Network Benefit Plans

EmblemHealth offering new ASO Bridge Network

The Bridge Network for ASO clients was introduced on Sept. 1, 2019 to give self-funded employer groups access to a combination of our existing provider networks and administrative services. Bridge Plan members do not have to elect a primary care doctor, and no referrals are required to access specialists.  Information on how to manage these members can be found in a Guide posted to our Provider Toolkit under Your Plan Members. Payments will be made by PNC’s company, ECHO Health. Payments through ECHO follow a different workflow than those that may be in place with ECHO’s parent company, PNC. EFT elections must be made for ECHO even if in place for other EmblemHealth claims payments. For information regarding payments, see: Bridge Network Members and New Claims Payment Process.
 

Introducing: Millennium Network

Narrowest network. Being offered to individuals and small groups and selected large groups to provide a cost-effective alternative to the Select Care and Prime Networks.

New network for out-of-area care: First Health Network

MultiPlan is being replaced by First Health Network for both EmblemHealth and ConnectiCare. This will be a rolling transition as member plans renew starting Jan. 1, 2020. Member ID cards will be redistributed with the First Health logo.

Network Changes for 2020

Large Group

  • ·We anticipate the HIP Prime HMO, EmblemHealth HMO Plus, EmblemHealth EPO Value, and EmblemHealth EPO Value HDHP large group plans will be offered on all three of our HIP and HIPIC commercial networks: Prime Network, Select Care Network, and Millennium Network.
     

Small Group

  • All Prime Network plans will be non-gated (no referral required)
  • All Select Care plans will be non-gated
  • New Millennium Network tailored to the eight downstate counties (NYC boroughs, Long Island, and Westchester)
     

Individual

  • New MillenniumN tailored to the eight downstate counties (NYC boroughs, Long Island, and Westchester)
     

Plan Changes for 2020

Large Group

  • New Plan
    •  EmblemHealth EPO Value HDHP
       

Small Group

  • New Plans
    • Platinum POS
    • Platinum Value-P
    • Platinum Premier-S
    • Platinum Premier-M
    • Platinum Value-M
    • Gold POS
    • Gold Premier-M
    • Gold Value-M
    • Silver Value-P
    • Silver Premier-M
    • Silver Value-M
    • Bronze Premier-P
    • Bronze Value-P
    • Bronze Premier-S
    • Bronze Premier-M
    • Bronze Premier-M
  • Name Change*
    • Platinum Premier to Platinum Premier-P
    • Platinum Choice to Platinum Value-S
    • Gold Plus to Gold Premier-P
    • Gold Premier 1 to Gold Value-P
    • Gold Choice to Gold Premier-S
    • Gold Value to Gold Value-S
    • Silver Plus 1 to Silver Plus H.S.A.
    • Silver Premier to Silver Premier-P
    • Silver Choice to Silver Premier-S
    • Silver Value to Silver Value-S
    • Bronze Value to Bronze Value-S

    *Only Bronze Plus H.S.A. will not have a plan name change from 2019 to 2020.

  • Discontinued Plans
    •  Gold Premier will map to Gold Premier-P (formerly Gold Plus)
    • Gold Plus 1 will map to Gold Premier-P (formerly Gold Plus)
    • Silver Premier 1 will map to Silver Premier-P (formerly Silver Premier)
    • Silver Plus will map to Silver Premier-P (formerly Silver Premier)

Individual Plans

  • New Plans
    • Silver Bold/Silver Bold D (on Millennium Network)
    • Silver Bold CSR 1/2/3

Non-city of NY GHI PPO member changes

GHI PPO members (other than City of New York) are migrating upon plan renewal to our new claims platform through the end of 2020. You will know a member has been migrated when you see an 11-digit alphanumeric member ID. The IDs start with the letter “K” followed by a unique 8-digit number. The final two digits distinguishes the subscriber from each dependent (01, 02, 03, etc.). The old IDs were all numeric and 11 digits long and didn’t start with letter "K". Please ask your patients for their current member ID card at each appointment. Please submit pre-authorization requests and claims using the applicable member ID in effect on the date of service. The following changes apply once members are on the new system: 

Annual wellness visit - calendar year vs. medical benefit plan year

  • Large group and small group commercial plan members are eligible for an annual wellness visit once every benefit plan year.
  • Individual commercial plan members are eligible for an annual wellness visit once every calendar year.
     

