Emblemhealth ghi hmo card

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Keep in mind: You should store your Original Medicare red, white, and blue card in a safe place. Please refer to your ID card to see if it has the ConnectiCare logo. This means you can use providers in Connecticut. If you have a dental benefit, you will have contact information for Healthplex on the back of your ID card. Healthplex has been selected to administer dental benefits to you in You are now leaving the Medicare section of the website. You are now leaving.

Please check the Privacy Statement of the website to which you are going. Any information provided on this Website is for informational purposes only.

It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.

Switch to: providers brokers employers. Navigation Open. Switch to:. Careers Why Work with Us? EmblemHealth Family of Companies. A primary and specialty care practice. Well-being solutions for companies and their employees. Find a Doctor. Find Care Find a doctor, dentist, specialty service, hospital, lab and more.

Telehealth About Telehealth How to Enroll. Member Sign In If you're already a member, finding the right care is as easy as signing in to your myEmblemHealth account.

Sign In. Our Plans. If you have any concerns about your health, please contact your health care provider's office. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan.

Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage. Switch to: members brokers employers. Sign in Contact Us Search. Navigation Open. Switch to:. Access the ConnectiCare Portal. Sign in. All Rights Reserved. Back to Top. Enter your ZIP code:.

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Dec 7, What is a policy number? Your health insurance policy number is typically your member ID number. You can also provide this number to your health insurance company so they can look up your information when you have questions about your benefits and any recent claims. Anthem, Inc. As of , the company had approximately 40 million members.

A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. GHI Home Care is very comfortable in dealing with insurance companies. Under this plan, GHI supplements Medicare for the following benefits, subject to a deductible: Office visits.

In-hospital physician services. You can see any network doctor without a referral. EmblemHealth: If you applied for major medical health insurance and your enrollment was received in the first fifteen days of the month, your coverage will typically begin on the first day of the following month. Generally, you will be covered as soon as your insurance plan becomes effective unless it has specific requirements, such as those that require you to undergo a health exam.

If your insurance is an employer-sponsored group plan, it may be active immediately, allowing you to seek treatment or routine care. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.

You may be billed for services received. 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 is no longer eligible to use your health insurance coverage. Preventing Medical Mistakes An influential report from the Institute of Medicine estimates that up to 98, Americans die every year from medical mistakes in hospitals alone.

While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own health care, and that of your family members. Take these simple steps: 1. Ask questions if you have doubts or concerns. Keep and bring a list of all the medicines you take. Be sure to write down what your doctor or pharmacist says.

Ask your pharmacist about the medication if it looks different than you expected. Especially note the times and conditions when your medicine should and should not be taken. Get the results of any test or procedure. Talk to your doctor about which hospital is best for your health needs. Make sure you understand what will happen if you need surgery.

Patient Safety Links -www. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care you receive.

The National Patient Safety Foundation has information on how to ensure safer health care for you and your family. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medicines.

The Leapfrog Group is active in promoting safe practices in hospital care. The American Health Quality Association represents organizations and health care professionals working to improve patient safety. This policy helps to protect you from preventable medical errors and improve the quality of care you receive. Although some of these complications may not be avoidable, too often patients suffer from injuries or illnesses that could have been prevented if the hospital had taken proper precautions.

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. Self and Family coverage is for 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 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 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 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 marry.

Please tell us immediately of changes in family members status including your marriage, divorce, annulment, or when your child reaches age If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by 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. Children Natural, adopted children, and stepchildren Coverage Natural,adopted children and stepchildren are covered until their 26th birthday.

Foster Children 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 Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage.

Married Children Married children but NOT their spouse or their own children are covered until their 26th birthday. Children with or eligible for employerChildren who are eligible for or have their provided health insurance own employer-provided health insurance are covered until their 26th birthday.

You can find additional information at www. If this law applies to you, you must enroll for 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.

Contact your employing office for further information. 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 paid according to the benefits of your old plan or option.

However, if your old plan left the FEHB Program and the end of the year, you are covered under that plan's 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. You may be billed for services received directly from your provider.

It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage TCC. Any person covered under the day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st 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 60th day after the end of the day temporary extension.

This is the case even when the court has ordered your former spouse to provide health coverage to you. 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.

Enrolling in TCC. It explains what you have to do to enroll. This is a website provided by the U. Department of Health and Human Services that provides up-to-date information on the Marketplace. For assistance in finding coverage, please contact us at or visit our website at www. You can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health- related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan.

If you have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate from those plans. We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.

