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Extended Medical Benefit (Full-Time Actives)
If you and your covered dependents are enrolled in the GHI-CBP/Empire Blue Cross Blue Shield (BCBS) plan, you are automatically enrolled in the extended medical benefit at no cost to you. This benefit, administered by Administration Services Only, Inc. (ASO), covers medical expenses that are not reimbursed in full by your basic GHI-CBP Plan-including expenses from out-of-network medical providers.
In order to receive a reimbursement from the extended medical benefit, you must first meet an annual deductible. Your deductible depends on whether or not you purchase the optional rider from the City as part of your Basic Benefits.
|2014 Annual Deductible|
|If You Purchase the Optional Rider||If You Do Not Purchase the Optional Rider|
Once you meet the deductible, the extended medical benefit will pay 60% of the difference between the amount you receive as reimbursement under the basic GHI-CBP Plan and the reasonable and customary charges. You will be responsible for the remaining 40% plus any amount in excess of reasonable and customary charges. If payments from the extended medical benefit reach the coinsurance maximum in a calendar year, the extended medical benefit will pay 100% of the difference between the amount reimbursed and the reasonable and customary charges for the rest of the calendar year.
This page includes only highlights of your extended medical benefit. See the Details Tab for more information.
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This benefit changed, effective 01/01/2007
The carrier changed 07/01/2008
Plan participants who have basic coverage through GHI-CBP have an additional level of medical cost protection through the PSC-CUNY Welfare Fund extended medical benefit. The benefit is designed to provide a buffer against large medical expenses associated with serious or long-term illness that are not met by the basic employer-provided insurance, and better coverage (additional payment) for out-of-network provider use of medical services. The program is administered by Administrative Services Only, Inc. (ASO). It was formerly administered by GHI. This extended medical benefit does not cover procedures that are not covered under the basic health plan, nor does it lift any frequency limitations.
Expenses are considered after an annual deductible has been met. The amount of the deductible is determined by whether or not the participant has elected the GHI-CBP optional rider. If the participant has elected the rider, the deductible is $1,000 per person for the year, with a maximum of $2,000 for a family. If the participant has not elected the rider, the deductible is $4,000 per person for the year, with a maximum of $8,000 for a family. The amount that is applied to calculate the deductible is the total difference between the GHI-CBP allowance on covered services and the participant's payment to the provider for those services.
After the deductible is met, the Welfare Fund extended medical benefit will pay 60% of the difference between the amount reimbursed and the "reasonable and customary" charges. "Reasonable and Customary" charges are determined by a schedule maintained by the carrier and the Fund. This schedule may change from time to time at the discretion of the Trustees of the Fund. As of 1/1/2007, the Fund is using the 80th percentile level of the HIAA/Ingenix Schedule that is generally considered the industry standard. Once coinsurance payments have reached $3,000 for a covered individual in a year (or $6,000 for the family) the plan will pay without a co-insurance, i.e., 100% of the difference between the amount reimbursed and the reasonable and customary charges according to the schedule.
Benefits are limited to those covered by the GHI benefit plan. Annual and lifetime caps are in accordance with the GHI contract with the NYC Employee Benefits Program. Reimbursement claims should be filed no later than 3 months after the end of the calendar year during which medical services and procedures were performed. Members who are participating in the group Catastrophic Major Medical benefit must first submit reimbursement claims to The United States Life Insurance Company in the City of New York.
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