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:
- Training and technical assistance to the expanded array of providers on billing, coding, data interface, documentation requirements, provider profiling programs, and utilization management requirements.
- 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.
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.
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:
Toll-free hotline: 888-4KO-FRAUD (888-456-3728)
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.
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
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