Medicaid and HARP Plan Summaries

The table below summarizes the network and benefit plans for our Medicaid and HARP members.

HIP Medicaid Network and Plan Summary for 2019
Enhanced Care Prime Network

Network Plan
Name
Plan
Type
PCP Req'd Referral Req'd OON Coverage In-Network Cost-Sharing Service Area1 Comments
Enhanced Care
Prime Network1
EmblemHealth 
Enhanced Care
HMO  Yes2 Yes2 Yes3 Rx Copays 8 county Medicaid Managed Care 
plan for Medicaid-eligible individuals4including Medicaid children’s health and behavioral health benefits
Enhanced Care 
Prime Network1
EmblemHealth 
Enhanced Care Plus
HMO  Yes2 Yes2 Yes3 Rx Copays 8 county HARP for Medicaid-eligible individuals aged 21 and older4

ER = emergency room; IN = in-network; N/A = not applicable; OON = out-of-network; MOOP = maximum out-of-pocket; PCP = primary care provider; FPL = federal poverty level; Req'd = Required

8 county = Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island), Nassau, Suffolk, & Westchester counties. NYC = Bronx, Kings (Brooklyn), New York (Manhattan), Queens, & Richmond (Staten Island) Counties.

1Medicaid and HARP members traveling outside of the continental United States can get coverage for urgent and emergency care only in the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. Members needing any type of care while in any other country (including Canada and Mexico) will be responsible for payment.

2Except for self-referral services and services that Medicaid members can access from Medicaid FFS providers.

3Medicaid members can access certain services from county departments of health and academic dental centers. (See the Access to Care and Delivery Systems chapter for a list of applicable services where OON coverage applies.)

4See Medicaid Managed Care Model Contract for more details.

Chapter 6 2019 Provider Networks and Member Benefit Plans