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The Sample ID Cards section of the EmblemHealth Provider Manual shows representative ID cards for all our members.
The ID cards show when a referral is needed for a specialist visit. Plans that do not need a referral state “No Referral Required” on the ID card.
Here is a sample of our standard ID card:
When a ConnectiCare logo appears on an EmblemHealth Medicare ID card, it means ConnectiCare Choice Network providers can see the member.
Please note VIP Dual members enrolled in the Integrated Benefits for Dual Eligible (IB Duals) plans in 2023 will be disenrolled at the end of the year and will need to select a new Part D plan to keep their prescription drug coverage. Affected members will receive a non-renewal letter with instructions on how to select a new plan.
Here are sample ID cards for the IB Dual plans being reintroduced in 2024 under the new plan contract ID.
For plan details and complete lists of the Medicare plans offered, see:
- 2024 Summary of Companies, Lines of Business, Networks, and Benefit Plans
- 2023 Summary of Companies, Lines of Business, Networks, and Benefit Plans
Integrated Benefits for Dual Eligible (IB-Duals) Program.
In 2023, some of our members were retroactively enrolled into the Integrated Benefits for Dual Eligible (IB-Duals) Program. This triggered the need to recoup payments made under the members’ old plans and reprocess the claims under their new one. See full explanation in the article IB-Dual Program – Claims Reprocessing Under New Member IDs.
We are making some changes to the IB-Duals Programs offered in 2024. IB-Dual members who have the EmblemHealth VIP Dual (HMO D-SNP) plan will be disenrolled as of Dec. 31, 2023, as we will no longer be offering this plan. Affected members will receive a non-renewal letter with instructions on how to select a new Part D plan to keep their prescription drug coverage.
EmblemHealth and ConnectiCare Network Reciprocity
Some of our Medicare plans allow members to see providers in both EmblemHealth and ConnectiCare plans. The summaries of companies, lines of business, networks, and benefit plans above indicate whether there is reciprocity between the companies, and which networks the members may use. When a ConnectiCare logo appears on an EmblemHealth Medicare member ID card or an EmblemHealth logo is on a ConnectiCare Medicare member ID card, it means reciprocity is in place and the affiliate language in the provider agreements apply. This allows the member to see providers in both companies’ Medicare networks. The member’s underwriting company will determine the policies and procedures that must be followed.
Checking a Provider’s Network Status for a Member
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 look-up tool in the Member Management section of the provider portal. Our provider portals are connected, so you may conduct business for both EmblemHealth and ConnectiCare members in one place.
VIP Medicare Plans Have Primary Care Providers
All VIP Medicare plan members need to select a primary care provider (PCP). If a member fails to select a PCP, EmblemHealth will assign one. For certain members, the selected or assigned PCP can be found on the member’s ID card. You can also locate the assigned PCP on the Member Details page when you check the member’s eligibility in the provider portal. Providers can see their assigned plan of members by running a PCP Member Panel report using our provider portal.
EmblemHealth is modifying its Medicare plan portfolio. The following plans will not be offered in 2024:
- EmblemHealth VIP Essential (HMO)
- EmblemHealth VIP Reserve Classic (HMO)
- EmblemHealth VIP Dual (HMO D-SNP) will be closing and re-introduced under H5991 contract ID with revised benefits. Members enrolled in this plan in 2023, including IB-Duals, will be disenrolled on Dec. 31, 2023. Affected members of these plans will receive a non-renewal letter with instruction on how to select a new plan.
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.
Health Survey for Medicare and Special Needs Plan Members
Medicare special needs plan members will receive a call from EmblemHealth asking them to complete the health assessment (HA). Please encourage your members to complete this survey. This will help our Care Management team direct them to appropriate care and support services. Members may also be eligible for EmblemHealth’s Member Rewards Program when completing their HA within the first 90 days of enrollment, and annually thereafter.
EmblemHealth Member Rewards Program
In 2024, EmblemHealth will continue to offer Medicare Advantage and special needs plan members the EmblemHealth Member Rewards Program to encourage them to receive primary care and key health screenings. Members may be eligible to receive a reloadable reward card with $10 to $100 for each of the eligible services they complete. Please reach out to your patients to schedule these important preventive exams. Members can see a list of possible rewards and earned rewards by signing in to the member portal and following prompts for Wellness Rewards. Once they register for the rewards, they will be able to receive their reward card as they complete reward activities.
