Understanding Your GHI PPO Share Program

Transcription

1 Understanding Your GHI PPO Share Program

2 Welcome to the GHI PPO Share Program Since its founding in 1937, GHI has been providing its members with access to quality health insurance. Our goal remains helping our members get the health care benefits they need should they become sick. The challenge today is preserving the high level of benefits members seek, at costs that are affordable for groups and members at all budget levels. Through an innovative combination of cost-sharing elements, the new GHI PPO Share Program accomplishes that goal, and sets the standard for a new generation of health coverage programs. With the PPO Share Program, you have the freedom to receive benefits for most covered services from any provider, but also the responsibility to carefully manage your cost-sharing expenditures to make sure you are getting the most value out of your coverage. It s important that you read through this brochure to understand how these cost-sharing requirements work, and how to make your coverage work best for you. Stay In- for Lower s and Out-of-Pocket Costs The in-network deductibles and coinsurance that apply to this program are almost exclusively for in-patient hospital services. You generally do not have to pay deductibles or coinsurance for services received at your doctor s office. The following are some of the services covered in-network at no out-of-pocket cost, except for copayments when applicable: Office visits Annual physical check-up Chiropractic care Well-baby and Well-child care up to age 19 Diagnostic lab tests and radiology procedures Surgical procedures performed in the doctor s office This brochure provides only general information regarding the GHI PPO Share Program. Please review your GHI PPO Share Program Certificate of Insurance carefully for a full explanation of your benefits. Coverage is subject to all terms, conditions, limitations and exclusions contained in the Certificate of Insurance.

3 PPO Share Plan Examples Copayment per calendar year (/Family) Coinsurance (GHI/Member) Annual Coinsurance s per calendar year (/Family) Cost Sharing Non- $25 /$1,500 90%/10% $1,000/$3,000 N/A $1,000/$3,000 70%/30% $3,000/$9,000 How Copayments, s, Coinsurance and Annual Coinsurance s Work The following illustrates how copayments, deductibles, coinsurance and annual coinsurance maximums apply in a given calendar year under the PPO Share Program. The examples are based on the coverage shown above. In January, Jack goes to a network dermatologist, who performs a biopsy in the office. 1 1 In February, Jack goes to a network provider for a procedure performed in the hospital. 2 Provider s Charge $600 (Charges include: Office visit, surgical procedure and diagnostic procedure) GHI s Rate $550 GHI Payment $475 Member s Responsibility $75 (Office visit copayment, surgical copayment, and diagnostic copayment) Amount Applied Towards $0 Non - $1,000 Provider s Charge GHI s Rate $400 Amount Applied Towards $400 $100 Non - $1,000 $600 $400 $400 UPDATE Because Jack went to a Provider and received services in the doctor s office, he is only responsible for applicable copayments in this case, three separate $25 copayments. Jack s responsibility is $75. The deductible and coinsurance do not apply. $100 remaining balance. SHARED DEDUCTIBLE The amount applied to the is also applied to the Non- $600 remaining Non- balance. UPDATE Jack s responsibility is $400 to the provider, because his deductible for the calendar year has not yet been satisfied. Since Jack went to a network provider, he is not responsible for the difference between the provider s charge and GHI s network rate.

4 Provider s Charge $650 GHI s Allowed Charge $600 The difference between the Provider s Charge and GHI s Allowed charge = $50 Amount applied towards the Non- = $600 3 In July, Jack goes to a Non- Provider for a procedure performed in a hospital s ambulatory surgery center. Non- $1,000 In October, Jack goes to a network provider for a procedure performed in a hospital s ambulatory surgery center. Provider s Charge $1,500 GHI s Rate $1,200 $0 is applied towards Jack s deductible since it has been satisfied from previous charges. GHI pays (90% of $1,200) $1,080 Jack s coinsurance $120 responsibility (10% of $1,200) 4 Non- Annual Coinsurance $3,000 $600 Non- Annual Coinsurance $1,000 $400 SHARED DEDUCTIBLE The amount applied to the non-network individual deductible is also applied to the remaining network individual deductible balance Jack s claim in February had satisfied $400 of the Non- UPDATE Jack s responsibility to the provider is $650, this includes the $600 (GHI s allowed charge) applied towards the non-network individual deductible, and the difference between the providers charge and the allowed charge, $50. Both the network deductible and the non-network deductible have been satisfied with this claim. Any subsequent claims for covered services during that calendar year will not be subject to the deductibles. SHARED DEDUCTIBLE The amount of Jack s coinsurance is applied toward his Annual Coinsurance. It applies towards both the and Non- Annual Coinsurance s UPDATE Since Jack has met his deductible for the year, he is responsible only for his coinsurance portion applied to the Rate. The provider is within the program s network, and Jack is responsible to pay the network provider $120 (10% of $1,200). The amount paid by GHI and the amount paid by Jack total $1,200, which the provider accepts as payment in full. $120

5 Cost Sharing Elements The GHI PPO Share Program has cost-sharing elements that specify out-of-pocket costs you may incur as you receive covered services. The important elements to cost sharing that you should understand include: 1. Copayments A copayment is a fixed dollar amount members must pay for certain covered services. It is usually paid to a participating network provider at the time the service is rendered. You can be subject to up to a maximum of three copayments per office visit, including surgical and lab services. 2. The deductible amount is the amount that an individual and/or family must pay during a calendar year before GHI will begin to pay benefits for covered services. The deductible(s) differs for network services and non-network services. Any deductible amount paid counts toward both and Non- deductibles. Important Note for Those with Eligible Dependents: The deductible and coinsurance maximum figures are for individuals; the family deductible is based on three times the individual amount. 3. The network is made up of providers who have agreed to accept GHI s network rate as payment in full for covered services and is a member of the GHI provider network that applies to this program. 4. Non- Non- refers to providers who do not have an agreement with GHI to accept GHI s network rate as payment in full and/or do not UPDATE Please refer to your Certificate Attachment for the specific COPAYMENT, DEDUCTIBLE, COINSURANCE and ANNUAL COINSURANCE MAXIMUM amounts that apply to your coverage. participate with the GHI provider network that applies to this program. 5. Coinsurance Coinsurance is the percentage of the network rate or allowed charge for covered services that you must pay to your provider after you have met your deductible. You are also responsible to pay for charges from a non-network provider in excess of GHI s allowed charge; provider charges in excess of benefit limits or maximums; and charges for services that are not covered, but these charges are not considered to be coinsurance. 6. Annual Coinsurance s How much you pay in coinsurance is capped by Annual Coinsurance maximums, which limit the amount of coinsurance expenses you have to pay in any particular year. There are two Annual Coinsurance maximum amounts for your program one that applies to network charges, and another that applies to non-network charges. Member coinsurance payments applied to network or non-network annual coinsurance maximums are shared, all coinsurance amounts you pay count toward both maximums. 7. Allowed Charge The Allowed Charge is the amount GHI will reimburse for covered services rendered by non-network providers. You will be responsible to pay the doctor s charge in excess of GHI s allowed charge, in addition to other applicable cost-sharing elements. 8. Rate The Rate refers to the amount that a GHI network provider has agreed to accept as payment in full for covered services rendered to GHI members.

6 For More Information If you have questions, or need more information, please visit or call the GHI AnswerLine at (212) (within New York City), or (800) (outside of New York City). 441 Ninth Avenue New York, NY Form # /04 10M