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  • Provider Networks and Member Benefit Plans > Commercial Networks

    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)

    GHI Underwritten Commercial Networks

    The tables that follow summarize the benefit plans through which our commercial members receive their health care benefits and services. Certain plans allow members to self-refer to network specialists for office visits; however, Prior Approval is still required before certain procedures can be performed.

    GHI Underwritten Commercial Networks

    GHI-underwritten Commercial Network and Plan Summary for 2016
    CBP, National, Network Access & Tristate Networks

    Network Plan
    Name
    Plan
    Type
    PCP/
    Referral Req'd
    Deductibles
    (Individual/ Family)
    PCP/
    Specialist/
    ER Copay
    OON Coverage

    MOOP
    (Individual/ Family)

    Co-insurance
    CBP
    Network

    Federal Employee
    Health Benefit
    (FEHB)1

    EPO No/No
    N/A $30/$30/$150 No  $6,600/$13,200 No
    CBP
    Network

    Federal Employee
    Health Benefit
    (FEHB)1

    PPO
    No/No IN: N/A
    OON: $150
    $20/$20/$150 Yes $6,600/$13,200  OON only
    CBP Network/
    National
    Network
    EPO
    HD6300 (Bronze)
    EPO No/No $6,300/$12,600
    (Includes Rx)
    No No $6,300/$12,600 No
    CBP Network/
    National
    Network
    CBP (Non-
    standard legacy GHI plan)
    PPO No/No IN: N/A
    OON: Various
    Various Yes $6,850/$13,700 OON Only
    Network Access Network Network Access EPO/PPO
    network
    lease
    No/No Various Various EPO: No
    PPO: Yes
    $6850/
    $13,700
    EPO: No
    PPO: Yes
    CBP Network
    City of New York PPO
    (medical only)
    No/No In: N/A
    OON: $200/$500
    $15/$20/N/A Yes $6,850/$13,700 No
    CBP Network
    DC 37 Med-Team PPO No/No IN: N/A
    OON: $150
    $10/$10/$50 Yes $6,850/
    $13,700
    OON only
    CBP Network EPO HD Bronze EPO No/No $6,300/$12,600
    (includes Rx)
    No No $6,300/$12,600 No
    CBP Network EPO HD Gold EPO No/No

    $1,800/$12,600
    (includes Rx)

    No No $2,200/
    $4,400
    Yes (10% after
    deductible)
    CBP Network EPO HD Platinum EPO No/No $900/$1,800 
    (includes Rx)
    No No $900/$1,800 No
    CBP Network EPO HD Silver EPO No/No $2,000/$4,000
    (includes Rx)
    No No $6,350/
    $12,700
    Yes (20% after deductible)
    National
    Network
    EmblemHealth EPO EPO No/No N/A Various No Up to $6,850/$13,700 No
    National
    Network
    EmblemHealth PPO PPO No/No IN: N/A
    OON: Various
    Various Yes Up to $6,850/
    $13,700
    OON only
    National
    Network
    EmblemHealth
    ConsumerDirect EPO
    EPO No/No Various
    (includes Rx)
    No No Up to $6,850/
    $13,700
    Yes
    National
    Network
    EmblemHealth
    ConsumerDirect PPO
    PPO No/No Various
    (includes Rx)
    No Yes Up to $6,850/
    $13,700
    Yes
    National
    Network
    EmblemHealth
    HealthEssentials Plus
    EPO No/No N/A $40 (limited to
    3 outpatient visits only)
    No $3,000/$6,000 No
    National
    Network
    EmblemHealth
    InBalance EPO
    EPO No/No Various on facility/
    non-preventive
    surgical services
    Various No Up to $6,850/
    $13,700
    Yes
    National
    Network
    EmblemHealth
    InBalance PPO
    PPO No/No IN: Various on facility/
    non-preventive
    surgical services
    OON: Various
    Various Yes Up to $6,850/
    $13,700
    Yes

    ER = emergency room; IN = in-network; N/A = not applicable; OON = out-of-network; MOOP = maximum out-of-pocket;
    PCP = primary care provider; FPL = federal poverty level.

    1 Copays are $10 for Telemedicine physician and $5 for dietitian/nutritionist for Federal Employee Health Benefit (FEHB) plans telemedicine coverage.

    Note: Member Identification Cards for plans associated to the Comprehensive Benefits Plan (CBP) Network may display the network name as CBP, EPO, EPO1, PPO, PPO1 or PPO4.

