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HIP HMO Preferred Gold Plan
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GHI CBP

NYCE PPO replaced GHI CBP and Anthem (for hospital care) as of Jan, 1, 2026. For more information, visit nyceppo.com.

GHI CBP was previously offered to employees and non-Medicare eligible retirees. Under the old plan, GHI covered medical and surgical services and hospital benefits were covered by Anthem Blue Cross and Blue Shield (formerly known as Empire BlueCross BlueShield). Effective January 1, 2026, NYCE PPO (offered jointly through EmblemHealth and UnitedHealthcare) replaces the CBP plan.

We know that you might have had care provided to you at the end of 2025 and not all claims have been submitted or processed yet. Below is information to help you understand how 2025 claims for 2025 services will be paid under your GHI CBP coverage. If you registered for the EmblemHealth member portal by December 31, 2025, you can view the previous two years of EOBs and other historical plan materials there until July 1, 2027. Your Anthem materials will be available in the Anthem portal through December 31, 2027.

Care Provided by an Out-of-Network Health Care Professional

Payment for covered services provided by out-of-network doctors will be based on the NYC Non-Participating Provider Schedule of Allowable Charges. The reimbursement rates in the Schedule set a fixed amount that in many cases will be less than the fee charged by the out-of-network provider. In that instance, 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 for services provided by an out-of-network provider.  

Some services needed prior approval. If you did not get required prior approval, you may not get reimbursed and may be responsible for paying the full amount of the service to the provider.

This chart shows the estimated cost of seeing a doctor outside of our network.

Quick Links

Customer Service:
(212) 501-4444, Monday-Friday (excluding major holidays), 8 am-6 pm

TYPICAL OUT-OF-POCKET COSTS FOR RECEIVING CARE FROM OUT-OF-NETWORK PROVIDERS
Established Patient Office Visit (typically 15 minutes) — CPT Code 99213
Estimated charge for a doctor in Manhattan $215
Reimbursement under the schedule $36
Member out-of-pocket responsibility $179
Routine Maternity Care and Delivery — CPT Code 59400
Estimated charge for a doctor in Manhattan $9,500
Reimbursement under the schedule $1,379
Member out-of-pocket responsibility $8,121
Total Hip Replacement Surgery — CPT Code 27130
Estimated charge for a doctor in Manhattan $20,000
Reimbursement under the schedule $3,011
Member out-of-pocket responsibility $16,989

Plan Details

2025 In-Network Costs

  • ACPNY PCP: $0 copay
  • ACPNY Specialist: $0 copay
  • All Other PCPs: $15 copay
  • All other specialty providers: $30 copay
  • Urgent Care: $50 copay*
  • Diagnostic/Lab: $20 copay
  • MRI/CAT/High-Tech Radiology: $50 copay for participating RadNet facilities, Zwanger-Pesiri Radiology, Memorial Sloan Kettering, NewYork-Presbyterian Health System, and Hospital for Special Surgery**
  • Physical Therapy: $20 copay
  • Emergency Room: $150 copay

*$100 for PROHealth and CityMD

**$100 for all other New York State facilities; $50 for out-of-state facilities 

Out-of-network costs

There will be no changes to your current out-of-pocket costs. You will still pay any applicable out-of-network cost-sharing plus the difference between the provider’s fee and GHI’s reimbursement (which may be substantial).

Benefits are subject to approval by the New York State Department of Financial Services.

Maximum Out-of-Pocket (MOOP)

MOOP refers to the maximum amount of in-network cost-sharing expenses that you will pay in each calendar year for covered services received from Participating Providers under the GHI/Anthem Blue Cross and Blue Shield (formerly known as Empire BlueCross BlueShield) plans combined. MOOP includes deductibles, coinsurance, and copay charge amounts that you must pay for covered in-network services and any applicable riders in a calendar year. Cost-sharing amounts attributable to services received from Non-Participating Providers generally do not count toward MOOP. Amounts incurred for non-covered services and other non-covered expenses, such as amounts in excess of plan allowances as well as any financial penalties, do not count toward MOOP. Premiums and/or premium contributions also do not count toward MOOP. The MOOP amount may change from calendar year to calendar year.**

For calendar years beginning Jan. 1, 2022 – Dec. 31, 2022** (Subject to indexing by the federal government)

Individual MOOP

  • GHI Medical MOOP: $4,550
  • EBCBS Hospital MOOP: $2,600

Family MOOP

  • GHI Medical MOOP: $9,100
  • EBCBS Hospital MOOP: $5,200
 

Plan Documents

  • Summary of Benefits and Coverage (Base Plan)

  • Summary of Benefits and Coverage (Enhanced)

  • Summary of Benefits and Coverage (Enhanced with Rx)
 

Certificate of Insurance

Your Certificate of Coverage describes the benefits available under the group contract.

  • EHPI/GHI CBP Certificate of Insurance, Base Plan

  • EHPI/GHI CBP Certificate of Insurance - Base Plan + Enhanced Rider, Less Rx

  • EPHI/GHI CBP Certificate of Insurance, Base Plan + Enhanced Rider + Rx

 

Drugs Covered

For City of New York employees who have prescription drug coverage:

To find your plan’s formulary, simply locate the letter identifiers in the “Formulary” section on the
front of your member ID card, which will match one of the options found in parenthesis below.

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Also of Interest: 
HIP HMO Preferred Gold Plan   |   Our Story   |   Serving Our City with Care