The Plan is solely responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory. HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms. You cannot change plans because a provider leaves our Plan. How we pay providers We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance.

Who provides my health care? GHI HMO organizes preventive and routine health care as well as needed services for serious illness or injury. Affiliated primary care doctors, specialists and other health care providers are conveniently located throughout the service area.

You may get information about us, our networks, providers, and facilities. Some of the required information is listed below. You may also contact us by fax at or visit our Web site at www.

Please note that we may disclose your medical and claims information including your prescription drug utilization to any of your treating physicians or dispensing pharmacies. This is where our providers practice. Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits.

We will not pay for any other health care services out of our service area unless the services have prior plan approval. If you or a covered family member move outside of our service area, you can enroll in another plan.

If your dependents live out of the area for example, if your child goes to college in another state , you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans.

Contact your employing or retirement office. Changes for Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits. The benefit will include up to two consectuive months per condition if significant improvement can be expected within two months.

Habilitative services will be subject to the same copay and visits as rehabilitative services. The plan will count cost sharing for prescription drugs, essential health benefits, deductibles, copays and coinsurance toward the member's out-of-pocket maximum.

Please refer to the Rate Information on the back for more details. How you get care Identification cards 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, your health benefits enrollment confirmation letter for annuitants , or your electronic enrollment system such as Employee Express confirmation letter. You may also request replacement cards through our Web site: www. 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 on our Web site at www. We list these in the provider directory, which we update periodically. The list is also on our Web site, www. 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. Your primary care physician can be a doctor who specializes in Family Practice, Internal Medicine, or Pediatrics. 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 at We will help you select a new one.

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. Your primary care physician will create your treatment plan. The physician may have to get an authorization or approval from us 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.

Generally, we will not pay for you to see a specialist who does not participate with our Plan. You may receive services from your current specialist until we can make arrangements for you to see someone else. 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.

This includes admission to a skilled nursing or other type of facility. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 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.

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.

For certain services, however, you 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. Please contact ValueOptions clinical referral line at , Monday through Friday from 8 am to 5 pm ET; Centralized Night Services CNS covers non-business hours, 24 hours a day, 7 days a week, days a year.

All inpatient admissions are reviewed to evaluate that the services are covered services, Medically Necessary and being rendered at the appropriate level of care.

You have the right to designate a representative for utilization review. GHI HMO will notify you and your provider, by phone and in writing of prospective and concurrent utilization review decisions.

We will notify you in writing of any retrospective Utilization Review decisions. If we deny services or won't pay your claim, you may ask us to reconsider our decision. Your request must: 1. Be in writing 2. Refer to specific brochure wording in explaining why you believe our decision is wrong; and 3. Be made within six months from the date of our initial denial or refusal.

We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control. We have 30 days from the date we receive your reconsideration request to: 1. Maintain our denial in writing; 2. Pay the claim; 3. Arrange for a health care provider to give you the service; or 4.

Ask for more information. If we ask your medical provider for more information, we will send you a copy of our request. We must make a decision within 30 days after we receive the additional information. If we do not receive the requested information within 60 days, we will make our decision based on the information we already have.

We will make our decision within 15 days of receipt of the preservice 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 you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether it is an urgent care claim by applying the judgment of a prudent layperson who 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 provide notice of the specific information we need to complete our review of the claim.

We will allow you up to 48 hours from the receipt of this notice to provide the necessary 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 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 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.

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 appeal 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, then we will make a decision within 24 hours after we receive the claim. What happens when you do not follow the precertification rules when using non-network facilities You must precertify services in order to receive full coverage.

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

If you disagree with our pre-service claim decision If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If you have already received the service, supply, or treatment, then you have a postservice claim and must follow the entire disputed claims process detailed in Section 8. 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 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. Write to you and maintain our denial. Subject to a request for additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.

Your costs for covered services This is what you will pay out-of-pocket for covered care: Cost -Sharing Cost-sharing is the general term used to refer to your out-of-pociet costs e. Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc.

There is no copay for children through age 26 for all primary care physician visits. Deductible We do not have a deductible. Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you have met your calendar year deductible.

Your catastrophic protection out-of-pocket maximum We protect you against catastrophic out-of-pocket expenses for covered services. When Government facilities bill us Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member.

They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.

