NYCE PPO
Compare the existing GHI CBP plan to the New York City Employees PPO Plan (NYCE PPO). Both the GHI CBP plan and the NYCE PPO plan must follow all federal and New York State mandates regarding health benefit coverage.
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Plan Comparison
| Current (as administered today)
GHI CBP Plan (Emblem/Anthem) |
NYCE PPO (new plan) | |||||
|---|---|---|---|---|---|---|
| In-Network | Out-Of-Network | In-Network Preferred (H+H, ACPNY) | In-Network Standard | Out-Of-Network* | ||
| Preferred Providers | MSK, HSS, ACPNY | None | H+H added | None | None | |
| Deductible - Single | $0 Individual | $200 Individual | $0 Individual | $0 Individual | $200 Individual | |
| Deductible - Family | $0 Family | $500 Family | $0 Family | $0 Family | $500 Family | |
| Out of Pocket Max - Single | $4,550 (prof) + $2,600 (facility) = $7,150 | No limit | $7,150 Individual (combined Pref / Non-Pref) | No limit | ||
| Out of Pocket Max - Family | $9,100 (prof) + $5,200 (facility) = $14,300 | No limit | $14,300 Family (combined Pref / Non-Pref) | No limit | ||
| Professional Services | ||||||
| Preventative Services | $0 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0 | $0 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Routine Pediatric Eye Exam | $15 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0, H+H added | $15 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Routine Hearing Screening | $15 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0, H+H added | $15 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Primary Care Office Visits | $0 ACP, $15 otherwise | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0, H+H added | $15 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Specialist Visit | $30 ($0 ACP) | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0, H+H added | $30 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Centers of Excellence | $0 (MSK, HSS), does not apply to physician fees | NA | $0 (MSK, HSS), does not apply to physician fees | NA | NA | |
| Telemedicine Direct w/Docs | $0 ACP, $15 PCP, $30 Spec | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0, H+H added | $15 PCP/$30 Specialist | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Allergy testing | $20 per visit, two copay limit w/lab, x-ray, and office visit from same provider on same day | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0, H+H added | $20 per visit, two copay limit w/lab, x-ray, and office visit from same provider on same day | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Teladoc | $10 | NA | NA | $10 | NA | |
| Walk-In Clinics | $0 ACP, $15 for PCP, $30 for Specialist | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0, H+H added | $15 for PCP, $30 for Specialist | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Prenatal Care | $0 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0 | $0 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
*Provider payment at 100% of Medicare
Balance-billing may also apply to all out-of-network services (current and NYCE PPO)
Inpatient/Outpatient Services
| Current (as administered today)
GHI CBP Plan (Emblem/Anthem) |
NYCE PPO (new plan) | |||||
|---|---|---|---|---|---|---|
| In-Network | Out-Of-Network | In-Network Preferred (H+H, ACPNY) | In-Network Standard | Out-Of-Network* | ||
| Inpatient Services | ||||||
| Facility | $300 per stay max $750/year | $500 per stay max $1,250/year; 20% coinsurance w/$2,000 max | $0, H+H added | $300 per stay (max $750 per year) | $500 per stay max $1,250/year; 20% coinsurance w/$2,000 max | |
| Professional/Surgeon | $0 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0 | $0 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Skilled Nursing | $300 per stay max $750/year (Limit 90 days/yr) | $500 per stay max $1,250/year; 20% coinsurance w/$2,000 max | N/A | $300 per stay max $750/year (Limit 90 days/yr) | $500 per stay max $1,250/year; 20% coinsurance w/$2,000 max | |
| Hospice | $0, 210 day lifetime max | $0, 210 day lifetime max | $0, limit removed | $0, limit removed | $0, limit removed | |
| Private Duty Nursing | $0 | $250 Deductible, 20% coinsurance | $0 | $0 | Deductible, 20% coinsurance | |
| Outpatient Services | ||||||
| Outpatient Surgery - Facility | 20% (up to $200 per person per calendar year) | $500 Copay per person per visit and 20% coinsurance and balance billing | $0, H+H added | 20% (up to $200 per person per calendar year) | $500 Copay per person per visit and 20% coinsurance and balance billing | |
| Outpatient Surgery - Professional | $0 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0 | $0 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Diagnostic X-Ray | $20 per visit, two copay limit w/lab, x-ray, and office visit from same provider on same day | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0, H+H added | $20 per visit, two copay limit w/lab, xray, and office visit from same provider on same day | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Diagnostic Laboratory | $20 per visit, two copay limit w/lab, x-ray, and office visit from same provider on same day | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0, H+H added | $20 per visit, two copay limit w/lab, xray, and office visit from same provider on same day | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Diagnostic Complex Imaging | $50 Preferred, $100 Non-preferred | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $25, H+H | $50 Preferred, $100 Non-preferred | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Chemotherapy | $0 in PCP or Specialist Office, 20% (up to $200 per year) in Outpatient Hospital Facility | $500 copayment per visit ($1,250 max), 20% coinsurance and balance billing | $0, H+H added | $0 in PCP or Specialist Office, 20% (up to $200 per year) in Outpatient Hospital Facility | $500 copayment per visit ($1,250 max), 20% coinsurance and balance billing | |
