CurrentEmpire BluecrossPolicy N/A

Essential Plan subscriber contract (NY) — Administrative/Operational Policy

Governs terms, coverage rules, provider network, member rights and obligations for an individual Essential Plan subscriber in New York; affects enrolled members and participating providers.

Policy Summary

PayerEmpire Bluecross

PolicyEssential Plan subscriber contract (NY)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must request preauthorization at least two weeks before scheduled inpatient admissions or outpatient surgeries, or as soon as reasonably possible when not feasible.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsautomatic renewal period

30 daysmember notice period to terminate contract

2 weeksrecommended preauthorization timeframe

800-300-8181Member Services phone

60rehab visit limit (per condition)

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vision exam frequency

Coverage rules, limits, and medical necessity

Coverage criteria and rules

Coverage is provided only when specified criteria are met; in-network providers are required for coverage except for emergencies.

Member is enrolled in the Essential Plan and coverage is in effect at time of service

Service is medically necessary

See medical necessity standards for required clinical appropriateness and supporting evidence

Service is a listed covered service and does not exceed benefit limits in the Table of Benefits

Services must be provided by a participating provider to be covered, except for emergency services, prehospital emergency medical services and ambulance transport

Exceptions to participating provider requirement

Emergency services for a condition of emergency (no prior authorization required)
Prehospital emergency medical services and emergency ambulance transport
Out‑of‑network services specifically authorized by the plan (see preauthorization rules)

Certain services require prior authorization as listed in the Table of Benefits; participating provider is responsible for requesting prior authorization

Member must follow PCP selection and referral rules when applicable; some services do not require PCP referral as listed in the contract

When outside the service area, coverage limited to emergency services, prehospital emergency medical services and ambulance services for emergency conditions unless otherwise authorized

Member is responsible for applicable cost‑sharing amounts; balance billing by nonparticipating providers is limited per contract protections

Coverage and criteria

Coverage is contingent on network status, medical necessity, and preauthorization rules; certain out-of-network services are covered when authorized or by specified contract provisions.

Nonparticipating provider services are not covered except for emergency services, prehospital emergency medical services, ambulance transport for emergency conditions, or when specifically authorized by the plan

Provider must request prior authorization at least two (2) weeks before scheduled inpatient admissions, outpatient surgeries/procedures, or as soon as reasonably possible if not feasible; air ambulance (non-emergency) requires prior authorization

Benefits are subject to utilization review (prospective, concurrent, retrospective); covered services must meet medical necessity criteria

Medical necessity determinations may be based on clinical records, medical policies/guidelines, peer‑reviewed literature, specialty opinions and treating provider input; services must meet clinical appropriateness, direct care purpose, adverse impact if withheld, accepted practice standards, not be primarily for convenience, and be cost‑effective

Protections and exceptions

Cost-sharing criteria

Cost-sharing and payment rules for covered services under the Essential Plan.

Member pays copays or fixed dollar amounts listed in the Table of Benefits unless the allowed amount for the service is less than the copay (member pays the lesser)

Member pays coinsurance as a percentage of the allowed amount when applicable; plan pays the remainder as specified in the Table of Benefits

When member reaches the plan year out‑of‑pocket limit shown in the Table of Benefits, plan pays 100% of the allowed amount for covered services for the remainder of the plan year; certain out‑of‑network cost‑sharing (except emergencies, plan‑approved out‑of‑network exceptions and dialysis) does not count toward this limit

Out-of-area coverage rules

Rules for services received outside the plan area and international coverage.

When members access services outside the plan service area within a Host Blue area, claims are processed through the Host Blue (BlueCard) and payment is based on the Host Blue negotiated price (real, estimated, or average) or lesser of billed charge and Host Blue price per program rules

Member obligation for out‑of‑area claims processed via BlueCard is the lesser of provider billed charge or Host Blue negotiated price as provided by the Host Blue; final member price is not later adjusted by the plan

If services are provided by non‑participating providers outside our area, member may be responsible for the difference between provider charge and plan payment unless an exception applies (e.g., no reasonable access to participating provider); in exceptional cases plan may pay billed charges or negotiate payment

For services received outside the BlueCard area (including internationally), members generally pay providers and must submit BCBS Global Core claim form with itemized bills to the Service Center for reimbursement; pre‑certification required for non‑emergency inpatient services

Eligibility and Enrollment

Eligibility and enrollment rules for the Essential Plan.

Subscriber must reside in the plan service area and have household income above 138% up to 250% of the federal poverty level; individuals enrolled in Medicare/Medicaid or employer‑sponsored low‑cost coverage are not eligible

Only individual coverage is offered under the Essential Plan; additional family members receive separate contracts

Enrollment may occur any time of year; for new NYSOH applicants coverage begins the first day of the month in which the plan is selected; transfers from another NYSOH program begin first day of the month after selection

Coverage criteria and rules

Coverage rules, limitations and member responsibilities described in these sections:

Preventive services recommended by HRSA, USPSTF 'A' or 'B', and ACIP vaccines are covered without copayment when provided per those guidelines; cost‑sharing may apply for other services during the same visit

One annual adult physical exam covered once per calendar year; mammography screening coverage per age guidelines (initial 35–39; annual ≥40)

National Diabetes Prevention Program covered: 22 group sessions over 12 months for eligible adults with referral and qualifying risk criteria

Emergency and prehospital ambulance services covered worldwide when provided by certified ambulance services; no prior authorization required; payment rules and member bill protections apply for nonparticipating ambulance providers

Dialysis covered for acute and chronic renal disease; nonparticipating provider dialysis covered subject to certification, written order, 30‑day notice (with exceptions), preauthorization rights, and up to 10 treatments per calendar year when conditions met

Cobertura de servicios profesionales y ambulatorios

Se cubren los siguientes servicios y con las condiciones y limitaciones indicadas:

Advanced diagnostic imaging (PET, MRI, nuclear medicine, CT) covered

Allergy testing, evaluations and treatments (including injections and desensitization) covered

Ambulatory surgical center procedures and day‑of‑surgery supplies covered

Chemotherapy and immunotherapy covered in outpatient centers or physician offices; oral anticancer drugs covered under prescription drug benefits

Chiropractic care covered when provided by a licensed chiropractor (evaluations, manipulation and modalities) per policy terms

Approved clinical trials: routine costs covered for approved trials for cancer or other life‑threatening conditions when eligibility and referral criteria are met; investigational costs excluded

Criterios de cobertura — fragmentos 90-109

Cobertura y limitaciones para servicios ambulatorios, quirúrgicos, rehabilitativos, telemedicina, trasplantes y dispositivos/suministros (incluyendo diabetes).