Page 66 and page 67 are a benefits summary of the High Option. Make sure that you review the benefits that are available under the option in which you are enrolled. Section 5. Medical services and supplies provided by physicians and other health care professionals Surgical and anesthesia services provided by physicians and other health care professionals Services provided by a hospital or other facility, and ambulance services Mental health and substance abuse benefits Prescription drug benefits Dental benefits Special features Benefits for the High Option are described in Section 5.

Make sure that you review the benefits that are available under the High Option before you enroll. The High Option in Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also, read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filling advice, or more information about the High Option Benefits, contact us at or on our Web site at www.

Also, read Section 9 about coordinating benefits with other coverage, including with Medicare. We will extend your inpatient stay if medically necessary. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision. Services are limited to three 3 cycles to achieve pregnancy. Note: We cover injectible fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

See pages Note: We will only cover GHT when we preauthorize the treatment. Call or have your physician call for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary.

Please refer to Prescription Benefits for more information. High Option Note: Physical and occupational therapy is provided on an inpatient or outpatient basis for up to two consecutive months per condition if significant improvement can be expected within two months. Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved functioning in other activities of daily living.

Note: For information on the professional charges for the surgery to insert an implant, see Section 5 b Surgical procedures. Note: Call us at as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

Look in Section 5 c for charges associated with the facility i. Please refer to the pre-certification information shown in Section 3 to be sure which services require pre-certification and identify which surgeries require pre-certification.

For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes. Refer to Other services in Section 3 for prior authorization procedures. For the diagnoses listed below, the medical necessity limitation is considered satisfied if the patient meets the staging description..

Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial. High Option Note: We cover related medical and hospital expenses of the donor when we cover the recipient. Any costs associated with the professional charge i. Please refer to Section 3 to be sure which services require pre-certification. NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Hospital care is only available when a medical condition necessitates such care. We do not cover the dental procedures. Not covered: Custodial care All Charges Hospice care High Option Supportive and palliative care for the terminally ill member is covered in the home or hospice facility.

Services include inpatient and outpatient care and family counseling. Benefits are limited to days; bereavement counseling services are covered up to five 5 days.

What is a medical emergency? A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care.

Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies — what they all have in common is the need for quick action. Emergencies within our service area In the event of a medical emergency you should seek immediate medical treatment at the nearest emergency facility anywhere in the world whether or not they participate with GHI HMO.

However, you or a family member must contact your PCP, unless it is not reasonably possible to do so. All emergency room visits that do not result in a hospital admission will require an emergency room copay. Urgent care is defined as a sudden onset of illness or accident that does not require acute care treatment and would not result in a severe disability.

Examples of conditions we do not consider to be emergencies are, but are not limited to: head colds, influenza, tension headaches, toothaches, minor cuts and bruises, muscle strain, hemorrhoids and intoxication. You must contact your PCP prior to obtaining care. You will be responsible for the full cost of the visit if you do not contact your PCP.

If referred to the emergency room by your PCP, you will pay a copay. It is your responsibility or that of a family member to contact your PCP prior to receiving non-emergency care, unless it was not reasonably possible to do so. However, if the emergency care you receive is relatively minor in cost, you may be asked to pay for services rendered.

If you were admitted to the hospital from the Emergency Room the emergency room copay is waived. You will, however, be subject to the inpatient copayment. Care provided by a non-participating provider will not be covered for follow-up visits. Mental health and substance abuse benefits You need to get Plan approval preauthorization for services and follow a treatment plan we approve in order to get benefits. When you receive services as part of an approved treatment plan, cost-sharing and limitations for Plan mental health and substance abuse benefits are no greater than for similar benefits for other illnesses and conditions.

Benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure. OPM wil generally not order us to pay or provide one clincially appropriate treatment plan in favor of another. Benefit Description You pay Professional Services High Option When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance abuse practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists..

Value Options has been contracted to manage your behavioral health benefits. In order to access your benefits, please call Value Options toll free number at You will be connected to a customer service representative who will be able to assist you in identifying a behavioral health care provider in your area or to verify if your current provider is a participating provider in the Value Options network.

The provider will continue to follow their contractual obligations and submit treatment plan reports for continued authorization. The treatment reports will be reviewed by a New York State licensed clinician to determine if the treatment you are receiving meets medical necessity criteria for the level of care and the intensity of treatment you are receiving.

If the provider is non-participating, the customer service representative will either offer you a provider participating in the network that specializes in your area of need or will offer to forward a treatment report to you. You will be responsible for your provider completing the forms in their entirety and returning them to the address provided.

Treatment will not be interrupted if the licensed clinician reviewer finds your treatment to be needed and appropriately provided.