EmblemHealth/CUNY STUDENT HEALTH ­INSURANCE PROGRAM Spring 2013 Underwritten by Group Health Incorporated (GHI) 1 EmblemHealth is committed to providing access to affordable, quality health coverage. It matters to us that you get the care you need, when you need it. When It Comes to Health Coverage, Some Things Really Matter It’s easy to take good health for granted — until you get sick or have an accident. Could you pay for the full expense of a serious illness or injury? Few people can. EmblemHealth wants to help protect students against health care expenses, and to provide the peace of mind that will let them focus on their education. With our EmblemHealth/CUNY Student Health Insurance ­Program, you will receive the hospital, medical and prescription drug coverage you need. The program provides coverage for a wide range of network-only medical, hospital and prescription drug benefits, including annual checkups, lab tests, preventive care, emergency room care and much more, with no referrals to specialists needed. In addition, there are no claim forms to file, b­ ecause the network doctor files claim forms for you. Who Is Eligible? This coverage is available to matriculated CUNY ­students and international students who are enrolled for six c­ redits or more this semester, as well as their dependents (spouses, domestic partners and children up to the end of the month in which they reach age 26). Please see the How to Enroll ­section on page 10 for more information. Note that students who are eligible for Medicare are not eligible for this program. 2 The Choice Is Yours We realize that nothing is more important to you than access to quality doctors, particularly those who speak your language, have specialized expertise and are affiliated with great hospitals. That’s why we work hard to attract and keep great doctors and hospitals in our network. As a member, you will have access to many of the tristate area’s leading doctors and other medical practitioners. You also can receive care at many of the region’s leading hospitals, including: •Memorial Sloan-Kettering Cancer Center in Manhattan •Montefiore Medical Center in the Bronx •Maimonides Medical Center in Brooklyn •Elmhurst Hospital Center in Queens •Richmond University Medical Center on Staten Island The choice of practitioners is yours, but you must select an in-network practitioner to receive benefits. Your only out-of-pocket expenses for most covered services will be a small copay. You are not eligible to receive coverage when you use an out-of-network doctor, except as specifically indicated in the Certificate of Insurance. Pre-Existing Conditions For individuals age 19 and older, there is an 11-month waiting period for p ­ re-existing conditions (whether p ­ hysical or mental) if medical treatment or advice was recommended or received within the six-month period prior to the date you enrolled in the EmblemHealth/CUNY program. There will generally be no coverage for pre-existing conditions during this waiting period. This waiting period will be reduced if you are entitled to a credit for coverage under a previous health plan and did not have a lapse in coverage of 63 days or more. The pre-existing condition waiting period does not apply to individuals under age 19. Your Coverage Is Available During the Summer and After You Graduate Your coverage remains in effect during the summer, even if you are not attending the summer session. You may also remain enrolled in the program for up to six months after you graduate. This means that you and any enrolled dependents (spouse, domestic partner and dependent children) can maintain coverage during a six-month transition period following your graduation. Please see the How to Enroll section on page 10 for more information. Keep in mind that if you falsify a claim to obtain benefits, or if you obtain services you are no longer entitled to receive, you can be prosecuted for fraud. 3 International Coverage A foreign exchange visitor assistance program is also available through International SOS Assistance, Inc. This program provides medical evacuation to your homeland in case of serious illness or death if you’re a foreign student studying at CUNY or a CUNY student studying abroad. For more information on how to enroll in this program, call 1-800-523-8930. The program is not administered by EmblemHealth or underwritten by GHI. Your Hospital, Medical and Prescription Drug Benefits Hospital Benefits The table below briefly summarizes in-network hospital benefits available under this program. Semiprivate room and board for hospitalization 365 days* Hospital copay per single hospital confinement $150 copay Outpatient emergency room care $50 copay per visit Ambulatory surgery Covered in full Outpatient substance abuse/rehabilitation 60 visits** Routine nursing care Covered in full Outpatient dialysis Covered in full Organ transplants Covered in full Chemotherapy/radiation therapy/ lab tests/X-rays $25 copay per service Home care 40 visits** Hospice care 210 days*** Presurgical testing Covered in full Mammography screening Covered in full Pap smear screening Covered in full Inpatient mental health care**** 30 days** *Per person per single hospital confinement. **Per person per calendar year. ***Per person per lifetime. ****Additional mental health benefits may be available for biologically based medical conditions and children with serious emotional disturbances. 