FAQs
Member Flyers
These flyers are provided for educational purposes only, and the information contained therein may not be applicable to all EMI Health plans. For specifics on your plan, see your plan documents or contact customer service at 801-262-7475 or toll free at 800-662-5851.
Common Exclusions (Medical Plans)
Common Exclusions (Dental Plans)
Common Exclusions (Pharmacy Plans)
Health Coverage away from home
Insurance 101
How can I determine what services are subject to the deductible?
Look for the symbol identified on your Summary of Benefits chart.
The deductible is the amount you must pay for eligible expenses out of your own money before any benefits will be paid by your plan.
Most plans include separate deductibles for Participating Provider Option benefits and Nonparticipating Provider Option benefits.
Are out-of-pocket maximum and out-of-pocket expenses the same thing?
When you have satisfied any applicable deductible and paid eligible expenses up to the out-of-pocket maximum, the plan will pay remaining eligible expenses at 100 percent of the Table of Allowances. However, this does not mean that you will not have any additional out-of-pocket medical expenses.
If you receive any service or treatment specified as a limited benefit, the plan will pay for services only up to the specified amounts.
Any expense incurred for amounts in excess of the specified percentage, day, or dollar limits, and expenses you pay for not following preauthorization procedures, will not be reimbursed by the plan and will not accumulate toward the annual out-of-pocket maximum.
The Participating Provider and Non-participating Provider Options each have a separate out-of-pocket maximum.
What is the Table of Allowance?
The Table of Allowances is the schedule for payment of eligible charges.
All benefits are subject to the Table of Allowances. For example, if a provider charges $125 for a procedure for which the Table of Allowances permits a $100 payment, EMI Health will pay the specified percentage of $100, not $125.
Participating providers have agreed to write off any amounts in excess of the Table of Allowances. Nonparticipating providers are under no such obligation.
If EMI Health pays for services from a nonparticipating provider according to the Participating Provider Option of your plan (because of an emergency situation), you may still be responsible for any amount exceeding the Table of Allowances.
If I have two insurance plans, could I still have out-of-pocket expenses?
You may still need to pay some expenses out-of-pocket. EMI Health will never pay more than we would have paid if we were the primary carrier.
The plan deductibles, copayments, and Table of Allowances still apply. For example, if the claim is for $100, and the primary carrier paid $80 (leaving a balance of $20), and your EMI Health plan has a $100 deductible, the $20 balance would be applied toward your deductible, but EMI Health would not pay anything toward that claim. However, if your EMI Health plan would have paid $80 (with no deductible) as the primary carrier, EMI Health would pay the $20 balance.
Coordination rules for high deductible health plans (HDHP) may vary, due to federal regulations.
Enrollment and ID Cards
Can I add, change, or terminate coverage during the plan year (outside of my Open Enrollment period)?
Generally, changes to coverage can only be done during the Open Enrollment period. However, some life events will qualify you for a Special Enrollment period during the plan year. Special Enrollment qualifying events include marriage, divorce, birth, adoption, death, or loss of other insurance coverage. If you experience a qualifying event and wish to add, change, or terminate coverage, contact your plan sponsor as soon as possible, but no later than 31 days after the qualifying event.
When will I receive my EMI Health ID card?
You should receive your card within two weeks after EMI Health receives your enrollment application.
You will receive two ID cards attached to the bottom of a welcome letter. EMI Health will never send you junk mail, so please carefully review anything you receive from EMI Health. You can also access your ID card through the EMI Health app.
If you require medical services or prescriptions after your effective date, but before you receive your ID card, check the mobile app. If it is not yet available there, contact EMI Health enrollment department at 800-662-5851.
What if I can’t find my ID card or don’t have it with me?
You can access your ID card anytime, anywhere by logging into your EMI Health account on the mobile application on your phone. Download the EMI Health app through the Apple Store or the Google Play store for free, then login, and under your account information you will be able to pull up your insurance ID card.
Coverage
What immunizations are covered by my plan?
Most plans cover immunizations that are recommended by the Advisory Committee on Immunizations Practices of the Center for Disease Controls and Prevention (CDC) at 100 percent if received from a participating provider.
What diabetic supplies are covered by my plan?
Diabetic equipment and supplies fall under various provisions of your plan, including the major medical benefit and prescription drug (pharmacy) benefit. Here are some common coverages. Contact customer service for the specifics of your plan.
