It’s important that you and your staff remind Medicaid members to recertify with their local Department of Social Services or the health exchange about two months prior to their Eligibility End Date. If members do not recertify by the Eligibility End Date, they will lose eligibility for Medicaid, lose their health insurance coverage, and will have to reapply for Medicaid.
To help ensure that Medicaid members retain their coverage and don’t lose access to valuable care, the Medicaid Recertification or Eligibility End Date is being added to the Health Care Eligibility Benefit Inquiry and Response (270/271) report for those that are close to their recertification dates.
Members requiring assistance with recertification should contact our Marketplace Facilitated Enrollers at 888-432-8026.
Mandatory Enrollment of the New York City Homeless Population
According to the New York State Department of Health (NYSDOH), all of New York City's homeless population must be enrolled into Medicaid Managed Care (MMC).
Primary Care Services Offered in Homeless Shelters
Homeless members can select any participating PCP. However, to improve access to care for our members with no place of usual residence, we've expanded our provider network to include practitioners who practice in homeless shelters. A PCP practicing at a homeless shelter is available only to members who reside in that shelter.
Medicaid Managed Care (MMC): EmblemHealth Enhanced Care
EmblemHealth’s Medicaid Managed Care Plan is called EmblemHealth Enhanced Care. The plan name “Enhanced Care” can be found in the upper right corner of the member’s ID card. The letter “R” will appear after the plan name on the ID cards of members who are in the Restricted Recipient Program (RRP).
Health and Recovery Plan (HARP): EmblemHealth Enhanced Care Plus
EmblemHealth’s Health and Recovery Plan (HARP) is called EmblemHealth Enhanced Care Plus. The plan name “Enhanced Care Plus” can be found in the upper right corner of the member’s ID card. The letter “R” will appear after the plan name on the ID cards of members who are in the Restricted Recipient Program (RRP).
Homeless and HARP Members Enrolled with EmblemHealth
Since homeless and HARP members may present with unique health needs, we have identified which of your Medicaid Managed Care patients are homeless and/or HARP members. The following symbols are included within the secure provider website’s panel report feature:
- ”H“ next to the name of homeless members.
- ”R“ next to the name of HARP members.
- ”P“ next to the name of homeless HARP members.
A homeless indicator is present on eligibility extracts. The homeless indicator ”H“ is included if the member is homeless, and blank if the member is not homeless.
EmblemHealth is also required to identify members already enrolled that need to be restricted. All EmblemHealth RRP members are in an Employer Group that begins with “1R0.” Additionally, EmblemHealth RRP member ID cards have an “R” after the plan name on the front of the card so providers will know that they are restricted (i.e., Enhanced Care - R or Enhanced Care Plus - R).
Restricted Recipient Program
MMC and HARP members are placed in the Restricted Recipient Program (RRP) when a review of their service utilization and other information reveals that they are:
- Getting care from several doctors for the same problem.
- Getting medical care more often than needed.
- Using prescription medicine in a way that may be dangerous to their health.
- Allowing someone else to use their plan ID card.
- Using or accessing care in other inappropriate ways.
The Office of the Medicaid Inspector General (OMIG) is responsible for sending previous Managed Care Organization’s restriction notification for new enrollee to EmblemHealth within 30 days.
RRP members are restricted to certain provider types (dentists, hospitals, pharmacies, behavioral health professionals, etc.) based on a history of overuse or inappropriate use of specific services. Members are further restricted to using a specific provider of that type. EmblemHealth is required to continue the Medicaid Fee-for-Service (FFS) program restrictions for MMC and HARP members until their existing restriction period ends.
Neither the provider nor enrollee may be held liable for the cost of services when the provider could not have reasonably known that the enrollee was restricted to another provider. See above for instructions for identifying restricted recipients.
To report suspicious activity, please contact EmblemHealth’s Special Investigations Unit in one of the following ways:
Toll-free hotline: 888-4KO-FRAUD (888-456-3728)
Attention: Special Investigations Unit
55 Water Street
New York, NY 10041
A trained investigator will address your concerns. The informant may remain anonymous. For more information, please see the Fraud and Abuse chapter.
NYSDOH Medicaid Provider Non-Interference
Medicaid providers and their employees or contractors are not permitted to interfere with the rights of Medicaid recipients in making decisions about their health care coverage. Medicaid providers and their employees or contractors are free to inform Medicaid recipients about their contractual relationships with Medicaid plans. However, they are prohibited from directing, assisting, or persuading Medicaid recipients on which plan to join or keep.
In addition, if a Medicaid recipient expresses interest in a Medicaid Managed Care program, providers and their employees or contractors must not dissuade or limit the recipient from seeking information about Medicaid Managed Care programs. Instead, they should direct the recipient to New York Medicaid Choice, New York state’s enrollment broker responsible for providing Medicaid recipients with eligibility and enrollment information for all Medicaid Managed Care plans.
