RN Health Plan

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 facilities 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.