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  • Provider Networks and Member Benefit Plans > Medicare Networks

    Medicare Plans

    EmblemHealth companies HIP and GHI underwrite all Medicare plans associated with the VIP Prime Network (HIP Health Plan of New York), Medicare Essential Network (HIP Health Plan of New York) and Medicare Choice PPO Network (Group Health Incorporated). EmblemHealth Medicare plans are authorized by Medicare through two contracts:

    1. Plans associated with the Medicare Choice PPO Network utilize the H5528 Medicare Contract.
    2. Plans associated with the Medicare Essential Network and VIP Prime Network utilize the H3330 Medicare Contract.

    As a reminder, providers are deemed participating in all benefit plans associated with their participating networks and may not terminate participation in an individual benefit plan. Providers can subscribe to receive updates to this chapter by clicking the subscribe icon above.

    Maximum Out-of-Pocket Threshold

    The maximum out-of-pocket (MOOP) threshold for Medicare Parts A and B services covered under the EmblemHealth Medicare Advantage plans has changed. This includes the in-network MOOP under the EmblemHealth Medicare HMO plans and both the in-network and combined (in- and out-of-network) MOOPs under the EmblemHealth Medicare PPO plans. The MOOP for each plan is contained within the Medicare Network and Plan Summary section of this chapter.

    Coinsurance and Copay Changes

    • Transferability of Maximum Out-of-Pocket (MOOP):If a member makes a mid-year change from an EmblemHealth Medicare HMO to an EmblemHealth Medicare PPO plan, or vice versa, the MOOP accumulated thus far in the contract year now follows the member and counts toward the MOOP in the new EmblemHealth Medicare plan.
    • Cost-Sharing May Apply to Some EmblemHealth Dual Eligible Special Needs Plan (HMO SNP) Members: Cost-sharing for many of our HMO SNP benefits will increase from the current amount of $0. The change will affect most services and will vary depending on the benefit.

    A statement of members' out-of-pocket spending to date will appear on their Explanation of Benefits. Members will continue to be notified by mail upon reaching the MOOP for their plan. This notice will also list services with $0 cost-sharing available to the member for the remainder of the calendar year. Sign in to the provider section of the EmblemHealth website at www.emblemhealth.com/providers to confirm MOOPs for your members who are enrolled in any of the EmblemHealth Medicare plans associated with the EmblemHealth Medicare Choice PPO Network, VIP Prime Network or Medicare Essential Network.

    Members can consult their Evidence of Coverage (EOC) for a list of covered services and the associated cost-sharing. Many HMO SNP plan members are qualified Medicare beneficiaries (QMB), which means they receive help from New York State Medicaid to pay their cost-sharing. As a result, the provider must bill Medicaid for the cost-sharing upon receipt of payment from EmblemHealth. The correct address to bill Medicaid is located on these members’ Common Benefits Identification Card (CBIC).

    Wellness Exams

    Medicare Part B services now include an annual wellness exam in addition to the "Welcome to Medicare" physical exam.

    • "Welcome to Medicare" Physical Exam: Our Medicare plans cover a one-time "Welcome to Medicare" physical exam. This exam includes a health review, education and counseling about preventive services (including screenings and vaccinations) and referrals for care, if necessary. Note: Members must have the "Welcome to Medicare" physical exam within 12 months of enrolling in Medicare Part B. When making their appointment, they should let you know they are scheduling their "Welcome to Medicare" physical exam.
    • Annual Wellness Visit:A Health Risk Assessment (HRA) is to be used as part of the Annual Wellness Visits (AWV). Members enrolled in Medicare Part B for over 12 months are eligible for an annual wellness visit to develop or update a personalized prevention plan based on their health needs and risk factors. This is covered once every 12 months. Note: Following their "Welcome to Medicare" physical exam, members must wait 12 months before having their first annual wellness visit. However, once members have been enrolled in Medicare Part B for at least 12 months, they do not need to have had a "Welcome to Medicare" physical exam to be covered for annual wellness visits. Providers may bill for this service using HCPCS codes G0438 and G0439 for initial and subsequent visits, respectively.
    • No Cost-Sharing for Preventive Care Services: CMS has released National Coverage Determinations for preventive services that are to be offered without cost-sharing. All of the services are listed in Appendix C. For HMO members, including Dual Eligible, Medicare-required covered services that are not available in network and receive prior approval from our plan, or the member's assigned managing entity, as applicable, will be allowed at $0 cost-sharing as well. For PPO Dual Eligible members, all of the services outlined in Appendix C are covered at $0 cost-sharing. For EmblemHealth PPO I and EmblemHealth Advantage (PPO) members, all of the services listed in Appendix C are covered at the out-of-network cost-sharing percentage.

