Medical, behavioral, and community-based and facility-based long-term services and supports providers are encouraged to take cultural, linguistic and disability competency trainings, required to comply with ADA guidelines, and be educated about their legal obligations under State and Federal law. Additional information about training can be found in the Training section of this chapter.
EmblemHealth policies ensure culturally, linguistically, and disability-competent and service delivery. Available resources, such as the multi-language interpreter service, give providers the capacity to communicate with participants in languages other than English, when necessary, as well as those who are deaf, hard-of-hearing, blind or visually impaired.
For information about cultural and linguistic competence, please refer to the Member Rights section of the Your Plan Members chapter.
Glossary terms found on this page:
A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.
A range of medical, social or rehabilitation services a person needs over months or years to improve or maintain function or health that are provided in a long-term care facility such as a nursing home (not including assisted-living residences). Also called facility-based LTSS.
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.
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 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.
A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.