Office visits covered for diagnosis and treatment, may include home visits

Outpatient hospital services and supplies covered as described for inpatient services; outpatient hospital labs may be nonparticipating unless hospital is participating

Pre‑admission tests covered when indicated by physician, performed at same hospital, surgery occurs within 7 days, bed/OR reserved and patient present

Medications administered in provider office (non‑self‑injectables) covered under office medication benefit, not duplicate of prescription drug benefit

Rehabilitation services (PT/OT/Speech) covered up to 60 visits per condition per plan year (combined); must be related to diagnosis/treatment, requested by physician, start within 6 months and not continue beyond 365 days

Criterios de cobertura (extracto)

Criterios generales y límites para la cobertura de equipos, suministros, prótesis, hospicio y servicios hospitalarios según este contrato.

Durable medical equipment (DME) and standard braces covered for home use when medically necessary; repairs/replacement for wear and tear covered; comfort/convenience and over‑the‑counter equipment not covered

External hearing aids covered with written physician recommendation including fitting and testing; one purchase per ear every three (3) years; repairs/replacement included as described

Bone‑anchored hearing aids/implants (e.g., cochlear bone conduction) covered when medically necessary; one aid per ear for duration of enrollment; repairs/replacement only for malfunction

Hospice care covered when attending physician certifies life expectancy ≤6 months; coverage up to 210 days with specified support visits and program certification requirements

Medical supplies necessary for treatment or maintenance covered in appropriate quantities; over‑the‑counter supplies not covered

Cobertura y criterios principales

Cobertura, límites y condiciones aplicables a centros de enfermería especializada, cuidados al final de la vida, servicios de salud mental y por abuso de sustancias, y medicamentos recetados.

Skilled nursing facility care (non‑custodial) covered up to 200 days per plan year; admission requires provider‑prepared plan of treatment approved by the plan

End‑of‑life acute care for advanced cancer with life expectancy <60 days covered in certified centers; nonparticipating provider reimbursement per negotiated rate, Medicare acute care rate or 75% for alternate level care as applicable

Private room charges not covered unless medically necessary; coverage based on semiprivate rate when private room not medically necessary

Hospital charges for non‑medical items (radio, phone, TV, beauty) not covered; charges after date care deemed not medically necessary not covered unless external appeal reverses denial

Inpatient mental health services covered in authorized/certified hospitals/centers; outpatient mental health services covered including partial hospitalization, intensive outpatient and up to 20 family counseling visits per plan year

Criterios generales de cobertura

Cobertura sujeta a nivel del formulario, tipo de farmacia, preautorización, terapia escalonada, y límites específicos.

Certain medications require prior authorization; provider is responsible for obtaining authorization; antiretrovirals and SUD medications are exempt from prior authorization

Drugs may be subject to step‑therapy requirements; providers or members may request step‑therapy exceptions per utilization review and appeals processes

Formulary exceptions process available: standard review decision in 72 hours with written notice in 3 business days; expedited review decision in 24 hours with written notice in 3 business days; coverage provided if approved

Plan reserves right to limit quantities, days’ supply, early refills and therapy duration per medical necessity and FDA guidance; compounded drugs over $200 require prior authorization

Programas y límites de suministro

Programas y límites operativos (farmacia minorista designada 90 días, pedido por correo 90 días, límite de 30 días en retail, programas: media tableta, surtido dividido, límites de cantidad y suministro inicial de opioides).

Designated retail pharmacy program: select long‑term medications may be filled at a designated retail pharmacy for up to 90‑day supply; member pays lesser of applicable cost‑sharing or pharmacy charge

Mail‑order pharmacy allowed for up to 90‑day supplies; member may pay up to 2.5 times the 30‑day cost‑sharing amount for a 90‑day mail order supply (one cost share per 30‑day period up to 2.5)

Formulary tier status may change up to four times per calendar year; members will be notified at least 30 days before changes that raise cost‑sharing or remove a drug from formulary; exceptions process available

Program of tablet splitting (optional) and split supply dispensing available for eligible drugs to reduce member cost sharing; program details available on plan website

Initial limited opioid prescriptions (≤7 days) subject to proration of copay; proration rules ensure total prorated copay will not exceed the 30‑day copay amount

Limitaciones y exclusiones

Exclusiones y restricciones: no cubre OTC salvo excepciones, no cubre reemplazos por pérdida/robo, no cubre inyectables administrados en consultorio bajo esta sección, medicamentos experimentales no cubiertos.

Plan may limit quantities, days supply, early refills and duration of therapy; medicines not medically necessary or investigational/experimental may be denied

Prescription drug coverage excludes over‑the‑counter (OTC) medicines except where specifically stated (e.g., smoking cessation products) and excludes replacement for lost/stolen medications

Injectable medications administered by provider (except self‑administered injectable) and insulin for diabetes are covered under other sections (professional services or DME/diabetes sections) rather than the prescription drug section

Vision and Dental Coverage Criteria

Covered services and applicable limits or conditions

Vision exams covered once per plan year; more frequent exams covered when medically necessary with documentation

Prescription lenses or contact lenses and frames covered once per plan year; non‑standard options require member cost‑share for difference (not applied to out‑of‑pocket limit)

Emergency dental care covered and not subject to prior authorization; preventive dental prophylaxis covered every six (6) months

Routine dental services covered per schedule (exams every six months, radiographs per specified intervals); crowns, endodontics and certain prosthodontics require prior authorization and supporting documentation

Removable prosthodontics (dentures) covered when medically necessary; replacement not allowed within eight (8) years unless medically necessary; documentation required for early replacement

Exclusions and limitations

Listed exclusions and limitations to coverage in this contract include the following categories and conditions.

