Active Member Catastrophic Benefit
(GHI Members only)
Outline of Benefits
This benefit was established to assist our members and eligible dependents to defray some of the non-covered medical and surgical expenses incurred for services rendered by non-participating or out-of-net-work providers and to provide coverage for catastrophic illness
- Members must incur out-of-pocket expenses of more than $3000 Per year. (Out-of-pocket expenses are those medical and hospital charges that are considered reasonable and customary by GHI and that are not reimbursed by either the City Health Plan or private insurers).
- Members must produce a statement of services, explanation of benefits form and cancelled checks for expenses submitted.
- Reimbursement is based on a contract year (January - December) 100% of GHI reasonable and customary charges based on the current profile.
- The maximum lifetime benefit is 2 million dollars.(Limitatons apply)
The SOC provides a self-funded $1,000 direct reimbursement payable to the member after the member has submitted, qualified under the GHI Catastrophic Rider outlined above and the member still has a minimum of at least $3,000.00 of out-of-pocket qualified. The exclusions and restrictions are the same as the requirement for the catastrophic coverage benefit.
For example you may have paid $10,000 dollars out-of-pocket expenses, but GHI's payment schedule only deems the reasonable and customary payment for the services to be $7,000 dollars. The Member pays the remaining $3,000 dollars of the balance and may now be eligible to receive $1,000 dollars from the SOC Catastrophic Benefit.
The first $25,000 is covered for Private Duty Nursing care and thereafter 50% of the remainder with a lifetime cap of $50,000 per person. The cap for in-hospital Mental Health charges is $10,000 individual lifetime maximum.
The exclusions and restrictions are the same as the requirements for the GHI Catastrophic Coverage Benefit. The benefit does not cover prescription drug charges. Ineligible charges such as experimental procedures or services not approved by GHI/CBP and/or Empire Blue Cross Blue Shield are likewise not eligible for this benefit.