Provider Manual

Chapter 6: 2019 Provider Networks and Member Benefit Plans

This chapter contains information about our Provider Networks and Member Benefit Plans. Providers may be required to sign multiple agreements in order to participate in all the benefit plans associated with our provider networks. EmblemHealth may amend the benefit programs and networks from time to time. If we do, we will send advance notice to affected providers.

In this chapter, plan information is presented in the following sections:

  • Commercial and Child Health Plus
  • Medicaid Managed Care/HARP/Essential Plan
  • Medicare
  • Medicare Special Needs Plans (SNPs)

EmblemHealth’s HIP HMO, GHI HMO, and Vytra HMO plans are underwritten by Health Insurance Plan of Greater New York. HIP POS plans are underwritten by both Health Insurance Plan of Greater New York and HIP Insurance Company of New York (HIPIC), and HIP EPO/PPO plans are underwritten by HIPIC. EmblemHealth’s GHI EPO/PPO plans are underwritten by Group Health Incorporated (GHI).

You can help your patients keep their costs down by using in-network services and providers. To do this, you need to understand:

  • Your own network participation.
    Knowing your network participation is critical. It will determine whether you are in-network for your patient and which facilities and health care professionals you may coordinate with in the care of your EmblemHealth patients.
  • How to identify the network your patients can access.
    See our Access to Care chapter for instructions for keeping your information current.
  • How to refer your patients for services and identify in-network facilities.
    • Help your members avoid surprise bills and avoidable costs by keeping care in-network even if no formal referral is needed for the benefit plan. Examples of plans that do not require referrals include: 

      Commercial

      • Access I
      • Access II
      • EmblemHealth Platinum Choice
      • EmblemHealth Gold Choice
      • EmblemHealth Silver Choice
      • EmblemHealth Gold Premier 1
      • EmblemHealth Silver Plus 1
      • EmblemHealth Silver Premier
      • EmblemHealth Platinum Premier
      • EmblemHealth Gold Premier
      • EmblemHealth EPO Value
      • EmblemHealth EPO Value HDHP


      Medicare

      • EmblemHealth VIP GO
      • EmblemHealth Affinity Medicare Ultimate (HMO SNP)
      • EmblemHealth Affinity Medicare Solutions (HMO SNP)
      • EmblemHealth Affinity Medicare Passport Essentials (HMO)
      • EmblemHealth Affinity Medicare Passport Essentials NYC (HMO)


    • Use "Find-A-Doctor

    • “Referral & Prior Approval” feature has doctor search feature that will return results that are limited to the member’s network.
    • Use our hospital PEAR grid to see which hospitals are in-network and which have participating pathology, emergency, anesthesia, and radiology (PEAR) physician groups to help guide where you admit your patients.
  • In addition to the networks described in this chapter, you are required to utilize and refer your patients to appropriate participating laboratories, and other ancillary services that make up the networks our members are entitled to access. Generic referrals should never be given.

 

Our mutual success is contingent on our having accurate information on file for all of our network providers. You are required to tell us if your information changes. See our Access to Care chapter for instructions on how to keep your information current. Please make sure we have a valid email address so you can receive important updates and reminders.

The following table summarizes how our Provider Networks and Member Benefit Plans relate to our underwriting companies. You can print this page as a reference tool for the staff who schedule appointments for you. Check the boxes to show them which networks your contract covers. The blank spaces allow you to customize for each practice location.

Dr.____________at ____________________________can accept patients who have these networks:

