NYC Health Benefits Program

Important Changes to Your GHI CBP Plan

Effective July 1, 2016

The information in the table below lists the Care, Place and Time to receive medical treatment. The table also includes the cost of in-network services if provided by an AdvantageCare Physician (ACPNY) or by a non-ACPNY physician, as well as emergency services.

Hover over items marked with a green dotted underline for a definition of the term.

In-Network Care and Costs





Preventive Care

Visit for a full list of preventive services.

$0 $0

PCP (including Mental Health Providers)

View a list of GHI PPO Providers

$0 $15

Specialist Care

$0 $30
Diagnostic/Lab $0 $20
MRI/CAT1/High-Tech Radiology $0 $50
Physical Therapy $0 $20
Telehealth (beginning July 1, 2016) $15 $15
Urgent Care Center $50  
Emergency Room $150  



Some ACPNY Offices offer Extended, Urgent Care and Weekend Hours

Scheduling - Some doctors appointments may be scheduled online using ZocDoc

Telehealth is available 24 hours a day.



Out-of-Network Costs: There will be no changes to your current out-of-pocket costs. You will still pay any applicable out-of-network cost-sharing plus the difference between the provider’s fee and GHI’s reimbursement (which may be substantial).



Preventive Prescriptions and Diabetic Medications as listed on

  Base plan
Self-Injectibles and Chemotherapy   PICA Program
Other Prescriptions   Union Welfare Fund or High-Optional Rider

Other Services

GHI-CBP/EBCBS Services Requiring Pre-Certification

If you are an employee or non-Medicare eligible retiree participating in GHI-CBP/Empire BlueCross BlueShield

As previously communicated, many procedures require pre-certification. Your provider should call NYC Healthline at 1-800-521-9574 for pre-certifications including:

  • In-patient Admissions
    Within 48 hours of an emergency admission

  • Ambulatory Surgery

  • Physical and Speech Therapy
    After the 16th visit.

View the Announcement Letter

View the List of Services Requiring Pre-Certification

Maximum Out-of-Pocket (MOOP)

MOOP refers to the maximum amount of in-network cost-sharing expenses that you will pay in each plan year for covered services/essential health benefits received from Participating Providers under the GHI/Empire BlueCross BlueShield plans combined. MOOP includes deductibles, coinsurance and copay charge amounts that you must pay for covered in-network services and any applicable riders in a calendar year.

Cost-sharing amounts attributable to services received from Non-Participating Providers generally do not count toward MOOP.

Amounts incurred for non-covered services and other non-covered expenses, such as amounts in excess of plan allowances as well as any financial penalties do not count toward MOOP. Premiums and/or premium contributions also do not count toward MOOP. The MOOP amount may change from calendar year to calendar year**.

For July 1, 2016 – December 31, 2016

  Individual Family
GHI Medical MOOP $2,175 $4,350
EBCBS Hospital MOOP $1,250 $2,500


For calendar years beginning January 1, 2017 – December 31, 2017** (Subject to indexing by the federal government)

  Individual Family
GHI Medical MOOP $4,550 $9,100
EBCBS Hospital MOOP $2,600 $5,200
GHI CBP Member ID Cards Your new GHI CBP member ID card will be mailed to you approximately 10 days prior to the July 1, 2016 effective date of your plan changes. Please begin using it when claiming benefits, and be sure to destroy your previous card once you receive your new one.


If you have any questions about the changes to your GHI CBP medical benefits, please call EmblemHealth Customer Service at 1-800-624-2414, Monday to Friday, 8 am to 6 pm.  If you have a hearing or speech impairment and use a TTY/TDD, please call 711. Or, visit

If you have any questions about changes to your Empire BlueCross BlueShield hospital benefits, call 1-800-433-9592. Or visit


View the GHI CBP Notification Letter

View a List of GHI PPO Providers

View a List of ACPNY Locations

Glossary of Terms

Learn More About the PICA Program