1102308001_UNITED NATIONS_MH002017_BS.pdf
MAJOR COST SHARING PROVISIONS PARTICIPATING PROVIDER
Benefit Period
Maximum Out-of-Pocket Limit
Plan Year
Covered in full
$6,600 Individual / $13,200 Family
PCP Office visits
Specialist Office visits Covered in full Hospital admission No Copayment
Emergency Room copay (waived if Hospital admission) Covered in full
Prescription Drug Deductible Not Applicable
Prescription drugs – 30 day supply $5 generic / $5 brand
Prescription drugs – 90 day supply $7.50 generic / $7.50 brand
INPATIENT HOSPITAL SERVICES PARTICIPATING PROVIDER
• Hospital and physician services
• Semi-private room and board
Subject to Hospital Admission Copayment Physician Services Covered in Full
Included in Hospital Admission Copayment
• Operating and recovery room, intensive and special care units, general nursing care, prescribed drugs,anesthesia, X-rays, lab tests, mastectomy care, cardiac and pulmonary rehabilitation and end of life care
Included in Hospital Admission Copayment
• Inpatient Rehabilitation & Habilitation Services (Physical,Speech and Occupational Therapy)
Subject to Hospital Admission Copayment; 90 days combined therapies
• Human organ transplants Included in Hospital Admission Copayment
MATERNITY AND NEW BORN CARE PARTICIPATING PROVIDER
• Prenatal care Covered in full
• Inpatient Hospital Services and Birthing Center Covered in full
• Physician and Midwife Services for Delivery Covered In Full
• Breast Pump Covered in full
• Postnatal care Covered in full
Medical Deductible Not Applicable
SUMMARY OF BENEFITS
HIP Prime Network
UNITED NATIONS
PrimeHMO for NY CT and NJ Residents
1102308
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SUMMARY OF BENEFITS
HIP Prime Network
UNITED NATIONS
PrimeHMO for NY CT and NJ Residents
1102308 • Postnatal care Covered in full SURGICAL SERVICES PARTICIPATING PROVIDER
• Inpatient Hospital Surgery Covered in full
• Outpatient Hospital Surgery Covered in full
• Surgery performed in a PCP Office Covered in full
• Surgery performed in a Specialist Office Covered in full
• Surgery performed at an Ambulatory Surgical Center Covered in full
CARDIAC REHABILITATION PARTICIPATING PROVIDER
• Performed as Inpatient Hospital Services Included as part of Inpatient Hospital Service Cost-Sharing
• Performed as Outpatient Hospital Services Covered in full ; 32 visits, combined with Specialist Officelimits
• Performed in a Specialist Office Covered in full ; 32 visits, combined with OutpatientHospital limits
OUTPATIENT MEDICAL CARE PARTICIPATING PROVIDER • PCP office visits Covered in full
• Specialists office visits Covered in full
• Preventive care, including well-child visits and immunizations, adult annual physical examinations, adult immunizations, routine gynecological services/well woman exams, mammograms, screening and diagnostic imaging for the detection of breast cancer, sterilization procedures for women, and bone density testing
Covered in full
• Laboratory Procedures, • Performed in a PCP Office
• Performed in Specialist Office
• Performed in a Free Standing Laboratory • Performed as Outpatient Hospital Services
Covered in full
Covered in full Covered in full
Covered in full
• Diagnostic Radiology
• Performed in a PCP Office
• Performed in Specialist Office
• Performed in a Free Standing Radiology Facility
• Performed as Outpatient Hospital Services
Covered in full
Covered in full
Covered in full
Covered in full
• Diagnostic Testing
• Performed in a PCP Office Covered in full
(continued on next page) MH002017
SUMMARY OF BENEFITS
HIP Prime Network
UNITED NATIONS
PrimeHMO for NY CT and NJ Residents
1102308 • Performed in a PCP Office
• Performed in Specialist Office
• Performed as Outpatient Hospital Services
Covered in full
Covered in full
Covered in full
• Advanced Imaging Services (PET scans, MRI, nuclear medicine, CAT scans)
• Performed in a Specialist Office
• Performed in a Free Standing Radiology Facility
• Performed as Outpatient Hospital Services
Covered in full
Covered in full
Covered in full
• Infusion Therapy
• Performed in a PCP Office
• Performed in a Specialist Office Referral required
• Performed as Outpatient Hospital Services
• Home Infusion Therapy
Covered in full
Covered in full
Covered in full
Covered in full
• Ambulatory surgery center facility Covered in full
• Outpatient hospital surgery facility Covered in full