Offering commercial members a tristate experience

EmblemHealth Prime Network Providers in New York are in-network for EmblemHealth’s subsidiary, ConnectiCare, a regional insurance company based in Connecticut. All members with ConnectiCare commercial group plans can be seen in-network by EmblemHealth Prime Network providers in New York. This includes fully-insured and self-insured plans. These members will present ConnectiCare member ID cards with an EmblemHealth logo on the front or back of the cards. You can also sign in to ConnectiCare’s provider portal  to check the members’ benefits and eligibility.
 

New contact information for Long Term Support Service (LTSS) for GHI PPO members

We have a new fax number and email address for you to request LTSS services for GHI PPO members needing Private Duty Nursing. You may also send us your LTSS questions by email.
 

fax: 212-510-5248

email: longtermsupportservices@emblemhealth.com

Infertility benefits changing January 1 for commercial members

New York State has mandated changes for infertility benefits for our commercial members. Commercial benefits, effective Jan. 1, 2020, cover additional services and the male population but have no drug coverage. For details about infertility and the state's demonstration project, see the DOH website.

 

Montefiore CMO

Starting Jan. 1, 2020, Montefiore Management Company (CMO) will no longer manage EmblemHealth’s Medicare members. Instead, EmblemHealth will directly manage claims payment, case, disease, and utilization management for medical services. Behavioral health services will be managed by Beacon Health Options. The CMO’s referrals and authorizations will be honored. EmblemHealth will not change members’ Primary Care Physician (PCP) assignments. New member IDs will be issued without the CMO logo. Key changes in how care for our members will be managed:
 

  • Referrals
    For dates of service on or after Jan. 1, 2020, referrals will need to be submitted through and retrieved from emblemhealth.com. For an optimal member experience, please enter referrals while the patient is in the office and provide a copy to them before they leave the appointment. Our portal gives you the option to fax or print the referral, as needed. Specialists may look up referrals made to them. Reminder: Medicare members with the Go Plan do not require referrals.
  • Pre-authorizations
    For dates of service on or after Jan. 1, 2020, EmblemHealth or one of its delegates will conduct utilization management services using the Medicare Pre-authorization List going into effect Jan. 1. Pre-authorization requests will need to be submitted through emblemhealth.com. Utilization management for behavioral health services will be conducted by Beacon Health Options. You may contact them at 888-447-2526.
  • Claims Submissions
    For dates of service on or after Jan. 1, 2020, please submit all claims to the claims address listed on the back of the member’s new ID card or electronically using EDI Payor Number 55247. Claims should no longer be submitted to CMO. Claims submission addresses are available in our Provider Manual on the Claims Contacts page.

Affinity plans – new names and new care management provider

In 2019, EmblemHealth partnered with Independent Living Systems (ILS) to provide care management and perform Health Risk Assessments for our Affinity Medicare members. In 2020, we will be renaming the Affinity plans and transitioning ILS’ responsibilities to EmblemHealth.
 

From

To

Affinity Ultimate

EmblemHealth VIP Dual Select

Affinity Solutions

EmblemHealth VIP Solutions

Affinity Passport

EmblemHealth VIP Passport

Affinity Passport NYC

EmblemHealth VIP Passport NYC


VIP Prime Network Changes

Capital Region Starting Jan. 1, EmblemHealth will offer its VIP Prime Network to all Medicare Advantage members in the follow Capital Region counties: Albany, Broome, Columbia, Delaware, Greene, Rensselear, Saratoga, Schenectady, Warren, Washington.
 

Hudson Valley In 2019, EmblemHealth expanded to the following Hudson Valley counties: Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, and Westchester.
 

