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
• Physician services
Note: To be an inpatient, your provider must write an order to admit
you formally as an inpatient of the hospital. Even if you stay in the
hospital overnight, you might still be considered an “outpatient.” If you
are not sure if you are an inpatient or an outpatient, you should ask the
hospital staff .
You can also fi nd more information in a Medicare fact sheet called “Are
You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!”
Th is fact sheet is available on the Web at http://www.medicare.gov/
Publications/Pubs/pdf/11435.pdf or by calling 1-800-MEDICARE
(1-800-633-4227). TTY users call 1-877-486-2048. You can call these
numbers for free, 24 hours a day, 7 days a week.
Inpatient mental health care
* Prior authorization is required through Value Options at
1-866-318-7595.
Except in an emergency, your doctor must tell the plan that you are
going to be admitted to the hospital.
• Covered services include mental health care services that require a
hospital stay. Th ere is a 190-day lifetime limit for inpatient services
in a psychiatric hospital. Th e 190-day limit does not apply to Mental
Health services provided in a psychiatric unit of a general hospital.
What you must
pay when you get
these services
In Network:
$150 copayment per
day for days 1 - 7 for
each benefi t period
A benefi t period begins
when you are admitted
to the hospital and
ends when you are
discharged.
Out of Network:
25% of the Medicare
allowable amount for
each benefi t period
A benefi t period begins
when you are admitted
to the hospital and
ends when you are
discharged.