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  • 2019 Provider Networks and Member Benefit Plans > Commercial and Child Health Plus Networks

    Commercial Networks Covered by Agreements

    The table that follows summarizes the benefit plans our commercial members use to receive their health care benefits and services. EPO/PPO plans typically allow members to self-refer to network specialists for office visits; however, prior approval is still required before certain procedures can be performed.

    GHI Commercial Network and Plan Summary for 2019
    (CBP, National, Network Access, & Tristate Networks)
    Network Plan
    Name
    Plan
    Type
    PCP
    Req'd
    Referral
    Req'd
    Deductibles 
    (Individual/
    Family)
    PCP/
    Special/
    ER Copay
    OON
    Coverage
    MOOP
    (Ind/
    Family)
    Co-ins.
    CBP
    Network
    Federal Employee
    Health Benefit 
    (FEHB)1
    EPO No No N/A $30/
    $30/
    $150
    No  $6,850/
    $13,700
    No
    CBP
    Network
    Federal Employee
    Health Benefit 
    (FEHB)1
    PPO No No IN: N/A
    OON: $150
    $20/
    $20/
    $150
    Yes $6,850/
    $13,700
    OON
    only
    Network Access Network Network
    Access
    EPO/
    PPO
    network
    lease
    No No Various Various EPO: No
    PPO: Yes
    Up to
    $7,350/
    $14,700
    EPO: No
    PPO: Yes
    CBP Network City of
    New York
    PPO
    (medical only)
    No No IN: N/A
    OON: $175/$500
    Preferred
    PCP/Speci
    alist
    $0/$0 All other
    PCP/Speci
    alists
    $15/$30/
    N/A
    $25/$25/
    $150
    Yes $4,550/
    $9,100
    No
    CBP Network DC 37 Med-Team PPO No No IN: N/A
    OON: 
    $1,000/
    $3,000
    $25/
    $25/
    $150
    Yes $7,150/
    $14,300
    OON
    only
    National
    Network
    EmblemHealth
    EPO
    EPO No No N/A Various No Up to
    $7,350/
    $14,700
    No
    National
    Network
    EmblemHealth
    PPO
    PPO No No IN: N/A
    OON: Various
    Various Yes Up to
    $7,350/
    $14,700
    OON
    only
    National
    Network
    EmblemHealth 
    ConsumerDirect
    EPO
    EPO No No Various 
    (includes Rx)
    No No Up to
    $7,350/
    $14,700
    Yes
    National
    Network
    EmblemHealth 
    ConsumerDirect
    PPO
    PPO No No Various 
    (includes Rx)
    No Yes Up to
    $7,350/
    $14,700
    Yes
    National
    Network
    EmblemHealth 
    HealthEssentials
    Plus
    EPO No No N/A $40 (limited
    to 3 outpatient
    visits only)
    No $3,000/
    $6,000
    No
    National
    Network
    EmblemHealth 
    InBalance EPO
    EPO No No Various on facility/
    non-preventive 
    surgical services
    Various No Up to
    $7,350/
    $14,700
    Yes
    National
    Network
    EmblemHealth 
    InBalance PPO
    PPO No No IN: Various 
    on facility/
    non-preventive 
    surgical services
    OON: Various
    Various Yes Up to
    $7,350/
    $14,700
    Yes

    ER = emergency room; IN = in-network; N/A = not applicable; OON = out-of-network; MOOP = maximum out-of-pocket; PCP = primary care provider; Req'd = Required; Co-ins. = Co-insurance.

    1Copays are $10 for telemedicine physicians [and $5 for dietitians/nutritionists] for Federal Employee Health Benefit (FEHB) plans’ telemedicine coverage.

    Note: Member ID cards for plans associated with the Comprehensive Benefits Plan (CBP) Network may display the network name as CBP, EPO, EPO1, EPO2, PPO, PPO1, or PPO4.

    GHI Plan Descriptions

    EmblemHealth HDHP Programs: ConsumerDirect EPO and ConsumerDirect PPO

    To meet the growing demand for consumer-directed health care, EmblemHealth has two high-deductible health plans (HDHP), ConsumerDirect EPO and ConsumerDirect PPO. These benefit plans allow employers and employees more power and choice in how to spend their health care dollars and make health care decisions.

