Summary of 2017 Medicare Benefit and Plan Changes

For coverage effective January 1, 2017, the Medicare annual enrollment period began October 15, 2016, and ends December 7, 2016. Please speak with your patients and encourage them to make sure their health coverage meets their needs and that they check to ensure any associated costs and coinsurance requirements are within their budget. Review the changes in our Policy Alert.

2017 Benefit Changes to Select Care Plans and Essential Plan

The Open Enrollment Period began on November 1, 2016, and ends on January 31, 2017 for individual Select Care plans both on- and off-exchange. Small group Select Care plans and the Essential Plan have a rolling open enrollment, making them available any month of the year.

Select Care plans use the Select Care Network, and Essential Plan uses the Enhanced Care Prime Network. View some of the changes in EmblemHealth's individual and small group plans for 2017.



Please remind Medicaid members to recertify with their local Department of Social Services or the New York State of Health Marketplace two months prior to their Eligibility End Date. To determine when that will be, look for it on the 270/271 report*. If members do not recertify on time, they will lose eligibility for Medicaid, lose their health insurance coverage and will have to reapply for Medicaid. (More)

*If you do not receive this report, please advise members that they will receive a letter in the mail alerting them about their recertification deadline.

Optional Health Home Benefit for Medicaid Members

The Medicaid State Plan offers an optional Health Home benefit that coordinates care for Medicaid patients who have chronic conditions. Find out if a Health Home is an option for your Medicaid patients.

Pharmacy Changes for Medicaid and HARP Members

Effective January 1, 2017, our Medicaid/HARP members will no longer be able to fill prescriptions at CVS or Target. When writing prescriptions for these members, especially when ePrescribing or prescribing controlled substances, please ask them to designate a new pharmacy. Although members can arrange to have certain prescriptions moved from CVS or Target to a new pharmacy, if you are able to have the prescription sent to the right place it will improve the memberís experience and increase the likelihood of medication compliance.

Use the Medicaid pharmacy locator to find alternate pharmacies to recommend to your Medicaid members.

EmblemHealth Prime Network Expands Into Connecticut

Beginning January 1, 2017, EmblemHealth is expanding its Prime Network to the Tri-State region by adding ConnectiCare's HMO provider network to the EmblemHealth Prime Network. Members will now also have access to providers in CT — just as they do NY and NJ. Prime Network members will be able to select any eligible* provider in the Prime Network as their PCP, regardless of where a member is domiciled and regardless of where the Prime provider offers services, e.g., provider may offer services in NY, NJ or CT.

*Providers must have an open panel (accepting new members), be a provider that can be considered as a primary care physician following all existing business rules.


   Striving for Five

Enhance Patient Engagement Among Frontline Staff

  • Greet patients with a warm and friendly smile.
  • Minimize wait times by analyzing bottlenecks in your office workflow.
  • Ask patients if they need help with their care, such as scheduling an appointment with a specialist.
  • At end of the visit, make sure patients can recall in their own words what they were told, and understand follow-up actions.
  • During flu season, remind patients to get a flu vaccination.

Benefit Changes for City of New York HMO/PPO PBA Members

Effective October 14, 2016 for HMO members, and September 30, 2016 for PPO members, the Tiered Benefit Product no longer applies to Patrolmen's Benevolent Association (PBA) members retroactive to July 1, 2016. New ID cards reflecting the correct copays will be sent to members. Please note: Certain Affordable Care Act (ACA) mandated benefits will remain in place for PBA members.

Claims Corner

New Reimbursement Methodology for Injectables and In-Office Medications

EmblemHealth periodically reviews and adjusts reimbursement levels to reflect changes in market prices for acquiring and administering drugs. Effective February 1, 2017, we are implementing a new reimbursement methodology for injectables and other in-office medications.

Take Advantage of 837D Electronic Claims Transactions for Commercial Coordination of Benefits

The HIPAA ASC X12N 837 transaction applies to services rendered by health care professionals, including 837D for dental practitioners, in which payment responsibility is apportioned between the primary insurance carrier and a second carrier. Learn more at our EDI Transactions webpage.

Medical Technologies Database 2016

The Medical Technologies Database 2016 contains a comprehensive list of medical technologies reviewed by the Medical Policy Subcommittee for coverage consideration.



Religion is Key in Cultural Competency

EmblemHealth is pleased to offer The Medical Manual for Religio-Cultural Competency. It provides practical information to help practitioners understand how a patient's medical decisions can be influenced by their religious observances and is the most comprehensive guide to religion and health care available. Sign on to the secure provider site to get a FREE copy of The Medical Manual.



Monthly Instructor-Led Webinars

For in-depth information about our Networks, benefit plans, web-based tools and resources, join us for one of our monthly live Webinars.

Offered the second Wednesday of each month, at 10 am and 2 pm, this informational session shows you how to get the most value from our website.

All instructor-led webinars are hosted by EmblemHealth provider network staff who can answer questions in real time. Space is limited, so register early.

Register today.

REMINDER: Complete Your
SNP MOC Training

Complete the 2016 EmblemHealth Special Needs Plan (SNP) Model of Care (MOC) Training with the user ID/PIN that was recently sent to you via fax or email. Each year, as mandated by the Centers for Medicare & Medicaid Services (CMS), all providers in the Medicare Choice PPO Network and the VIP Prime Network are required to complete the SNP MOC Training for each of the Dual Eligible SNPs in which they participate.

Know Your Network Participation

Your provider profile lists your network affiliations. To view it, please login to your Provider/Practice Profile on our secure provider portal at emblemhealth.com. If the network information on the member's ID card matches your network affiliations, then you are in-network for that member's benefit plan. See the Provider Networks and Member Benefit Plans chapter of the EmblemHealth Provider Manual for a listing of all networks and plans.

Review Our Access and Availability Standards

Find Out How You and Your Staff Can Improve the Patient Experience

Take a Tour

PCPs can obtain a current member Panel Report under My Reports after log-in; and all practitioners can check eligibility online. To learn more, Take a Tour today.

Help Your Patients Stay Fit

EmblemHealth has health and wellness programs, and tools and resources to help members stay fit and enhance their quality of life. EmblemHealth members have access to Healthy Discounts at no additional cost. Participating vendors offer discounts for health club memberships, acupuncture, massage therapy and nutrition counseling, weight loss services, hearing and vision care, vitamins and supplements, and other comprehensive health care services and products.

Do More On the Go!

Our myEmblemHealth mobile app provides useful benefit and plan information for members, right at their fingertips:

•  Search for a doctor or hospital

•  See copay, benefit and claims

•  Access their ID card

•  Pay their bill

•  View their physician (PCP)

Easy access — anytime, anywhere! Encourage your patients to download it today.

Available on all iOS and Android devices.


Use Quest Diagnostics

Quest is our preferred, free-standing, independent commercial lab for members. Please direct our members to the nearest Quest Laboratory Patient Service Center. If you need to establish an account with Quest, please contact them at 1-866-697-8378.

For specialty lab tests not available from Quest, you may use one of the other contracted, free-standing, independent commercial labs.



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Coverage underwritten by Group Health Incorporated (GHI) and HIP Health Plan of New York (HIP).
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