Enhanced Care Plus (HARP)

  • Are you eligible for a Health and Recovery Plan, or HARP?

    If so, then you may qualify for our state-sponsored Enhanced Care Plus plan. HARPs are a new kind of plan that provide Medicaid members with their health care, plus care for behavioral health. Members get access to excellent doctors within the EmblemHealth network. There is no monthly premium payment for this plan. However, pharmacy copayments are required for some individuals.

    PCP required Referral for Specialists Visits PCP Specialist Copay Network Out of network coverage Deductibles Out of pocket maximum
    Yes Yes No Enhanced Care Prime Yes* N/A N/A
    *Requires prior authorization from plan


    If you are facing a mental health or substance use crisis, reach out to us here.

  • EmblemHealth is to provide you with access to high-quality dental care, which is why we have contracted with DentaQuest to manage the dental needs of our Medicaid Managed Care members. DentaQuest gives you access to their large network of quality dentists, which includes a dental clinic operated by an academic dental center. Medicaid Managed Care members will receive the following services:

    • Routine exams
    • X-rays
    • Cleanings, fillings and tooth pulling
    • Emergency treatment
    • Replacement of missing teeth (full and partial dentures). Covered when conditions meet Medicaid guidelines.
    • Root canals. Patients must be evaluated on a case-by-case basis to determine if conditions meet Medicaid coverage guidelines. Coverage will generally be provided when the number of teeth needing or likely to need root canals is "not excessive" and the patient has good oral hygiene, and has a healthy mouth and gums, and:
      • Has few, if any cavities; and
      • Has a full complement of natural teeth; and
      • Has had all other necessary restorations completed; and/or
      • Is undergoing orthodontic treatment
    • Root canals will not be covered when the prognosis of the tooth is questionable or extraction and replacement is a reasonable alternative course of treatment. Molar root canals will not be covered for patients over the age of 21, except where the tooth is a critical abutment for an existing prosthesis.
    • Crowns will not routinely be approved if restorative materials can restore the teeth. Crowns will not be covered on molar teeth for patients over the age of 21.
    • Fixed bridges are considered beyond the scope of the program and are not covered.

    When you need covered dental specialty services, your DentaQuest network dentist will refer you.

    EmblemHealth covers braces for children up to age 21 who have a severe problem with their teeth, such as: can’t chew food due to severely crooked teeth, cleft palette or cleft lip.

    If you have questions about your dental coverage or would like to change your network dentist, visit dentaquest.com or call DentaQuest at 1-844-776-8748, Monday through Friday from 8 am to 5 pm.


    If you are facing a mental health or substance use crisis, reach out to us here.

  • What does Enhanced Care Plus (HARP) cover?

    In this section, we explain the benefits EmblemHealth covers for all members, the ones EmblemHealth covers for some members, the ones that are available from both EmblemHealth and Medicaid, and the ones that are only covered by Medicaid.

    Learn what the plan offers and how it can benefit you.

    You must get these services from the providers who are in our plan.  All services must be medically or clinically necessary and provided or referred by your PCP (primary care provider).  Please call our Customer Service department at 1-855-283-2146 if you have any questions or need help with any of the services below.

    • office visits with your PCP
    • referrals to specialists
    • eye / hearing exams
    • help staying on schedule with medicines
    • coordination of care and benefits
    • regular check-ups
    • access to free needles and syringes
    • smoking cessation counseling
    • HIV education and risk reduction
    • referral to Community Based Organizations (CBOs) for supportive care
    • smoking cessation care
    • pregnancy care
    • doctors/mid-wife and hospital services
    • screening for depression during pregnancy and up to a year after birth
    • Must be medically needed and arranged by EmblemHealth
    • One medically necessary post-partum home health visit, additional visits as medically necessary for high-risk women
    • Other home health care visits as needed and ordered by your PCP/specialist
    • Must be medically needed and arranged by EmblemHealth
    • Personal Care/Home Attendant - Help with bathing, dressing and feeding, and help preparing meals and housekeeping.
    • CDPAS – Help with bathing, dressing and feeding, help preparing meals and housekeeping, plus home health aide and nursing. This is provided by an aide chosen and directed by you. If you want more information contact EmblemHealth at 1-855-283-2146.

    This is an item you wear in case you have an emergency and need help. To qualify and get this service, you must be receiving personal care/home attendant or CDPAS services.