    Depending on the HDHP selected and other factors, members may also establish a separate health savings account (HSA) to pay for qualified medical expenses with tax-free dollars. Individual HSAs are member owned, and contributions, interest, and withdrawals are generally tax-free.

    For members, ConsumerDirect EPO and ConsumerDirect PPO benefit plans feature:

    • Lower monthly premiums based on higher annual deductibles.
    • Network and out-of-network coverage for the PPO plan.
    • No non-emergent coverage for out-of-network services for the EPO plan.
    • No out-of-pocket costs for covered preventive care in network.

    HealthEssentials

    HealthEssentials is an EmblemHealth EPO plan designed for people seeking health coverage primarily for catastrophic injury or illness. Its core benefits are hospital and preventive care services and three additional office visits.

    The HealthEssentials plan features:

    • Network hospital or ambulatory surgical center benefits.
      • Inpatient and outpatient hospital services provided in and billed by a network hospital or facility.
      • Well-Baby and Well-Child Care provided by a network practitioner.
      • Emergency room services (provided in and billed by a hospital or facility).
      • Inpatient and outpatient mental health and chemical dependency services provided in and billed by a network hospital or facility.
    • Covered preventive care services consistent with guidelines of the Patient Protection and Affordable Care Act.
      • Preventive care services covered at 100 percent when provided by a network practitioner.
      • Sick visits not covered.
    • Pharmacy benefit.
      • $15 generic drug card.

    Note: With the exception of preventive care services provided by network practitioners, services billed by a practitioner are not covered under this plan except for three office visits.

    HIP Commercial Networks

    Commercial Networks Covered by Agreements with HIP Health Plan, HIP Health Plan of New York, Health Insurance Plan of Greater New York, HIP Network Services, IPA. and HIP Insurance Company of New York

    Our HMO plans only offer in-network coverage for non-emergent services. If you see a member who is NOT in a plan associated with your participating network(s), and no prior approval has been given, the member may incur a surprise bill or avoidable expenses. So when a member calls for an appointment, be sure to check that you participate in the member’s plan at that location. If you do not participate in their plan, please refer them back to our online directory, Find-A-Doctor, to find a provider in their network.

    Prime Network

    Large Group: The Prime Network includes a robust network of practitioners, hospitals, and facilities in 28 New York state counties: Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Kings, Montgomery, Nassau, New York, Orange, Otsego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington, and Westchester. New Jersey Qualcare HMO Network services a variety of HMO and POS plans. ConnectiCare Network services a variety of HMO, POS, and EPO plans.

    Small Group: The Prime Network includes a robust network of practitioners, hospitals, and facilities in 28 New York state counties. Small Group plan members also have access to providers in New Jersey via Qualcare’s network, and Connecticut via ConnectiCare’s network.

    Small Group Standard plans follow the plan designs established by New York state, and Nonstandard plans can change the cost-sharing required in any benefit category.

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

    Select Care Network

    The Select Care Network is located in the following New York state counties: Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Kings, Montgomery, Nassau, New York, Orange, Otsego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington, and Westchester.

    The Select Care Network, a subset of our existing Prime Network, is a tailored network that helps keep costs down and supports an integrated model of care. Providers in the Select Care Network are chosen on measures such as geographic location, hospital affiliations, and sufficiency of services. The network includes a full complement of physicians, hospitals, community health centers, facilities, and ancillary services. Urgent care and immediate care are also available.

    EmblemHealth offers six Small Group plans on the Select Care Network.

    EmblemHealth offers seven individual plans on the Select Care Network. These benefit plans are offered both on and off the NY State of Health: The Official Health Plan Marketplace. EmblemHealth Silver Value and EmblemHealth Gold Value plans, both non-standard plans, provide a specific number of primary care physician (PCP) visits at no cost before the deductible. The plans offer acupuncture, dental, and vision benefits for adults and children.

    Individual and Small Group Standard plans follow the plan designs established by New York state, and Nonstandard plans can change the cost-sharing required in any benefit category.

    Our Select Care Network plans are HMOs. All non-emergency care must be provided by Select Care Network providers. Most plans require referrals and prior authorization for certain services. To locate the closest care for your patient, please use the-Find A-Doctor online directory at emblemhealth.com/find-a-doctor.

