Our Medicaid, HARP, and Essential Plan members all utilize the Enhanced Care Prime Network. This network covers the following eight counties in New York: Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island), Nassau, Suffolk, and Westchester.
For announcements and requirements for our Medicaid, HARP and Child Health Plus Programs, see our dedicated State-Sponsored Programs resource hub.
Recertification
It’s important that you and your staff remind Essential Plan, Medicaid and HARP members to recertify with the NY State of Health Marketplace, their Local Department of Social Services, or Human Resources Administration prior to their End Date. If members do not recertify by the Eligibility End Date, they will lose eligibility, lose their health insurance coverage, and will have to reapply.
To help ensure members retain their coverage and don’t lose access to valuable care, the Recertification or Eligibility End Date is included on the Health Care Eligibility Benefit Inquiry and Response (270/271) report for those members close to their recertification dates. The recertification date is also on the PCP Member Panel Report available on our Provider Portal. See the video and user guide for PCP Member Panels under the Member Management section on the portal’s training materials page.
Members requiring assistance with recertification should contact our Marketplace Facilitated Enrollers at888-432-8026.
Essential Plan Benefits
Essential Plan offers health coverage to low-income individuals ata $0 monthly premium. There are five variants of this plan, and eligible individuals may enroll throughout the year viatheNY State of Health Marketplaceor through enrollment facilitators. Once enrolled, members have coverage for 12 months regardless of income or eligibility changes.
Essential Plan offers coverage for the 10Essential Health Benefits included in theAffordable Care Act(ACA). There is no cost-sharing (no deductible, copay, or coinsurance) on preventive care services, such as screenings, tests, and shots. For more information, please see thePreventive Health Guidelineslocated on ourHealth and Wellnesswebpage.
All Essential Plan variants also include adult vision and dental benefits at no additional cost.Members in Essential Plan 3 and 4 are eligible for sixadditional benefits at no cost. These include: dental, vision, non-emergencytransportation, non-prescription drugs, orthopedic footwear, and orthotic devices.
Essential Plan Eligibility
The Essential Plan covers adult individuals only. If eligible, spouses must enroll in Essential Plan separately. To qualify for the Essential Plan, individuals must:
- Be a New York state resident.
- Be between the ages of 19 and 64 (U.S. citizens) or 21 to 64 (legally residing immigrants).
- Not be eligible for Medicare, Medicaid, Child Health Plus, affordable health care coveragefrom an employer, or another type of minimum essential health coverage.
- Be either:
- A U.S. citizen (residing in New York) with an income between 138% and 250% of the federalpoverty level (FPL).
- Legally residing immigrant with an income of less than 138% of the FPL.
How to Enroll in the Essential Plan
There are four ways to apply:
- Online.VisitNYSOHonline and go to theIndividuals & Familiessection. Once there, start an account and begin shopping for a plan.
- In person.Get help from a Navigator, certified application counselor (CAC), Marketplace Facilitated Enroller (MFE), or broker/agent.
- By phone.Call EmblemHealth at877-411-3625, Monday through Sunday from 8 a.m. to 8 p.m. ET, and the NYSOH at855-355-5777, Monday through Friday from 8 a.m. to 8 p.m. ET, and Saturday from 9 a.m. to 1 p.m. ET.
- By mail.Print an application atnystateofhealth.ny.govand send it back to NYSOH, which will then confirm eligibility and enroll you in the variant for which you are eligible.You can enroll in the Essential Plan as soon as you think you are eligible.
Medicaid and Health and Recovery Plan (HARP) BenefitsSeeAppendix Kof theMedicaid Managed Care Model Contractfor a listing of covered services. The benefit information provided in Appendix K does not list every service that is covered or list every limitation or exclusion.
Medicaid Benefits:Our Medicaid members are entitled to a standard set of benefits. They may directly access certain services. A list of these services can be found in the Direct Access (Self-Referral) Services section of theAccess to Care and Delivery Systemchapter.
HARP Benefits:EmblemHealth offers a Health and Recovery Plan (HARP) designed to meet the unique needs of our eligible MMC members living with serious mental illness and/or substance use disorder. The plan includes access to home and community-based services (HCBS)and Community Oriented Recovery Empowerment Services (CORE). Below is a list of covered HCBS and CORE services for HARP members only. (See theHCBS manualfor full details.)
