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  • 2019 Provider Networks and Member Benefit Plans > Medicaid Managed Care/HARP/Essential Plan

    Medicaid Recertification

    It’s important that you and your staff remind Medicaid members to recertify with their local Department of Social Services or the health exchange about two months prior to their Eligibility End Date. If members do not recertify by the Eligibility End Date, they will lose eligibility for Medicaid, lose their health insurance coverage, and will have to reapply for Medicaid.

    To help ensure that Medicaid members retain their coverage and don’t lose access to valuable care, the Medicaid Recertification or Eligibility End Date is being added to the Health Care Eligibility Benefit Inquiry and Response (270/271) report for those that are close to their recertification dates.

    Members requiring assistance with recertification should contact our Marketplace Facilitated Enrollers at 888-432-8026.

    Mandatory Enrollment of the New York City Homeless Population

    According to the New York State Department of Health (NYSDOH), all of New York City's homeless population must be enrolled into Medicaid Managed Care (MMC).

    Primary Care Services Offered in Homeless Shelters

    Homeless members can select any participating PCP. However, to improve access to care for our members with no place of usual residence, we've expanded our provider network to include practitioners who practice in homeless shelters. A PCP practicing at a homeless shelter is available only to members who reside in that shelter.

    Identifying Members

    Medicaid Managed Care (MMC): EmblemHealth Enhanced Care
    EmblemHealth’s Medicaid Managed Care Plan is called EmblemHealth Enhanced Care. The plan name “Enhanced Care” can be found in the upper right corner of the member’s ID card. The letter “R” will appear after the plan name on the ID cards of members who are in the Restricted Recipient Program (RRP).

    Health and Recovery Plan (HARP): EmblemHealth Enhanced Care Plus
    EmblemHealth’s Health and Recovery Plan (HARP) is called EmblemHealth Enhanced Care Plus. The plan name “Enhanced Care Plus” can be found in the upper right corner of the member’s ID card. The letter “R” will appear after the plan name on the ID cards of members who are in the Restricted Recipient Program (RRP).

    Homeless and HARP Members Enrolled with EmblemHealth
    Since homeless and HARP members may present with unique health needs, we have identified which of your Medicaid Managed Care patients are homeless and/or HARP members. The following symbols are included within the secure provider website’s panel report feature:

    • ”H“ next to the name of homeless members.
    • ”R“ next to the name of HARP members.
    • ”P“ next to the name of homeless HARP members.

    A homeless indicator is present on eligibility extracts. The homeless indicator ”H“ is included if the member is homeless, and blank if the member is not homeless.

    Restricted Recipients
    EmblemHealth is also required to identify members already enrolled that need to be restricted. All EmblemHealth RRP members are in an Employer Group that begins with “1R0.” Additionally, EmblemHealth RRP member ID cards have an “R” after the plan name on the front of the card so providers will know that they are restricted (i.e., Enhanced Care - R or Enhanced Care Plus - R).

    Restricted Recipient Program
    MMC and HARP members are placed in the Restricted Recipient Program (RRP) when a review of their service utilization and other information reveals that they are:

    • Getting care from several doctors for the same problem.
    • Getting medical care more often than needed.
    • Using prescription medicine in a way that may be dangerous to their health.
    • Allowing someone else to use their plan ID card.
    • Using or accessing care in other inappropriate ways.

    The Office of the Medicaid Inspector General (OMIG) is responsible for sending previous Managed Care Organization’s restriction notification for new enrollee to EmblemHealth within 30 days.

    RRP members are restricted to certain provider types (dentists, hospitals, pharmacies, behavioral health professionals, etc.) based on a history of overuse or inappropriate use of specific services. Members are further restricted to using a specific provider of that type. EmblemHealth is required to continue the Medicaid Fee-for-Service (FFS) program restrictions for MMC and HARP members until their existing restriction period ends.

    Neither the provider nor enrollee may be held liable for the cost of services when the provider could not have reasonably known that the enrollee was restricted to another provider. See above for instructions for identifying restricted recipients.

    To report suspicious activity, please contact EmblemHealth’s Special Investigations Unit in one of the following ways:

    E-mail: KOfraud@emblemhealth.com
    Toll-free hotline: 888-4KO-FRAUD (888-456-3728)
    Mail:
    EmblemHealth
    Attention: Special Investigations Unit
    55 Water Street
    New York, NY 10041

    A trained investigator will address your concerns. The informant may remain anonymous. For more information, please see the Fraud and Abuse chapter.