Common exclusions

Routine foot care excluded except when related to specified medical conditions (circulatory deficiency or areas with decreased sensation)
Care provided in government‑owned/operated hospitals not covered except where law requires or for emergency services at closest facility
Services not medically necessary are not covered except if external appeal reverses a denial and service is otherwise covered under contract
Services covered by Medicare or other government programs (except Medicaid) are excluded
Conditions arising from military service excluded

Criterios de revisión y revisores

Determinaciones de que servicios no son médicamente necesarios deben ser realizadas por personal con la misma profesión/especialidad o por especialistas en salud conductual según corresponda; se usan guías y protocolos basados en evidencia designadas por OASAS/OMH.

Initial and appeal determinations that services are not medically necessary will be made by qualified professionals: physicians or licensed clinicians of same profession/specialty as the treating provider; for mental health/SUD cases, reviewers specialized in behavioral health

Clinical review will use evidence‑based, peer‑reviewed clinical review criteria and age‑appropriate tools; designated OASAS/OMH tools will be used for SUD and mental health reviews; criteria available on request

Plazos y proceso para revisiones concurrentes y retrospectivas

Plazos y procesos para revisiones concurrentes, retroactivas y consecuencias si los plazos no se cumplen.

Concurrent non‑urgent reviews: decision and notice to member/provider by phone and in writing within 1 business day after receiving all necessary information; if additional information requested, 45 days to respond and final decision timelines specified

Concurrent urgent reviews (extensions of urgent care): determinations within 24 hours if requested ≥24 hours before expiration of approved treatment; otherwise decision within 72 hours when information complete; information request timelines and response windows apply

Retrospective reviews: when all information present, decision and notice within 30 calendar days of receipt; if additional information requested, 45 days to respond and decision within 15 days of receipt or end of 45‑day period

If plan fails to make utilization review determination within required timeframes, the denial will be treated as adverse and eligible for internal appeal

Pago de reclamaciones

Política de pago de reclamaciones cuando la obligación es razonablemente clara.

If plan's obligation to pay a claim is reasonably clear, payment will be made within 30 days for claims submitted online/email and within 45 days for claims submitted by other means; if additional information is requested, payment will be made within 15 days of determination and before the 30/45 day deadline

Reclamos administrativos

Procedimiento de reclamos administrativos (no relacionados con necesidad médica).

Administrative claims may be filed by phone, in person or in writing; plan will send confirmation letter within 15 business days including contact for claims handler and any additional required information; member or designee has up to 180 days to file from the adverse decision

Members may request electronic notifications for claim/appeal determinations by contacting the number on their ID card; electronic notification can be cancelled at any time

Utilization review, appeals, and external appeal criteria

Coverage and review rules for substance use disorder services, retrospective review, and step-therapy exception determinations.

Inpatient SUD treatment at OASAS‑certified centers not subject to preauthorization and exempt from concurrent review for first 28 days if admission and initial treatment plan are reported within two (2) business days; after 28 days plan may review medical necessity using OASAS tools

Outpatient SUD treatment at OASAS‑certified centers not subject to preauthorization and exempt from concurrent review for first 4 weeks (up to 28 visits) if start and initial plan are reported within two (2) business days; thereafter plan may review medical necessity using OASAS tools

Retrospective review timing: when all info present decision within 30 days; if additional info requested allow 45 days to respond and decide within 15 days of receipt or end of 45‑day period

Preauthorized services may be reversed retrospectively only when materially different or withheld medical information exists that would have prevented authorization; same standards used as preauthorization review

Step‑therapy exception determinations

Outcomes when external appeal reverses denial

If an external appeals agent overturns an internal denial:

If a certified external appeals agent reverses a plan denial (for formulary exception, medical necessity, experimental/ investigational or out‑of‑network approval), the plan will provide coverage consistent with the external decision subject to other contract terms; clinical trial approvals limited to routine trial‑related services (investigational drug/device and research administration costs excluded)

External appeal eligibility criteria

Requirements to pursue external appeal for out-of-network services or nonparticipating providers:

To pursue an external appeal for out‑of‑network service determinations, member must meet the external appeal prerequisites and have requested preauthorization for the out‑of‑network treatment; treating physician must certify the out‑of‑network service is substantially different and provide two scientific/medical documents supporting greater clinical benefit

To pursue external appeal of denial of authorization for a nonparticipating provider, treating physician must certify that the in‑network provider recommended by plan lacks adequate training/experience and recommend a specific nonparticipating provider with appropriate qualifications

Administrative coverage-related provisions

Administrative provisions that affect coverage limits, member information rights, and recovery rights.

Some benefits are limited to a specific number of visits or days (e.g., rehabilitation visit limits); no additional entitlement if coverage status changes during the year

Members may request copies of board information, financials, confidentiality procedures, formulary, quality program description, medical policies, clinical review criteria and provider affiliations; clinical review criteria available on request

Subrogation and reimbursement: plan has rights to recovery/subrogation from third parties responsible for member injury/illness; member must notify plan within 30 days of filing notice with any party and provide requested information to preserve subrogation/reimbursement rights

Overpayments: members must repay overpayments within 60 days of notice; plan will generally not pursue recovery after 24 months except in cases of fraud or intentional misrepresentation

Contract renews automatically every 12 months if member remains eligible unless terminated per contract

Billing, code groups, and numeric limits

Allowed amount rulesmixed

'Monto permitido' — el monto máximo que pagaremos por los servicios o suministros cubiertos; será el monto negociado con el proveedor participante o el cargo del proveedor participante si es menor.

Advanced diagnostic imagingmixedCovered

Tomografías por emisión de positrones (PET), resonancias magnéticas (MRI), medicina nuclear y tomografías axiales computarizadas (TAC)

Pruebas de laboratorio y biomarcadoresmixedCovered

Pruebas médicas de precisión de biomarcadores y pruebas de laboratorio realizadas en laboratorios participantes certificados CLIA (o exentos por la FDA) cuando están respaldadas por indicaciones aprobadas por la FDA, determinaciones de cobertura de CMS, guías clínicas nacionales o literatura científica revisada por pares.

