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