4 The program provides 365 days of inpatient, semiprivate room and board, including necessary hospital medical supplies, ­facilities, services, equipment, general nursing care and preadmission testing. It also ­covers ­emergency room care provided and billed by a hospital. We will determine whether the care you receive qualifies as emergency care based upon the following definition of emergency care and the information we receive from your doctors: Emergency care is care for 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, p ­ ossessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: •Placing the health of the person afflicted with such a condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy •Serious impairment to bodily functions •Serious dysfunction of any bodily organ or part •Serious disfigurement You must precertify all planned, nonemergency h ­ ospital admissions. Precertification requires you or your doctor to call us for approval before ­admission. Failure to p ­ recertify will result in a b­ enefit reduction of up to $250. How to Precertify Initiate the precertification process by calling our Care Management Department at 1-800-223-9870, Monday through Friday, from 9 am to 5 pm. If you have a hearing or speech impairment and use a TDD, please call 1-888-447-4833. To expedite the precertification process, please have the following information available when you call: •Identification number/Social Security number •Home phone number •Doctor’s full name, phone number and address •Date of admission •Facility name •Diagnosis •Procedure Our health professionals in Complex Case ­Management can help you get appropriate treatment for major illnesses or injuries. 5 Medical Benefits The table below briefly summarizes the range of in-network medical benefits available under this program. In-hospital/out-of-hospital surgery/surgical assistants Covered in full Anesthesia Covered in full Home/office visits $27 copay per visit X-ray/laboratory tests $25 copay per service* Chemotherapy Covered, subject to copay1 Pediatric immunizing agents Covered in full Durable medical equipment $100 annual per person deductible; $10,000 annual per person maximum Routine mammography/Pap smear Covered in full Physical therapy 10 visits** Allergy visits and speech therapy 8 visits** Diabetes management Covered in full Specialist consultation $25 copay per visit Annual physical checkup (in an approved screening center only — see contact information below)*** Covered in full Out-of-hospital well-baby care Covered in full Maternity care Covered in full Care of premature infants Covered in full Prostate screening Covered, subject to copay1 Sonogram/MRI Covered, subject to copay*1 Ambulance (not available through network practitioners) We will reimburse you up to our usual and customary charge Outpatient mental health care**** 20 visits** *A maximum of one copay will apply per date of service per provider. **Per person per calendar year, subject to home/­office visit copay. ***Annual physical exams can be received at a Professional Evaluation Medical Group (PEMG) screening center. Call 1-800-811-7364 for the location nearest you. ****Additional mental health benefits may be available for biologically based medical conditions and c­ hildren with serious emotional disturbances. 1 Copay may vary according to the service provided. Prescription Drug Benefits The prescription drug benefit program is family friendly and easy to use. You have access to an outstanding pharmacy network that includes more than 40,000 pharmacies nationwide and over 7,000 pharmacies near where you live, work or go to school. Our network offers access to all popular chains such as Walgreens, Duane Reade, Rite Aid and CVS. To find a participating pharmacy, visit www.emblemhealth.com or call Pharmacy Services at 1-877-444-3614, Monday through Friday, from 8 am to 6 pm. 6 Your prescription drug plan is based on the EmblemHealth 2013 Select Formulary, which is a list of preferred drugs covered under your plan. This formulary is intended to help you get the most out of your prescription drug coverage while l­imiting your outof-pocket costs. There are two ways that you can obtain prescription drugs: •Retail Prescription Drug Program: For a 30-day supply of medications received at a participating pharmacy, you pay a $10 copay for generic drugs and a $40 copay for preferred, brand-name drugs. If you have any questions about this program, please visit www.emblemhealth.com or call Pharmacy Services at 1-877-444-3614, Monday through Friday, from 8 am to 6 pm. •Home-Delivery Drug Program: If you take long-term maintenance drugs for the treatment of chronic conditions such as diabetes or asthma, you need to use our home-delivery pharmacy. Up to a 90-day supply of your medication will be mailed to your home. You