PPO II - EmblemHealth

68
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
Outpatient mental health care
* Prior authorization is required through Value Options at
1-866-318-7595 before the fi rst visit.
* Th e initial prior authorization will be good for the fi rst 5 visits. After 5
visits, additional prior authorization must be obtained.
Covered services include:
Mental health services provided by a state-licensed psychiatrist or doctor,
clinical psychologist, clinical social worker, clinical nurse specialist, nurse
practitioner, physician assistant, or other Medicare-qualifi ed mental
health care professional as allowed under applicable state laws.
Outpatient rehabilitation services
* Prior authorization is required through EmblemHealth after the fi rst
visit.
Covered services include: physical therapy, occupational therapy, and
speech language therapy.
Outpatient rehabilitation services are provided in various outpatient
settings, such as hospital outpatient departments, independent
therapist offi ces, and Comprehensive Outpatient Rehabilitation
Facilities (CORFs).
What you must
pay when you get
these services
If you reside in New
York, Queens, Kings,
Richmond, Bronx,
Westchester, Rockland
and Nassau, you pay:
In Network:
$30 copayment for
each Medicare-covered
individual or group visit
If you reside in
Suff olk, you pay:
In Network:
$25 copayment for
each Medicare-covered
individual or group visit
For all counties, you
pay:
Out of Network:
25% of the Medicare
allowable amount for
each Medicare-covered
individual or group visit
If you reside in New
York, Queens, Kings,
Richmond, Bronx,
Westchester, Rockland
and Nassau, you pay:
In Network:
$30 copayment for each
Medicare-covered visit
If you reside in
Suff olk, you pay:
In Network:
$25 copayment for each
Medicare-covered visit