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  • Provider Networks and Member Benefit Plans > Medicaid Network

    The table below summarizes the network and benefit plans through which our Medicaid members receive their health care benefits and services.

    HIP-underwritten Medicaid Network and Plan Summary for 2016
    Enhanced Care Prime Network

    Network Plan
    Referral Req'd
    OON Coverage In-Network
    Cost Sharing
    Service Area1 Comments
    Enhanced Care Prime Network1 EmblemHealth Enhanced Care HMO Yes/Yes2 Yes3 Rx Copays 8 county Medicaid Managed Care plan for Medicaid-eligible individuals5
    Enhanced Care Prime Network1 EmblemHealth Enhanced Care Plus HMO Yes/Yes2 Yes3 Rx Copays NYC MedHARP for Medicaid-eligible individuals aged 21 and older4

    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.

    8 county = Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island), Nassau, Suffolk & Westchester counties

    NYC = Bronx, Kings (Brooklyn), New York (Manhattan), Queens & Richmond (Staten Island) counties

    1 Medicaid and HARP members traveling outside of the United States can get coverage for urgent and emergency care only in the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands and American Samoa. Members needing any type of care while in any other country (including Canada and Mexico) will be responsible for payment.

    2 Except for self-referral services and services that Medicaid members can access from Medicaid FFS providers.

    3 Medicaid Members can access certain services from county departments of health and academic dental centers. (See the Access to Care and Delivery Systems chapter for a list of applicable services where OON coverage applies.)

    4 See Medicaid Managed Care Model Contract for more details.


    Medicaid Managed Care (MMC): EmblemHealth Enhanced Care

    EmblemHealth’s Medicaid Managed Care Plan is now called EmblemHealth Enhanced Care.

    The plan name “Enhanced Care” can be found in the upper right corner of the member’s ID card. The letter “R” will appear after the plan name on the ID cards of members who are in the Restricted Recipient Program (RRP). This will help you and your staff quickly identify our MMC members.

    Our Medicaid members are entitled to a standard set of benefits as set out in the Medicaid Managed Care Model Contract . They may directly access certain services. See the Direct Access (Self-Referral) Services section of the Access to Care and Delivery Systems chapter for a list of services that do not require a referral.

    On October 1, 2015, EmblemHealth replaced Medicaid FFS for the coverage of behavioral health services for its MMC members aged 21 and older who reside in the five boroughs of New York City.

    Behavioral Health Covered Services

    EmblemHealth covers the following additional behavioral health benefits:

    • Medically supervised outpatient withdrawal services
    • Outpatient clinic and opioid treatment program services
    • Outpatient clinic services
    • Comprehensive psychiatric emergency program services
    • Continuing day treatment
    • Partial hospitalization
    • Personalized recovery oriented services
    • Assertive community treatment
    • Intensive and supportive case management
    • Health home care coordination and management
    • Inpatient hospital detoxification
    • Inpatient medically supervised inpatient detoxification
    • Rehabilitation services for residential substance use disorder treatment
    • Inpatient psychiatric service

    For more information on the Behavioral Health Services Program, please see the Behavioral Health Services chapter.

    Health and Recovery Plan (HARP): EmblemHealth Enhanced Care Plus

    As of October 1, 2015, EmblemHealth offers a new Health and Recovery Plan (HARP) designed to meet the unique needs of our eligible MMC members living with serious mental illness and/or substance use disorder. The new plan includes access to home and community based services (HCBS) and support from their assigned Health Home.

    EmblemHealth Medicaid providers are automatically included in HARP. Providers who do not wish to participate in all of EmblemHealth’s Medicaid-based benefit plans must decline participation in writing. Network opt-out requests may be faxed to Provider Modifications at 1-877-889-9061 or mailed to:

    Provider Modifications Team
    55 Water Street, 6th Floor
    New York, New York, 10041-8190

    In the subject line, you must indicate “Medicaid/HARP Opt Out.” Failure to include this subject line may result in inaccurate processing.