pay a $20 copay for generic drugs and an $80 copay for preferred, brand-name drugs. If you have any questions about this program, please visit www.emblemhealth.com or call 1-877-866-5798. Please note that there is no deductible or annual out-of-pocket maximum for the ­prescription drug program. Prescription Drug Plan Summary Benefit Retail Program (30-day supply) Home Delivery (90-day supply) Generic drugs $10 copay $20 copay Brand-name drug $40 copay $80 copay Out-of-pocket maximum None None Deductible None None Quality Coverage at a Competitive Price The benefits of our program were designed with the student’s well-being in mind. Here are the monthly premiums for this program: Single $445.80 Family $1,254.25 Important! Do not enclose payment with your enrollment form — we will bill you. Payment in full is required for each bill. Failure to pay in full will result in t­ ermination of coverage. 7 Value-Added Programs The Healthy Discounts Program This popular supplement to the program, available at no additional cost to plan members, encourages a healthy lifestyle through attractive discounts on the most popular and widely used health-related products and services, including exercise p ­ rograms and dietary plans. Visit our Web site at www.emblemhealth.com/stayhealthy for each of our discount programs to find locations or access discounts. Jenny Craig® — Members and their eligible dependents can join Jenny Craig and receive a FREE 30-day program, plus the cost of food and shipping when ­applicable. Call 1-800-96-JENNY (1-800-965-3669) or visit www.jennycraig.com/CorporateChannel/emblem.aspx. Jazzercise — Get one week free and 15 percent off the monthly fee for this unique dance and body-conditioning program. Call 1-800-FIT-IS-IT (1-800-348-4748) or visit www.jazzercise.com. Nutrisystem® — Members can save $30 off all Select, Basic, Silver, Diabetic and Vegetarian program orders, plus take advantage of all the benefits found at www.nutrisystem.com. Once you enroll in a program, you’ll receive meals that are easy to prepare, help you control portion size and are delivered right to your door. And you have over 130 menu items to choose from. You can also take advantage of separate meal plans for men and women. You can sign up online at www.nutrisystem.com/emblem or call 1-877-690-6534 to talk with a Nutrisystem consultant. Vision Care — Save on examinations, eyewear and contact lenses. Call 1-877-92-DAVIS (1-877-923-2847) or visit www.davisvision.com. Go to “Members” and enter client ­control number 7810. Laser Vision Correction — Get discounts on LASIK procedures. Call 1-800-584-2866 or visit www.davisvision.com. Go to “Members” and enter client control number 7940. 8 Hearing Care Through TruHearing — Free hearing screening and discounts of up to 60 percent off certain private label and brand-name hearing aids. Call 1-866-961-3152 (TDD: 1-800-975-2674) to locate participating practitioners and service centers near you, or go online to view hearing aid options at www.truhearing.com/hearing_aids/emblemhealth. Hearing Care Through HeaRx, a HearUSA Company — Receive complimentary screenings and product discounts. Call 1-800-442-8231 (TDD: 1-888-300-3277) or visit www.hearusa.com. Health Care Products and Services — Get significant discounts on medical and dental supplies and on home nursing care. Call 1-866-635-9532 or visit www.carexpresshealth.com/Emblem/index-main.asp. Vitamins and Herbal Supplements — Get free shipping and discounts on b­ rand-name skin care and nutrition products. Call 1-877-335-2746 or visit www.choosehealthy.com/Default.aspx?hp=Emblem. Acupuncture, Massage Therapy and Nutrition Counseling Services — Get discounts through a network of participating practitioners. Call 1-877-327-2746 or visit www.choosehealthy.com/Default.aspx?hp=Emblem. Fitness Club Memberships — Get the lowest publicly available rate or at least a 10 percent discount on enrollment fees and/or monthly membership fees at participating facilities. Call 1-877-327-2746 or visit www.choosehealthy.com/Default aspx?hp=Emblem. Note: EmblemHealth and GHI do not insure or underwrite the Healthy Discounts programs and cannot g­ uarantee continued participation of a particular vendor. Health and Wellness Programs Your Guide to Stop Smoking — Our Tobacco-Free PATH program offers the Quit For Life® program offered by the American Cancer Society and Alere Wellbeing at no cost to you. This program provides materials and support to members 18 years of age and older in their efforts to quit smoking and includes full coverage for smoking cessation medication (nicotine patch, gum, lozenge, bupropion (generic Zyban®) and Chantix®). Make sure to talk to your doctor about which medication is right for you. Visit our Web site at www.emblemhealth.com/stayhealthy. To join our program, call 1-866-611-QUIT (1-866-611-7848), 24 hours a day, seven days a week. Condition-Specific Programs — We offer a full spectrum of programs developed specifically for members with certain chronic health conditions and/or rare diseases. The goal of each program is to help members better manage their conditions and work together with their health care practitioners to maximize their health and quality of life. To get more information about programs for which you may be eligible, visit www.emblemhealth.com or call 1-866-360-5659. 