Commercial and Child Health Plus Networks

Commercial Networks Covered by Agreements

The table that follows summarizes the benefit plans our commercial members use to receive their health care benefits and services. EPO/PPO plans typically allow members to self-refer to network specialists for office visits; however, prior approval is still required before certain procedures can be performed.

GHI Commercial Network and Plan Summary for 2019
(CBP, National, Network Access, & Tristate Networks)

Network Plan
Name
Plan
Type
PCP 
Req'd
Referral 
Req'd
Deductibles 
(Individual/ 
Family)
PCP/
Special/
ER Copay
OON
Coverage
MOOP
(Ind/
Family)
Co-ins.
CBP
Network
Federal Employee
Health Benefit 
(FEHB)1
EPO No No N/A $30/
$30/
$150
No  $6,850/
$13,700
No
CBP
Network
Federal Employee
Health Benefit 
(FEHB)1
PPO No No IN: N/A
OON: $150
$20/
$20/
$150
Yes $6,850/
$13,700
OON
only
Network Access Network Network
Access
EPO/
PPO
network
lease
No No Various Various EPO: No
PPO: Yes
Up to 
$7,350/
$14,700
EPO: No
PPO: Yes
CBP Network City of 
New York
PPO
(medical only)
No No IN: N/A
OON: $175/$500
Preferred
PCP/Speci
alist
$0/$0 All other
PCP/Speci
alists
$15/$30/
N/A
$25/$25/
$150
Yes $4,550/
$9,100
No
CBP Network DC 37 Med-Team PPO No No IN: N/A
OON: 
$1,000/
$3,000
$25/
$25/
$150
Yes $7,150/
$14,300
OON
only
National
Network
EmblemHealth 
EPO
EPO No No N/A Various No Up to 
$7,350/
$14,700
No
National
Network
EmblemHealth 
PPO
PPO No No IN: N/A
OON: Various
Various Yes Up to 
$7,350/
$14,700
OON
only
National
Network
EmblemHealth 
ConsumerDirect 
EPO
EPO No No Various 
(includes Rx)
No No Up to 
$7,350/
$14,700
Yes
National
Network
EmblemHealth 
ConsumerDirect 
PPO
PPO No No Various 
(includes Rx)
No Yes Up to 
$7,350/
$14,700
Yes
National
Network
EmblemHealth 
HealthEssentials 
Plus
EPO No No N/A $40 (limited 
to 3 outpatient
visits only)
No $3,000/
$6,000
No
National
Network
EmblemHealth 
InBalance EPO
EPO No No Various on facility/
non-preventive 
surgical services
Various No Up to 
$7,350/
$14,700
Yes
National
Network
EmblemHealth 
InBalance PPO
PPO No No IN: Various 
on facility/
non-preventive 
surgical services
OON: Various
Various Yes Up to 
$7,350/
$14,700
Yes

ER = emergency room; IN = in-network; N/A = not applicable; OON = out-of-network; MOOP = maximum out-of-pocket; PCP = primary care provider; Req'd = Required; Co-ins. = Co-insurance.

1Copays are $10 for telemedicine physicians [and $5 for dietitians/nutritionists] for Federal Employee Health Benefit (FEHB) plans’ telemedicine coverage.

Note: Member ID cards for plans associated with the Comprehensive Benefits Plan (CBP) Network may display the network name as CBP, EPO, EPO1, EPO2, PPO, PPO1, or PPO4.

GHI Plan Descriptions

EmblemHealth HDHP Programs: ConsumerDirect EPO and ConsumerDirect PPO

To meet the growing demand for consumer-directed health care, EmblemHealth has two high-deductible health plans (HDHP), ConsumerDirect EPO and ConsumerDirect PPO. These benefit plans allow employers and employees more power and choice in how to spend their health care dollars and make health care decisions.

Depending on the HDHP selected and other factors, members may also establish a separate health savings account (HSA) to pay for qualified medical expenses with tax-free dollars. Individual HSAs are member owned, and contributions, interest, and withdrawals are generally tax-free.

For members, ConsumerDirect EPO and ConsumerDirect PPO benefit plans feature:

  • Lower monthly premiums based on higher annual deductibles.
  • Network and out-of-network coverage for the PPO plan.
  • No non-emergent coverage for out-of-network services for the EPO plan.
  • No out-of-pocket costs for covered preventive care in network.

HealthEssentials

HealthEssentials is an EmblemHealth EPO plan designed for people seeking health coverage primarily for catastrophic injury or illness. Its core benefits are hospital and preventive care services and three additional office visits.

