Making the Most of your health Plan - e

Making the most of
your health Plan
Wellness Resources and Services for
Pratt Institute
55 Water Street, New York, New York 10041-8190
Dear Pratt Institute Employee:
Welcome to EmblemHealth! Pratt Institute has chosen EmblemHealth for your health care benefits. We put care first every
day, helping members stay healthy, get well and live better. We’re committed to doing the little things — and the big things
— that add up to something wonderful: you feeling good.
Get Started
Pratt Institute has selected HIP Prime HMO as the right plan for you. To enroll, your benefit administrator. The plan's
benefits will start on January 1, 2013.
Soon after you enroll you’ll get a Welcome Kit in the mail, which will include the
. You’ll also get your ID
When you’re healthy, you feel better. We want to make it easy for you to use health-related products and services so you can feel
your best.
Making the Most of Your Health Plan, is designed so that you get the most out of the great features
much more.
In this folder’s pocket is the
plan, costs, lists of excluded services and other important information.
Keep these materials in a safe place to refer back to them when using your coverage.
Customer Care
We’re here to help. So give us a call if you have any questions. We can be reached at 1-888-839-7375, Monday through Friday,
from 8:30 am to 5 pm.
We look forward to providing you and your family with access to quality health care.
Sincerely,
Charlene A. Maher
Senior Vice President, Marketing and Sales
Group Health Incorporated (GHI), GHI HMO Select, Inc. (GHI HMO), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and
EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the
EmblemHealth companies.
55 Water Street, New York, New York 10041-8190
Dear Pratt Institute Employee:
We are honored that for 15 consecutive years Pratt Institute has chosen EmblemHealth for your health care benefits. We
are commited to doing what we have always done: Putting your care first every day and helping your stay healthy, get well
and live better. It's doing the little things - and the big things - that add up to something wonderful: you feeling good.
Get Started
Pratt Institute has selected HIP Prime HMO as the right plan for you. If you want to stay in your current plan, you don’t
have to do anything — your coverage will continue automatically. If you need to make a change to your plan, your benefit
administrator. Your benefits will start on January 1, 2013.
Soon you’ll be receiving your new ID card – the key to all the benefits available under your selected plan.
When you’re healthy, you feel better. We want to make it easy for you to use health-related products and services so you can feel
your best.
Making the Most of Your Health Plan, is designed so that you get the most out of the great features
much more.
In this folder’s pocket is the
plan, costs, lists of excluded services and other important information.
Keep these materials in a safe place to refer back to them when using your coverage.
Customer Care
We're here to help. So give us a call if you have any questions. For HIP-branded plans, call 1-800-447-8255, Monday
through Friday, from 8:30 am to 5:00 pm.
We look forward to providing you and your family with access to quality health care.
Sincerely,
Charlene A. Maher
Senior Vice President, Marketing and Sales
Group Health Incorporated (GHI), GHI HMO Select, Inc. (GHI HMO), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and
EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the
EmblemHealth companies.
Marital Status:
Single
Married
Domestic Partner
NO
YES
26 - 29 — Single
Social Security Number
State
ZIP Code
Subscriber Employment Status: ___________________________________
Applicant working at least 20 hours per week
Status:
Add Dependent
Remove Dep.
Address Change
Name Change
-
-
Social Security Number
Spouse
DP
Child
Sex Relationship
Mo. Day
Yr.
Birth Date
✓ if
Disabled
(Not required for EPO/PPO members)
Primary Care Physician
Name/ID Number
-
Child
-
Child
Date: _____ / _____ / _____
Waiting Period:
Date Submitted:
EmblemHealth
GHI
GHI HMO
HIP
Plan Name: ________________________________________
8/12
Family
Employee & Child
Approved By: (Group Plan Administrator)
Individual Employee & Spouse/DP (Optional)
Instructions to Benefit Administrators or Group Representatives: For groups with 50 employees or fewer, you MUST complete Section A on the reverse side of this form. Required documentation MUST be attached to this Transaction Form to be processed.
Hire Date:
Requested Effective Date:
Medical: ____ / ____ / ____
Dental: ____ / ____ / ____
Group Number:
Name of Group:
Pratt Institute
III. EMPLOYER INFORMATION – THIS SECTION TO BE COMPLETED BY EMPLOYER/CONTRACTOR GROUP
Applicant must sign here: ______________________________________________________
Your signature is required to process this form. Your signature attests that you have read the reverse side of this form.
Type of
Coverage:
Carrier Name: ____________________________________________________ Coverage Begin Date: ____ / ____ / ____ Coverage End Date: ____ / ____ / ____
-
Carrier Name: ____________________________________________________ Coverage Begin Date: ____ / ____ / ____ Coverage End Date: ____ / ____ / ____
-
Carrier Name: ____________________________________________________ Coverage Begin Date: ____ / ____ / ____ Coverage End Date: ____ / ____ / ____
First Name
Note: A birth/marriage certificate or 1040 Form will be required for spouse/dependents with different last name.
Current/Prior Health Insurance Information:
DEPENDENT
Current/Prior Health Insurance Information:
DEPENDENT
Current/Prior Health Insurance Information:
DEPENDENT
Last Name (if different)
OB/GYN Selection
Name/ID Number
Transfer:
To Another Carrier
EmblemHealth Group Change:
From: _________________
To: ___________________
II. ENROLLMENT INFORMATION ­—­IF YOU ARE ENROLLING YOUR SPOUSE/DP AND/OR CHILDREN, PLEASE LIST EACH ONE BELOW ­— SEE ELECTION OF COVERAGE FOR ELIGIBILITY
Check One:
New Enrollment
Reinstatement
Termination
Change to Ind.