    Medicare Network and Plan Summary

    To view benefit summaries and copies of members' Evidences of Coverage for each of these Medicare plans, please visit www.emblemhealth.com/Our-Plans/Medicare.aspx:

    Medicare Choice PPO Network

    • EmblemHealth PPO I (PPO)
    • EmblemHealth Advantage (PPO)
    • EmblemHealth Group Access Rx PPO
    • EmblemHealth Group Access PPO

      Medicare Essential Network

      • EmblemHealth Essential (HMO)
      • EmblemHealth VIP High Option (HMO) 

        VIP Prime Network

        • EmblemHealth VIP (HMO)
        • EmblemHealth VIP Premier (HMO)
        • EmblemHealth VIP Rx Carve-out (HMO)
        • EmblemHealth Part A Payers (HMO)

          The table below summarizes our Medicare suite of products. Special Needs and FIDA plans are located within the Medicare Special Needs Plans section of this chapter.

          GHI-underwritten Medicare Network And Plan Summary for 2016
          Medicare Choice PPO Network
          Network Plan Name Plan Type PCP/
          Referral Req'd
          OON Coverage In-network Cost-Sharing Service Area Comments

          Medicare Choice PPO Network

          EmblemHealth Advantage (PPO)

          EmblemHealth Medicare PPO

          No/No

          Yes

          Copays/
          coinsurance

          National

          Individual Medicare Advantage prescription drug plan. No drug coverage in the "donut hole."

          Medicare Choice PPO Network

          EmblemHealth Group Access PPO

          EmblemHealth Medicare PPO

          No/No

          Yes

          Copays/
          coinsurance

          National

          Employer Group MAPD plan. Each group contracts individually with the plan for benefit design. Pharmacy benefits excluded.

          Medicare Choice PPO Network

          EmblemHealth Group Access Rx PPO

          EmblemHealth Medicare PPO

          No/No

          Yes

          Copays/
          coinsurance

          National

          Employer Group MAPD plan. Each group contracts individually with the plan for benefit design. Pharmacy benefits included.

          Medicare Choice PPO Network

          EmblemHealth PPO I (PPO)

          EmblemHealth Medicare PPO

          No/No

          Yes

          Copays/
          coinsurance

          8 County

          Individual Medicare Advantage plan. No Part D coverage.

          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

          Members can access certain services from county departments of health, academic dental centers and, for Medicaid members, Medicaid FFS providers. (See the Access to Care and Delivery System chapter for a list of these services)

          Members are covered for urgent and emergency care. HIP covers in all 50 United States, Canada, Mexico, Puerto Rico, the US Virgin Islands, Guam and the Northern Mariana Islands. Medicare members have worldwide urgent and emergency coverage.

           

          HIP-underwritten Medicare Network And Plan Summary for 2016
          Medicare Essential & VIP Prime Network
          Network Plan Name Plan Type PCP/
          Referral Req'd
          OON Coverage In-network Cost-Sharing Service Area Comments
          Medicare Essential Network  EmblemHealth Essential (HMO) EmblemHealth Medicare HMO Yes/Yes No

          Copays/
          coinsurance

          8 county1 Limited PCP network. Provider should confirm participation as PCP prior to accepting new patients.

          Medicare Essential Network

          EmblemHealth VIP High Option (HMO)

          EmblemHealth Medicare HMO

          Yes/Yes

          No

          Copays/
          coinsurance

          8 county1

          Individual Medicare Plan. Limited PCP network. Provider should confirm participation as PCP prior to accepting new patients. No copays for most services, including office visits and hospital stays. Coinsurance does apply to Part B drugs.

          N/A

          GHI/CNY Enhanced Prescription Drug Plan

          EmblemHealth Medicare PDP

          N/A

          Yes

          Copays/
          coinsurance

          New York State

          Part D drug coverage.

          VIP Prime Network

          EmblemHealth Part A Payers (HMO)

          EmblemHealth Medicare HMO

          Yes/Yes

          No

          Copays/
          coinsurance

          8 county1

          Employer Group plan.

          VIP Prime Network

          EmblemHealth VIP (HMO)

          EmblemHealth Medicare HMO

          Yes/Yes

          No

          Copays/
          coinsurance

          8 county1

          Individual Medicare plan.