Connecticut Starting Jan. 1, EmblemHealth’s Medicare Advantage members will gain access to in-network providers in Connecticut. Medicare members using VIP Prime Network (except Dual SNP members) can use Medicare Choice Network in Connecticut. Some services are available through delegated networks and providers only. These include routine vision care and eyewear (EyeMed); behavioral health (Beacon Health Options); chiropractic, occupational and physical therapy (Palladian); and dental (DentaQuest).
 

Similarly, Medicare members using ConnectiCare’s Medicare Choice Network (except Choice Dual plan members) will have access to the VIP Prime Network in New York. Some services are only available through ConnectiCare’s delegated networks and providers such as behavioral health offered through Optum.
 

Transportation Vendor change for City of New York (CNY) transportation will be transitioned to Coordinated Transportation Solutions (CTS). CTS will provide applicable covered transportation for both EmblemHealth and ConnectiCare members.
 

2020 Key Benefit Changes

Medicare Supplement Insurance Plans

In 2020, EmblemHealth will offer six (6) Medicare Supplement Insurance plans to assist Medicare members in covering such costs as deductibles, coinsurance, and copayments. All EmblemHealth Medicare Supplement plans cover four (4) Basic Benefits, which include hospitalization, medical expenses, blood, and hospice care.
 

EmblemHealth Medicare Connect Concierge

On Jan. 1, 2020, our Medicare members will have access to EmblemHealth Medicare Connect Concierge. This is the one phone number members can call when they need help solving their health care needs. EmblemHealth Medicare Connect Concierge can help:

  • Make a doctor’s appointment.
  • Get referrals if needed on a member’s plan.
  • Coordinate prior approvals.
  • Answer benefit questions.
  • Verify mailing address.
  • Arrange transportation.
  • Confirm your over-the-counter (OTC) drug card balance.

To reach Medicare Connect Concierge, please call 877-344-7364 (TTY: 711), 8 a.m. to 8 p.m., seven days a week.

Required: SNP MOC training due December 15, 2019

CMS requires all Medicare providers to complete Special Needs Plan (SNP) Model of Care (MOC) training each year. Providers in the VIP Prime Network must complete the 2019 EmblemHealth SNP MOC provider training by Dec. 15. Look for a notice to arrive via email, fax, and postal mail with the user ID and PIN number needed to access the training online. Providers who prefer to download the training and an attestation form may do so here. Providers who do not complete the training may be removed from the EmblemHealth Provider Directory. Access the hyperlink from the Learn Online section of our Provider Resources webpage.

 

Health survey for Medicare and Special Needs Plan members

Please encourage your Medicare and Special Needs Plan members to log in to emblemhealth.com/members and take a Health Risk Assessment (HRA) Survey. This will help our care management team direct them to appropriate care and support services. Members may also take this survey by phone at 888-246-2934, 24 hours a day, seven days a week.

Medicare Outpatient Observation Notice (MOON)

All hospitals and critical access hospitals are required by CMS to provide Medicare beneficiaries, including Medicare Advantage enrollees, with the OMB-approved Medicare Outpatient Observation Notice (MOON). The MOON and instructions for completing it are available on CMS’ website.

 

Medicare/Medicaid

Do not bill dual eligible members for any Medicare balance due.

Medicare-Medicaid dual eligible individuals who qualify to have their Medicare Parts A and B cost-share covered by their state Medicaid plan are not responsible for paying their Medicare Advantage plan cost-shares for covered services. Federal and New York State law prohibit providers from balance billing Medicare-Medicaid dual eligible individuals for any Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments, if any, received for services provided to dual eligible individuals must be accepted as payment in full. To comply with this requirement, providers treating dual eligible individuals enrolled in an EmblemHealth Medicare Advantage plan must do the following:

  • Bill the managing entity as primary payor.
  • Bill the state Medicaid plan as secondary payor.
  • Accept the Medicaid payment as payment in full and do not collect any cost-share from the member.
  • Prior to providing services, notify the member if you do not accept the state Medicaid payment as payment in full.

