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  • 2019 Provider Networks and Member Benefit Plans > Medicare Special Needs Plans (SNPs)

     

    SNPs Meet Our Members’ Special Needs

    Medicare Special Needs Plans (SNPs) are specially designated Medicare Advantage Plans with custom-designed benefits to meet the needs of a specific population. Enrollment in an SNP is limited to Medicare beneficiaries within the target SNP population. The target populations for the EmblemHealth SNPs are individuals who live within the plan service area, are eligible for Medicare Part A and Part B, and are eligible for Medicaid.

    Starting January 1, 2019, all Affinity plans have been transitioned to EmblemHealth, including two Affinity SNPs: 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, including our SNP Model of Care, as for all other members managed by EmblemHealth, Monte CMO and HCP. There is one exception – no referrals are required. To identify these new members, look for the plan names on the member ID cards.

    EmblemHealth's SNPs consist of:

    Medicare Choice PPO Network
    ArchCare Advantage (HMO SNP)

    VIP Prime Network
    EmblemHealth VIP Dual Group (HMO SNP)
    EmblemHealth VIP Dual (HMO SNP)

    EmblemHealth Affinity Medicare Ultimate (HMO SNP)
    EmblemHealth Affinity Medicare Solutions (HMO SNP)

    The Medicare benefit for each of these plans is supplemented by a specific set of Medicaid benefits.

    Provider Obligations/Responsibilities for Participation in Dual-Eligible Special Needs Plans

    Members have no copayment for covered services other than for prescriptions drugs. The provider must verify Medicaid eligibility of every member enrolled in Dual SNP and may not collect a copayment for covered services from a Medicaid member eligible for Medicaid coverage of Medicare cost-sharing. EmblemHealth Affinity Medicare Solutions (HMO SNP) members may not be eligible for full Medicaid and may pay cost-sharing for covered services.

    Provider Obligations/Responsibilities for Participation in Medicare-Medicaid Plans (MMPs)

    Members have no copayment for covered services other than for prescriptions drugs. The provider may not collect a copayment for covered services from a Medicare-Medicaid Plan (MMP) member (including Affinity and ArchCare members).

    HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect any pertinent information of your medical practice, including books, contracts, records, including medical records, and documentation related to CMS’ contract with EmblemHealth for a period of 10 years from the final date of the contract period or the completion of any audit, whichever is later.

    The provider may not hold members liable for payment of fees that are the legal obligation of EmblemHealth or a payor (including Affinity and ArchCare members).

    For information about provider obligations and responsibilities, see Medicare/Advantage-Medicaid Required Provisions in the Required Provisions to Network Provider Agreements chapter.

    The SNP Interdisciplinary Team

    Our SNP goals are to:

    • Improve access to medical, mental health, social services, affordable care, and preventive health services.
    • Improve coordination of care through an identified point of contact.
    • Improve transitions of care across health care settings and providers.
    • Assure appropriate utilization of services.
    • Assure cost-effective service delivery.
    • Improve beneficiary health outcomes.

    The SNP interdisciplinary team provides the framework to coordinate and deliver the plan of care and to provide appropriate staff and program oversight to achieve the SNP goals. The care management staff assumes an important role in developing and implementing the individualized care plan, coordinating care, and sharing information with the interdisciplinary care team, and with the member, their family, or caregiver.

    Practitioners providing care to our SNP members are important members of the SNP interdisciplinary team. As such, they participate in one of our regularly scheduled care coordination or case rounds meetings to discuss their plan of care and the health status of the SNP-enrolled patient. These practitioners also share their progress with the team to ensure we are meeting our SNP program goals.

    Required Training for EmblemHealth Practitioners, Providers, and Vendors

    Each year, all Medicare providers are required to complete the Special Needs Plan (SNP) Model of Care Training for each of the Dual Eligible SNPs in which they participate, as mandated by Centers for Medicare & Medicaid Services (CMS). For training presentations and other learning opportunities, please visit our Learn Online webpage.

    Medicare Special Needs Plans Summary

    The summary table below outlines the key components of the SNPs, such as Medicaid eligibility level, service area, and whether referrals are needed.

    HIP Medicare Special Needs 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 Dual EmblemHealth Medicare HMO Yes Yes No Copays/
    Coinsurance
    14 counties Individual Medicare Plan. Special needs plan limited to individuals with both Medicare and full Medicaid coverage. Individuals with full Medicaid coverage are not required to pay cost-sharing.
    VIP Prime Network EmblemHealth VIP Dual Group EmblemHealth Medicare HMO Yes Yes No Copays/ Coinsurance 14 counties Employer Group Plan. Special needs plan limited to individuals with both Medicare and full Medicaid coverage. Individuals with full Medicaid coverage are not required to pay cost-sharing.
    VIP Prime Network EmblemHealth Affinity Medicare Ultimate Affinity Medicare HMO SNP Yes Yes No Copays/ Coinsurance 10 counties $0 PCP Copay, $0 Specialist Copay, Dental, Vision and Hearing Coverage, and OTC benefit at $60 Per Month/$720.
    VIP Prime Network EmblemHealth Affinity Medicare Solutions Affinity Medicare HMO SNP Yes Yes No Copays/ Coinsurance 10 counties $0 PCP Copay, Dental, Vision and Hearing Coverage, and Routine Transportation.

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

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

    10 county2 = Bronx, Kings, Nassau, New York, Orange, Queens, Richmond, Rockland, Suffolk and Westchester

    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:

    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.

    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 person authorized by the insured to assist in obtaining access to, or payment to, the insured for health care services. If the insured has already received health care services and has no liability for payment of services, a designee will not be authorized for the purpose of requesting an external appeal.

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

    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.

    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.

    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.

    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.



    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 benefits for hospitalization, extended care and nursing home care to Medicare beneficiaries with no premium payment for qualified individuals.

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

    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.

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