Hospital Program and Medical/Surgical Program Work Together
SEHP is made up of multiple programs that work together to provide you comprehensive coverage. Certain services you receive at a hospital may be covered by the Medical/Surgical Program instead of the Hospital Program.
Call 1-877-769-7447 if you have questions about your coverage.
Emergency Care
In an emergency, go to the nearest emergency department. Network coverage applies in emergency situations, even if the hospital is not in network. This includes:
- When you receive emergency or urgent services in a non-network hospital
- When you use a non-network hospital because you do not have access to a network hospital nearby
Call the program for more details.
Benefits Management Program
Call 1-877-769-7447 for precertification
To receive the maximum benefits under the plan, you must follow the Benefits Management Program requirements.
Some services require preadmission certification. This includes:
- Before scheduled (nonemergency) hospital admission
- Within 48 hours (or as soon as reasonably possible) after an emergency or urgent hospital admission
- For admission resulting from complications due to pregnancy or for any reason other than the delivery of the baby
- It is also recommended that you call if you or the baby are hospitalized for more than 48 hours for a vaginal delivery or 96 hours for a cesarean delivery
If you do not call the Benefits Management Program, you will be responsible for the entire cost of care determined not to be medically necessary. If the hospitalization is determined to be medically necessary but was not precertified, these services will be subjected to a $200 penalty.
Other services provided by the Benefits Management Program include:
- Concurrent review of hospital inpatient treatment
- Discharge planning for medically necessary services post-hospitalization
- Inpatient medical case management for coordination of covered services for certain catastrophic and complex cases that may require extended care
- The Building Healthy Families Program for access to pre-pregnancy, maternity and postpartum care and parenting support
Network and Non-Network Coverage
SEHP uses The Empire Plan network for Hospital coverage.
If you go to a hospital or hospice that is in the network, you pay only applicable copayments for services/supplies that are covered. No deductible or coinsurance apply.
When you use a hospital that is not part of The Empire Plan network and it is not for an emergency situation, your out-of-pocket costs are higher. After you pay the deductible amount, the plan pays 80% of the allowable amount. You are responsible for the balance.
Hospital Coverage
Services covered under the Hospital Program include:
- Hospital inpatient stays, including inpatient detoxification and maternity care
- Services at a hospital outpatient department or extension clinic. This includes (but is not limited to):
- outpatient surgery
- diagnostic radiology
- diagnostic laboratory tests
- bone mineral density screening
- Certain infertility treatments that are provided in the inpatient or outpatient departments of a hospital
The amount you pay for services depends on both the service provided and whether you use a network or non-network provider.
Hospice Care
Enrollees are eligible for hospice care if the doctor and hospice medical director certify that the covered patient is terminally ill and likely has less than 12 months to live.
Coverage under the Hospital Program is up to 210 days. The cost is determined by whether you use a network or non-network hospice.