Company Provider Network Member Benefit Plan
GHI Commercial: 
CBP Network
(Member ID cards may
show: CBP, EPO, EPO1, EPO2,
PPO, PPO1 or PPO4)
New York City Plans
  • GHI CBP plan
  • DC37 Med-Team
Commercial:
National Network 
Tristate Network
EmblemHealth EPO/PPO
Commercial:
Network Access Network
Network Access Plan
Medicare:
Medicare Choice PPO Network
EmblemHealth Group Access Rx (PPO)
EmblemHealth Group Access Rx National (PPO) 
ArchCare Advantage HMO SNP
HIP/HIPIC Commercial:
Select Care Network
Individual On/Off Exchange:
  • EmblemHealth Platinum/EmblemHealth Platinum D
  • EmblemHealth Gold/EmblemHealth Gold D
  • EmblemHealth Silver/EmblemHealth Silver D
  • EmblemHealth Bronze/EmblemHealth Bronze D
  • EmblemHealth Basic/EmblemHealth Basic D
  • EmblemHealth Gold Value/EmblemHealth Gold Value D
  • EmblemHealth Silver Value/EmblemHealth Silver Value D
Small Group:
  • EmblemHealth Platinum Choice
  • EmblemHealth Gold Choice
  • EmblemHealth Gold Value S
  • EmblemHealth Silver Choice
  • EmblemHealth Silver Value S
  • EmblemHealth Bronze Value S
Commercial:
Prime Network
Prime Network – NYC, LI & Westchester
  • Child Health Plus
Large Group – Prime Network with Tristate Access:
  • Prime HMO
  • HIP HMO Preferred (City of NY)
  • EmblemHealth HMO Plus
  • EmblemHealth HMO Preferred Plus
  • Prime POS
  • Access I
  • Access II
  • EmblemHealth EPO Value
  • GHI HMO
  • Vytra HMO
Large Group – Prime Network:
  • Prime PPO
  • HIP Select PPO
Small Group - Prime Network with Tristate Access:
  • EmblemHealth Platinum Premier
  • EmblemHealth Gold Premier
  • EmblemHealth Gold Premier1
  • EmblemHealth Gold Plus
  • EmblemHealth Gold Plus1
  • EmblemHealth Healthy NY Gold
  • EmblemHealth Silver Premier
  • EmblemHealth Silver Premier1
  • EmblemHealth Silver Plus
  • EmblemHealth Silver Plus1
  • EmblemHealth Bronze Plus H.S.A.
Medicaid/Commercial:
Enhanced Care Prime Network
EmblemHealth Enhanced Care (Medicaid)
EmblemHealth Enhanced Care Plus (HARP)
Essential Plan (BHP)
Medicare:
VIP Prime Network
EmblemHealth VIP Dual (HMO SNP)
EmblemHealth VIP Gold (HMO)
EmblemHealth VIP Gold Plus (HMO)
EmblemHealth VIP Premier (HMO)
EmblemHealth VIP Rx Carve-Out (HMO)
EmblemHealth VIP Dual Group (HMO SNP)
EmblemHealth VIP Rx Saver (HMO)
EmblemHealth VIP Part B Saver (HMO)
EmblemHealth VIP Go (HMO-POS)
EmblemHealth VIP Essential (HMO)
EmblemHealth VIP Value (HMO)
EmblemHealth Affinity Medicare Passport Essentials (HMO)
EmblemHealth Affinity Medicare Passport Essentials NYC (HMO)
EmblemHealth Affinity Medicare Ultimate (HMO SNP)
EmblemHealth Affinity Medicare Solutions (HMO SNP)
ConnectiCare, Inc. Commercial:
Choice Network (includes full Prime Network)

Passage Network (includes Prime Network except PCPs)
Choice HMO
Choice POS
Passage HMO
Passage POS
ConnectiCare Insurance Company, Inc. Commercial:
Choice Network (includes full Prime Network)

Flex Network (includes full Prime Network)

Passage Network (includes Prime Network except PCPs)

Choice EPO
Choice POS
FlexPOS
Passage EPO
Passage POS
Medicare:
Passage Network
Medicare Advantage
HMO-SNP Plans
ConnectiCare of Massachusetts Commercial: 
Choice Network (includes full Prime Network)
Choice HMO
Choice POS

The benefits available to our members are provided in accordance with the terms of the members’ benefit plans. Below, we provide links to sample benefit summaries for the following plans:

Note: These sample benefit summaries are provided for informational use only. They do not constitute an agreement, do not contain complete details of the plan benefits and cost-sharing, and the benefits may vary based on riders purchased. To view a member’s actual benefits, sign in to our secure provider website at emblemhealth.com/Providers, and use the Eligibility/Benefits function.

Medicaid Recertification

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.

 

Identifying Members

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.

Restricted Recipients
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:

E-mail: KOfraud@emblemhealth.com
Toll-free hotline: 888-4KO-FRAUD (888-456-3728)
Mail:
EmblemHealth
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:

  1. Training and technical assistance to the expanded array of providers on billing, coding, data interface, documentation requirements, provider profiling programs, and UM requirements.
  2. 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 877-411-3625, 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.

