HIP Prime HMO

  • Offers Extensive Coverage from an Expanding Network of Doctors

    This is the right plan for employers who want to control costs while providing an extensive set of benefits to their employees. The plan features little or no paperwork and you can choose expanded network coverage with our Premium network.  Gives comprehensive coverage, including hospital, medical and pharmacy benefits.

    Key Features

    • For businesses headquartered in New York State
    • Businesses must have 101 or more employees
    • In-network coverage
    • Wide range of covered services, including prescription drug coverage
    • Referrals are required
    • Little or no paperwork

    Helping Members Stay Healthy

    We know good health is worth holding onto. That's why we want to make it as easy as possible for you. We have programs, tools and more to help you stay fit and enhance your quality of life.

    PATH Wellness Programs

    Looking for ways to live healthier? Check out our wellness programs.*

    • Healthy Beginnings PATH Pregnancy Management Program - For the health of mom and baby.
    • Tobacco-Free PATH Smoking Cessation Program - Get help quitting.

     

    We help members stay healthy with:

    • Discounts on weight-loss programs, laser vision, acupuncture and more** 
    • Quit-smoking programs 
    • A Nurse Advice Line that members may call 24/7 to speak with a Registered Nurse 
    • Self-management help tools on our secure member portal of emblemhealth.com

     

    Take a closer look at the health and wellness programs we offer.

    * Availability of health and wellness programs may vary based on the EmblemHealth product selected.

    ** EmblemHealth cannot ensure that a particular vendor will remain in the program. The services available under these programs are not covered services underwritten by Group Health Incorporated ("GHI") or HIP Health Plan of New York (“HIP”) as part of the plan.

    Information Purposes Only

    Some services are subject to prior authorization.

    This summary is provided for information only; it does not contain complete details of the plan (which are available only in the Contract or Certificate of Coverage and Schedule of Benefits) and it does not constitute an Agreement.

  • Search our Provider Directories

    Large Network of Medical Providers

    With the HIP Prime network, you can find network providers in all five boroughs — and all neighborhoods — of New York City, plus Nassau, Suffolk, Westchester, Rockland and Orange counties. Providers include clinicians, specialists, hospitals, labs and other health care facilities.

    You also have coverage at many of the area’s most acclaimed hospitals, such as:

    • Lenox Hill Hospital
    • Montefiore Medical Center
    • North Shore-Long Island Jewish Health System
    • NYU Hospital Center
    • Staten Island University Hospital

    Extensive and Convenient Doctor Care

    In addition to individual doctors in private practice, our network features independent physician group practices (PGPs). At PGPs, many practitioners work together in one location.

    PGPs offer the convenience of getting many of your medical needs addressed during a single instance of care. Also, PGPs combine the personal experience of a doctor’s office with the latest technology and treatments you expect from a hospital. Other benefits at many PGP locations include:

    • A full range of health services, from preventive and primary care to specialty care
    • Testing services 
    • Extended evening and weekend hours
    • Same day appointments for routine medical care
    • Urgent care centers

    In-Network Care

    To take advantage of all the benefits this plan offers, you need to see providers in the plan. You can get covered services from any provider within this network.

    Receiving care from out-of-network doctors or providers is not covered under this plan. You may have to pay for the medical services if you go out of network.

    In cases of emergency, your care is covered regardless of the provider's network status; you will be completely covered at any hospital nationwide. Emergency admissions should be reported within 48 hours, or as soon as reasonably possible.

  • Dental Coverage

    Our HIP Dental options give you access to preventive dental services from participating dentists. You also may purchase additional dental benefits with our EmblemHealth dental plans: Preferred Plus, Preferred and Dental Access.


    HIP and CompreHealth Preventive Dental Services
    Benefits Access to a network of providers that charge discounted fees. No claims are involved. The member pays the provider at the time of service.
    Network Careington International Participating Dentists
    Cost sharing Out-of-network benefits for covered services

    Through our HIP health plan and CompreHealth health plan, we give access to preventive dental services from participating dentists.


    Services Cost
    One exam (comprehensive or periodic) every six months $5 per visit*
    One prophylaxis (cleaning) every six months $10 per visit**
    One topical application of fluoride (for children age 16 and under) every six months $5 per visit

    *Participating dentists may suggest that members get extra services and procedures consistent with generally approved dental practices. For example, a recent full mouth series of X-rays is needed at the time of exam. Frequency of X-rays depends on the practitioner’s judgment of each person’s case based upon a number of factors.