Multiple surgical procedures billing rulemixed

Cuando se realizan múltiples procedimientos quirúrgicos en la misma operación, se paga el procedimiento con el monto permitido más alto y el 50% del monto permitido por los procedimientos secundarios; reglas separadas aplican según si las incisiones son mismas o distintas y conforme a normas de codificación reconocidas nacionalmente; ciertos procedimientos secundarios pueden estar exentos de la reducción.

Hearing aids and prostheticsmixedCovered

	Audífonos externos: cubiertos con recomendación médica escrita; incluye colocación y pruebas; una compra (incluida reparación/reemplazo) por oído cada 3 años.
	Implantes cocleares: cubiertos cuando médicamente necesarios; un audífono por oído durante la inscripción; reparación/reemplazo únicamente por mal funcionamiento.
	Dispositivos protésicos externos: prótesis externas (incluidas pelucas bajo condiciones específicas) cubiertas; un (1) dispositivo prostético por extremidad de por vida; reparación/reemplazo cubiertos salvo garantías o abuso.
	Dispositivos protésicos internos: prótesis implantadas cubiertas si mejoran/recuperan función; incluye prótesis mamarias implantadas; reparación/reemplazo por crecimiento o desgaste normales.

Prescription drugs (general)mixedCovered

Medicamentos recetados médicamente necesarios aprobados por la FDA que figuran en el formulario del plan y son dispensados por una farmacia certificada; incluye autoinyectables, inhaladores, fórmulas enterales y clases terapéuticas de especialidad; reposiciones sujetas a condiciones (dispensación en farmacia participante o especializada, límite de reemplazo dentro de 1 año desde la receta original).

Out-of-network coverage limit

Out-of-area coverage limitOnly emergency services and emergency prehospital ambulance services are covered outside the plan area or when provided by non‑participating providers; other out‑of‑network services are not covered unless authorized.

Exception — authorized out‑of‑network careIf we approve authorization to a non‑participating provider because no suitable in‑network provider exists, payment is made as if in‑network and member pays in‑network cost‑sharing.

Ambulance (non‑emergency)Air ambulance for non‑emergency requires prior authorization before services are provided.

Balance billing protection for emergenciesMembers are only responsible for in‑network cost‑sharing for emergency services from non‑participating providers; providers may not balance‑bill beyond cost‑sharing for covered emergency services.

Authorizations, documentation, and operational duties for providers

Billing Rule

Submitting Global Core claims / prior certification

When members pay for covered services received outside the BlueCard service area, they may submit a BCBS Global Core claim for reimbursement. For institutional and professional claims, members must complete the BCBS Global Core claim form and attach itemized provider bills, then mail to the Service Center address on the form. The form is available from the Service Center or online at www.bcbsglobalcore.com. Members who need help may call the Service Center at 1.800.810.BLUE (2583) or collect at 1.804.673.1177, 24 hours a day, seven days a week.

Members must submit itemized provider bills with the BCBS Global Core claim form.
Form and mailing address available at www.bcbsglobalcore.com or by contacting the Service Center.

Prior Authorization

Excepción médica para equipos/suministros diabéticos

Key terms and definitions used in the contract

Key terms (multiple)

Medically necessaryServices are medically necessary if clinically appropriate in type, frequency, extent, place and duration; required for direct care/management; would adversely affect the condition if not provided; provided per accepted standards; not primarily for convenience; not more costly than alternatives; appropriate site of service considered.

Preauthorization (Pre‑service claim)A decision taken before you receive a service, procedure, treatment, device or drug determining medical necessity; services requiring preauthorization are listed in the Table of Benefits.

Telesalud (Telehealth)Use of electronic information and communication technologies by a participating provider to deliver covered services when member location differs; coverage cannot be denied solely because service is via telehealth.

Allowed amount (Monto permitido)The maximum amount we will pay for covered services — the negotiated rate with a participating provider or the provider's charge if less.

Telesalud

Policy Summary

PayerEmpire Bluecross

PolicyEssential Plan subscriber contract (NY)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must request preauthorization at least two weeks before scheduled inpatient admissions or outpatient surgeries, or as soon as reasonably possible when not feasible.

SourceLink

On This Page

Members are protected from balance billing for surprise bills per contract and applicable law
Telehealth services will not be denied solely because they are provided via telehealth; utilization review and cost‑sharing rules apply but must be at least as favorable as in‑person services
Continuation of care permitted when a provider leaves the network (up to 90 days) or for new members with ongoing treatment by an out‑of‑network provider (up to 60 days) for certain conditions

Members may verify participating provider status via directory, phone or website; erroneous directory listings can entitle members to reimbursement if they paid amounts exceeding applicable cost‑sharing

Cost‑sharing (copays, coinsurance) applies as shown in the Table of Benefits and is calculated against the allowed amount unless otherwise stated

Advanced diagnostic imaging (PET, MRI, nuclear medicine, CT) is covered; see benefit table for applicable cost‑sharing and preauthorization/referral requirements

Rehabilitation and habilitation services (PT/OT/speech) are limited to 60 visits per condition per plan year (combined therapies) for outpatient and up to 60 days per plan year for inpatient services; services must meet clinical criteria and timing rules

Home health care covered when provided by certified agency, per a written plan of treatment and as replacement for hospitalization or SNF care; limited to 40 visits per plan year

Clinical trials: routine patient costs for approved clinical trials for cancer or other life‑threatening conditions covered without utilization review when eligibility and referral criteria met; investigational drug/device and research costs excluded

Diabetes services: in‑network no cost‑sharing for diagnosis/management visits, annual retina and foot exams and related labs; other services during same visit may have cost‑sharing

Dialysis covered with limits and requirements for nonparticipating providers (see dialysis criteria) including notification and preauthorization rights

Habilitation services covered (PT/OT/Speech) up to 60 visits per condition per plan year (combined) for outpatient services

Home health care covered by certified agencies per plan of treatment; visits count toward home health visit limit (40/year)

Infertility evaluation and treatment covered (basic and comprehensive) per professional society guidance; fertility preservation covered when treatment causes iatrogenic infertility

Infusion therapy covered when administered via specialized delivery systems in office or by authorized/certified agency; home infusion visits count toward home health limit

Abortion services covered including associated medications with no cost‑sharing

Laboratory and diagnostic imaging covered; precision biomarker testing covered when performed in CLIA‑certified labs and supported by recognized guidance

