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  • Provider Networks and Member Benefit Plans > Medicare Special Needs Plans

    SNPs Meet Our Members' Special Needs

    Medicare Special Needs Plans (SNPs) are specially designated Medicare Advantage plans, with custom designed benefits to meet the needs of a specific population. Enrollment in a SNP is limited to Medicare beneficiaries within the target SNP population. The target populations for the EmblemHealth SNPs are individuals who live within the plan service area, are eligible for Medicare Part A and Part B, and are eligible for Medicaid.

    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.

    EmblemHealth's SNPs consist of:

    Medicare Choice PPO Network

      VIP Prime Network

          EmblemHealth Dual Assurance Network

          Associated Dual Assurance Network

          • ArchCare Community Advantage FIDA Plan — terminated on 10/31/2015
          • GuildNet Gold Plus FIDA Plan POS

          The Medicare benefit for each of these plans is supplemented by a specific set of Medicaid benefits.

           

          The SNP Interdisciplinary Team

          Our SNP goals are to:

          • Improve access to medical, mental health, social services, affordable care and preventive health services
          • Improve coordination of care through an identified point of contact
          • Improve transitions of care across health care settings and providers
          • Assure appropriate utilization of services
          • Assure cost-effective service delivery
          • Improve beneficiary health outcomes

            The SNP interdisciplinary team provides the framework to coordinate and deliver the plan of care and to provide appropriate staff and program oversight to achieve the SNP goals. The care management staff assumes an important role in developing and implementing the individualized care plan, coordinating care, and sharing information with the interdisciplinary care team and with the member, their family or caregiver.

            Practitioners providing care to our SNP members are important members of the SNP interdisciplinary team. As such, they participate in one of our regularly scheduled care coordination or case rounds meetings to discuss their plan of care and the health status of the SNP-enrolled patient. These practitioners also share their progress with the team to ensure we are meeting our SNP program goals.

            The summary table below outlines the key components of the SNPs, such as Medicaid eligibility level, service area and whether referrals are needed.

            Required Training for EmblemHealth Practitioners, Providers and Vendors

            Each year, all Medicare Choice PPO Network and VIP Prime Network providers are required to complete the Special Needs Plan (SNP) Model of Care Training for each of the Dual Eligible SNPs with which they participate, as mandated by Centers for Medicare & Medicaid Services (CMS). For training presentations and other learning opportunities, please visit our Learn Online webpage at http://www.emblemhealth.com/en/Providers/Provider-Resources/Learn-Online.aspx.

             

            Medicare Special Needs Plans

             

            GHI-underwritten Medicare Special Needs 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 Dual Eligible (PPO SNP)

            EmblemHealth Medicare PPO

            No/ No

            Yes

            Copays/ Coinsurance 8 county1 Individual Medicare Advantage prescription drug plan. Special needs plan limited to individuals with both Medicare and Medicaid coverage. Individuals with full Medicaid coverage are not required to pay cost-sharing.
            Medicare Choice PPO Network ArchCare Advantage (HMO SNP) EmblemHealth Medicare ASO No/No Yes Coinsurance 8 county2 N/A
            Medicare Choice PPO Network GuildNet Gold EmblemHealth Medicare ASO No/No No Part D only 7 county Third party administration MAPD plan. Plans customized to meet client's health plan needs. Individuals must have Medicare and full Medicaid 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 county1 = Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island), Nassau, Suffolk & Westchester

            8 county2 = Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island), Dutchess, Orange & Westchester counties

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

            HIP-underwritten Medicare Special Needs Network and
            Plan Summary for 2016 VIP Prime Network
            Network Plan Name Plan Type PCP/ Referral Req'd? OON Coverage In-network Cost-Sharing Service Area Comments

            VIP Prime Network

            EmblemHealth Dual Eligible Group (HMO SNP)

            EmblemHealth Medicare HMO

            Yes/Yes

            Yes*

            Varies by group 8 county Employer Group plan. Special needs plan limited to individuals with both Medicare and Medicaid coverage. Individuals with full Medicaid coverage are not required to pay cost-sharing.

            VIP Prime Network

            EmblemHealth Dual Eligible (HMO SNP)

            EmblemHealth Medicare HMO

            Yes/ Yes

            Yes*

            Copays/ Coinsurance

            8 county Individual Medicare Plan. Special needs plan limited to individuals with both Medicare and Medicaid coverage. Individuals with full Medicaid coverage are not required to pay cost-sharing.

