GROUP HEALTH INCORPORATED

Transcription

1 GROUP HEALTH INCORPORATED (hereinafter referred to as "GHI") 441 Ninth Avenue, New York NY HEALTH INSURANCE FOR YOU AND YOUR DEPENDENTS GHI-THE CITY UNIVERSITY OF NEW YORK EXCEPT AS SPECIFICALLY PROVIDED OTHERWISE, YOU MUST RECEIVE COVERED SERVICES FROM A GHI PARTICIPATING PROVIDER IN ORDER TO BE ELIGIBLE FOR BENEFITS UNDER THIS PROGRAM GROUP HEALTH INCORPORATED PLH-5144B 8/05

2 The insurance evidenced by this Certificate meets the minimum standards for basic hospital and basic medical insurance as defined by the New York State Insurance Department. It does NOT meet the minimum standards for major medical insurance as defined by the New York State Insurance Department.

3 TABLE OF CONTENTS Section One Introduction/Who Is Covered [1] Section Two Definitions [6] HOSPITAL BENEFITS Section Three Covered Inpatient Hospital Care [8] Section Four Covered Outpatient Hospital Care [11] Section Five Covered Home Care Services [14] Section Six Covered Out-Patient Treatment of Alcoholism and Substance Abuse [15] Section Seven Hospice Care [16] MEDICAL BENEFITS Section Eight Use of Participating Providers for Paid-In-Full Benefits [17] Section Nine Covered Medical Services [17] Section Ten Durable Medical Equipment [24] ADDITIONAL BENEFITS & PROGRAMS Section Eleven Pre-Hospital Emergency Medical Services [25] Section Twelve Centers of Specialized Care [25] Section Thirteen Coordinated Care Program [26] GENERAL PROVISIONS Section Fourteen Principal Limitations and Exclusions [27] Section Fifteen Coordination of Benefits [32] Section Sixteen Filing of Claims [33] Section Seventeen Termination of Coverage [38] Section Eighteen Continuation of Coverage [39] Section Nineteen Coverage for Those Eligible for Medicare [39] Section Twenty Miscellaneous Provisions [39]

4 SECTION ONE. - INTRODUCTION/WHO IS COVERED: 1. Your Coverage Under GHI/HSP/CBP. Your University has entered into a Group Contract with Group Health Incorporated (GHI) to provide you with health insurance benefits. Under this Group Contract, GHI will provide the benefits described in this booklet to covered persons. Your coverage will be referred to in this booklet as GHI CUNY Program or as this Program. This booklet is your Certificate of Insurance. It is evidence of your coverage under the Group Contract. It is not a contract between you and GHI. You should keep this booklet with your other important papers so that it is available for your future reference. This Program protects you with benefits for covered health services rendered by GHI Participating Providers. The full extent of your coverage is detailed in the Sections that follow. EXCEPT AS SPECIFICALLY PROVIDED OTHERWISE IN THIS CERTIFICATE, GHI WILL NOT COVER SERVICES RENDERED BY A NON-PARTICIPATING PROVIDER. 2. Who is Covered. You are eligible for coverage if you are a matriculated student at the City University of New York carrying more than six (6) credit hours of class per semester. Student status shall be determined by CUNY. Eligibility may continue for a period not to exceed six (6) months for all graduating students. 3. Coverage of Spouse and Dependent Children. If you have family coverage, benefits are available for your covered spouse and covered, unmarried dependents under the age of 19. Unmarried dependent children are covered until the end of the year in which they attain age 19. Your newborn child is covered from the moment of birth for injury or sickness. You must add the newborn child to your coverage within 30 days of the child s birth. If you have individual coverage, you may elect to cover your newborn child from the moment of birth for injury and sickness. You must add the newborn child to your coverage within 30 days of the child s birth. This will change your individual coverage to family coverage. An ex-spouse is never covered under this Program regardless of the terms of any settlement agreement. The submission of a claim by or for an ex-spouse of a covered student is an insurance fraud. A dependent who is not your spouse or natural child may be eligible for coverage. A dependent who is an adoptive child or stepchild is eligible for coverage. The child must be chiefly dependent upon you for support. A dependent adoptive child will be covered on the same basis as a natural child during any waiting period prior to finalization of the adoption. A dependent child or stepchild is covered at the earliest of the dates set forth below. A court of Law accepts consent to adopt and you enter into an agreement to support the child. A court of Law makes you legally responsible for the support and maintenance of the child. An adopted newborn is covered from the moment of birth for injury and sickness if you add the adopted newborn to this Policy within thirty (30) days of birth. You must take physical custody of the newborn upon the newborn s release from the hospital. You must also file a petition for adoption or apply for temporary guardianship within thirty (30) days after the child s birth. Benefits for the adopted newborn s initial hospital stay are not available if a natural parent has insurance coverage available to cover the newborn. An unmarried child over age 19 may also be eligible for benefits. In order to be eligible, he or she must meet all of the conditions set forth below. (a) He or she must be incapable of self-sustaining employment due to mental illness, developmental disability, mental retardation as defined in the New York State Mental Hygiene Law, or physical handicap. (b) He or she must have been so incapable before the age at which dependent coverage would otherwise terminate. (c) He or she must have been eligible for benefits before the age at which dependent coverage would otherwise terminate. (d) The child s condition must be certified by a physician. 1

