The DC37 Med-Team gives you the freedom to choose in-network or out-of-network doctors. You can see any network doctor without a referral. In most cases, when you see a network doctor, your cost will just be a copay. When you choose to use out-of-network doctors, payment for covered services will be made under your plan. You will be responsible for any difference between the provider’s fee and the amount of the reimbursement, in addition to deductibles and coinsurance; therefore, you may have a substantial out-of-pocket expense. This plan is offered to employees and non-Medicare eligible retirees.
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DC37 Med Team | EmblemHealth
Key Features
- Coverage for in-network services
- No required primary care physician (PCP)
- Coverage of out-of-network services
- Low copays for in-network services
- No payroll deduction for base coverage
- No referrals for in-network doctors
Current in-network copays:
ACPNY PCP: $25 copay
ACPNY Specialist: $25 copay
All Other PCPs: $25 copay
All Other Specialty Providers: $25 copay
Urgent Care: $50 copay
Diagnostic/Lab: $25 copay
MRI/CAT/Hi-Tech Radiology: $50 copay
Physical Therapy: $25 copay
Emergency Room: $150 copay
Out-of-Network Cost
There will be no changes to your current out-of-pocket costs. You will still pay any applicable out-of-network cost-sharing plus the difference between the provider’s fee and GHI’s reimbursement (which may be substantial).
Benefits are subject to approval by the New York State Department of Financial Services.
Costs Covered
MOOP generally refers to the maximum amount of in-network cost-sharing expenses that you will pay in each calendar year for covered services received from Participating Providers under your plan. MOOP includes deductibles, coinsurance and copay charge amounts that you must pay for covered in-network services and any applicable riders in a calendar year. Cost-sharing amounts attributable to services received from Non-Participating Providers generally do not count toward MOOP. Amounts incurred for non-covered services and other non-covered expenses, such as amounts in excess of plan allowances as well as any financial penalties do not count toward MOOP. Premiums and/or premium contributions also do not count toward MOOP. The MOOP amount may change from calendar year to calendar year*.
Individual MOOP: $7,150
Family MOOP: $14,300
*For calendar years beginning January 1, 2019 – December 31, 2019 (Subject to indexing by the federal government)
EmblemHealth has a new partner in place to administer your vision benefits — EyeMed Vision Care with CPS Optical. EyeMed Vision Care with CPS Optical offer a comprehensive network including independent and retail providers, world-class customer service and exceptional value for you and your dependents through additional discounts and savings.
You don’t need to do anything as a result of this change. EmblemHealth, EyeMed and CPS are working to make sure this transition is seamless, so when your group’s new vision plan starts on January 1, 2017, you will have everything you need to receive your vision care.
Effective January 1, 2017, your current vision benefits will change as shown below, once every 12 months. You will receive your new DC37 Med Team ID card during December, 2016. No other benefits are changing under the DC37 Med Team program.
When you get your care from an optometrist in network, you are covered for:
- Examinations. You are covered for one routine eye examination to check if you need corrective lenses. You are not covered for medical treatment of eye disease or injury under this benefit, but you are covered for medical treatment under your regular insurance benefit. Your copay will be $0.
- Eyeglasses: One pair of glasses which includes the lenses and the frame.
- Spectacle Lenses: The fitting and dispensing of one pair of spectacle lenses.
- Standard spectacle lenses include:
- Glass or plastic lenses
- Single vision, bifocal or trifocal lenses
- Tinting of lenses
- Non-standard lens options include:
- Standard progressive lenses: $50 copay
- Premium progressive lenses: $50 copay plus 80% of retail minus $120
- Ultraviolet treatment: $15 copay
- Standard plastic scratch coating: $15 copay
- Standard polycarbonate lenses: $40 copay ($0 copay for children under 19)
- Standard anti-reflective coating: $45 copay
- Standard spectacle lenses include:
- Frames: We will pay an allowance of up to $130 for one frame. If you choose a frame that costs more than this allowance, you pay the difference in cost to the provider.
- Contact Lenses: EmblemHealth will not cover both eyeglasses and contact lenses in the same benefit cycle, but you can get contact lenses instead of glasses during any given cycle. Once contact lenses have been selected and fitted, they may not be exchanged for eyeglasses. You are covered for the fit and follow up of standard contact lenses. You are not covered for the fit and follow up of premium contact lenses. Your contact lenses are covered at 100% up to your allowance of $130. If you choose contact lenses that cost more than your allowance, you pay the difference to the provider.
Keep in mind that you are not covered for services received from a provider who is not a Participating Vision Provider.
Provider Coverage
With our robust network of quality doctors, you can get care from many of the region’s leading doctors, clinicians and facilities, including hospitals and urgent care centers.
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The Right Care, Right in Your Neighborhood
AdvantageCare Physicians are the newest addition to the EmblemHealth family and are now one of the largest primary and specialty care practices in New York City. With 37 locations throughout New York City and Long Island, you can find a convenient location near home or work.