The HealthEssentials plan features:

  • Network hospital or ambulatory surgical center benefits.
    • Inpatient and outpatient hospital services provided in and billed by a network hospital or facility.
    • Well-Baby and Well-Child Care provided by a network practitioner.
    • Emergency room services (provided in and billed by a hospital or facility).
    • Inpatient and outpatient mental health and chemical dependency services provided in and billed by a network hospital or facility.
  • Covered preventive care services consistent with guidelines of the Patient Protection and Affordable Care Act.
    • Preventive care services covered at 100 percent when provided by a network practitioner.
    • Sick visits not covered.
  • Pharmacy benefit.
    • $15 generic drug card.

Note: With the exception of preventive care services provided by network practitioners, services billed by a practitioner are not covered under this plan except for three office visits.

HIP Commercial Networks

Commercial Networks Covered by Agreements with HIP Health Plan, HIP Health Plan of New York, Health Insurance Plan of Greater New York, HIP Network Services, IPA. and HIP Insurance Company of New York

Our HMO plans only offer in-network coverage for non-emergent services. If you see a member who is NOT in a plan associated with your participating network(s), and no prior approval has been given, the member may incur a surprise bill or avoidable expenses. So when a member calls for an appointment, be sure to check that you participate in the member’s plan at that location. If you do not participate in their plan, please refer them back to our online directory, Find-A-Doctor, to find a provider in their network.

Prime Network

Large Group: The Prime Network includes a robust network of practitioners, hospitals, and facilities in 28 New York state counties: Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Kings, Montgomery, Nassau, New York, Orange, Otsego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington, and Westchester. New Jersey Qualcare HMO Network services a variety of HMO and POS plans. ConnectiCare Network services a variety of HMO, POS, and EPO plans.

Small Group: The Prime Network includes a robust network of practitioners, hospitals, and facilities in 28 New York state counties. Small Group plan members also have access to providers in New Jersey via Qualcare’s network, and Connecticut via ConnectiCare’s network.

Small Group Standard plans follow the plan designs established by New York state, and Nonstandard plans can change the cost-sharing required in any benefit category.

*Providers must have an open panel (accepting new members), and be a provider that can be considered a primary care physician (PCP) following all existing business rules.

Select Care Network

The Select Care Network is located in the following New York state counties: Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Kings, Montgomery, Nassau, New York, Orange, Otsego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington, and Westchester.

The Select Care Network, a subset of our existing Prime Network, is a tailored network that helps keep costs down and supports an integrated model of care. Providers in the Select Care Network are chosen on measures such as geographic location, hospital affiliations, and sufficiency of services. The network includes a full complement of physicians, hospitals, community health centers, facilities, and ancillary services. Urgent care and immediate care are also available.

EmblemHealth offers six Small Group plans on the Select Care Network.

EmblemHealth offers seven individual plans on the Select Care Network. These benefit plans are offered both on and off the NY State of Health: The Official Health Plan Marketplace. EmblemHealth Silver Value and EmblemHealth Gold Value plans, both non-standard plans, provide a specific number of primary care physician (PCP) visits at no cost before the deductible. The plans offer acupuncture, dental, and vision benefits for adults and children.

Individual and Small Group Standard plans follow the plan designs established by New York state, and Nonstandard plans can change the cost-sharing required in any benefit category.

Our Select Care Network plans are HMOs. All non-emergency care must be provided by Select Care Network providers. Most plans require referrals and prior authorization for certain services. To locate the closest care for your patient, please use the-Find A-Doctor online directory at emblemhealth.com/find-a-doctor.

Note: Most of these plans have a deductible that applies to in-network services.

Wellness Visits: Large Group and Small Group plan members are eligible for an annual wellness visit once every benefit plan year. Individual plan members are eligible for an annual wellness visit once every calendar year. Please log in to emblemhealth.com/providers to check the member's Benefit Summary.

Telemedicine: EmblemHealth Small Group Prime Network plans, Individual and Small Group Select Care Network plans both on- and off-exchange and the Essential Plan offer telemedicine services at no cost. EmblemHealth Basic plan off-exchange offers telemedicine at 0% after deductible.

