With GHI HMO, you get a wide range of covered services from GHI HMO network doctors and hospitals for a small copay. With this plan, you choose a regular doctor who will manage and oversee your care, including administering referrals to network specialists and arranging for hospital stays. A network is a group of health care professionals and facilities that arranges with EmblemHealth to provide covered services and products to members, like you. The Prime Network is robust. There are more than 100,000 doctors across New York, New Jersey, and Connecticut to take care of you.
- Catastrophic coverage is when a member reaches $3,700 of true out-of-pocket (TrOOP) costs for the calendar year. The member will then pay either a $3.30 copay for generic ($8.25 copay for brand drugs), or a 5% coinsurance, whichever is the greater amount.
- EmblemHealth VIP Go (HMO-POS) H3330-041 is a 2021 Medicare Advantage Plan or Medicare Part-C plan by EmblemHealth Medicare HMO available to residents in New York. This plan includes additional Medicare prescription drug (Part-D) coverage. The EmblemHealth VIP Go (HMO-POS) has a monthly premium of $72.00 and has an in-network Maximum Out-of-Pocket limit of $7,550 (MOOP).
Important Notices
Please click here for our Testing for Coronavirus Disease 2019 (COVID-19) policy effective Feb. 11, 2021.
Please click here for our COVID-19 Vaccine and Monoclonal Antibody Infusions Reimbursement Policy - Revised March 2021.
During the COVID-19 State of Emergency, EmblemHealth will follow CMS guidance and waive the requirement that Medicare Advantage members obtain a primary care physician referral to receive specialist services.
No Member Responsibility for Personal Protective Equipment (PPE) Costs
According to New York State Department of Financial Services (DFS) Insurance Circular Letter No. 14 (2020), participating providers may not charge EmblemHealth members in our Commercial plans for COVID-19-related provider expenses, including sanitizing exam rooms and using personal protective equipment (PPE) such as masks, gowns, and gloves. Any money collected from members for PPE must be returned to the member. DFS has asked insurers to report back on:
- Member(s) impacted
- Total refunded to member(s)
- A description of how refunds will be provided
If you charged any EmblemHealth member(s) for PPE, please complete and return this form to us for all affected members no later than October 30, 2020. Note that this directive does not affect applicable member cost-sharing for the underlying visit or health care service.
Additionally, the New York State Department of Health says, “the Medicaid program prohibits enrolled providers from billing recipients for charges for COVID-19 protective measures, including sanitizing exam rooms and using personal protective equipment, such as masks, gowns, and gloves (collectively, 'PPE'). Cost sharing for Medicaid fee-for-service and managed care members is limited to applicable copays based on federal rules, including the New York's Medicaid State Plan and 1115 Medicaid Redesign Team Waiver. Billing Medicaid recipients for PPE is considered an ‘Unacceptable Practice’ under Medicaid rules, which may result in provider sanctions up to and including termination from the Medicaid program.”
UPDATE: No COVID-19 Member Cost-Sharing
At this time, EmblemHealth members across all product lines will have no cost-sharing (including copayments, coinsurance, or deductibles) for the diagnostic visit and related lab test for the coronavirus (COVID-19).
As state and federal guidelines evolve in response to the pandemic, EmblemHealth will continue to evaluate the latest guidance and make appropriate adjustments to our policies. We will also continue to carefully monitor utilization in support of our members’ diagnostic needs, while upholding our commitment to detecting, correcting and preventing fraud, waste and abuse. This is essential to maintaining a health care system that is affordable for everyone.
(Nov. 24, 2020) We have published COVID-19 Billing Guidelines for our Commercial and Medicare Advantage Lines of Business. Please click here for that guide.
Medicare Advantage and the CARES Act
EmblemHealth will follow Medicare guidelines in the federal coronavirus (COVID-19) stimulus bill (known as the “CARES Act”) to:
- Add 20 percent to inpatient DRG weighting factor portion of the facility reimbursement for both in-network and out-of-network COVID-19 care given to Medicare Advantage members.
