Group Health Incorporated (GHI), now part of the insurance plans offered through EmblemHealth, is one of the largest insurance companies in New York State. If you have a GHI insurance plan, or are considering joining one, you may have questions about how it will affect your physical therapy costs. To help you understand GHI, and its impact on your PT treatment, here are answers to 10 common questions.
What is GHI Insurance?˄
GHI Insurance was founded in 1937 as the Group Health Association of New York. Over the past 80+ years, GHI has grown into one of the biggest insurance plans in NY state.
In 2006, GHI merged with the Health Insurance Plan (HIP) of Greater New York, becoming EmblemHealth. Today, members can obtain a wide variety of GHI insurance plans through EmblemHealth, including the following:
- PPO Plans
- HMO Plans
- CBP (Comprehensive Benefits) Plans
- Medicare Plans
- Dental and Vision Coverage
This array of choices makes it possible for many individuals and families to find the insurance coverage they need with a GHI plan.
Is GHI the same as EmblemHealth?˄
GHI and EmblemHealth are not the same. EmblemHealth describes itself as a “health and wellness company” that provides insurance plans as well as other health-related services, including primary care, specialty care, and more.
It consists of a family of companies that work together to provide comprehensive healthcare for individuals and families. GHI is one of these EmblemHealth companies, and focuses on providing health insurance solutions for EmblemHealth members.
Other companies within EmblemHealth include HIP, AdvantageCare Physicians, and neighborhood health and wellness programs.
What other names does GHI go by?˄
By June, 2021, EmblemHealth had replaced GHI and HIP’s names within the organization with new, EmblemHealth specific branding. GHI became EmblemHealth Plan, Inc., and HIP became EmblemHealth Insurance Company.
However, there are still some plans within EmblemHealth that are called GHI plans. For example, the GHI CBP (Comprehensive Benefits Plan) still appears on the EmblemHealth website.
Does the GHI name change affect my benefits?˄
The name of your plan should not affect your benefits. Even if you have a GHI plan that becomes an EmblemHealth Plan, Inc., plan, you should still receive the same benefits and coverage that you did before the name change. If you do have any questions about changes in your benefits or about your plan in general, you should reach out to EmblemHealth through their customer service portal.
What is the difference between an HMO and a PPO plan?˄
GHI insurance plans include both HMO and PPO plans. But what is the difference?
The biggest difference between these two types of plans is the way in which they handle out-of-network providers. An HMO plan only provides coverage when you visit an in-network provider, AND you have to visit your primary care physician (PCP) to get referrals to in-network specialists.
A PPO plan provides the most benefits when you visit an in-network provider, but you can still receive some benefits if you choose an out-of-network provider. Plus, you can see a specialist even without seeing your PCP first. As a result, a PPO tends to give you the most flexibility when it comes to choosing providers.
How do GHI HMOs and PPOs affect physical therapy?˄
When it comes to physical therapy, you may benefit the most from a PPO plan, thanks to the flexibility it gives you to find, and use the physical therapy clinic of your choice, without needing to visit your PCP first. Plus, you can select the PT office you want without worrying about having to pay entirely out of pocket if you choose an out-of-network provider.
If you seek physical therapy with an HMO plan from GHI, you will need to follow the rules of your plan to ensure maximum coverage. This means visiting your PCP to get a referral to a physical therapist (after your Direct Access visits are completed, see below), and it means making sure your physical therapist is in-network.
Is GHI a Medicare Plan?˄
Among the many types of insurance plans GHI provides are supplemental HMO Medicare plans for seniors. This means that their plans provide additional benefits not included under regular Medicare insurance. These benefits can include things such as deductibles, co-pays, and prescription costs. By adopting one of these plans, seniors can enjoy more complete insurance coverage.
Is GHI insurance only employer-based?˄
GHI insurance plans are available through EmblemHealth both in the form of employer plans for employees of New York State and in the form private plans you can purchase directly through EmblemHealth.
For example, certain individual and family plans are available for purchase through a healthcare exchange, while the GHI CBP plan is available as an NYS employee plan.
Does GHI cover physical therapy costs?˄
GHI does cover physical therapy costs. However, the exact terms and amount of coverage will depend upon your specific GHI plan.
For example, here are some of the factors that may affect your PT coverage under a GHI plan:
- Whether your plan is HMO or PPO
- Whether your physical therapist is in-network
- Your plan’s copays and deductibles
- Whether you have more visits than allowed under your plan
Because physical therapy coverage varies by plan, you will need to confirm coverage with your insurance provider. However, here at In Touch NYC, we are happy to help you determine your coverage and work with you to obtain the maximum benefits available to you under your GHI plan.
