EmblemHealth Plan, Inc. (Group Health Incorporated (GHI)) Commercial Networks
Commercial Networks Covered by Agreements with EmblemHealth Plan, Inc.
EmblemHealth Plan, Inc. contracts cover participation in the CBP, Tristate, and/or National Networks. These networks as used to support EPO and PPO plans typically allow members to self-refer to network specialists for office visits. However, preauthorization is still required before certain procedures can be performed.
In addition, Bridge Program members may access the National Network’s providers. See the Bridge Program page for details on identifying the applicable utilization management, claims submission, fee schedule, and other operational processes that apply.
For announcements about our Commercial plans, see our dedicated Commercial Networks and Benefit Plans resource hub.
Sample Plan Description
Health Essentials Plus EPO
Health Essentials Plus EPO is a unique EmblemHealth EPO plan designed for people seeking health coverage primarily for catastrophic injury or illness. Its core benefits are hospital and preventive care services and three additional office visits.
The Health Essentials plan features:
- Network hospital or ambulatory surgical center benefits
- Inpatient and outpatient hospital services provided in and billed by a network hospital or facility
- Well-baby and well-child care provided by a network practitioner
- Emergency room services (provided in and billed by a hospital or facility)
- Inpatient and outpatient mental health and chemical dependency services provided in and billed by a network hospital or facility
- Covered preventive care services consistent with guidelines of the Patient Protection and Affordable Care Act
- Preventive care services covered at 100% when provided by a network practitioner
- Sick visits not covered
- Pharmacy benefit
- $15 generic drug card
Note: Except for preventive care services provided by network practitioners, services billed by a practitioner are not covered under this plan except for three (3) office visits.
HIP Commercial Networks
Commercial Networks Covered by Agreements with Health Insurance Plan of Greater New York (HIP) (doing business as HIP Health Plan and HIP Health Plan of New York), HIP Network Services, IPA, and EmblemHealth Insurance Company (fka HIP Insurance Company of New York)
Prime Network
The Prime Network includes a robust network of practitioners, hospitals, and facilities in 28 New York state counties: Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Kings (Brooklyn), Montgomery, Nassau, New York (Manhattan), Orange, Otsego, Putnam, Queens, Rensselaer, Richmond (Staten Island), Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington, and Westchester.
For Large Group members, New Jersey QualCare HMO Network services a variety of HMO and POS plans. ConnectiCare Network services a variety of HMO, POS, and EPO plans.
Small Group members also have access to providers in New Jersey via QualCare’s network, and Connecticut via ConnectiCare’s network.
Select Care Network
The Select Care Network is in the following 28 New York state counties: Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Kings (Brooklyn), Montgomery, Nassau, New York (Manhattan), Orange, Otsego, Putnam, Queens, Rensselaer, Richmond (Staten Island), Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington, and Westchester.
The Select Care Network, a subset of our Prime Network, is tailored to help keep costs down and supports an integrated model of care. Providers in the Select Care Network are chosen on measures such as geographic location, hospital affiliations, and sufficiency of services. The network includes a full complement of physicians, hospitals, community health centers, facilities, and ancillary services. Urgent care and immediate care are also available.
EmblemHealth offers multiple Large Group, Small Group, and Individual plans on the Select Care Network. Individual plans are offered both on and off the NY State of Health: The Official Health Plan Marketplace. EmblemHealth Silver Value and EmblemHealth Gold Value plans, both non-standard plans, provide a specific number of primary care physician (PCP) visits at no cost before the deductible. The plans offer acupuncture, dental, and vision benefits for adults and children.
Millennium Network
The Millennium Network is in the nine New York downstate counties: Bronx, Kings (Brooklyn), Nassau, New York (Manhattan), Queens, Richmond (Staten Island), Rockland, Suffolk, and Westchester.
Providers in the Millennium Network are chosen on measures such as geographic location, hospital affiliations, and sufficiency of services. The network includes a full complement of physicians, hospitals, community health centers, facilities, and ancillary services. Urgent care and immediate care are also available.
EmblemHealth offers certain Large Group plans, multiple Small Group plans and an Individual plan, Silver Bold, on the Millennium Network. This plan is offered both on and off the NY State of Health: The Official Health Plan Marketplace. EmblemHealth Silver Bold, a non-standard plan, provides a specific number of primary care physician (PCP) visits at no cost before the deductible. These plans offer acupuncture, dental, and vision benefits for adults and children.
HIP Commercial Plan Covered Services
Our HMO plans only offer in-network coverage for non-emergent services. Most plans require referrals and preauthorization for certain services and have a deductible that applies to in-network services. If you see a member who is NOT in a plan associated with your participating network(s) without preauthorization, the member may incur a surprise bill or avoidable expenses. When scheduling appointments, be sure to check your participation in the member’s plan at that location. If you do not participate in their plan, refer them back to their PCP or our online directory, Find-A-Doctor at Find-A-Doctor, to find a provider in their network.
Individual and Small Group Standard plans follow the plan designs established by New York State, and Nonstandard plans can change the cost-sharing required in any benefit cate.
Wellness Visits:
Large Group and Small Group plan members are eligible for an annual wellness visit once every benefit plan year. Individual plan members are eligible for an annual wellness visit once every calendar year. Sign in to Provider Portal to check the member’s Benefit Summary under the Member Management tab and Eligibility drop-down.
Telemedicine:
EmblemHealth Individual and Small Group plans, and the Essential Plan offer telemedicine services at no cost. EmblemHealth Basic plan offers telemedicine at 0% after deductible.
HIP Commercial Plan Descriptions
Child Health Plus
Child Health Plus (CHPlus) is a New York state-sponsored program that provides uninsured children under 19 years of age with a full range of health care services for free or for a low monthly cost, depending on family income. In addition to immunizations and well-child care visits, CHPlus covers pharmaceutical drugs, vision, dental, and mental health services. There are no copays for any covered services and members may visit any of our Prime Network providers who see children.
The service area for CHPlus includes the following eight New York state counties: Bronx, Kings (Brooklyn), Nassau, New York (Manhattan), Queens, Richmond (Staten Island), Suffolk, and Westchester. CHPlus members are covered for emergency care in the U.S., Puerto Rico, the Virgin Islands, Mexico, Guam, Canada, American Samoa, and the Northern Mariana Islands.
Enrollment period restrictions do not apply to CHPlus. Eligible individuals may enroll throughout the year via the NY State of Health Marketplace or through enrollment facilitators.
10/26/2022