| Cardiac Rehab | $0 | $500 copayment per visit ($1,250 max), 20% coinsurance and balance billing | $0, includes Emblem Cardiac Rehab network in the NY downstate 13 counties | $30 if outside of the NY downstate 13 counties | $500 copayment per visit ($1,250 max), 20% coinsurance and balance billing | |
| PT/OT/ST | PT:$20 per office visit ST:$0 at ACPNY, $15 if at PCP, $30 if at Specialist office OT: Available as part of Home Health visit; or through Skilled Nursing Facilities |
PT/ST: After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee OT: See OON description for home health visit or skilled nursing facilities |
$0, H+H added | $20 per visit | After plan deductible is met, you pay the difference between the plan allowance and the provider's fee | |
| Dialysis | 20% (up to $200 per person per calendar year) | 20% Coinsurance, up to a maximum of $200 per person per calendar year. | $0 H+H | 20% (up to $200 per person per calendar year) | 20% Coinsurance, up to a maximum of $200 per person per calendar year. | |
| Medications in OP or Office | $0 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0 | $0 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Chiropractor | $15 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0 | $15 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Outpatient Behavioral Health/Substance Use Disorder | $0 Preferred, $15 Non-preferred | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $0 | $15 | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Urgent Care Provider | $50 Preferred, $100 Non-Preferred | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | $25 H+H, $50 ACPNY | $50 Preferred $100 Non-preferred | After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
| Emergency Room | $150; waived if admitted within 24 hours | $150; waived if admitted within 24 hours | ||||
| Ambulance (emergency only) | $0 | $0 | $0 | $0 | $0 | |
| Home Health Care | $0 (max 200 visits) | $50 per episode, 20% coinsurance, max 40 visits | $0 (max 200 visits) | $50 per episode, 20% coinsurance, max 40 visits | ||
| Durable Medical Equipment | $100 deductible, combined w/Orthotic Braces and Prosthetics | $100 deductible, combined w/Orthotic Braces and Prosthetics, 50% of U&C | NA | $100 deductible, combined w/Orthotic Braces and Prosthetics | $100 deductible, combined w/Orthotic Braces and Prosthetics, balance billing after provider payment at 100% of medicare | |
| Orthotic Braces | $100 deductible, combined w/DME and Prosthetics | $100 deductible, combined w/DME and Prosthetics, 50% of U&C | NA | $100 deductible, combined w/DME and Prosthetics | $100 deductible, combined w/DME and Prosthetics, balance biling after provider payment at 100% of medicare | |
| Prosthetics | $100 deductible, combined w/Orthotic Braces and DME | $100 deductible, combined w/Orthotic Braces and DME, 50% of U&C | NA | $100 deductible, combined w/Orthotic Braces and DME | $100 deductible, combined w/DME and Orthotic Braces, balance billing after provider payment at 100% of medicare | |
*Provider Payment at 100% of Medicare
Balance-billing may also apply to all out-of-network services (current and NYCE PPO)
Preventive Rx Through the Affordable Care Act and NY State Diabetes Mandates
| Current (as administered today)
GHI CBP Plan (Emblem/Anthem) |
NYCE PPO (new plan) | ||||
|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | ||
| Preventive / Diabetes | Preventive Rx: $0
Retail: $0 insulin; $5-$15 supplies Mail Order: $12.50-$37.50 supplies |
After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | Preventive Rx: $0 Retail: $0 insulin; $5-$15 supplies
Mail Order: $12.50-$37.50 supplies |
After plan deductible is met, you pay the difference between the plan allowance and the provider’s fee | |
Optional RX Rider
| Current (as administered today)
GHI CBP Plan (Emblem/Anthem) |
NYCE PPO (new plan) | ||||
|---|---|---|---|---|---|
| Retail | Mail Order | Retail | Mail Order | ||
| Generic Drugs | Retail - 30 day supply - 2 fills; 20% coninsurance with min. charge of $5 or actual cost, if less | Mandatory Mail Order - 90 day supply; $12.50 copay. Prescriptions will not be filled at retail after 2 fills. The 90 day supply can be obtained through Express Scripts or participating Duane Reade or Walgreens | Retail - 30 day supply - 2 fills; 20% coninsurance with min. charge of $5 or actual cost, if less | Mandatory Mail Order - 90 day supply; $12.50 copay. Prescriptions will not be filled at retail after 2 fills. The 90 day supply can be obtained through pharmacy(ies) selected by Plan Sponsor | |
| Preferred Brand Drugs | Retail - 30 day supply - 2 fills; 40% coninsurance with min. charge of $25 or actual cost, if less | Mandatory Mail Order - 90 day supply; $50.00 copay. Prescriptions will not be filled at retail after 2 fills. The 90 day supply can be obtained through Express Scripts or participating Duane Reade or Walgreens | Retail - 30 day supply - 2 fills; 40% coninsurance with min. charge of $25 or actual cost, if less | Mandatory Mail Order - 90 day supply; $50.00 copay. Prescriptions will not be filled at retail after 2 fills. The 90 day supply can be obtained through pharmacy(ies) selected by Plan Sponsor | |
| Non-Preferred Brand Drugs | Retail - 30 day supply - 2 fills; 50% coninsurance with min. charge of $40 or actual cost, if less | Mandatory Mail Order - 90 day supply; $75.00 copay. Prescriptions will not be filled at retail after 2 fills. The 90 day supply can be obtained through Express Scripts or participating Duane Reade or Walgreens | Retail - 30 day supply - 2 fills; 50% coninsurance with min. charge of $40 or actual cost, if less | Mandatory Mail Order - 90 day supply; $75.00 copay. Prescriptions will not be filled at retail after 2 fills. The 90 day supply can be obtained through pharmacy(ies) selected by Plan Sponsor | |
| Specialty Drugs* | Covered (cost based on above categories) | Must be dispensed by the Specialty Pharmacy Program Provider. Precertification required contact NYC Healthline | Covered (cost based on above categories) | Must be dispensed by the Specialty Pharmacy Program Provider. Precertification required contact Prime Therapeutics | |
* Must be dispensed by a Specialty Pharmacy