Provider Manual

Chapter 6: 2020 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 to participate in all the benefit plans associated with our provider networks. EmblemHealth may amend the benefit programs and networks from time to time with advance notice sent 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

Health Insurance Plan of Greater New York (HIP) underwrites EmblemHealth’s HMO and POS plans, including those branded HIP, GHI HMO, and Vytra. HIP offers commercial, Medicaid/HARP, Medicare, and Medicare Special Needs Plans (SNPs). HIP also underwrites the City of New York Gold plan and many of our plans offered to individuals and small groups on the New York State of Health and directly through our company. As of Jan. 1, 2019, all HIP members were migrated to our new systems and all have member IDs starting with the letter K – i.e., a “K” ID.

HIP Insurance Company of New York (HIPIC) underwrites some of EmblemHealth’s EPO and PPO plans including our popular EmblemHealth Value EPO plan. As of Jan. 1, 2019, all HIPIC members were migrated to our new systems and all have member IDs starting with the letter K – i.e., a “K” ID.

Group Health Incorporated (GHI) underwrites EmblemHealth’s GHI commercial EPO/PPO. GHI PPO has plans for New York City employees as well as plans for large employer groups. Non-City members are in the processes of moving to our new systems. As plans renew, members are being moved to our new systems and being assigned member IDs starting with the letter K – i.e., a “K” ID. This set of members with K IDs will be following new processes for preauthorizations and are being included in new programs. 

 

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 your patient’s network. 
    See our Access to Care chapter for instructions on keeping your information current.

The table of companies, lines of business, networks, and benefit plans summarizes how our provider networks and member benefit plans relate to our underwriting companies. You can print this page as a reference tool for your staff. Check the boxes to show them which networks your contract covers. The blank spaces allow you to customize for each practice location.

The benefits available to our members are provided in accordance with the terms of the members’ benefit plans. Below, are links to sample benefit summaries for the following types of 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. View a member’s actual benefits on our provider portal.

GHI Commercial Networks

Commercial Networks Covered by Agreements with Group Health Incorporated (GHI)

EPO/PPO plans typically allow members to self-refer to network specialists for office visits. However, preauthorization is still required before certain procedures can be performed.

To see the table of networks and benefit plan summaries for our GHI Commercial members, refer to the 2020 Summary of Companies, Networks & Benefit Plans.


GHI Plan Descriptions

Health Essentials Plus

Health Essentials Plus is a unique 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 Health Essentials 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% when provided by a network practitioner
    • Sick visits not covered
  • Pharmacy benefit
    • $15 generic drug card

Note: Except for 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. Most plans require referrals and preauthorization for certain services and have a deductible that applies to in-network services. If you see a member who is NOT in a plan associated with your participating network(s) without preauthorization, the member may incur a surprise bill or avoidable expenses. When a member calls for an appointment, be sure to check your participation in the member’s plan at that location. If you do not participate in their plan, refer them back to our online directory, Find-A-Doctor at emblemhealth.com/find-a-doctor, to find a provider in their network.

To see the table of networks and benefit plan summaries for our HIP Commercial members, refer to the 2020 Summary of Companies, Networks & Benefit Plans.

Prime Network
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.

For Large Group members, 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 members also have access to providers in New Jersey via QualCare’s network, and Connecticut via ConnectiCare’s network.

Select Care Network
The Select Care Network is 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 Prime Network, is tailored to help 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 multiple Large Group, Small Group, and Individual plans on the Select Care Network. Individual 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.


Millennium Network
The Millennium Network is in the nine New York downstate counties: Bronx, Kings, Nassau, New York, Queens, Richmond, Rockland, Suffolk, and Westchester.

Providers in the Millennium 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 certain Large Group plans, multiple Small Group plans and an Individual plan, Silver Bold, on the Millennium Network. This plan is offered both on and off the NY State of Health: The Official Health Plan Marketplace. EmblemHealth Silver Bold, a non-standard plan, provides a specific number of primary care physician (PCP) visits at no cost before the deductible. These plans offer acupuncture, dental, and vision benefits for adults and children.

HIP Commercial Plan Covered Services
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.