- Effective with admissions occurring on or after Sept. 1, 2020, claims eligible for the 20 percent increase in the MS-DRG weighting factor will also be required to have a positive COVID-19 laboratory test documented in the patient’s medical record. Positive tests must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with CDC guidelines. The test may be performed either during the hospital admission or no less than 14 days prior to the hospital admission.
Adding 20 percent to COVID-19 inpatient reimbursement
In accordance with Centers for Medicare & Medicaid Services (CMS) methodology, EmblemHealth will add 20 percent to the MS-DRG-based inpatient reimbursement (operating component only) for Medicare Advantage patients who were discharged with COVID-19 diagnosis code B97.29 on or after Jan. 27, 2020 and on or before March 31, 2020 or with diagnosis code U07.1 on or after April 1, 2020 through the duration of the COVID-19 public health emergency period.
Effective with Sept. 1, 2020 admission dates, CMS requires that a positive viral COVID-19 test result be documented in the medical record for inpatient claims to be eligible for the 20 percent increase.
Effective for all out-of-network and in-network hospitals
- Inpatient admission MS-DRG claims having COVID-19 as the primary diagnosis, as designated by U071.1 will process with the COVID Add-On. We may audit paid claims, and we may ask the hospital to provide medical records to validate the presence of a positive COVID-19 test.
- Inpatient admission MS-DRG claims where COVID-19 was not the primary diagnosis for the admission, but COVID-19 was a secondary or subsequent diagnosis, will initially process without the COVID19 add-on payment.
- Claims will process with a remittance message informing the facility that, if the COVID-19 DRG add-on payment is warranted, the provider is to submit medical records validating the documentation of a positive COVID-19 lab test within 14 days of the admission date.
- The claim will be adjusted to pay the COVID-19 add-on amount once EmblemHealth validates an eligible positive COVID-19 test.
Temporary suspension of the Medicare sequestration fee
We are continuing the suspension of the 2 percent Medicare sequestration fee for in-network providers. This temporary suspension was due to expire at the end of March but, in anticipation of legislative action by Congress, we are choosing to maintain this policy until we receive additional federal guidance.
Telehealth Services
(Update: March 10, 2021) The following telehealth rules reflect current guidance from the New York State Department of Financial Services:
Our Temporary Telehealth Policy, with allowable procedure codes, and Frequently Asked Questions provides guidance on these services for our members. Telehealth services include visits by phone, virtual check-in, or virtual visit via Skype, FaceTime, or other video exchange.
- EmblemHealth members in our commercial line of business will have no cost sharing (including copayments, coinsurance, or deductibles) for in-network telehealth visits conducted through May 4, 2021.
- Members with a benefit plan that includes the Teladoc™ program will have no cost-sharing for Teladoc visits through May 4, 2021. There are two exceptions:
- The $0 cost-sharing waiver for Medicare plans ended Dec. 31, 2020.
- The $0 cost-sharing waiver for ASO plans ended on Sept. 9 2020.
- The telehealth cost-sharing waiver may not apply to ASO plans.
- On Sept. 9, the telehealth waiver expired for our Medicare line of business. You may begin collecting member cost shares for dates of service beginning Sept. 10.
Click here to learn how you can use Telehealth to close gaps in care and get the data needed for commercial, Medicaid, and Medicare Advantage health plan risk adjustment programs.
UM and Emergency Admission Notifications
(February 22, 2021) The temporary suspension of preauthorization for certain inpatient admissions, transfers and discharges required by the New York State Department of Financial Services’ Circular Letter 17 has expired.
Beginning today, all preauthorization requirements for the following areas have been restored: Inpatient admissions, hospital transfers, and inpatient discharges to inpatient rehabilitation, skilled nursing facilities, home health care, or inpatient behavioral health facilities. Please refer to our Provider Manual and our UM and Medical Management page for guidance.
As always, we are committed to collaborating with our hospital and facility partners to ensure our members receive the care they need.