    EmblemHealth HDHP Programs: ConsumerDirect EPO and ConsumerDirect PPO

    To meet the growing demand for consumer-directed health care, EmblemHealth has two high-deductible health plans (HDHP), ConsumerDirect EPO and ConsumerDirect PPO. These benefit plans allow employers and employees more power and choice in how to spend their health care dollars and make health care decisions.

    Members may also choose to activate a separate health savings account (HSA) to pay for qualified medical expenses with tax-free dollars. Individual HSAs are member owned, and contributions, interest and withdrawals are tax-free.

    For members, ConsumerDirect EPO and ConsumerDirect PPO benefit plans feature:

    • Lower monthly premiums based on higher annual deductibles
    • Two- and four-tier rate structures
    • Network and out-of-network coverage for the PPO plan
    • No non-emergent coverage for out-of-network services for the EPO plan
    • No out-of-pocket costs for covered preventive care in network

    HealthEssentials

    HealthEssentials is an EmblemHealth EPO plan designed for people seeking health coverage primarily for catastrophic injury or illness. Its core benefits are hospital and preventive care services and three additional office visits.

    The HealthEssentials plan features:

    • Network hospital or ambulatory surgical center benefits
      • Inpatient and outpatient hospital services provided in and billed by a network hospital or facility
      • Well baby and child care provided by a network practitioner
      • Emergency room services (provided in and billed by a hospital or facility)
      • Inpatient and outpatient mental health and chemical dependency services provided in and billed by a network hospital or facility
    • Covered preventive care services consistent with guidelines of the Patient Protection and Affordable Care Act
      • Preventive care services covered at 100 percent when provided by a network practitioner
      • Sick visits not covered
    • Pharmacy benefit
      • $15 generic drug card

      Note: With the exception of preventive care services provided by network practitioners, services billed by a practitioner are not covered under this plan except for three office visits.


      HIP Underwritten Commercial Networks

      HIP-underwritten Commercial Network and Plan Summary for 2016
      NY Metro, Premium & Prime Networks

      Network Plan
      Name
      Plan
      Type
      PCP/
      Referral Req'd
      Deductibles
      (Individual/ Family)
      PCP/
      Specialist/
      ER Copay
      OON Coverage

      MOOP
      (Individual/ Family)

      Co-insurance
      NY Metro
      Network
      EmblemHealth
      CompreHealth EPO
      EPO No/No N/A Various No Up to $6,850/
      $13,700
      No
      Premium Network
      or Prime Network
      HIP Prime® POS POS Yes/Yes IN: N/A
      OON: Various
      Various Yes Up to $6,850/$13,700 OON only
      Premium Network
      or Prime Network
      HIP Prime® PPO PPO No/No IN: N/A
      OON: Various
      Various Yes Up to $6,850/
      $13,700
      OON only
      Premium Network
      or Prime Network
      HIP Prime® EPO EPO No/No N/A Various No Up to $6,850/
      $13,7003
      No
      Premium Network
      or Prime Network
      HIPaccess® II POS Yes/No IN: N/A
      OON: Various
      Various Yes Up to $6,850/
      $13,700
      OON only
      Premium Network
      or Prime Network
      (includes upstate)
      HIP Prime® HMO HMO Yes/Yes N/A Various No Up to $6,850/
      $13,700
      No
      Premium Network
      or Prime Network
      (includes upstate)
      HIPaccess® I HMO Yes/No N/A Various No Up to $6,850/
      $13,700
      No
      Premium Network
      or Prime Network
      (with QualCare
      and MultiPlan)
      HIP Select® EPO EPO No/No Various on facility services Various No Up to $6,850/
      $13,700
      Yes
      Premium Network
      or Prime Network
      (with QualCare
      and MultiPlan)
      HIP Select® PPO PPO No/No IN: Various on facility services
      OON: Various
      Various Yes Up to $6,600/
      $13,200
      Yes
      Prime
      Network
      Child Health Plus2 HMO Yes/Yes N/A No No N/A No
      Prime
      Network
      GHI HMO HMO Yes/Yes N/A Various No Up to $6,850/
      $13,700
      No
      Prime
      Network
      GHI HMO Value Plan HMO Yes/Yes N/A Various No Up to $6,850/
      $13,700
      No
      Prime
      Network
      HIP HMO Preferred HMO  Yes/Yes N/A

      Prime Network Preferred PCP/Specialist $0

      All other PCP/Specialist $10 /$10  ER $50
      No N/A No
      Vytra
      Network
      Vytra HMO HMO Yes/Yes N/A Various No Up to $6,850/
      $13,700
      No

      ER = emergency room; IN = in-network; N/A = not applicable; OON = out-of-network; MOOP = maximum out-of-pocket;
      PCP = primary care provider; FPL = federal poverty level.