Claims must be received by Dec. 31 of the calendar year for the incentive to be paid. Members must receive and redeem the reward before Dec. 31, 2024. Only one reward can be earned for each health service shown in the table below.
| Activity | Eligible Medicare Population | Reward Trigger/ Description |
Incentive Frequency | Incentive Per Activity |
|---|---|---|---|---|
| EmblemHealth Member Portal Registration | All members not yet registered | Create a new EmblemHealth Member portal account in the calendar year. | Once a lifetime | $25 |
| Sign up for paperless materials | All members | Complete process to sign up for paperless materials. | Once a lifetime | $25 |
| Initial Health Assessment (90 days) | All new members | Complete assessment within 90 days of enrollment | Once a year | $50 |
| Annual Health Assessment | D-SNP members only | Complete assessment within calendar year (by D-SNP member). | Once a year | $50 |
| Initial Medicare Annual Well-Visit (90 days) | All new members | Complete a Medicare annual well-visit within 90 days of Medicare eligibility. | Once a year | $50 |
| Colorectal Cancer Screening | Members, ages 40+ | Complete a fecal occult blood test (FOBT), flexible sigmoidoscopy, colonoscopy, FIT DNA test, or colonography. | Once a year | $25 |
| Diabetes A1C Test | Diabetic members, ages 18+ | Complete an A1C blood test. | Once a year | $25 |
| Diabetes Eye Exam | Diabetic members, ages 18+ | Complete a retinal or dilated eye exam by an eye care professional. | Once a year | $25 |
| Mammogram Exam | Women, ages 40+ | Complete a mammogram. | Once every two years | $50 |
| Kidney Health Evaluation | Diabetic members, ages 18+ | Complete an estimated glomerular filtration rate (eGFR) test and a urine albumin-creative ratio within the calendar year | Once a year | $25 |
| Bone Mineral Density (BMD) Test | Women with a fracture | Complete a BMD within six months after fracture | Once a year | $100 |
In addition, VIP Dual and VIP Dual Reserve DSNP members who are eligible to participate in our Medication Therapy Management Program and complete a comprehensive medication review with one of our pharmacists can earn rewards for filling Select Care Drugs (Tier 6) medications for high blood pressure, high cholesterol, and diabetes. Annual PCP visit reward is not offered in 2024.
Care Management Plans for D-SNP Members
Enrollees covered under our dual-eligible special needs plans (D-SNPs) have care plans on file with our Care Management team. We make care plans available to providers on our provider portal unless they contain sensitive information.
If you do not see an expected care plan posted on the portal, contact us to receive a copy.
EmblemHealth:
Phone: 800-447-0768, Monday through Friday, 9 a.m. to 5 p.m.
Email: complexcasemgmt@emblemhealth.com
ConnectiCare:
Phone: 800-390-3522, Monday, Thursday, and Friday, 8 a.m. to 4 p.m., or Tuesday and Wednesday, 8 a.m. to 7:30 p.m.
Email: hmpreferrals@connecticare.com
Medicare Connect Concierge
Our Medicare members will have continued access to Medicare Connect Concierge in 2024. This is the one phone number members can call when they need help solving their health care needs. Medicare Connect Concierge can help:
- Schedule a doctor’s appointment.
- Get referrals for group plan members.
- Coordinate preauthorizations.
- Answer benefit questions.
- Update mailing address.
- Arrange transportation for members with Medicaid when covered.
To reach Medicare Connect Concierge, please call 877-344-7364 (TTY: 711), 8 a.m. to 8 p.m., seven days a week.
If you provide clinic visits to our Medicare members and are owned and operated by a hospital, please review our clinic visit policy and correct coding requirements.
Reminder: For services rendered in place of service (POS) 19, off-campus hospital-owned location, claims billed with the G0463 clinic code should include the Modifier PO.
For helpful claims resources for EmblemHealth members, see Claims Corner and the Claims chapter of the EmblemHealth Provider Manual; for ConnectiCare members, see Billing and Claims and Our Policies.
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.