Medicare Plans

EmblemHealth companies HIP and GHI underwrite the Medicare plans associated with the VIP Prime Network (HIP Health Plan of Greater New York), and Medicare Choice PPO Network (Group Health Incorporated). Our Important Plan Documents section includes benefit summaries and copies of members' Evidences of Coverage for each of these Medicare plans.

As a reminder, providers are deemed participating in all benefit plans associated with their participating networks and may not terminate participation in an individual benefit plan.

Starting January 1, 2019, all Affinity plans have been transitioned to EmblemHealth. This includes four Affinity Medicare HMO plans: EmblemHealth Affinity Medicare Passport Essentials, EmblemHealth Affinity Medicare Passport Essentials NYC, EmblemHealth Affinity Medicare Ultimate (HMO SNP) and EmblemHealth Affinity Medicare Solutions (HMO SNP). Members will access the VIP Prime Network for these plans. Providers will follow the same medical management and claim protocols as for all other members managed by EmblemHealth, Montefiore CMO and HealthCare Partners. There is one exception – no referrals are required. To identify these new members, look for the plan names on the member ID cards.

 

Maximum Out-of-Pocket Threshold

The maximum out-of-pocket (MOOP) threshold for Medicare Parts A and B services covered under the EmblemHealth Medicare Advantage Plans has not changed for existing plans. This includes the in-network MOOP under the EmblemHealth Medicare HMO plans and both the in-network and combined (in- and out-of-network) MOOPs under the EmblemHealth Medicare PPO plans. The MOOP for each benefit plan is shown in the Medicare Network and Plan Summary section of this chapter. Sign in to the provider section of the EmblemHealth website at emblemhealth.com/providers to confirm MOOPs for you members.

How MOOP is Communicated to Members: A statement of members’ out-of-pocket spending to date will appear on their Explanation of Benefits. Members will continue to be notified by mail upon reaching the MOOP for their plan. This notice will also list services with $0 cost-sharing available to the member for the remainder of the calendar year.

Transferability of Maximum Out-of-Pocket (MOOP): If a member makes a mid-year change from one EmblemHealth Medicare plan to another, the MOOP accumulated thus far in the contract year will follow the member and count toward the MOOP in the new EmblemHealth Medicare plan.

 

Coinsurance and Copay Changes for 2019

Members: Member cost-sharing for our HMO Special Needs Plan (SNP) benefits has not changed from the current amount of $0. The amount of cost-sharing providers may need to bill to Medicaid has changed on some benefits (inpatient hospital, skilled nursing facility, rehabilitation therapies have increased and podiatry has decreased to $0). Our HMO SNP plan members are qualified Medicare beneficiaries (QMB), which means they receive help from New York State Medicaid to pay their cost-sharing. As a result, the provider must bill Medicaid for the cost-sharing upon receipt of payment from EmblemHealth. The correct address to bill Medicaid is located on these members’ Common Benefits Identification Card (CBIC).

 

Annual Physical Exam

Most EmblemHealth Medicare HMO Plans cover an Annual Physical exam at no cost to the member. This is a great opportunity for members and providers to review and discuss management of chronic health conditions such as diabetes and hypertension, and complete preventive steps such as flu shots, breast cancer screenings and others.

 

Wellness Exams

Medicare Part B services include an annual wellness exam in addition to the ”Welcome to Medicare“ physical exam.

"Welcome to Medicare" Physical Exam: Our Medicare plans cover a one-time ”Welcome to Medicare“ physical exam. This exam includes a health review, education, and counseling about preventive services (including screenings and vaccinations) and referrals for care, if necessary. Note: Members must have the ”Welcome to Medicare“ physical exam within 12 months of enrolling in Medicare Part B. When making their appointment, they should let you know they are scheduling their ”Welcome to Medicare“ physical exam.

Annual Wellness Visit: A Health Risk Assessment (HRA) is to be used as part of the Annual Wellness Visits (AWV). Members enrolled in Medicare Part B for over 12 months are eligible for an annual wellness visit to develop or update a personalized prevention plan based on their health needs and risk factors. This is covered once every 12 months. Note: Following their ”Welcome to Medicare“ physical exam, members must wait 12 months before having their first annual wellness visit. However, once members have been enrolled in Medicare Part B for at least 12 months, they do not need to have had a ”Welcome to Medicare“ physical exam to be covered for annual wellness visits. Providers may bill for this service using HCPCS codes G0438 and G0439 for initial and subsequent visits, respectively.

