Podiatry > Applicable Members/Benefit Plans
The following members have been selected to participate in the Market Share Payment Podiatry Program. Their member ID cards and our website will show either HIP or HealthCare Partners as the assigned managing entity.
- HMO/HIPaccess® I
- Point of Service/HIPaccess® II
- Child Health Plus
All members whose care is managed by Montefiore Medical Group (CMO), even if they have one of the above-listed benefits plans (see the member's ID or eligibility information on www.emblemhealth.com to determine if CMO is responsible for a member's care), have been excluded from the Podiatry Program.
In addition, if a member has selected a PCP assigned to one of the following physician group practices (see the member's ID), they will be excluded from this program's requirements.
The excluded physician group practices are:
- AdvantageCare Physicians* (fka, Manhattan's Physicians Group, Preferred Health Partners, Queens-Long Island Medical Group, Staten Island Physician Practice)
- St. Barnabas Hospital
- HealthCare Partners* (center ID 14HH)
- Union Health Center (center ID 14UN)
* Under some circumstances, podiatrists affiliated with this physician group practice may be included in the reimbursement program.
The information captured in this section only applies to these members. All other members for all other EmblemHealth benefit plans are reimbursed in accordance with their contracted fee schedule in the same way as they are for all other services.
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).
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 determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.
The fee determined by the insurer to be acceptable for a procedure or service that the physician agrees to accept as payment in full.
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.
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 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.
A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.