PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II Chapter 3. 3: Using the plan’s coverage for your medical services What if you are outside the plan’s service area when you have an urgent need for care? When you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed care that you get from any provider at the lower in-network cost-sharing amount. Our plan covers urgently needed care anywhere in the world. SECTION 4 WHAT IF YOU ARE BILLED DIRECTLY FOR THE FULL COST OF YOUR COVERED SERVICES? Section 4.1 You can ask us to pay our share of the cost of covered services If you have paid more than your share for covered services, or if you have received a bill for the full cost of covered medical services, go to Chapter 7 (Asking us to pay our share of a bill you have received for covered medical services or drugs) for information about what to do. Section 4.2 If services are not covered by our plan, you must pay the full cost Our plan covers all medical services that are medically necessary, are listed in the plan’s Medical Benefi ts Chart (this chart is in Chapter 4 of this booklet), and are obtained consistent with plan rules. You are responsible for paying the full cost of services that aren’t covered by our plan, either because they are not plan covered services, or plan rules were not followed. If you have any questions about whether we will pay for any medical service or care that you are considering, you have the right to ask us whether we will cover it before you get it. If we say we will not cover your services, you have the right to appeal our decision not to cover your care. Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) has more information about what to do if you want a coverage decision from us or want to appeal a decision we have already made. You may also call Customer Service to get more information about how to do this (phone numbers are printed on the back cover of this booklet). For covered services that have a benefi t limitation, you pay the full cost of any services you get after you have used up your benefi t for that type of covered service. Th e amount you pay for services after you have used up your benefi t for that type of covered service will not count toward an out-of-pocket maximum. You can call Customer Service when you want to know how much of your benefi t limit you have already used. SECTION 5 HOW ARE YOUR MEDICAL SERVICES COVERED WHEN YOU ARE IN A “CLINICAL RESEARCH STUDY”? Section 5.1 What is a “clinical research study”? A clinical research study (also called a “clinical trial”) is a way that doctors and scientists test new types of medical care, like how well a new cancer drug works. Th ey test new medical care procedures or drugs 39
40 2013 Evidence of Coverage for PPO II Chapter 3. 3: Using the plan’s coverage for your medical services by asking for volunteers to help with the study. Th is kind of study is one of the fi nal stages of a research process that helps doctors and scientists see if a new approach works and if it is safe. Not all clinical research studies are open to members of our plan. Medicare fi rst needs to approve the research study. If you participate in a study that Medicare has not approved, you will be responsible for paying all costs for your participation in the study. Once Medicare approves the study, someone who works on the study will contact you to explain more about the study and see if you meet the requirements set by the scientists who are running the study. You can participate in the study as long as you meet the requirements for the study and you have a full understanding and acceptance of what is involved if you participate in the study. If you participate in a Medicare-approved study, Original Medicare pays most of the costs for the covered services you receive as part of the study. When you are in a clinical research study, you may stay enrolled in our plan and continue to get the rest of your care (the care that is not related to the study) through our plan. If you want to participate in a Medicare-approved clinical research study, you do not need to get approval from us or your provider. Th e providers that deliver your care as part of the clinical research study do not need to be part of our plan’s network of providers. Although you do not need to get our plan’s permission to be in a clinical research study, you do need to tell us before you start participating in a clinical research study. Here is why you need to tell us: 1. We can let you know whether the clinical research study is Medicare-approved. 2. We can tell you what services you will get from clinical research study providers instead of from our plan. If you plan on participating in a clinical research study, contact Customer Service (phone numbers are printed on the back cover of this booklet) . Section 5.2 When you participate in a clinical research study, who pays for what? Once you join a Medicare-approved clinical research study, you are covered for routine items and services you receive as part of the study, including: • Room and board for a hospital stay that Medicare would pay for even if you weren’t in a study. • An operation or other medical procedure if it is part of the research study. • Treatment of side eff ects and complications of the new care. Original Medicare pays most of the cost of the covered services you receive as part of the study. After Medicare has paid its share of the cost for these services, our plan will also pay for part of the costs. We will pay the diff erence between the cost sharing in Original Medicare and your cost sharing as a member of our plan. Th is means you will pay the same amount for the services you receive as part of the study as you would if you received these services from our plan. Here’s an example of how the cost sharing works: Let’s say that you have a lab test that costs $100 as part of the research study. Let’s also say that your share of the costs for this test is $20
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PPO II - EmblemHealth

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