OB/GYN Selection Name: (Optional)
____________________________________________________________________
ID Number: ___________________________________________________________
Parent ID: __________________________________________________
Primary Care Physician Name: (Not required for EPO/PPO members)
____________________________________________________________________
ID Number: ___________________________________________________________
26 And Under ­— Family
Yr.
Sex
Telephone #:
E-Mail Address: ______________________________________________
Home: (_____) ______________________
“GO PAPERLESS” and save trees (see back of application)*
Work: (_____) ______________________
City
M.I.
Are you covered by any other health insurance or Medicare?
Prior Health Insurance Information:
NO
YES If YES, indicate:
Carrier Name: ______________________________
Insurance Co. Name:__________________________________________
Coverage Begin Date: ____ / ____ / ____
Insurance Co. Telephone #: (_____) _____________ Type of Coverage: ______________
Coverage End Date: ____ / ____ / ____
Policy #: ____________________________________ Effective Date: ____ / ____ / ____
Disabled?
Young Adult Coverage:
Mo. Day
Birth Date:
Apt.
Street Address
Were you ever a member of EmblemHealth?
NO
YES
If YES, member ID ______________________
First Name
Last Name
I. SUBSCRIBER INFORMATION
TRANSACTION FORM FOR GROUP ACCOUNTS
VISION CARE
CompreHealth HMO and HIP-Branded Plans
As a member of one of our plans underwritten by HIP,
you will receive a standard level of optical benefits:
• Eye exams and written prescriptions for corrective lenses
are covered every 24 months.
• You also get a selection of eyeglasses for your optical copayment every
24 months. If you prefer, you can use an $80 credit toward eyeglasses
not included in the selection, and you just pay the difference.
HOW THE OPTICAL PROGRAM WORKS
Step 1: Find a Network Optometrist
Check Find a Doctor on www.emblemhealth.com for a network optometrist, and see if he or she is
accepting new patients.
Step 2: Get Your Eyes Examined and Obtain a Prescription
eyeglass frames and lenses made at the participating optical provider.
Depending on your particular coverage, you may be able to get your eye exam at a non-participating
provider.
Step 3: Choose Your Frames or Lenses
Once you have your prescription, go to a network optical provider to have your covered or discounted
eyeglass frames and lenses made for you.
cosmetic lining are also covered. All frames conform to current guidelines established by the American
National Standards.
Note: If you use an out-of-network provider or choose eyeglasses or contact lenses not in the collection,
you will pay higher out-of-pocket costs.
Refer to HIP policy form HMO 155-23-EMHMOCONTR (0508), et al.
VISION CARE
GHI- and EmblemHealth-Branded Plans
As a member of one of our plans underwritten by GHI, your vision benefits are administered
by Davis Vision, Inc., a leading national administrator of routine vision care programs. Eligibility for
vision care benefits is determined by the same rules that apply to your other health care benefits.
As an eligible member, you will receive a standard level of optical benefits:
• Eye exams and written prescriptions for corrective lenses are covered every 24 months.
• You also get any eyeglasses or contact lenses from the Davis Vision Collection for your optical
copay every 24 months.
• If you prefer not to use the Davis Vision Collection, you can use a credit toward any other
eyeglasses, and you just pay the difference. Or you can use up to a $45 credit toward any other
contact lenses, and you just pay the difference.
HOW THE OPTICAL PROGRAM WORKS
Step 1: Find a Network Optometrist
Please call Davis Vision at 1-800-999-5431 to get the names and addresses of the network providers
nearest you, or go to www.davisvision.com and use the Find a Doctor feature. If you use a TDD, please
call 1-800-523-2847. You may also receive services from an out-of-network provider, although you will
receive the greatest value if you select a Davis Vision provider.
Make sure to identify yourself as a member of EmblemHealth.
Step 2: Get Your Eyes Examined and Obtain a Prescription
eyeglass frames and lenses made at the participating optical provider.
Step 3: Choose Your Frames or Lenses
Once you have your prescription, go to a participating optical provider to have your eyeglasses — with
perform eye exams and will have the Davis Vision Collection of frames to choose from.
Note: If you use an out-of-network provider or choose eyeglasses or contact lenses not in the collection,
you will pay higher out-of-pocket costs.
WELLNESS PROGRAMS
Quality health benefits are
about more than just providing
coverage when you are sick.
They are also about helping you
to achieve your personal wellness
goals. So that you are at your
healthiest — every day.
At EmblemHealth, health
coverage is about total care.
See how our free EmblemHealth PATH programs and discounted access to wellness services can help you stay
healthy. You can choose the services that are right for you.
WELLNESS PROGRAMS
Eligible members can take charge of an illness through PATH, our wellness programs. PATH (Positive Actions
Toward Health) programs complement the care provided by your doctor by helping you better manage your
condition and meet your health goals.
Here are some of EmblemHealth’s PATH programs:
• Healthy Beginnings PATH Pregnancy Management Program — Made for women who want to do everything they can to have a healthy baby, this program gives the mom-to-be important health information,
so she can make healthy choices before getting pregnant, during pregnancy and after her baby is born.
• Tobacco-Free PATH Program
Cancer Society and Alere Wellbeing. Plan members age 18 and older who join our program will receive
educational materials by mail, a personalized quit plan developed by trained quit-smoking experts, unlimited phone counseling and full coverage for smoking cessation medication.
• Weight Management
heart disease. Losing weight can be challenging, and we’re here to help you improve your eating and exercise habits, which can lead to positive health changes.
• Emblem Behavioral Health Services — We have a range of mental health and substance abuse services
and resources to help you stay healthy, both physically and mentally.