    • Must be recommended by your Primary Care Provider (PCP).
    • Provides health education, nutrition, nursing and social care, help with daily living, rehabilitative therapy, pharmacy services, plus referrals for dental and other specialty care.

    This is help with taking your medication for TB and follow up care.

    • Hospice helps patients and their families with their special needs that come during the final stages of illness and after death.
    • Must be medically needed and arranged by EmblemHealth.
    • Provides support services and some medical services to patients who are ill and expect to live for one year or less.
    • You can get these services in your home or in a hospital or nursing home.
    • Services of an ophthalmologist, ophthalmic dispenser and optometrist.
    • Coverage for contact lenses, polycarbonate lenses, artificial eyes, and/or replacement of lost or destroyed glasses, including repairs, when medically necessary.  Artificial eyes are covered as ordered by a plan provider
    • Eye exams, generally every two years, unless medically needed more often
    • Glasses, with new pair of Medicaid approved frames every two years, or more often if medically needed
    • Low vision exam and vision aids ordered by your doctor

    * Your routine vision benefits are administered by EyeMed. If you’d like help finding an eye care provider, visit eyemedvisioncare.com/emblem or call EyeMed at 1-877-324-2791, 7:30 am to 11 pm, Monday through Saturday or 11 am to 8 pm on Sunday.

    • Prescription drugs
    • Over-the-counter medicines
    • Insulin and diabetic supplies
    • Smoking cessation agents, including OTC products
    • Hearing aid batteries
    • Emergency Contraception (6 per calendar year)
    • Medical and surgical supplies
    • inpatient care
    • outpatient care
    • lab, x-ray, other tests
    • Emergency care services are procedures, treatments or services needed to evaluate or stabilize an emergency.
    • After you have received emergency care, you may need other care to make sure you remain in stable condition. Depending on your need, you may be treated in the Emergency Room, in an inpatient hospital room, or in another setting. This is called Post Stabilization Services.

    Includes the services of other practitioners, including:

    • Occupational, physical and speech therapy — Limited to twenty (20) visits per therapy per calendar year. Children under age 21, members that have a developmental disability as determined by the Office for People With Developmental Disabilities and members that have a traumatic brain injury do not have a limit on the number of visits for these services.
    • Audiologists
    • Durable medical equipment (DME), including hearing aids, artificial limbs and orthotics.
    • Renal and hemodialysis.
    • HIV/AIDS treatment services.
    • Midwifery services.
    • Cardiac rehabilitation.
    • Outpatient detoxification services.
    • Podiatrists if you are diabetic
    • Other covered services as medically needed.
    • includes short term, or rehab, stays and long term care;
    • must be ordered by a physician and authorized by EmblemHealth Enhanced Care Plus;
    • covered nursing home services include medical supervision, 24-hour nursing care, assistance with daily living, physical therapy, occupational therapy, and speech-language pathology.

    If you are in need of long term placement in a nursing home, your local department of social services must determine if you meet certain Medicaid income requirements. EmblemHealth Enhanced Care Plus and the nursing home can help you apply.

    You must get this care from a nursing home that is in EmblemHealth’s provider network. If you choose a nursing home outside of EmblemHealth’s network, you may have to transfer to another plan. Call New York Medicaid Choice at 1-800-505-5678 for help with questions about nursing home providers and plan networks.

    Call 1-855-283-2146 for help finding a nursing home in our network.

     

     

    Behavorial Health Care

    Behavioral health care includes mental health and substance use (alcohol and drugs) treatment and rehabilitation services. All of our members have access to services to help with emotional health, or to help with alcohol or other substance use issues. These services include:

    • Intensive psychiatric rehab treatment (IPRT)
    • Outpatient Clinic Services
    • Inpatient mental health treatment
    • Partial hospitalization program
    • Continuing day treatment
    • Personalized Recovery Oriented Services (PROS)
    • Assertive Community Treatment Services (ACT)
    • Individual and group counseling
    • Crisis intervention services
    • Inpatient substance use disorder (alcohol and drug) treatment
    • Inpatient and outpatient detoxification services
    • Outpatient clinic and opioid treatment program services (OTP), including Methadone Maintenance treatment
    • Residential Substance Use Disorder Treatment
    • Outpatient alcohol and drug treatment services
    • Rehabilitation services for residential substance use treatment supports

    BHHCBS can help you with life goals such as employment, school, or other areas of your life you want to work on. To find out if you qualify, a Health Home Care Manager must complete a brief screening with you that will show if you can benefit from these services. If the screening shows you can benefit, the Care Manager will complete a full assessment with you to find out what your whole health needs are including physical, behavioral and rehabilitation services.

