Spring 2013
Underwritten by Group Health Incorporated (GHI)
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.
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.
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.
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
Our health professionals in Complex Case ­Management can help you get appropriate
treatment for major illnesses or injuries.
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
Covered in full
Covered in full
Home/office visits
$27 copay per visit
X-ray/laboratory tests
$25 copay per service*
Covered, subject to copay1
Pediatric immunizing agents
Covered in full
Durable medical
$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
Covered, subject to copay*1
Ambulance (not available through network
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.
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 or call
Pharmacy Services at 1-877-444-3614, Monday through Friday, from 8 am to 6 pm.
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 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 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
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
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:
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.
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 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
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
Nutrisystem® — Members can save $30 off all Select, Basic, Silver, Diabetic
and Vegetarian program orders, plus take advantage of all the benefits found
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 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 Go to “Members” and enter client
­control number 7810.
Laser Vision Correction — Get discounts on LASIK procedures. Call 1-800-584-2866
or visit Go to “Members” and enter client control number 7940.
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
Hearing Care Through HeaRx, a HearUSA Company — Receive complimentary
screenings and product discounts. Call 1-800-442-8231 (TDD: 1-888-300-3277) or
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
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
Acupuncture, Massage Therapy and Nutrition Counseling Services — Get
discounts through a network of participating practitioners. Call 1-877-327-2746 or
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 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 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 or call 1-866-360-5659.
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.
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.
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 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.
441 Ninth Avenue, New York, New York 10001-1681 |
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.
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