Summary of Changes to EmblemHealth Medicare, Effective January 1, 2015

Date Issued: 10/16/2014

Effective January 1, 2015, EmblemHealth will offer the following suite of Medicare Advantage HMO and PPO plans and networks in New York City and Nassau, Suffolk and Westchester counties:

Medicare Advantage HMO Plans

2015 Plan Name 2015 Network
EmblemHealth VIP (HMO) VIP Prime
EmblemHealth Dual Eligible (HMO SNP) VIP Prime
NEW! EmblemHealth MLTC Plus (HMO SNP) VIP Prime
EmblemHealth Essential (HMO) Medicare Essential
EmblemHealth VIP High Option (HMO) Medicare Essential

Medicare Advantage PPO Plans

2015 Plan Name 2015 Network
EmblemHealth PPO I Medicare Choice PPO
NEW! EmblemHealth Advantage (PPO) Medicare Choice PPO
EmblemHealth Dual Eligible (PPO SNP) Medicare Choice PPO

Note: Members can access a full list of services and any benefit limitations by referencing their Evidence of Coverage (EOC).

Important Medicare Changes for 2015

Plan Closings

  • EmblemHealth PPO II and PPO III — Members in these plans need to select a new plan during the annual enrollment period, which runs from October 15 to December 7, 2014. These members may continue care with their existing providers if they choose a plan that uses the Medicare Choice PPO network. These plans include EmblemHealth PPO I and EmblemHealth Advantage PPO (see table above).
  • EmblemHealth HMO SNP Medicaid Advantage Plan — Members in this plan will automatically transition to the EmblemHealth Dual Eligible (HMO SNP) plan, which uses the same VIP Prime network. Providers will need to bill the state directly for Medicaid-covered services for these members.

New Plans

  • EmblemHealth MLTC Plus (HMO SNP) — This new plan uses the VIP Prime network.
  • EmblemHealth Advantage PPO — This new plan uses the Medicare Choice PPO network.

Both new plans are offered in the following eight counties: Bronx, New York, Kings, Richmond, Queens, Nassau, Suffolk and Westchester.

Service Area Reduction for Medicare PPO Plans

EmblemHealth will no longer offer individual Medicare Advantage PPO plans in Rockland County. If you are a participating provider in the Medicare Choice PPO network, this change may affect your patients in an EmblemHealth Medicare PPO plan.

Please ensure that you have accurate health plan contact and payment information on file for your patients that reside in Rockland County for services they receive on or after January 1, 2015. As a best practice, you should verify coverage for your patients each time they visit with you.

This service area reduction does not affect your participation status in any of our networks.

Coinsurance and Copay Changes

  • Transferability of Maximum -Out-of-Pocket (MOOP) — If a member makes a mid-year change from an EmblemHealth Medicare HMO to an EmblemHealth Medicare PPO plan, or vice versa, the MOOP accumulated thus far in the contract year now follows the member and counts toward the MOOP in the new EmblemHealth Medicare plan.
  • Cost-Sharing May Apply to Some EmblemHealth Dual Eligible Special Needs Plan (HMO SNP) Members — Cost-sharing for many of our HMO SNP benefits will increase from the current amount of $0. The change will affect most services and will vary depending on the benefit.

    EmblemHealth Dual Eligible (HMO SNP) members have coverage for Medicare benefits and also receive some level of assistance from Medicaid. Our SNP plans allow all dual eligible members, those with full and partial Medicaid benefits, to enroll.

    Members can consult their Evidence of Coverage (EOC) for a list of covered services and the associated cost-sharing. Many HMO SNP plan members are qualified Medicare beneficiaries (QMB), which means they receive help from New York State Medicaid to pay their cost-sharing. As a result, the provider must bill Medicaid for the cost-sharing upon receipt of payment from EmblemHealth. The correct address to bill Medicaid is located on these members’ Common Benefits Identification Card (CBIC).

Speak With Your Patients About Their Benefits

The annual enrollment period begins October 15, 2014 and ends December 7, 2014. Please speak with your patients and encourage them to make sure their health coverage meets their needs and that they check to ensure any associated costs and coinsurance requirements are within their budget. Any health plan changes must be made during this open enrollment period.

Policy & Alerts