- What if I go to the emergency room and the doctor assigned to me is not a participating provider?
- What is the Table of Allowance?
- If I have two insurance plans, could I still have out-of-pocket expenses?
- I have coverage under more than one plan, how do I file claims with the secondary carrier?
- When will I receive my EMI Health ID card?
- Will my plan pay for a routine or screening colonoscopy?
- How can I determine what services are subject to the deductible?
- Are out-of-pocket maximum and out-of-pocket expenses the same thing?
- What immunizations are covered by my plan?
- What diabetic suppplies are covered under my plan?
What if I go to the emergency room and the doctor assigned to me is not a participating provider?
Answer: In the case of a legitimate emergency, the claim will be paid as participating to the Table of Allowances. If you visited a nonparticipating facility, even in an emergency, you may be responsible for amounts exceeding the Table of Allowance.
What is the Table of Allowance?
Answer: The Table of Allowances is the schedule for payment of eligible charges.
- All benefits are subject to the Table of Allowances. For example, if a provider charges $125 for a procedure for which the Table of Allowances permits a $100 payment, EMI Health will pay the specified percentage of $100, not $125.
- Participating providers have agreed to write off any amounts in excess of the Table of Allowances. Nonparticipating providers are under no such obligation.
- If EMI Health pays for services from a nonparticipating provider according to the Participating Provider Option of your plan (because of an emergency situation), you may still be responsible for any amount exceeding the Table of Allowances.
If I have two insurance plans, could I still have out-of-pocket expenses?
Answer: You may still need to pay some expenses out-of-pocket. EMI Health will never pay more than we would have paid if we were the primary carrier.
- The plan deductibles, copayments, and Table of Allowances still apply. For example, if the claim is for $100, and the primary carrier paid $80 (leaving a balance of $20), and your EMI Health plan has a $100 deductible, the $20 balance would be applied toward your deductible, but EMI Health would not pay anything toward that claim. However, if your EMI Health plan would have paid $80 (with no deductible) as the primary carrier, EMI Health would pay the $20 balance.
- Coordination rules for high deductible health plans (HDHP) may vary, due to federal regulations.
I have coverage under more than one plan; how do I file claims with the secondary carrier?
Answer: Most providers will file the claims with both insurance companies if you give them all of the information. When EMI Health is the secondary carrier, we require an explanation of benefits from the primary carrier, as well as an itemized statement from the provider, including the medical diagnosis and procedure codes.
When will I receive my EMI Health ID card?
Answer: You should receive your card within two weeks after EMI Health receives your enrollment application.
- You will receive two ID cards attached to the bottom of a welcome letter. EMI Health will never send you junk mail, so please carefully review anything you receive from EMI Health. You can also access your ID card through the EMI Health app.
- If you require medical services or prescriptions after your effective date, but before you receive your ID card, check the mobile app. If it is not yet available there, contact EMI Health enrollment department at 800-662-5851.
Will my plan pay for a routine or screening colonoscopy?
Answer: One screening colonoscopy a year is covered at 100 percent when you use a participating provider. If you have a medical condition or are experiencing symptoms, medically-necessary colonoscopies are covered according to the appropriate benefits of your plan (usually outpatient medical/surgical).
How can I determine what services are subject to the deductible?
Answer: Look for the symbol identified on your Summary of Benefits chart.
- The deductible is the amount you must pay for eligible expenses out of your own money before any benefits will be paid by your plan.
- Most plans include separate deductibles for Participating Provider Option benefits and Nonparticipating Provider Option benefits.
Are out-of-pocket maximum and out-of-pocket expenses the same thing?
Answer: When you have satisfied any applicable deductible and paid eligible expenses up to the out-of-pocket maximum, the plan will pay remaining eligible expenses at 100 percent of the Table of Allowances. However, this does not mean that you will not have any additional out-of-pocket medical expenses.
- If you receive any service or treatment specified as a limited benefit, the plan will pay for services only up to the specified amounts.
- Any expense incurred for amounts in excess of the specified percentage, day, or dollar limits, and expenses you pay for not following preauthorization procedures, will not be reimbursed by the plan and will not accumulate toward the annual out-of-pocket maximum.
- The Participating Provider and Non-participating Provider Options each have a separate out-of-pocket maximum.
What immunizations are covered by my plan?
Answer: Most plans cover immunizations that are recommended by the Advisory Committee on Immunizations Practices of the Center for Disease Controls and Prevention (CDC) at 100 percent if received from a participating provider.
What diabetic supplies are covered by my plan?
supplies fall under various provisions of your plan. Here are some common
coverages. Contact customer service for the specifics of your plan.
Most EMI Health plans cover the following
supplies under the medical benefit. Refer to the Diabetic Testing Supplies
(90-day supply) line item of your benefit grid for your member cost-share.
- Blood sugar (glucose) test strips
- Lancet devices and lancets
EMI Health has
contracted providers for diabetes testing supplies. Testing supplies obtained through any other
provider (including pharmacies) may not be covered; or if covered, will be
subject to your Non-Participating Provider benefit option. The preferred
- Edgepark/Cardinal - 877-215-2568
- Byram Healthcare - 800-775-4372
- JQ Medical Supply - 801-942-8582
The following items are covered under the
medical benefit. Refer to the Durable Medical Equipment line item of your
benefit grid for your member cost-share.
- Therapeutic shoes or inserts
- Insulin pump and insulin pump supplies, subject to preauthorization criteria and plan review
- Continuous Glucose Monitoring Systems (CGMS) and sensors, subject to preauthorization criteria and plan review
Insulin is covered under the pharmacy benefit. You
may receive up to a 30-day supply (maximum of two vials) per retail copayment
or up to a 90-day supply (maximum of six vials) per mail-order copayment. If
necessary, additional vials may be purchased by paying an additional copayment.
Please refer to the Prescription Drug section of your benefit grid for your
Blood sugar testing monitors and glucose control
solutions are NOT covered under the medical or pharmacy benefit.