    The plan name “Enhanced Care Plus” can be found in the upper right corner of the member’s ID card and the network name “Enhanced Care Prime” is displayed in the network field. The letter “R” will appear after the plan name on the ID cards of members who are in the Restricted Recipient Program (RRP). This will help you and your staff, identify our HARP members.

    To be eligible for HARP enrollment consumers must:

    • Be a New York City Medicaid beneficiary 21 years of age and over
    • Have a serious mental illness or substance use disorder diagnosis
    • Be eligible for enrollment in a MMC plan
    • Not be Medicaid-Medicare enrolled ("duals")
    • Not be either participating or enrolled in a program with the Office for People with Developmental Disabilities (OPWDD)
    • Not be in a nursing home for long term care

    HARP Enrollment Process

    1. Individuals initially identified by NYSDOH as HARP eligible, who are already enrolled in EmblemHealth’s MMC plan, will be passively enrolled in EmblemHealth Enhanced Care Plus.
    2. Individuals identified for passive enrollment into EmblemHealth Enhanced Care Plus will be contacted by the NYSDOH Enrollment Broker (Maximus). They will be given 30 days to opt out of EmblemHealth Enhanced Care Plus or choose to enroll in another HARP.
    3. Once enrolled in EmblemHealth Enhanced Care Plus, members will be given 90 days to opt out before they are locked into EmblemHealth Enhanced Care Plus until the next open enrollment period.

    EmblemHealth Enhanced Care Plus Covered Services

    HARP Services include all of the traditional Medicaid benefits listed in the Medicaid Managed Care Model Contract , the behavioral health services listed in the MMC section in addition to the following HCBS services:

    • Rehabilitation
    • Peer Supports
    • Habilitation
    • Respite
    • Non-medical transportation*
    • Family Support and Training
    • Employment Supports
    • Education Support Services
    • Supports for self-directed care

    *Covered by Medicaid FFS and not by EmblemHealth

    Federal requirements indicate that eligibility to HCBS must be based on an assessment of functional needs. The enhanced benefit package of HCBS is designed to assist enrollees in their recovery and continued tenure in the community. In order to maximize the benefits of this program, members are reassessed on an annual basis by their assigned Health Homes.

    Health Homes determine HCBS eligibility and develop a strengths-based, person-centered care plan using the standardized eligibility assessment tool, derived from the interRAI Community Mental Health assessment designed for New York. The Health Home Care Manager will facilitate the integration of physical health, mental health, and substance use disorder services for individuals requiring specialized expertise, tools, and protocols which are not consistently found within most medical plans.

    Medicaid Health Home Program

    Under the Federal Patient Protection and Affordable Care Act (PPACA), New York has developed a set of Health Home services for Medicaid members who have been identified and diagnosed with any of the following conditions:

    • Two or more conditions, such as asthma, diabetes, high blood pressure or heart disease
    • HIV+ or AIDS
    • Severe mental illness or substance use disorder

    The Health Home Program is offered at no cost to all eligible EmblemHealth Medicaid members. All HARP members are assigned a Medicaid Health Home to provide care plan coordination; however, members may opt out of the program at any time. EmblemHealth will then notify the member, and their PCP, of the Health Home assignment by letter. The member’s assigned Health Home Care Manager will contact the member’s PCP to ensure the treatment plan is included in the member’s comprehensive care plan.

    The following services are available through the Medicaid Health Home program:

    • Comprehensive case management with an assigned, personal care manager
    • Assistance with getting necessary tests and screenings
    • Help and follow-up when leaving the hospital and going to another setting
    • Personal support and support for their caregiver or family
    • Referrals and access to community and social support services

    More information on the NYS Medicaid Health Home Program can be found on the NYSDOH website:

    Medicaid Members who are not eligible to participate in the Medicaid Health Home Program may still meet our criteria for Case Management services. If you think a member would benefit from case management, please refer the patient to the program by calling 1-800-447-0768, Monday through Friday, from 9 am to 5 pm.