    Note: Most of these plans have a deductible that applies to in-network services.

    Wellness Visits: Large Group and Small Group plan members are eligible for an annual wellness visit once every benefit plan year. Individual plan members are eligible for an annual wellness visit once every calendar year. Please log in to emblemhealth.com/providers to check the member's Benefit Summary.

    Telemedicine: EmblemHealth Small Group Prime Network plans, Individual and Small Group Select Care Network plans both on- and off-exchange and the Essential Plan offer telemedicine services at no cost. EmblemHealth Basic plan off-exchange offers telemedicine at 0% after deductible.

    HIP Commercial and Child Health Plus Networks and Plan Summary for 2019
    (Prime Network and Select Network) 
    Network Plan
    Name
    Plan
    Type
    PCP Req'd Referral Req'd Deductibles 
    (Ind/Family)
    PCP/
    Special/
    ER Copay
    OON
    Coverage
    MOOP
    (Ind/
    Family)
    Co-ins.
    Prime Network HIP Prime® POS POS Yes Yes IN: N/A
    OON: Various
    Various Yes Up to
    $7,350/
    $14,700
    OON only
    Prime Network HIP Prime® PPO PPO No No IN: N/A
    OON: Various
    Various Yes Up to
    $7,350/
    $14,700
    OON only
    Prime Network HIPaccess® II POS Yes No IN: N/A
    OON: Various
    Various Yes Up to
    $7,350/
    $14,700
    OON only
    Prime Network HIP Prime® HMO HMO Yes Yes N/A Various No Up to
    $7,350/
    $14,700
    No
    Prime Network HIPaccess® I HMO Yes No N/A Various No Up to
    $7,350/
    $14,700
    No
    Prime
    Network
    HIP Select® PPO PPO No No IN:
    Various on
    facility
    services
    OON:
    Various
    Various Yes Up to
    $7,350/
    $14,700
    Yes
    Prime
    Network
    Child Health Plus HMO Yes Yes N/A No No N/A No
    Prime
    Network
    GHI HMO HMO Yes Yes N/A Various No Up to
    $7,350/
    $14,700
    No
    Prime
    Network
    Vytra HMO HMO Yes Yes N/A Various No Up to
    $6,850/
    $13,700
    No
    Prime
    Network
    EmblemHealth EPO Value EPO No No Various Various No Up to
    $7,350/
    $14,700
    No
    Prime
    Network
    EmblemHealth HMO Plus HMO Yes Yes Various Various No Up to
    $7,350/
    $14,700
    No
    Prime
    Network
    EmblemHealth HMO Preferred Plus HMO Yes Yes Various Various No Up to
    $7,350/
    $14,700
    No
    Prime Network HMO Preferred (City) HMO Yes Yes No $0/
    $0/
    $150