5 (e) Proof of the condition is submitted to GHI within 31 days of the date the dependent reaches the age at which dependent coverage would otherwise terminate. GHI may ask you to prove that the child is and continues to qualify as a dependent incapable of self-sustaining employment. 4. Domestic Partners. Benefits are available for your covered domestic partner and his or her eligible dependents. Your domestic partner and any eligible dependents will be covered following a one-semester waiting period. The domestic partnership must consist of two people who are 18 years of age or older and who live together and have been living together on a continuous basis for at least six (6) months. The domestic partnership must involve a close and committed personal relationship. Neither you nor your domestic partner may be married or related by blood in a manner that would bar marriage in New York State. Your domestic partner must be chiefly dependent upon you for support and maintenance. In order to be eligible for coverage, you must show that you and your domestic partner are economically interdependent by meeting the criteria set forth below. (a) The domestic partnership must be registered under the Domestic Partnership Registration Program of the City of New York Office of the Mayor as well as with the City Clerk. (In the case of students living outside of the City of New York, an alternate affidavit of domestic partnership recognized by the City University of New York may be presented in lieu of registration.) (b) You must supply proof of cohabitation. This may be shown by means of drivers licenses, tax returns or other proof recognized by the City University of New York. (c) You must present evidence of at least two of the indications of economic interdependency set forth below. A joint bank account. A joint credit or charge card. A joint obligation on a loan. Status as an authorized signatory on your domestic partner s bank account, credit card or charge card. Joint ownership or holding of investments. Joint ownership of a residence. Joint ownership of real estate other than a residence. Listing of both you and your domestic partner as tenants on the lease of a shared residence. Shared rental payments for a residence. Listing of you and your domestic partner as tenants on a lease or shared rental payments for property other than a residence. A common household and shared household expenses, such as grocery bills, utility bills and telephone bills. Shared household budget for purposes of receiving government benefits. Status of one as representative payee for the other s government benefits. Joint ownership of major items of personal property, such as appliances and furniture. Joint ownership of a motor vehicle. Joint responsibility for child care. This may be shown be means of school documents, guardianship papers or similar documents. Shared child care expenses, such as baby sitting, day care and school bills. Execution of wills naming each other as executor and/or beneficiary. 2

6 Designation of one as beneficiary under the other s life insurance policy. Designation of one as beneficiary under the other s retirement benefits account. Mutual grant of power of attorney. Mutual grant of authority to make health care decisions, such as a health care power of attorney. Affidavit by a creditor or other individual able to testify to your partner s financial interdependence. Other items of proof acceptable to the City University of New York showing economic interdependency. 5. Medicare. If you are eligible for Medicare due to age, you are not eligible for coverage under this Program. Refer to the section entitled Coverage for Those Eligible for Medicare for more information. 6. Criteria for Coverage. In order to request benefits, you must file a claim with GHI. You, your authorized representative or your provider may file a claim for benefits with GHI on your behalf. For information about how to file a claim, please see the section of this Certificate entitled Filing of Claims, Grievances and Appeals. GHI will provide benefits only for the services that are listed as covered in this Certificate. GHI will cover these services only if they are medically necessary and not otherwise excluded from coverage. The services must also be rendered by an eligible Provider. Medically necessary services are health care services that are rendered by a Hospital or a licensed Provider and are determined by GHI to meet all of the criteria listed below. They are provided for the diagnosis, or direct care or treatment of the condition, illness, disease, injury or ailment. They are consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment. They are in accordance with accepted standards of good medical practice in the community. They are furnished in a setting commensurate with the patient s medical needs and condition. They cannot be omitted under the standards referenced above. They are not in excess of the care indicated by generally accepted standards of good medical practice in the community. They are not furnished primarily for the convenience of the patient, the patient s family or the Provider. In the case of a hospitalization, the services cannot be rendered safely or adequately on an outpatient basis and, therefore, require that the patient receive acute care as a bed patient. 7. Utilization Review Decisions. Utilization review is the process by which GHI decides whether or not an item or service for which you request benefits is medically necessary and/or experimental or investigational in nature. Utilization review is performed under the supervision of GHI s Medical Director. A clinical peer reviewer will confirm each finding by GHI that an item or service is not medically necessary or that an item or service is experimental or investigational and, therefore, not covered. GHI will notify you of utilization review decisions as set forth below. If you disagree with GHI s decision that an item or service(s) is not medically necessary or is experimental or investigational in nature and therefore, not covered, you may file an appeal. Please see the section of this Certificate entitled Filing of Claims, Grievances and Appeals for instructions on how to file an appeal. (a) Pre-Service Claims. A pre-service claim is a claim for a service that you must pre-certify with GHI under the terms of this Certificate. GHI will notify you and your Provider of its decision on a pre-service claim within the earlier of three (3) business days or five (5) calendar days after GHI s receipt of the claim. GHI will notify you in writing and by telephone. 3

