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
Outpatient surgery, including services
provided at hospital outpatient facilities and
ambulatory surgical centers
* Prior authorization is required.
For surgical procedures, your provider is allowed to bill you a separate
copayment for professional services.
Note: If you are having surgery in a hospital facility, you should check
with your provider about whether you will be an inpatient or outpatient.
Unless the provider writes an order to admit you as an inpatient to the
hospital, you are an outpatient and pay the cost-sharing amounts for
outpatient surgery. Even if you stay in the hospital overnight, you might
still be considered an “outpatient.”
Partial hospitalization services
* Prior authorization is required through Value Options at
1-866-318-7595.
“Partial hospitalization” is a structured program of active psychiatric
treatment provided in a hospital outpatient setting or by a community
mental health center, that is more intense than the care received in
your doctor’s or therapist’s offi ce and is an alternative to inpatient
hospitalization.
What you must
pay when you get
these services
In Network:
$100 copayment for
each Medicare-covered
ambulatory surgical
center visit.
$100 copayment for
each Medicare-covered
outpatient hospital
facility visit.
Out of Network:
25% of the Medicare
allowable amount for
each Medicare-covered
ambulatory surgical
center visit.
25% of the Medicare
allowable amount for
each Medicare-covered
outpatient hospital
facility 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
individual or group visit
If you reside in
Suff olk, you pay: