EmblemHealth HDHP Programs ConsumerDirect EPO and ConsumerDirect PPO

To meet the growing demand for consumer-directed health care, EmblemHealth has created two high-deductible health plans (HDHP), ConsumerDirect EPO and ConsumerDirect PPO. These benefit plans allow employers and employees more power and choice in how to spend their health care dollars and in their health care decisions.

Members may also choose to activate a separate health savings account (HSA) to pay for qualified medical expenses with tax-free dollars. Individual HSAs are member-owned and contributions, interest and withdrawals are tax-free.

Some features for members of ConsumerDirect EPO and ConsumerDirect PPO benefit plans include:

  • Lower monthly premiums based on higher annual deductibles.
  • Two- and four-tier rate structures.
  • Network and out-of-network coverage for PPO.
  • There is no coverage for out-of-network services in the EPO.
  • No out-of-pocket costs for covered preventive care in network.

ConsumerDirect features for practitioners

  • Deductibles and coinsurance apply to all services except preventive care.
  • Practitioners submit claims directly to EmblemHealth for reimbursement.
  • Reimbursement for covered services is subject to your contracted fee regardless of whether the payment is from the plan or your patient.

Member Payment Responsibility

Please submit your claims for medical care for members in ConsumerDirect EPO or ConsumerDirect PPO plans to EmblemHealth. You can expedite reimbursement and avoid payment errors by submitting your claim to us and billing your patient after you receive and review your Explanation of Benefits (EOB) for the claim.

Because member liability is determined after a claim is processed, the EOB will clearly state the member's payment responsibility. If any coinsurance or deductible remains, you may bill your patient directly for the balance.