7 If GHI requires more information to decide your claim, GHI will request such information within fifteen (15) days after its receipt of the claim. GHI will give you at least forty-five (45) days to supply the information. If you supply all of the requested information to GHI within the time that GHI gives you to supply it, then GHI will notify you of its decision within three (3) business days, but not later than five (5) calendar days after its receipt of the information. Otherwise, GHI will notify you of its decision within fifteen (15) days of its receipt of partial information or within fifteen (15) days of the end of the time period GHI gives you to supply it. If you fail to pre-certify a service when it is required by this Certificate, GHI will inform you of the proper precertification procedure within five (5) days (or within twenty-four (24) hours in the case of a pre-service urgent care claim) of receipt of the claim by a GHI person or unit customarily responsible for handling benefit matters. (b) Post-Service Claims. A post service claim refers to any claim for benefits relating to a service that has already been provided to you. GHI will notify you, and if appropriate your provider, of its decision on a post-service claim within thirty (30) days after its receipt of the claim. GHI will notify you in writing. If GHI requires more information to decide your claim, GHI will request such information within thirty (30) days after its receipt of the claim. GHI will give you at least forty-five (45) days to supply the information. If GHI requests more information, GHI will notify you of its decision on your claim within fifteen (15) days after GHI s receipt of all or part of the information or within fifteen (15) days after the end of the time period GHI gives you to supply the information. (c) Urgent Care Claims. An urgent care claim refers to a claim that, if subjected to the other time periods set forth in this section, could seriously jeopardize the life or health of the patient or the patient s ability to regain maximum function, or subject the patient to severe pain that cannot be managed adequately. GHI may reasonably require you or your provider to explain the medical reasons that give rise to a need for urgent care. If care has not yet been initiated, GHI will notify you and your provider of its decision on your urgent care claim within seventy-two (72) hours from receipt of the claim. GHI will notify you in writing and by telephone. If GHI requires more information to make a decision, GHI will notify you of the required information within twenty-four (24) hours after GHI s receipt of the claim. GHI will give you at least forty-eight (48) hours to supply the information. GHI will notify you of its decision on your claim within forty-eight (48) hours of its receipt of the information or within forty-eight (48) hours of the end of the time period GHI gives you to supply the information. If care has already been initiated and you are seeking an extension of urgent care, the time in which GHI will decide your urgent care claim will vary. It will depend upon when GHI receives your claim. If GHI receives your claim at least twenty-four (24) hours before the end of the previously approved treatment plan, then GHI will notify you and your provider of its decision on your urgent care claim within twenty-four (24) hours after GHI s receipt of the claim. If GHI receives your claim less than twenty-four (24) hours before the end of the previously approved treatment plan, then GHI will notify you and your provider of its decision within the earlier of one (1) business day of its receipt of all necessary information or seventy-two (72) hours of its receipt of the claim. GHI will notify you in writing and by telephone. (d) Concurrent Care Decisions. A concurrent care decision refers to a claim decision by GHI that affects an ongoing course of treatment taking place over a period of time or a number of treatments. If you or your provider request a non-urgent continuation, extension or addition to a previously approved plan of care, GHI will notify you and if appropriate, your provider of its decision within one (1) business day of GHI s receipt of all necessary information, but not more than fifteen (15) days after GHI s receipt of the claim. If GHI reduces or terminates a previously approved course of treatment (for reasons other than amendment or termination of the Group Contract or your GHI coverage), GHI will notify you and if appropriate, your provider of its decision sufficiently in advance so that you that you can appeal the decision. GHI will notify you in writing and by telephone. 4

8 8. Other Claim Decisions. Your claim may not involve any issues relating to medical necessity. When this is the case, GHI will review your claim by confirming your eligibility for benefits, verifying that the service you received or will receive is a covered service under this Program and, if appropriate, determining the proper amount of payment. If your claim does not involve a determination by GHI regarding the medical necessity or experimental or investigational nature of the requested service(s), GHI will notify you of its decision on your claim as set forth below. (a) Pre-Service Claims. A pre-service claim is a claim for a service that you must pre-certify with GHI under the terms of this Certificate. GHI will notify you and your Provider of its decision on a pre-service claim within fifteen (15) days after GHI s receipt of the claim. GHI will notify you in writing. If GHI requires more information to decide your claim, GHI will request such information within fifteen (15) days after its receipt of the claim. GHI will give you at least forty-five (45) days to supply the information. If GHI requests more information, GHI will notify you of its decision on your claim within fifteen (15) days after its receipt of all or part of the information or within fifteen (15) days after the end of the time period GHI gives you to supply it. If you fail to pre-certify services when it is required by this Certificate, GHI will inform you of the proper precertification procedures within five (5) days (or within twenty-four (24) hours in the case of a pre-service urgent care claim) of receipt of the claim by a GHI person or unit customarily responsible for handling benefit matters. (b) Post-Service Claims. A post service claim refers to any claim for benefits that is not a pre-service claim. GHI will notify you of its decision on a post-service claim within thirty (30) days of its receipt of the claim. GHI will give such notice in writing. If GHI requires more information to decide your claim, GHI will request such information within thirty (30) days after its receipt of the claim. GHI will give you at least forty-five (45) days to supply the information. If GHI requests more information, GHI will notify you of its decision on your claim within fifteen (15) days after the earlier of GHI s receipt of all or part of the information or the end of the time period GHI gives you to supply it. GHI may combine its request for more information with a notice of denial. If GHI does not receive any information, then this denial will apply. In such a case, you will not receive a notice from GHI at the end of the time period GHI gives you to supply information. If you receive services from a GHI participating provider, and your only liability for the service(s) is a Co-pay Charge, then the time periods above do not apply. (c) Urgent Care Claims. An urgent care claim refers to a claim that, if subjected to the other time periods set forth in this section, could seriously jeopardize the life or health of the patient or the patient s ability to regain maximum function, or subject the patient to severe pain that cannot be managed adequately. GHI may reasonably require you or your provider to explain the medical reasons that give rise to a need for urgent care. If care has not yet been initiated, GHI will notify you of its decision on your urgent care claim within seventy-two (72) hours of its receipt of the claim. If care has already been initiated and you are seeking an extension of urgent care, the time in which GHI will decide your urgent care claim will vary. It will depend upon when GHI receives your claim. If GHI receives your claim at least twenty-four (24) hours before the end of the previously approved treatment plan, then GHI will notify you of its decision on your urgent care claim within twenty-four (24) hours after GHI s receipt of the claim. If GHI receives your claim less than twenty-four (24) hours before the end of the previously approved treatment plan, then GHI will notify you and your provider of its decision within seventy-two (72) hours of its receipt of the claim. GHI will provide such notice in writing. If GHI requires more information to make a decision on your urgent care claim, GHI will notify you of the required information within twenty-four (24) hours after GHI s receipt of the claim. If GHI requests more information, GHI will give you at least fortyeight (48) hours to supply the information. GHI will notify you of its decision on your claim within forty-eight (48) hours of the earlier of its receipt of the information or the end of the time period GHI gives you to supply the information. 5