Maternity and newborn care covered including prenatal, delivery, postpartum and lactation support (one standard breast pump per pregnancy) and doula visit when recommended; eight prenatal/postpartum visits covered

Office visits for diagnosis and treatment covered (including home visits when applicable)

Outpatient hospital services and supplies covered similar to inpatient services; hospitals generally not participating providers for outpatient lab services unless hospital is participating

Second opinions covered including oncology second opinion; nonparticipating specialist may be used with written referral and will be treated as in‑network for second opinion

Surgical services covered including surgeons, assistants and anesthesia; multiple procedure payment rules apply (highest paid procedure at full allowed amount and 50% for others with coding exceptions)

Limited oral surgery covered for specified jaw/adjacent tissue conditions, congenital anomalies, trauma and TMJ/orthognathic indications

Breast reconstruction after mastectomy covered including all stages, symmetry procedures, complications and nipple‑areola tattooing; implanted breast prostheses covered

Other reconstructive/corrective surgery covered only when correcting congenital functional defect of a covered child, resulting from trauma/infection/disease, or otherwise medically necessary

Telemedicine consultations covered for non‑emergency conditions through the telemedicine program; technical requirements and participating provider list apply

Transplants covered only if not experimental, indicated by specialists and performed at plan‑approved hospitals; hospital and physician transplant expenses and donor search charges covered; investigational transplant/drug costs and travel/lodging excluded

Diabetes equipment and supplies covered when prescribed by authorized prescriber (broad list of supplies) and obtained from designated manufacturer/pharmacy; supplies limited to 30–90 day supply when obtained at pharmacy

Designated manufacturer/pharmacy requirement: diabetes equipment/supplies covered only when obtained from a designated manufacturer with agreement to provide via participating pharmacies; medical exceptions may be requested

Diabetes self‑management education and nutrition covered at diagnosis, significant change or refresher courses and may be provided in home when medically necessary

Diabetes‑related items subject to step therapy and prior authorization; step‑therapy exceptions may be requested per utilization review process; step therapy changes to diabetes drugs limited for one plan year absent FDA safety concerns

External prosthetic devices (incl. wigs under conditions) covered; generally one prosthesis per extremity per lifetime; repairs/replacement covered except when under warranty or due to misuse

Internal prosthetic implants covered when they restore/improve function (including implanted breast prostheses); repair/replacement for growth or wear covered; coverage limited to standard devices

Hospital inpatient services covered for acute care per hospital services section; applicable cost‑sharing from Table of Benefits applies

Maternity inpatient minimum coverage: 48 hours after vaginal birth and 96 hours after cesarean, including parent education and lactation support; home health visit covered if discharged earlier

Inpatient services for mastectomy/disection covered for appropriate duration as determined medically necessary

Inpatient habilitation and rehabilitation services covered up to 60 days per plan year for hospital patients; timing and clinical criteria apply

Skilled nursing facility (SNF) coverage: non‑custodial SNF services covered up to 200 days per plan year; admission requires approved plan of treatment

End‑of‑life care for advanced cancer with life expectancy <60 days covered in certified centers; accelerated external appeal available if admission disputed; reimbursement rules for nonparticipating providers described

Autism spectrum disorder services covered when prescribed by certified physician/psychologist and determined medically necessary: assessments, assistive communication devices, applied behavior analysis, PT/OT/Speech and prescription drugs; limits apply for services provided under educational plans

Substance use disorder services covered for inpatient and residential care in licensed/certified OASAS centers (or equivalent) and outpatient programs including intensive programs and medication‑assisted treatment; certain OASAS services exempt from preauthorization and concurrent review rules

Prescription drugs covered when FDA‑approved and listed on plan formulary, dispensed by certified pharmacy; includes mental health/SUD drugs, contraceptives, cancer drugs and specialty categories subject to program rules

Prescription refill rules: refills covered only when dispensed at approved pharmacies (specialty, retail or mail); no benefits if >1 year since original prescription; emergency refill provisions during declared state disaster apply with exceptions for controlled substances

Cost‑sharing design uses three (3) tiers (Levels 1–3) and applies to drugs obtained at participating pharmacies; members pay lowest of applicable cost‑sharing or pharmacy charge for participating pharmacies

Specialty medications program: many specialty drugs require use of a designated specialty pharmacy; if member declines to obtain through the specialty pharmacy, coverage may be denied except where retail pharmacy participates and accepts equivalent reimbursement

Quantity limits and early refill controls apply per plan criteria; members/providers may appeal denials or limits via utilization review and appeals

Dental implants and related services covered when medically necessary with preauthorization and supporting dentist documentation

Orthodontia covered when medically necessary for severe conditions (cleft palate, severe skeletal anomalies, etc.)

No‑fault automobile insurance benefits supplant coverage where applicable

Services not listed as covered in the contract are not covered

Services provided by direct family members are excluded

Services billed separately by hospital employees, labs or other institutions are not covered

Services generally provided without charge are not covered

Vision exam and fitting of eyeglasses/contact lenses not covered under certain sections (see vision benefit)

War‑related conditions excluded

Workers' compensation or employer liability covered services excluded

Standard step‑therapy exception: decision within 72 hours after receiving required rationale and documentation showing contraindication, prior failure, likely ineffectiveness, stability on current agent, or adherence barrier
Accelerated step‑therapy exception: if delay poses serious risk to health, decision within 24 hours after receiving documentation; if granted, immediate coverage authorized

If required documentation is missing, plan will request missing information within specified windows (72 hours/24 hours as applicable) and allow 45 days (48 hours for accelerated) to provide it; decision timelines vary by review type and receipt of information

Internal appeal rights: member/designee (and provider for retrospective) may file within 180 days of adverse notice; appeals decided by independent clinical reviewer not subordinate to initial reviewer

Preauthorization timeframe

Recommended preauthorization timeframeProviders must request preauthorization at least two (2) weeks before scheduled inpatient admissions or outpatient surgeries/procedures; if not possible, request as soon as reasonably possible during normal business hours.

Air ambulance (non‑emergency)Prior authorization required before services are provided.

Urgent/expedited timingFor urgent pre‑service requests, determinations by phone within 72 hours and written notice within 3 days when information is complete.

