Medicare Networks
EmblemHealth’s company, Health Insurance Plan of Greater New York (HIP), underwrites the Medicare plans associated with the VIP Prime Network, VIP Bold Network, and VIP Reserve Network.
EmblemHealth’s company, EmblemHealth Plan, Inc. (fka Group Health Incorporated (GHI)), underwrites plans associated with the Medicare Choice PPO Network.
Provider Obligations/Responsibilities
For information about provider obligations and responsibilities, see Medicare Advantage Required Provisions in the Required Provisions to Network Provider Agreements chapter. Also see the EmblemHealth Medicare Advantage Plans page for participation requirements and key information for managing these members.
See the ConnectiCare Medicare Advantage Plans page for participation requirements and key information for managing our affiliate’s members who have access to EmblemHealth’s network.
Maximum Out-of-Pocket Threshold
The MOOP for each benefit plan is shown in the 2021 Summary of Companies, Lines of Business, Networks & Benefit Plans, 2022 Summary of Companies, Lines of Business, Networks & Benefit Plans and in the member’s Benefit Summary on our secure Provider Portal under the Member Management tab and Eligibility option on the drop-down menu.
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 Assessment (HA) 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.
Special Needs Plans
Our Medicare Dual Special Needs Plans (DSNPs) are designated Medicare Advantage plans with custom-designed benefits to meet the needs of a specific population. 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.
SNP Coinsurance and Copay
Our HMO DSNP members are members with Medicaid, including full dual benefit eligibles, Qualified Medicare Beneficiaries (QMBs), and Specified Low-Income Medicare Beneficiaries (SLMBs), 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, Medicaid Managed Care (including EmblemHealth Enhanced Care or Enhanced Care Plus), or Medicaid Managed Long Term Care plan for any applicable member cost-sharing. Providers can find information about the secondary coverage during eMedNY eligibility verification. EmblemHealth VIP Solutions (HMO D-SNP) members may not be eligible for full Medicaid or QMB 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.
10/26/2022