HCBS:
- Habilitation Services
- Education Support Services
- Pre-Vocational Services
- Transitional Employment Services
- Intensive Supported Employment (ISE)
- Ongoing Supported Employment Services
- Non-Medical Transportation* (related to a goal in the member’s plan of care)
*Covered by Medicaid Fee-for-Service, not EmblemHealth
CORE:
- Psychosocial Rehabilitation (PSR)
- Community Psychiatric Support and Treatment (CPST)
- Family Support and Training
- Empowerment Services - Peer Supports
Adult Behavioral Health Covered Services
EmblemHealth covers the following behavioral health benefits for its MMC members aged 21 and older who reside in theEmblemHealth MMC service area:
- Medically supervised outpatient withdrawal services
- Outpatient clinic and opioid treatment program services
- Outpatient clinic services
- Comprehensive psychiatric emergency program services
- Continuing day treatment
- Partial hospitalization
- Personalized recovery-oriented services
- Assertive community treatment
- Intensive and supportive case management
- Health home care coordination and management
- Inpatient hospital detoxification
- Inpatient medically supervised inpatient detoxification
- Rehabilitation services for residential substance use disorder treatment
- Inpatient psychiatric services
For more information on the Behavioral Health Services Program, please see theBehavioral Health Serviceschapter.
Health Home Program
Health Home is a care management service model for individuals enrolled in Medicaid with complex chronic medical and/or behavioral health needs. Health Home care managers provide person-centered, integrated physical health and behavioral health care management, transitional care management, and community and social supports to improve health outcomes of high-cost, high-need Medicaid members with chronic conditions. A listing of EmblemHealth network Health Homes that support our Medicaid and HARP benefit plans are listed in theDirectorychapter.
Under the federal Patient Protection and Affordable Care Act, New York state has developed a set of Health Home services for Medicaid members. To be eligible for Health Home services, the member must be enrolled in Medicaid and must have:
- Two or more chronic conditions*, or
- One single qualifying chronic condition:
- HIV/AIDS
- Serious Mental Illness (SMI)
- Serious Emotional Disturbance (SED) or Complex Trauma (Children)
- Sickle Cell Anemia (Adults and Children)
*Chronic conditions include but are not limited to mental health, substance use, asthma, diabetes, heart disease and being overweight.
Members enrolled in a Health and Recovery Plan (HARP) donot have to be determined to be at risk of conditions to be eligible for Health Home services.
The Health Home Programis offered at no cost to all eligible EmblemHealth Medicaid and HARP members.Once the member agrees to enroll, they will be designated to a Health Home. The Health Homes, and/or affiliated Care Management Agency (CMA), will assign them a care coordinator and begin providing services. EmblemHealth also notifies providers that their patient has been identified for this program.
The following services are available through the Medicaid Health Home Program:
- Comprehensive case management with an assigned, personal care manager
- Assistance with getting necessary tests and screenings
- Help and follow-up when leaving the hospital and going to another setting
- Personal support and support for their caregiver or family
- Referrals and access to community and social support services
More information on the NYS Medicaid Health Home Program can be found on theNYSDOH website.See ourguidefor Health Home assistance with submitting claims.
Medicaid members who are not eligible to participate in the Medicaid Health Home Program may still meet our criteria for case management services. If you think a member would benefit from case management, please refer the patient to the program by calling800-447-0768, Monday through Friday, from 9 a.m. to 5 p.m.ET.
Children’s Health and Behavioral Health Benefits
EmblemHealth manages the delivery of expanded behavioral and physical health services for Medicaid-enrolled children and youth under 21 years of age (see the table ofMedicaid State Plan and Demonstration Benefits). This includes medically fragile children, children with behavioral health diagnosis(es), and children in foster care with developmental disabilities. Benefits includeHCBS designed to provide children/youth access to a vast array of habilitative services (additional details can be found in theChildren’s HCBS Provider ManualandChildren’s Health and Behavioral Health Services Billing and Coding Manual. All HCBS are available to any child/youth determined eligible. Eligibility is based on Target Criteria, Risk Factors, and Functional Limitations. Health Homes provide care management tochildren/youth eligible for HCBS.
