Summary of Changes to EmblemHealth Medicare – Effective January 1, 2014

Date Issued: 11/19/2013

The following changes to EmblemHealth Medicare products and plans will take effect on January 1, 2014. Some may have a direct impact on your practice and your patients. Members can access a full list of services and any benefit limitations by referencing their Evidence of Coverage (EOC).

Network and Plan Changes

  • Network Change for EmblemHealth VIP High Option Members. The network used by the EmblemHealth VIP High Option plan will change from the VIP Prime network to the EmblemHealth Essential network. This change means that VIP Prime network primary care physicians (PCPs) who are not also part of the EmblemHealth Essential network may no longer serve as PCPs for EmblemHealth VIP High Option HMO members. Affected VIP Prime PCPs received a letter about this change, along with a panel report of their affected EmblemHealth VIP High Option HMO patients. These patients can either enroll in an EmblemHealth plan that their current PCP participates with during the annual enrollment period that ends on December 7, 2013, or select an Essential network PCP.
  • EmblemHealth PPO High Option Plan Closes. The EmblemHealth PPO High Option plan is closing in all service areas. Members will be transitioned to EmblemHealth PPO III and advised that they have the option of selecting a different plan during the annual enrollment period, from October 15 to December 7, 2013. Both EmblemHealth PPO High Option and EmblemHealth PPO III use the Medicare PPO network. Members may continue care with their existing providers. 
  • All Medicare Plans to Include “EmblemHealth” in Their Names. See the updated plan names and networks in the table below.
2013 Plan Name 2013 Network 2014 Plan Name 2014 Network
VIP (HMO) Prime EmblemHealth VIP (HMO) Prime
VIP Essential (HMO) Essential EmblemHealth Essential (HMO) Essential
VIP High Option Prime EmblemHealth VIP High Option Essential
Dual Eligible (HMO SNP) Prime EmblemHealth Dual Eligible (HMO SNP) Prime
PPO I Medicare PPO EmblemHealth PPO I Medicare PPO
PPO II Medicare PPO EmblemHealth PPO II Medicare PPO
PPO III Medicare PPO EmblemHealth PPO III Medicare PPO
PPO High Option Medicare PPO Plan Closed Plan Closed
Dual Eligible
Medicare PPO EmblemHealth Dual Eligible (PPO SNP) Medicare PPO

Coinsurance and Copay Changes

  • Cost-Sharing May Apply to Some EmblemHealth Dual-Eligible (PPO-SNP) Members. Dual-eligible members qualify for both Medicare and some form of Medicaid assistance. Cost-sharing affects most services, but only applies after the plan payment and varies by the benefit. Members can consult their EOC for a list of services and the associated cost-sharing. The cost-sharing is $0 for qualified Medicare beneficiaries (QMBs), which include most members with full Medicaid benefits. For these members, Medicaid covers the cost-sharing percentage and the practitioner providing the service is responsible for billing Medicaid. Our SNP plans allow all dual-eligible members (full and partial) to enroll.
  • Part B Drug Cost-Sharing. The 20 percent cost-share for Part B drugs must be paid at the time of service. This applies to all covered Part B drugs administered in an outpatient office or hospital/facility setting. EmblemHealth Medicare plans cover Medicare Part B drugs, including certain oral cancer drugs and those used with some types of durable medical equipment (DME) like nebulizers and external infusion pumps. These medications are also subject to a 20 percent cost-share for Medicare members. This change does not apply to flu or pneumonia vaccines.
  • Cost-Sharing Added for Dialysis Services. A cost-sharing of 20 percent will be applied to renal dialysis services rendered both in the hospital and at participating dialysis centers. The member is responsible for this additional cost.  
  • DME In-Network Cost-Sharing Reduced. Cost-sharing has been reduced to 10 percent for in-network DME in EmblemHealth Medicare PPO plans. Coverage can be verified and a participating DME vendor located by signing in to our secure site and checking member eligibility and benefits. You may also find participating DME vendors in the Provider Directory at

Benefit Changes

  • Coverage for Diabetic Supplies. Supplies are provided by Abbott Diabetes Care and apply to in-network benefits only. There is no cost-sharing for Medicare members, and they should consult their EOC for a list of covered supplies.
  • Annual Physical Exam Coverage. EmblemHealth Medicare plans cover an annual physical exam as a preventive service, with a $0 copay. Physicals include a comprehensive exam of all body systems, vital signs, and a review of lab and diagnostic tests where applicable. Note: If after an annual physical exam, a diagnosis other than well-care is billed, it will not be considered a preventive service and cost-sharing may apply.
  • Preventive Pap and Pelvic Exams. Preventive Pap and pelvic exams are covered every two years, with a $0 copay. Previously, these exams were covered annually as a supplemental benefit. However, members at high risk may have Pap/pelvic screenings (apart from their physical exams) more frequently (cost-sharing applies).
  • Supplemental Education Benefits. EmblemHealth provides a robust supplemental education program that includes health education and enhanced disease management. Additionally, a 24-hour Nurse Line is covered for all Medicare plans.
    • The health education program is provided by EmblemHealth’s Integrative Wellness team and can be reached at 1-646-447-5000.
    • The 24-hour Nurse Line is provided by Alere and can be reached at 1-877-444-7988.
    • Enhanced disease management is provided by Inovalon and can be reached at 1-866-447-8080.
  • Changes to the MAPD Formulary. The following changes go into effect for the Medicare Advantage Prescription Drug (MAPD) formulary: 
    • The MAPD direct-pay plan’s formulary expands from four tiers to five. This additional tier for generic drugs with very low cost-sharing was added to help encourage drug adherence.
    • Cost-sharing on the second generic tier increases by $5. This does not apply to members who are eligible for low-income subsidies.
  • Dental Benefit Added to the EmblemHealth Essential (HMO) Plan. The new plan benefit is administered by Healthplex. Members do not need a referral to access their dental benefits. Member cost-sharing varies based on the type of service performed.