COMMERCIAL NETWORKS AND BENEFIT PLANS
Bridge Program
Extended Networks’ Geographic Coverage Area
Provider Networks and Member Benefits
2024 Changes to Plans’ Service Areas and Networks
2024 Essential Plan
2024 Individual & Family Plans
2024 Small Group Plans
Member ID Cards for 2024
Coordinating Care for Members
Dispute Resolution
Provider Educational Resources
Sample Member ID Cards for 2023
EmblemHealth offers fully insured large groups and organizations seeking administrative services the Bridge Program. Bridge is an innovative concept that gives our members access to a combination of our existing networks through our affiliated companies and partners. See Extended Networks’ Geographic Coverage Area below. Learn more about the Bridge Program.
EmblemHealth and its affiliate ConnectiCare Insurance Company, Inc. partner with QualCare and First Health to provide coverage for some of our plans beyond our own contracted networks’ geographic coverage. These extended networks are considered in-network for our members, based on their geography, as follows:
Bridge Program (EmblemHealth and ConnectiCare)
QualCare = New Jersey only
First Health Network (FHN) = National access except in the states listed below:
*FHN is in-network in New York, outside of these 28 counties.
ConnectiCare Insurance Company, Inc.’s Flex Network
First Health Network (FHN) = National access except in the states listed below:
*FHN is in-network in New York, outside of these 28 counties.
For a complete list of the commercial plans offered and their corresponding networks, along with details including member cost-shares, service areas, and referral requirements, see:
To easily determine if you or a provider you manage is in-network for an EmblemHealth or ConnectiCare member, use the Check Provider Network Status tool in the Member Management section of the provider portal.
In 2024, we are making some changes to the service areas and networks that are linked to certain benefit plans.
We are not changing the composition of the provider networks. You may continue to see members who have the networks you participate in. It is possible, however, that some of your patients will select plans with networks you do not participate in. For each appointment, check member ID cards and use the Check Provider Network Status tool in the Member Management section of the provider portal to see if you are in-network for the patient.
To make it easier to see if a benefit plan uses a network you are in, we are changing some plan names to include the network name.
See the sections below for our 2024 portfolio updates.
The Essential Plan offers health insurance for eligible low-income New Yorkers who do not qualify for Medicaid, Child Health Plus or minimum essential coverage through an employer. Members in an Essential Plan have access to the Enhanced Care Prime Network.
There are five variations of the Essential Plan: Essential Plan 200-250, 1, 2, 3, and 4. Depending on the individual’s income and other eligibility criteria, they will be enrolled in the variation that they qualify for.
As of April 1, 2024, there is a new variant of the Essential Plan called Essential Plan 200-250. This is in addition to the existing Essential Plans 1-4. The new variant is nearly identical to Essential Plan 1; the only difference is the member’s maximum out-of-pocket expense. See the updated 2024 Summary of Companies, Lines of Business, Networks, and Benefit Plans for details on the Essential Plan.
This variant expands Essential Plan eligibility to individuals who have an annual income of 200 – 250% of the Federal Poverty Level (FPL). Prior to April 1, 2024, this annual income level would have qualified someone for an individual and family plan with a cost-share reduction, but they would still have a monthly premium. All Essential Plan variations, including the new Essential Plan 200-250, have no monthly premium or deductible and low-to-no cost-shares!
What this means for our providers
Benefits for members
Please share this with your staff and any patients you think can take advantage of the features of this new variant:
Beginning Jan. 1, 2025 (delayed from Oct. 1. 2024), EmblemHealth will cover doula services in hospital, clinic, and community settings for Medicaid, Health and Recovery Plan (HARP), and Essential Plan members who are pregnant, birthing, and postpartum (for up to 12 months after the delivery date). For more information see Improving Health Outcomes With Doula Services.
In preparation for this new benefit, EmblemHealth is now inviting doulas to join our provider networks. If you are interested in partnering with EmblemHealth, please contact medicaidproduct@emblemhealth.com.
In 2024, individual and family plans underwritten by Health Insurance Plan of Greater New York (HIP) will continue to be sold on and off the New York State of Health Marketplace. The plans offered and the networks paired with each plan will be determined by the plan subscriber’s county of residence. To make it easier to see which network a benefit plan uses, we are changing the plan names to include the network name. The following chart summarizes which plans and networks will be offered based on county.
Note: Unlike the 2023 benefit plans that use the Prime Network with reciprocity with ConnectiCare’s Choice Network and QualCare coverage in New Jersey, the Select Care Network and Millennium Network are limited to providers in New York.
In 2024, EmblemHealth small group plans are sold on and off the NY State of Health Marketplace. All plans are underwritten by Health Insurance Plan of Greater New York (HIP) and have access to the Select Care Network (New York only) beginning Jan. 1, 2024, or upon the group renewal.
EmblemHealth Platinum, Gold, and Silver Premier plans have out-of-network coverage for most services.
To help members keep costs down, their cost-sharing responsibilities for the following services may be lower based on place of service:
For example, the highest cost-sharing will apply when the services are provided in an outpatient hospital setting and the lowest cost-sharing will apply when services are provided in freestanding facilities and/or provided by primary care physicians (PCPs) in their offices.
Note: Unlike the 2023 benefit plans that use the Prime Network with reciprocity with ConnectiCare’s Choice Network and QualCare coverage in New Jersey, the Select Care Network is limited to providers in New York.
The following chart summarizes which plans and networks will be offered:
2024 Dental Plans
We are also simplifying our dental plan offerings, and in 2024 small groups will have the option of enrolling in one of four plan choices.
Please look at the member ID card when determining which network(s) the member’s plan uses. Plans that need a referral have a PCP shown on the front of the card. Plans that don’t require referrals no longer have a PCP name on the ID card. Providers and members can confirm PCP names through our provider and member portals, respectively. Members can select a PCP whether their plan requires it or not. Members may also change their PCP at any time.
Please refer to the Sample ID Cards section of the EmblemHealth Provider Manual to see representative ID cards for all our members.
For helpful resources to assist your practice in coordinating care for EmblemHealth members, see Clinical Corner and the Utilization and Care Management chapter of the EmblemHealth Provider Manual. For ConnectiCare members, see Clinical Information and Coverage Guidelines.
Also take advantage of the Quality Improvement resources including the Comprehensive CAHPS Guide and Tips to Improve Member Satisfaction.
Please encourage your members to complete the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) if they are selected for the survey sample.
See the Dispute Resolution for Commercial and Child Health Plus Plans chapter of the EmblemHealth Provider Manual. Contracted time frames in provider agreements will supersede time frames in this guide. For facility time frames, see the EmblemHealth Provider Manual or applicable agreement.
Member ID cards for 2022 have been redesigned. Plans that need a referral have a primary care doctor (PCP) shown on the front of the card. Plans without referrals no longer have a PCP name on the ID cards. Providers and members can confirm PCP names through our Provider and Member portals, respectively. Members can select a PCP whether their plan requires it or not, and this ID card design change does not affect the member’s PCP selection. There will be no changes made to a member’s assigned PCP.
Please refer to the Sample ID Cards section of the EmblemHealth Provider Manual to see representative ID cards for all our members.
JP63157 10/23