Out-of-pocket limit effect

Effect after OOP reachedWhen a member reaches the plan year out‑of‑pocket limit shown in the Benefit Table, the plan pays 100% of the allowed amount for covered services for the remainder of that plan year.

What counts toward OOPCosts for out‑of‑network services generally do not count toward the out‑of‑pocket limit except for emergencies, approved out‑of‑network exceptions, and dialysis outside the network.

Definition of allowed amount'Allowed amount' is the negotiated rate with a participating provider or the provider's charge if less; plan pays based on allowed amount when computing 100% coverage post‑OOP.

colorectal_screening_age_range

Colorectal screening age rangeCovered for members aged 45 to 65, including initial colonoscopy or other USPSTF‑recommended screening tests and follow‑up colonoscopy after a positive non‑colonoscopy screening test.

Guiding standardScreening provided in accordance with USPSTF recommendations for average‑risk individuals.

Included servicesIncludes colonoscopy and other preventive colorectal screening tests and related lab analyses as indicated.

Límites de visitas

Habilitación — visits per condition60 visits per condition per plan year (combined habilitation therapies: physical, occupational, speech).

Home health — annual limitHome health care provided by a certified agency is limited to 40 visits per plan year; each visit by a home health worker counts as one visit.

Definition of 'per condition''Per condition' refers to the illness or injury that gives rise to the need for therapy; limit applies to all therapies combined for that condition.

Límite de visitas de rehabilitación

Rehabilitation visit limit60 visits per condition per plan year (combined physical, speech and occupational therapy).

Therapy start and duration rulesTherapy must be requested by a physician, relate to the diagnosis/treatment, begin within six months of the triggering event and not continue beyond 365 days.

Applies inpatient and outpatientLimits apply to habilitation and rehabilitation services provided in outpatient settings and per condition definitions.

Audífonos - frecuencia de reemplazo

Hearing aid replacement frequencyOne purchase per ear once every three (3) years (includes placement and associated testing; repair/replacement covered as described).

Requires physician recommendationCoverage available when purchase follows a written recommendation from a physician.

Repairs/replacementsRepair or replacement covered when necessary due to normal wear and tear; not covered for loss, misuse or abuse unless specified.

Terapias habilitacion/rehabilitación - límite anual

Combined habilitation/rehabilitation annual limit60 days per plan year for habilitation/rehabilitation services for hospitalized patients (limit applies to combined therapies).

Inclusion criteriaServices must relate to diagnosis/treatment, be requested by a physician, and begin within six months of the qualifying event.

Duration capTherapy must not continue beyond 365 days from the triggering event.

Reposición máxima desde receta original

Maximum refill from original prescription dateRefills are not covered if more than one (1) year has passed since the original prescription date.

Eye drop early refill exceptionLimited early refill allowance for prescription eye drops before the end of the approved dosing period, with copay applied per Table of Benefits.

Pharmacy dispensing requirementRefills must be dispensed at a specialty pharmacy, retail pharmacy or by mail order as indicated to be eligible for benefits.

copago prorrateado for initial limited opioid supply

Copay proration for initial limited opioid supplyIf initial prescription supply is 7 days or less for opioids (Schedules II–IV) and a copay applies, the copay will be prorated; if additional supply provided within the same 30‑day period, remainder of 30‑day copay is prorated — total prorated copay will not exceed the 30‑day copay.

Timing and limitsApplies to initial limited opioid prescriptions intended for acute pain; subsequent supplies within 30 days subject to proration rules.

Reference to schedulesApplies to opioids listed in Schedules II, III or IV as noted in policy section on initial limited opioid supply.

suministro y costos para pedido por correo

Mail‑order supply limitMail order dispensing allowed for up to a 90‑day supply for covered medications.

Member cost responsibility for 90‑day mail orderMember pays one 30‑day cost‑share amount per 30 days up to a maximum of 2.5 times the 30‑day cost‑share when obtaining a 90‑day supply by mail.

Retail supply limitsStandard retail supply limit is 30 days; retail designated pharmacies may provide up to 90 days for maintenance medications as designated.

service frequency limits

Vision exam frequencyOne (1) vision exam per plan year (more frequent if medically necessary with documentation).

Lenses/contacts and framesPrescription lenses or contacts: one (1) per plan year; frames: one (1) per plan year (non‑standard options may require member cost‑share for the difference).

Dental frequency — prophylaxis and X‑raysDental prophylaxis (cleaning) every 6 months; full‑mouth or panoramic dental X‑rays every 36 months; bitewing radiographs every 12 months.

Claim submission timeframe

Claim submission timeframeClaims for services must be submitted within 120 days after the service date; if not possible, submit as soon as reasonably possible.

Required claim informationClaims must include member ID, patient details, date of service, service charges, procedure and diagnosis codes as applicable, provider name/address and supporting medical records if required.

How to submitClaim forms available via the phone number on the member ID card or online; members may submit claims electronically or by mail per instructions.

Plazo de pago según medio

Payment timing by submission mediumIf our obligation to pay a claim is reasonably clear, we will pay within 30 days for claims submitted via Internet/e‑mail and within 45 days for claims submitted by other means (paper/fax).

If additional info requestedIf we request additional information, we will pay within 15 days of our payment determination but before the 30/45‑day deadline depending on submission method.

Applies when obligation clearThese timeframes apply when the obligation to pay the claim is reasonably clear as described in the policy.

outpatient protected period

Outpatient protected period for SUDOutpatient substance use disorder services at OASAS‑certified centers are exempt from preauthorization and concurrent review for the first 4 weeks (up to 28 visits) if the center notifies the plan of treatment start and initial plan within two business days.

Notification requirementThe OASAS‑certified center must notify the plan of the start of treatment and initial treatment plan within two (2) business days to qualify for the protected period.

Post‑protected reviewAfter the protected period, the plan may review treatment for medical necessity using OASAS‑designated clinical review tools.

inpatient protected period

Inpatient protected period for SUDInpatient substance use disorder treatment at OASAS‑licensed/certified centers is exempt from preauthorization and concurrent review for the first 28 days if the center notifies the plan of admission and initial treatment plan within two business days.

