EmblemHealth has set up a Population Health Management model. It identifies members who require help to meet their care needs.
EmblemHealth’s strategy is focused on keeping members healthy, managing those members with emerging risk, assessing social determinants of health, patient safety, and supporting members who have multiple complex health conditions.
Using sophisticated predictive modeling tools, we can identify members with developing risk to engage them earlier, as well as identify members who would most benefit from field-based care management.
Members’ needs are addressed through various initiatives. In the past, members with chronic conditions would have been managed through a standalone disease management program. Now, they are identified through our predictive modeling data, so we can provide them with the appropriate care.
Focus on care management programs assists with the overall care management of members. Our programs are designed to complement the care our members receive.
Activities include, but are not limited to:
- Collaborating with community-based organizations and hospitals to improve transitions of care from one setting to another and different levels of care.
- Coordinating care between practitioners and specialists, and behavioral health and medical practitioners.
- Providing information to you (the physician) regarding progress, member educational materials, member calls as appropriate, and other services as noted on the EmblemHealth website.
- We offer:
- Scheduled outbound calls.
- Field-based care managers’ face-to-face interactions.
- Ongoing education, as appropriate to each program.
Referrals for these programs are received through health risk surveys, claims data, self-referrals, caregiver referrals, discharge planner referrals, or directly from you, as the practitioner.
Program goals include:
- Higher compliance with physician instructions.
- Coordinating member continuum of care across potential settings, providers, and levels of care.
- Increased patient condition knowledge.
- Symptom improvement and/or stabilization.
- Reduction in inappropriate utilization.
- Positive behavioral health changes.
Practitioners may refer members to our care management programs, or the member may contact us directly at 800-447-0768 (TTY: 711). Our hours are 9 a.m. to 5 p.m., Monday to Friday. Enrollment is voluntary and, if applicable, allows members to receive:
- Educational tools to assist with understanding their diseases, symptom management, diet and nutrition needs, treatment options, and planning for doctor visits.
- An opportunity to work one on one with a nurse, social worker, or behavioral health care manager by telephone or face-to-face interaction.
- Access to community-based support services.
- Access to additional care through our other care management programs.
Care Management Program Components
The care management programs support practitioner care plans by using evidence-based clinical practice guidelines (CPGs) to emphasize ways to prevent complications and flare-ups of chronic conditions.
Key components include the following, as applicable:
- Matching members with disease-specific programs that meet their individual needs.
- Prompting practitioners and members to follow evidence-based clinical practice guidelines in treating chronic illness.
- Coordinating care amongst practitioners, support services providers, the health plan, the member, and caregivers.
- Educating and empowering members to make lifestyle choices that may prevent or control their conditions (including behavioral modification and compliance/surveillance).
- Providing health coaching and monitoring centered around a care plan created by a registered nurse and/or other clinically trained or licensed health professional.
- Making appropriate use of information technology. This may include specialized software, data registries, automated decision support tools, and tickler systems for materials and/or calls.
- Measuring progress and outcomes of care for quality improvement, reporting, and performance-based payment purposes.
Healthy Beginnings Pregnancy Program
The Healthy Beginnings pregnancy program helps eligible members better understand and manage their pregnancies and gives them support and education throughout their pregnancy. Program services include:
- A series of health-risk surveys that identify potential high-risk factors.
- Specialized care management services for members identified with risk factors.
- Comprehensive educational materials.
- Access to a 24-hour toll-free Nurse Line staffed by experienced nurses able to answer questions on pregnancy-related topics (note, no medical advice is given).
- Depression screening.
- Reminder mailings encouraging postpartum visits.
EmblemHealth follows New York State Prenatal Care Assistance Program (PCAP) guidelines to provide comprehensive care and information to women during and after pregnancy.
Healthy Beginnings pregnancy program provides screenings for high-risk behaviors, depression, tobacco, and drug and alcohol use, as well as education to expectant mothers about community services available in their area. Medicaid members also receive child birth/parenting education and receive Women, Infants and Children (WIC) Food Nutrition Service Program referrals free of charge.
More information, clinical guidelines, and resources can be found online at the PCAP website at health.state.ny.us/nysdoh/perinatal/en/pcap.htm.
For more information about the Healthy Beginnings pregnancy program, or to refer a member, please call 888-447-0337 (TTY: 711). Our hours are 9 a.m. to 5 p.m., Monday through Friday.
