Understanding Medicaid, Enhanced Care Plus (HARP) and Child Health Plus (CHPlus)

EmblemHealth offers New York State-sponsored programs that include a full range of health care benefits and services for families, for children and for individuals. In addition, we offer managed care plans for those in need of long-term skilled nursing care in their home. All three programs provide access to top-quality doctors and hospitals in the Bronx, Queens, Brooklyn, Manhattan, Staten Island, Nassau, Suffolk and Westchester.

Medicaid Managed Care is a low or no-cost health and dental insurance program. It is for some low-income people, families and children; pregnant women; the elderly; and people with disabilities. Some members pay a small copayment for drugs.

Children under age 21 who are covered by Medicaid and have mental health and/or substance use needs can get additional Children's Family Treatment and Support Services at no additional cost. These children’s services are provided at home or in the community.

Enhanced Care Plus is a Health and Recovery Plan (HARP) product. You need to have Medicaid Managed Care to get it. EmblemHealth manages physical health and behavioral health (mental health, and substance use) services in an integrated way. To be eligible, an individual must be 21 years or older, insured only by Medicaid and be eligible for Medicaid managed care enrollment.

Enhanced Care Plus includes an enhanced benefit package of Home and Community-Based Services (HCBS) for eligible members. It also provides members with enhanced care management to help coordinate all their physical health, behavioral health and non-Medicaid support needs. Some members pay a small copayment for drugs.

Child Health Plus is low or no-cost health and dental insurance for children ages 0-19 who are not eligible for Medicaid. The amount you pay each month for Child Health Plus depends on your family income. You pay nothing when your child receives services for covered benefits with CHPlus.

We're committed to providing you with care that's easy to obtain and that meets your needs. The questions and answers below give you important information about choosing doctors, getting referrals to specialists and much more.

What is a Primary Care Physician (PCP)?

Primary Care Physicians (PCPs) include doctors and Advanced Practice Nurse Practitioners in family practice, general practice, internal medicine or pediatrics. Your PCP is the best resource to help you access the health care system. Members are required to choose a PCP to manage their health care needs and are encouraged to do so as soon as they enroll. Most members can choose a PCP that works either at a medical group practice or an office that is convenient for them, and change their PCP at any time, for any reason. In addition, each family member can have a different PCP.

Your PCP will:

  • Provide most of your health care, including hospital admissions
  • Refer you to specialists when needed

Can I choose a PCP now?

Yes, you can. Choosing a PCP as soon as possible makes it easier for you to receive care once you are a member. If you are already a member, look on your EmblemHealth ID card. Your PCP's name and phone number are printed on the front of the card. If the name that appears is not the PCP you selected, or if no name appears, you can change or select your PCP online. Sign in to your myEmblemHealth account to search and select a new PCP. Your change will be effective immediately. If you need help, call the Customer Service line at 1-855-283-2146.

 

Note: Some members have special procedures they must follow for changing their PCP.

 

Do I need a referral to see a specialist?

Yes, with a few exceptions as noted below. Referrals must be provided by your PCP or OB/GYN, or by an EmblemHealth network specialist to which your PCP or OB/GYN has referred you.

You can get the following specialty services without a referral or prior approval:

  • Chemical dependence assessments and treatments for alcohol and substance abuse
  • Dental services
  • Eye exams and eyeglasses
  • Mental health assessments and treatments
  • Midwife services
  • OB services (prenatal care)
  • GYN services (such as family planning, sexually transmitted disease services and routine women's health care, such as breast and pelvic exams and mammographies)
  • Emergency care

In addition to the services listed above, Medicaid and CHPlus members can also obtain immunizations, TB and HIV counseling, and testing services from public health clinics without a PCP referral or plan approval.

Medicaid members may also get the following services without a PCP referral from any provider that will accept their Medicaid card:

  • Family planning, reproductive health services.
  • Services covered by regular Medicaid that are not covered by EmblemHealth.

Please refer to the Medicaid Member Handbook for a complete listing of these services.

 

What happens if I see a specialist without a referral from my PCP?

Except for the self-referral services listed above, EmblemHealth will not cover specialty services received without a referral from your PCP, OB/GYN, or an EmblemHealth network specialist to whom your PCP or OB/GYN referred you for testing and treatment.

 

Should I choose a PCP practicing at a physician group practice or one that works in a neighborhood office?

Whichever is more convenient for you. Many members choose a PCP in one of our group practices, where members can see their PCP and specialists all under one roof. Other covered services are also available in the same location. Other members choose a PCP in a neighborhood office because the office is near their home or they know the doctor. The online provider directory lists network doctors in both types of settings.

 

Will I have to get approval from the plan before getting care?

You do not need approval before you get care from your PCP. However, certain covered services do require a PCP referral and/or prior EmblemHealth approval. Your Member Handbook lists these services. When your PCP refers you for services, he or she will provide a referral and, when needed, get the approvals for you.

 

How long does it usually take to get an appointment with a network doctor?

In emergencies, you can get care right away. In urgent situations, you can get an appointment within 24 hours. Just call your PCP. The wait time for other appointments depends on:

  • The type of appointment (routine care or sick care)
  • The type of doctor you are seeing (PCP or specialist)
  • The level of urgency

Your Member Handbook lists the appointment standards that all of our network doctors must follow, including:

  • Urgent care – Within 24 hours of calling your doctor for a visit
  • Non-urgent sick visits – Within 48 to 72 hours from calling your doctor
  • Routine care – Within four weeks from calling your doctor

 

These time frames are consistent with industry norms. We advise calling well in advance to schedule your annual physical exam because it requires more time than other appointments.

 

How do I get help in an emergency?

Call 911 or go to the emergency room. Be prepared for emergencies ahead of time by learning what you can do if one occurs. Check the "Emergency Care" section of your Member Handbook before you have a problem. This section can help you understand what is meant by "emergency." If you do not have an emergency, call your PCP's office to get the care you need. You can call your PCP 24 hours a day, seven days a week.

 

When in need of medical attention that is not life threatening, consider our Urgent Care Centers.

Find an urgent care center