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As you should have read in an email from EmblemHealth earlier this month, New York City employees, pre-Medicare retirees, and their dependents will be offered the New York City Employees PPO (NYCE PPO) plan, a health insurance plan delivered through a partnership between EmblemHealth and UnitedHealthcare. This plan launches Jan. 1, 2026.

We have a website for providers and will be publishing updates there, but will also use this newsletter to remind our network in these final 11 weeks before launch. 

Please become familiar with this plan as there are geographic requirements that may impact your participation. The email and website both provide more details as well as what your practice can do now to ensure you can see NYCE PPO members after Jan. 1.

Providers are encouraged to consult our Clinical Practice Guidelines for assistance in the treatment of acute, chronic, and behavioral health issues.

The following 14 guidelines were updated to reflect current recommendations and guidelines for prevention, treatment, and management of certain medical conditions:  

• Chronic Kidney Disease
• Chronic Pain
• Congestive Heart Failure
• Low Back Pain Diagnosis and Treatment
• Stroke Prevention
• Urinary Incontinence
• Cholesterol Management for Adults at Risk for Cardiovascular Disease
• Diabetes Mellitus
• Obesity and Weight Management in Adults
• Obesity and Weight Management in Children and Adolescents
• Appropriate Use of Antibiotics for Adults and Children
• Preconception Care
• Prenatal/Postpartum
• AIDS/HIV

Clinical Practice Guidelines are not intended as a substitute for the professional assessment of the health care practitioner. They are put in place to help manage certain types of preventive and clinical care.

The American Diabetes Association has provided recommendations to help people living with diabetes manage their condition and improve their health.

Here are some recommended preventive screenings for your patients with diabetes:

• Regular A1C testing.
• Kidney function testing.
• Ankle-brachial index.
• Annual retinal eye exam.
• Cholesterol and triglycerides testing.
• Blood pressure testing.

Please visit Health Checks for People with Diabetes | ADA for more information and resources.

Information is also available to assist with coding guidance for Quality gap in care closure. Please visit Quality Improvement on our website and download the Quality Measure Resource Guide for more information.

Ten years have passed since the U.S. Preventive Services Task Force (USPSTF) first recommended low-dose CT for lung cancer screening, yet lung cancer screening rates remain low, with less than 1 in 10 eligible individuals having undergone CT screening.

November is a good time to encourage your patients to get screened for lung cancer. The American Cancer Society and USPSTF recommend yearly lung cancer screening with a low-dose CT scan for current and former heavy smokers ages 50 and older.

Find valuable resources sponsored by the American Cancer Society to support your patients’ screening here:

National Lung Cancer Roundtable

Lung.org

As an EmblemHealth network provider, you may be responsible for providing primary care services for children/youth who are Medicaid members in direct placement foster care and in the care of Voluntary Foster Care Agencies (VFCAs), even if you are not the assigned primary care provider (PCP) on the member’s ID card. 

As a reminder, New York State Medicaid allows PCP teams to provide care to Medicaid members. Any PCP at a practice can see the foster care member should the assigned PCP on their member ID card not be available at the scheduled appointment.

Please see Medicaid Managed Care for Foster Care Members for more information. 

Providers must notify Medicaid of any change of address, telephone number, or other pertinent information within 15 days of the change. For more information on this requirement and how to submit changes, see Reminder: Keep Your Directory Information Current.

View the latest Medicaid Updates from the New York State Department of Health.

For upcoming changes to the EmblemHealth Preauthorization List, see Notable Changes for code changes and effective dates.

If you need help navigating our provider portals, please see our videos, quick guides, and Frequently Asked Questions pages: 

• EmblemHealth Videos and Guides.
• EmblemHealth Frequently Asked Questions.
• ConnectiCare Videos and Guides.
• ConnectiCare Frequently Asked Questions.

If you still have questions or need additional support, contact Provider Customer Service using the provider portal’s Message Center or live agent chat.

EmblemHealth works with Veradigm to offer free monthly webinars to help educate providers on best practices for the risk adjustment process. This includes accurate medical record documentation and claims coding to capture the complete health status of each patient.

The Veradigm webinars are held on Tuesdays and Thursdays; one in the morning and one in the afternoon. View topics and dates here. Click the Register button, then the Public Event List link, and search by webinar date or title of interest.

Here are the upcoming topics:

• Oct. 28/30: Arm Yourself: Battling Through Coding and Documentation for Cancer
• Nov. 18/20: Fill Your Plate with Knowledge: Coding and Documentation for Gastroenterology

EmblemHealth also works with Veradigm to promote risk adjustment and gap-closure education for primary care providers caring for EmblemHealth members enrolled in these products:

• NY State of Health.
• Medicare HMO.
• Medicaid.

If you have any questions, or you would like to set up a private session for your practice, please email Veradigm at providerengagement@veradigm.com or call Veradigm's Customer Support team at 410-928-4218, extension 7, from 8 a.m. to 8 p.m., Monday through Friday.

We recommend that you take advantage of the training opportunities offered by CMS’ Medicare Learning Network and eMedNY.