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. Log in to emblemhealth.com/providers to check the member’s Benefit Summary.

Telemedicine:
EmblemHealth Individual and Small Group plans, and the Essential Plan offer telemedicine services at no cost. EmblemHealth Basic plan offers telemedicine at 0% after deductible.

 

HIP Commercial Plan Descriptions

 

Child Health Plus
Child Health Plus (CHPlus) 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, CHPlus covers pharmaceutical drugs, vision, dental, and mental health services. There are no copays for any covered services and members may visit any of our Prime Network providers who see children

.The service area for CHPlus includes the following New York state counties: Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, and Westchester. CHPlus 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 CHPlus. Eligible individuals may enroll throughout the year via the NY State of Health Marketplace or through enrollment facilitators.

Medicaid and Health and Recovery Plan (HARP) Benefits

See Appendix K for a listing of covered services under Medicaid Managed Care (MMC) and HARP. The benefit information provided in Appendix K does not list every service that is covered or list every limitation or exclusion.

Medicaid Benefits:
Our Medicaid members are entitled to a standard set of benefits. They may directly access certain services without a required referral. A list of these services can be found in the Direct Access (Self-Referral) Services section of the Access to Care and Delivery Systems chapter.

HARP Benefits:
EmblemHealth offers a Health and Recovery Plan (HARP) designed to meet the unique needs of our eligible MMC members living with serious mental illness and/or substance use disorder. The plan includes access to home and community-based services (HCBS) and support from their assigned Health Home. Below is a list of covered HCBS for HARP members only. (See the HCBS 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

Adult Behavioral Health Covered Services
EmblemHealth covers the following behavioral health benefits for its MMC members aged 21 and older who reside in the EmblemHealth MMC service area:

  • 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

For more information on the Behavioral Health Services Program, please see the Behavioral Health Services chapter.

Health Home Program
Health Home 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. A listing of EmblemHealth network Health Homes that support our Medicaid and HARP benefit plans are listed in the Directory chapter.

Under the federal Patient Protection and Affordable Care Act, New York state has developed a set of Health Home services for Medicaid members. 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 notifies the member and their PCP of the Health Home assignment by letter. The member’s assigned Health Home Care Manager contacts 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

More information on the NYS Medicaid Health Home Program can be found on the NYSDOH website. See our guide for Health Home 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. ET.

Children’s Health and Behavioral Health Benefits
EmblemHealth manages the delivery of expanded behavioral and physical health services for Medicaid enrolled children and youth under 21 years of age (see the table of Medicaid State Plan and Demonstration Benefits). This includes medically fragile children, children with behavioral health diagnosis(es), and children in foster care with developmental disabilities. Benefits include HCBS designed to provide children/youth access to a vast array of habilitative services (additional details can be found in the Children’s HCBS Provider Manual and Children’s Health and Behavioral Health Services Billing and Coding Manual. All HCBS are available to any child/youth determined eligible. Eligibility is based on Target Criteria, Risk Factors, and Functional Limitations. Health Homes provide Care Management to children/youth eligible for HCBS.

Health Home Care Management for Children
Children eligible for HCBS are enrolled in Health Home. Unless the child or guardian opts out, the Health Home provides care coordination of the children’s HCBS. Health Homes administer all HCBS assessments through the Uniform Assessment System, which has algorithms (except for the foster care developmentally disabled (DD) and the Office for People with Developmental Disabilities (OPWDD) care at home medically fragile developmentally disabled (CAH MF) populations) to determine functional eligibility criteria. Health Homes ensure the child meets all other eligibility criteria for HCBS (i.e., a child must live in a setting that meets HCBS settings criteria to be eligible for HCBS, such as Target and Risk criteria for Level of Care and Level of Need populations). The Health Homes develop one comprehensive plan of care that includes HCBS, as well as all the other services the member needs (e.g., health, behavioral health, specialty services, other community and social supports, etc.).

EmblemHealth collaborates with Beacon Health Options, Health Homes, and HCBS providers to gather information to support the evaluation of the member’s level of care; adequacy of service plans; provider qualifications; member health and safety; financial accountability and compliance, etc. EmblemHealth utilizes 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. See the Health Homes Serving Children homepage for more information. 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 utilization management 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 Learning Online webpage.

