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Health Benefits
EPO, POS, and PPOs > HIP Prime POS



HIP Prime POS

HIP Prime® POS is a point-of-service plan offering both in and out-of-network coverage. Members can go to virtually any doctor or specialist at any location and still take advantage of HIP’s value. There is no charge if you are referred by your primary care physician (PCP) and use doctors, hospitals and services in the HIP network. Non-referred and out-of-network services are subject to deductibles and coinsurance.

In-Network Benefits – In-network, you and your family receive comprehensive hospital and medical benefits from HIP participating providers. HIP’s New York service area includes:

  • Brooklyn
  • The Bronx
  • Manhattan
  • Queens
  • Staten Island
  • Nassau County
  • Suffolk County
  • Westchester County
  • Rockland County
  • Orange County

HIP’s participating network now numbers over 22,000 participating providers in more than 33,000 service locations. Members have access to top quality health care providers through HIP’s alliances with outstanding medical groups and hospitals, including Montefiore Medical Center, Lenox Hill Hospital, St. Barnabas Hospital, St. Luke’s Roosevelt Hospital and Beth Israel Medical Center.

You and each family member choose a PCP practicing in a private office or in any of HIP’s convenient neighborhood health care centers. You may visit your PCP as often as necessary. Your PCP coordinates your care and works with specialists from virtually every area of medical practice to provide you with the health care you need.

As a HIP Prime POS member, you and your dependents will be covered for a broad range of in-network hospital and medical services that include routine examinations, medical screenings, X-rays, mammography services, inpatient hospital rehabilitation and skilled nursing facility care, outpatient rehabilitation (physical therapy, occupational therapy, speech therapy) dialysis, home care, well-child care, urgent care, mental health services and a preventive dental program.

Emergency Care
HIP provides coverage for emergency services around-the-clock, whenever and wherever needed. If you experience a medical emergency when traveling outside of the HIP service area – anywhere in the world – you are covered for hospital and medical care. Simply obtain the care you need and notify HIP with 48 hours.

Out-of-Network Benefits
HIP Prime POS offers you the freedom to choose medical and hospital care outside the HIP network. If you choose to bypass your PCP and receive non-referred care or use a physician not affiliated with HIP, you are reimbursed after the deductible for up to 80% of HIP customary charges. Your hospital stay is covered for up to 80% of HIP customary charges as long as it is approved in advance by HIP. Routine preventive care such as periodic health exams, routine immunizations and eye exams are covered only when provided by a participating provider. Routine pediatric and well-child care is covered up to 80% of HIP customary charges. For maternity care, newborn nursing services and mother’s hospital services are covered in full in- and out-of-network.

Following an annual deductible of $250 per individual or $500 per family, members receive 80% reimbursement of HIP customary charges. You must pay any charges that exceed HIP customary charges. When the 20% coinsurance reaches $2,000 per individual or $4,000 per family in a calendar year, HIP Prime POS pays 100% of customary charges for the remainder of the calendar year up to a maximum of $5 million. You must first contact the HIP Member Advocacy Program to obtain prior approval for services such as hospital and skilled nursing facility care, ambulatory surgery, home care, MRI’s, CAT Scans and outpatient alcohol and substance abuse treatment (see your Evidence of Coverage for details and a complete listing of services requiring HIP’s prior approval). Failure to obtain prior approval will result in a 50% penalty.

Prescription Drugs
Prescription drug coverage is available under the Optional Rider.  The copays are $5 generic/$25 formulary drug which can be filled at any of HIP’s participating pharmacies and $5 generic/$25 formulary for 60-day supply at mail order. 

Cost
Please see the rate page for payroll and pension deductions.
See the rate page

For More Information
To learn more about HIP, please write to:

HIP
55 Water Street
New York, New York 10041
(800) 447-6929
hipusa.com

Updated to reflect prescription drug benefit change effective July 1, 2008

 

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