    NYSDOH Medicaid Provider Non-Interference

    Medicaid providers and their employees or contractors are not permitted to interfere with the rights of Medicaid recipients in making decisions about their health care coverage. Medicaid providers and their employees or contractors are free to inform Medicaid recipients about their contractual relationships with Medicaid plans. However, they are prohibited from directing, assisting, or persuading Medicaid recipients on which plan to join or keep.

    In addition, if a Medicaid recipient expresses interest in a Medicaid Managed Care program, providers and their employees or contractors must not dissuade or limit the recipient from seeking information about Medicaid Managed Care programs. Instead, they should direct the recipient to New York Medicaid Choice, New York state’s enrollment broker responsible for providing Medicaid recipients with eligibility and enrollment information for all Medicaid Managed Care plans.

    For assistance, please call New York Medicaid Choice: 800-505-5678, Monday to Friday, 8:30 a.m. to 8 pm, and Saturday from 10 a.m. to 6 p.m.

    Any suspected violations will be turned over to the New York Office of the Medicaid Inspector General (OMIG) and potentially the Federal Office of Inspector General (OIG) for investigation.

    Medicaid and HARP Benefits

    Medicaid Benefits: Our Medicaid members are entitled to a standard set of benefits as set out in the Medicaid Managed Care Model Contract. They may directly access certain services. See the Direct Access (Self-Referral) Services section of the Access to Care and Delivery Systems chapter for a list of services that do not require a referral.

    Below is a list of covered Home and Community Based Services (HCBS) for HARP members only. (See HCBS billing manual for full details.)

    • Psychosocial Rehabilitation (PSR)
    • Community Psychiatric Support and Treatment (CPST)
    • Habilitation Services
    • Family Support and Training
    • Short-Term Crisis Respite
    • Intensive Crisis Respite
    • Education Support Services
    • Peer Supports
    • Pre-Vocational Services
    • Transitional Employment
    • Intensive Supported Employment (ISE)
    • Ongoing Supported Employment
    • Care Coordination

    Children’s Health and Behavioral Health Benefits

    Beginning January 1, 2019, EmblemHealth will manage the delivery of expanded behavioral and physical health services for Medicaid enrolled children and youth under 21 years of age. This will include medically fragile children, children with behavioral health diagnosis(es), and in 2019 children in foster care with developmental disabilities. Benefits will include Home and Community Based Services (HCBS) designed to provide children/youth access to a vast array of habilitative services (additional details can be found in the draft HCBS Manual). All HCBS are available to any child/youth determined eligible. Eligibility is based on Target Criteria, Risk Factors, and Functional Limitations. Health Homes will provide Care Management to children/youth eligible for HCBS.

    Health Home Care Management for Children

    Starting January 1, 2019, children eligible for HCBS will be enrolled in Health Home. The care coordination service of the children’s HCBS will transition to Health Home unless the child opts out of Health Home. Health Homes will administer all HCBS assessments through the Uniform Assessment System, which will have algorithms (except for the foster care developmentally disabled (DD) and the OPWDD care at home medically fragile developmentally disabled (CAH MF) populations) to determine functional eligibility criteria. Health Homes will ensure that the child meets all other eligibility criteria for HCBS (i.e., a child must live in a setting meeting HCBS settings criteria to be eligible for HCBS (i.e., Target and Risk criteria for LOC and LON populations). The Health Homes will develop one comprehensive plan of care that includes HCBS, as well as all the other services the member needs (e.g., health, behavioral health, specialtyservices, other community and social supports, etc.).

    Health Homes is a care management service model for individuals enrolled in Medicaid with complex chronic medical and/or behavioral health needs. Health Home care managers provide person-centered, integrated physical health and behavioral health care management, transitional care management, and community and social supports to improve health outcomes of high-cost, high-need Medicaid members with chronic conditions.

    EmblemHealth will collaborate with Beacon Health Options, Health Homes, and HCBS providers to gather information to support the evaluation the Enrollee’s level of care; adequacy of service plans; provider qualifications; Enrollee health and safety; financial accountability and compliance, etc. EmblemHealth will utilize aggregated data from its care management and claims systems to identify trends and opportunities for improving member care.

