Page 24 - 2016-2021-ASU

required to provide pre-transplant evaluation, hospital and physician

service (inpatient and outpatient), transplant procedures, follow-up care for

transplant-related services as determined by the Center and any other
services as identified as part of an all-inclusive global rate. A travel

allowance for transportation and lodging will be included as part of the
Centers of Excellence Program. The Joint Committee on Health Benefits

will work with the State and Empire Plan carriers to provide ongoing
oversight of this benefit.

(f) Anesthesiology, pathology and radiology services received at a
network hospital will be paid-in-full less any appropriate copayment even

if the provider is not participating in the Empire Plan participating provider
network under the medical component.

2. Non-Network Coverage
(a) The Hospital component (inpatient and outpatient services) of the

Empire Plan will be as follows:
• Covered inpatient services received at a non-network hospital will

be reimbursed at 90% of charges. Covered expenses for hospital

services will be included in the combined coinsurance maximum set
forth in section 9.5(b) of the Agreement.

• Covered outpatient services received at a non-network hospital will
be reimbursed at 90% of charges or a $75 copayment, whichever is

greater. The non-network outpatient coinsurance will be applied
toward the annual coinsurance maximum.

• Services received at a non-network hospital will be reimbursed at
the network level of benefits under the following situations;

1. Emergency outpatient/inpatient treatment;
2. Inpatient/outpatient treatment only offered by a non-network

hospital;

3. Inpatient/outpatient treatment in geographic areas where access
to a network hospital exceeds 30 miles;
4. Care received outside of the United States; and

5. When another insurer, including Medicare is providing primary

coverage.
• Once the annual coinsurance maximum has been met, coverage for

inpatient services are paid in full and coverage for outpatient
services shall be subject to the same copayments as those in effect

23