HIP Commercial and Child Health Plus Networks and Plan Summary for 2019

(Prime Network and Select Network) 

Network Plan
Name
Plan
Type
PCP Req'd Referral Req'd Deductibles 
(Ind/Family)
PCP/
Special/
ER Copay
OON
Coverage
MOOP
(Ind/
Family)
Co-ins.
Prime Network HIP Prime® POS POS Yes Yes IN: N/A
OON: Various
Various Yes Up to 
$7,350/
$14,700
OON only
Prime Network HIP Prime® PPO PPO No No IN: N/A
OON: Various
Various Yes Up to 
$7,350/
$14,700
OON only
Prime Network HIPaccess® II POS Yes No IN: N/A
OON: Various
Various Yes Up to 
$7,350/
$14,700
OON only
Prime Network HIP Prime® HMO HMO Yes Yes N/A Various No Up to 
$7,350/
$14,700
No
Prime Network HIPaccess® I HMO Yes No N/A Various No Up to 
$7,350/
$14,700
No
Prime
Network
HIP Select® PPO PPO No No IN: 
Various on 
facility 
services
OON: 
Various
Various Yes Up to 
$7,350/
$14,700
Yes
Prime
Network
Child Health Plus HMO Yes Yes N/A No No N/A No
Prime
Network
GHI HMO HMO Yes Yes N/A Various No Up to 
$7,350/
$14,700
No
Prime
Network
Vytra HMO HMO Yes Yes N/A Various No Up to 
$6,850/
$13,700
No
Prime
Network
EmblemHealth EPO Value EPO No No Various Various No Up to 
$7,350/
$14,700
No
Prime
Network
EmblemHealth HMO Plus HMO Yes Yes Various Various No Up to 
$7,350/
$14,700
No
Prime
Network
EmblemHealth HMO Preferred Plus HMO Yes Yes Various Various No Up to 
$7,350/
$14,700
No
Prime Network HMO Preferred (City) HMO Yes Yes No $0/
$0/
$150

