The GHI Catastrophic Rider (GHI members only) was established to assist our members and their eligible dependents (includes spouses, registered domestic partners, and eligible dependent children; full-time students ages 19–23) to defray some of the non-covered medical and surgical expenses incurred for services rendered by non-participating or out-of-network providers and to provide coverage for catastrophic illness.
- Members must incur out-of-pocket expenses of more than $4,000 per year. (Out-ofpocket expenses are those medical and hospital charges that are considered reasonable and customary by GHI and are not reimbursed by either the City Health Plan or private insurers).
- Members must produce a statement of services, Explanation of Benefits Form (EOB) and cancelled checks for expenses submitted.
- Reimbursement is based on a contract year (January – December) 100% of GHI reasonable and customary charges based on the current profile.
- The maximum lifetime benefit is $2 million (limitations apply).
The first $25,000 is covered for private duty nursing care, and thereafter 50% of the remainder, with a lifetime cap of $50,000 per person. The cap for in-hospital mental health charges is $10,000 individual lifetime maximum.
$1,000 SOC Catastrophic Benefit
The SOC provides a self-funded $1,000 direct reimbursement payable to the member after the member has submitted the required documentation and has qualified under the GHI Catastrophic Rider outlined above. The member still has a minimum of at least $4,000 of out-of-pocket to qualify. The exclusions and restrictions of the SOC Catastrophic Reimbursement are the same as the requirements outlined above for the GHI Catastrophic Benefit.
The benefit does not cover prescription drug charges. Ineligible charges such as experimental procedures or services not approved by GHI/CBP and/or Empire Blue Cross Blue Shield are likewise not eligible for this benefit.
Example: You paid $10,000 in out-of-pocket expenses, but GHI’s reasonable and customary payment for those services is deemed to be $6,000. The member is responsible for and pays the remaining $4,000 of the balance and is now eligible to receive $1,000 from the SOC’s Catastrophic Reimbursement Benefit.