    ** An exam and X-rays are needed prior to a cleaning.

    Discounted Services

    We also give extra services, including but not limited to X-rays, fillings, crowns or dentures, at a discounted rate subject to a fee schedule which may change from time to time. The schedules of services are based on the location of the provider's office. Therefore, members will pay different fees based on the location (region) of the dentist's office.

    Specialist dental services such as endodontic, oral and maxillofacial surgery, orthodontic, pediatric, periodontic and prosthodontic procedures are also available from participating dentists. Charges for specialist services are discounted by 20 percent off the dentist's usual and customary rates. No schedule of services applies to specialist dental services.

    Selecting a Participating Dentist

    Both general and specialist dental services may be self-referred, referred by a participating dentist or arranged through Careington International. Members may select any participating HIP and CompreHealth dentist and may change their choice of provider at any time. Members must use participating dentists for all care under this benefit to take advantage of the discounted rates.

    If you need help finding a participating dentist near you, have questions about your benefits or want a schedule of services or directory, call Careington International at
    1-800-290-0523 or 1-877-548-4447, Monday through Friday, from 8 am to 8 pm.

    Important Notes

    This benefit is not for Child Health Plus members, Medicaid members, HIP/HMO Direct subscriber, HIP/CHOICE Plus Direct subscribers, or Healthy New York members.

    These benefits are for (1) members enrolled through a group or an organization, such as an employer, labor union, association or welfare fund, that acts as a remitting agent and sends HIP and CompreHealth the premium for the member's coverage and (2) members enrolled through a HIP/HMO direct payment contract before 01/01/96.

    EmblemHealth Medicare HMO members, please refer to our Medicare Web site for information about your plan.

    Through HIP and CompreHealth’s agreements with Careington International Corporation, this program gives HIP and CompreHealth members discounts on services given by Careington.


    Dental Coverage

    Groups can choose to add an EmblemHealth dental program* to their medical plan. We offer three different dental programs that feature different benefit designs, network size and member and group cost-sharing responsibilities. * EmblemHealth dental programs are underwritten by Group Health Incorporated (GHI).


    Preferred Plus Preferred Dental Access

    Benefits

    Traditional benefits with cost sharing and a larger network

    Roll-over feature for unused annual benefits maximum

    No approvals or referrals required

    Paid-in-full, in-network coverage for all covered services

    Roll-over feature for unused annual benefits maximum

    No approvals or referrals required

    Paid-in-full, in-network coverage for preventive and diagnostic care

    100% coverage for crown, bridge and denture repair

    Network

    8,100 dentists and specialists in NY and NJ

    Nationwide coverage available

    6,300 dentists and specialists in NY and NJ

    5,500 dentists and specialists in NY and NJ

    Cost sharing

    Out-of-network benefits for covered services

    Out-of-network benefits for covered services.

    In-network discounts for more costly services

    Out-of-network benefits for covered services

    *Individuals in a group plan: These dental benefits can be selected at the time your employer purchases your health plan.

  • Vision Care

    As a member of this plan, refractive eye exams are covered every 12 months.

    Hardware (i.e., frames, lenses and contacts) is covered under an optical benefit, as follows:

    • The optical benefit offers one pair of corrective glasses (within either a 12- or 24-month period) prescribed by a network physician and filled through a network optical provider. Copayment options include $0 or $45. If you choose any other frames or lenses, you will pay the difference between the retail price of the item selected and the retail price of the item covered.
    • A group may also purchase coverage for one pair of corrective contact lenses every 12 or 24 months. Copayment options include $25 or $70 for contact lenses. Contact lenses must be prescribed by a network physician and filled through a network optical provider.

  • For more than 80 years, EmblemHealth has been a health care partner with New York businesses and the people they employ.

    We know companies like yours want to offer health care your employees can afford and that meets their ever-changing needs. Health care that provides access to quality doctors where they live and work. Health care with hassle-free administration that saves you time and resources.

    Let us help you find the right plan for your group. Contact us today.

    For more information, call John Kobi, Director of Group Sales, at 646-447-5038.