Hub for resources to help you care for our Medicare members.

If you have a member who is interested in our Medicare Advantage plans, please encourage them to visit:

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 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 (Beacon Health Options); chiropractic, occupational, and physical therapy (Palladian); and dental (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 offered through Optum, vision care and eyewear (EyeMed Insight network), and dental (Healthplex).

See the 2022 Summary of Companies, Lines of Business, Networks & Benefit Plans for details on all of 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.


City of New York Offers Medicare Advantage Option in 2022

The City of New York (CNY) recently awarded its group retiree business to Retiree Health Alliance, a collaboration between EmblemHealth and Empire BlueCross BlueShield (BCBS). In 2022, Medicare-eligible City of New York retirees will transition to Retiree Health Alliance’s NYC Medicare Advantage Plus plan. Please continue to monitor our website and newsletters for updates.

This Medicare Advantage PPO plan allows retirees to receive services from both in-network and out-of-network providers with no difference in cost-share. Out-of-network providers must be eligible to receive Medicare payments. NYC Medicare Advantage Plus coves all Medicare Part A and Part B services, as well as additional benefits Medicare does not provide such as an annual routine physical exam, hearing, health and fitness tracker LiveHealth Online, and SilverSneakers®. CNY retirees enrolled in EmblemHealth Medicare Advantage plans can choose to opt out of enrollment in the new plan.

We will continue to add resources as new information becomes available.

Value-Based Insurance Design and New Benefits

The EmblemHealth family of companies is pleased to announce our participation in the CMS-approved Value-Based Insurance Design (VBID) Model. This program is designed to promote 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 NY D-SNP (VIP Dual and VIP Dual Reserve) plans
  • ConnectiCare’s Choice Dual plan

Starting Jan. 1, 2022, as part of VBID, members of these dual plans can use their over-the-counter (OTC) allowance to buy healthy foods, fresh produce and other groceries in participating pharmacies, retail locations, and online. This valuable benefit will help our vulnerable members with both Medicaid and Medicare to address food insecurity and will improve health outcomes.

Many of our plans continue to offer OTC benefits and more plans will offer OTC benefits for the first time in 2022. For more information, please see the new 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.

Member ID cards for 2022 have been redesigned. Plans that need a referral will have a primary care doctor (PCP) shown on the front of the card. Plans without referrals will no longer have a PCP name on the ID cards. All members of VIP Medicare plans need to select a 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. Members can select a PCP whether their plan requires it or not, and this ID card design change does not affect the member’s PCP selection. There will be no changes made to a member’s assigned PCP.

2022 Sample Card
Click to View Sample ID Card

Please refer to the Sample ID Cards section of the EmblemHealth Provider Manual to see representative ID cards for all our members.

For helpful resources 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 2022, 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 will receive a gift card from $10 to $50 for each of the eligible services they complete (earning up to $175 per calendar year). Please reach out to your patients to schedule these important preventive exams. To get the list of rewards members may have earned or can earn, members must sign into the Member Portal and follow 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 use the reward before Dec. 31, 2022. 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
Colorectal Cancer Screening Members, ages 50-74 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 18-75 Complete an A1c blood test Once a year $25
Diabetes Eye Exam Diabetic members, ages 18-75 Complete a retinal or dilated eye exam by an eye care professional Once a year $25
Annual Visit with PCP All Medicare members Complete an office visit with primary provider Once a year $25
Mammogram Exam Women, ages 50-74 with no record of mammogram within the past 27 months Complete a mammogram Once every two years $50
Bone Density Test Women, ages 67-85 who have suffered a fracture Complete a bone mineral density (BMD) test in the six months after the fracture Once a year $50
Initial Health Assessment (90 days) All new Medicare members Complete HA within 90 days of enrollment Once a year $25
Initial Medicare Annual Well-Visit (90 days) All new Medicare members Complete a Medicare annual well-visit within 90 days Once a year $50
Annual Health Assessment D-SNP members only Completion of HA within calendar year by D-SNP member Once a year $15
Portal Registration All Medicare members Member registration within portal Once a lifetime $10


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 Department. We make these care plans available to providers and are happy to share a copy. Please contact us to receive a copy for member(s) you are treating.