9 (d) Concurrent Care Decisions. A concurrent care decision refers to a claim decision by GHI that affects an ongoing course of treatment taking place over a period of time or a number of treatments. If you or your provider request a non-urgent continuation, extension or addition to a previously approved plan of care, GHI will notify you of its decision within fifteen (15) days from GHI s receipt of the claim. If GHI reduces or terminates a previously approved course of treatment (for reasons other than amendment or termination of the Group Contract or your GHI coverage), GHI will notify you of its decision sufficiently in advance so that you that you can appeal the decision. GHI will give such notice in writing. The following definitions apply to your benefits. SECTION TWO. - DEFINITIONS: 1. You. The word you refers to you, the subscriber. It also refers to any members of your family who are covered under this Program. 2. Group Contract. The Group Contract is the agreement GHI has with your group, the City University of New York. 3. Certificate of Insurance. This document and any riders or amendments thereto is your Certificate of Insurance. It is evidence of your coverage under the Group Contract. 4. Certificate. The word Certificate in the text refers to the Certificate of Insurance. 5. Hospital. Hospital is a general hospital that has medical and surgical facilities for the care and treatment of the sick. It must be a short-term acute care general hospital. A short-term acute care general hospital is an institution engaged primarily in providing inpatient diagnostic and therapeutic facilities for surgical and medical diagnosis, treatment and care of injured and sick persons. The hospital must provide 24-hour nursing service by registered graduate nurses who are present and on duty. The hospital must be supervised by a staff of physicians. A hospital is not one of the following. (a) An old age, rest, or nursing home. (b) A convalescent home or similar institution. (c) A sanitarium. (d) A camp, school, college, or university infirmary. (e) A facility for the treatment of mental problems, tuberculosis, drug abuse, or alcoholism. (f) A weight loss or fitness center. (g) A skilled nursing center or facility. (h) An institution utilized primarily for custodial care or as a domicile. (I) Health resorts or spas. (j) Places for hospice care treatment. (k) Rehabilitation facilities. 6. Schedule of Allowances. The Schedule of Allowances ( Schedule ) is GHI s listing of the payments for covered medical services rendered by most Participating Providers. The Schedule 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 GHI s offices. Payment is made under the Schedule directly to a Participating Provider. 7. Provider. A Provider is a medical practitioner or covered facility recognized by GHI for reimbursement purposes. A Provider may be any of the following subject to the conditions listed in this paragraph: 6

10 (a) A doctor of medicine. (b) A doctor of osteopathy. (c) A dentist. (d) A chiropractor. (e) A doctor of podiatric medicine. (f) A physical therapist. (g) A nurse midwife. (h) A certified and registered psychologist. (I) A certified and qualified social worker. (j) An optometrist. (k) A nurse anesthetist. (l) A speech therapist. (m) An audiologist. (n) A clinical laboratory. (o) A screening center. (p) A general hospital. (q) Any other type of practitioner or facility specifically listed in this Certificate as a practitioner or facility recognized by GHI 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. Please note that not all services rendered by a specific class of Providers listed above are covered services. In order for you to be covered, the service rendered to you must be covered. In addition, the practitioner or facility rendering the service must be listed in this Certificate as a Provider who is recognized by GHI to render the covered service. Please refer to the benefit description to find out if a service is covered. 8. Participating Provider. A Participating Provider is any doctor, hospital or other Provider who has agreed with GHI to accept GHI s Schedule or negotiated rate as payment in full for covered services, subject to the applicable Co-pay Charge(s), and who is a member of the GHI network that applies to this Program. Consult your Directory of Physicians and other Providers for the names of Participating Providers. You may also call or write to GHI or visit GHI s website at for this information. 9. Co-pay Charge. A Co-pay Charge is a fixed dollar amount you must pay to a Provider for certain services. Copay Charges may apply to home and office visits, out-of-hospital consultations, certain diagnostic services and other services as noted in this Certificate. 10. Allowed Charge. The Allowed Charge is the amount that GHI will reimburse for a covered hospital inpatient or outpatient services rendered by a non-participating Provider. Allowed Charges are determined differently depending upon the type of service you receive. If you are a registered bed patient in a non-participating Hospital or you receive outpatient services from a nonparticipating Hospital, the Allowed Charge will be the lesser of the following: the negotiated rate between GHI and the Hospital the negotiated rate between the Hospital and any network arrangements with which GHI has an agreement; the Hospital s published rate for the service; 7

11 for out of area Hospitals and facilities, the Hospital or facility s published rate for the service, not to exceed the average charge of GHI Participating Hospitals for the same or similar services; charges. There may be occasions where GHI does not have an Allowed Charge for a particular hospital service. When this is the case, GHI will make payment based upon either Medicare guidelines and/or the Relative Value Scale to determine comparability between procedures. The Relative Value Scale is a standard of rating generally accepted in the health insurance field. HOSPITAL BENEFITS SECTION THREE. - COVERED INPATIENT HOSPITAL CARE: GHI will cover for the services listed below when you are an inpatient in the Hospitals described below. 1. Services Provided in a GHI Participating Hospital. After you pay a $150 Co-pay Charge per single hospital confinement, GHI will provide benefits for covered inpatient services rendered in a GHI Participating Hospital. A GHI Participating Hospital is any Hospital that has an agreement with GHI to provide services to persons covered under GHI Hospital Service contracts. If you are a registered bed patient in a Hospital, GHI will pay for most of the services provided by the Hospital. GHI will pay only for services covered by this Certificate. GHI will provide coverage in full for the benefits described herein. GHI will not pay for any service unless the conditions set forth below are met. (i) The service is given to you by an employee of the Hospital. (ii) The Hospital submits a bill for the service. (iii) The Hospital retains the money paid for the service. Your benefits include all patient care services customarily provided by the Hospital. These services vary from Hospital to Hospital. They do not include services charged for by a private practitioner. Typically, covered services consist of the items set forth below. (a) Bed and board. This includes special diet and nutritional therapy. It also includes routine nursery care during the mother s covered Hospital stay. (Family coverage only). (b) General, special, and critical care nursing service other than private-duty nursing service. (c) Facilities, services, supplies and equipment related to surgical operations, recovery facilities, cystoscopic rooms and equipment, anesthesia and facilities for intensive or special care. (d) Oxygen and other inhalation therapeutic services and supplies. (e) Drugs and medications which are listed and approved for such use in the U.S. Pharmacopoeia, the National Formulary, the U.S. Homeopathic Pharmacopoeia, or in New Drugs or Accepted Dental Remedies. (f) Sera, biologicals, vaccines, intravenous preparations and visualizing dyes for care in the Hospital, and administration thereof, dressings, casts, and materials for diagnostic studies. Visualizing dyes that are not commercially available for purchase and readily obtainable by the Hospital are not covered. (g) Services, supplies and equipment related to the administration of blood, blood products, and blood derivatives. You are also covered for blood if it is not replaced and if it is charged for by the Hospital. (h) Facilities, services, supplies and equipment related to physiotherapy and occupational therapy and rehabilitation. (i) Facilities, services, supplies and equipment related to diagnostic studies. This includes, but is not limited to, laboratory, pathology, X-ray examinations, radiation therapy, cardiographic, endoscopic, and electroencephalographic studies and examinations and electrocardiographs. (j) Social, psychological, and pastoral services. 8