Will my plan pay for a routine or screening colonoscopy?
One screening colonoscopy a year is covered at 100 percent when you use a participating provider. If you have a medical condition or are experiencing symptoms, medically-necessary colonoscopies are covered according to the appropriate benefits of your plan (usually outpatient medical/surgical).
How can I determine what my medication will cost before I fill my prescription?
Log into your My EMI Health account from your computer or using the EMI Health mobile app. Click on “Express Scripts.” Choose the “Prescriptions” menu and select “Price a Medication.” Provide the information requested, and you will receive a cost estimate for retail pharmacy and home delivery (if applicable). You can also compare prices between up to three retail pharmacies and between brand and generic prescriptions.
Some plans use PBMs other than Express Scripts.Claims
I have coverage under more than one plan; how do I file claims with the secondary carrier?
Most providers will file the claims with both insurance companies if you give them all of the information. When EMI Health is the secondary carrier, we require an explanation of benefits from the primary carrier, as well as an itemized statement from the provider, including the medical diagnosis and procedure codes.
How do I appeal a claim that was denied?
If you are logged in to your My EMI Health account, you are able to select the claim you would like appealed on the Claims page of your dashboard. Simply fill out the short form that pops up when you click “Appeal,” making sure to clearly state your reasons for appealing, and it will get submitted to the correct department.
How do I submit a claim?
Usually, your provider will submit claims to EMI Health for you, but if you need to submit a claim you can do so here.
Paper claims can be sent to the following address:
EMI Health
PO Box 21482
Eagan, MN 55121
Payer ID (for EDI claims): SX110
Network and Providers
What is preauthorization? And how do I get preauthorization for services?
Usually, your provider will handle everything related to obtaining preauthorization. But if you have questions on this process, you can learn more about it here.
And if you are looking for information on prescription preauthorization, go here.
I have a provider I want to nominate to become part of EMI Health’s network. How do I do that?
Fill out the form at this link.
What if I go to the emergency room and the doctor assigned to me is not a participating provider?
In the case of a legitimate emergency, the claim will be paid as participating to the Maximum Allowable Charge. It is possible that a non-participating doctor or hospital may balance bill you for amounts exceeding the Maximum Allowable Charge. Depending on the staffing in the Emergency Room and the seriousness of your condition, you may not have a choice of physicians. However, if you are in a participating hospital, and you are able, consider requesting a physician that participates with your health plan.
What if my provider wants to perform a procedure at a non-participating facility?
Benefits are generally greater for services provided by participating facilities. While your plan may have a lesser benefit for non-participating facilities, EMI Health will not reimburse a non-accredited facility. You have the right to request that a participating provider perform the services in a participating facility. Of course, the decision of which providers to use is yours. If you decide to use a non-participating facility, be sure to confirm that it is accredited when considering your benefits.
Online Services
How can I access EMI Health’s secure online services?
Setting up a My EMI Health account is easy. Simply hover over the Sign In button on the top right-hand corner, click on Register Account, and select Member as the type of account. Enter the information requested to identify yourself and click Continue. Make sure to have your Member ID card handy; you will need the ID number found on your card to register your account.
Once your account is registered, you will have secure online access to view benefit descriptions, review enrollment, check claims, order ID cards, manage your prescriptions, access the Smart Cost Calculator, and more—either on our website or through the EMI Health Mobile App.
Can I speak directly to a doctor over the phone?
EMI TeleMed through Recuro Health is included with all medical plans, and gives you access to a U.S. board-certified doctor over the phone from the convenience of your own home. Video consultations are available from 7 a.m. to 7 p.m.
Some 70 percent of all doctor visits can be handled over the phone, and 40 percent of urgent care visits can be managed using EMI TeleMed.
Individual Plans
How do I sign up for an individual plan?
EMI Health offers individual dental, vision, and telemedicine plans directly through our website and through the Federal Marketplace at www.healthcare.gov.
If you are interested in getting an individual plan, you can compare and shop our plans here.
Newborn and Adopted Children Coverage
Who can be included in a group's newborn coverage?
A group may include a new child upon their birth, adoption, or placement for adoption.
Does "dependent" include an unborn fetus in the coverage?
No, the term "dependent" does not include an unborn fetus.
What protections does the Health Insurance Portability and Accountability Act (HIPAA) provide for newborn and adopted children?
