Commercial Networks and Benefit Plans

Provider Networks and Member Benefits

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:

• 2025 Summary of Companies, Lines of Business, Networks & Benefit Plans.
• 2024 Summary of Companies, Lines of Business, Networks & Benefit Plans.

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.

2025 Changes to Service Areas and Networks

In 2025, we are making a change to the network that services individual and family plan members living in Rockland County, NY. Members who live in this county will now have access to providers in the Millennium network only.

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.

2025 Essential Plan

The Essential Plan offers health insurance for eligible low-income New Yorkers who do not qualify for Medicaid or minimum essential coverage through an employer. Members in an Essential Plan have access to the Enhanced Care Prime Network.

There are five Essential Plan variants: Essential Plan 200-250, 1, 2, 3, and 4. Individuals will be enrolled in a variant based on income and other eligibility criteria.

All Essential Plan variations have no monthly premium or deductible and low or no cost-shares. See the updated 2025 Summary of Companies, Lines of Business, Networks, and Benefit Plans for details on the Essential Plan.

Benefits for members

Please share this with your staff and any patients you think may be eligible for the Essential Plan:

• No monthly premiums and annual deductibles.
• Low or no cost-shares.
• No referrals required.
• Preventive care at no cost.
• Robust network with top hospitals.
• Telemedicine at no cost with Teladoc^® Primary360.
• Gym reimbursement.
  • Eligible members can earn up to $200 in reimbursement per six-month period (Jan. 1 – June 30 and July 1 – Dec. 31) each calendar year if they complete 50 workouts each period.
• Wellness program.
• New for Jan. 1, 2025, an over the counter (OTC) credit of $100 per quarter ($400 per year) which can be used to purchase eligible healthy foods and health-related items. For more information, visit emblemhealth.com/esssentialplanotc.

Doula Services

Beginning April 1, 2025, EmblemHealth will cover doula services in hospital, clinic, and community settings for Essential Plan, Medicaid, and Health and Recovery Plan (HARP) 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.

2025 Individual and Family Plans

In 2025, individual and family plans underwritten by Health Insurance Plan of Greater New York (HIP) will continue to be sold on and off the NY State of Health insurance marketplace.

Please note that beginning Jan. 1, 2025, members living in Rockland County have access to the Millennium network only. If you see members residing in this county, please encourage your staff to verify if you are in-network prior to providing care. 

2025 Small Group Plans

In 2025, EmblemHealth small group plans are sold on and off the NY State of Health insurance 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).

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:

• Infusion therapy.
• Laboratory services.
• Radiology services.

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 providers (PCPs) in their offices.

The following chart summarizes which plans and networks will be offered:

2025 Dental Plans
In 2025 small groups will continue to have the option of enrolling in one of four dental plans.

• Access
• Preferred
• Preferred Plus
• Preferred Premier

2025 Member ID Cards

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 do not 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 sample ID cards for all members.

Coordinating Care for 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 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.

Dispute Resolution

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.

Provider Educational Resources

• Provider Portal Training Materials.
• EmblemHealth Learning Online.
• Cultural Competency Continuing Education and Resources.

Bridge Program

EmblemHealth offers the Bridge Program to fully insured large groups and organizations seeking administrative services. The Bridge Program 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.