RN Health Plan
Individual/Family Deductible
RN Montefiore Provider Network
None
Empire Indemnity Network
$50/$150
Out-of-network
$50/$150
Individual/Family Out-of-pocket Maximum (Deductible + Copayment+ Coinsurance)
RN Montefiore Provider Network
$5,600/$11,200
Empire Indemnity Network
$5,600/$11,200
Out-of-network
None
Your Cost:
Inpatient Care
- Hospitalization • illness or injury
- Mental Health/Substance Abuse Care
- Physical/Occupational Therapy or Rehab
RN Montefiore Provider Network
$0
Empire Indemnity Network
$0
Out-of-network
$0
Hospice • 210 days
RN Montefiore Provider Network
$0
Empire Indemnity Network
$0
Out-of-network
$0
Skilled Nursing Facility
RN Montefiore Provider Network
$0
Empire Indemnity Network
$0
Out-of-network
$0
Emergency Room in a bona fide emergency
RN Montefiore Provider Network
$0
Empire Indemnity Network
$0
Out-of-network
$0
Emergency Room other than a bona fide emergency
RN Montefiore Provider Network
$0
Empire Indemnity Network
$0
Out-of-network
$0
Urgent Care Facility
RN Montefiore Provider Network
$0
Empire Indemnity Network
20%1 coinsurance after deductible
Out-of-network
20%2 coinsurance after deductible
Preventive Care
- Routine Physical Exam with PCP including OB/GYN
- Routine Well Child Exams/Immunizations
- Routine Mammography
RN Montefiore Provider Network
$0
Empire Indemnity Network
$0
Out-of-network
You may be balance billed for amounts in excess of the in-network reimbursement
Outpatient Diagnostic and Laboratory Tests
- X-rays • bone density • blood • urine
- MRI • MRA • CAT Scan • PET • Nuclear Cardiology
RN Montefiore Provider Network
$0
Empire Indemnity Network
20%1 coinsurance
Out-of-network
20%2 coinsurance
Physicians Services (office visits including Mental Health/Substance Abuse Care)
RN Montefiore Provider Network
Primary Care Physician • $0
Specialist • $0
Chiropractic Care (10 visits) •$0
Surgery • $0
Empire Indemnity Network
Primary Care Physician • 20%1 coinsurance
Specialist • 20%1 coinsurance
Chiropractic Care (10 visits) • 20%1 coinsurance after deductible
Surgery • $0 up to $2000; then 20%1 coinsurance after deductible
Out-of-network
Primary Care Physician • 20%2 coinsurance
Specialist • 20%2 coinsurance
Chiropractic Care (10 visits) • 20%2 coinsurance after deductible
Surgery • $0 up to $2000; then 20%2 coinsurance after deductible
Outpatient Surgery
RN Montefiore Provider Network
$0
Empire Indemnity Network
$0
Out-of-network
$0
Home Health Care • 100 visits
RN Montefiore Provider Network
$0
Empire Indemnity Network
$0
Out-of-network
$0
Maternity
RN Montefiore Provider Network
$0
Empire Indemnity Network
$0 up to $2,000; then 20%1 coinsurance after deductible
Out-of-network
$0 up to $2,000; then 20%2 coinsurance after deductible
Allergy Test and Treatment
RN Montefiore Provider Network
$0
Empire Indemnity Network
20%1 coinsurance
Out-of-network
20%2 coinsurance
Physical • Occupational and Speech Therapy
RN Montefiore Provider Network
$0
Empire Indemnity Network
20%1 coinsurance after deductible; 20%1 coinsurance for physical therapy
Out-of-network
20%2 coinsurance after deductible; 20%2 coinsurance for physical therapy
Durable Medical Equipment
RN Montefiore Provider Network
Not applicable
Empire Indemnity Network
20%1 coinsurance after deductible
Out-of-network
20%2 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 facility's actual charge if it is outside of the Empire area.
2 Reasonable and Customary charges are based on 330% of the National Medicare Physician Fee Schedule. Empire establishes its payment schedule for out-of-network claims based on the 70th percentile of these charges. The Plan benefit is then determined by applying the cost-sharing percentage (80%) to this amount; you are responsible for paying the balance of the bill to the provider.