• Preadmission testing Covered in full
• Second opinions on the diagnosis of cancer, surgery and other
90 visits, combined therapies • Outpatient Habilitation Services
Covered in full
• Performed in a PCP Office
• Performed in a Specialist Office
• Performed as Outpatient Hospital Services
Covered in full
Covered in full
Covered in full
• Radiation therapy
• Performed in a Specialist Office
• Performed in a Free Standing Radiology Facility
Covered in full
Covered in full
• Performed as Outpatient Hospital Services Covered in full
OUTPATIENT MEDICAL CARE PARTICIPATING PROVIDER
(continued on next page) MH002017
SUMMARY OF BENEFITS
HIP Prime Network
UNITED NATIONS
PrimeHMO for NY CT and NJ Residents
1102308 • Performed as Outpatient Hospital Services Covered in full
• Chemotherapy
• Performed in a PCP Office
• Performed in a Specialist Office
Covered in full
Covered in full
• Performed as Outpatient Hospital Services Covered in full
• Outpatient Rehabilitation Services(physical therapy,occupational therapy, speech therapy, pulmonary rehabilitation)
• Performed in a PCP Office
• Performed in a Specialist Office
Covered in full
Covered in full
• Performed as Outpatient Hospital Services Covered in full
• Allergy Testing and Treatment
• Performed in a PCP Office Covered in full
• Performed in a Specialist Office Covered in full
• Acupuncture Not Covered
• Telemedicine Program Provided by a Telemedicine Physician Not Covered
MENTAL HEALTH AND ALCOHOL AND SUBSTANCE USE SERVICES PARTICIPATING PROVIDER • Mental Health Care
• Inpatient Covered in full, Unlimited Days
• Outpatient Covered in full, Unlimited Visits
• Substance Use Services
• Inpatient Covered in full, Unlimited Days
• Outpatient Covered in full
SPECIAL KINDS OF CARE PARTICIPATING PROVIDER Urgent Care Center Covered in full
Non-Emergency Ambulance Services Covered in full Pre-Hospital Emergency Medical Services (Ambulance Services) Covered in full
90 visits, combined therapies
OUTPATIENT MEDICAL CARE PARTICIPATING PROVIDER
(continued on next page) MH002017
SUMMARY OF BENEFITS
HIP Prime Network
UNITED NATIONS
PrimeHMO for NY CT and NJ Residents
1102308 Pre-Hospital Emergency Medical Services (AmbulanceServices) Covered in full
Home health care Covered in full; 200 visits
Hospice care
Skilled Nursing Facility (including cardiac and pulmonary rehabilitation) Covered in full, Unlimited Days
Dialysis treatment
• Performed in PCP Office
• Performed in Specialist Office
$10 Copayment
$10 Copayment
• Performed in Free Standing Center $10 Copayment
• Performed as Outpatient Hospital Services $10 Copayment
Diabetes equipment, supplies, Insulin and education Covered in full
Chiropractic Services Covered in full
Family Planning Services Covered Vasectomy Covered in full
Infertility Diagnosis and Treatment 3 Cycles IVF, Per Lifetime, Subject To ApplicableCopayment Dental Care • Preventive Dental Preventive Included
Durable Medical Equipment and Braces No Deductible, Covered In Full
Prosthetics Covered In Full
Orthotics Covered In Full
Medical Supplies Covered in full
External Hearing Aids Not Covered
Cochlear Implants No Copayment - One (1) per ear per time Covered
Optical Care
• Refractive Eye Exams Covered in full / Once per covered period
• Eyeglasses Eyeglasses $35 Every 24 Months
ABA Treatment for Autism Spectrum Disorder Covered in full Assistive Communication Devices for Autism Spectrum Disorder Covered in full
Covered in full, 210 days
SPECIAL KINDS OF CARE PARTICIPATING PROVIDER
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SUMMARY OF BENEFITS
HIP Prime Network
UNITED NATIONS
PrimeHMO for NY CT and NJ Residents
1102308 Assistive Communication Devices for Autism SpectrumDisorder Covered in full ADDITIONAL BENEFITS PARTICIPATING PROVIDER
• Nurse Advice Line Not Covered
• WellSpark Not Covered
• Gym Reimbursement Not Covered
FOOTNOTES
Drugs are dispensed in accordance with EmblemHealth’s Drug Formulary. (...) Except for emergency care, the above benefits and services are covered only when provided or referred by an EmblemHealth Primary Care Physician and/or approved in advance by the EmblemHealth Care Management Program.
Language:English
Score: 425692
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https://www.un.org/insurance/s.../files/hip_medical_plans_0.pdf
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