Retired Member Catastrophic Benefit
Outline of Benefits
This benefit was established to assist our members and eligible dependents to defray some of the non-covered medical and surgical expenses incurred for services rendered by non-participating or out-of-net-work providers and to provide coverage for catastrophic illness.
- Members must incur out-of-pocket expenses of more than $4000.00 per year. (Out-of-pocket expenses are those medical and hospital charges that are considered reasonable and customary by GHI and that are not reimbursed by either the City Health Plan or private insurers).
- Members must produce a statement of services, explanation of benefits form 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 dollars.
$1000 Reimbursement Benefit
The SOC provides a self-funded $1,000 direct reimbursement payable to the member after the member has submitted, qualified under the GHI Catastrophic Rider outlined above and the member still has a minimum of at least $4,000.00 of out-of-pocket qualified. The exclusions and restrictions are the same as the requirement for the catastrophic coverage benefit.
For example you may have paid $10,000 dollars out-of-pocket expenses, but GHI's payment schedule only deems the reasonable and customary payment for the services to be $6,000 dollars. The Member pays the remaining $4,000 dollars of the balance and may now be eligible to receive $1,000 dollars from the SOC Catastrophic Benefit.
Limitations
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.