    Health Home care management not only provides comprehensive, integrated, child, and family-focused care management, but also ensures the efficient and effective implementation of the expanded array of State Plan services and HCBS. Please see the Health Homes Serving Children homepage for more information at: https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/hh_children/index.htm Additional strategies to promote behavioral health-medical integration for children, including at-risk populations, include:

    • Provider access to rapid consultation from child and adolescent psychiatrists
    • Provider access to education and training
    • Provider access to referral and linkage support for child and adolescent patients

    Required Training for Providers

    All Enhanced Care Prime Network providers are required to complete an initial orientation and training on the expanded children's benefit and populations, including:

    1. Training and technical assistance to the expanded array of providers on billing, coding, data interface, documentation requirements, provider profiling programs, and UM requirements.
    2. Training on processes for assessment for HCBS eligibility (e.g., Targeting Criteria, Risk Factors, Functional Limitations) and Plan of Care development and review.
      For training opportunities, please visit our Learn Online webpage at https://www.emblemhealth.com/en/Providers/Provider-Resources/Learn-Online.

    Adult Behavioral Health Covered Services

    For more information on the Behavioral Health Services Program, please see the Behavioral Health Services chapter. On October 1, 2015, EmblemHealth replaced Medicaid FFS for the coverage of behavioral health services for its MMC members aged 21 and older who reside in the five boroughs of New York City. EmblemHealth covers the following additional behavioral health benefits:

    • Medically supervised outpatient withdrawal services.
    • Outpatient clinic and opioid treatment program services.
    • Outpatient clinic services.
    • Comprehensive psychiatric emergency program services.
    • Continuing day treatment.
    • Partial hospitalization.
    • Personalized recovery-oriented services.
    • Assertive community treatment.
    • Intensive and supportive case management.
    • Health home care coordination and management.
    • Inpatient hospital detoxification.
    • Inpatient medically supervised inpatient detoxification.
    • Rehabilitation services for residential substance use disorder treatment.
    • Inpatient psychiatric services.

    Health Home Program

    Under the Federal Patient Protection and Affordable Care Act (PPACA), New York state has developed a set of Health Home services for Medicaid members. In order to be eligible for Health Home services, the member must be enrolled in Medicaid and must have:

    • Two or more chronic conditions (e.g., Substance Use Disorder, Asthma, Diabetes*), or
    • One single qualifying chronic condition: HIV/AIDS, or
    • Serious Mental Illness (SMI) (Adults), or
    • Serious Emotional Disturbance (SED) or Complex Trauma (Children)

    If a Medicaid member has HIV or SMI, he or she does not have to be determined to be at risk of another condition to be eligible for Health Home services.

    Substance use disorders (SUD) are considered chronic conditions, but the presence of SUD by itself does not qualify a member for Health Home services. Members with SUD must have another chronic condition to qualify.

    The Health Home Program is offered at no cost to all eligible EmblemHealth Medicaid members. All HARP members are assigned a Medicaid Health Home Care Manager to provide care plan coordination; however, members may opt out of the program at any time. EmblemHealth will then notify the member, and his or her PCP, of the Health Home assignment by letter. The member’s assigned Health Home Care Manager will contact the member’s PCP to ensure the treatment plan is included in the member’s comprehensive care plan.

    The following services are available through the Medicaid Health Home program:

    • Comprehensive case management with an assigned, personal care manager.
    • Assistance with getting necessary tests and screenings.
    • Help and follow-up when leaving the hospital and going to another setting.
    • Personal support and support for their caregiver or family.
    • Referrals and access to community and social support services.

    Health Home Services and Information is also available in the Forms, Brochure & More chapter. More information on the NYS Medicaid Health Home Program can be found on the NYSDOH website.

    See our guide for Health Homes that need assistance with submitting claims.

    Medicaid Members who are not eligible to participate in the Medicaid Health Home Program may still meet our criteria for Case Management services. If you think a member would benefit from case management, please refer the patient to the program by calling 800-447-0768, Monday through Friday, from 9 a.m. to 5 p.m.

    A listing of EmblemHealth network Health Homes that support our Medicaid and HARP benefit plans are listed in the Directory chapter.

    Permanent Placement in Nursing Homes

    The Medicaid Managed Care (MMC) nursing home benefit includes coverage of permanent stays in residential health care facilities for Medicaid recipients aged 21 and over who reside in the five boroughs of New York City, Westchester, Nassau, or Suffolk county. 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

    If a Medicaid member needs long-term residential care, the facility is required to request increased coverage from the Local Department of Social Services (LDSS) within 48 hours of a change in a member’s status via submission of the DOH-3559 (or equivalent).

    The facility must also submit a completed Notice of Permanent Placement Medicaid Managed Care (MAP Form) within 60 days of the change in status to the LDSS. The facility must notify EmblemHealth of the change in status. If requested, the facility must submit a copy of the MAP form to EmblemHealth for approval prior to facility’s submission of the MAP form to the LDSS.

    Payment for residential care is contingent upon the LDSS’ official designation of the member as a Permanent Placement Member.