For EmblemHealth Enrollees:

Phone: 800-447-0768


For ConnectiCare Enrollees:


Phone: 800-390-3522

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 Carve Out (HMO) Group

See for a handy, quick reference showing all EmblemHealth plans that do not need a referral.

ConnectiCare Medicare Members – Optum/ProHEALTH Delegation

As of Oct. 1, 2021, 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 contact Optum for preauthorization. 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. We will provide updates on our website as our agreement with Optum evolves.

Medicare Connect Concierge

Our Medicare members will have continued access to Medicare Connect Concierge in 2022. 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.

For helpful resources in regarding claims 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.

Billing for Hospice Services

EmblemHealth covers hospice consultation services (one time only) for a terminally ill Medicare Advantage member. Thereafter, hospice providers should submit claims for hospice care-related services to the terminal diagnosis directly to Original Medicare. EmblemHealth will continue to pay for care that is unrelated to the terminal condition or not covered by Original Medicare (like OTC benefit, routine dental, and vision).

Medicare/Medicaid and Qualified Medicare Beneficiaries (QMBs)

EmblemHealth offers a number of plans to members who have Medicaid (VIP Dual, VIP Dual Select, VIP Dual Reserve, VIP Solutions). 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 law 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, see our 2022 Medicare Advantage Guide or call the New York State eMedNY Call Center at 800-343-9000.

For ConnectiCare members, you can contact the Connecticut Department of Social Services at 800-842-8440 or visit their website.

Pharmacy Billing for EmblemHealth Dual-Eligible Members

Both Federal and State laws protect dual eligibles from being balance billed. For more information about coordinating benefits with Medicaid for pharmacy providers, see the Pharmacy Balance Billing guide for instructions.

See Medicare Dispute Resolution in 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.


See our Medicare Formularies for 2022.

New Cancer Drugs Require Preauthorization

As of Aug. 15, 2021, additional oncology-related chemotherapeutic drugs and supportive agents require preauthorization when delivered in the physician’s office, outpatient hospital, or ambulatory setting. See our Frequently Asked Questions: EmblemHealth Oncology Drug Management to determine where to submit the preauthorization request.

Pharmacy Networks Aligned to Benefits

Our Express Scripts, Inc. pharmacy networks are aligned with the corresponding prescription drug benefits and include preferred pharmacy cost-sharing as follows:

  • Express Scripts Broad Performance Network: VIP Dual SNP plan members, Group Prescription Drug Plan (PDP) members and other plan members without preferred pharmacy drug benefits will access this network.
  • Express Scripts Medicare Preferred Value Network: Most VIP members will access this network.

Preferred pharmacies help members save on prescription drugs and improve medication adherence, so we ask that you remind members to use a preferred pharmacy when you can.

Some of the preferred pharmacies in New York include:

  • Costco
  • Rite Aid
  • ShopRite
  • Walgreens
  • Duane Reade
  • Walmart

Standard pharmacies that participate in the Preferred Value Network but only offer standard cost-sharing include:

  • CVS
  • Hannaford
  • Target

Pharmacy locator links are available on our website to help you and your members find a nearby participating pharmacy.

Help Members Stick with Their Medication Regimen by Using Our Mail Order Pharmacy

Taking medications as prescribed (medication adherence) is important for treating and controlling chronic conditions. Doctors play an important role in helping members stay adherent. Here are some steps as a doctor you 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).

Starting Jan. 1, 2022, many of our plans will 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)

Pharmacy Billing for EmblemHealth Dual-Eligible Members

Both Federal and State laws protect dual eligibles from being balance billed. For more information about coordinating benefits with Medicaid for pharmacy providers, see the Pharmacy Balance Billing guide for instructions.

Fraud, Waste, and Abuse

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

If you would specifically like to report concerns about fraud, waste, or abuse, please call 888-4KO-FRAUD or send an email to the Special Investigations Unit by using this email address:

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. Training may be accessed from the Special Needs Plans Model of Care Provider Training page in the Learning Online section of our website. Providers who do not complete the training by Nov. 30, 2021 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.

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