      1 The MOOP for the Brookhaven National Lab HIP Prime EPO plan is up to $5,100 individual / $10,200 family.

      2 TMembers can access certain services from county departments of health and academic dental centers (See the Direct Access (Self-Referral) Services section of the Access to Care and Delivery Systems chapter for a list of these services).


      Prime Network

      The Prime Network includes a robust network of practitioners, hospitals and facilities in 28 NY State counties that services a variety of HMO, POS, EPO and PPO members.

      The Prime Network is located in the following New York State counties: Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Kings, Montgomery, Nassau, New York, Orange, Otsego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington and Westchester.


      EmblemHealth Prime Network Expands into Connecticut

      On January 1, 2017, EmblemHealth will expand its Prime Network to the Tristate region by adding ConnectiCare's HMO provider network to the EmblemHealth Prime Network. Members will now have access to providers in CT — just as they do NY and NJ. Prime Network members will be able to select any eligible* provider in the Prime Network as their PCP, regardless of where a member is domiciled and regardless of where the Prime provider offers services, e.g., provider may offer services in NY, NJ or CT.

      *Providers must have an open panel (accepting new members), and be a provider that can be considered a primary care physician following all existing business rules.

      Child Health Plus

      Child Health Plus (CHP) is a New York State-sponsored program that provides uninsured children under 19 years of age with a full range of health care services for free or for a low monthly cost, depending on family income. In addition to immunizations and well-child care visits, CHP covers pharmaceutical drugs, vision, dental and mental health services. There are no copays for CHP members for any covered services. CHP members may visit any one of our Prime Network providers that see children.

      The service area for CHP includes the following New York State counties: Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk and Westchester.

      CHP members are covered for emergency care in the U.S., Puerto Rico, the Virgin Islands, Mexico, Guam, Canada and the Northern Mariana Islands.

      Enrollment period restrictions do not apply to CHP. Eligible individuals may enroll in CHP throughout the year via the NY State of Health Marketplace or through enrollment facilitators.

      Premium Network aka Vytra Premium Network

      The Premium Network includes a robust network of practitioners, hospitals and facilities in 28 NY State counties that services a variety of HMO, POS, EPO and PPO members.

      The Premium Network is located in the following New York State counties: Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Kings, Montgomery, Nassau, New York, Orange, Otsego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington and Westchester.

      Effective January 1, 2016, Vytra HMO plan will be associated with the Vytra Premium Network. Vytra HMO providers will have access to an expanded network of radiologists as the Vytra Radiology Program will sunset on December 31, 2015. At that time, all utilization management program exemptions for our Vytra HMO providers and members will end. Going forward providers will follow our standard HIP policies and submit all requests (referrals, prior approvals, etc.) directly through our secure provider website at emblemhealth.com/Providers.

      Additionally, if you are employed by a New York company and reside in New Jersey, you and your dependents now have access to the NJ QualCare Network. Beginning January 1, 2017, if you are employed by a New York company, you and your dependents will also have access to the ConnectiCare Network.

      Select Care Network

      EmblemHealth has membership in a suite of commercial benefit plans that use the Select Care network. EmblemHealth offers Select Care Network benefit plans to individuals and small groups — both on and off the NY State of Health: The Official Health Plan Marketplace.

      The Select Care Network is located in the following New York State counties: Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Kings, Montgomery, Nassau, New York, Orange, Otsego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington and Westchester.

      The Select Care Network, a subset of our existing HMO network, is a tailored network that helps keep costs down and supports an integrated model of care. Providers in the Select Care Network are chosen on measures such as geographic location, hospital affiliations and sufficiency of services.

      Starting November 1, 2015, a sub-population of applicable current Select Care Silver members and the current Medicaid "legally residing immigrant" population will transition into the new Essential Plan via auto-enrollment or standard NY State of Health enrollment for plans effective January 1, 2016. Essential Plans will either automatically include an adult vision and dental benefit, or individuals can purchase the benefit for an additional premium cost. For more information, see the Enhanced Care Prime Network section.