          VIP Prime Network

          EmblemHealth VIP Premier (HMO)

          EmblemHealth Medicare HMO

          Yes/Yes

          No

          Copays/
          coinsurance

          8 county1

          Employer Group plan.

          VIP Prime Network

          EmblemHealth VIP Rx Carve-Out (HMO)

          EmblemHealth Medicare HMO

          Yes/Yes

          No

          Copays/
          coinsurance

          8 county1

          Employer Group plan.

          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 county1 = New York City (Bronx, Kings, New York, Queens, Richmond), Nassau, Suffolk & Westchester

          Members can access certain services from county departments of health, academic dental centers and, for Medicaid members, Medicaid FFS providers. (See the Access to Care and Delivery System chapter for a list of these services)

          Members are covered for urgent and emergency care. HIP covers in all 50 United States, Canada, Mexico, Puerto Rico, the US Virgin Islands, Guam and the Northern Mariana Islands. Medicare members have worldwide urgent and emergency coverage.

           

          Changes for 2017

          Below is a summary of Medicare benefit plans and networks changes for 2017:

          • Discontinued Plans: Individual PPO plans including EmblemHealth PPO I, EmblemHealth Advantage PPO and EmblemHealth Dual Eligible (PPO SNP) will sunset.
          • New Plan: EmblemHealth VIP Value (HMO) provides in-network coverage from providers in our Medicare Essential Network, and benefits with $30 copay for PCPs and $50 copay for specialists, plus Part D prescription drug coverage.
          • New Plan Names: All HMO plans will have new names.
          • Provider Network: EmblemHealth VIP Gold Plus (HMO), formerly EmblemHealth VIP High Option (HMO) will transition from the Medicare Essential Network to the VIP Prime Network of providers.
          • New Vendors: Dental services will transition to DentaQuest and vision services will transition to EyeMed.
          • Preferred Pharmacy Network: Part D prescription drug deductibles will apply to medications on formulary Tier 3, Tier 4 and Tier 5. A subset of “preferred pharmacies” within the Medicare pharmacy network will offer lower cost-sharing with $0 copay for preferred generic drugs.
          • Fitness Benefit: Access to membership in SilverSneakers®, an exercise program designed for older adults, are included in some HMO plans.
          • Plan Enhancements: EmblemHealth VIP Dual (HMO SNP), formerly EmblemHealth Dual Eligible (HMO SNP), will have additional benefits such as acupuncture visits and increased limits on over-the-counter (OTC) items debit card.
          • ID Cards: Urgent Care copay will display on member ID cards.

          2016 Plan
          Name
          2017 Plan
          Name
          2017 Provider
          Network
          2017 Plan Highlights
          EmblemHealth VIP (HMO) EmblemHealth VIP Gold (HMO) VIP Prime Network SilverSneakers Fitness, Comprehensive and Preventive Dental Services, $0 copay for preferred generic drugs, $0 copay for PCP visits
          EmblemHealth VIP High Option (HMO) EmblemHealth VIP Gold Plus (HMO) VIP Prime Network SilverSneakers Fitness, Comprehensive and Preventive Dental Services, $0 copay for preferred generic drugs, $0 copay for PCP visits
          New Plan for 2017 EmblemHealth VIP Value (HMO) Medicare Essential Network Preventive Dental Services, $0 copay for preferred generic drugs, offered in 6 counties (Manhattan, Queens, Richmond, Nassau, Suffolk and Westchester)
          EmblemHealth Dual Eligible (HMO SNP) EmblemHealth VIP Dual (HMO SNP) VIP Prime Network 48 acupuncture visits per year, $720 annual over-the-counter (OTC) debit card, $0 copay for covered services, $0 copay for preferred generic drugs, Comprehensive and Preventive Dental Services

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          Glossary terms found on this page:

          Services that have been approved for payment based on a review of EmblemHealth's policies.

          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).

          The government agency responsible for administering the Medicare and Medicaid programs.

          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.

          A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

          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.

          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 form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment and the claims appeal process. Also called an EOB.

          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 list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality. Also called a drug formulary.

          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.

          The agreement EmblemHealth has with the member's group to provide health insurance.

          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.

          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.

          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 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. Also known as MA.

          This part of Medicare provides medical surgical benefits for Medicare beneficiaries for a modest premium.

          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.

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

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

          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.

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