No Cost-Sharing for Preventive Care Services: CMS has released National Coverage Determinations for preventive services that are to be offered without cost-sharing. All of the services are listed in the chart referenced below. For HMO members, including Dual Eligible members, Medicare required covered services that are not available in-network and receive prior approval from our plan, or the member’s assigned managing entity, as applicable, will be allowed at $0 cost-sharing as well.

Medicare Preventive Services
The preventive care services listed on this chart are those CMS has determined should be provided to all Medicare recipients with no cost-sharing. This requirement applies to original Medicare, as well as to all of our Medicare plans, when provided on an in-network basis.

 

Review Medicare Network and Plan Summary here

 

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.

SNPs Meet Our Members’ Special Needs

Medicare Special Needs Plans (SNPs) are specially designated Medicare Advantage Plans with custom-designed benefits to meet the needs of a specific population. Enrollment in an SNP is limited to Medicare beneficiaries within the target SNP population. The target populations for the EmblemHealth SNPs are individuals who live within the plan service area, are eligible for Medicare Part A and Part B, and are eligible for Medicaid.

Starting January 1, 2019, all Affinity plans have been transitioned to EmblemHealth, including two Affinity SNPs: EmblemHealth Affinity Medicare Ultimate (HMO SNP) and EmblemHealth Affinity Medicare Solutions (HMO SNP). Members will access the VIP Prime Network for these plans. Providers will follow the same medical management and claim protocols, including our SNP Model of Care, as for all other members managed by EmblemHealth, Monte CMO and HCP. There is one exception – no referrals are required. To identify these new members, look for the plan names on the member ID cards.

EmblemHealth's SNPs consist of:

Medicare Choice PPO Network
ArchCare Advantage (HMO SNP)

VIP Prime Network
EmblemHealth VIP Dual Group (HMO SNP)
EmblemHealth VIP Dual (HMO SNP)

EmblemHealth Affinity Medicare Ultimate (HMO SNP) 
EmblemHealth Affinity Medicare Solutions (HMO SNP)

The Medicare benefit for each of these plans is supplemented by a specific set of Medicaid benefits.

Provider Obligations/Responsibilities for Participation in Dual-Eligible Special Needs Plans

Members have no copayment for covered services other than for prescriptions drugs. The provider must verify Medicaid eligibility of every member enrolled in Dual SNP and may not collect a copayment for covered services from a Medicaid member eligible for Medicaid coverage of Medicare cost-sharing. EmblemHealth Affinity Medicare Solutions (HMO SNP) members may not be eligible for full Medicaid and may pay cost-sharing for covered services.

Provider Obligations/Responsibilities for Participation in Medicare-Medicaid Plans (MMPs)

Members have no copayment for covered services other than for prescriptions drugs. The provider may not collect a copayment for covered services from a Medicare-Medicaid Plan (MMP) member (including Affinity and ArchCare members).

HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect any pertinent information of your medical practice, including books, contracts, records, including medical records, and documentation related to CMS’ contract with EmblemHealth for a period of 10 years from the final date of the contract period or the completion of any audit, whichever is later.

The provider may not hold members liable for payment of fees that are the legal obligation of EmblemHealth or a payor (including Affinity and ArchCare members).

For information about provider obligations and responsibilities, see Medicare/Advantage-Medicaid Required Provisions in the Required Provisions to Network Provider Agreements chapter.

 

The SNP Interdisciplinary Team

Our SNP goals are to:

  • Improve access to medical, mental health, social services, affordable care, and preventive health services.
  • Improve coordination of care through an identified point of contact.
  • Improve transitions of care across health care settings and providers.
  • Assure appropriate utilization of services.
  • Assure cost-effective service delivery.
  • Improve beneficiary health outcomes.

The SNP interdisciplinary team provides the framework to coordinate and deliver the plan of care and to provide appropriate staff and program oversight to achieve the SNP goals. The care management staff assumes an important role in developing and implementing the individualized care plan, coordinating care, and sharing information with the interdisciplinary care team, and with the member, their family, or caregiver.

Practitioners providing care to our SNP members are important members of the SNP interdisciplinary team. As such, they participate in one of our regularly scheduled care coordination or case rounds meetings to discuss their plan of care and the health status of the SNP-enrolled patient. These practitioners also share their progress with the team to ensure we are meeting our SNP program goals.

