How GHI Insurance Works and What It Covers

What GHI Insurance Is

GHI Insurance is a health insurance company that operates primarily in the New York area, though it has served other regions at different points in its history. GHI stands for Group Health Incorporated, and it functions as a health maintenance organization (HMO) and also offers preferred provider organization (PPO) plans. The company is now part of EmblemHealth, a larger health insurance system that manages multiple insurance brands across the Northeast.

GHI sells insurance directly to individuals and families, and also through employers as a group health plan. If you have a GHI policy, your coverage works through a network of doctors, hospitals, and specialists — you pay a monthly premium, and GHI pays a portion of your medical costs when you use in-network providers. Out-of-network care typically costs you more or may not be covered at all, depending on your specific plan.

Key Takeaways

GHI is an HMO and PPO health insurance company now owned by EmblemHealth, primarily serving New York and surrounding areas.
You choose an in-network primary care doctor who coordinates your care and provides referrals to specialists under most GHI plans.
Your costs include a monthly premium, copays for office visits, and coinsurance or deductibles depending on the plan type you select.
GHI coverage is available through your employer, through the New York State of Health marketplace, or directly from the company if you may have access to.
You can change plans during open enrollment periods or if you experience a may have access to life event like losing other coverage or moving.

How GHI Plans Are Structured

GHI offers different plan types, and the structure of your coverage depends on which one you have. Most GHI HMO plans require you to select a primary care physician (PCP) from their network. This doctor acts as a gatekeeper — you see them first for most health concerns, and they provide referrals if you need to see a specialist. If you go to a specialist without a referral, or see an out-of-network provider, you typically pay the full cost yourself.

GHI PPO plans give you more flexibility. You can see any doctor or specialist without a referral, and you can use out-of-network providers, though you will pay more. With a PPO, you still have in-network and out-of-network costs, but the plan covers a portion of out-of-network care rather than none at all.

All GHI plans include a monthly premium you pay to keep coverage active. On top of that, you pay copays when you visit a doctor or fill a prescription — these are fixed amounts like $15 or $30 per visit. Some plans also have a deductible, which is an amount you must pay out of your own pocket before the insurance starts to pay. After you meet your deductible, you typically pay coinsurance, which is a percentage of the cost (for example, you pay 20 percent and GHI pays 80 percent).

Where to Get GHI Coverage

The most common way people get GHI insurance is through an employer. If your employer offers GHI as one of the health plan choices, you can enroll during your company's open enrollment period, usually once a year. Your employer typically pays part of the premium, and you pay the rest through payroll deduction.

If you do not have employer coverage, you can purchase GHI directly through the New York State of Health marketplace, which is the state's official health insurance exchange. You can enroll during the annual open enrollment period (usually November through January) or if you have a may have access to life event, such as losing your job, moving to New York, getting married, or having a baby. The marketplace will show you available GHI plans and their costs, and you can compare them side by side.

Some people also get GHI through Medicaid or Medicare Advantage plans if they meet income or age requirements. These are government programs that contract with GHI to provide coverage. If you think you might be may be able to access for Medicaid or Medicare, you can check through the New York State of Health website or by calling 1-855-355-5777.

What GHI Covers and What It Does Not

GHI plans cover a broad range of medical services, including doctor visits, hospital stays, emergency care, prescription drugs, preventive care (like annual checkups and screenings), and mental health services. Preventive care is typically covered at no cost to you — you do not pay a copay for things like a yearly physical or certain vaccinations.

What GHI does not cover varies by plan, but common exclusions include cosmetic procedures, fertility treatments (though some plans offer limited coverage), experimental treatments not yet approved by the FDA, and care from out-of-network providers if you have an HMO plan. Dental and vision care are usually not included in standard GHI health plans, though you can purchase separate dental and vision plans through GHI or other companies.

Your specific coverage depends on which GHI plan you have. Before you enroll or use a service, check your plan documents or call the member services number on your insurance card to confirm whether something is covered. This is especially important for expensive procedures, specialist visits, or medications.