Service Area Expansion

Starting Jan. 1, EmblemHealth will offer its Enhanced Care Prime Network and Medicaid and HARP plans in six additional counties: Albany, Schenectady, Rockland, Putnam, Dutchess, and Orange.
 

Children and Family Treatment and Support Services (CFTSS)

Children and Family Treatment and Support Services (CFTSS) are for children under age 21 with behavioral health needs. Services may be provided at home or in the community. Starting Jan. 1, 2020, EmblemHealth will cover two new CFTSS: Youth Peer Support and Training and Crisis Intervention.

Youth Peer Support and Training A Credentialed Youth Peer Advocate, or Certified Recovery Peer Advocate who has similar experiences, can help children and families to:

  • Develop skills to manage health challenges and be independent
  • Feel empowered to make decisions
  • Make connections to natural supports and resources
  • Transition to the adult health system when the time is right
     

Crisis Intervention A professional teaches children and families to use crisis plans to de-escalate a crisis and prevent or reduce future crises. Services are provided at home or in the community when a child or youth is distressed and cannot be helped by family, friends, or other supports.
 

Transition of Children in the Care of a Voluntary Foster Care Agency (VFCA) into Managed Care

Effective Feb. 1, 2020, children/youth in the care of VFCAs will receive Medicaid benefits through Medicaid Managed Care, unless otherwise exempt or excluded from enrolling in a Managed Care plan. VFCAs will continue to provide or arrange for health care services based on federal and state health care standards. Starting Feb. 1, 2020, EmblemHealth will provide reimbursement for medical or health-related Medicaid covered services provided by contracted VFCAs to EmblemHealth members in foster care.
 

Community First Choice Option (CFCO)

Starting Jan. 1, 2020, additional CFCO services will be available to eligible EmblemHealth members through the Medicaid Managed Care benefit package.

  • Assistive Technology
  • Environmental Modifications (E-Mod)
  • Vehicle Modification (V-Mod)
  • Moving Assistance
  • Community Transitional Services (CTS)
  • Skill Acquisition Maintenance and Enhancement (SAME)
  • Home Delivered / Congregate Meals

What is the Community First Choice Option (CFCO)?

  • CFCO is an optional set of services under Medicaid authorized in the Affordable Care Act.
  • CFCO allows long-term services and supports that were previously only available through a waiver.
  • CFCO provides additional federal money to expand home and community-based services and supports to individuals in need of help with everyday activities and health-related tasks that can be performed by an aide or direct care worker (for example, Activities of Daily Living [ADLs] and Instrumental Activities of Daily Living [IADLs]).
  • CFCO is designed to be person-centered and consumer-driven, and intended to maximize independence and participation in the community.
  • CFCO services focus on person-centered, individually directed services that help the recipient maximize his or her independence and participation in the community.
     

CFCO Eligibility

State Plan Services under CFCO are available to individuals who fulfill all the following criteria:

  • Eligible for medical assistance under New York State Medicaid.
  • Have an institutional level of care as determined by the functional assessment used by this population (UAS).
  • Are living in their own home or a family member´s home (not a congregate setting).

Infertility benefits changed October 1 for Medicaid 

New York State has mandated changes for infertility benefits for our Medicaid members. Effective Oct. 1, 2019, changes for Medicaid are limited to female infertility and offers certain drug coverage. For details about infertility and the state’s demonstration project, see the DOH website.
 

Change in Medicaid coverage for child annual wellness visits

Medicaid members less than 21 years old are now covered for an annual wellness visit once every calendar year. Previously, child wellness visits were only covered once every 12 months.
 

Permanent placement process for Medicaid members

For Medicaid members in need of long-term residential care, the facility must request increased coverage from the Local Department of Social Services (LDSS) via submission of the LDSS-3559 (DOH-5182) form (or equivalent) within 48 hours of a change in a member’s status.
 