      All Select Care plans are HMOs and all non-emergency care must be provided by Select Care Network providers. The network includes a full complement of physicians, hospitals, community health centers, facilities and ancillary services. Urgent care and immediate care are also available. To locate the closest care to your patient, please use the Find a Doctor online directory at www.emblemhealth.com/find-a-doctor.

      Note: Most of these plans have a deductible that applies to in-network services.

      HIP-underwritten Commercial Network and Plan Summary for 2016
      Select Care Network

      Network Plan
      Name
      Plan
      Type
      PCP/
      Referral Req'd
      Deductibles
      (Individual/ Family)
      PCP/
      Specialist/
      ER Copay
      OON Coverage

      MOOP
      (Individual/ Family)

      Co-insurance
      Select Care
      Network
      Select Care
      Platinum D HMO
      HMO Yes/Yes $0/$0 $15/$35/$100 No  $2,000/$4,000 No
      Select Care
      Network
      Select Care
      Gold D HMO
      HMO
      Yes/Yes $600/$1,200
      (does not include Rx)
      $25/$40/$150 No $4,000/$8,000  No
      Select Care
      Network
      Select Care
      Silver D HMO
      HMO Yes/Yes $2,000/$4,000
      (does not include Rx)
      $30/$50/$150 No $5,500/$11,000 No
      Select Care
      Network
      Select Care
      Bronze D HMO
      HMO Yes/Yes $3,500/$7,000 (includes Rx) 50% cost-sharing after deductible No $6,850/$13,700 yes
      Select Care
      Network
      Select Care Platinum HMO Yes/Yes $0/$0 $15/$35/$100 No $2,000/$4,000 No
      Select Care
      Network
      Select Care Gold HMO Yes/Yes $600/$1,200 (does not apply to Rx) $25/$40/$150 No $4,000/$8,000 No
      Select Care
      Network
      Select Care Silver (Standard) HMO Yes/Yes $2,000/$4,000 (does not apply to Rx) $30/$50/$150 No $5,500/$11,000 No
      Select Care
      Network
      Select Care Silver (200-250% FPL) HMO Yes/Yes $1,500/$3,000 (does not apply to Rx) $30/$50/$150 No $5,450/$10,900 No
      Select Care
      Network
      Select Care Silver (150-200% FPL) HMO Yes/Yes $250/$500 (does not apply to Rx) $15/$35/$75 No $2,000/$4,000 No
      Select Care
      Network
      Select Care Silver (100-150% FPL) HMO Yes/Yes $0/$0 $10/$20/$50 No $1,000/$2,000 No
      Select Care
      Network
      Select Care Bronze HMO No/No $3,500/$7,000 (includes Rx) 50% cost-sharing after deductible No $6,850/$13,700 Yes
      Select Care
      Network
      Select Care Basic HMO Yes/Yes $6,850/$13,700 (includes Rx) 0% cost-sharing after deductible No $6,850/ $13,700 No
      Select Care
      Network
      Healthy NY HMO (Gold) HMO Yes/Yes $600/$1,200 (does not apply to Rx) $25/$40/$150 No $4,000/$8,000 No
      Select Care
      Network
      Brooklyn HealthWorks Healthy NY HMO (Gold) HMO Yes/Yes $600/$1,200 (does not apply to Rx) $25/$40/$150 No $4,000/$8,000 No
      Select Care
      Network
      HMO 40/60 (Gold) HMO Yes/Yes
      $200/$400
      Rx: $100/$200
      $40/$60/$200 No $5,500/$11,000 No
      Select Care
      Network
      HMO 35/55 (Silver) HMO Yes/Yes $3,000/$6,000 on facility services
      Rx: $100/$200
      $35/$55/$200 No $6,000/$12,000 Yes
      Select Care
      Network
      HMO HD6300 (Bronze) HMO Yes/Yes $6,300/$12,600 (includes Rx) 0% cost-sharing after deductible No $6,300/$12,600 No
      Select Care
      Network
      EmblemHealth HMO 15/35 (Platinum) HMO Yes/Yes $0/$0 $15/$35/$100 Yes $2,000/$4,000 No
      Select Care
      Network
      Select Care Platinum S HMO Yes/Yes $0/$0 $15/$35/$100 No $2,000/$4,000 No
      Select Care
      Network
      Select Care Gold S HMO Yes/Yes $600/$1,200 (does not apply to Rx) $25/$40/$150 No $4,000/$8,000 No
      Select Care
      Network
      EmblemHealth HMO 40/60 S (Gold) HMO Yes/Yes $200/$400
      Rx: $100/$200
      $40/$60/$200 No $5,500/$11,000 No
      Select Care
      Network
      Select Care Silver S HMO Yes/Yes $2,000/$4,000 (does not apply to Rx) $30/$50/$150 No $5,500/ $11,000 No
      Select Care
      Network
      EmblemHealth HMO 35/55 S (Silver) HMO Yes/Yes $3,000/$6,000 on facility services
      Rx: $100/$200
      $35/$55/$200 No $6,000/$12,000 Yes
      Select Care
      Network
      Select Care Bronze S HMO Yes/Yes $3,500/$7,000 (includes Rx) 50% cost-sharing after deductible No $6,850/ $13,700 Yes
      Select Care
      Network
      EmblemHealth HMO HD6300 S (Bronze) HMO Yes/Yes $6,300/$12,600 (includes Rx) 0% cost-sharing after deductible No $6,300/$12,600 Yes

