What GHI CBP Covers and Costs

Summary of Benefits and Coverage

Benefits At-a-Glance: GHI CBP

Medical Care Your In-Network Cost Your Out-of-Network Cost‡
Specialist office visit $20 copay For specialist office visits, diagnostic lab/X-ray, routine physical exams, well child care, outpatient mental health and urgent care, you pay the difference between the provider’s fee and GHI’s reimbursement†
Diagnostic lab/X-ray $15 copay
Routine physical exam (age 45 or older) $0 copay
Well child care $0 copay
Outpatient mental health $15 copay
Urgent care $15 copay
Ambulatory surgery* 20% coinsurance/maximum of $200 per person per year $500 per person per admission to a maximum of $1,250 per year plus 20% coinsurance
Ambulance Not applicable Reimbursement at 80% of the allowed charge†
Inpatient care* $300 per person/$750 max per year $500 per person per admission per visit to a maximum of $1,250 per year plus 20% coinsurance
Anesthesia Included in hospital copay Reimbursement at 80% of the allowed charge†
Emergency room* $50 copay (waived if admitted) $50 copay (waived if admitted)
Cost Sharing In-Network Out-of-Network
Annual deductible $0 $200 individual/$500 family
Annual coinsurance None None
Coinsurance maximum None None
Out-of-network annual maximum Not applicable Unlimited
Out-of-network lifetime maximum Not applicable Unlimited

*Hospital benefits are underwritten by and provided through Empire BlueCross and BlueShield. Certain services billed by physicians and providers who are not hospital employees during an emergency room visit or inpatient stay may not be considered to be a part of your emergency room and/or hospitalization benefit. These services are covered according to the terms and conditions that otherwise apply to the type of service under the GHI CBP plan.

†The allowed charge from out-of-network providers is determined by the reimbursement rates set in the NYC Non-Participating Provider Schedule of Allowable Charges. The reimbursement rates in the schedule are not related to usual and customary rates or to what the provider may charge but are set at a fixed amount based on GHI’s 1983 reimbursement rates.

‡Covered services from out-of-network doctors have deductibles and coinsurance. Payment for services provided by out-of-network providers is made directly to you under the NYC Non-Participating Provider Schedule of Allowable Charges. You will be responsible for any difference between the provider’s fee and the amount of the reimbursement; therefore, you may have a substantial out-of-pocket expense.

Optional Rider

You can add the following optional rider benefits to your GHI CBP plan through a payroll deduction if the benefits are not provided by the welfare fund:

  • Enhanced Non-Participating Provider Schedule — For lower out-of-pocket costs. It increases the reimbursement of the basic program’s non-participating provider fee schedule for some in-hospital services, on average, by 75 percent.
  • Prescription drugs — For generic and brand drugs from network retail drug stores and home delivery service.

For details, see the plan’s Certificate of Insurance.

Special Provisions

Coverage for Psychotropic, Injectable, Chemotherapy and Asthma Medications
For Non-Medicare eligible employees retirees and their dependents, pharmacy benefits for Chemotherapy and Injectable Medications are provided under the City of New York PICA Program and pharmacy benefits for Psychotropic and Asthma medication are provided under the GHI Optional Rider Program. The City of New York PICA Program is administered by NPA, a division of Express-Scripts, Inc. (ESI). If you have questions regarding the PICA program, you should call ESI at 1-800-467-2006.

Coverage for Cancer Second Opinions
Coverage is provided for second opinions for eligible members who have been diagnosed with cancer. Members may visit any appropriate specialist for the second opinion.

Coverage for Breast Reconstructive Surgery
Coverage for breast reconstructive surgery following a mastectomy, including breast reconstruction on a healthy breast required to achieve reasonable symmetry, is provided.