9 How to Enroll If you already have the EmblemHealth/ CUNY coverage you want, TAKE NO ACTION. We will continue to bill you for your coverage automatically. To join, you must sign up during the enrollment period held twice each year, during the spring and fall semesters. This spring’s enrollment period ends March 15, 2013. The enrollment process is different for individual students, families and domestic partners. Student-Only Coverage To enroll for student-only coverage, simply complete the enrollment form, have it stamped by the Registrar’s Office confirming your college enrollment and return it to us. Family Coverage If you elect family coverage for yourself, your spouse and/or your eligible d ­ ependents, please submit a copy of your marriage certificate for your spouse, birth certificates for eligible children and your completed application to us. Please note that young adult children are eligible for coverage until the end of the month in which they turn 26. Your newborn child is covered for injury or illness from the moment of birth. In order to add your ­newborn to your coverage, you must notify us within 30 days of the child’s birth. Domestic Partner Coverage To enroll your domestic partner, please send the following information along with your completed application to us: 1. A copy of your City of New York Certificate of Domestic Partnership or the Alternative Affidavit of Domestic Partnership if you do not have a certificate. 2. The Declaration of Cohabitation & Financial Interdependence Form (DCFIF) with proof of cohabitation and two proofs of financial interdependence. The specific list of documents is shown on the Declaration of Cohabitation & Financial Interdependence Form. Please note both of these forms must be notarized. Payment Please do not send payment with your application. After we approve your application, we will send you a bill (new members also receive their ID card at that time). Your coverage will become effective when we receive your payment for the full initial ­premium. If you do not receive your bill within two weeks after you receive your ID card, please notify us. Failure to pay an outstanding bill will result in the termination of your policy. Keep a copy of your application for your records. Once you are enrolled, your payment is expected by the 1st of each month. If you fail to make payment within a 10-day grace period following the 1st of the month, your health insurance coverage will be terminated. 10 How to Contact Us If you have any questions, please call Customer Service at 1-800-624-2414, Monday through Friday, from 8 am to 6 pm. If you use a TDD, please call 1-866-248-0640. Visit Our Web Site for Helpful Information Visit www.emblemhealth.com/cuny to download the application form you’ll need to enroll and to view an up-to-date listing of network p ­ hysicians and specialists — including maps and directions to their offices. As a registered member you will have 24-hour access to myEmblemHealth for Members, a secure PIN-protected area where you can: •Specify your preference for print or e-mail communications. •View an electronic version of your Explanation of Benefits statements (EOBs). •View detailed information about your benefits. •Verify eligibility for yourself and your dependents. •Request replacement ID cards. •Access up-to-date consumer health information. •Update your name and/or your home or e-mail address. •Start a Personal Health Record. •Complete a Health Risk Assessment. •Learn about our Health and Wellness programs. •Learn about baby care. In addition, you may view and pay your insurance premium bill safely and securely online with a credit card or a checking account through the web pay f­ eature on myEmblemHealth for Members. 11 441 Ninth Avenue, New York, New York 10001-1681 | www.emblemhealth.com It’s Easy to Enroll: •Complete the enrollment form. •Get it stamped by your school’s Registrar’s Office to confirm your eligibility. •Mail it to us. It must be postmarked by March 15, 2013. •Do not send any payment with your ­application — we will bill you. If you already have our coverage, TAKE NO ACTION. We will continue to bill you automatically. Your next chance to add this important coverage will not occur until next semester. This brochure provides only a brief overview of benefits. Coverage is subject to all terms, conditions, limitations and exclusions contained in the group contract and the Certificate of Insurance. In the event of any inconsistency between this brochure, the group contract and the Certificate of Insurance, the terms of the group contract and Certificate of Insurance shall be controlling. EmblemHealth insurance plans are underwritten by Group Health Incorporated (GHI), GHI HMO Select, Inc. (GHI HMO), HIP Health Plan of New York (HIP) and HIP Insurance Company of New York. GHI Policy Forms: PLH-5144B, PLH-5339, et al. EMB_MP_BRO_12815_CUNY_Opn_Enroll_Spring13 1/13