Health Home Care Management for Children
Children eligible for HCBS are enrolled in Health Home. Unless the child or guardian opts out, the Health Home provides care coordination of the children’s HCBS. Health Homes administer all HCBS assessments through the Uniform Assessment System, which has algorithms (except for the foster caredevelopmentally disabled (DD) and the Office for People with Developmental Disabilities (OPWDD) care at home medically fragiledevelopmentally disabled (CAH MF) populations) to determine functional eligibility criteria. Health Homes ensure the child meets all other eligibility criteria for HCBS (i.e., a child must live in a setting that meets HCBS settings criteria to be eligible for HCBS, such as Target and Risk criteria for Level of Care and Level of Need populations). The Health Homes develop one comprehensive plan of care that includes HCBS, as well as all the other services the member needs (e.g., health, behavioral health, specialty services, other community and social supports, etc.).
EmblemHealth collaborates with Carelon Behavioral Health (formerly Beacon Health Options), Health Homes, and HCBSproviders to gather information to support the evaluation of the member’s level of care; adequacy of service plans; provider qualifications; member health and safety; financial accountability and compliance, etc. EmblemHealth utilizes aggregated data from its care management and claims systems to identify trends and opportunities for improving member care.
Health Home care management not only provides comprehensive, integrated, child, and family-focused care management, but also ensures the efficient and effective implementation of the expanded array of State Plan services and HCBS. See theHealth Homes Serving Childrenhomepage for more information. Additional strategies to promote behavioral health-medical integration for children, including at-risk populations, include:
- Provider access to rapid consultation from child and adolescent psychiatrists
- Provider access to education and training
- Provider access to referral and linkage support for child and adolescent patients
Identifying Members
Medicaid Managed Care (MMC): EmblemHealth Enhanced Care
EmblemHealth’s Medicaid Managed Care plan is called EmblemHealth Enhanced Care. The plan name “Enhanced Care” can be found in the upper right corner of the member’s ID card.
Health and Recovery Plan (HARP): EmblemHealth Enhanced Care Plus
EmblemHealth’s Health and Recovery Plan (HARP) is called EmblemHealth Enhanced Care Plus. The plan name “Enhanced Care Plus” can be found in the upper right corner of the member’s ID card.
Homeless and HARP Members Enrolled with EmblemHealth
Since homeless and HARP members may present with unique health needs, we have identified which of our Medicaid Managed Care (MMC) members are homeless and/or HARP members. See the respective columns on the PCP Member Panel Report found under the Member Management tab in our secure Provider Portal. See the video and user guide for PCP Member Panels under the Member Management section on the portal’s training materials page..
A homeless indicator is present on eligibility extracts. The homeless indicator ”H“ is included if the member is homeless, and blank if the member is not homeless.
Recipients Restricted
EmblemHealth is also required to identify enrolled members who need to be restricted. If an enrolled member is restricted, EmblemHealth provides members with a member ID card with an “R” after the plan name on the front of the card (i.e., Enhanced Care - R or Enhanced Care Plus - R). This informs providers that the member is restricted. For more information, see the PCP Member Panel Report found under the Member Management tab in our secureProvider Portal. If you need assistance on how to access the PCP member Panels, a video and user guide for PCP Member Panels are located under the Member Management section on the portal’s training materialspage.
Medicaid Recipient Restricted Program
MMC and HARP members are placed in the Medicaid Recipient Restricted Program (RRP) when a review of their service utilization and other information reveals they are:
- Getting care from several doctors for the same problem
- Getting medical care more often than needed
- Using prescription medicine in a way that may be dangerous to their health
- Allowing someone else to use their plan ID card
- Using or accessing care in other inappropriate ways
RRP members are restricted to certain provider types (dental, dental clinic, pharmacy, physician, physician group, nurse, nurse practitioner, alternate pharmacy clinic, inpatient hospital, durable medical equipment provider, and podiatrist) based on a history of overuse, inappropriate use, and/or fraud of specific services. Members are further restricted to using a specific provider of the restricted service. EmblemHealth is required to continue the Medicaid Fee-for-Service (FFS) program restrictions for MMC and HARP members until their existing restriction period ends.
The Office of the Medicaid Inspector General (OMIG) is responsible for sending notification to EmblemHealth of previous Managed Care Organization’s restriction for a new member and currently enrolled restricted members within 30 days.In an effort to assure quality care and to contain costs under the Medicaid program, payment will not be made for medical care and services which were not rendered, ordered, or referred by a restricted enrollee’s primary care provider unless the service was provided in an emergency, was a methadone maintenance claim, or a service provided in an inpatient setting. For more information, see the NYS Medicaid Program Information for All Providers General Policy. See above for instructions on identifying restricted recipients.
