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As of April 1, 2024, we began offering a new variant of the Essential Plan called Essential Plan 200-250. This is in addition to the existing Essential Plans 1 through 4. The new variant is nearly identical to Essential Plan 1; the only difference is the member’s maximum out-of-pocket expense. See the updated 2024 Summary of Companies, Lines of Business, Networks, and Benefit Plans for details on the Essential Plan.

This variant expands Essential Plan eligibility to individuals who have an annual income of 200 – 250% of the Federal Poverty Level (FPL). Prior to April 1, 2024, this annual income level would have qualified someone for an individual and family plan with a cost-share reduction, but they would still have a monthly premium. All Essential Plan variations, including the new Essential Plan 200-250, have no monthly premium or deductible and low-to-no cost-shares!

What this means for our providers

• More members using the Enhanced Care Prime Network.
• Reimbursement will be consistent with Essential Plan 1 and 2.
• Simple administration with no referrals.

Benefits for members

Please share this with your staff and any patients you think would benefit from the features of this new variant:

• No monthly premiums and annual deductibles.
• $2,000 maximum out-of-pocket.
• No referrals required.
• Preventive care at no cost.
• Robust network with top hospitals.
• Telemedicine at no cost with Teladoc^® Primary360.
• Gym reimbursement. Eligible members can earn up to $200 in reimbursement per six-month period (Jan. 1 – June 30 and July 1 – Dec. 31) each calendar year if they complete 50 workouts each period.
• Wellness program.

On May 1, 2024, we disconnected the fax lines used for preauthorization requests and concurrent reviews. Many providers have already adjusted their processes, moving away from antiquated fax transmissions or spending time in telephone queues. We have seen thousands of transactions move to our provider portal since the start of the new year, and our providers are reaping the benefits of greater efficiency and transparency. For those of you who haven’t used the provider portal, we encourage you to use it to submit your requests and supporting documentation. It is a better way to keep your business moving.

See full announcements (EmblemHealth | ConnectiCare).

If you need directions for sending us documents using the provider portal, see our video and user guides Find Submitted Preauthorization Requests and Add Supporting Documents (EmblemHealth | ConnectiCare).  

We also have a convenient summary for the best ways to use the portal to submit all kinds of information.

Getting a Provider Portal Account

If your practice already has an account set up for its tax ID(s), your Administrator/Office Manager can simply add you as a new user or update your existing sign-in credentials by giving you the Clinical Staff role. For a new account, you will need a unique email address for account authentication.

If your practice does not have an account (tied to your tax ID), please ask your Administrator/Office Manager to sign up using the online Portal Account Request Form and then add you as a user.

If you need help finding the person designated as your provider portal Administrator/Office Manager, you may also use the Portal Account Request Form to ask who we have on file.

Find the above-mentioned forms here: 

EmblemHealth: emblemhealth.com/providerportal

ConnectiCare: connecticare.com/providerportal

If you are a non-participating provider who has never submitted a claim to us, you will not be able to use our provider portal without our assistance. Instead, you must call EmblemHealth at 866-447-9171 or ConnectiCare at 860-674-5850 so we can help you.

Inviting Doulas to Join Our Networks

EmblemHealth is now inviting doulas to join our provider networks. EmblemHealth will cover doula services in hospital, clinic, and community settings for Medicaid, Health and Recovery Plan (HARP), and Essential Plan members who are pregnant, birthing, and postpartum (for up to 12 months after the delivery date) beginning Oct. 1, 2024.

If you know a doula who may be interested in partnering with EmblemHealth, please contact medicaidproduct@emblemhealth.com.

For more information on doula reimbursement rates and member benefits, see the article posted in the provider hubs for State-Sponsored Programs and Commercial Networks and Benefit Plans.

Doulas must be enrolled as New York State Medicaid fee-for-service providers.

EmblemHealth Works With SimpliFed to Support New Mothers
SimpliFed, a leader in lactation support, is now an in-network provider with EmblemHealth. This unique maternal health platform offers a bundled, baby-feeding care plan for each patient.

