With GHI-CBP, you have the freedom to choose any provider worldwide. You can select a GHI participating provider and not pay any deductibles or coinsurance, or go out-of-network and still receive coverage, subject to deductibles and coinsurance.

GHI’s provider network includes all medical specialties. When you need specialty care, you select the specialist and make the appointment. Payment for services will be made directly to the provider - you will not have to file a claim form when you use a GHI participating provider.

Participating Provider Benefits:   There is a $15 copayment per visit to GHI participating medical providers/practitioners and participating mental health care providers. These include practices such as Family Practice, General Practice, Internal Medicine, OB/GYN, Pediatrics, and providers such as Allergists, Cardiologists, Chiropractors and Gastroenterologists (a full list is available on ghi's web site).

There is a $20 copayment per visit for GHI participating Surgeons, all Surgical Subspecialities, and Dermatologists. Examples of these providers are those who practice: Cardiothoracic and Thoracic Surgery; Colon and Rectal Surgery; General Surgery; Neurological Surgery; Ophthalmology; Oral Surgery; Orthopedics, and many others (a full list is available on ghi's web site).

Home Care Services:  These services include intermittent home care services, home infusion therapy, private duty nursing and durable medical equipment. Benefits are paid in full when precertified by the GHI Managed Care Department. Contact GHI Coordinated Care at (212) 615-4662 in New York City, or 800-223-9870 outside New York City. Durable medical equipment is subject to an annual $100 per person deductible. Coverage for home infusion therapy is available only through GHI participating providers, but all other services can be obtained through non-participating providers, subject to separate annual deductibles and coinsurance.

Mental Health and Chemical Dependency Program:  This plan offers both inpatient and outpatient chemical dependency and mental health benefits. You can choose from over 8,000 psychiatrists, psychologists, social workers and other providers in the metropolitan New York City area who comprise the GHI Behavioral Management provider network. Out-of-network benefits are also available. Complete details on this program are available by calling GHI at 800-NYC-CITY (800-692-2489).

Centers of Specialized Care:  This network of specialty hospitals offers focused expertise in cardiac care and certain transplant procedures. These services are paid in full, without deductibles or coinsurance, when provided at a Center of Specialized Care hospital. Details are available by calling GHI at 800-223-9870 or 212-615-4662.

Non-Participating Provider Benefits:  When you do not use the services of a participating provider, GHI provides coverage for the services of non-participating providers. Payment for these services is made directly to you under the NYC Non-Participating Provider Schedule of Allowable Charges (Schedule). The rate at which you will be reimbursed for a particular service is contained within the Schedule. These reimbursement rates were originally based on 1983 procedure allowances, and some have been increased periodically. The reimbursement levels, as provided by the Schedule, may be less than the fee charged by the non-participating provider. Please note that certain non-participating provider reimbursement levels may be increased if you have the optional rider. The subscriber is responsible for any difference between the fee charged and the reimbursement, as provided by the Schedule. A copy of the Schedule is available for inspection at GHI.

Non-participating provider reimbursement is subject to calendar year deductibles ($200 per person, up to a maximum of $500 per family) and a lifetime maximum of $2 million per person.

Catastrophic Coverage:  If you choose non-participating providers for predominantly in-hospital care and incur $1,500 or more in covered expenses (based on physicians’ reasonable and customary charges, as determined by GHI), you are eligible for additional “Catastrophic Coverage.” Under this coverage, GHI pays 100% of reasonable and customary charges, as determined by GHI.

Retail Pharmacy:   up to a 30-day supply (2 fills) subject to deductible of $150 per ind./$450 per family. After deductible, you pay: Generic - 20% coinsurance with a min. charge of $5 or actual cost if less; Brand-Name Formulary - 40% coinsurance with min. charge of $25 or actual cost if less; Brand-Name Non-Formulary - 50% coinsurance with min. charge of $40 or actual cost if less.  If you choose a formulary or non-formulary brand that has a generic equivalent, you will pay the difference in cost between the drug and the generic coinsurance. Mandatory Maintenance Mail Order:  Up to a 60-day supply. You pay: $10 Generic/$40 Brand-Name Formulary/$60 Brand-Name Non-Formulary. You must use Mail Service for medications.  Prescriptions will not be filled at retail after two (2) fills.
Prior Authorization is required for certain brand-name medications.
Step-therapy Prescription Program encourages use of best medications for your condition.
Over-the-Counter Equivalent Program (OTC) - Prescription Medications that have an OTC equivalent will not be covered.

