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  • Access to Care and Delivery System > Medical Care Delivery System

    Medical care for EmblemHealth plan members is provided by a network of thousands of contracted practitioners (including multi-specialty practices) that provide care both in medical centers and in their own offices within the community.

    We have contracted with an extensive and comprehensive array of facilities and ancillary clinicians to ensure a full continuum of care including an extensive network of prestigious teaching and community hospitals, skilled nursing facilities and freestanding ambulatory care centers.

    EmblemHealth will maintain a network of practitioners adequate to meet the comprehensive and diverse health needs of its enrollees. Practitioner selection is based on meeting our minimum criteria for credentialing, geographic standards for accessibility, compliance with the Americans with Disability Act and cultural and linguistic competency.

    In the event that a participating practitioner is not available with the skills required to meet a member's needs or is not available within a reasonable distance from the member’s place of residence, EmblemHealth, when appropriate, will arrange and authorize the use of a nonparticipating practitioner at no additional out-of-pocket expense to the member.

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    Glossary terms found on this page:

    All types of health services that are provided on an outpatient basis.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

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

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

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