12 (k) Facilities, services, supplies and equipment related to radiation, nuclear therapy, and chemotherapy. (l) Facilities, services, supplies and equipment related to emergency medical care. (m) Any additional medical, surgical, or related services, supplies and equipment which are customarily furnished by Hospitals with agreements with GHI, except to the extent that such are excluded by this Certificate. GHI will never pay benefits for care rendered on any day when, by its determination, acute hospital care was not necessary. GHI will pay only for a semi-private room or Hospital ward. A semi-private room is a room which the Hospital considers to be semi-private. If you occupy a private room in a Hospital, GHI will only pay the Hospital s most common semi-private room charge. You will have to pay the difference between that charge and the charge for the private room. The Hospital portion of this Certificate does not cover the following services. (a) Private-duty nursing services. (b) Special braces, appliances or equipment which only you can use. (c) Non-medical items, such as television rental. (d) Medications, supplies and equipment which you take home from the Hospital. (e) Doctor s charges, unless the doctor is employed by the Hospital. (These may be covered under other sections of this Certificate). (f) Emergency Ambulance. (Please refer to the Pre-Hospital Emergency Medical Services section for information regarding ambulance coverage.) 2. Services Provided in a Non-Participating Hospital. (a) A non-participating Hospital is a short-term acute care general Hospital that does not have an agreement with GHI. A short-term acute care general Hospital is a licensed institution primarily engaged in providing inpatient diagnostic and therapeutic facilities for surgical and medical diagnosis. It also provides treatment and care of injured and sick persons by or under the supervision of physicians. It also provides twenty-four hour nursing service by or under the supervision of registered nurses. (b) If you are a registered bed patient in a non-participating Hospital, GHI will pay up to 80% of the Allowed Charge for a semi-private room. GHI will also pay up to 80% of the Allowed Charge for the other services that would be covered in a GHI Participating Hospital. 3. Number of Days of Care Covered. Except as specifically provided otherwise in this section, GHI will cover the first 365 days of care in each single hospital confinement. A single hospital confinement begins when you enter a Hospital that meets the requirements set forth above. Successive stays in one or more Hospitals count as a single hospital confinement unless 90 days or more elapse between the day of discharge and the next admission. Different limitations apply for admissions for physical therapy, physical medicine and physical rehabilitation. Any hospital stay that is the result of an accidental injury counts as a separate hospital confinement. This is true so long as there was not a hospital stay for the same or related injury in the previous 90 days. If there was, then the new stay is part of a continuing single hospital confinement for the accidental injury. Hospital stays for accidental injuries do not count as part of a single hospital confinement for any other unrelated injury or illness. A hospital stay which is the result of an accidental injury is not counted as part of any other single hospital confinement if the stay is not related to any other injury or illness. You are always entitled to 365 days of hospital care for each single hospital confinement related to the same accidental injury. The day you are admitted to a Hospital will be counted as one day. The day you are discharged will not be counted. If you are admitted and discharged on the same day, one day will be counted. 9

13 GHI will pay for consecutive days of care from the date of your admission to the Hospital. You cannot choose which days of care in a Hospital you want GHI to pay for. Each day of care as an inpatient in a Hospital counts as one day of care toward the 365-day single hospital confinement limit. 4. Benefits for Inpatient Maternity Care. GHI will cover the services set forth below in connection with maternity care, other than perinatal complications. GHI will cover inpatient Hospital services for a covered mother and her newborn for forty-eight (48) hours immediately after any delivery other than a cesarean section. GHI will cover inpatient Hospital services for a covered mother and her newborn for ninety-six (96) hours immediately after delivery by cesarean section. The mother has the option to be discharged from the Hospital earlier than the time periods set forth above. In such case, GHI will cover one (1) home health care visit for a covered mother and her newborn. This visit is in addition to the other home health care visits covered under this Policy. The mother must request this visit during the time period after delivery in which she would otherwise be covered for inpatient Hospital services under this provision. The visit is not subject to any deductible or coinsurance. Coverage includes parent education, assistance and training in breast or bottle feeding, and the performance of any necessary maternal and newborn child assessments provided and billed for by the Hospital or home health care provider during the covered Hospital stay or home care visit. 5. Coverage for Mastectomy Services. GHI will cover the number of inpatient days that your attending physician determines to be medically appropriate following the procedures listed below for the treatment of breast cancer. Lymph Node Dissection. Lumpectomy. Mastectomy; whether full/radical or partial. Your coverage includes prostheses and physical complications for all stages of mastectomy, including lymphedemas. 6. Infertility Services. GHI will cover the inpatient hospital services for the diagnosis and treatment of correctable medical conditions that result in infertility. Infertility refers to the inability to conceive after one (1) year of unprotected intercourse. The diagnosis and treatment must also be consistent with the guidelines for infertility coverage set forth by the New York State Department of Insurance. GHI will cover the types of services set forth below. Surgical or medical procedures that correct malformation, disease or dysfunction resulting in infertility. Diagnostic tests and procedures that are necessary to determine infertility or that are necessary in connection with any surgical or medical treatments or prescription drug regimens. A physician must prescribe the diagnosis and treatment as part of his/her overall plan of care. Covered services include: Hysterosalpingogram. Hysteroscopy. Endometrial biopsy. Laparoscopy. Sono-hysterogram. Post coital tests. Testis biopsy. Semen analysis. 10

