Medicare Advantage Plans

2027 Plan Updates

4-Star Medicare Quality Rating

We are pleased to share that our Medicare plans earned a 4-star rating from the Centers for Medicare & Medicaid Services (CMS) for the second consecutive year. We appreciate the important role you and your practice play in helping our members stay healthy and engaged in their care.

Let’s keep the momentum going by encouraging patients to schedule recommended preventive screenings, annual wellness visits, post-hospitalization follow-up appointments, and stay on top of their medications.

To check if your patient has open gaps in care, you can access member-level care-gap information, quality performance reports, medication adherence opportunities, and other quality resources through:

• Provider Portal reports
• Gaps in Care Reports
• Quality scorecards and performance reports
• Pharmacy and medication adherence reports
• Provider engagement consultations and quality review meetings

For assistance accessing reports, interpreting results, or developing an improvement plan, contact quality_provider_engagement@emblemhealth.com.

Removal of Referrals for Medicare plans

Starting Jan. 1, 2027, EmblemHealth Medicare group plans will not require a referral. This means members can schedule a specialist appointment without prior approval from their primary care provider (PCP). Please ask your patients for an updated Member ID card for your records. Plans that do not need a referral are clearly marked "No Referral Required” on the ID card.

New Benefit!

We are happy to introduce a new supplemental benefit to help members with transitions between care settings. Most of our individual Medicare plan members can get 14 post-discharge meals following a minimum 2-day stay at an inpatient hospital or skilled nursing facility. We will be working with Mom’s Meals (NPI 1093834020) to deliver meals to members’ homes.

Please check back for updated information on how members can receive meals. 

Changes to Prescription Drug Coverage for Medicare Members

Checking to see if a prescription drug is covered in 2027 is easy! Members can log into their member portal and connect to Prime Central, a prescription drug coverage tool that can help them get drug pricing, pharmacy information and more. Providers can find drug coverage information online using the plan’s formulary lookup tools.

Plan benefits and cost sharing change each year. In 2027, the out-of-pocket limit will increase to $2,400, after which all covered prescription drugs will be available at $0 copay. See Formulary Changes for details.

Non-renewing Plans

EmblemHealth will not be offering Dual Special Needs Plans, including Integrated Benefits Duals (IBD) in 2027. These plans include VIP Dual (HMO DSNP), VIP Dual Reserve (HMO DSNP), VIP Dual Enhanced (HMO DSNP).  We notified impacted members with non-renewal notices in October of 2026 and provided them with a list of available resources to help select a new plan.

Checking a Provider’s Network Status for a Member

To confirm whether you or a provider you manage is in-network for an EmblemHealth member, use the Check Provider Network Status tool in the Member Management section of the provider portal.  

Coordinating Care for Members

To support your efforts in coordinating care for EmblemHealth members, see Clinical Corner and the Utilization and Care Management chapter of the EmblemHealth Provider Manual.

Pharmacy

Formularies
See the 2027 Medicare formularies and the changes to them.

New Medicare Pilot Program for GLP-1 Started July 1
Medicare is offering a temporary program called the Medicare GLP-1 Bridge. This short-term program that started July 1, 2026, may help eligible Medicare Part D beneficiaries access weight loss drugs. Certain GLP-1 medicines for weight loss and weight management may be covered by Medicare through Dec. 31, 2027.

EmblemHealth plans with prescription drug coverage cover GLP-1 medications for members with diabetes and other FDA-approved indications other than weight loss alone. Providers should refer to the applicable plan’s prior authorization criteria for coverage requirements and additional details. Visit cms.gov for more information on the Medicare GLP-1 Bridge program.

Fraud, Waste, and Abuse

Annual Training Requirement
EmblemHealth requires all contracted providers to complete annual training on Fraud, Waste, and Abuse (FWA) prevention. To learn about this important topic, see Medicare Learning Network’s Web-Based Training.

Recommended Centers for Medicare & Medicaid Services (CMS) trainings include:

• Combating Medicare Parts C & D Fraud, Waste, and Abuse (CMS contact hours: 30 min.)
  Learn to recognize health care 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 and 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.

Reporting a Concern
To report suspected health care fraud, waste, or abuse:

• Call: 888-4KO-FRAUD
• Email: kofraud@emblemhealth.com.

To report other compliance issues:

• Call: 844-I-COMPLY (844-426-6759), toll free, 24/7
• Online: emblemhealth.mycompliancereport.com.

EmblemHealth will not retaliate against anyone who, in good faith, reports a compliance concern.