The GHI Comprehensive Benefits Plan (CBP) 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.
Using an Out-of-Network Health Care Professional
When you choose to use out-of-network doctors, payment for covered services will be made under 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. Most of the reimbursement rates have not increased since that time, and will likely be less (and in many instances substantially less) than the fee charged by the out-of-network provider.
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 and covers medical and surgical services. Hospitalization benefits are provided to you by Anthem Blue Cross and Blue Shield (formerly known as Empire BlueCross BlueShield).
Some services may need a prior approval. If you do not get a required prior approval, you may not get reimbursed.
If you choose to get services outside of our network, you can use our self-service treatment cost calculator available in the myEmblemHealth member portal. The calculator provides estimates for out-of-pocket costs, or what you may pay for certain items and services.
Using a health care professional in our network is a cost-effective way to use this plan. This chart shows the estimated cost of seeing a doctor outside of our network.