The facility must also submit to the LDSS a completed Notice of Permanent Placement Medicaid Managed Care (MAP form) within 60 days of the change in status. The facility must also notify EmblemHealth of the change in status.
 

If requested, the facility must submit a copy of the MAP form to EmblemHealth for approval prior to the facility’s submission of the MAP form to the LDSS. Payment for residential care is contingent on the LDSS’ official designation of the member as a “Permanent Placement Member.”
 

New contact information for Long Term Support Service (LTSS) for Medicaid members

We have a new fax number and email address for you to request LTSS services for Medicaid members needing Personal Care Services, Consumer Directed Personal Assistance Services, Private Duty Nursing, Adult Day Health Care, and Personal Emergency Response Services. Please email: longtermsupportservices@emblemhealth.com or fax requests to: 212-510-5248. You may also use the email to send us your LTSS questions.
 

Informed consent required for Medicaid hysterectomy/sterilization

Federal regulations require Medicaid patients’ consent to hysterectomy and sterilization procedures. A signed consent form must be submitted for the claim to be processed.
 

Compliance: Home Care Worker Wage Parity Law

Organizations, hospitals, or hospital systems contracted with entities to provide home care services for EmblemHealth Medicaid, CHP, and HARP members in New York City as well as Nassau, Suffolk, or Westchester counties are required to provide the New York State Department of Health and EmblemHealth with quarterly written certification of their organization’s or hospital’s compliance with the minimum wage requirements of the Home Care Worker Wage Parity-Public Health Law of §3614-c. We will contact you via fax several times each year to ask you to fax us your wage parity certifications. Please comply with this regulation and send the information when requested.
 

Medicaid provider disclosure of ownership and control

The New York State Department of Health requires written disclosure regarding ownership, control, and criminal convictions related to certain controlling persons’ involvement in Medicare, Medicaid, or Title XX programs. Specifically:

  • Section 42 CRF455.104 ‒ Requires Managed Care Organizations, like EmblemHealth, to collect the disclosure of complete ownership, control, and relationship information from certain entities identified in the statute. These include:
    • all participating hospitals
    • skilled nursing facilities
    • home health agencies
    • independent clinical laboratories
    • renal disease facilities; and
    • any entity (other than an individual practitioner or group of practitioners) that furnishes or arranges for health-related services for which it provides claims payment under any plan or program established under Title V or Title XX of the Social Security Act
  • Section 42 CRF455.106 ‒ Requires Managed Care Organizations, like EmblemHealth, to collect and report health care-related criminal conviction disclosure information (initially and upon renewal of their contracts) of any managing employee who has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or a Title XX program.

Disclosure forms must be completed and submitted as part of the credentialing and recredentialing processes. This applies to both directly contracted providers and delegated entities. Disclosure forms must also be submitted when a reportable event occurs and upon request of the New York State Department of Health and EmblemHealth.
 

Required annual compliance certification on Office of the Medicaid Inspector General’s website

If you are a Medicaid provider, you are likely required to attest each December you have developed and implemented a compliance program to detect and prevent fraud, waste, and abuse in the Medicaid program. Depending on the type of provider you are, or the extent to which you treat Medicaid members, you may be required to complete one or both Office of the Medicaid Inspector General (OMIG) Annual Compliance Certifications. The certifications may only be done by completing the certification form available on OMIG’s website and clicking on the appropriate certification button (“SSL Certification” or “DRA Certification”). One attestation is needed for each Federal Employer Identification Number (FEIN) or Social Security number (SSN) used to receive Medicaid payments. You do not need to submit a copy of the compliance plan or self-assessment of your plan. With regard to the Social Services Law (SSL) certification, New York State’s (NYS’s) mandatory compliance program law applies to Medicaid providers subject to Public Health Law (PHL) Articles 28 or 36, or Mental Hygiene Law (MHL) Articles 16 or 31, regardless of the amount they bill, order, or receive from NYS’s Medicaid program. Plans will need to monitor network provider compliance with the SSL certification requirement.
  