Is preventative physical therapy covered by GHI insurance?˄
Physical therapy can often prevent injury and falls while keeping you stronger and healthier. The good news is that GHI insurance may cover preventative physical therapy because it contributes so strongly to your overall health and wellbeing.
Typically, insurance companies will cover physical therapy that they deem to be “essential.” This term can refer to treatment that addresses an existing illness or injury and to treatment that prevents illness and encourages health and wellbeing.
If your GHI insurance plan determines that your preventative course of physical therapy qualifies as “essential,” you can expect your plan’s benefits to apply to your PT.
How do I determine the PT benefits of my GHI plan?˄
Because there are so many factors that can affect the specific coverage you can expect from your GHI plan, you will need to understand your plan before committing to a course of PT.
One way to determine your coverage is to contact EmblemHealth and ask about the coverage for the PT you require.
Your PT office should also be able to help you determine your coverage. Here at In Touch, we can identify your treatment needs and work with your insurance company to discover exactly what your financial obligations will be for your PT treatment.
How many physical therapy visits does a GHI insurance plan cover?˄
Many insurance plans, GHI included, put a cap on the number of PT visits you can have in a year. For most GHI plans, you will be limited to 30 visits per year (PDF). This means that you will need to pay out of pocket once you exceed 30 visits within the year.
What do I do once I meet my PT visit limit through GHI?˄
Depending upon your needs and tailored treatment plan, you may benefit from more than 30 PT visits a year. In that case, you can submit a benefit extension request (PDF) online at emblemhealth.com. This request, once approved, will entitle you to additional PT visits covered under your GHI insurance plan.
Does GHI insurance require a prescription for PT?˄
Regardless of your insurance, the state of New York allows you to begin seeing a physical therapist without a doctor’s referral or prescription. This law allows you to save time on waiting for a doctor’s appointment and money spent on that appointment. Under Direct Access, you may see a physical therapist for up to 10 visits or 30 days before needing to see your doctor. Fast, direct access to the care you need can lead to faster relief and better healing.
Does GHI have exceptions to Direct Access?˄
Members of some insurance companies may still need a prescription or a referral to see a physical therapist, or may need one after their Direct Access visits are up. Currently, most GHI plans DO NOT require a referral from a physician in order for you to pursue physical therapy. [NOTE: May want to double check this with client to make sure I understood correctly]
Do I have to use an in-network provider for my physical therapy?˄
In all GHI insurance plans, using in-network providers will lead to the greatest coverage and the lowest out of pocket costs. However, you can choose out-of-network providers and still receive some compensation from your GHI insurance plan. You just need to be aware that the reimbursement you receive may not entirely, or even mostly, cover, the cost of your out-of-network visit.
The exact reimbursement you receive, and the extent to which you can see out-of-network providers, depends upon your GHI plan. HMO plans tend to have the least flexibility, while the GHI CBP plan has the most flexibility when it comes to seeing out-of-network providers.
Does GHI have a deductible?˄
Deductibles are costs you need to pay before your insurance pays your benefits. Whether or not you have a deductible with your GHI plan depends on the plan you have.
For example, the GHI CBP plan has no deductibles for in-network providers, but does require deductibles for out-of-network providers. GHI Senior Care, on the other hand, does require you to pay deductibles when you see a doctor.
How much are my GHI deductibles?˄
When you do owe a deductible under your GHI insurance plan, the amount will vary depending upon your plan. For example, the GHI CBP plan has a $200 individual and $500 family deductible when you visit out-of-network providers. The GHI Senior Care Plan, however, has a $233 Medicare Part B deductible and a $50 Senior Care deductible. Here at In Touch NYC, we can help you determine your deductible before you begin treatment to give you clarity and peace of mind regarding your financial obligations.
Will I have a copay for physical therapy?˄
Similar to deductibles, whether or not you have a copay for your physical therapy will depend upon your GHI insurance plan, and whether or not you visit an in-network provider. For Senior Care, for example, you may owe a small copay of $15, while the CBP plan may have a copay of up to $30 for specialist visits.
Does In Touch NYC accept GHI plans?˄
The good news is that yes, In Touch NYC accepts GHI plans. We would be happy to provide you with tailored treatment plans for your physical therapy needs and help you to determine the coverage and benefits you enjoy through your GHI plan.
If you are ready to get started on the path to health, contact us today. We look forward to helping you!
This post has been updated with new information on 05/05/2022.