How to Use Your GHI Insurance

Once you have a GHI plan, you will receive an insurance card in the mail. This card has your member ID number, your group number (if you have employer coverage), and the phone number for member services. Keep this card with you whenever you go to a doctor or hospital.

To use your coverage, find a doctor in the GHI network. You can search the network on the GHI website or call member services. If you have an HMO plan, choose your primary care doctor first — this is usually required before you can see other providers. Once you have a PCP, you can schedule appointments and present your GHI card at the visit. The doctor's office will handle the billing with GHI, and you will pay your copay at the time of service.

If you need a specialist, ask your primary care doctor for a referral. With an HMO plan, the referral is required; with a PPO, it is not, but it helps with billing. For prescriptions, use a pharmacy in the GHI network and present your card. GHI covers most common medications, but some may require prior authorization from GHI before the pharmacy will fill them — your doctor or pharmacist can request this.

Costs and How to Manage Them

Your total cost for GHI coverage includes the monthly premium, copays, deductibles, and coinsurance. The premium is the largest ongoing cost and varies based on your age, where you live, and which plan you choose. If you get coverage through an employer, your employer pays part of the premium and you pay the rest. If you buy coverage through the marketplace, you may be may be able to access for a tax credit or subsidy that lowers your premium if your income is below a certain level.

To keep costs down, use in-network providers whenever possible. Out-of-network care costs significantly more. Use preventive care services, which are covered at no cost — getting a yearly checkup and screenings can catch problems early and save money in the long run. Ask your doctor about generic medications instead of brand-name drugs, as they are usually cheaper and covered at a lower copay.

If you receive a bill you do not understand, call the member services number on your card. GHI member services can explain what you owe, why you owe it, and whether there is a way to reduce the cost. If you think you were billed incorrectly, you can file an appeal with GHI.

Making Changes to Your GHI Coverage

You can change your GHI plan or switch to a different insurance company during open enrollment, which typically runs from November 15 through January 31 each year for coverage starting January 1. If you have employer coverage, your company's open enrollment period may be different — check with your HR department for the exact dates.

Outside of open enrollment, you can make changes if you have a may have access to life event. These include losing your current coverage, moving to a new state or county, getting married or divorced, having a baby, or experiencing a significant change in income. You usually have 60 days from the event to make a change. If you think you have a may have access to event, contact GHI or the New York State of Health marketplace to report it and see what options are available to you.

If you want to cancel your GHI coverage, you can do so during open enrollment or if you have a may have access to event. If you cancel outside of open enrollment without a may have access to event, you may not be able to get new coverage until the next open enrollment period, so make sure you have another plan lined up before you cancel.

Frequently Asked Questions

Do I need a referral to see a specialist with GHI?

It depends on your plan type. If you have a GHI HMO plan, you need a referral from your primary care doctor to see a specialist. If you have a GHI PPO plan, you do not need a referral, but using an in-network specialist will cost you less than an out-of-network one.

What happens if I see an out-of-network doctor with a GHI HMO plan?

With an HMO plan, GHI typically does not cover out-of-network care except in emergencies. You will be responsible for paying the full bill yourself. The exception is emergency care — if you go to an emergency room, GHI covers it even if the hospital is out-of-network.

How do I find a GHI in-network doctor?

You can search the GHI provider directory on the GHI website by entering your location and the type of doctor you need. You can also call the member services number on your insurance card and ask for a referral. Member services can tell you which doctors are accepting new patients.

Can I keep my current doctor if I switch to GHI?

Only if your current doctor is in the GHI network. Before you enroll in a GHI plan, check the provider directory to see if your doctor participates. If your doctor is not in the network, you will need to choose a different doctor or consider a different insurance plan.

What do I do if GHI denies coverage for something I think should be covered?

You can file an appeal. Contact GHI member services and ask for the appeals process. You will need to provide information about the service or medication that was denied, and GHI will review your case. If you disagree with the appeal decision, you can request an external review through the New York State Department of Financial Services.

This guide is for general information only and is not medical, financial, legal, or other professional advice. For decisions specific to your situation, consult a qualified professional. See our Editorial Policy.