To report suspicious activity, please contact EmblemHealth’s Special Investigations Unit in one of the following ways:
Email:
KOfraud@emblemhealth.comToll-free hotline:
888-4KO-FRAUD (888-456-3728)Mail:
EmblemHealth
Attention: Special Investigations Unit
55 Water Street
New York, NY 10041A trained investigator will address your concerns. The informant may remain anonymous. For more information, please see theFraud and Abusechapter.
Mandatory Enrollment of the New York City Homeless Population
According to the New York State Department of Health (NYSDOH), all of New York City’s homeless population must be enrolled into MMC.
Primary Care Services Offered in Homeless Shelters
Homeless members can select any participating PCP. We haveexpanded our provider network to include practitioners who practice in homeless shelters to improve access to care for our members with no place of usual residence. A PCP practicing at a homeless shelter is available only to members who reside in that shelter.
Permanent Placement in Nursing Homes
The MMC nursing home benefit includes coverage of permanent stays in residential health care facilities for Medicaid recipients aged 21 and over who reside in the EmblemHealth MMC service area. Covered nursing home services include:
- Medical supervision
- 24-hour nursing care
- Assistance with daily living
- Physical therapy
- Occupational therapy
- Speech-language pathology and other services
If a Medicaid member needs long-term residential care, the facility is required to request increased coverage from the Local Department of Social Services (LDSS) within 48 hours of a change in a member’s status via submission of the DOH-3559 (or equivalent).The facility must also submit a completed Notice of Permanent Placement Medicaid ManagedCare (MAP form) within 60 days of the change in status to the LDSS. The facility must notify EmblemHealth of the change in status. If requested, the facility must submit a copy of the MAP form to EmblemHealth for approval prior to the facility’s submission of the MAP form to the LDSS.
Payment for residential care is contingent upon the LDSS’ official designation of the member as a Permanent Placement Member.
Veterans Nursing Homes
Eligible Veterans, Spouses of Eligible Veterans, and Gold Star Parents of Eligible Veterans may choose to stay in a Veterans’ nursing home.If EmblemHealth does not have a Veterans’ home in their provider network and a member requests access to a Veterans’ home, the member will be allowed to change enrollment into an MMC plan that has the Veterans’ home in their network. While the member’s request to change plans is pending, EmblemHealth will allow the member access to the Veterans’ home and pay the home the Medicaid daily benchmark rate until the member has changed plans.
NYSDOH Medicaid Provider Non-Interference
Medicaid providers and their employees or contractors are not permitted to interfere with therights of Medicaid recipients in making decisions about their health care coverage. Medicaid providers and their employees or contractors are free to inform Medicaid recipients about their contractual relationships with Medicaid plans. However, they are prohibited from directing, assisting, or persuading Medicaid recipients on which plan to join or keep.
In addition, if a Medicaid recipient expresses interest in a Medicaid Managed Care program, providers and their employees or contractors must not dissuade or limit the recipient from seeking information about Medicaid Managed Care programs. Instead, they should direct the recipient to New York Medicaid Choice, New York state’s enrollment broker responsible for providing Medicaid recipients with eligibility and enrollment information for all Medicaid Managed Care plans.For assistance, please call New York Medicaid Choice:800-505-5678, Monday to Friday, 8:30 a.m. to 8 p.m. ET, and Saturday from 10 a.m. to 6 p.m. ET.
Any suspected violations will be turned over to the New York Office of the Medicaid Inspector General (OMIG) and potentially the federal Office of Inspector General (OIG) for investigation.
Required Training for Providers
Providers and their staff, who have regular and substantial contact with EmblemHealth Enhanced Care (Medicaid Managed Care) and Enhanced Care Plus (HARP) members, are required to certify completion of cultural competency training. To certify completion of cultural competency training, please seeCultural Competency Training Certification.
All Enhanced Care Prime Network providers are required to complete an initial orientation and training on the expanded children’s benefit and populations, including:
- Training and technical assistance to the expanded array of providers on billing, coding, data interface, documentation requirements, provider profiling programs, and utilization management requirements.
- Training on processes for assessment for HCBS eligibility (e.g., Targeting Criteria, Risk Factors, Functional Limitations) and Plan of Care development and review.
For training opportunities, please visit ourLearning Onlinewebpage.