    A listing of EmblemHealth network Health Homes that support our Medicaid and HARP benefit plans are listed in the Directory chapter.


    Permanent Placement in Nursing Homes

    The Medicaid Managed Care (MMC) nursing home benefit now includes coverage of permanent stays in residential health care facilities for Medicaid recipients aged 21 and over who reside in the five boroughs of New York City.

    Medicaid recipients in permanent nursing home status prior to February 1, 2015 continued to be covered by Medicaid FFS, however they may choose to voluntarily enroll in a MMC plan as of October 1, 2015. MMC plans will be responsible for members who enter permanent resident status on and after February 1, 2015, and these members will no longer be disenrolled from a Medicaid Managed Care plan.

    Voluntary Enrollment

    Effective October 1, 2015, eligible New York City, Westchester, Nassau and Suffolk county Medicaid recipients who were in permanent residence in a nursing home are able to enroll in managed care on a voluntary basis. Covered nursing home services include:

    • Medical supervision
    • 24-hour nursing care
    • Assistance with daily living
    • Physical therapy
    • Occupational therapy
    • Speech-language pathology and other services

    Effective April 1, 2015, the MMC nursing home benefit was expanded to include Medicaid recipients aged 21 and over who reside in Nassau, Suffolk and Westchester counties.

    Veterans’ Nursing Homes

    Eligible Veterans, Spouses of Eligible Veterans, and Gold Star Parents of Eligible Veterans may choose to stay in a Veterans’ nursing home.

    If EmblemHealth does not have a Veterans’ home in their provider network and a member requests access to a Veterans’ home, the member will be allowed to change enrollment into a MMC plan that has the Veterans’ home in their network. While the member’s request to change plans is pending, EmblemHealth will allow the member access to the Veterans’ home and pay the home the benchmark Medicaid rate until the member has changed plans.

    We make every effort to assist new members whose current providers are not participating with one of our plans. See the Continuity/Transition of Care - New Members section of the Care Management chapter for information on transition of care.


    Mandatory Enrollment of the New York City Homeless Population

    According to the New York State Department of Health (NYSDOH), all of New York City's homeless population must be enrolled into Medicaid Managed Care.

    Identifying Homeless and HARP Members Enrolled with EmblemHealth

    Since homeless and HARP members may present with unique health needs, we have identified which of your Medicaid Managed Care patients are homeless and/or HARP members. The following symbols are included within the secure provider website’s panel report feature:

    • "H" next to the name of homeless members
    • "R" next to the name of HARP members
    • "P" next to the name of homeless HARP members

    A homeless indicator is present on eligibility extracts. The homeless indicator "H" is included if the member is homeless and blank if the member is not homeless.

    Primary Care Services Offered in Homeless Shelters

    Homeless members can select any participating PCP. However, to improve access to care for our members with no place of usual residence, we've expanded our provider network to include practitioners who practice in homeless shelters. A PCP practicing at a homeless shelter is available only to members who reside in that shelter.


    NYSDOH Medicaid Provider Non-Interference

    Medicaid and MLTC providers and their employees or contractors are not permitted to interfere with the rights of Medicaid recipients in making decisions about their healthcare coverage. Medicaid and MLTC providers and their employees or contractors are free to inform Medicaid recipients about their contractual relationships with Medicaid or MLTC plans. However, they are prohibited from directing, assisting or persuading Medicaid recipients on which plan to join or keep.

    In addition, if a Medicaid recipient expresses interest in a Medicaid Managed Care or MLTC program, providers and their employees or contractors must not dissuade or limit the recipient from seeking information about Medicaid Managed Care or MLTC programs. Instead, they should direct the recipient to New York Medicaid Choice, New York State’s enrollment broker responsible for providing Medicaid recipients with eligibility and enrollment information for all MMC and MLTC plans.

    For assistance, please call New York Medicaid Choice: 1-800-505-5678, Monday - Friday, 8:30 a.m. to 8:00 pm, Saturday, 10:00 am to 6:00 pm.

