PPO II - EmblemHealth

2013 Evidence of Coverage for PPO II) II
Medical Chapter Benefi 4: Medical ts Chart Benefi ts Chart (what is covered and what you pay)
Services that are covered for you
Covered items include, but are not limited to: wheelchairs, crutches,
hospital bed, IV infusion pump, oxygen equipment, nebulizer, and
walker.
We cover all medically necessary durable medical equipment covered
by Original Medicare. If our supplier in your area does not carry a
particular brand or manufacturer, you may ask them if they can special
order it for you.
Generally, our plan covers any durable medical equipment covered by
Original Medicare from the brands and manufacturers on this list. We
will not cover other brands and manufacturers unless your doctor or
other provider tells us that the brand is appropriate for your medical
needs. However, if you are new to our plan and are using a brand of
durable medical equipment that is not on our list, we will continue to
cover this brand for you for up to 90 days. During this time, you should
talk with your doctor to decide what brand is medically appropriate for
you after this 90-day period. (If you disagree with your doctor, you can
ask him or her to refer you for a second opinion.)
If you (or your provider) don’t agree with the plan’s coverage decision,
you or your provider may fi le an appeal. You can also fi le an appeal if
you don’t agree with your provider’s decision about what product or
brand is appropriate for your medical condition. (For more information
about appeals, see Chapter 9, What to do if you have a problem or
complaint (coverage decisions, appeals, complaints).)
Emergency care
Emergency care refers to services that are:
• Furnished by a provider qualifi ed to furnish emergency services, and
• Needed to evaluate or stabilize an emergency medical condition.
A medical emergency is when you, or any other prudent layperson with
an average knowledge of health and medicine, believe that you have
medical symptoms that require immediate medical attention to prevent
loss of life, loss of a limb, or loss of function of a limb. Th e medical
symptoms may be an illness, injury, severe pain, or a medical condition
that is quickly getting worse.
What you must
pay when you get
these services
57
In and Out Of
Network:
$65 copayment for each
visit
If you receive
emergency care at an
out-of-network hospital
and need inpatient care
after your emergency
condition is stabilized,
you must move to a
network hospital in
order to pay the