Tobacco-Free Quit-Smoking Program
EmblemHealth has partnered with the New York State Smokers Quitline to provide comprehensive smoking cessation services. New York State Smokers Quitline is a state program based at the Roswell Park Cancer Institute in Buffalo, NY. The program is available at no cost to all individuals residing in New York State.
Services available through the New York State Smokers Quitline include:
- Help developing a quit plan by phone from trained quit-smoking experts.
- Recorded phone messages and tips available 24 hours a day, seven days a week.
- Receipt of educational guides and materials by mail.
- A two-week supply of nicotine replacement therapy (nicotine patch or gum) for those who qualify.
- Access to information and services through the New York State Quitline website.
- Full coverage for smoking cessation medication (nicotine patch, gum, lozenge, bupropion [generic Zyban®], and Chantix®) for members with EmblemHealth pharmacy benefit coverage enrolled in the Tobacco-Free quit-smoking program. Medicare members will be responsible for a copay for the smoking-cessation prescription products.
Practitioners are encouraged to refer members directly to the New York State Smokers Quitline at 866-NY-QUITS (866-697-8487), or 311 in New York City. Referral forms can be found online at nysmokefree.com. For out-of-state members, referrals can be made directly to the program by calling 877-500-2393.
Studies show that a follow-up visit or phone call within one week of the patient's quit date can double the effectiveness of any intervention. EmblemHealth provides reimbursement for smoking-cessation counseling based on current Centers for Medicare & Medicaid Services guidelines. We will reimburse for CPT codes 99406 and 99407.
We also offer a Tobacco-Free quit-smoking program.
For clinical practice guidelines, go to the Clinical Corner on our website.
Healthy Living Program
EmblemHealth provides many tools to help members manage their weight.
For more information about body mass index (BMI), clinical practice guidelines, recommendations, coding and tools, and the Childhood Obesity Action Network's implementation guide to prevention and treatment of childhood obesity, visit the Provider Weight Management Resources section of our website.
Serious and Persistent Mental Illness Disease Management Services
Our Serious and Persistent Mental Illness Disease Management Services is designed to help members with serious mental illness and high risk of hospitalization remain engaged in treatment in the most appropriate and least restrictive settings possible.
This program, delivered by master's-level clinicians, emphasizes communication with practitioners and family members, proper medication and treatment adherence, education for members and their families, access to community resources, and coordination of care.
HIP members may be enrolled by calling 888-447-2526 (TTY: 711)/GHI members 800-692-2489 (TTY: 711). If your patient’s ID card has a Montefiore logo in the lower left corner, please call 800-401-4822 (TTY: 711) for help finding a mental health or substance abuse practitioner.
Contract Management Organization Programs
The Contract Management Organization (CMO) programs are delegated for EmblemHealth plan members who receive treatment under the care of a CMO (i.e., Montefiore Medical Center) provider. They offer care management programs for members with chronic medical and behavioral health conditions.
For questions or more information about CMO Programs, please call 844-209-4932 (TTY: 711). Our hours are 9 a.m. to 5 p.m., Monday to Friday.
Note: For members with multiple chronic illnesses, or with severe or end-stage illness, this guidelines-based care should not take precedence over the provision of care that corresponds to patient preferences and needs. Such members require highly individualized care plans and are therefore typically not suited for participation in some of the care management programs.
Glossary terms found on this page:
An activity of EmblemHealth or its subcontractor that results in:
- Denial or limited authorization of a service authorization request, including the type or level of service
- Reduction, suspension or termination of a previously authorized service
- Denial, in whole or in part, of payment for a service
- Failure to provide services in a timely manner
- Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals
Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.
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 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.
An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.
A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality health care for a patient population who have or are at risk for a specific chronic illness or medical 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.
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 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.
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 permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.
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 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.
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.
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
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- 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.
The process to objectively and systematically monitor and evaluate the quality, timeliness and appropriateness of covered services, including both clinical and administrative functions, to pursue opportunities to improve health care and resolve identified problems in any of these services.
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 use of one or more drugs for purposes other than those for which they are prescribed or recommended.
Provides managed mental health and substance abuse (MHSA) programs, workplace services, employee assistance programs (EAP), psychiatric disability management, Medicaid behavioral health management and child welfare programs for over 23 million lives. Visit the ValueOptions Web site at www.valueoptions.com.