    Any suspected violations will be turned over to the New York Office of the Medicaid Inspector General (OMIG) and potentially the Federal Office of Inspector General (OIG) for investigation.


    Restricted Recipient Program

    MMC and HARP members are placed in the Restricted Recipient Program (RRP) when a review of their service utilization and other information reveals that they are:

    • Getting care from several doctors for the same problem
    • Getting medical care more often than needed
    • Using prescription medicine in a way that may be dangerous to their health
    • Allowing someone else to use their plan ID card
    • Using or accessing care in other inappropriate ways

    The Office of Medicaid Inspector General (OMIG) refers members to EmblemHealth for restricted services.

    RRP members are restricted to certain provider types (dentists, hospitals, pharmacies, behavioral health professionals, etc.) based on a history of overuse or inappropriate use of specific services. Members are further restricted to using a specific provider of that type.

    EmblemHealth is required to continue the Medicaid FFS program restrictions for MMC and HARP members until their existing restriction period ends. EmblemHealth is also required to identify members already enrolled that need to be restricted. All EmblemHealth RRP members are in an Employer Group that begins with “1R0”.

    Additionally, EmblemHealth RRP member ID cards have an “R” after the plan name on the front of the card so that providers will know that they are restricted. (i.e., Enhanced Care - R or Enhanced Care Plus - R) Neither the provider nor enrollee may be held liable for the cost of services when the provider could not have reasonably known that the enrollee was restricted to another provider. To report suspicious activity, please contact EmblemHealth's Special Investigations Unit in one of the following ways:

    • E-mail:
    • Toll-free hotline: 1-888-4KO-FRAUD (1-888-456-3728)
    • Mail:
      Attention: Special Investigations Unit
      441 Ninth Avenue
      New York, NY 10001

    A trained investigator will address your concerns. The informant may remain anonymous. For more information, please see the Fraud and Abuse chapter.


    Essential Plan

    HIP-underwritten Commercial Network and Plan Summary for 2016
    Enhanced Care Prime Network




    Referral Req'd

    (Individual/ Family)

    ER Copay

    OON Coverage

    (Individual/ Family)

    Service Area


    Enhanced Care Prime Network1

    Essential Plan 1


    Yes/ Yes





    8 county

    Yes, for certain services

    Enhanced Care Prime Network1

    Essential Plan 1 Plus


    Yes/ Yes





    8 county

    Yes, for certain services

    Enhanced Care Prime Network1

    Essential Plan 2


    Yes/ Yes


    $0 copay



    8 county


    Enhanced Care Prime Network1

    Essential Plan 2 Plus


    Yes/ Yes


    $0 copay



    8 county


    Enhanced Care Prime Network1

    Essential Plan 3


    Yes/ Yes


    $0 copay



    8 county


    Enhanced Care Prime Network1

    Essential Plan 4


    Yes/ Yes


    $0 copay



    8 county


    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.

    8 county = Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island), Nassau, Suffolk & Westchester counties.

    1 Enhanced Care Prime Network members traveling outside of the United States can get coverage for urgent and emergency care only in the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands and American Samoa. Members needing any type of care while in any other country (including Canada and Mexico) will be held responsible for payment.

    The Essential Plan is a new, lost-cost plan for adult individuals to be purchased on the NY State of Health marketplace, effective January 1, 2016. The Essential Plan is modeled after our Select Care Silver Plan. As with Qualified Health Plans (QHPs), the Essential Plan includes all benefits under the 10 categories of the ACA-required Essential Health Benefits. Premiums for the Essential Plan are either $20 or $0.

    The Essential Plan pulls member from two already existing member populations – the current QHP Select Care Silver CSR 2&3 and the current Medicaid Aliessa population. The Aliessa population is New York’s legally residing immigrant population. Eligible individuals in the Aliessa population, who previously were only eligible for coverage through state-only-funded Medicaid, will also transition into the Essential Plan. Essential Plan Members are covered for emergency care in the U.S., Puerto Rico, the Virgin Islands, Mexico, Guam, Canada and the Northern Mariana Islands.


