PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II
Chapter 4: Medical Benefi ts Chart (what is covered Medical and what Benefi you ts Chart pay)
Services that are covered for you
Covered supplemental services include:
• World Wide Coverage
• If you are admitted to the hospital within one day for the same
condition, you pay $0 for the emergency room visit
Hearing services
Diagnostic hearing and balance evaluations performed by your provider
to determine if you need medical treatment are covered as outpatient
care when furnished by a physician, audiologist, or other qualifi ed
provider.
What you must
pay when you get
these services
in-network cost-sharing
amount for the part of
your stay after you are
stabilized. If you stay
at the out-of-network
hospital, your stay will
be covered but you will
pay the out-of-network
cost-sharing amount
for the part of your stay
after you are stabilized.
If you reside in New
York, Queens, Kings,
Richmond, Bronx,
Westchester, Rockland
and Nassau, you pay:
In Network:
$30 copayment for
each Medicare-covered
service
If you reside in
Suff olk, you pay:
In Network:
$25 copayment for
each Medicare-covered
service
For all counties, you
pay:
Out of Network:
25% of the Medicare
allowable amount for
each Medicare-covered
service