 

Required Training for EmblemHealth Practitioners, Providers, and Vendors

Each year, all Medicare providers are required to complete the Special Needs Plan (SNP) Model of Care Training for each of the Dual Eligible SNPs in which they participate, as mandated by Centers for Medicare & Medicaid Services (CMS). For training presentations and other learning opportunities, please visit our Learn Online webpage.

 

Review Medicare Special Needs Plans Summary here

 

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.

Please see the Appendix K table for a listing of all covered services under Medicaid Managed Care Supplemental Security Income (SSI), non-SSI related, Fee-for-Service, and HARP. Family Health Plus and HIV Special Needs Plan members are not applicable.

Medicaid State Plan and Demonstration Benefits for all Medicaid Managed Care

Services Current Delivery System MMCO Benefit Package

Assertive Community Treatment

(minimum age is 18 for medical necessity for this adult-oriented service)

FFS 10/1/2019

CFCO State Plan Services for

children meeting eligibility criteria8

FFS 7/1/2019
Children’s Crisis Intervention FFS/1915(c) Children’s Waiver service 1/1/2020
Children’s Day Treatment FFS TBD

Comprehensive psychiatric

emergency program (CPEP)

including Extended Observation Bed

Current MMC Benefit for individuals age 21 and over 10/1/2019

Continuing day treatment

(minimum age is 18 for medical necessity

for this adult-oriented service)

FFS 10/1/2019
CPST9 N/A (new SPA service) 1/1/2019

Crisis Intervention Demonstration

Service

MMC Demonstration Benefit for all ages 1/1/2020
Family Peer Support Services FFS/1915(c) Children’s waiver service 7/1/2019
Health Home Care Management FFS 1/1/2019
Inpatient psychiatric services Current Medicaid Managed Care Benefit Current Benefit

Intensive Psychiatric Rehabilitation

Treatment (IPRT)

FFS 7/1/2018

Licensed Behavioral Health Practitioner

(NP-LBHP) Service

MMC Demonstration Benefit for all ages Combined with OLP for 1/1/2019
Licensed outpatient clinic services Current MMC Benefit Current Benefit

Medically Managed detoxification

(hospital based)

Current Medicaid Managed Care Benefit Current Benefit

Medically supervised inpatient

detoxification

Current Medicaid Managed Care Benefit Current Benefit

Medically supervised outpatient

withdrawal

Current Medicaid Managed Care Benefit Current Benefit

OASAS Inpatient Rehabilitation

Services

Current Medicaid Managed Care Benefit Current Benefit

OASAS opioid treatment program

(OTP) services

FFS 10/1/2019

OASAS Outpatient Rehabilitation

Services

FFS 10/1/2019
OASAS Outpatient Services FFS 10/1/2019
OMH State Operated Inpatient FFS TBD
Other Licensed Practitioner (OLP) N/A (New SPA service) 1/1/2019
Partial hospitalization FFS 10/1/2019

Personalized Recovery Oriented

Services (minimum age is 18 for

medical necessity for this adult-oriented

service)

FFS 10/1/2019
Psychosocial Rehabilitation (PSR) N/A (New SPA service) 1/1/2019

Rehabilitation Services for residents of

community residences

FFS TBD
Residential Addiction services MMC Demonstration Benefit for all ages 10/1/2019

Residential Rehabilitation Services for

Youth (RRSY)

FFS TBD

Residential Supports and Services

(VFCA) (New Early and Periodic

Screening, Diagnostic and Treatment [EPSDT] Prevention effect 10/1/2019)

OCFS Foster Care 10/1/2019
Residential Treatment Facility (RTF) FFS TBD
Teaching Family Home FFS TBD
Youth Peer Support and Training FFS/1915(c) Children’s Waiver service 1/1/2020

8 Beginning 7/1/18, eligibility for CFCO benefits will become available to children who are eligible for Medicaid solely because of receipt of HCBS (i.e., Family of One children who meet institutional admission criteria and receive HCBS). These children are not eligible for CFCO under the State Plan but will be eligible for identical benefits under the 1115 Demonstration Waiver Amendment.

9 NYS is exploring the use of EBPs. Pending CMS approval, these services will be billed through CPST and/or OLP, depending upon provider qualifications. Additional guidance will be issued regarding provider designation as well as the rate structure.