Medicaid Managed Care

  • Are you eligible for Medicaid?

    If so, then you may qualify for our state-sponsored Medicaid Managed Care plan. 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 Prime Yes* N/A N/A
    *Requires prior authorization from plan
  • Having healthy teeth is part of staying healthy

    Our goal at 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 or call DentaQuest at 1-844-776-8748, Monday through Friday from 8 am to 5 pm.

  • What does Medicaid Managed Care 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.

    Download the Medicaid Member Handbook and learn how EmblemHealth will work for you

    Benefits covered for all of our Medicaid Managed Care members.

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

    These services help prevent health problems and help find problems before they get serious. Care includes routine and sick visits to your primary care physician (PCP) and other network providers for:

    This type of care helps prevent health problems. It also helps find problems before they get serious. Care includes routine and sick visits to your PCP and other EmblemHealth network doctors for:

    • Regular checkups
    • Well-baby and well-child care (shots, checkups and developmental screenings)
    • Eye and hearing exams
    • Eyeglasses and other medically needed vision aids
    • Regular gynecological exams
    • Breast exams (including mammography)
    • Allergy testing and treatment
    • HIV counseling and testing services
    • Smoking cessation counseling
    • Four fluoride varnish applications (for children under 7 years of age)
    When medically needed, your doctor will refer you for:
    • Lab work
    • X-rays
    • Specialty care
    • Prenatal care
    • Childbirth classes
    • Doctor/midwife services
    • Hospital delivery
    • Newborn nursery care

    We cover pharmacy benefit services for all our Medicaid managed care members. You must use our network pharmacies to fill all of your prescriptions and any covered over-the-counter medications, diabetic supplies, select durable medical equipment and medical supplies.

    We offer a large network of well-known pharmacies, as well as many independent pharmacies. Ask your pharmacy if they are a network pharmacy. If they are, you can continue to use that pharmacy. If not, you will need to switch to a pharmacy that is in our network. This is easy to do; and it's important for getting your prescriptions filled in a timely manner and for avoiding out-of-pocket costs. To search for a list of participating pharmacies, click here.

    Please make sure to use your member ID Card when filling a prescription or obtaining other covered pharmacy benefits at a network pharmacy. It has information that your pharmacy needs to process your prescriptions. To locate a network pharmacy near you, use the Pharmacy Locator. You can also call our Pharmacy Customer Service department at 1-888-447-7364.

    Our formulary is a list of medications that network doctors and other medical experts have approved for treating disease and maintaining the health of our Medicaid members. The main purpose of the formulary is to support the use of safe, effective and affordable drugs and treatments while providing our Medicaid members with quality care. Your doctors will prescribe medications listed on the formulary for your benefit plan unless there is a medical need to prescribe a drug that is not on the list. To see a list of drugs covered for Medicaid members, click here.

    You may get home delivery of your maintenance drugs through our mail order pharmacy partner Express Scripts, Inc. (ESI). Maintenance drugs are used to treat chronic conditions and are usually prescribed in quantities greater than 30-day supplies. All you need to do is get a new written prescription from your doctor or other licensed health care provider, and mail it to ESI along with the completed order form. You may request an ESI order form to be mailed to you by calling our Pharmacy Customer Service at 1-888-447-7364. Mail the form and the original prescription(s) along with the required copayment to ESI as directed on the form. You may include multiple new prescriptions in your order.

    If you prefer, your doctor or other licensed health care professional can assist you. You can bring your order form to them and they can fax it to ESI directly with your prescription. Or they can submit your prescription via the Web. In both cases, they must have your member ID number. Only doctors or other licensed health care providers may submit new prescriptions via fax or Web.

    To use the Home Delivery tool, go to myEmblemHealth and register if you haven't already. After you sign in, click on “Pharmacy Services” and then select “Home Delivery”. You will be able to do things like check order status and request refills to existing prescriptions. You will need to register the first time you use the tool, and you will need your member ID to create an account. You or your doctor will still need to send ESI the actual written prescription when using the online option. Please allow 7 to 10 days for delivery from the day ESI receives the prescription(s) to receive your home delivery.