    BHHCBS includes:

    • Psychosocial Rehabilitation (PSR) – helps you improve your skills to reach your goals.
    • Community Psychiatric Support and Treatment (CPST) - is a way to get treatment services you need for a short time at a location of your choosing, such as your own home. CPST helps connect you with a licensed treatment program.
    • Habilitation Services - helps you learn new skills in order to live independently in the community.
    • Family Support and Training - is teach skills to help the people in your life support you in your recovery.
    • Short-term Respite - gives you a safe place to go when you need to leave a stressful situation. 
    • Intensive Respite - helps you stay out of the hospital when you are having a crisis by providing a safe place to stay that can offer you treatment.
    • Education Support Services - helps you find ways to return to school to get education and training that will help you get a job.
    • Pre-Vocational Services - helps you with skills needed to prepare for employment.
    • Transitional Employment Services - gives you support for a short time while trying out different jobs. This includes on-the job training to strengthen work skills to help keep a job at or above minimum wage.
    • Intensive Supported Employment Services- helps you find a job at or above minimum wage and keep it.
    • Ongoing Supported Employment Services- helps you keep your job and be successful at it.
    • Empowerment Services-Peer Supports - people who have been there help you reach your recovery goals.
    • Non-Medical Transportation – transportation to non-medical activities related to a goal in your plan of care.
    • Durable Medical Equipment (DME) / Hearing Aids / Prosthetics / Orthotics
    • Court Ordered Services
    • Social Support Services (help in getting community services)
    • FQHC or similar services 

     

     

    Health Home Care Management

    BHHCBS can help you with life goals such as employment, school, or other areas of your life you want to work on. To find out if you qualify, a Health Home Care Manager must complete a brief screening with you that will show if you can benefit from these services. If the screening shows you can benefit, the Care Manager will complete a full assessment with you to find out what your whole health needs are including physical, behavioral and rehabilitation services.

    EmblemHealth can help you enroll with a Health Home that will assign your personal Health Home Care Manager. Your Health Home Care Manager can help you make appointments, help you get social services, and keep track of your progress.

    Your Health Home is responsible for giving you an assessment to see what Behavioral Health Home and Community Based Services you may need. Using the assessment, you and your Health Home Care Manager will work together to make a Plan of Care that is designed especially for you.

    • Work with your PCP and other providers to coordinate all of your physical and behavioral health care;
    • Work with the people you trust, like family members or friends, to help you plan and get your care;
    • Support you getting social services, like SNAP (food stamps) and other social service benefits;
    • Develop a plan of care with you to help identify your needs and goals;
    • Help with appointments with your PCP and other providers;
    • Help managing ongoing medical issues like diabetes, asthma, and high blood pressure;
    • Help you find services to help with weight loss, healthy eating, exercise and to stop smoking;
    • Support you during treatment;
    • Identify resources you need that are located in your community;
    • Help you with finding or applying for stable housing;
    • Help you safely return home after a hospital stay; and
    • Make sure you get follow up care, medications and other needed services.

    Your Health Home Care Manager will be in touch with you right away to find out what care you need and to help you with appointments. Your Health Home Care Manager or someone from your Health Home provider is available to you 24 hours a day, 7 days a week at 1-855-283-2146.

    If you are in a behavioral health (mental health or substance use) crisis and need to talk to someone right away, call 1- 888-447-2526. If your PCP in the Montefiore network, call 1-800-401-4822. Your Health Home Care Manager will work with you, your caregiver, your provider and an EmblemHealth Care Manager to put into place your plan of care. The EmblemHealth Care Manager may specialize in behavioral health or medical health, depending upon your needs.

    The EmblemHealth Care Manager can support you when you need to move from one kind of care to another, such as inpatient to the community and will be in contact with you, your caregiver(s), your providers and the Health Home Care Manager to make sure that you get the medically necessary services and supports. The Care Manager may request information from your providers so that we can make decisions on requests for care and supports for you. We will meet with your Home Health Care manager regularly so that everyone is updated on what care and support you are receiving and if your care plan needs to be updated.

     

     

    Benefits You Can Get From Our Plan OR With Your Medicaid Card

    For some services, you can choose where to get your care. You can get these services by using your EmblemHealth membership card. You can also go to providers who will take your Medicaid Benefit card. You do not need a referral from your PCP to get these services. Call Customer Service if you have questions at 1-855-283-2146.

