EmblemHealth shall not prohibit or restrict any practitioner from disclosing to any member, patient or designated representative any information that the practitioner deems appropriate regarding a condition or course of treatment with a member including the availability of other therapies, tests, medications, etc., regardless of benefit coverage limitations. EmblemHealth shall not prohibit or restrict a health care professional, acting within the lawful scope of practice, from advocating on behalf of an individual who is a patient and enrolled under EmblemHealth. Practitioners shall not be prohibited from discussing the risks, benefits and consequences of treatment (or absence of treatment) with the member, patient or designated representative. Patients shall have the opportunity to refuse treatment and to express preferences about future treatment decisions.
EmblemHealth Medicaid and Child Health Plus Responsibilities to Government Agencies
Any activities and reporting responsibilities delegated to a subcontractor, including a practitioner, shall be performed pursuant to standards set forth by the SDOH. In the event such policies and procedures are not complied with and the practitioner does not meet the SDOH requirements, EmblemHealth and/or SDOH may revoke the delegation in whole or in part. SDOH may also impose other sanctions if the practitioner's performance does not satisfy standards set forth in the agreement between EmblemHealth and SDOH for the Medicaid program. As required, the practitioner shall take any necessary corrective action(s) with respect to any delegated activities and responsibilities.
Subcontractors, including practitioners, shall perform all work and render all services in accordance with the terms of the agreement between EmblemHealth and SDOH for Medicaid. Practitioners agree to comply with and be bound by the confidentiality provisions set forth in the above referenced agreement. Any obligations and duties imposed on sub-contactors, including participating practitioners, do not impair any rights accorded to LDSSs, SDOH, the New York City Department of Health and Mental Hygiene (NYCDOHMH) or DHHS.
Glossary terms found on this page:
An activity of EmblemHealth or its subcontractor that results in:
- Denial or limited authorization of a service authorization request, including the type or level of service
- Reduction, suspension or termination of a previously authorized service
- Denial, in whole or in part, of payment for a service
- Failure to provide services in a timely manner
- Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals
Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
A business entity that performs delegated functions on behalf of the insurer or managed care organization.
An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.
The process by which the organization permits another entity to perform functions and assume responsibilities covered under these standards on behalf of the organization, while the organization retains final authority to provide oversight to the delegate.
The US government's principal agency for protecting the health of all Americans and providing essential human services. Also called the Department of Health and Human Services.
A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.
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.
A city or county social services district as constituted by Section 61 of the New York State Social Services Law (SSL). Also called a Local Department of Social Services.
Specific circumstances or services listed in the contract for which benefits will be limited.
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.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
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.
A public agency that works to control the spread of infectious diseases, monitor the health of New Yorkers and create an environment that protects and promotes health by using regulations, education and advocacy and providing direct health services. Also known as NYCDOHMH.
A public agency that works to control the spread of infectious diseases, monitor the health of New Yorkers and create an environment that protects and promotes health by using regulations, education and advocacy and providing direct health services. Also known as the New York City Department of Health and Mental Hygiene.
A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.
A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.
New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.