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  • 2019 Provider Networks and Member Benefit Plans > Medicare Networks

    Medicare Plans

    EmblemHealth companies HIP and GHI underwrite the Medicare plans associated with the VIP Prime Network (HIP Health Plan of Greater New York), and Medicare Choice PPO Network (Group Health Incorporated). Our Important Plan Documents section includes benefit summaries and copies of members' Evidences of Coverage for each of these Medicare plans.

    As a reminder, providers are deemed participating in all benefit plans associated with their participating networks and may not terminate participation in an individual benefit plan.

    Starting January 1, 2019, all Affinity plans have been transitioned to EmblemHealth. This includes four Affinity Medicare HMO plans: EmblemHealth Affinity Medicare Passport Essentials, EmblemHealth Affinity Medicare Passport Essentials NYC, EmblemHealth Affinity Medicare Ultimate (HMO SNP) and EmblemHealth Affinity Medicare Solutions (HMO SNP). Members will access the VIP Prime Network for these plans. Providers will follow the same medical management and claim protocols as for all other members managed by EmblemHealth, Montefiore CMO and HealthCare Partners. There is one exception – no referrals are required. To identify these new members, look for the plan names on the member ID cards.

    Maximum Out-of-Pocket Threshold

    The maximum out-of-pocket (MOOP) threshold for Medicare Parts A and B services covered under the EmblemHealth Medicare Advantage Plans has not changed for existing plans. This includes the in-network MOOP under the EmblemHealth Medicare HMO plans and both the in-network and combined (in- and out-of-network) MOOPs under the EmblemHealth Medicare PPO plans. The MOOP for each benefit plan is shown in the Medicare Network and Plan Summary section of this chapter. Sign in to the provider section of the EmblemHealth website at emblemhealth.com/providers to confirm MOOPs for you members.

    How MOOP is Communicated to Members: A statement of members’ out-of-pocket spending to date will appear on their Explanation of Benefits. Members will continue to be notified by mail upon reaching the MOOP for their plan. This notice will also list services with $0 cost-sharing available to the member for the remainder of the calendar year.

    Transferability of Maximum Out-of-Pocket (MOOP): If a member makes a mid-year change from one EmblemHealth Medicare plan to another, the MOOP accumulated thus far in the contract year will follow the member and count toward the MOOP in the new EmblemHealth Medicare plan.

    Coinsurance and Copay Changes for 2019

    Members: Member cost-sharing for our HMO Special Needs Plan (SNP) benefits has not changed from the current amount of $0. The amount of cost-sharing providers may need to bill to Medicaid has changed on some benefits (inpatient hospital, skilled nursing facility, rehabilitation therapies have increased and podiatry has decreased to $0). Our HMO SNP plan members are qualified Medicare beneficiaries (QMB), which means they receive help from New York State Medicaid to pay their cost-sharing. As a result, the provider must bill Medicaid for the cost-sharing upon receipt of payment from EmblemHealth. The correct address to bill Medicaid is located on these members’ Common Benefits Identification Card (CBIC).

    Annual Physical Exam

    Most EmblemHealth Medicare HMO Plans cover an Annual Physical exam at no cost to the member. This is a great opportunity for members and providers to review and discuss management of chronic health conditions such as diabetes and hypertension, and complete preventive steps such as flu shots, breast cancer screenings and others.

    Wellness Exams

    Medicare Part B services include an annual wellness exam in addition to the ”Welcome to Medicare“ physical exam.

    "Welcome to Medicare" Physical Exam: Our Medicare plans cover a one-time ”Welcome to Medicare“ physical exam. This exam includes a health review, education, and counseling about preventive services (including screenings and vaccinations) and referrals for care, if necessary. Note: Members must have the ”Welcome to Medicare“ physical exam within 12 months of enrolling in Medicare Part B. When making their appointment, they should let you know they are scheduling their ”Welcome to Medicare“ physical exam.

    Annual Wellness Visit: A Health Risk Assessment (HRA) is to be used as part of the Annual Wellness Visits (AWV). Members enrolled in Medicare Part B for over 12 months are eligible for an annual wellness visit to develop or update a personalized prevention plan based on their health needs and risk factors. This is covered once every 12 months. Note: Following their ”Welcome to Medicare“ physical exam, members must wait 12 months before having their first annual wellness visit. However, once members have been enrolled in Medicare Part B for at least 12 months, they do not need to have had a ”Welcome to Medicare“ physical exam to be covered for annual wellness visits. Providers may bill for this service using HCPCS codes G0438 and G0439 for initial and subsequent visits, respectively.

    No Cost-Sharing for Preventive Care Services: CMS has released National Coverage Determinations for preventive services that are to be offered without cost-sharing. All of the services are listed in the chart referenced below. For HMO members, including Dual Eligible members, Medicare required covered services that are not available in-network and receive prior approval from our plan, or the member’s assigned managing entity, as applicable, will be allowed at $0 cost-sharing as well.

    Medicare Preventive Services
    The preventive care services listed on this chart are those CMS has determined should be provided to all Medicare recipients with no cost-sharing. This requirement applies to original Medicare, as well as to all of our Medicare plans, when provided on an in-network basis.

    Medicare Network and Plan Summary

    The table below summarizes our Medicare HMO/POS suite of products. Special Needs plans are located within the Medicare Special Needs Plans section of this chapter.