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.

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.

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 (MMC) 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 who need to be restricted. EmblemHealth 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 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

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.

The Office of the Medicaid Inspector General (OMIG) is responsible for sending notification of previous Managed Care Organization’s restriction for a new member to EmblemHealth within 30 days. Neither the provider nor member may be held liable for the cost of services when the provider could not have reasonably known the member was restricted to another provider. See above for instructions on identifying restricted recipients.

To report suspicious activity, please contact EmblemHealth’s Special Investigations Unit in one of the following ways:

Email: 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.

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 MMC.

Primary Care Services Offered in Homeless Shelters
Homeless members can select any participating PCP.  We have expanded our provider network to include practitioners who practice in homeless shelters to improve access to care for our members with no place of usual residence. A PCP practicing at a homeless shelter is available only to members who reside in that shelter.

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 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 Medicaid members retain their coverage and don’t lose access to valuable care, the Medicaid Recertification or Eligibility End Date is included on the Health Care Eligibility Benefit Inquiry and Response (270/271) report for those members close to their recertification dates.

Members requiring assistance with recertification should contact our Marketplace Facilitated Enrollers at 888-432-8026.

Permanent Placement in Nursing Homes

The 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 EmblemHealth MMC service area. 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 the 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 Medicaid daily benchmark rate until the member has changed plans.

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 p.m. ET, and Saturday from 10 a.m. to 6 p.m. ET.

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.

Essential Plan Benefits
The Essential Plan is a low-cost plan for adult individuals available on the NY State of Health Marketplace. Premiums for the Essential Plan are either $0 or $20.

As with Qualified Health Plans (QHPs), the Essential Plan includes all benefits under the 10 categories of the Affordable Care Act (ACA)-required Essential Health Benefits with no cost-sharing (no deductible, copay, or coinsurance) on preventive care services, such as screenings, tests, and shots. For more information, please see the Preventive Health Guidelines located on our Health and Wellness webpage.

Unlike QHP Standard Plans, some Essential Plan members are also eligible for adult vision and dental benefits for a small additional monthly cost. The Aliessa population (New York’s legally residing immigrant population) receives six additional benefits at no extra cost. These include: dental, vision, non-emergency transportation, non-prescription drugs, orthopedic footwear, and orthotic devices

Eligibility
The Essential Plan covers adult individuals only. If eligible, spouses and children must enroll into Essential Plan separately under an individual policy. To qualify for the Essential Plan, individuals must:

  • Be a New York state resident.
  • Be between the ages of 19 and 64 (U.S. citizens) or 21 to 64 (legally residing immigrants).
  • Not be eligible for Medicare, Medicaid, Child Health Plus, affordable health care coverage from an employer, or another type of minimum essential health coverage.
  • Be either:
    • A U.S. citizen (residing in New York) with an income between 138% and 200% of the federal poverty level (FPL).
    • Legally residing immigrant with an income of less than 138% of the FPL.
  • Not be pregnant or eligible for long-term care. In both cases, members would be eligible for Medicaid instead of the Essential Plan.

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. ET, and the NYSOH at 855-355-5777, Monday through Friday from 8 a.m. to 8 p.m. ET, and Saturday from 9 a.m. to 1 p.m. ET.
  • By mail. Print an application at nystateofhealth.ny.gov and send it back to NYSOH, which 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 CHPlus throughout the year via the NY State of Health Marketplace or through enrollment facilitators.

Medicaid, HARP, and Essential Plan Summaries
To see the table of network and benefit plan summaries for our Medicaid, HARP, and Essential Plan members, refer to the 2020 Summary of Companies, Networks & Benefit Plans    

Note: Starting Jan. 1, 2020, Montefiore Management Company (CMO) will no longer manage EmblemHealth’s Medicare members. Instead, EmblemHealth and its delegates will directly manage claims payment, case, disease, and utilization management. For more information on how care for our Medicare members is managed, refer to the 2020 Medicare Advantage Plans Reference Guide.

