Medical Comparison Associate

2019 MONTECARE EPO – MONTECARE PPO MEDICAL COMPARISON

INDIVIDUAL/FAMILY DEDUCTIBLE

Montefiore Network

MonteCare EPO – None
MonteCare PPO – None

Empire BlueCard PPO Network

MonteCare EPO – $500/$1,000
MonteCare PPO – $625/$1,250

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – $1,250/$2,750

INDIVIDUAL/FAMILY OUT-OF-POCKET MAXIMUM (DEDUCTIBLE + COPAYMENT+ COINSURANCE)

Montefiore Network

MonteCare EPO – $5,350/$10,700
MonteCare PPO – $5,350/$10,700

Empire BlueCard PPO Network

MonteCare EPO – $5,350/$10,700
MonteCare PPO – $5,350/$10,700

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – $6,000/$17,500

INPATIENT CARE

* HOSPITALIZATION – ILLNESS OR INJURY
* MENTAL HEALTH/SUBSTANCE ABUSE CARE
* PHYSICAL/OCCUPATIONAL THERAPY OR REHAB

Montefiore Network

MonteCare EPO – $0
MonteCare PPO – $0 

Empire BlueCard PPO Network Preferred Facility

MonteCare EPO – 20%1 coinsurance after deductible if precertified by Conifer Value Based Care3; otherwise 30%1 coinsurance after deductible

MonteCare PPO – $1,000 copay if precertified by Conifer Value Based Care3; otherwise $1,500 copay

Empire BlueCard PPO Network Non-preferred Facility

MonteCare EPO – 40%1 coinsurance after deductible if precertified by Conifer Value Based Care3; otherwise 50%1 coinsurance after deductible

MonteCare PPO – $2,000 copay if precertified by Conifer Value Based Care3; otherwise $2,500 copay

Out-of-network

MonteCare EPO – Not covered except in the case of an emergency

MonteCare PPO – 40%2 coinsurance after $1,000 copay if precertified by Conifer Value Based Care3; otherwise $1,500 copay

HOSPICE – 210 DAYS

Montefiore Network

MonteCare EPO – $0
MonteCare PPO – $0 

Empire BlueCard PPO Network

MonteCare EPO – $0
MonteCare PPO – $0 

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible

SKILLED NURSING FACILITY – 120 DAYS

Montefiore Network

MonteCare EPO – $0
MonteCare PPO – $0 

Empire BlueCard PPO Network

MonteCare EPO – $0
MonteCare PPO – $0 

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible

EMERGENCY ROOM IN A BONA FIDE EMERGENCY

Montefiore Network

MonteCare EPO – $100 copay (waived if admitted)
MonteCare PPO – $100 copay (waived if admitted)

Empire BlueCard PPO Network

MonteCare EPO – $100 copay (waived if admitted)
MonteCare PPO – $100 copay (waived if admitted)

Out-of-network

MonteCare EPO – $100 copay (waived if admitted)
MonteCare PPO – $100 copay (waived if admitted)

EMERGENCY ROOM OTHER THAN A BONA FIDE EMERGENCY

Montefiore Network

MonteCare EPO – 20% coinsurance
MonteCare PPO – 30% coinsurance

Empire BlueCard PPO Network

MonteCare EPO – 20%1 coinsurance after deductible
MonteCare PPO – 30%1 coinsurance after deductible

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible

URGENT CARE FACILITY

Montefiore Network

MonteCare EPO – $0
MonteCare PPO – $0 

Empire BlueCard PPO Network

MonteCare EPO – $30 copay/visit
MonteCare PPO – $30 copay/visit

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible

URGENT CARE PROFESSIONAL

Montefiore Network

MonteCare EPO – $15 copay/visit
MonteCare PPO – $15 copay/visit

Empire BlueCard PPO Network

MonteCare EPO – $30 copay/visit
MonteCare PPO – $30 copay/visit

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible

PREVENTIVE CARE

* ROUTINE PHYSICAL EXAM WITH PCP INCLUDING OB/GYN
* ROUTINE WELL CHILD EXAMS/IMMUNIZATIONS
* ROUTINE MAMMOGRAPHY

Montefiore Network

MonteCare EPO – $0
MonteCare PPO – $0 

Empire BlueCard PPO Network

MonteCare EPO – $0
MonteCare PPO – $0 

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible

OUTPATIENT DIAGNOSTIC AND LABORATORY TESTS

* X-RAYS, BONE DENSITY, BLOOD, URINE

Montefiore Network

MonteCare EPO – $0
MonteCare PPO – $0 

Empire BlueCard PPO Network

MonteCare EPO – 20%1 coinsurance after deductible
MonteCare PPO – 20%1 coinsurance after deductible