      ER = emergency room; IN = in-network; N/A = not applicable; OON = out-of-network; MOOP = maximum out-of-pocket;
      PCP = primary care provider; FPL = federal poverty level.

      1 Qualifying individuals will be eligible for added cost-sharing subsidies that further lower their costs. Please check the member’s ID card for exact cost-sharing. Qualified Native Americans can have an individual Select Care network plan with $0 cost-sharing (except for the Select Care Basic plan).

      2 Copays are $10 for telemedicine physician and $5 for dietitian/nutritionist for Select Care members.

      3 Child-only plans mirror the individual Select Care plans.



      Changes for 2017

      Below is a summary of changes for Select Care plans in 2017:

      • Pediatric Dental Benefits: New for 2017, pediatric dental benefits are embedded in all individual and small group Select Care plans both on- and off-exchange. EmblemHealth’s standalone dental plan FirstSmiles is discontinued.
      • Two Nonstandard Plans: New for 2017, Select Care Silver Value and Select Care Bronze Value plans, both on- and off-exchange, provide a specific number of primary care physician (PCP) visits at no cost before the deductible and also offer dental and vision benefits for adults and children, no-cost lab services, and no-cost telemedicine. Standard plans follow the standardized plan designs established by New York State and nonstandard plans can change the cost-sharing required in any benefit category.
      • Telemedicine: All EmblemHealth individual and small group Select Care plans both on- and off-exchange and the Essential Plan offer telemedicine services at no cost.

      Learn more about changes in the EmblemHealth Select Care plans for 2017.

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      Glossary terms found on this page:

      Auxiliary or supplemental services (i.e., diagnostic services, physical therapy and medications) used to support diagnosis and treatment of a patient's condition.

      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.

      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).

      The use of one or more drugs for purposes other than those for which they are prescribed or recommended.

      An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

      An individual person who is the direct or indirect recipient of the services of the organization. Depending on the context, consumers may be identified by different names, such as "member," "enrollee," "beneficiary" or "patient." A consumer relationship may exist even in cases where there is not a direct relationship between the consumer and the organization. For example, if an individual is a member of a health plan that relies on the services of a utilization management organization, then the individual is a consumer of the utilization management organization.

      The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

      A medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.

      A portion of eligible expenses that an individual or family must pay during a calendar year before EmblemHealth will begin to pay benefits for covered services.

      An individual other than the subscriber who is eligible to receive health care services under the member's Certificate of Insurance. Generally, dependents are limited to the subscriber's spouse and eligible children.

      Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

      Care for a person with an emergency condition.

      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 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 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.

      A drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug.

      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.

      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

      A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.

      A card that allows the subscriber to identify himself or his covered dependents to a provider for health care services.

      The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.



      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.

      Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

      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.

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

      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 hospital that is part of EmblemHealth's provider network and has signed an agreement to provide covered services to its members. Sometimes, network hospitals and facilities are referred to as participating hospitals.

      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.

      The use of health care providers who have not contracted with the health plan to provide services. Depending on the member's contract, out-of-network services may not be covered.

      A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

      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.

      Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, and generally including routine physical examinations and immunization.

      A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a PCP.

      The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

      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.

      A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

      The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.

      Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or severe pain, such as a high fever.

      A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.

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