In addition, a compliance program is required for other persons, providers, or affiliates who provide care, services, or supplies under the Medicaid program, or who submit claims for care, services, or supplies for or on behalf of another person for which Medicaid is, or should be reasonably expected by the provider to be, a substantial portion of their business operations as follows:

  1. A person, provider, or affiliate who claims, orders, has claimed or ordered, or should be reasonably expected to claim or order at least $500,000 in any consecutive 12-month period from Medicaid;
  2. A person, provider, or affiliate who receives, has received, or should be reasonably expected to receive at least $500,000 in any consecutive 12-month period directly or indirectly from Medicaid or a Medicaid Managed Care Plan; or
  3. A person, provider, or affiliate who submits or has submitted claims for care, services, or supplies to the Medicaid program on behalf of another person or persons in the aggregate of at least $500,000 in any consecutive 12-month period.

The law and regulations contain a set of eight minimum core elements applicable to all providers, regardless of size. However, the law also recognizes compliance programs should reflect the provider’s size, complexity, resources, and culture as long as the compliance program meets the requirements. The second annual compliance attestation, referred to as the Deficit Reduction Act (DRA) certification, must be completed by health care entities that receive or make $5 million or more in Medicaid payments. Providers required to meet both provisions usually include the DRA requirements in their (typically more comprehensive) mandatory compliance programs. OMIG suggests Medicaid providers review OMIG’s published Compliance Guidance, Medicaid Updates, and Compliance Alerts, among other OMIG publications and outreach methods, for information on how to meet NYS mandatory compliance program requirements. There is a Compliance Library on OMIG’s website to guide providers in developing and implementing an effective compliance program. Medicaid providers are encouraged to subscribe to OMIG’s listserv. The listserv provides an email notification of any changes to OMIG’s website, including changes to published compliance program-related materials. To see more detail on the compliance program requirements, see: OMIG's ssl certification and OMIG's dra certification.

Nondiscrimination rule

Practitioners shall comply with all applicable laws prohibiting discrimination against any member and in accordance with the same standards and priority as the provider treats his/her/its other patients regardless of any of the following factors:

  • Age
  • Amount of payment
  • Claims experience
  • Color
  • Creed
  • Disability
  • Ethnicity
  • Evidence of insurability (including conditions arising out of acts of domestic violence)
  • Gender
  • Genetic information
  • Health literacy
  • Health needs
  • Health status
  • HIV status
  • Language
  • Marital status
  • Medical history
  • Mental or physical disability or medical condition
  • National origin
  • Need for health services
  • Place of residence
  • Plan membership
  • Race
  • Religion
  • Sex
  • Sexual orientation
  • Source of payment
  • Type of illness or condition
  • Veteran status
     

In addition, providers are to comply with:

  • Age Discrimination Act of 1975
  • Americans with Disabilities Act
  • Title VI of the Civil Rights Act of 1964
  • Terms of the plan’s contracts with NYSDOH and/or CMS
  • Health Insurance Portability and Accountability Act
  • HIV confidentiality requirements of Article 27-F of the Public Health Law and Mental Hygiene Law
  • Section 1557 of the Affordable Care Act (ACA) of 2010
  • Other laws applicable to recipients of federal funds, AND
  • All other applicable laws and rules, as required by applicable laws or regulations


Practitioner Rights During the Credentialing and Recredentialing Processes

EmblemHealth notifies practitioners in the EmblemHealth Provider Manual Credentialing chapter about their right to:

  • Review information obtained from outside sources submitted to support their credentialing application.
  • Correct erroneous information from other sources, the time frame for making corrections in the required format, and where to submit the corrections. EmblemHealth is not required to reveal the source of information obtained to meet verification requirements or if federal or state law prohibits disclosure. EmblemHealth documents receipt of corrected information in the practitioner’s credentialing file.
  • Be informed of the status of their application, upon request.
  • Information EmblemHealth is allowed to share with practitioners about their credentialing or recredentialing application.
  • Know EmblemHealth process for responding to requests for application status. 
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