    Veterans’ Nursing Homes

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

    If EmblemHealth does not have a Veterans’ home in their provider network and a member requests access to a Veterans’ home, the member will be allowed to change enrollment into an MMC plan that has the Veterans’ home in their network. While the member’s request to change plans is pending, EmblemHealth will allow the member access to the Veterans’ home and pay the home the benchmark Medicaid daily benchmark rate until the member has changed plans.

    Medicaid and HARP Plan Summaries

    The table below summarizes the network and benefit plans for our Medicaid and HARP members.

    HIP Medicaid Network and Plan Summary for 2019
    Enhanced Care Prime Network
    Network Plan
    Name
    Plan
    Type
    PCP Req'd Referral Req'd OON Coverage In-Network Cost-Sharing Service Area1 Comments
    Enhanced Care
    Prime Network1
    EmblemHealth
    Enhanced Care
    HMO  Yes2 Yes2 Yes3 Rx Copays 8 county Medicaid Managed Care
    plan for Medicaid-eligible individuals4 including Medicaid children’s health and behavioral health benefits
    Enhanced Care
    Prime Network1
    EmblemHealth
    Enhanced Care Plus
    HMO  Yes2 Yes2 Yes3 Rx Copays 8 county HARP for Medicaid-eligible individuals aged 21 and older4

    ER = emergency room; IN = in-network; N/A = not applicable; OON = out-of-network; MOOP = maximum out-of-pocket; PCP = primary care provider; FPL = federal poverty level; Req'd = Required

    8 county = Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island), Nassau, Suffolk, & Westchester counties. NYC = Bronx, Kings (Brooklyn), New York (Manhattan), Queens, & Richmond (Staten Island) Counties.

    1Medicaid and HARP members traveling outside of the continental United States can get coverage for urgent and emergency care only in the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. Members needing any type of care while in any other country (including Canada and Mexico) will be responsible for payment.

    2Except for self-referral services and services that Medicaid members can access from Medicaid FFS providers.

    3Medicaid members can access certain services from county departments of health and academic dental centers. (See the Access to Care and Delivery Systems chapter for a list of applicable services where OON coverage applies.)

    4See Medicaid Managed Care Model Contract for more details.

    Essential Plan Summaries

    The table below summarizes the network and benefit plans for our Essential Plan members.

    HIP Commercial Network and Plan Summary for 2019
    Enhanced Care Prime Network
    Network Plan
    Name
    Plan
    Type
    PCP Req'd Referral Req'd Deductibles
    (Ind/ Family)
    PCP/
    Special/
    ER Copay
    OON Coverage MOOP
    (Ind/
    Family)
    Service Area Co-ins.
    Enhanced Care Prime Network1 Essential Plan 1 HMO Yes Yes N/A $15/$25/$75 No $2,000 8 county Yes, for certain services
    Enhanced Care Prime Network1 Essential Plan 1 Plus HMO Yes Yes N/A $15/$25/$75 No $2,000 8 county Yes, for certain services
    Enhanced Care Prime Network1 Essential Plan 2 HMO Yes Yess N/A $0 copay No $200 8 county No
    Enhanced Care Prime Network1 Essential Plan 2 Plus HMO Yes Yes N/A $0 copay No $200 8 county No
    Enhanced Care Prime Network1 Essential Plan 3 HMO Yes Yess N/A $0 copay No $200 8 county No
    Enhanced Care Prime Network1 Essential Plan 4 HMO Yes Yess N/A $0 copay No $0 8 county No

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

    8 county = Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island), Nassau, Suffolk, & Westchester counties.

    1Enhanced Care Prime Network members traveling outside of the United States can get coverage for urgent and emergency care only in the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. Members needing any type of care while in any other country (including Canada and Mexico) will be held responsible for payment.

    Essential Plan
    The Essential Plan is a low-cost plan for adult individuals available on the NY State of Health Marketplace. As with Qualified Health Plans (QHPs), the Essential Plan includes all benefits under the 10 categories of the ACA-required Essential Health Benefits. Premiums for the Essential Plan are either $0 or $20.

    The Essential Plan includes members from two already-existing member populations – a subset of the current QHP EmblemHealth Silver population and the current Medicaid Aliessa population. The Aliessa population is New York’s legally residing immigrant population. Eligible individuals in the Aliessa population, who previously were only eligible for coverage through state-only-funded Medicaid, will transition into the Essential Plan. Essential Plan members are covered for emergency care in the U.S., Puerto Rico, the Virgin Islands, Mexico, Guam, Canada, and the Northern Mariana Islands.

