtHy Ny ePO HDHP




This is a high deductible health plan. With the exception of (1) well-baby and well-child care (up to the age of 19)
including immunizations; and (2) adult preventive services (including a physical examination once every three years,
mammography, pap smear, prostate screening exam and immunizations); and (3) pre-natal care, the deductible
must be satisfied before GHI will provide coverage for covered services.
The individual deductible amount for 2010-2011* is $1,200; the family deductible amount for 2010-2011* is
$2,400. Family coverage applies if the policy covers more than one person. The family deductible may be satisfied
by one individual family member or by expenses incurred by various family members. However, the entire
plan year deductible must be satisfied before services will be covered for any member of the family.
The Out-of-pocket maximum amount for an individual for 2010-2011 is $5,250; the out-of-pocket maximum
amount for a family for 2010-2011 is $10,500. Family coverage applies if the policy covers more than one person.
Out-of-pocket expenses include the deductible and copayments paid for Healthy NY benefits covered by this plan.
Once the out-of-pocket maximum for the plan year is reached, no further copayments will apply and covered ben-
efits will be covered in full. For more information about high deductible plans, please see your certificate.

 Cost sharing
 Annual Plan Deductible                                                                 $1,200 Individual for plan year 2010-2011*
                                                                                        $2,400 Family for plan year 2010-2011*
                                                                                        *Treasury guidelines indicate that each year, the deductible amounts
                                                                                        required for a high deductible health plan may be increased to reflect a
                                                                                        cost-of-living adjustment. In order for this plan to continue to meet Healthy
                                                                                        NY high deductible health plan requirements, and for this plan to continue
                                                                                        to qualify as a high deductible health plan for use with a health savings
                                                                                        account, the deductible amounts set forth above for plan years 2012 –
                                                                                        2021 may automatically increase to the new deductible amounts estab-
                                                                                        lished in the Treasury guidelines.
 Annual Out-of-Pocket Maximum                                                           $6,050 individual
                                                                                        $5,250Individual
                                                                                        $12,100 Family
                                                                                        $10,500 family
 PhysiCians serviCes
 Diagnostic & treatment services                                                        $20 copayment per visit
 Consultant & referral services
 Anesthesia services
 Second surgical opinion
 Second opinion for cancer
 Physical therapy and occupational therapy
 Surgical services (including breast reconstruction following a mastectomy)             20% or $200, whichever is less
 emergenCy serviCes
                                                                                        $50 copayment per visit (waived if hospital admission results from visit)
 adult Preventive health Care
 Mammography screening                                                                  Covered in full
 Cervical cytology screening
 Prostate Screening

                                                                                                                                                        continued on back


                                                                                                                 Refer to GHI policy form number HNy Pla 90-10, et al.
GHI and HIP are EmblemHealth companies

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies.
EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.
                                                                                                                                                                  10-6937 10/10
Summary of Benefits
continued from front


 adult Preventive health Care (Continued)
 Periodic physical examinations                                                                Covered in full
 Adult immunizations
 maternity Care
 Prenatal care                                                                                 $10 copayment per visit (prenatal)
 Postnatal care                                                                                $10 copayment per visit (postnatal)
 Delivery                                                                                      20% or $200, whichever is less
 Home visit                                                                                    No copayment
 Child Preventive health serviCes
 Preventive and primary care immunization                                                      Covered in full
 Scheduled well-care visits                                                                    Covered in full
 Pre-admission testing
                                                                                               $20 copayment per visit
 inPatient hosPital serviCes (inCluding inPatient maternity Care)
 Daily room & board                                                                            $500 copayment per continuous confinement
 General nursing care
 Special diets
 Miscellaneous hospital services & supplies
 outPatient hosPital serviCes
 Diagnostic & treatment services                                                               $20 copayment per visit
 Home Health Care
 Outpatient surgery                                                                            $75 facility copayment
 diabetiC equiPment & suPPlies and self-management eduCation
                                                                                               $20 copayment per visit for self-education
                                                                                               $20 copayment per each item of equipment
                                                                                               $20 copayment per 34-day supply of insulin, hypoglycemics and supplies
 diagnostiC X-ray & lab serviCes
                                                                                               $20 copayment per visit
 theraPeutiC serviCes
 Radiological services                                                                         $20 copayment per visit
 Chemotherapy
 Renal Dialysis
 blood and blood ProduCts
                                                                                               $20 copayment per visit
 PresCriPtion drugs (oPtional)
                                                                                               Copayment:
                                                                                               $10 per generic drug per 34-day supply
                                                                                               $20 per brand name drug plus difference in cost between the brand name
                                                                                               drug and its generic equivalent per 34-day supply
                                                                                               Mail order program:
                                                                                               $20 per generic drug per 90-day supply
                                                                                               $40 per brand name drug per 90-day supply plus the difference in cost
                                                                                               between the brand name drug and its generic equivalent
                                                                                               Benefit Maximum:
                                                                                               Unlimited

NOT COVERED: Ambulance, Dental Care, Durable Medical Equipment, External Prosthetics, Ostomy Supplies, Mental Health Services, Advance
Infertility Services, Chiropractic Care, Skilled Nursing Facility, Substance Abuse Diagnoses and Treatment Detoxification and Rehabilitation.
This chart is intended to provide a general outline of GHI EPO Healthy NY HDHP/HSA benefits.

				
DOCUMENT INFO
Description: EmblemHealth Healthy NY Application for Small Businesses