14 Blood tests. Ultrasound. GHI will NOT cover the items or services set forth below. GHI also will not cover any items or services provided to you in connection with the items or services set forth below. Prescription drugs for use in the diagnosis and treatment of infertility as set forth above. (However, if you have prescription drug insurance through GHI, then GHI will cover prescription drugs for use in the diagnosis and treatment of infertility according to the terms that apply to your GHI prescription drug insurance.) In vitro fertilization (IVF). Gamete intrafallopian tube transfers. Zygote intrafallopian tube transfers. Reversal of elective sterilization. Sex change procedures. Cloning. Medical or surgical services or procedures that are deemed experimental pursuant to guidelines for infertility coverage set forth by the New York State Department of Insurance. 7. How To Obtain Hospital Benefits. Your GHI Hospital Service Identification Card must be shown upon admission to a Hospital. The Hospital will contact GHI to check eligibility and coverage. In most instances, the Hospital will bill GHI directly. If you are billed, you should submit your bill to GHI in order for GHI to determine your eligibility and process the claim. 8. Criteria for In-Hospital Coverage. In addition to other criteria set forth in this Certificate, you must meet all of the following conditions set forth below in order to qualify for benefits. (a) Be a registered bed patient in a Hospital. (b) Need to stay in the Hospital for the proper care and treatment of the illness or injury. (c) Be under the care of a physician. SECTION FOUR. - COVERED OUTPATIENT HOSPITAL CARE: A. General Outpatient Care. You are covered for the outpatient services set forth below. In order to be covered under this section, the service must be provided and billed by a Hospital. Except as specifically provided otherwise, GHI covers the same services to the same extent that it would if you were an inpatient when you receive services in the outpatient department of a Participating Hospital or a non-participating Hospital in connection with the services below. 1. Emergency Care. GHI will cover emergency care rendered in the emergency room of a Hospital. This applies whether you receive services from a GHI Participating Provider or a non-participating Hospital. You are subject to a $50 Co-pay Charge for outpatient emergency care. If you are admitted to the Hospital immediately from the emergency room, GHI will waive the Co-pay Charge for the emergency room visit. You should call GHI within two (2) business days after your admission or as soon thereafter as you are medically able to do so. This applies whether you are hospitalized in a Participating or a non-participating Hospital. GHI will determine whether you require emergency care based upon the definition of emergency care below and data received from the Provider. Emergency care is defined as 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, possessing 11

15 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 condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy, or serious impairment to such person s bodily functions; serious dysfunction of any bodily organ or part of such person; or serious disfigurement of such person. If you receive a medical service that is listed as covered in Section Nine from a physician or other Provider that is not an employee of the Hospital during your emergency room visit, GHI will cover the service. If the Provider is a GHI Participating Provider, then GHI will provide benefits according to the terms set forth in Sections Eight and Nine. If the Provider is a non-participating Provider, then GHI will reimburse you for the service at the GHI CBP Schedule of Allowances. 2. Surgery. Surgery includes closed reduction of fractures, dislocations of bones, endoscopies requiring use of the surgical facilities of the Hospital and any incision or puncture of the skin or other tissue except for inoculation, vaccination, collection of blood, and drug administration or injection. 3. Referred Ambulatory Care. You are covered for referred ambulatory care in Hospital outpatient facilities. There is a $25 Co-pay Charge for each referred ambulatory procedure. You are covered for the services as set forth below. (a) Laboratory Tests. You are covered for laboratory tests only if they are required for the treatment or diagnosis of your illness or injury. The tests must be ordered by a doctor. Coverage is not provided for charges billed by a physician for interpretation of laboratory tests. (b) Diagnostic X-Rays and Radiation Therapy. GHI will pay for diagnostic X-rays only if they are required for the treatment or diagnosis of your illness or injury and they are ordered by a doctor. Radiation therapy, including the use of isotopes, for therapeutic or diagnostic purposes is also covered. Coverage is not provided for charges billed by a physician for interpretation of X-rays. (c) Chemotherapy Care. You are covered for care and drugs used for non-experimental cancer chemotherapy and cancer hormone therapy. 4. Pre-admission Testing. You are covered for tests ordered by a doctor that are given to you as a planned preliminary to your admission to the Hospital as a registered bed patient for surgery. The tests must meet the conditions set forth below. (a) They must be necessary for and consistent with the diagnosis and treatment of the condition for which surgery is to be performed. (b) You must have a reservation for the hospital bed and for the operating room before the tests are given. (c) You must be physically present at the Hospital when the tests are given. (d) Surgery must actually take place within seven (7) days after the tests are performed. If surgery is canceled due to these pre-surgical test findings, GHI will still cover the cost of these tests. 5. Mammography Screening. You are covered for mammography screening as set forth below. A mammography screening is a breast X-ray examination that is done using dedicated mammography equipment. (a) A mammography at any time if recommended by a physician. (b) A single baseline mammography if you are thirty-five through thirty-nine years of age. (c) An annual mammography if you are forty years of age or older. 12

