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Your member handbook tells you how your plan coverage works to get the medical care you need and avoid out-of-pocket costs.
Your quick start guide is a brief, easy-to-read summary of the most important things you need to know about your plan.
Here are some important facts to help you be an informed patient in all health care settings.
Don’t know what something means? Try searching through this list of health care terms.
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Same-day, ambulatory or outpatient surgery is surgery that does not require overnight stay in a hospital.
The Schedule of Allowances is a EmblemHealth listing of the payments for covered medical or dental services rendered by EmblemHealth's Participating Providers. The Schedule of Allowances applicable to your Certificate is on file with the New York State Insurance Department. It is available for inspection at the offices of the New York State Insurance Department and at EmblemHealth's offices. Payment is made under the Schedule of Allowances directly to your Participating Provider.
The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed. Refer to your contract for specific guidelines.
Practice of an individual, group of individuals, employer or organization assuming complete responsibility for the losses that might be insured against such as healthcare expenses. Often, self-insured groups maintain a fund out of which is paid the contingent liability subject to self-insurance.
The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.
Refers to treatment or care intended to improve or restore a member's functioning within a reasonable period of time. Short-term care is expected to produce a positive result, not maintain functioning or prevent decline.
A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.
The Affordable Care Act gives a tax credit for qualifying small employers who pay at least 50% of their employees’ health premium costs. Qualifying for-profit small employers may be eligible for a tax credit of up to 35% of the cost of health premiums paid by the employer. The greatest tax credit for qualifying tax-exempt small employers is 25%.
Services provided by specialists, not by your PCP. For example, an allergist (who treats allergies) or a radiologist (who uses x-rays for diagnosis and treatment) are specialists.
A facility accredited or designated by an agency or the state or by a voluntary national health organization as having special expertise in treating a specified condition or disease.
The specialty care coordinator is a network specialist with expertise in a disabling, degenerative, or life-threatening condition, who manages the treatment of a member with such a condition and shares authority for treatment options with the PCP. In some cases, the specialty care coordinator will initiate an Out-of-Network referral.
Treatment of the correction of a speech impairment which resulted from birth, disease, injury, or prior medical treatment
A subscriber is an active member enrolled under a EmblemHealth group Certificate or an individual enrolled under a direct payment contract. A "Retiree" may also be a subscriber under a group Certificate. Please review the terms of your Certificate to determine whether Retirees are eligible for coverage. You may also contact EmblemHealth or your group health plan administrator for additional information.
The use of one or more drugs for purposes other than those for which they are prescribed or recommended.
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