Medicare/Medicaid and Qualified Medicare Beneficiaries (QMBs)
EmblemHealth offers two plans to members who have Medicaid (either VIP Dual or VIP Dual Reserve). In addition, many Qualified Medicare Beneficiaries (QMBs) enroll in our Medicare Advantage plans. Members with full Medicaid or QMBs are not responsible for paying any member cost-share for their plan-covered benefits.
Do Not Bill Dual Eligible and QMB Members for Any Medicaid Cost-Sharing
Medicare-Medicaid full dual eligible and QMB individuals who qualify to have their Medicare Parts A and B cost-share covered by their state Medicaid are not responsible for paying their Medicare Advantage plan cost-shares for Medicare-covered Part A and Part B services. Please do not balance bill these members.
Federal and New York state laws prohibit providers from balance billing Medicare-Medicaid dual eligible individuals for any Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments, if any, received for services provided to dual eligible individuals must be accepted as payment in full. To comply with this requirement, providers treating dual eligible and QMB individuals enrolled in an EmblemHealth Medicare Advantage plan must do the following:
- Verify plan and Medicaid/QMB eligibility prior to providing a service.
- Do not bill the member or collect cost-sharing during the visit.
- Bill New York State Medicaid for the member’s cost-share.
- Consider the claim as “paid in full,” regardless of the Medicaid or plan payment.
- Notify member in writing if you do not accept Medicaid and member is not a QMB.
Federal law and provider contracts prohibit Medicare (EmblemHealth)-enrolled providers from balance billing beneficiaries with Medicare and QMB, and Medicaid providers from balance billing dual eligibles. Providers may reference Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997.
For EmblemHealth members, you can use eMedNY to check whether the member has full or partial Medicaid benefits. For more detail, call the New York State eMedNY Call Center at 800-343-9000 Pharmacy providers may use this Pharmacy Balance Billing guide for instructions on coordinating benefits with New York State’s eMedNY program.
For ConnectiCare members, you can contact the Connecticut Department of Social Services at 800-842-8440.
See the Medicare Dispute Resolution section 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.
Formularies
See the 2024 Medicare formularies and the changes to them.
Help Members Stick with Their Medication Regimen by Using Our Mail Order Pharmacy
Taking medicines as prescribed (medication adherence) is important for treating and controlling chronic conditions. Clinicians play an important role in helping members stay adherent. Here are some steps clinicians can take to help members remain adherent:
- Talk to members about the importance of taking their medications on time as prescribed.
- Remind members to track their refills and make an appointment for a new prescription before they run out.
- Educate members on the side effects of the medications and how to treat them.
- Help identify and resolve barriers to members not taking their medications as prescribed.
- Consider prescribing 90-day supply prescriptions for maintenance medications.
- Consider prescribing generic drugs or less-expensive brand-name drugs on the member’s formulary if cost is a barrier.
- Talk to the member about potential state drug assistance programs or pharmaceutical prescription assistance programs that may be able to help with the cost of medications.
- Educate members on pharmacy-based adherence tools that may help:
- Medication synchronization (limit the member’s trip to the pharmacy for medications).
- Compliance packing or blister packs.
- Auto refills.
- Encourage members to leverage available technologies (medication reminder apps on your phone or tablet, like the Express Scripts mobile app).
Many of our plans continue to offer generic drugs (Tier 1 and Tier 2) for $0 copay for members who get their refills through Express Scripts Preferred Mail Order pharmacy. D-SNP members can get rewards for eligible part D refills. Please help your members stay adherent and save on their prescription drugs by recommending members switch to preferred mail order:
Express Scripts Home Delivery Service
PO Box 66577
St. Louis, MO 63166-6577
Call: 877-866-5828 (TTY: 711)
Pharmacy Billing for EmblemHealth Dual-Eligible Members
Both Federal and State laws protect dual eligibles from being balance billed. This Pharmacy Balance Billing guide provides instructions for pharmacy providers on coordinating benefits with New York State’s eMedNY program.
Fraud, Waste, and Abuse
Required Training
EmblemHealth expects its contracted providers to prevent and address health care fraud, waste, and abuse and to meet their annual training requirement. To learn about this important topic, see Medicare Learning Network’s Web-Based Training:
- Combating Medicare Parts C & D Fraud, Waste, & Abuse (CMS contact hours: 30 min.)