Notification timingThe center must notify us of admission and the initial treatment plan within two (2) business days to qualify for the 28‑day protected period.

Post‑protected reviewAfter the first 28 days, the plan may review the full stay for medical necessity using OASAS clinical review tools; if denied, member owes in‑network cost‑sharing only.

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Diabetic equipment and supplies are covered only when obtained from a designated diabetic equipment/supplies manufacturer that has an agreement with us to provide required items through participating pharmacies. If a needed item is not available from the designated manufacturer, the member or provider must request a medical exception by calling the number on the member’s ID card. The medical director will make determinations on exceptions. Diabetic supplies are limited to a 30‑day supply (up to 90 days when dispensed by a pharmacy).

Coverage limited to designated manufacturer agreements and participating pharmacies.
Request a medical exception via the phone number on the member ID card if item unavailable.
Supply limits: 30 days (up to 90 days by pharmacy).

Prior Authorization

Admisión en centro de enfermería especializada

Admission to a skilled nursing facility must be supported by a treatment plan prepared by the provider and approved by us. Covered skilled nursing facility services (not custodial/convalescent/home care) are covered up to 200 days per plan year, subject to the plan's hospital services provisions and any applicable limits.

Admission requires provider-prepared treatment plan and insurer approval.
Coverage limit: up to 200 days per plan year for non-custodial skilled care.

Denial Risk

Apelación externa acelerada para admisión terminal

For terminal admissions (end‑of‑life care) when we do not agree with the admission to a certified acute or hospice center, we may initiate an expedited external appeal. Providers and members should be aware that an external appeal agent will make the final decision; we will reimburse and continue payment to the center pending the external appeal’s decision as specified in the contract. Reimbursement to nonparticipating end‑of‑life providers follows negotiated rates or Medicare acute care rates as outlined in the contract.

Insurer may initiate an expedited external appeal for disputed terminal admissions.
If external appeal is initiated, payment to the center will continue pending appeal decision.
Nonparticipating provider reimbursement rules: negotiated rate or Medicare-based rules per contract.

Step Therapy

Terapia escalonada

Step therapy (terapia escalonada) may require use of one or more medications before we cover an alternate drug. Step therapy protocols use evidence‑based clinical criteria and are applied to certain medications; drugs subject to step therapy also require any applicable prior authorization. Members, their designees, or prescribing clinicians may request a step‑therapy exception/override per the utilization review and exception processes in this contract.

Step‑therapy protocols are evidence‑based and reviewed by peers.
If applicable, step‑therapy drugs also require prior authorization.
Exception/override may be requested by patient, designee, or prescribing clinician per contract procedures.

Prior Authorization

Excepción al formulario / revisión acelerada

Exception to the formulary (formularios) may be requested in writing, electronically, or by phone. Standard exception determinations will be made within 72 hours of receipt and written notice provided within three (3) business days. If approved, the requested medication will be covered while the member is taking it. For urgent situations meeting the contract criteria, an expedited/form accelerated review is available with a decision within 24 hours and written notice within three (3) business days.

Standard exception decision: within 72 hours; written notice within 3 business days.
Expedited exception decision: within 24 hours when medical urgency criteria met; written notice within 3 business days.
If denied, member has right to external appeal as described in the contract.

Prior Authorization

Preautorizaciones no urgentes

Non‑urgent prior authorization reviews: when we have all necessary information, determinations will be made and the member (or designee) and the provider notified by phone and in writing within three (3) business days of receipt of the request. If additional information is needed, we will request it within three (3) business days; the member/provider then have 45 calendar days to provide the information. If we receive the information within 45 days, we will decide and notify within three (3) business days of receipt. If information is not received within 45 days, we will make a determination within 15 calendar days thereafter.

Complete non‑urgent preauthorization determinations and phone/written notice within 3 business days.
If additional info requested: member/provider have 45 calendar days to respond; subsequent decision within 3 business days of receipt or within 15 calendar days if not supplied.

Prior Authorization

Preautorizaciones urgentes

Urgent prior authorization reviews: when we have all necessary information for an urgent request, we will decide and notify the member (or designee) and the provider by phone within 72 hours of receipt. We will send written notice within three (3) business days. If additional information is needed, we will request it within 24 hours and the member/provider have 48 hours to respond; we will then decide and notify by phone within 48 hours of receiving the information or at the end of the 48‑hour period, whichever comes first, with written notice within three (3) business days.

Urgent determination by phone within 72 hours when complete.
If more info requested: 48 hours to provide; decision and phone notice within 48 hours after receipt (or end of 48‑hour period); written notice within 3 business days.

Note

Exenciones de preautorización para centros de estabilización de crisis

Services provided at participating crisis stabilization centers (certified under NY Mental Hygiene Law §36.01 or Joint Commission‑accredited detox/substance programs in other states) are not subject to prior authorization. Treatment provided at participating crisis stabilization centers may be reviewed retrospectively for medical necessity using OASAS/OMH designated clinical review tools. If retrospective review finds services not medically necessary, the member’s financial responsibility is limited to the in‑network cost‑sharing that would have applied.

Participating crisis stabilization centers are exempt from preauthorization.
Retrospective medical necessity review may occur; member liability limited to in‑network cost‑share if parts are denied.

Note

Preautorización y revisiones para abuso de sustancias (hospitalizado)

Inpatient substance use disorder (SUD) treatment at participating OASAS‑certified centers is not subject to prior authorization and is exempt from concurrent review for the first 28 days if the center notifies us of the admission and initial treatment plan within two (2) business days of admission. After the initial protected period, we may review the remainder of the stay for medical necessity using OASAS clinical review tools; if portions are denied, member financial obligation is limited to in‑network cost‑sharing.

No prior authorization or concurrent review for first 28 days when admission and initial plan are reported within 2 business days.
Post‑28 days: concurrent review may occur using OASAS tools; member cost‑share limited to in‑network amounts if denied.

Note

Preautorización y revisiones para abuso de sustancias (ambulatorio)

Outpatient SUD treatment, intensive outpatient, rehabilitation and opioid outpatient treatment at participating OASAS‑certified centers are not subject to prior authorization and are exempt from concurrent review for the first four (4) weeks (not to exceed 28 visits) if the center notifies us of treatment initiation and the initial treatment plan within two (2) business days. After this initial protected period, we may review continued outpatient treatment for medical necessity using OASAS tools; if portions are denied, member liability is limited to in‑network cost‑sharing.

