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Providers should continue to use the ID cards to see when a referral is needed for a specialist visit. Plans that do not need a referral state “No Referral Required” on the ID card.
All members of VIP Medicare plans need to select a primary care provider (PCP). EmblemHealth will assign a PCP for members who have not selected one. Providers and members can confirm PCP names through our provider and member portals, respectively.
Here is a sample of our standard ID card:
Here is a sample ID card for the new Integrated Benefits for Dual Eligibles (IB Duals) plans being introduced in 2023:
When a ConnectiCare logo appears on EmblemHealth Medicare ID cards, it means ConnectiCare Choice network providers can see members of this plan.
Please refer to the Sample ID Cards section of the EmblemHealth Provider Manual to see representative ID cards for all our members.
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.
For plan details and complete lists of the Medicare plans offered, see:
- 2023 Summary of Companies, Lines of Business, Networks, and Benefit Plans
- 2022 Summary of Companies, Lines of Business, Networks, and Benefit Plans
New in 2023
EmblemHealth will offer a new benefit plan, VIP Reserve Classic (HMO), in Bronx, Brooklyn, Manhattan, and Queens in addition to the Integrated Benefits for Dual Eligibles plan described below.
Integrated Benefits for Dual Eligibles (IB Duals)
The New York State Department of Health has given approval for EmblemHealth to launch an integrated plan for dual eligibles. Members enrolled in Enhanced Care (Medicaid Managed Care) or Enhanced Care Plus (HARP) plans who become Medicare-eligible due to age or disability will be enrolled in the VIP Dual (HMO D-SNP) Medicare plan while continuing enrollment in their Medicaid or HARP plan. Theses members, referred to as IB Duals, receive all their covered Medicare and Medicaid benefits through EmblemHealth. For additional information on provider reimbursement for these new members, please see the Provider Manual.
| Plan Name | Network | Deductible (Individual/Family) Copay (PCP/Specialist/ER) MOOP (Individual/Family) Coinsurance |
Service Area Where Plans Will Be Sold |
|---|---|---|---|
VIP Rx Saver (HMO) No referrals required. PCP needed.
|
VIP Bold Network
|
Deductibles: $0 Copay: $5/$40/$95 MOOP: $7,550 Coinsurance: Up to 20% |
OON Coverage: No Service Area: Albany, Broome, Columbia, Delaware, Greene, Rensselaer, Saratoga, Schenectady, Warren, Washington EH/CCI Reciprocity: Yes. Members may access ConnectiCare’s Choice Network for most services. |
VIP Reserve Classic (HMO) No referrals required. PCP needed.
|
VIP Reserve Network
|
Deductibles: $0 Copay: $0/$25/$95 MOOP: $0–$7,550 Coinsurance: 20% |
OON Coverage: No Service Area: Bronx, Kings, New York, Queens EH/CCI Reciprocity: No |
EmblemHealth and ConnectiCare Reciprocity for Network Access
EmblemHealth’s Medicare Advantage members using VIP Prime and VIP Bold networks (except members of dual eligible special needs plans (D-SNPs) and VIP Reserve Classic members) can use ConnectiCare’s Medicare Choice Network in Connecticut. Some services are available only through delegated networks and providers. These include routine vision care and eyewear (EyeMed); behavioral health (Carelon Behavioral Health); chiropractic, occupational, and physical therapy (Palladian); and dental care (Healthplex).
Similarly, Medicare members using ConnectiCare’s Medicare Choice Network (except members of D-SNPs and Passage plan members) have access to the VIP Bold Network in New York. Some services are only available through ConnectiCare’s delegated networks and providers, such as behavioral health and chiropractic services (offered through Optum), vision care and eyewear (EyeMed Insight network), and dental care (Healthplex).
See the 2023 Summary of Companies, Lines of Business, Networks & Benefit Plans for details on all our Medicare plans, including PCP and specialist copay amounts, deductibles, maximum out-of-pocket expenses, service area where the plan will be offered, and whether there is reciprocity between EmblemHealth and ConnectiCare networks.
Value-Based Insurance Design and New Benefits
The EmblemHealth family of companies is pleased to share that we will renew participation with the CMS-approved Value-Based Insurance Design (VBID) Model for 2023 (based on our success in 2022). This program promotes wellness and advance care planning to help ensure our Medicare members receive medical care that is consistent with their values, goals, and preferences. Plans participating in VBID include the following D-SNPs:
- EmblemHealth’s VIP Dual and VIP Dual Reserve plans
- ConnectiCare’s Choice Dual, Choice Dual Basic, and Choice Dual Vista plans
Starting Jan. 1, 2023, EmblemHealth will offer $0 copays on Select Care Drugs (Tier 6 generic drugs).
Members of EmblemHealth’s D-SNPs can continue to use their over-the-counter (OTC) allowance to buy select healthy foods, fresh produce, and other groceries in participating pharmacies, retail locations, and online. This valuable benefit helps our vulnerable members with both Medicaid and Medicare address food insecurity and improve their health outcomes.
