Medicare Network and Plan Summary

The table below summarizes our Medicare HMO/POS suite of products. Special Needs plans are located within the Medicare Special Needs Plans section of this chapter.

HIP Medicare HMO/POS Network and Plan Summary for 2019 (VIP Prime Network)
Network	Plan Name	Plan Type	PCP Req'd	Referral Req'd	OON Coverage	In-Network Cost-Sharing	Service Area	Comments
VIP Prime Network	EmblemHealth VIP Value	EmblemHealth Medicare HMO	Yes	Yes	No	Copays/ coinsurance	12 counties	$15 PCP copays Provider should confirm participation as PCP prior to accepting new patients.
VIP Prime Network	EmblemHealth VIP Essential	EmblemHealth Medicare HMO	Yes/	Yes	No	Copays/ coinsurance	14 counties	$0 PCP copays Provider should confirm participation as PCP prior to accepting new patients.
VIP Prime Network	EmblemHealth VIP Gold	EmblemHealth Medicare HMO	Yes	Yes	No	Copays/ coinsurance	14 counties	$10 Chiropractic copays
VIP Prime Network	EmblemHealth VIP Gold Plus	EmblemHealth Medicare HMO	Yes	Yes	No	Copays/ coinsurance	14 counties	$0 PCP copays $0 Specialist copays
VIP Prime Network	EmblemHealth VIP Premier	EmblemHealth Medicare HMO	Yes	Yes	No	Copays/ coinsurance	14 counties	Employer Group plan.
VIP Prime Network	EmblemHealth VIP Rx Carve-out	EmblemHealth Medicare HMO	Yes	Yes	No	Copays/ coinsurance	14 counties	Employer Group plan.
VIP Prime Network	EmblemHealth VIP Rx Saver	EmblemHealth Medicare HMO	Yes	Yes	No	Copays/ coinsurance	2 counties	$5 PCP copays and Comprehensive dental and fitness benefits with no maximums
VIP Prime Network	EmblemHealth VIP Part B Saver	EmblemHealth Medicare HMO	Yes	Yes	No	Copays/ coinsurance/ deductible applies to some services	14 counties	Optional dental and fitness benefit riders are available at a low cost
VIP Prime Network	EmblemHealth VIP Go	EmblemHealth Medicare HMO-POS	No	No	Yes	Copays/ coinsurance/ deductible applies to some services	14 counties	Out-of-network coverage allowed on many benefits
VIP Prime Network	EmblemHealth Affinity Passport Medicare Essentials	Affinity Medicare HMO	Yes	Yes	No	Copays/ coinsurance	4 counties	$5 PCP copays Dental, Vision and Hearing Coverage Acupuncture Fitness Program (Silver Sneakers)
VIP Prime Network	EmblemHealth Affinity Medicare Passport Essentials NYC	Affinity Medicare HMO	Yes	Yes	No	Copays/ coinsurance	5 counties	$10 PCP copays Dental, Vision and Hearing Coverage Acupuncture Fitness Program (Silver Sneakers)

OON = out-of-network; PCP = primary care provider.; Req'd = Required

14 county¹ = New York City (Bronx, Kings, New York, Queens, Richmond), Nassau, Suffolk, Orange, Rockland, Westchester , Dutchess, Sullivan, Ulster, and Putnam

12 county² = New York, Queens, Richmond, Nassau, Suffolk, Orange, Rockland, Westchester, Dutchess, Sullivan, Ulster, and Putnam

2 county³=Bronx, Westchester

4 county⁴= Orange, Rockland, Westchester and Nassau

5county⁵= New York, Bronx, Kings, Queens and Richmond

Members are covered for urgent and emergency care. HIP covers members in all 50 United States, Canada, Mexico, Puerto Rico, the U.S. Virgin Islands, Guam, and the Northern Mariana Islands. Medicare members have worldwide urgent and emergency coverage.

EmblemHealth Affinity Passport Medicare Essentials (HMO), EmblemHealth Affinity Medicare Passport Essentials NYC (HMO), EmblemHealth VIP Essential (HMO), EmblemHealth VIP Gold (HMO), and EmblemHealth VIP Gold Plus (HMO) members have access to SilverSneakers® membership, an exercise program designed for older adults.

GHI Medicare Network and Plan Summary for 2019 Medicare Choice PPO Network
Network	Plan Name	Plan Type	PCP Req'd	Referral Req'd	OON Coverage	In-Network Cost-Sharing	Service Area	Comments
Medicare Choice PPO Network	EmblemHealth Group Access PPO	EmblemHealth Medicare PPO	No	No	Yes	Copays/ coinsurance	National	Employer Group MAPD plan. Each group contracts individually with the plan for benefit design. Pharmacy benefits excluded.
Medicare Choice PPO	GHI Retirees		No	No
N/A	EmblemHealth National Drug Plan	EmblemHealth Medicare PDP	N/A	N/A	Yes	Copays/ coinsurance	National	Part D drug Coverage

Chapter 6 2019 Provider Networks and Member Benefit Plans

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.