Mail Order Pharmacy Program

A program that offers drugs ordered and delivered through the mail to plan members.

Mailing Address

The address designated by the member for all correspondence

Managed Care

Maternity care includes all services provided to a pregnant female including evaluation and management (ante and postpartum care), diagnostic testing, delivery (c - section or vaginal), and various miscellaneous services.


A jointly funded federal and state program that provides hospital and medical coverage to the low income population and certain aged and disabled individuals.

Medical Care

Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.

Medical Director

A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and who is an employee of, or party to a contract with, a utilization management organization, and who has responsibility for clinical oversight of the utilization management organization's utilization management,   credentialing, quality management, and other clinical functions.

Medical Loss Ratio

The percentage of premium revenue a health plan spends on health care services, compared to the amount it spends on administrative services or keeps as profit.

Medically Necessary

Medically necessary care is health care that is rendered by a Hospital or a licensed or certified Provider and is determined by EmblemHealth to meet all of the criteria listed below:

  • It is provided for the diagnosis, or direct care or treatment of the condition, illness, disease, injury or ailment
  • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment
  • It is in accordance with accepted standards of good medical practice in the community
  • It is furnished in a setting commensurate with the Member's medical needs and condition
  • It cannot be omitted under the standards referenced above
  • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community
  • It is not furnished primarily for the convenience of the Member, the Member's family or the Provider
  • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis and, therefore, requires that the Member receive acute care as a bed patient

The fact that a Provider has prescribed a service or supplies care does not automatically mean that the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.


A nationwide insurance program for the disabled and people aged 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

Medicare Carve Out Contract

A contract that stipulates the Medicare-eligible members of a group receive benefits at least equal to benefits received by non-Medicare group members. Members are reimbursed up to the group's contract limitations, reduced by what Medicare paid or would have paid if the member were Medicare-eligible and Medicare were the primary coverage.

Medicare Part A

This is part of Medicare providing benefits for hospitalization, extended care and nursing home care to Medicare beneficiaries with no premium payment for qualified individuals.

Medicare Part B

This is part of Medicare providing medical surgical benefits for Medicare beneficiaries for a modest premium.

Medicare Supplement Contract

Health insurance policy designed to supplement Medicare, beginning at the point Medicare coverage ceases for a particular service. Also referred to as a Medigap policy.


The term "member" refers to you, the subscriber, to whom a Certificate has been issued. The term "member" also refers to any members of your family who are eligible for coverage under your Certificate as a dependent.

Member ID Number

A unique number that identifies the person as a member with EmblemHealth.

Member Services

The department responsible for helping members with problems, and questions.

Mental Health/Behavioral Health

Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.