    $10/
    $10/
    $150
    No $7,150/
    $14,300
    No
    Select Care Network EmblemHealth Platinum HMO Yes Yes IN:$0 $15/
    $35
    /$100
    No Up to
    $2,000/
    $4,000
    No
    Select Care Network EmblemHealth Gold  HMO Yes Yes IN:
    $600/
    $1,200
    $25/
    $40/
    $150
    No Up to
    $4,000/
    $8,000
    No
    Select Care Network EmblemHealth Silver HMO Yes Yes IN:
    $1,700/
    $3,400
    $30/
    $50/
    $250
    No Up to
    $7,500/
    $15,000
    No
    Select Care Network EmblemHealth Bronze HMO Yes Yes IN: $4,000/
    $8,000
    50% No Up to
    $7,600/
    $15,200
    Yes
    Select Care Network EmblemHealth Basic HMO Yes Yes IN:
    $7,900/
    $15,800
    0% No Up to
    $7,900/
    $15,800
    Yes
    Select Care Network EmblemHealth Gold Value HMO Yes Yes/ IN:
    $3,000/
    $6,000
    $45**/
    $65**/
    $0
    (3 free
    PCP visits)
    No Up to
    $3,000/
    $6,000
    No
    Select Care Network EmblemHealth Silver Value HMO Yes Yes IN:
    $3,000
    /$6,000
    $35**/
    $70**/
    $0
    (3 free
    PCP visits)
    No Up to
    $6,100/
    $12,200
    No
    Select Care Network EmblemHealth Platinum D HMO Yes Yes IN:$0 $15/
    $35/
    $100
    No Up to
    $2,000/
    $4,000
    No
    Select Care Network EmblemHealth Gold D HMO Yes Yes IN:
    $600/
    $1,200
    $25/
    $40/
    $150
    No Up to
    $4,000/
    $8,000
    No
    Select Care Network EmblemHealth Silver D HMO Yes Yes IN:
    $1,700/
    $4,000
    $30/
    $50/
    $250
    No Up to
    $7,500/
    $15,000
    No
    Select Care Network EmblemHealth Bronze D HMO Yes Yes IN:
    $2,000/
    $4,000
    50% No Up to
    $7,6,00/
    $15,200
    Yes
    Select Care Network EmblemHealth Basic D HMO Yes Yes IN:
    $7,900/
    $15,800
    0% No Up to
    $7,900 /
    $15,800
    Yes
    Select Care Network EmblemHealth Gold
    Value D
    HMO Yes Yes IN:
    $3,000/
    $6,000
    $45**/
    $65**/
    $0
    (3 free
    PCP visits)
    No Up to
    $3,000/
    $6,000
    No
    Select Care Network EmblemHealth Silver
    Value D
    HMO Yes Yes IN:
    $6,100/
    $12,200
    $35**/
    $70**/
    $0
    (3 free
    PCP visits)
    No Up to
    $6,100/
    $12,200
    No
    Prime Network EmblemHealth Platinum Premier HMO Yes No IN:
    $0
    Rx deductible
    $0
    $15/
    $35/
    $200
    No Up to
    $2,000/
    $4,000
    No
    Prime Network EmblemHealth Gold
    Premier
    HMO Yes No IN:
    $450/$900
    Rx deductible
    $0
    $30**/
    $50**/
    $300
    (3 free
    PCP visits)
    No Up to
    $4,000/
    $8,000
    No
    Prime Network EmblemHealth Gold
    Premier1
    HMO Yes No IN:
    $2,000/
    $4,000
    Rx deductible
    $100/$200
    $30**/
    $60**/
    $500
    No Up to
    $6,800/
    $13,600
    Yes
    Prime Network EmblemHealth Gold Plus HMO Yes Yes IN:
    $550/$1,100
    Rx deductible
    $0
    $40**/
    $60**/
    $300
    (3 free
    PCP visits)
    No Up to
    $4,500/
    $9,000
    No
    Prime Network EmblemHealth Gold Plus1 HMO Yes Yes IN:
    $1,000
    /$2,000
    Rx deductible
    $100/$200
    $30**/
    $60**/
    $300
    No Up to
    $4,000/
    $8,000
    No
    Prime Network EmblemHealth Healthy
    NY Gold
    HMO Yes Yes IN: $600/
    $1,200
    $25/
    $40/
    $150
    No Up to
    $4,000/
    $8,000
    No
    Prime Network EmblemHealth Silver
    Premier
    HMO Yes No IN:
    $3,300/
    $6,600
    Rx deductible
    $0
    $30**/
    $55**/
    $500
    (3 free
    PCP visits)
    No Up to
    $7,000/
    $14,000
    No
    Prime Network EmblemHealth Silver
    Premier1
    HMO Yes Yes IN:
    $2,700/
    $5,400
    Rx deductible
    $200/$400
    $40**/
    $70**/
    30%
    No Up to
    $7,300/
    $14,600
    Yes
    Prime Network EmblemHealth Silver Plus HMO Yes Yes IN:
    $2,550/
    $5,100
    Rx deductible
    $0
    $40/
    $60/
    $500
    (3 free
    PCP visits)
    No Up to
    $7,300/
    $14,600
    No
    Prime Network EmblemHealth Silver Plus1 HMO Yes No IN:
    $3,000/
    $6,000
    Rx deductible
    $200/$400
    $35**/
    $55**/
    $700
    No Up to
    $7,000/
    $14,000
    Yes
    Prime Network EmblemHealth Bronze Plus H.S.A. HMO Yes Yes IN:
    $5,500/
    $11,000
    50% No Up to
    $6,550/
    $13,100
    Yes
    Select Care Network EmblemHealth Platinum Choice HMO Yes No IN:
    $200/
    $400
    $15**/
    $35**/
    $200
    No Up to
    $2,200/
    $4,400
    No
    Select Care Network EmblemHealth Gold Choice HMO Yes No IN:
    $750/
    $1,500
    $30**/
    $50**/
    $300
    (3 free
    PCP visits)
    No Up to
    $5,000/
    $10,000
    No
    Select Care Network EmblemHealth Gold Value HMO Yes Yes IN:
    $3,000/
    $6,000
    $45**/
    $65**/
    $0
    (3 free
    PCP visits)
    No Up to
    $3,000/
    $6,000
    No
    Select Care Network EmblemHealth Silver Choice HMO Yes No IN:
    $2,800/
    $5,600
    $30**/
    $50/
    $500
    (3 free
    PCP visits)
    No Up to
    $7,100/
    $14,200
    No
    Select Care Network EmblemHealth Silver Value HMO Yes Yes IN:
    $6,300/
    $12,600
    $35**/
    $70**/
    $0
    (3 free
    PCP visits)
    No Up to
    $6,100/
    $12,600
    No
    Select Care Network EmblemHealth Bronze Value HMO Yes Yes IN:
    $7,690/
    $15,380
    0%
    (3 free
    PCP visits)
    No Up to
    $7,690/
    $15,380
    Yes