Starting at 28 weeks and continuing well into postpartum, all appointments are done virtually through a secure, easy-to-use portal. SimpliFed offers care in multiple languages and 24/7 support from care navigators or “allies.” And with a simple bi-directional referral process, SimpliFed reduces clinic and provider burden while increasing patient engagement, utilization, and outcomes. 

This emphasis on nurtured, cyclical care has had impressive results: 

• 87% of SimpliFed patients feed with breast milk for at least three months (national average is 69%).
• SimpliFed providers have received a 96% patient satisfaction score.
• 2% no-show rate for all appointments.

For more information on how to refer your commercial, Medicaid, and HARP patients, email contactus@simplifed.us or visit simplifed.com. 

Take Advantage of Elektra Health to Help Your Patients Through Menopause
Menopause is a process that can take place over several years and usually happens to a woman in her 40s and 50s, mostly between the ages of 45 and 55. It can have mild to severe physical and emotional symptoms that can impact a wide range of daily life experiences and relationships. 

To help members with their journey from perimenopause through postmenopause, EmblemHealth and ConnectiCare’s provider networks now include Elektra Health, a specialized women’s health virtual care and education provider. They offer valuable information and expertise for managing menopause, which can supplement the care you give your patients.

Telehealth visits

You may send your EmblemHealth and ConnectiCare members to Elektra Health for telehealth visits without a referral or preauthorization. Elektra Health’s board-certified health care providers are certified by The Menopause Society (formerly The North American Menopause Society). They can order labs and write prescriptions for hormonal and non-hormonal treatments and evidence-backed supplements. The member’s normal cost-sharing for in-network specialist visits under their health insurance plan will apply.

Educational materials

Elektra’s website has evidence-based articles and recommendations on symptoms, hormone replacement therapy, and more. One key resource we recommend sharing with your patients is Elektra’s menopause guide.

Other services

Elektra offers other services that are not covered by our plans but may be of interest to your patients.

Elektra for EmblemHealth

Elektra for ConnectiCare

Management Is Key: Osteoporosis and Treating Women After a Fracture

Managing osteoporosis is an important part of delivering needed care to our older members. Be sure to assess women 67 – 85 years of age who suffered a fracture and recommend to them a bone mineral density (BMD) test or a prescription for a drug to treat osteoporosis in the six months after the fracture. This is also a key quality measure under the Healthcare Effectiveness Data and Information Set (HEDIS^®).

There are several exclusions:

• Patients who had a BMD test during the 730 days (24 months) prior to the episode.
• Patients who had a claim/encounter for osteoporosis therapy during the 365 days (12 months) prior to the episode.
• Patients who received a dispensed prescription or had an active prescription to treat osteoporosis during the 12 months prior to the episode.

Helpful tips to close gaps in care:

• Ask all female patients 67 – 85 years of age if they have had a fracture since their last visit.
• Consider writing a prescription for a BMD test at time of fracture.
• If patients are unable or unwilling to have a BMD test, prescribe osteoporosis medications if appropriate.
• Place a reminder in the patient’s chart for a BMD test.
• Partner with your EmblemHealth team to offer in home BMD screening assessments. If you do not already have a contact, please email us at quality_providerengagement@emblemhealth.com.
• Use telehealth visits to review, document, and prescribe medication, when appropriate.
• Educate patients on safety and fall prevention.

EmblemHealth and ConnectiCare recently contracted with Movn Health, a virtual home-based cardiac rehabilitation provider, to offer our members more options for these services. EmblemHealth and ConnectiCare are working with Movn to identify patients who are eligible for cardiac rehabilitation and ensure they are offered the option to enroll in virtual cardiac rehab when a facility isn't available or appropriate.

Movn's providers will let you know if they enroll a patient in their program. Movn will also provide you with detailed notes at the onset of services and at 30-day intervals. Any medical concerns will be given to a patient’s primary cardiologist or primary care provider (PCP).

If you have any questions or concerns with this process, please contact Neena Arora, Movn Health’s director of implementations, at neena.arora@movnhealth.com. To refer a patient, call 833-426-6686 or visit signup.movnhealth.com