This section includes a helpful guide to member ID cards that you may see for members enrolled in our various plans. These are examples of the templates we use on the dozens of member ID cards in circulation. These diagrams are meant to help you quickly locate key coverage details and contact information when inspecting a member’s ID card, but do not capture all the information you may see. Please refer to the member’s ID card presented at the point of service for specific addresses, telephone numbers, plan names, plan restrictions etc. Member ID cards may also contain logos for managing entities or extended networks that affect utilization management, member access to specific networks, and more. A list of these managing entities and networks, as well as some important information about each, appears below the Member ID diagrams.
Please note: This first example is an ID card template used for most EmblemHealth Plans, including the new Affinity plans introduced in 2019. It is likely to be the most common design you will see, though the information on each card will be customized to the member’s plan and benefits.
Managing Entities and Extended Networks
ConnectiCare: Some members who access care through the Prime Network may also access care through ConnectiCare in Connecticut. Similarly, some ConnectiCare members may access care through EmblemHealth’s Prime Network. See the 2019 Provider Networks and Member Benefit Plans chapter for applicable plans.
HealthCare Partners: The member is assigned to an HCP primary care physician. The managing entity is responsible for utilization management for assigned members.
Montefiore Medical Center: The member is assigned to a Montefiore primary care physician. The managing entity is responsible for utilization management for assigned members.
PHCS/MultiPlan: Members in the National Network have access to PHCS/MultiPlan outside of New York.
QualCare: Certain members in the Prime Network have access to QualCare’s network in New Jersey. Likewise, HMO members have access to the QualCare HMO network; other plans have access to QualCare PPO network. See the 2019 Provider Networks and Member Benefit Plans chapter for applicable plans.
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 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.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
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 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 family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a PCP.
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.
A set of providers contracted with a health plan to provide services to the enrollees.
A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.