    You can go to any doctor or clinic that takes Medicaid and offers family planning services. Or you can visit one of our family planning providers. Either way, you do not need a referral from your PCP.

    You can get birth control drugs, birth control devices (IUDs and diaphragms) that are available with a prescription, plus emergency contraception, sterilization, pregnancy testing, prenatal care, and abortion services. You can also see a family planning provider for HIV and sexually transmitted infection (STI) testing and treatment and counseling related to your test results. Screenings for cancer and other related conditions are also included in family planning visits.

    You can get this service any time from your PCP or EmblemHealth doctors. When you get this service as part of a family planning visit, you can go to any doctor or clinic that takes Medicaid and offers family planning services. You do not need a referral when you get this service as part of a family planning visit.

    Everyone should talk to their doctor about having an HIV test. To access free HIV testing or testing where your name isn’t given, call 1-800-541-AIDS (English) or 1-800-233-SIDA (Spanish).

    You can choose to go either to your PCP or to the county public health agency for diagnosis and/or treatment. You do not need a referral to go to the county public health agency.

     

     

    Benefits Using Your MEDICAID CARD Only

    There are some services EmblemHealth Enhanced Care Plus does not provide. You can get these services from any provider who takes Medicaid by using your Medicaid Benefit card.

    Emergency and non-emergency transportation are covered by regular Medicaid.

    To get non-emergency transportation, you or your provider must call LogistiCare at 1-877-564-5922. If possible, you or your provider should call LogistiCare at least 3 days before your medical appointment and provide your Medicaid identification number (ex. AB12345C), appointment date and time, address where you are going, and doctor you are seeing. Non-emergency medical transportation includes: personal vehicle, bus, taxi, ambulette and public transportation.

    If you have an emergency and need an ambulance, you must call 911.

    • Long-term therapies
    • Day treatment
    • Housing services
    • Medicaid Service Coordination (MSC) program
    • Services received under the Home and Community Based Services Waiver
    • Medical Model (Care-at-Home) Waiver Services


    If you are facing a mental health or substance use crisis, reach out to us here.

  • Services Not Covered by Enhanced Care Plus (HARP)

    These services are not available from EmblemHealth or Medicaid. If you get any of these services, you may have to pay the bill.

    • Cosmetic surgery if not medically needed
    • Services of a Podiatrist (unless you are a diabetic)
    • Personal and comfort items
    • Infertility treatments
    • Services from a provider that is not part of EmblemHealth, unless it is a provider you are allowed to see as described elsewhere in this handbook, or EmblemHealth or your PCP sends you to that provider.


    If you are facing a mental health or substance use crisis, reach out to us here.

  • Some Enhanced Care Plus members are required to make copayments when receiving pharmacy services. Others do not have to make these payments. See the following list of pharmacy services that require copayments and information about who does not have to make copayments. If you have questions, please call Customer Service at 1-800-447-8255. If you have a pharmacy benefit question, please call EmblemHealth Pharmacy Customer Services at 1-888-447-7364, Monday through Friday, 8 am to 6 pm.

    Services Copay

    Brand-name prescription drugs

    $3.00

    Preferred brand-named prescription drugs

    $1.00

    Generic prescription drugs

    $1.00

    Over-the-counter medications(e.g., for smoking cessation and diabetes)

    $0.50 per medication


    • Note: There will be one copay charge for each new prescription and each refill regardless of the number of days’ supply of the prescription.
    • The maximum copayment per calendar year is $200.
    • There are no copayments for the following members and/or services:
      • Members younger than 21 years old.
      • Members who are pregnant. Pregnant women are exempt during pregnancy and for the two months after the month in which the pregnancy ends.
      • Residents of community-based residential facilities licensed by the Office of Mental Health or the Office for People With Developmental Disabilities.
      • Members in a Comprehensive Medicaid Case Management (CMCM) or Service Coordination Program.
      • Members in an OMH or OPWDD Home and Community Based Services (HCBS) Waiver Program.
      • Members in a DOH HCBS Waiver Program for Persons with Traumatic Brain Injury (TBI).
      • Family Planning drugs and supplies like birth control pills and condoms.
      • Drugs to treat mental illness (psychotropic) and tuberculosis.
      • Members who are financially unable to make copayments at any time who tell the provider that they are unable to pay
      • Members Who Do Not Have to Make Copayments


    Learn how to enroll in Enhanced Care Plus


    If you are facing a mental health or substance use crisis, reach out to us here.