HIPAA allows a member who is not enrolled in an employer's health plan to enroll themselves, their spouse, and their new child upon the birth, adoption, or placement for adoption of a new child.
Do newborns get automatically added to the policy when they are born?
No, newborns are not automatically added to the policy upon their birth.
Is there a specific timeframe for this special enrollment?
Yes, this special enrollment is available regardless of when the next open enrollment might otherwise be. To be eligible, a member must request special enrollment in the plan within 30 days of birth, adoption, loss of coverage, or placement for adoption.
What is the process for enrolling a newborn on the policy??
To enroll a newborn, parents should contact their insurance provider within the 30-day window and follow the provided enrollment procedures.
What happens if parents do not enroll the newborn within the 30-day timeframe?
If the parent misses the 30-day deadline, coverage will not be available for the newborn until the next open enrollment period.
Can claims for services for a newborn or adopted child be denied?
Yes, a claim for services for a newly born child or an adopted child may be denied until the child is enrolled. However, denied claims are eligible for payment and may be resubmitted or reprocessed once a child is enrolled within the allowed time frame.
When must a policyholder enroll a newly born child or an adopted child if a specific premium is required for coverage?
If a specific premium is required to provide coverage for the child, the policyholder must enroll a newly born child within 30 days after the date of birth or an adopted child within 30 days after the day of placement.
What if a specific premium is not required for coverage of the child?
If a specific premium is not required to provide coverage for the child, the policyholder must still enroll a newly born child or an adopted child no later than 30 days from the date of birth.
When does coverage for newborn special enrollment become effective?
Coverage is effective retroactive to the date of birth once enrollment is received within the 30 days from the date of birth.
Contact
Don’t see your question here?
Our Customer Service department is filled with people who are happy to help you. Simply call 1-800-662-5851 (1-801-262-7475 if you are local to Utah) and be sure to have your member number or social security number ready. Hours are 6:00 am to 6:00 pm MST Monday-Friday.
You can also reach us by text or email. Be sure to include the policyholder’s name and member ID or social security number, the patient’s name and date of birth, and your mailing address.
Text: 1-801-436-8243
Email: cs@emihealth.com
Emails and texts are monitored during business hours only.
Employer Flyers
These flyers are provided for educational purposes only, and the information contained therein may not be applicable to all EMI Health plans. For specifics on your plan, see your plan documents or contact customer service at 801-262-7475 or toll free at 800-662-5851.
Health Coverage away from home
Maintenance Medication Options
Transparency in Coverate and Consolidated Appropriations Act
FAQs
What products does EMI Health offer?
EMI Health is a full-service insurance carrier. For employers, we offer medical, dental, vision, and telemedicine products. Our plans come in a variety of shapes and sizes to fit any employer’s needs. For individuals, we offer dental, vision, and telemedicine plans, along with plans specific for seniors.
We have a variety of funding options, including self-funding/ASO. Our innovative level-funded mechanism gives employers the look and feel of a fully-insured plan, with advantages similar to a self-funded plan. Reach out to your Account Executive to learn more about how this works.
What does EMI Health offer for cost controls?
EMI Health is always looking for ways to spread the risk of high claims and bend the trend of rising healthcare expenses. Our pooling concept protects small businesses from the fluctuations of renewal rates that come with a smaller population. Our analytics tool is helping our customers make more data-driven decisions on their benefits. Our value-added services (i.e. $0 copay TeleMed) are there to help save money, get members access to healthcare services more conveniently, and put tools in members’ hands to take charge of their health and well-being.
What added services are included with your products?
For employer sponsored medical plans, we offer the following services at no extra charge to the employer:
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$0 Copay TeleMed: Members get free, unlimited virtual consultations with board-certified physicians no matter where they are in the country with 24/7 access, 365 days a year.
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Robust wellness program: Through partnerships with trusted brands Magellan Rx and WebMD, we incorporate a wellness program in our medical plans with free biometric screenings, free flu shot clinics, rewards programs, health coaching, and more.
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Rx Savings Programs: Members can take advantage of mail order prescriptions, 90-day refills, and other ways to save on their prescription drugs. We also offer a program that reduces the cost of certain specialty drugs to $0 for the member and $0 to the plan.
How do I contact EMI Health?
View this contact page to know who to reach out to for all your questions. You can also always reach out to your EMI Health Account Executive and they can direct you to the right place.