    You can easily check the status of your order via the EmblemHealth/Express Scripts pharmacy benefits tool on this page. You will need to sign in using your member ID and password. You can also call ESI at 1-877-866-4165. If you have a hearing or speech impairment, and use a TDD, you can call 1-800-899-2114. You will need your member ID number and your prescription number(s) to access this information.

    Specialty drugs are usually injectable, oral or inhaled drugs. They are used to treat chronic conditions such as multiple sclerosis, growth deficiencies, hepatitis C and cancer. They also require special storage and/or handling. You have the choice of filling your specialty drug prescription using one of the following options:
    • Our Specialty Pharmacy Program
      If you choose to use our Specialty Pharmacy Program, your doctor or other health care professional will contact our Specialty Pharmacy Program and your prescriptions will be filled and sent directly to your home or doctor's office.  For more information regarding how to use our Specialty Pharmacy Program call EmblemHealth's Specialty Pharmacy Program at 1-888-447-0295.

    Medicaid Managed care pharmacy benefit includes:

    • Prescription drugs
    • Over-the-counter medicines (OTC)
    • Insulin and diabetic supplies
    • Smoking cessation agents, including OTC products
    • Hearing aid batteries
    • Enteral formula
    • Emergency Contraception (six per calendar year)
    • Medical and surgical supplies

    This type of care includes:

    • Inpatient care
    • Outpatient care
    • Emergency care
    • Lab work and other tests
    • X-rays
    • Nursing services
    • Inpatient and outpatient surgery, including dental surgery
    • Inpatient detoxification services
    • Emergency care services are procedures, treatments or services needed to evaluate or stabilize an emergency condition.
    • Care you need after you have received emergency care to make sure you remain in stable condition. Depending on the need, you may be treated in the emergency room, in an inpatient hospital room, or in another setting. These are called Post Stabilization Services.

    This type of care includes but is not limited to medically needed care:

    • 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.
    • Durable medical equipment (DME), including hearing aids, artificial limbs and orthotics
    • Renal and Hemodialysis
    • HIV/AIDS treatment services
    • Midwife services
    • Cardiac rehabilitation
    • Outpatient detoxification services.
    • Other covered services as medically needed

    These services are generally provided so that you do not have to stay in a hospital. Your doctor or case manager must agree that your medical needs can be met at home with this help, and request prior approval from you plan. Services also include:

    • One medically necessary post partum home health visit, additional visits as medically necessary for high-risk women.
    • At least 2 visits to high-risk infants. (newborns)
    • Other home health care visits as needed and ordered by your PCP/specialist.
    • Must be medically needed and arranged by us
    • Provide some or total assistance with personal hygiene, dressing and feeding and assist in preparing meals and housekeeping.
    • Personal Care/Home Attendant - Provides some or total assistance with personal hygiene, dressing and feeding and assist in preparing meals and housekeeping when medically needed and arranged by EmblemHealth.
    • CDPAP - Under this program you receive the personal care/home attendant services indicated above, as well as home health aid and nursing tasks. The difference is that the services are provided by an aide chosen and directed by you. The aide may provide some or total assistance with personal hygiene, dressing and feeding, assistance in preparing meals and housekeeping as well as home health aide and nursing tasks. For more information about CDPAP, contact customer services at 1-800-447-8255.

    PERS is an in-home health emergency alert system available only to members receiving home health and/or personal care services.

    This type of care includes:

    • Services of an ophthalmic dispenser, ophthalmologist and optometrist.
    • Low-vision eye exams and vision aids ordered by a network doctor (every two years, but more often if medically needed).
    • Medically needed contact lenses.
    • Eyeglasses (a new pair of Medicaid-approved frames every two years, or more often if medically needed). Progressive lenses are not covered.
    • Scratch-resistant, break-resistant and polycarbonate eyeglass lenses.
    • Artificial eyes (when ordered by an EmblemHealth network doctor).
    • Replacement of lost or destroyed glasses, including repairs, when medically needed.
    • Specialist referrals for eye diseases and defects.
    • Members diagnosed with diabetes may self-refer for a dilated eye (retinal) examination once in any 12-month period.

    * Your routine vision benefits are administered by EyeMed. If you’d like help finding an eye care provider, visit 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.