            Associated Dual Assurance Network

            GuildNet Gold Plus FIDA Plan

            EmblemHealth Medicare ASO

            No/No

            N/A

            None**

            6 county IDT makes all prior approval/ prior authorization decisions. Medicaid-related services should be billed directly to GuildNet c/o Relay Health.

            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.

            6 county = Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island) & Nassau counties
            (Suffolk and Westchester delayed indefinitely)
            8 county = Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island), Nassau, Suffolk & Westchester counties
            *GuildNet Gold Plus FIDA Plan POS members are not required to have a PCP. However, EmblemHealth is required to populate PCP information on the member's ID card to comply with NYSDOH requirements. The provider listed on the member's ID card may be a participating or non-participating provider in accordance with GuildNet’s policy and procedures. For more information, please contact the member’s case manager.
            **No in-network or out-of-network cost-sharing.

            For more information on EmblemHealth’s FIDA Plans, see the Fully Integrated Dual Advantage (FIDA) chapter.

            Provider Obligations/Responsibilities for Participation

            Provider Obligations/Responsibilities for Participation in Dual-Eligible Special Needs Plans

            1. Members have no copayment for covered services other than for prescriptions drugs. The provider may not collect a copayment for covered services from a Dual Eligible SNP member (including but not limited to ArchCare and GuildNet Inc.).
            2. HHS, the Comptroller General or their designees have the right to audit, evaluate and inspect any pertinent information of your medical practice including books, contracts, records, including medical records, and documentation related to CMS’ contract with EmblemHealth for a period of 10 years from the final date of the contract period or the completion of any audit, whichever is later.
            3. The provider may not hold members liable for payment of fees that are the legal obligation of EmblemHealth or a payor (including but not limited to ArchCare and GuildNet Inc.).

            Provider Obligations/Responsibilities for Participation in Medicare-Medicaid Plans (MMPs)

            1. Members have no copayment for covered services other than for prescriptions drugs. The provider may not collect a copayment for covered services from a Medicare-Medicaid Plan (MMP) member (including but not limited to  ArchCare andGuildNet Inc.).
            2. HHS, the Comptroller General or their designees have the right to audit, evaluate and inspect any pertinent information of your medical practice including books, contracts, records, including medical records, and documentation related to CMS’ contract with EmblemHealth for a period of 10 years from the final date of the contract period or the completion of any audit, whichever is later.
            3. The provider may not hold members liable for payment of fees that are the legal obligation of EmblemHealth or a payor (including but not limited to ArchCare and GuildNet Inc.).
            4. For information about provider obligations and responsibilities, see Medicare/Advantage-Medicaid Required Provisions in the Required Provisions to Network Provider Agreements chapter.

            Provider Obligations/Responsibilities for Participation in the GuildNet Inc. d/b/a GuildNet Gold Plus FIDA Plan

            1. GuildNet Inc. d/b/a GuildNet Gold Plus FIDA Plan (“GuildNet”) has the right to request that a particular provider participating in the EmblemHealth ASO program or practitioner or physician employed by or contracted with a provider no longer render services to a member enrolled in GuildNet Gold Plus FIDA Plan. Upon notice from EmblemHealth, provider shall immediately comply with such request and agrees to remove such practitioner or physician from rendering covered services to such members.
            2. If EmblemHealth delegates any services to provider, GuildNet has the right to revoke the delegated activities as they relate to members participating in their FIDA plans.
            3. GuildNet has the right to monitor the performance of providers on an ongoing basis.
            4. For information about provider obligations and responsibilities, see Standard Clauses for Managed Care Provider/IPA Contracts for the Fully-Integrated Duals Advantage Program in the Required Provisions to Network Provider Agreements chapter.

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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.

            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.

            An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.

            A person authorized by the insured to assist in obtaining access to, or payment to, the insured for health care services. If the insured has already received health care services and has no liability for payment of services, a designee will not be authorized for the purpose of requesting an external appeal.

            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.

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

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

            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.

            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.



            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 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 benefits for hospitalization, extended care and nursing home care to Medicare beneficiaries with no premium payment for qualified individuals.

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

            A health care provider, such as a physician, skilled nursing facility, home health agency or laboratory, that does not have an agreement with EmblemHealth plans to provide covered services to members. Also called an Out-of-Network Provider.

            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.

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

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

            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 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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