In addition, EmblemHealth D-SNP members with diabetes, hypertension, or hyperlipidemia who participate in the Medication Therapy Management Program (MTMP) are being offered an incentive payment for continued compliance with their care plan. They must complete a comprehensive medication review (CMR) and obtain a 30-day refill of their applicable maintenance medicine. They are able to earn a $10 member reward for each CMR and refill. We ask you to continue to help our members stay adherent with their medicines and encourage their participation in this program.
For more information about Medicare member rewards or OTC benefits, please see the Member Resource Hub.
Advance Directives
We remind all our providers to discuss the importance of having executed advance directives at every visit and ensure that completed directives are included in the member’s medical record. The purpose of these directives is to ensure our Medicare members receive medical care that is consistent with their values, goals, and preferences, and that they designate a health care agent for the time the member is unable to make decisions on their own. D-SNP members can receive online help to draft advance directive and values statement.
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 and special needs plan members will receive an automated 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 2023, 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 $50 for each of the eligible services they complete, up to $225. Please reach out to your patients to schedule these important preventive exams. Members can see a list of possible rewards and those they have earned by signing into the member portal and following prompts for Wellness Rewards. Once they register for the rewards, they will be able to get their gift cards as they earn the rewards.
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, 2023. Only one reward can be earned for each health service shown in the table below.
| Activity | Eligible Medicare Population | Reward Trigger/ |
Incentive Frequency | Incentive Per Activity |
|---|---|---|---|---|
| WellSpark/ Rewards Portal Registration | All members | Complete member registration within portal. | Once a lifetime | $10 |
| EmblemHealth Member Portal Registration | All members not yet registered | Create a new EmblemHealth Member portal account in the calendar year. | Once a lifetime | $15 |
Sign up for paperless materials |
All members |
Complete process to sign up for paperless materials. |
Once a lifetime | $15 |
Initial Health Assessment (90 days) |
All new members |
Complete assessment within 90 days of enrollment. |
Once a year | $15 |
| Annual Health Assessment | D-SNP members only |
Complete assessment within calendar year (by D-SNP member). |
Once a year | $15 |
| 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 |
| Annual Visit with PCP | All members |
Complete an office visit with primary provider provider (PCP). | Once a year | $10 |
| Mammogram Exam | Women, ages 40+ |
Complete a mammogram. | Once every two years | $25 |
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
Referral Requirements
While most of our Medicare plan members do not need referrals, referrals have been waived for those that do during the COVID-19 State of Emergency. A referral or approval is not a guarantee of payment. Payment is subject to the participation agreement, member’s eligibility and benefits on the date of service, compliance with utilization management policies, and application of EmblemHealth’s medical and claims policies. Once the COVID-19 State of Emergency ends, the following two plans that use the VIP Prime Network will require referrals:
- EmblemHealth VIP Premier (HMO) Group
- EmblemHealth VIP Rx CarveOut (HMO) Group
See our full Referral Guide and video. Use the Plans that Do Not Need a Referral tools for a handy, quick reference showing all EmblemHealth plans that do not need a referral.
ConnectiCare Medicare Members – Optum/ProHEALTH Delegation
As of April 1, 2023, providers caring for ConnectiCare Medicare Advantage members assigned or attributed to a primary care provider (PCP) who is part of the Optum Care Network of Connecticut IPA (which includes ProHealth Physicians) will need to submit claims to Optum for payment. Medicare Advantage members enrolled in ConnectiCare dual eligible special needs plans (D-SNPs) are excluded from this delegation and will continue to be managed by ConnectiCare. The new claims address is on the ID cards we will send members before April.
Medicare Connect Concierge
Our Medicare members will have continued access to Medicare Connect Concierge in 2023. 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 (VIP Dual, 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) 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
For 2023, we added a new Select Care Drugs tier on most of our formularies. The drugs on this tier are available to members without a deductible, at $0 copay, and are covered through the coverage gap. Select Care Drugs include maintenance drugs for diabetes, hypertension, and hyperlipidemia.As required by the Inflation Reduction Act of 2022, Medicare members with prescription drug coverage will pay no deductible and no more than $35 copay for a one-month supply of covered insulins (or less for members receiving extra help), and $0 copay for most Part D vaccines in both preferred and standard pharmacies in our network.
See our Medicare Formularies.
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 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 and D Fraud, Waste, & Abuse (Contact Hours 30 min.)
Learn to recognize 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 (Contact Hours 88 min.)
Learn how to identify what Medicare considers fraud and abuse, 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 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 providers to complete Special Needs Plan (SNP) Model of Care (MOC) training each year for each health plan’s MOC. Notices are sent to provider months in advance of the due date, but some providers have still not completed their training. Providers who do not complete the 2022 training by Nov. 30, 2022, will be referred to the EmblemHealth Credentialing Committee.
Cultural Competency Education
See these Cultural Competency Continuing Education and Resources to help you provide 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
- EmblemHealth Medicare Advantage Plans Hub
- ConnectiCare Medicare Advantage Plans Hub
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