For assistance, please call New York Medicaid Choice: 800-505-5678, Monday to Friday, 8:30 a.m. to 8 pm, and Saturday from 10 a.m. to 6 p.m.
Any suspected violations will be turned over to the New York Office of the Medicaid Inspector General (OMIG) and potentially the Federal Office of Inspector General (OIG) for investigation.
Medicaid and HARP Benefits
Medicaid Benefits: Our Medicaid members are entitled to a standard set of benefits as set out in the Medicaid Managed Care Model Contract. They may directly access certain services. See the Direct Access (Self-Referral) Services section of the Access to Care and Delivery Systems chapter for a list of services that do not require a referral.
Below is a list of covered Home and Community Based Services (HCBS) for HARP members only. (See HCBS billing manual for full details.)
- Psychosocial Rehabilitation (PSR)
- Community Psychiatric Support and Treatment (CPST)
- Habilitation Services
- Family Support and Training
- Short-Term Crisis Respite
- Intensive Crisis Respite
- Education Support Services
- Peer Supports
- Pre-Vocational Services
- Transitional Employment
- Intensive Supported Employment (ISE)
- Ongoing Supported Employment
- Care Coordination
Children’s Health and Behavioral Health Benefits
Beginning January 1, 2019, EmblemHealth will manage the delivery of expanded behavioral and physical health services for Medicaid enrolled children and youth under 21 years of age. This will include medically fragile children, children with behavioral health diagnosis(es), and in 2019 children in foster care with developmental disabilities. Benefits will include Home and Community Based Services (HCBS) designed to provide children/youth access to a vast array of habilitative services (additional details can be found in the draft HCBS Manual). All HCBS are available to any child/youth determined eligible. Eligibility is based on Target Criteria, Risk Factors, and Functional Limitations. Health Homes will provide Care Management to children/youth eligible for HCBS.
Health Home Care Management for Children
Starting January 1, 2019, children eligible for HCBS will be enrolled in Health Home. The care coordination service of the children’s HCBS will transition to Health Home unless the child opts out of Health Home. Health Homes will administer all HCBS assessments through the Uniform Assessment System, which will have algorithms (except for the foster care developmentally disabled (DD) and the OPWDD care at home medically fragile developmentally disabled (CAH MF) populations) to determine functional eligibility criteria. Health Homes will ensure that the child meets all other eligibility criteria for HCBS (i.e., a child must live in a setting meeting HCBS settings criteria to be eligible for HCBS (i.e., Target and Risk criteria for LOC and LON populations). The Health Homes will develop one comprehensive plan of care that includes HCBS, as well as all the other services the member needs (e.g., health, behavioral health, specialtyservices, other community and social supports, etc.).
Health Homes is a care management service model for individuals enrolled in Medicaid with complex chronic medical and/or behavioral health needs. Health Home care managers provide person-centered, integrated physical health and behavioral health care management, transitional care management, and community and social supports to improve health outcomes of high-cost, high-need Medicaid members with chronic conditions.
EmblemHealth will collaborate with Beacon Health Options, Health Homes, and HCBS providers to gather information to support the evaluation the Enrollee’s level of care; adequacy of service plans; provider qualifications; Enrollee health and safety; financial accountability and compliance, etc. EmblemHealth will utilize aggregated data from its care management and claims systems to identify trends and opportunities for improving member care.
Health Home care management not only provides comprehensive, integrated, child, and family-focused care management, but also ensures the efficient and effective implementation of the expanded array of State Plan services and HCBS. Please see the Health Homes Serving Children homepage for more information at: https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/hh_children/index.htm Additional strategies to promote behavioral health-medical integration for children, including at-risk populations, include:
- Provider access to rapid consultation from child and adolescent psychiatrists
- Provider access to education and training
- Provider access to referral and linkage support for child and adolescent patients
Required Training for Providers
All Enhanced Care Prime Network providers are required to complete an initial orientation and training on the expanded children's benefit and populations, including:
- Training and technical assistance to the expanded array of providers on billing, coding, data interface, documentation requirements, provider profiling programs, and UM requirements.
- Training on processes for assessment for HCBS eligibility (e.g., Targeting Criteria, Risk Factors, Functional Limitations) and Plan of Care development and review.
For training opportunities, please visit our Learn Online webpage at https://www.emblemhealth.com/en/Providers/Provider-Resources/Learn-Online.
Adult Behavioral Health Covered Services
For more information on the Behavioral Health Services Program, please see the Behavioral Health Services chapter. On October 1, 2015, EmblemHealth replaced Medicaid FFS for the coverage of behavioral health services for its MMC members aged 21 and older who reside in the five boroughs of New York City. EmblemHealth covers the following additional behavioral health benefits:
- Medically supervised outpatient withdrawal services.
- Outpatient clinic and opioid treatment program services.
- Outpatient clinic services.
- Comprehensive psychiatric emergency program services.
- Continuing day treatment.
- Partial hospitalization.
- Personalized recovery-oriented services.
- Assertive community treatment.
- Intensive and supportive case management.
- Health home care coordination and management.