    HIP Medicare HMO/POS Network and Plan Summary for 2019
    (VIP Prime Network)
    Network Plan Name Plan Type PCP Req'd Referral Req'd OON Coverage In-Network Cost-Sharing Service Area Comments
    VIP Prime Network EmblemHealth VIP Value EmblemHealth Medicare HMO Yes Yes No Copays/
    coinsurance
    12 counties $15 PCP copays Provider should confirm participation as PCP prior to accepting new
    patients.
    VIP Prime Network EmblemHealth VIP Essential EmblemHealth Medicare HMO Yes/ Yes No Copays/
    coinsurance
    14 counties $0 PCP copays Provider should confirm participation as PCP prior to accepting new patients.
    VIP Prime Network EmblemHealth VIP Gold EmblemHealth Medicare HMO Yes Yes No Copays/
    coinsurance
    14 counties $10 Chiropractic copays
    VIP Prime Network EmblemHealth VIP Gold Plus EmblemHealth Medicare HMO Yes Yes No Copays/
    coinsurance
    14 counties $0 PCP copays
    $0 Specialist copays
    VIP Prime Network EmblemHealth VIP Premier EmblemHealth Medicare HMO Yes Yes No Copays/
    coinsurance
    14 counties Employer Group
    plan.
    VIP Prime Network EmblemHealth VIP Rx Carve-out EmblemHealth Medicare HMO Yes Yes No Copays/
    coinsurance
    14 counties Employer Group
    plan.
    VIP Prime Network EmblemHealth VIP Rx Saver EmblemHealth Medicare HMO Yes Yes No Copays/
    coinsurance
    2 counties $5 PCP copays and Comprehensive
    dental and fitness benefits with no maximums
    VIP Prime Network EmblemHealth VIP Part B Saver EmblemHealth Medicare HMO Yes Yes No Copays/
    coinsurance/ deductible applies to some services
    14 counties Optional dental and fitness benefit riders are available at a low cost
    VIP Prime Network EmblemHealth VIP Go EmblemHealth Medicare HMO-POS No No Yes Copays/
    coinsurance/ deductible applies to some services
    14 counties Out-of-network coverage allowed on many benefits
    VIP Prime Network EmblemHealth Affinity Passport Medicare Essentials Affinity Medicare HMO Yes Yes No Copays/
    coinsurance
    4 counties $5 PCP copays
    Dental, Vision and Hearing Coverage
    Acupuncture
    Fitness Program
    (Silver Sneakers)
    VIP Prime Network EmblemHealth Affinity Medicare Passport Essentials NYC Affinity Medicare HMO Yes Yes No Copays/
    coinsurance
    5 counties $10 PCP copays
    Dental, Vision and Hearing Coverage
    Acupuncture
    Fitness Program
    (Silver Sneakers)

    OON = out-of-network; PCP = primary care provider.; Req'd = Required

    14 county1 = New York City (Bronx, Kings, New York, Queens, Richmond), Nassau, Suffolk, Orange, Rockland, Westchester , Dutchess, Sullivan, Ulster, and Putnam

    12 county2 = New York, Queens, Richmond, Nassau, Suffolk, Orange, Rockland, Westchester, Dutchess, Sullivan, Ulster, and Putnam

    2 county3=Bronx, Westchester

    4 county4= Orange, Rockland, Westchester and Nassau

    5county5= New York, Bronx, Kings, Queens and Richmond

    Members are covered for urgent and emergency care. HIP covers members in all 50 United States, Canada, Mexico, Puerto Rico, the U.S. Virgin Islands, Guam, and the Northern Mariana Islands. Medicare members have worldwide urgent and emergency coverage.

    EmblemHealth Affinity Passport Medicare Essentials (HMO), EmblemHealth Affinity Medicare Passport Essentials NYC (HMO), EmblemHealth VIP Essential (HMO), EmblemHealth VIP Gold (HMO), and EmblemHealth VIP Gold Plus (HMO) members have access to SilverSneakers® membership, an exercise program designed for older adults.

    GHI Medicare Network and Plan Summary for 2019
    Medicare Choice PPO Network
    Network Plan Name Plan Type PCP Req'd Referral Req'd OON Coverage In-Network Cost-Sharing Service Area Comments
    Medicare Choice PPO Network EmblemHealth Group Access PPO EmblemHealth Medicare PPO No No Yes Copays/
    coinsurance
    National Employer Group MAPD plan. Each group contracts individually with the plan for benefit design. Pharmacy benefits excluded.
    Medicare Choice PPO GHI Retirees   No No        
    N/A EmblemHealth National Drug Plan EmblemHealth Medicare PDP N/A N/A Yes Copays/
    coinsurance
    National Part D drug Coverage

    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:

    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).

    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.

    The government agency responsible for administering the Medicare and Medicaid programs.

    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.

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

    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 form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment and the claims appeal process. Also called an EOB.

    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.

    The agreement EmblemHealth has with the member's group to provide health insurance.

    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.

    A card that 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.

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

    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 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. Also known as MA.

    This part of Medicare provides medical surgical benefits for Medicare beneficiaries for a modest premium.

    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.

    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.

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

    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.

    A provision added to a contract whereby the scope of its coverage is increased or decreased.

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

    A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a SNF.

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