16 6. Cervical Cytology Screening. You are covered for an annual cervical cytology screening. This test is used to detect cervical cancer. Your coverage includes an annual pelvic examination. It also includes the collection and preparation of a Pap smear. It also includes the laboratory and diagnostic services needed to examine and evaluate the Pap smear. 7. Infertility Services. GHI will cover the inpatient hospital services for the diagnosis and treatment of correctable medical conditions that result in infertility. Infertility refers to the inability to conceive after one (1) year of unprotected intercourse. The diagnosis and treatment must also be consistent with the guidelines for infertility coverage set forth by the New York State Department of Insurance. GHI will cover the types of services set forth below. Surgical or medical procedures that correct malformation, disease or dysfunction resulting in infertility. Diagnostic tests and procedures that are necessary to determine infertility or that are necessary in connection with any surgical or medical treatments or prescription drug regimens. A physician must prescribe the diagnosis and treatment as part of his/her overall plan of care. Covered services include: Hysterosalpingogram. Hysteroscopy. Endometrial biopsy. Laparoscopy. Sono-hysterogram. Post coital tests. Testis biopsy. Semen analysis. Blood tests. Ultrasound. GHI will NOT cover the items or services set forth below. GHI also will not cover any items or services provided to you in connection with the items or services set forth below. Prescription drugs for use in the diagnosis and treatment of infertility as set forth above. (However, if you have prescription drug insurance through GHI, then GHI will cover prescription drugs for use in the diagnosis and treatment of infertility according to the terms that apply to your GHI prescription drug insurance.) In vitro fertilization (IVF). Gamete intrafallopian tube transfers. Zygote intrafallopian tube transfers. Reversal of elective sterilization. Sex change procedures. Cloning. Medical or surgical services or procedures that are deemed experimental pursuant to guidelines for infertility coverage set forth by the New York State Department of Insurance. 13

17 B. Outpatient Benefits for Dialysis. If you have chronic kidney failure and need hemodialysis or peritoneal dialysis, GHI will cover dialysis on an ambulatory basis as set forth below. 1. GHI will cover dialysis treatment in a hospital-based or free-standing facility, dialysis treatment on a walk-in basis. The dialysis program must be approved by the appropriate governmental authorities. 2. For facility-based benefits to be covered, the treatments must be provided, supervised, or arranged by a physician. You must also be a registered patient of an approved kidney disease treatment center. 3. Benefits for ambulatory dialysis are not subject to a time limit. The benefits continue while enrollment is in good standing or until you become eligible for coverage by Medicare. (Please see the section entitled Coverage for Those Eligible for Medicare. ) C. Freestanding Ambulatory Surgery Center Care. You are covered for ambulatory surgical care rendered only in a participating freestanding ambulatory surgery center. The ambulatory surgery center must be certified under the Public Health Law of the State of New York. If the facility is located outside New York State, it must be approved as a freestanding ambulatory surgery center by a comparable state authority. A GHI Participating Facility is a facility that has an agreement with GHI. This agreement is to provide ambulatory surgery services to GHI hospital insurance subscribers. GHI will reimburse the facility directly. You will not have to make any payments to the facility for covered services. SECTION FIVE. - COVERED HOME CARE SERVICES: 1. Type of Home Care Agency Covered. GHI will pay for home care visits made by a Hospital or a home care agency that is certified or licensed by the appropriate state authority(s) to provide home care services. 2. Conditions for Home Care Coverage. GHI will pay for home care visits only if the conditions set forth below are met. (a) If you had not received home care visits, you would have had to have been hospitalized or cared for in a skilled nursing facility. The home care visits must be a substitution for Hospital care or care in a skilled nursing facility. (b) A plan for your home care must have been established and approved in writing by a physician. 3. Home Care Services Covered. You are covered in full for the home care services listed below. (a) Part-time or intermittent home nursing care by or under the supervision of a registered professional nurse (R.N.). (b) Part-time or intermittent home health aide services which consist primarily of caring for the patient. (c) Physical, occupational, or speech therapy if the home care agency or Hospital provides these services. (d) Medical supplies, drugs, and medications prescribed by a doctor, but only if GHI would have paid for these items if you were in a Hospital or skilled nursing facility. (e) Laboratory services provided by or on behalf of the home care agency or Hospital. 4. Number of Home Care Visits. GHI will pay for home care visits and for the other services listed above only for as long as you would otherwise have had to be confined in a Hospital or in a skilled nursing facility. However, GHI will not pay for more than 40 visits in each calendar year. Each visit by a member of a home care team is counted as one home care visit. Up to four hours of home health aide service are counted as one home care visit. 5. Payments. GHI will only cover services rendered by a GHI Participating Provider. Participating Providers. You are covered in full for services rendered by a Participating Provider. GHI will pay the Provider directly. You will not have to make any payments. Non-participating Providers. GHI will NOT cover services rendered by a non-participating Provider. 14

18 SECTION SIX. - COVERED OUTPATIENT TREATMENT OF ALCOHOLISM AND SUBSTANCE ABUSE: 1. Covered Outpatient Visits. You are covered for outpatient visits in a GHI Participating facility described below for the diagnosis and treatment of alcoholism or substance abuse. In order to be covered, each visit must consist of at least one of the services listed below. (a) Individual or group alcoholism or substance abuse counseling. (b) Activity therapy. (c) Diagnostic evaluations by a doctor or other licensed medical professional to determine the nature and extent of your illness or disability. GHI will not pay for visits that consist primarily of participation in programs of a social, recreational, or companionship nature. An employee of the facility must provide all of the services. GHI will not make any payments to an individual who provides any of the covered services, nor will payment be made if the facility turns the payments over to the individual who provided the service. 2. Treatment Plan. The facility where you receive treatment must submit a treatment plan to GHI for its approval within 10 days after you begin treatment. If a treatment plan is not submitted within 10 days, or if we do not approve the treatment plan, GHI will not pay for any visit that takes place more than 10 days after you begin treatment. 3. Number of Visits Covered. You are covered for up to a total of 60 outpatient visits for alcoholism and/or substance abuse services in each calendar year for each person covered under this Program. The visits must take place at the type of facilities described below. GHI will only pay for one visit per day. However, GHI will pay for a family therapy visit that takes place on the same day that the person with the alcohol or substance abuse problem has a visit separate from the family visit. If you have family coverage, up to 20 of the 60 visits available to the person with the alcohol or substance abuse problem may be used for family therapy. The 20 family therapy visits are covered even if the person with the alcohol or substance abuse problem is not receiving treatment. The family therapy visits may only be used by members of the family who are covered under this Program. Regardless of the number of covered family members, only 20 family therapy visits are available for the treatment of the family member with the alcohol or substance abuse problem. Family therapy consists of visits for members of a family. The purpose of these visits is to aid in the understanding of the illness. These visits also help family members play a meaningful role in the recovery. Payment for a family therapy session will be the same amount, regardless of the number of family members who attend the family-therapy session. 4. Covered Facilities for Treatment. You are covered for treatment of alcoholism in New York State only if the facility where the outpatient visit takes place is certified by the New York State Division of Alcoholism and Alcohol Abuse to provide an alcohol treatment program. Coverage for substance abuse will be limited to facilities that are certified to provide medically supervised ambulatory substance abuse programs by the Division of Substance Abuse Services in New York State. If you receive treatment outside of New York State, the facility must be accredited to provide an alcohol or substance abuse treatment program by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). A person whose primary diagnosis is substance abuse or substance dependence may be treated only in a facility approved by the Division of Substance Abuse Services. A person whose primary diagnosis is alcoholism or alcohol abuse may be treated only in a facility certified by the Division of Alcoholism and Alcohol Abuse. 5. Payments. GHI will only cover services rendered by a GHI Participating Provider. Participating Providers. You are covered in full for services rendered by a Participating facility. GHI will pay the facility directly. You will not have to make any payments. Non-participating Providers. GHI will NOT cover services rendered by a non-participating facility. 15