$10/
$10/
$150
No $7,150/
$14,300
No
Select Care Network EmblemHealth Platinum HMO Yes Yes IN:$0 $15/
$35
/$100
No Up to 
$2,000/
$4,000
No
Select Care Network EmblemHealth Gold  HMO Yes Yes IN: 
$600/
$1,200
$25/
$40/
$150
No Up to 
$4,000/
$8,000
No
Select Care Network EmblemHealth Silver HMO Yes Yes IN: 
$1,700/
$3,400
$30/
$50/
$250
No Up to 
$7,500/
$15,000
No
Select Care Network EmblemHealth Bronze HMO Yes Yes IN: $4,000/
$8,000
50% No Up to 
$7,600/
$15,200
Yes
Select Care Network EmblemHealth Basic HMO Yes Yes IN: 
$7,900/
$15,800
0% No Up to 
$7,900/
$15,800
Yes
Select Care Network EmblemHealth Gold Value HMO Yes Yes/ IN: 
$3,000/
$6,000
$45**/
$65**/
$0
(3 free 
PCP visits)
No Up to 
$3,000/
$6,000
No
Select Care Network EmblemHealth Silver Value HMO Yes Yes IN:
$3,000
/$6,000
$35**/
$70**/
$0
(3 free 
PCP visits)
No Up to
$6,100/
$12,200
No
Select Care Network EmblemHealth Platinum D HMO Yes Yes IN:$0 $15/
$35/
$100
No Up to 
$2,000/
$4,000
No
Select Care Network EmblemHealth Gold D HMO Yes Yes IN: 
$600/
$1,200
$25/
$40/
$150
No Up to 
$4,000/
$8,000
No
Select Care Network EmblemHealth Silver D HMO Yes Yes IN: 
$1,700/
$4,000
$30/
$50/
$250
No Up to 
$7,500/
$15,000
No
Select Care Network EmblemHealth Bronze D HMO Yes Yes IN: 
$2,000/
$4,000
50% No Up to 
$7,6,00/
$15,200
Yes
Select Care Network EmblemHealth Basic D HMO Yes Yes IN: 
$7,900/
$15,800
0% No Up to 
$7,900 /
$15,800
Yes
Select Care Network EmblemHealth Gold 
Value D
HMO Yes Yes IN: 
$3,000/
$6,000
$45**/
$65**/
$0
(3 free 
PCP visits)
No Up to 
$3,000/
$6,000
No
Select Care Network EmblemHealth Silver 
Value D
HMO Yes Yes IN: 
$6,100/
$12,200
$35**/
$70**/
$0
(3 free 
PCP visits)
No Up to 
$6,100/
$12,200
No
Prime Network EmblemHealth Platinum Premier HMO Yes No IN:
$0
Rx deductible
$0
$15/
$35/
$200
No Up to
$2,000/
$4,000
No
Prime Network EmblemHealth Gold 
Premier
HMO Yes No IN:
$450/$900
Rx deductible
$0
$30**/
$50**/
$300
(3 free 
PCP visits)
No Up to
$4,000/
$8,000
No
Prime Network EmblemHealth Gold 
Premier1
HMO Yes No IN:
$2,000/
$4,000
Rx deductible
$100/$200
$30**/
$60**/
$500
No Up to
$6,800/
$13,600
Yes
Prime Network EmblemHealth Gold Plus HMO Yes Yes IN:
$550/$1,100
Rx deductible
$0
$40**/
$60**/
$300
(3 free 
PCP visits)
No Up to 
$4,500/
$9,000
No
Prime Network EmblemHealth Gold Plus1 HMO Yes Yes IN:
$1,000
/$2,000
Rx deductible
$100/$200
$30**/
$60**/
$300
No Up to
$4,000/
$8,000
No
Prime Network EmblemHealth Healthy 
NY Gold
HMO Yes Yes IN: $600/
$1,200
$25/
$40/
$150
No Up to 
$4,000/
$8,000
No
Prime Network EmblemHealth Silver 
Premier
HMO Yes No IN:
$3,300/
$6,600
Rx deductible
$0
$30**/
$55**/
$500
(3 free 
PCP visits)
No Up to
$7,000/
$14,000
No
Prime Network EmblemHealth Silver 
Premier1
HMO Yes Yes IN:
$2,700/
$5,400
Rx deductible
$200/$400
$40**/
$70**/
30%
No Up to
$7,300/
$14,600
Yes
Prime Network EmblemHealth Silver Plus HMO Yes Yes IN:
$2,550/
$5,100
Rx deductible
$0
$40/
$60/
$500
(3 free 
PCP visits)
No Up to
$7,300/
$14,600
No
Prime Network EmblemHealth Silver Plus1 HMO Yes No IN:
$3,000/
$6,000
Rx deductible
$200/$400
$35**/
$55**/
$700
No Up to
$7,000/
$14,000
Yes
Prime Network EmblemHealth Bronze Plus H.S.A. HMO Yes Yes IN: 
$5,500/
$11,000
50% No Up to 
$6,550/
$13,100
Yes
Select Care Network EmblemHealth Platinum Choice HMO Yes No IN:
$200/
$400
$15**/
$35**/
$200
No Up to
$2,200/
$4,400
No
Select Care Network EmblemHealth Gold Choice HMO Yes No IN:
$750/
$1,500
$30**/
$50**/
$300
(3 free 
PCP visits)
No Up to
$5,000/
$10,000
No
Select Care Network EmblemHealth Gold Value HMO Yes Yes IN: 
$3,000/
$6,000
$45**/
$65**/
$0
(3 free 
PCP visits)
No Up to 
$3,000/
$6,000
No
Select Care Network EmblemHealth Silver Choice HMO Yes No IN:
$2,800/
$5,600
$30**/
$50/
$500
(3 free 
PCP visits)
No Up to
$7,100/
$14,200
No
Select Care Network EmblemHealth Silver Value HMO Yes Yes IN: 
$6,300/
$12,600
$35**/
$70**/
$0
(3 free 
PCP visits)
No Up to 
$6,100/
$12,600
No
Select Care Network EmblemHealth Bronze Value HMO Yes Yes IN: 
$7,690/
$15,380
0% 
(3 free 
PCP visits)
No Up to 
$7,690/
$15,380
Yes

ER = emergency room; IN = in-network; N/A = not applicable; OON = out-of-network; MOOP = maximum out-of-pocket; PCP = primary care provider; Req'd = Required; Co-ins. = Co-insurance.

* Note: If your patient has the Access I, Access II, or other Direct Access benefit plan, with or without the HCP logo HCP Logo , the member does not need a referral to see a specialist. However, for plans that do require referrals and the member ID card has the HCP logo, please follow HCP’s referral process.

** Benefit is not subject to deductible.

HIP Commercial Plan Descriptions

Child Health Plus

Child Health Plus (CHP) is a New York state-sponsored program that provides uninsured children under 19 years of age with a full range of health care services for free or for a low monthly cost, depending on family income. In addition to immunizations and Well-Child care visits, CHP covers pharmaceutical drugs, vision, dental, and mental health services. There are no copays for CHP members for any covered services. CHP members may visit any one of our Prime Network providers that see children.

The service area for CHP includes the following New York state counties: Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, and Westchester. CHP members are covered for emergency care in the U.S., Puerto Rico, the Virgin Islands, Mexico, Guam, Canada, American Samoa and the Northern Mariana Islands.

Enrollment period restrictions do not apply to CHP. 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 Managementchapter for information on transitions of care.

Chapter 6 2019 Provider Networks and Member Benefit Plans