Please encourage interested patients to view our Medicare Advantage plans.
Medicare Advantage Plans
MEDICARE ADVANTAGE PLANS
Sample Member ID Cards for 2025
Provider Networks and Member Benefits
Checking a Provider’s Network Status for a Member
2025 Plan Changes
Coordinating Care for Members
Health Survey for Medicare and Special Needs Plan Members
EmblemHealth Member Rewards Program
Care Management Plans for D-SNP Members
Medicare Connect Concierge
Claims and Billing
Do Not Bill Dual Eligible and QMB Members for Any Medicaid Cost-Sharing
Dispute Resolution
Formularies
Help Members Stick with Their Medication Regimen by Using Our Mail Order Pharmacies and Free Pill Box
Pharmacy Billing for EmblemHealth Dual-Eligible Members
Fraud, Waste, and Abuse
Required: SNP MOC Training
Cultural Competency Education
Medicare Outpatient Observation Notice (MOON)
Requirement for Medicare Providers Caring for Special Needs Plans Members
Sample Member ID Cards for 2025
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.
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.
2025 Plan Changes
Integrated Benefits for Dual Eligible (IB-Duals) Program.
Please note VIP Dual members enrolled in the Integrated Benefits for Dual Eligible (IBD) plan in 2024 will be automatically enrolled in the EmblemHealth VIP Dual Enhanced (HMO D-SNP) plan. This is the new Applicable Integrated Plan (AIP) designed exclusively for IBD members.
Lower Prescription Drug Costs for Medicare Members With Part D
Plan benefits and cost-sharing change every year. See 2025 Formulary Changes. One of the big changes 2025 brings is the lower out-of-pocket costs for members with prescription drug coverage. The new threshold is $2,000, after which all covered prescription drugs will be available at $0 copay.
Medicare Prescription Payment Plan
In addition to having lower costs, Medicare Advantage members with prescription drug coverage can opt into Medicare Prescription Payment Plan — a new option to pay out-of-pocket costs throughout the year. Not all members are likely to benefit from this program. Our PBM will be happy to review the program and projected costs with members. Resources are available to learn more about the program and to apply.
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.
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. Members can complete their HA online by signing into the member portal. This will help our Care Management team to better address members' needs and 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. D-SNP members may also be eligible for a reward when completing an annual HA.
EmblemHealth Member Rewards Program
In 2025, 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 $25 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 and earned rewards by signing in to the member portal and following prompts for Wellness Rewards. Registration is required to receive a reward.
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 by:
Email: complexcasemgmt@emblemhealth.com
Phone: 800-447-0768, 9 a.m. to 5 p.m., Monday through Friday.
Medicare Connect Concierge
Our Medicare members will have continued access to Medicare Connect Concierge in 2025. This is the one phone number Medicare members can call when they need help solving their healthcare 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). From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Saturday.
Claims and Billing
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 if your provider agreement provides for a longer time period. For facility time frames, see the EmblemHealth Provider Manual or applicable agreement.
Clinic Visit Policy
If you provide clinic visits to our Medicare Advantage members that 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.
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.
Dispute Resolution
See the Medicare Dispute Resolution section of the EmblemHealth Provider Manual. Contracted time frames in provider agreements will supersede time frames in this guide to the extent that your agreement provides a greater time period than set forth here. For facility time frames, see the EmblemHealth Provider Manual or applicable agreement.
Help Members Stick With Their Medication Regimen by Using Our Mail Order Pharmacies and Free Pill Box
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 their 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. 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)
SortPak – new mail delivery pharmacy
We have added a new compliance packaging pharmacy, SortPak, to help our Medicare providers and members organize medication refills and support medication adherence.
SortPak’s services include:
- Coordinating prescription and nonprescription maintenance medication refills, up to a 90-day supply, to ensure the member receives all medicines at one time.
- Sorting medications into individual pouches organized by the day and hour.
- Delivering medications to the member’s doorstep with no additional delivery cost.
- Conducting medication adherence assessments.
- Contacting prescriber(s) at least one month in advance to check on the need for refills and sending refill reminders to the members.
If you have a member who could benefit from this type of service, you can:
- Call: 877-570-7787
- Fax: 877-475-2382
- Send e-scripts using:
- NCPDP/NABP: 0524733
- NPI number: 1063407252
- Mail: 124 S. Glendale Ave., Glendale, CA 91205
Free pill boxes
If you have a patient who needs help keeping their pills organized, let them know that we offer free pill boxes to everyone, regardless of coverage.
A form for ordering the pill boxes along with a helpful video on medication adherence can be found on this web page:
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.
Where To Report a Fraud, Waste, Abuse, or Other Compliance Concerns
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 our attention, 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 2024 training by Nov. 30, 2024, 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)
CMS requires all hospitals and critical access hospitals 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.
Requirement for Medicare Providers Caring for Special Needs Plans Members
EmblemHealth and ConnectiCare Special Needs Plan (SNP) member benefits 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:
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