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible

HIGH-TECH RADIOLOGY SERVICES

* MRI, MRA, CAT SCAN, PET, NUCLEAR CARDIOLOGY

Montefiore Network

MonteCare EPO – $0
MonteCare PPO – $0 

Empire BlueCard PPO Network Preferred Facility

MonteCare EPO – 20%1 coinsurance after deductible
MonteCare PPO – $250 copay

Empire BlueCard PPO Network Non-preferred Facility

MonteCare EPO – 40%1 coinsurance after deductible
MonteCare PPO – $500 copay

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible

PHYSICIANS SERVICES (OFFICE VISITS INCLUDING MENTAL HEALTH/SUBSTANCE ABUSE CARE)

Montefiore Network

MonteCare EPO
Primary Care Physician – $15 copay/visit
Specialist – $15 copay/visit
Chiropractic Care (10 visits) – $50 copay/visit
Surgery - $0

MonteCare PPO
Primary Care Physician – $15 copay/visit
Specialist – $15 copay/visit
Chiropractic Care (10 visits) – $35 copay/visit
Surgery - $0

Empire BlueCard PPO Network

MonteCare EPO
Primary Care Physician – 20%1 coinsurance after deductible
Specialist – 20%1 coinsurance after deductible
Chiropractic Care (10 visits) – 20%1 coinsurance after deductible
Surgery - 20%1 coinsurance after deductible

MonteCare PPO
Primary Care Physician – 20%1 coinsurance after deductible
Specialist – 20%1 coinsurance after deductible
Chiropractic Care (10 visits) – 20%1 coinsurance after deductible
Surgery – 20%1 coinsurance after deductible

Out-of-network

MonteCare EPO
Primary Care Physician – Not covered
Specialist – Not covered
Chiropractic Care (10 visits) – Not covered
Surgery - Not covered

MonteCare PPO
Primary Care Physician – 40%2 coinsurance after deductible
Specialist – 40%2 coinsurance after deductible
Chiropractic Care (10 visits) – 40%2 coinsurance after deductible
Surgery – 40%2 coinsurance after deductible

OUTPATIENT SURGERY

Montefiore Network

MonteCare EPO – $0
MonteCare PPO – $0 

Empire BlueCard PPO Network Preferred Facility

MonteCare EPO – 20%1 coinsurance after deductible
MonteCare PPO – $500 copay

 

Empire BlueCard PPO Network Non-preferred Facility
MonteCare EPO – 40%1 coinsurance after deductible
MonteCare PPO – $1,000 copay

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible

HOME HEALTH CARE – 200 VISITS

Montefiore Network

MonteCare EPO – $0
MonteCare PPO – $0 

Empire BlueCard PPO Network

MonteCare EPO – $0
MonteCare PPO – $0 

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – $02 after deductible

MATERNITY

Montefiore Network

MonteCare EPO – $0
MonteCare PPO – $0 

Empire BlueCard PPO Network

MonteCare EPO – 20%1 coinsurance after deductible
MonteCare PPO – 20%1 coinsurance after deductible

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible

ALLERGY TEST AND TREATMENT

Montefiore Network

MonteCare EPO – $15 copay/visit, $0 for treatment
MonteCare PPO – $15 copay/visit, $0 for treatment

Empire BlueCard PPO Network

MonteCare EPO – 20%1 coinsurance after deductible
MonteCare PPO – 20%1 coinsurance after deductible

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible

PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY

Montefiore Network

MonteCare EPO – $0
MonteCare PPO – $0 

Empire BlueCard PPO Network

MonteCare EPO – 20%1 coinsurance after deductible
MonteCare PPO – 20%1 coinsurance after deductible

Out-of-network

MonteCare EPO – Not covered
MonteCare PPO – 40%2 coinsurance after deductible

DURABLE MEDICAL EQUIPMENT

Montefiore Network

MonteCare EPO
Professional provider:  20% coinsurance 
Facility:  $0

MonteCare PPO
Professional provider:  20% coinsurance 
Facility:  $0

Empire BlueCard PPO Network

MonteCare EPO
Professional provider:  20%1 coinsurance 
Facility:  20%1 coinsurance after deductible

MonteCare PPO
Professional provider:  20%1 coinsurance 
Facility:  20%1 coinsurance after deductible

Out-of-network

MonteCare EPO – Not covered

MonteCare PPO
Professional provider:  20%1 coinsurance 
Facility:  20%1 coinsurance after deductible

 

1 If services are billed by a facility, then percentages are applied to covered charges which are based on the rate paid to like-kind Empire in-network facilities if the facility is within the Empire area (i.e., the New York metropolitan area including NJ and CT) or the facilities actual charge if it is outside of the Empire area.

2 Reasonable and Customary charges are based on 150% of the National Medicare Physician Fee Schedule. The Plan benefit is then determined by applying the cost-sharing percentage (70%/80%) to this amount; you are responsible for paying the balance of the bill to the provider.

3 Pre-certification will ensure that services are medically necessary and provided in an appropriate treatment setting.