    Eligibility
    The Essential Plan covers adult individuals only. If eligible, spouses and children must enroll into Essential Plan separately under an individual policy. To qualify for the Essential Plan, individuals must:

    • Be a New York state resident.
    • Be between the ages of 19 and 64 (U.S. citizens) or 21 to 64 (legally residing immigrants).
    • Not be eligible for Medicare, Medicaid, Child Health Plus, affordable health care coverage from an employer, or another type of minimum essential health coverage.
    • Be either:
      • A U.S. citizen (residing in New York) with an income between 138% and 200% of the federal poverty level (FPL). 
        • These individuals were formerly eligible for a QHP Silver Plan, but will now transition to Essential Plan based on income status.
      • Legally residing immigrant with an income of less than 138% of FPL.
        • These individuals were formerly eligible for Medicaid, but have been transitioned to Essential Plan based on immigration status (also known as Aliessa population).
    • Not be pregnant or eligible for long-term care. In both of these cases, members would be eligible for Medicaid instead of the Essential Plan.

    Covered Services
    Ten categories of essential health benefits are covered with no cost-sharing (no deductible, copay, or coinsurance) on preventive care services, such as screenings, tests, and shots. For more information, please see the Preventive Health Guidelines located on our Health and Wellness webpage. Information in our guidelines comes from medical expert organizations, such as the American Academy of Pediatrics, the U.S. Department of Health and Human Services, the Advisory Committee on Immunization Practices, and the Centers for Disease Control and Prevention (CDC).

    Unlike QHP Standard Plans, some Essential Plan members are also eligible for adult vision and dental benefits for a small additional monthly cost. The Aliessa population receives six additional benefits at no extra cost. These include: dental, vision, non-emergency transportation, non-prescription drugs, orthopedic footwear, and orthotic devices.

    How to Enroll

    There are four ways to apply:

    • Online. Visit NYSOH online and go to the Individuals & Families section. Once there, start an account and begin shopping for a plan.
    • In person. Get help from a Navigator, certified application counselor (CAC), Marketplace Facilitated Enroller (MFE), or broker/agent.
    • By phone. Call EmblemHealth at 877-411-3625, Monday through Sunday from 8 a.m. to 8 p.m., and the NYSOH at 855-355-5777, Monday through Friday from 8 a.m. to 8 p.m., and Saturday from 9 a.m. to 1 p.m.
    • By mail. Print an application at nystateofhealth.ny.gov and send it back to NYSOH, who will then confirm eligibility and enroll you in the chosen plan. Enrollment period restrictions do not apply to the Essential Plan. 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:

    An agreement in which a patient assigns to another party, usually a physician or hospital, the right to receive payment from a public or private insurance program for the service the patient has received.

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    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).

    A program that assists the patient in determining the most appropriate and cost-effective treatment plan, including coordinating and monitoring the care with the ultimate goal of achieving the optimum health care outcome.

    A process in which an individual, an institution or educational program is evaluated and recognized as meeting certain predetermined standards. Certification usually applies to individuals; accreditation usually applies to institutions.

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    A percentage of the allowed charge that is payable by the member, not EmblemHealth, for covered services rendered by an out-of-network provider. After the member has met his or her deductible, EmblemHealth will pay a percentage of the allowed charge for those covered services in accordance with the member's benefit program. The member is responsible to pay the remaining percentage of the allowed charge. This remaining percentage is the coinsurance charge.

    Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    A business entity that performs delegated functions on behalf of the insurer or managed care 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.

    The US government's principal agency for protecting the health of all Americans and providing essential human services. Also called the DHHS.

    A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

    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.

    An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member.

    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 payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.

    An individual who: (1) has undergone formal training in a health care field; (2) holds an associate or higher degree in a health care field, or holds a state license or state certificate in a health care field; and (3) has professional experience in providing direct patient care.

    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.

    A city or county social services district as constituted by Section 61 of the New York State Social Services Law (SSL). Also called a Local Department of Social Services.

    Specific circumstances or services listed in the contract for which benefits will be limited.

    A city or county social services district as constituted by Section 61 of the New York State Social Services Law (SSL). Also called a LDSS.

    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.

    Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    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.

    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 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 state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called NYSDOH.

    The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called the New York State Department of Health.

    Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting and bathing (activities of daily living).

    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.

    Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury or loss of limb.

    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.

    A written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.

    Drugs and medications that are required by law to be dispensed by written prescriptions from a licensed physician.

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

    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 set of providers contracted with a health plan to provide services to the enrollees.

    A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

    New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.

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

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