19 SECTION SEVEN. - HOSPICE CARE: You are covered for hospice benefits when you have been accepted as a hospice patient at a GHI Participating hospice organization. 1. Eligibility for Benefits. To obtain hospice benefits you must meet all of the conditions set forth below. (a) You must experience an illness for which the attending physician s prognosis for life expectancy is estimated to be 6 months or less. (b) Palliative care, rather than curative care, is considered most appropriate. Palliative care is pain control and symptom relief services. (c) The attending physician must refer you to the hospice organization s program and must be in agreement with the plan for care of your condition. (d) You must be formally admitted to the hospice program. 2. Hospice Organizations. GHI will cover hospice care provided by a GHI Participating hospice organization. GHI will NOT cover hospice care that you receive from a non-participating Provider. 3. Hospice Benefits. GHI will cover up to 210 days of hospice care per lifetime. Five visits are available for bereavement counseling services for the family at any time. GHI covers only those services provided by the Participating hospice organization, including drugs and medical supplies, in the patient s home, a hospice center, or a Hospital. GHI will cover home care and outpatient services that are provided and billed by the Participating hospice. The services may include the items below. (a) Intermittent nursing care by an R.N., L.P.N. or Home Health Aide. (b) Physical therapy. (c) Speech therapy. (d) Occupational therapy. (e) Respiratory therapy. (f) Social services. (g) Nutritional services. (h) Laboratory examinations, X-rays, chemotherapy and radiation therapy when required for control of symptoms. (i) Medical supplies. (j) Drugs and medications prescribed by a physician and which are considered approved under the Untied States Pharmacopoeia and/or National Formulary. This Program will not pay when the drug or medication is of an experimental nature. (k) Medical care provided by the hospice physician. (l) Durable medical equipment (rental only). (m) Transportation between home and Hospital or hospice organization when medically necessary. All services must be medically necessary and appropriate for the care of the patient. All services must be provided and billed for by the hospice organization. 4. Payments. GHI will only cover services rendered by a GHI Participating hospice organization. Participating Providers. You are covered in full for hospice services rendered by a Participating hospice organization. GHI will pay the organization directly. You will not have to make any payments. Non-participating Providers. GHI will NOT cover services rendered by a non-participating Provider. 16

20 MEDICAL BENEFITS SECTION EIGHT. - USE OF PARTICIPATING PROVIDERS FOR PAID-IN-FULL BENEFITS: 1. Benefits Available. Benefits listed under this section of this Certificate are available only through Participating Providers. Certain services are subject to annual limits or pre-authorization. Except as specifically provided otherwise, GHI WILL NOT COVER MEDICAL SERVICES THAT YOU RECEIVE FROM A NON- PARTICIPATING PROVIDER. 2. Participating Providers. GHI Participating Providers accept GHI s Schedule of Allowances or negotiated rate as payment in full for covered services. There is no deductible or co-insurance when you use a Participating Provider to receive covered medical services. However, there is a $27 Co-pay Charge for each home or office visit and a $20 Co-pay Charge for out-of-hospital specialist consultations. There is also a $20 Co-pay Charge for each diagnostic X-ray and laboratory test. However, a maximum of one Co-pay Charge will apply per date of service, per Provider, for diagnostic X-rays and lab tests. This means that if one Participating Provider performs two tests on the same day, you will be subject to one $20 Co-pay Charge only for the diagnostic tests. If, however, two or more different Participating Providers perform one or more lab or diagnostic services on the same day, you will be subject to one Co-pay Charge for each Provider. Consult your Directory of Participating Providers or phone GHI to obtain the names of Participating Providers in your area. You may also visit GHI s website at for this information. You must advise a Participating Provider of your GHI/CBP coverage before you receive services. You must verify that the Provider is a Participating Provider. You should not pay the Participating Provider directly for any covered services, except for the Co-pay Charge, if applicable. 3. As with all covered services, the medical service you receive must be medically necessary. GHI may require a Provider s statement to be furnished detailing the medical necessity of any service. The statement must be acceptable to GHI. In some cases, GHI may request that a treatment plan and statement be filed at the commencement of your treatment. SECTION NINE. - COVERED MEDICAL SERVICES: GHI will provide benefits for the covered medical services listed below only when you receive them from a GHI Participating Provider. 1. General Medical Care. You are covered for home and office visits. Payments are made for the types of services listed below. (a) Treatment or diagnosis of illness or injury. (b) Allergy desensitization. (c) Physio-Therapy, Occupational Therapy and Osteopathic Manipulations, subject to an annual maximum of ten (10) visits per person. (d) Speech Therapy, subject to an annual maximum of eight (8) visits per person. (e) Emergency first aid service. Office visits for immunizations. The cost of the immunizing agent is covered. (g) Chiropractic care. (h) Routine podiatric care, subject to a maximum of four (4) visits per person per calendar year. 17