Learn to recognize health care fraud, waste, and abuse (FWA), identify methods to prevent FWA, identify how to report FWA, recognize how to correct FWA, and recognize potential consequences and penalties associated with violations. - Medicare Fraud & Abuse: Prevent, Detect, Report (CMS contact hours: 88 min.)
Learn how to identify what Medicare considers health care fraud and abuse, the provisions and penalties, prevention methods, and recognize how to report fraud and abuse.
If you have concerns about compliance issues that you wish to bring to the attention of EmblemHealth/ ConnectiCare, please call toll free, 24/7, at 844-I-COMPLY (844-426-6759). You can also report online at emblemhealth.alertline.com.
Where To Report a Fraud, Waste, Abuse, or Other Compliance Concern
If you would specifically like to report concerns about health care fraud, waste, or abuse, please call 888-4KO-FRAUD or email the Special Investigations Unit at kofraud@emblemhealth.com.
If you have other concerns about compliance issues that you wish to bring to the attention of EmblemHealth/ConnectiCare, please call toll free, 24/7, at 844-I-COMPLY (844-426-6759). You can also report online at emblemhealth.alertline.com.
EmblemHealth/ConnectiCare will not retaliate against anyone who in good faith reports a compliance concern.
Required: SNP MOC Training
CMS requires Medicare-enrolled providers to complete Special Needs Plan (SNP) Model of Care (MOC) training each year for each health plan’s MOC. Notices are sent to providers months in advance of the due date, but some providers have still not completed their training. Providers who do not complete the 2023 training by Nov. 30, 2023, will be referred to the EmblemHealth Credentialing Committee and risk possible termination from EmblemHealth networks for failing to remain compliant.
Cultural Competency Education
See these Cultural Competency Continuing Education and Resources for your use in providing our members with care in the context of their cultural and linguistic needs.
Medicare Outpatient Observation Notice (MOON)
All hospitals and critical access hospitals are required by CMS to provide Medicare beneficiaries, including Medicare Advantage enrollees, with the OMB-approved Medicare Outpatient Observation Notice (MOON). The MOON and instructions for completing it are available on CMS’ website.
EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.
EMB_PR_WEB_59800_2023Mcare 11/22
New Requirement for Medicare Providers Caring for Special Needs Plans Members
Beginning Jan. 1, 2023, EmblemHealth and ConnectiCare Special Needs Plan (SNP) member benefits will include coverage for face-to-face encounters between members and providers for the delivery of health care, care management, or care coordination services. Face-to-face encounters must occur, as practical and with the member’s consent, on at least an annual basis beginning within the first 12 months of SNP enrollment.
A face-to-face encounter must be either in-person or through a virtual (visual, real-time, and interactive) encounter. Medicare providers caring for SNP members will be required to obtain the member’s consent for face-to-face virtual encounters.
When a provider reaches out to conduct a face-to-face virtual encounter with a SNP member, consent must be obtained from the SNP member prior to, or when scheduling, the encounter. At the time of the scheduled virtual encounter, the provider must inform the member on the purpose and intended outcomes of the visit.
At least annually, EmblemHealth and ConnectiCare care managers will review member usage history data to identify members who require outreach and face-to-face scheduling. All data collected will be reviewed with providers during the interdisciplinary care team (ICT) meetings.
Additional Requirements
As a reminder, when caring for SNP members, providers must also:
- Actively participate in the SNP member’s ICT and individualized care plan (ICP) development and implementation.
- Follow care transitions protocol.
- Use guidance from:
- EmblemHealth’s medical policies and clinical practice guidelines.
- ConnectiCare’s medical coverage criteria and clinical practice guidelines.
- Complete SNP model of care training annually for EmblemHealth and ConnectiCare.
- Encourage SNP members to complete their surveys:
- Health assessment
- Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
- Health Outcomes Survey (HOS)
Below are some additional resources to help you manage the health of your SNP patients:
- EmblemHealth Care/Case Management Programs
- ConnectiCare Clinical Information
- EmblemHealth Provider Manual
- ConnectiCare Coverage Guidelines
- ConnectiCare Medicare Advantage Plans Hub
JP 63314 10/23
JP 63314 11/23