    ER = emergency room; IN = in-network; N/A = not applicable; OON = out-of-network; MOOP = maximum out-of-pocket; PCP = primary care provider; Req'd = Required; Co-ins. = Co-insurance.

    * Note: If your patient has the Access I, Access II, or other Direct Access benefit plan, with or without the HCP logo HCP Logo , the member does not need a referral to see a specialist. However, for plans that do require referrals and the member ID card has the HCP logo, please follow HCP’s referral process.

    ** Benefit is not subject to deductible.

    HIP Commercial Plan Descriptions

    Child Health Plus

    Child Health Plus (CHP) is a New York state-sponsored program that provides uninsured children under 19 years of age with a full range of health care services for free or for a low monthly cost, depending on family income. In addition to immunizations and Well-Child care visits, CHP covers pharmaceutical drugs, vision, dental, and mental health services. There are no copays for CHP members for any covered services. CHP members may visit any one of our Prime Network providers that see children.

    The service area for CHP includes the following New York state counties: Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, and Westchester. CHP members are covered for emergency care in the U.S., Puerto Rico, the Virgin Islands, Mexico, Guam, Canada, and the Northern Mariana Islands.

    Enrollment period restrictions do not apply to CHP. Eligible individuals may enroll in CHP throughout the year via the NY State of Health Marketplace or through enrollment facilitators.

    Continuity of Care for Our Members

    We make every effort to assist new members whose current providers are not participating with one of our plans. We do the same when a health care professional or facility leaves the network. See the Continuity/Transition of Care - New Members and Continuity of Care - When Providers Leave the Network sections of the Care Management chapter for information on transitions of care.

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    Glossary terms found on this page:

    Auxiliary or supplemental services (i.e., diagnostic services, physical therapy and medications) used to support diagnosis and treatment of a patient's condition.

    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 use of one or more drugs for purposes other than those for which they are prescribed or recommended.

    An individual person who is the direct or indirect recipient of the services of the organization. Depending on the context, consumers may be identified by different names, such as "member," "enrollee," "beneficiary" or "patient." A consumer relationship may exist even in cases where there is not a direct relationship between the consumer and the organization. For example, if an individual is a member of a health plan that relies on the services of a utilization management organization, then the individual is a consumer of the utilization management organization.

    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.

    A portion of eligible expenses that an individual or family must pay during a calendar year before EmblemHealth will begin to pay benefits for covered services.

    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.

    Care for a person with an emergency condition.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

    A drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug.

    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.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    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.

    Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

    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.

    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 hospital that is part of EmblemHealth's provider network and has signed an agreement to provide covered services to its members. Sometimes, network hospitals and facilities are referred to as participating hospitals.

    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.

    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 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 prepaid payment or series of payments made to a health plan by purchasers and often plan members for health insurance coverage.

    Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, and generally including routine physical examinations and immunization.

    A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a PCP.

    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.

    The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.

    Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or severe pain, such as a high fever.

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