- Inpatient hospital detoxification.
- Inpatient medically supervised inpatient detoxification.
- Rehabilitation services for residential substance use disorder treatment.
- Inpatient psychiatric services.
Health Home Program
Under the Federal Patient Protection and Affordable Care Act (PPACA), New York state has developed a set of Health Home services for Medicaid members. In order to be eligible for Health Home services, the member must be enrolled in Medicaid and must have:
- Two or more chronic conditions (e.g., Substance Use Disorder, Asthma, Diabetes*), or
- One single qualifying chronic condition: HIV/AIDS, or
- Serious Mental Illness (SMI) (Adults), or
- Serious Emotional Disturbance (SED) or Complex Trauma (Children)
If a Medicaid member has HIV or SMI, he or she does not have to be determined to be at risk of another condition to be eligible for Health Home services.
Substance use disorders (SUD) are considered chronic conditions, but the presence of SUD by itself does not qualify a member for Health Home services. Members with SUD must have another chronic condition to qualify.
The Health Home Program is offered at no cost to all eligible EmblemHealth Medicaid members. All HARP members are assigned a Medicaid Health Home Care Manager to provide care plan coordination; however, members may opt out of the program at any time. EmblemHealth will then notify the member, and his or her PCP, of the Health Home assignment by letter. The member’s assigned Health Home Care Manager will contact the member’s PCP to ensure the treatment plan is included in the member’s comprehensive care plan.
The following services are available through the Medicaid Health Home program:
- Comprehensive case management with an assigned, personal care manager.
- Assistance with getting necessary tests and screenings.
- Help and follow-up when leaving the hospital and going to another setting.
- Personal support and support for their caregiver or family.
- Referrals and access to community and social support services.
Health Home Services and Information is also available in the Forms, Brochure & More chapter. More information on the NYS Medicaid Health Home Program can be found on the NYSDOH website.
See our guide for Health Homes that need assistance with submitting claims.
Medicaid Members who are not eligible to participate in the Medicaid Health Home Program may still meet our criteria for Case Management services. If you think a member would benefit from case management, please refer the patient to the program by calling 800-447-0768, Monday through Friday, from 9 a.m. to 5 p.m.
A listing of EmblemHealth network Health Homes that support our Medicaid and HARP benefit plans are listed in the Directory chapter.
Permanent Placement in Nursing Homes
The Medicaid Managed Care (MMC) nursing home benefit includes coverage of permanent stays in residential health care facilities for Medicaid recipients aged 21 and over who reside in the five boroughs of New York City, Westchester, Nassau, or Suffolk county. Covered nursing home services include:
- Medical supervision
- 24-hour nursing care
- Assistance with daily living
- Physical therapy
- Occupational therapy
- Speech-language pathology and other services
If a Medicaid member needs long-term residential care, the facility is required to request increased coverage from the Local Department of Social Services (LDSS) within 48 hours of a change in a member’s status via submission of the DOH-3559 (or equivalent).
The facility must also submit a completed Notice of Permanent Placement Medicaid Managed Care (MAP Form) within 60 days of the change in status to the LDSS. The facility must 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 facility’s submission of the MAP form to the LDSS.
Payment for residential care is contingent upon the LDSS’ official designation of the member as a Permanent Placement Member.
Veterans’ Nursing Homes
Eligible Veterans, Spouses of Eligible Veterans, and Gold Star Parents of Eligible Veterans may choose to stay in a Veterans’ nursing home.
If EmblemHealth does not have a Veterans’ home in their provider network and a member requests access to a Veterans’ home, the member will be allowed to change enrollment into an MMC plan that has the Veterans’ home in their network. While the member’s request to change plans is pending, EmblemHealth will allow the member access to the Veterans’ home and pay the home the benchmark Medicaid daily benchmark rate until the member has changed plans.
How to Enroll
There are four ways to apply:
- Online. Visit NYSOH online and go to the Individuals & Families section. Once there, start an account and begin shopping for a plan.
- In person. Get help from a Navigator, certified application counselor (CAC), Marketplace Facilitated Enroller (MFE), or broker/agent.
- By phone. Call EmblemHealth at 866-274-0060, Monday through Sunday from 8 a.m. to 8 p.m., and the NYSOH at 855-355-5777, Monday through Friday from 8 a.m. to 8 p.m., and Saturday from 9 a.m. to 1 p.m.
- By mail. Print an application at nystateofhealth.ny.gov and send it back to NYSOH, who will then confirm eligibility and enroll you in the chosen plan. Enrollment period restrictions do not apply to the Essential Plan. Eligible individuals may enroll in CHP throughout the year via the NY State of Health Marketplace or through enrollment facilitators.
Continuity of Care for Our Members
We make every effort to assist new members whose current providers are not participating with one of our plans. We do the same when a health care professional or facility leaves the network. See the Continuity/Transition of Care - New Members and Continuity of Care - When Providers Leave the Network sections of the Care Management chapter for information on transitions of care.