    These services include:

    • Birth control
    • Sterilization
    • Medically necessary abortions
    • Screening for anemia, cervical cancer, sexually transmitted diseases, hypertension, breast disease, pelvic abnormality and pregnancy

    You can get these services from EmblemHealth network OB/GYN doctors. Or, you can use your Medicaid card if you want to go to doctors or clinics out of our network. Either way, no approval or referral from an EmblemHealth network doctor is needed to get these services. Just make an appointment.

    When a temporary stay is ordered by your network doctor and approved by your health plan, services include:

    • Medical supervision
    • 24-hour nursing care
    • Assistance with activities of daily living
    • Physical and occupational therapy and speech language pathology

    EmblemHealth also covers long term placement in a nursing home for members 21 years of age.

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

    To get these nursing home services:

    • they must be ordered by your physician, and
    • authorized by EmblemHealth.

    You must also be found financially eligible for long term nursing home care by your County Department of Social Services to have Medicaid and/or EmblemHealth pay for these services. When you are eligible for long term placement, you must select one of the nursing homes that are in EmblemHealth’s network.

    If you want to live in a nursing home that is not part of EmblemHealth’s network, you may transfer to another plan that works with the nursing home you have chosen to receive your 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
    • Day treatment
    • Clinic continuing day treatment
    • Inpatient and outpatient mental health treatment
    • Partial hospital care
    • Rehab services if you are in a community home or in family-based treatment
    • Continuing day treatment
    • Personalized Recovery Oriented Services
    • Assertive Community Treatment Services
    • Individual and group counseling
    • Crisis intervention services
    • Inpatient and outpatient substance use disorder (alcohol and drug) treatment
    • Inpatient detoxification services
    • Opioid, including Methadone Maintenance treatment
    • Residential Substance Use Disorder Treatment
    • Outpatient alcohol and drug treatment services Detox services

    These services are covered for members under 21 years of age who are receiving hospice services from regular Medicaid.

    Includes assessment and nutritional counseling sessions with a network registered dietician. The result of the initial assessment will determine the number of sessions required. Both the assessment and the counseling sessions require a referral by your primary care physician. Members who particularly benefit from these services include those who are pregnant; newly diagnosed or living with diabetes, heart disease and/or kidney disease; have an eating disorder or other digestive problems; or have been diagnosed as overweight or obese by their physician.

    These services include the coordination of benefits and services for members that have complex or serious diseases or conditions. Members may be assigned to a case management nurse who will work with you and your doctors to ensure that you get the care and services you need, when you need them. You could be in the program for weeks, months or years depending on your condition and circumstances. The purpose of case management is to achieve the best health care outcome.

    These services include help in getting any community services you may need.

    These types of treatments are covered on a case-by-case basis according to New York State law.

    These services include any-covered services ordered by a judge.

    Benefits EmblemHealth Covers for Some Members

    EmblemHealth covers the following services for some, but not all, members. Check to see if we cover these benefits for you or in the county where you get Medicaid:

    EmblemHealth will cover 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.

    Includes land and air ambulance transportation. Our plan covers this service for Nassau and Suffolk county members only. Regular Medicaid covers this service for New York City and Westchester members. In an emergency, all members should just call 911 for emergency transportation.

    This type of care is covered for all children under 21 years of age and members (regardless of age) with physical conditions that pose a hazard due to the presence of localized illness, injury or symptoms involving the foot, or when performed as a necessary and integral part of otherwise covered services such as the diagnosis and treatment of diabetes, ulcers and infections.

    Services include routine hygienic care of the feet, the treatment of corns and calluses, the trimming of nails, and other hygienic care such as cleaning or soaking feet.

    Benefits you can get from EmblemHealth or through regular Medicaid with your Medicaid card.

    You can choose where to get the following services — from an EmblemHealth network doctor, or any doctor who will accept your Medicaid card — without a referral:

    You can get these services from EmblemHealth network doctors, or you can get them from any doctor or clinic that will take your Medicaid card. No approval or referral from network doctors is needed.

    All members must use EmblemHealth network doctors for hysterectomies, routine gynecological exams, prenatal care, delivery and postpartum (after-delivery) care.

    You can get these services from EmblemHealth network providers, or you can get them from any doctor or clinic that will take your Medicaid card if they are part of a family planning visit.

