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  • Member Policies and Rights > Copayment Policy and Procedures

    Some plan members have required copayment (copay) charges. Copays should be collected from members by the provider's office at the time of service. The copay, in conjunction with an office visit, is part of the provider's remuneration and its collection is the provider's responsibility.

    In the event that the copay is not collected from the member, the provider may not seek reimbursement of the copay from EmblemHealth. If the contracted fee under the participating provider agreement with the EmblemHealth companies is less than the copay amount, the participating provider is not permitted to collect the difference between the contracted fee and the copay and must refund such difference to the member if it was collected.

    Members with a Select Care Network-based benefit plan may have a deductible for in-network services. When collecting a copay at an office visit, please note that this amount may actually be a payment towards the member's deductible and that a true copay will not apply until after the deductible is met. Please see the remittance statement for the member's actual out-of-pocket responsibility.

    Patient-specific copay information is listed on the member's ID card. It can also be obtained from our secure website at emblemhealth.com in the member's Summary of Benefits or from our Customer Service departments as listed in the Directory chapter.

    Important things to note:

    • Copays may not be collected from Medicare members for the preventive care services as defined by CMS and listed in Appendix C.
    • Members enrolled in Dual Eligible PPO SNP, Dual Eligible HMO SNP and GuildNet Gold plans may not be charged cost-sharing greater than what would have been charged if the member was enrolled in NYS Medicaid.
    • Medicaid members do not have copays for the following services:
      • Emergency room visits for needed emergency care
      • Family planning services, drugs and supplies
      • Mental health visits
      • Chemical dependency visits
      • Drugs to treat mental illness
      • Drugs to treat tuberculosis
      • Prescription drugs for residents of adult care facilities
    • The following Medicaid members do not have copays for any services:
      • Children under age 21
      • Pregnant women (through 60 days postpartum)
      • Permanent residents of nursing homes
      • Residents of community-based residential facilities licensed by the Office of Mental Health or the Office of Mental Retardation and Developmental Disability
      • Those who are financially unable to make copays at any time and who tell the provider they are unable to pay
      • Medicaid members in a Comprehensive Medicaid Case Management (CMCM) or service coordination program
      • Medicaid members in an OMH or OPWDD Home and Community-Based Services (HCBS) waiver program
      • Medicaid members in a DOH HCBS waiver program for persons with traumatic brain injury (TBI)
      • Medicaid members cannot be denied health care services based on their inability to pay the copay at the time of service. However, providers may bill these members or take other action to collect the owed copay amount.
      • Members with Medicaid have only pharmacy copays and an annual $200 maximum copay obligation.
    • There are no plan copay requirements for CHPlus members.
    • Copays may not exceed the amount payable under the participating provider agreement.

    Preventive Services Covered Under the Affordable Health Care Act

    The Affordable Health Care Act dictates that any person who has a new insurance plan or policy as of September 23, 2010 must have certain preventive services covered without having to pay a copay or coinsurance or meet a deductible. Our Preventive Health Guidelines booklet (available at emblemhealth.com/en/Health-and-Wellness/PHG-Introduction.aspx) helps members learn more about the screenings, tests and immunizations that they and their family need every year.

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    Glossary terms found on this page:

    An activity of EmblemHealth or its subcontractor that results in:

    • Denial or limited authorization of a service authorization request, including the type or level of service
    • Reduction, suspension or termination of a previously authorized service
    • Denial, in whole or in part, of payment for a service
    • Failure to provide services in a timely manner
    • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

    A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    A program that assists the patient in determining the most appropriate and cost-effective treatment plan, including coordinating and monitoring the care with the ultimate goal of achieving the optimum health care outcome.

    The use of one or more drugs for purposes other than those for which they are prescribed or recommended.

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    The government agency responsible for administering the Medicare and Medicaid programs.

    A percentage of the allowed charge that is payable by the member, not EmblemHealth, for covered services rendered by an out-of-network provider. After the member has met his or her deductible, EmblemHealth will pay a percentage of the allowed charge for those covered services in accordance with the member's benefit program. The member is responsible to pay the remaining percentage of the allowed charge. This remaining percentage is the coinsurance charge.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

    The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

    A portion of eligible expenses that an individual or family must pay during a calendar year before EmblemHealth will begin to pay benefits for covered services.

    Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

    Care for a person with an emergency condition.

    An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

    A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.

    The use of providers who participate in the health plan's provider network. Many benefit plans encourage enrollees to use network providers to reduce the enrollee's out-of-pocket expense.

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    A permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A participating provider is a member of the EmblemHealth network of providers applicable to the member's certificate. Therefore, they are more commonly referred to as network providers. Payment is made directly to a participating provider. Please consult the EmblemHealth Directory or go online to search for participating providers.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    A written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.

    Drugs and medications that are required by law to be dispensed by written prescriptions from a licensed physician.

    Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, and generally including routine physical examinations and immunization.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

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