Enhanced Reimbursement Schedule for certain services increases the reimbursement of the basic program’s non-participating provider fee schedule, on average, by 75%.

Additional outpatient psychiatric and inpatient chemical dependency treatment services. Call 800-NYC-City (800-692-2489) for details about this benefit.

Cost
Please see the rate page for payroll and pension deductions.
See the rate page

For More Information
To contact the Plan directly:

Group Health Incorporated
441 Ninth Avenue
New York, NY 10001
(212) 501-4444
Visit the Plan Web site

The Empire BlueCross BlueShield Hospital Plan offers City of New York employees, retirees and their families enrolled in the GHI/Comprehensive Benefits Plan broad protection against the high cost of hospital care. With the Empire BlueCross BlueShield hospital identification card, employees and their families have access to more than 5,700 participating hospitals across the country. The hospitals file directly with their local Blue Cross and Blue Shield plan, nearly eliminating your out-of-pocket payments and claims filing.

Inpatient Care*: After you meet your $300 deductible per admission ($750 annual maximum per person), Empire’s Hospital Plan offers you paid-in-full inpatient care for up to 365 days of hospitalization. You are covered for such inpatient services as semi-private room and board, general nursing care, drugs and medicines, the use of blood transfusion equipment, and the administration of blood or blood derivatives. Maternity benefits are covered in full and are subject to a $300 deductible. Nursery charges are covered in full. Newborn children are covered from birth for treatment of illness or injury. Benefits are provided for air ambulance service (not subject to the inpatient deductible) to hospitals in connection with an emergency situation when no other transportation (such as commercial airlines or surface transportation) is available. Each family member must meet his or her own deductible; if you are admitted again within 90 days, you do not have to meet another deductible. In addition, you do not have to pay a deductible for the following: ill newborns who remain in the hospital after birth; or hospice benefits.

Emergency Care:  There is a $50 co-payment for emergency room care such as treatment for sudden and serious illness and accidental injury treatment. This co-payment is waived if the patient is admitted to the same hospital. Coverage is provided for emergency room physicians and non-invasive cardiology, radiology and pathology services. Charges for specialty doctors and/or follow-up care should be submitted to GHI.

Outpatient Care:   In addition to emergency room care, Empire BlueCross BlueShield’s Hospital Plan also provides coverage for ambulatory surgery, chemotherapy, and presurgical testing. Ambulatory surgery is covered at 80% of approved charges. You pay 20% coinsurance up to a maximum of $200 per calendar year.   After that, such treatment or surgery is covered in full.   There are up to 36 visits available for outpatient cardiac rehabilitation. (These benefits are subject to NYC Healthline precertification and approval.)*

*Enrollees must call NYC Healthline at 800-521-9574 prior to any scheduled hospital admission or within 48 hours of an emergency admission. Failure to call NYC Healthline may result in a penalty of up to $500.

Skilled Nursing Facility:  A maximum of 90 days is available for skilled nursing facility care, which may include 30 inpatient days in a rehabilitation hospital primarily for physical therapy, physical rehabilitation or physical medicine.

Hospice Care: The Hospital Plan also offers coverage for hospice care for up to 210 days. Full benefits for this service are provided when they are rendered in a participating facility.

Worldwide Protection:  If you travel abroad and need inpatient care you will receive full benefits if you are admitted to any general hospital. Empire’s Hospital Plan also offers you access to BlueCard Worldwide®, the international hospital and provider network of the Blue Cross and Blue Shield Association. If you need outpatient care you will receive full benefits in a participating or any general hospital for use of a hospital’s facilities for a surgical operation. For emergency care in non-participating hospitals, you may not be covered in full for physician or specialist services.

Cost
Please see the rate page for payroll and pension deductions.
See the rate page

For More Information
If you would like additional information about Empire’s Hospital Plan, please call (800) 433-9592. The Center telephone hours are from 8:30 A.M. to 5:00 P.M., Monday through Friday.

You may write the plan at:

Empire BlueCross BlueShield
City of New York Dedicated Service Center
P.O. Box 1407
Church Street Station
N.Y., NY 10008-1407
Visit the Plan Web site (opens in a new window)