    The Essential Plan covers adult individuals only. If eligible, spouses and children must enroll into EP separately under an individual policy. To qualify for the Essential Plan, individuals must:

    • Be a New York State resident
    • Be between the ages of 19 and 64 (US citizens) or 21 to 64 (legally residing immigrants)
    • Not be eligible for Medicare, Medicaid, Child Health Plus, affordable health care coverage from an employer, or another type of minimum essential health coverage
    • Be either:
      • US citizen with an income between 138% and 200% of FPL (in 2015 that comes to between $16,242.60 and $23,540)
        • These individuals were formerly eligible for eligible for a QHP Silver Plan, but will now transition to EP based on income status.
    • Legally residing immigrant with an income of less than 138% of FPL (in 2015 this comes to $16,242.60)
      • These individuals were formerly eligible for Medicaid, but have been transitioned to EP based on immigration status (also known as Aliessa population).
    • Not be pregnant or eligible for long-term care. In both of these cases, members would be eligible for Medicaid instead of the Essential Plan.

    Covered Services

    Ten categories of essential health benefits are covered with no cost-sharing (no deductible, copay or coinsurance) on preventive care services, such as screenings, tests and shots. For more information, please see the Preventive Health Guidelines located on our Health and Wellness webpage. Information in our guidelines comes from medical expert organizations, such as the American Academy of Pediatrics, the US Department of Health and Human Services, the Advisory Committee on Immunization Practices and the Centers for Disease Control and Prevention (CDC).

    Unlike QHP Select Care Plans, some Essential Plan members are also eligible for adult vision and dental benefits for a small additional monthly cost. The Aliessa population receives six extra benefits embedded in the plan at no extra cost. These include: dental, vision, non-emergency transportation, non-prescription drugs, orthopedic footwear, and orthotic devices.

    How to enroll

    There are four ways to apply:

    • Online. Visit NYSOH online and go to the Individuals & Families section. Once there, start an account and begin shopping for a plan.
    • In person. Get help from a Navigator, certified application counselor (CAC), Marketplace Facilitated Enroller (MFEs) or broker/agent. People can also get help applying from MFEs aboard the EmblemHealth vans.
    • By phone. Call EmblemHealth at 1-877-411-3625, daily from 8 a.m. to 8 p.m., and the NYSOH at 1-855-355-5777, Monday through Friday from 8 a.m. to 8 p.m., and Saturday from 9 a.m. to 1 p.m.
    • By mail. Print an application at and send it back to NYSOH, who will then confirm eligibility and enroll them in the chosen plan.

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


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    Glossary terms found on this page:

    An agreement in which a patient assigns to another party, usually a physician or hospital, the right to receive payment from a public or private insurance program for the service the patient has received.

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

    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.

    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 program that assists the patient in determining the most appropriate and cost-effective treatment plan, including coordinating and monitoring the care with the ultimate goal of achieving the optimum health care outcome.

    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.

    A percentage of the allowed charge that is payable by the member, not EmblemHealth, for covered services rendered by an out-of-network provider. After the member has met his or her deductible, EmblemHealth will pay a percentage of the allowed charge for those covered services in accordance with the member's benefit program. The member is responsible to pay the remaining percentage of the allowed charge. This remaining percentage is the coinsurance charge.

    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.

    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.

    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 general term for the deductible, copayment and coinsurance provisions in the member's plan.

    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.

    The US government's principal agency for protecting the health of all Americans and providing essential human services. Also called the DHHS.

    A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

    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.

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

    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 individual who: (1) has undergone formal training in a health care field; (2) holds an associate or higher degree in a health care field, or holds a state license or state certificate in a health care field; and (3) has professional experience in providing direct patient care.

    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.

    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.

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

    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.

    The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called NYSDOH.

    The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called the New York State Department of Health.

    Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting and bathing (activities of daily living).

    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.

    Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury or loss of limb.

    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 written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.

    Drugs and medications that are required by law to be dispensed by written prescriptions from a licensed physician.

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

    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.

    New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.

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


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