No prior authorization for outpatient OASAS‑certified services during first 4 weeks / up to 28 visits when notified within 2 business days.
After protected period, treatment may be reviewed for medical necessity; member pays only in‑network cost‑share if denied.

Definition of TelesaludTelesalud is the use of electronic information and communication technologies by a participating provider to deliver covered services when the member's location differs from the provider's location; telehealth services will not be denied solely because they are provided via telehealth.

Parity of termsCopays/coseguro applied to telehealth may be applied provided they are at least as favorable as for in‑person services; utilization review and quality requirements may apply.

Provider participationServices via telehealth must be provided by a participating provider to receive in‑network benefits unless otherwise authorized.

Surprise billing

Surprise billing — definitionA 'surprise bill' is a bill from a non‑participating provider for covered services in specified circumstances (e.g., non‑participating provider at an in‑network facility when no participant available, services without member's knowledge, or unforeseen services).

Member protectionMember is exempt from charges exceeding in‑network cost‑sharing for a surprise bill; non‑participating provider may only bill member for the in‑network cost‑sharing amount.

External appeal/right to disputeMembers may appeal out‑of‑network denials and use external appeal processes where applicable; treating physician certification and evidence required for certain out‑of‑network external appeals.

Medically necessary

Medical necessity definitionMedically necessary services are clinically appropriate in type, frequency, extent, place and duration; required for direct care or management; would adversely affect the condition if not provided; provided per accepted standards; not primarily for convenience; not more costly than alternatives; and provided in appropriate setting.

Decision sourcesDeterminations may consider clinical records, medical policies/guidelines, peer‑reviewed literature, professional society opinions, standards of safety/efficacy, and treating provider opinions.

Appeal rightsMember may pursue internal and external appeals of determinations that services are not medically necessary per review and appeal procedures.

Monto permitido

Allowed amount — definition'Allowed amount' is the maximum we will pay for covered services and is the negotiated amount with a participating provider or the provider's charge if less.

Negotiation with Host BlueWhen services are accessed outside the plan area under Host Blue/BlueCard, payment and member obligations are calculated based on Host Blue local negotiated price or estimates per program rules.

Incentives and impactPayments to participating providers may include incentive programs; such payments do not change member cost‑sharing for a specific service.

Acuerdos entre planes / Host Blue

Host Blue / Acuerdos entre planesAgreements with other Blue Cross/Blue Shield licensees (Host Blue) are used to process out‑of‑area claims; Host Blue negotiated prices or estimated/average prices may apply when members receive care outside the plan area.

BCBS Global Core — international claimsFor care outside BlueCard service area (including abroad), members may pay providers and submit BCBS Global Core claim form with itemized bills for reimbursement; call Service Center for assistance and precertify non‑emergency inpatient services.

Member payment calculationMember obligation for out‑of‑area claims is usually the lesser of the provider's billed charge or the Host Blue negotiated price; final price may not be adjusted later.

Emergency prehospital medical services

Emergency prehospital medical services — definitionImmediate evaluation and treatment of an emergency condition and/or non‑air transport to a hospital provided by a certified ambulance service; covered worldwide for treatment of emergency conditions.

Provider certificationServices must be provided by an ambulance service certified under the NY Public Health Law to be covered as prehospital emergency medical services.

Member cost exposureCertified ambulance services must not bill member beyond applicable copay/coinsurance; when no negotiated rate exists, payment to non‑participating ambulance providers is lesser of FAIR Health 80th percentile and billed charges.

Condition of emergency

Condition of emergency — layperson standardA condition with acute symptoms of such seriousness that a prudent layperson with average knowledge would reasonably believe lack of immediate medical attention could cause serious health danger, organ dysfunction, disfigurement or danger to self/others.

ExamplesIncludes severe chest pain, major trauma, severe difficulty breathing, sudden mental status change, heavy bleeding, suspected heart attack, poisoning, seizures, etc.

Coverage implicationEmergency services to treat or stabilize such conditions are covered regardless of provider participation and worldwide.

Infertilidad iatrogénica

Iatrogenic infertility — definitionInfertilidad iatrogénica refers to impairment of fertility caused by surgery, radiotherapy, chemotherapy or other medical treatment affecting reproductive organs or processes.

Coverage for fertility preservationStandard fertility preservation services (retrieval, preservation and storage of eggs, sperm or embryos) are covered when treatment will directly or indirectly cause iatrogenic infertility.

Documentation requirementCoverage subject to medical necessity determination and applicable procedural rules in the infertility section.

Ensayo clínico aprobado

Approved clinical trial — definitionAn approved clinical trial means a Phase I–IV trial that is federally approved or funded, conducted under an IND reviewed by the FDA, or is exempt from IND requirements; routine patient care costs for qualifying oncology or life‑threatening condition trials are covered without utilization review if conditions met.

ExclusionsDoes not cover investigational drug/device costs, research costs, or services otherwise excluded by the contract.

Referral requirementMember must be referred by a participating provider who deems trial participation appropriate to qualify for non‑utilization‑review coverage for routine costs.

Equipo médico duradero

Durable Medical Equipment (DME)DME means equipment designed for repeated use, primarily medical in nature, not generally useful to someone without illness/injury, and appropriate for home use; coverage limited to standard equipment with repair/replacement for normal wear and tear.

Orthotic splints (Férulas)Covers external orthotic devices (splints) that help wholly or partly replace lost/damaged external function; standard items only; replacements covered for growth or change in condition.

Hearing aids (DME related)Hearing aids covered with physician written recommendation; one purchase per ear every three years; repairs/replacements covered as described.

Por condición (rehabilitación)

'Per condition' (rehabilitation) — definition'Per condition' refers to the illness or injury that gives rise to the need for therapy; visit limits apply to all therapies combined for that originating condition.

ApplicationLimits such as 60 visits per condition per plan year apply across physical, occupational and speech therapies combined for that condition.

Timing rulesRehabilitation services must begin within six months of the triggering event and cannot continue beyond 365 days from that event.