Medicare Plans
EmblemHealth company, Health Insurance Plan of Greater New York (HIP), underwrites the Medicare plans associated with the VIP Prime Network, and EmblemHealth company, Group Health Incorporated (GHI), underwrites plans associated with the Medicare Choice PPO Network. 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.

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

Medicare Network and Plan Summaries
To see tables of network and benefit plan summaries for our Medicare suite of products, refer to the 2020 Summary of Companies, Networks & Benefit Plans.

The following EmblemHealth Medicare plans do not require referrals: VIP Go (HMO-POS), VIP Passport plans, VIP Dual Select, and VIP Solutions. To identify these members, look for the plan names as well as a No Referral Required indicator on the member ID cards.

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

Maximum Out-of-Pocket Threshold
The maximum out-of-pocket (MOOP) threshold varies for Medicare Parts A and B services covered under the EmblemHealth Medicare Advantage 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 2020 Summary of Companies, Networks & Benefit Plans and in the member’s Benefit Summary on emblemhealth.com/providers.

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 follows the member and counts toward the MOOP in the new EmblemHealth Medicare plan.

Preventive/Wellness Visit and Physical Exam
"Welcome to Medicare" Preventive Visit:
Our Medicare plans cover a one-time, “Welcome to Medicare” preventive visit, which is available for members who are new to Medicare. This visit includes a health review, education, and counseling about preventive services (including screenings and vaccinations) and referrals for care, if necessary.

Members must have the “Welcome to Medicare” preventive visit 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” preventive visit. Providers may bill for this service using HCPCS code G0438 for this initial visit.

Annual Wellness Visit:
This benefit is covered once every 12 months. Following their “Welcome to Medicare” physical exam, members enrolled in Medicare Part B must wait 12 months before having their first annual wellness visit. A Health Risk Assessment (HRA) is used as part of the annual wellness visit. 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. Providers may bill for this service using HCPCS code G0439 for subsequent visits.

Annual Physical Exam:
Most EmblemHealth Medicare plans cover an annual physical exam once every calendar year at no cost to the member. The annual physical exam may include updating medical history, and measurement of vital signs, including height, weight, body mass index, blood pressure, visual acuity screen, and other routine measurements. This benefit may not cover some services like lab tests and tests to diagnose or treat a condition. Members may have to pay for those tests, even when they are done during an annual physical exam.

Medicare Preventive Services:
The Medicare Preventative Services chart features services that the Centers for Medicare & Medicaid Services (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 our Medicare plans when provided on an in-network basis. For HMO members, including Dual Eligible members, Medicare-required covered services that are not available in-network and receive preauthorization from our plan or the member’s assigned managing entity, as applicable, are allowed at $0 cost-sharing, as well.

SNP Coinsurance and Copay
Our HMO SNP members are qualified Medicare beneficiaries (QMB), which means they receive help from New York State Medicaid to pay their cost-sharing. As a result, providers who see these Dual Eligible members must verify Medicaid eligibility and bill New York State Medicaid for cost-sharing. The correct address to bill Medicaid is located on these members’ Common Benefit Identification Card (CBIC). EmblemHealth VIP Solutions (HMO D-SNP) members may not be eligible for full Medicaid and may pay cost-sharing for covered services.

SNP Interdisciplinary Team
Practitioners are important members of the SNP interdisciplinary team. They participate in one of our regularly scheduled care coordination or case rounds meetings to discuss their patient’s plan of care and health status. Practitioners also share their progress with the team to ensure we are meeting our SNP program goals.

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 a key role in developing and implementing the individualized care plan, coordinating care, and sharing information with the interdisciplinary care team, and with the practitioners, member, their family, or caregiver.

SNP 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 (MOC) Training for each of the Dual Eligible SNPs in which they participate, as mandated by the Centers for Medicare & Medicaid Services (CMS). For training presentations and other learning opportunities, please visit our Learning Online webpage.

ArchCare Advantage (HMO SNP)
EmblemHealth leases its Network Access Network to ArchCare and administers the Medicare portion of the benefits they offer to their members. Providers in the Network Access Network must also complete ArchCare’s SNP MOC training, which can be found on our website’s Learning Online page.