    You can get these services from EmblemHealth network providers, or you can get them from a county public health clinic.

    Benefits using your Medicaid card only.

    The following services are covered by Medicaid, but not EmblemHealth. You can get these services from any provider who will take your Medicaid card:

    Emergency Transportation Services

    Regular Medicaid covers emergency transportation for our New York City and Westchester Medicaid members. In an emergency, all members just call 911 for emergency transportation.

    Nonemergency Transportation Services*

    All Members

    Nonemergency rides are covered by regular Medicaid and not by EmblemHealth for all Medicaid members. To arrange for transportation, members must call:

    • Nassau County members: Logisticare at 1-877-813-5602.
    • Suffolk County member: Servisair at 1 -866-952-1564.
    • Westchester County members: Medical Answering Services (MAS) at 1-866-883-7865.
    • New York City Members: Logisticare at 1-877-564-5922.

    If possible, you or your provider should call the above numbers at least three days prior to your medical appointment and give the representative:

    • Your Medicaid ID number (for example, AB12345C).
    • Appointment date and time.
    • Address where your appointment will take place.
    • Your doctor’s name.

    *Nonemergency 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
    • Home and community-based waiver program services
    • Medical model (Care-at-Home) waiver services
    • Preschool and school services programs (early intervention)
    • Early Start programs
    • Comprehensive Medicaid case management
    • Directly Observed Therapy (DOT) for tuberculosis
    • Adult day treatment for persons with HIV
    • Long-term health care
    • Hospice services

    Homelessness and Health Care in New York

    Life throws everyone a curve ball now and then. Loss of income and other life events can lead to homelessness. If it happens to you, call the customer service number on the back of your member ID card. We know you may be moving often and changing PCPs, so we’ll work with you to meet your needs and help make sure you continue to receive health care.

    Signing on to myEmblemHealth is the fastest and easiest way to:

    • View or change your PCP
    • Order a new ID card and/or print a temporary ID card
    • Change your mailing address and other contact information
    • Check your enrollment status
    • Review your claims and contact customer service
    photo of health plan pocket guide

    Did you receive your complementary health plan pocket guide? If not, you can request a hard copy from Customer Service using the Message Center after you sign in or call 1-800-447-8255. Just ask for the guide #45-7825. It’s also easy to download a copy by clicking on the cover to the left.

    Health Care Resources

    Case Management

    Dealing with a health condition can be stressful. Our Case Management Program can help relieve some of that stress by coordinating your care. Learn more.

    Disease Management

    If you have diabetes, asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure or coronary artery disease (CAD), the EmblemHealth PATH Program can help you. Learn more.

    Dental Services

    If you have questions about your dental coverage or would like to change your dentist, please call Healthplex at 1-800-468-9868, Monday through Thursday from 8 am to 8 pm, and Friday from 8 am to 6 pm.

    EmblemHealth Behavioral Services

    Call 1-888-447-2526 for information about mental health, alcohol and substance use disorder services.

    Urgent Care Facilities

    When you need to see a doctor after office hours or on weekends for non-emergency care such as a sore throat or other minor health problem, visit one of our network urgent care centers for treatment. No referrals are needed.

    We’re here to help. Call us to discuss your health plan concerns and get additional information about your coverage at 1-800-447-8255.

    Other Helpful Resources


    Domestic Violence

    Clothing and Footwear

    Cell Phone Services
  • Learn what is not covered by Medicaid Managed Care.

    For your information, the following services are not covered by EmblemHealth or regular 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 (for members 21 years of age and older)
    • Personal and comfort items
    • Infertility treatments
    • Chiropractic services
    • Gender re-assignment

    You may also have to pay for services that:

    • You get from a provider not in our network, unless it is a provider you are allowed to see as described in your handbook, or if your PCP refers you to that provider.
    • Require prior health plan approval and you get these services without prior approval.

      Also,if before you get non covered services, or an unauthorized service, and you agree to be a “ private-pay ” or “ self-pay ” patient you will have to pay for the services received.

      If you have any questions about your benefits, call Customer Service at 1-800-447-8255.

      Learn how to enroll in Medicaid Managed Care

    • Some Medicaid 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 Medicaid Managed Care