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  • Provider Networks and Member Benefit Plans

    This chapter contains information about our provider networks and member benefit plans, including commercial, Medicaid Managed Care, Medicare and Special Needs Plans (SNPs).

    Overview

    EmblemHealth’s HIP HMO, GHI HMO and Vytra HMO plans are underwritten by HIP Health Plan of New York, HIP POS plans are underwritten by both HIP Health Plan of New York and HIP Insurance Company of New York, and HIP EPO/PPO plans are underwritten by HIP Insurance Company of New York (HIPIC). EmblemHealth’s GHI EPO/PPO plans are underwritten by Group Health Incorporated. EmblemHealth may amend the benefit programs and networks from time to time by providing advance notice to affected providers.

    Use Network Practitioners

    It’s important to remember that our HIP-underwritten HMO plans offer in-network coverage only for non-emergent services. Why is this so important? Because if you see a member who is NOT in a plan associated with your participating networks, they may incur a surprise bill. So when a member calls for an appointment, be sure to check that you participate in the member’s plan at that location. If you do not participate in their plan, please refer them back to our online directory, Find-A-Doctor to find an in network provider.

    Providers may be required to sign multiple agreements in order to participate in all the benefit plans associated with our provider networks. For more information, please see the table below:

    Provider Network & Member Benefit Plan Crosswalk
    Company Provider Network
    Member Benefit Plan
    GHI
    Commercial:
    CBP Network, National Network, Tristate Network
    EmblemHealth EPO
    EmblemHealth PPO
    Network Access Network
    Network Access Plan
    Medicare:
    Medicare Choice PPO Network
    EmblemHealth Medicare ASO
    EmblemHealth Medicare PPO
    Medicare Dual Eligible (PPO) SNP
    HIP/ 
    HIPIC
    Commercial:
    NY Metro Network
    EmblemHealth CompreHealth EPO
    Select Care Network
    All Select Care-Based Plans, including EmblemHealth Healthy NY
    Prime Network
    Access I
    Prime HMO
    Access II
    Prime POS
    GHI HMO Plans
    Connecticare
    Prime EPO
    Select EPO
    Prime PPO
    Select PPO
    Child Health Plus
     
    Premium Network aka Vytra Premium Network
    Access I
    Prime HMO
    Access II
    Prime POS
    Vytra
    Prime EPO
    Select EPO
    Prime PPO
    Select PPO
     
    Medicaid:
    Enhanced Care Prime Network
    EmblemHealth Enhanced Care (MMC)
    EmblemHealth Enhanced Care Plus (HARP)
    Essential Plan (BHP)
    Medicare:
    Medicare Essential Network
    EmblemHealth Essential (HMO)
    EmblemHealth VIP High Option (HMO)
    VIP Prime Network
    EmblemHealth VIP (HMO)
    EmblemHealth Dual Eligible (HMO SNP)
    Medicare Supplemental (cost plan)
    FIDA:
    EmblemHealth Dual Assurance Network
    EmblemHealth Dual Assurance FIDA Plan
    (non-renewing 12/31/15)
    Associated Dual Assurance Network
    ArchCare Community Advantage FIDA Plan (non-renewing 10/31/15)
    GuildNet Gold Plus FIDA Plan (ASO)

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    Glossary terms found on this page:

    A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

    Any HMO (with or without primary care provider referral requirements), Point of Service, Medicaid, Family Health Plus, Child Health Plus, Medicare Advantage or Medicaid Advantage health plans, ASO or any other line of business offered by the EmblemHealth plans.

    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.

    A managed care plan under contract with the Centers for Medicare & Medicaid Services and the State to provide the fully-integrated Medicare and Medicaid benefits under the FIDA demonstration. Also called fully-integrated duals advantage plan.

    An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

    The use of providers who participate in the health plan's provider network. Many benefit plans encourage enrollees to use network providers to reduce the enrollee's out-of-pocket expense.

    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.

    Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain 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.

    A nationwide insurance program for the disabled and people age 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.

    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.

    A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A network provider is a member of the EmblemHealth network of network providers applicable to the member's certificate. Therefore, they are sometimes referred to as participating providers. Payment is made directly to a network provider. Please consult the EmblemHealth Directory or go online to search for network providers.

    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.

    A prepaid payment or series of payments made to a health plan by purchasers and often plan members for health insurance coverage.

    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
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • 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.

    A set of providers contracted with a health plan to provide services to the enrollees.

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