Lab Testing
To address the high demand for COVID-19 testing, EmblemHealth is providing additional lab options. Quest Diagnostics is EmblemHealth’s preferred, in-network lab.
| Northwell Health Laboratories | Use CPT code 87635 | 516-719-1100 |
| LabCorp | Use test code 139900 Use CPT code 87635 | 888-295-5915 |
| Bio-Reference | Use CPT code 87635 | 833-684-0508 |
If you send a specimen to a lab other than Quest, or have any collection or billing questions, please contact them at phone number above. While some of these additional labs are normally out-of-network for EmblemHealth members, we know partnering with you and providing expanded access to testing is in everyone’s best interests.
EmblemHealth does not require preauthorization for COVID-19 testing.
Screening and Coding Guidance
- Providers should make sure to follow Centers for Disease Control and Prevention (CDC) guidelines.
- New York State issued a special update on the Department of Health website: Medicaid Coverage and Reimbursement Policy for Services Related to Coronavirus Disease 2019 (COVID–19). The state’s public information page includes daily updates and additional guidance. Providers in other states should seek out guidance from their state departments of health.
- The CDC published the ICD-10-CM Official Coding Guideline with links to official diagnosis coding guidance for health care encounters and deaths related to COVID-19.
- Update (Aug. 21, 2020): The New York State Department of Health has issued coding guidance for Pharmacies engaged in COVID-19 testing Medicaid recipients, including our Medicaid and HARP members.
- (Update: Sept. 29, 2020): In accordance with State and Federal regulations, EmblemHealth is waiving members’ cost-share for COVID-19 testing as well as the diagnostic visit associated with testing. Please click here for our policy.
- (Update: Oct. 23, 2020): EmblemHealth is clarifying coding guidance for Pharmacies engaged in COVID-19 testing and specimen collection for members who are enrolled in commercial plans.
Prescription Coverage
Members may also have questions about their prescription coverage and having enough maintenance medication on hand. This provider update includes information we emailed to our members on March 10.
Time-Saving Ideas
Use our secure provider portal or fax. See this link for more information.
- Electronically submit claims for faster processing.
- Sign in to your secure portal account and make sure we have the correct email for you and your practice. If you don’t have a portal account, here is a guide for setting up your account.
Other Resources
- EmblemHealth is providing tips and updates to its members and the public. We are regularly updating this information and posting it here. The page includes accurate, fact-based information from our medical leadership as well as city, state, and federal authorities. Feel free to share this link with your patients.
- Centers for Medicare & Medicaid Services News Alert for March 26.
- New York State has published COVID-19 Guidance for Medicaid Providers. The state has also published Special Editions of their Monthly Medicaid Updates; here are the March and April issues.
- The New York City Department of Health hosted a webinar on how community health centers and independent practices can be authorized to enroll patients with COVID-19 in the COVID-19 Hotels Program sponsored by the City of New York. To view a recording of the 35-minute webinar, click here.
- Click here for a letter we sent to all in-network providers at the start of the COVID-19 emergency in March 2020.
Jump to:
EmblemHealth VIP Go (HMO-POS) H3330-041 is a 2021 Medicare Advantage Plan or Medicare Part-C plan by EmblemHealth Medicare HMO available to residents in New York. This plan includes additional Medicare prescription drug (Part-D) coverage. The EmblemHealth VIP Go (HMO-POS) has a monthly premium of $72.00 and has an in-network Maximum Out-of-Pocket limit of $7,550 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,550 out of pocket. This can be a extremely nice safety net.
EmblemHealth VIP Go (HMO-POS) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered by the plan.
EmblemHealth Medicare HMO works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for EmblemHealth VIP Go (HMO-POS) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from EmblemHealth Medicare HMO and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from EmblemHealth Medicare HMO except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.
Ready to Enroll?
Or Call
1-855-778-4180
Mon-Fri 8am-9pm EST
Sat 9am-9pm EST
2021 EmblemHealth Medicare HMO Medicare Advantage Plan Costs
| Name: | |
|---|---|
| Plan ID: | H3330-041 |
| Provider: | EmblemHealth Medicare HMO |
| Year: | 2021 |
| Type: | Local HMO |
| Monthly Premium C+D: | $72.00 |
| Part C Premium: | $4.10 |
| MOOP: | $7,550 |
| Part D (Drug) Premium: | $67.90 |
| Part D Supplemental Premium | $0 |
| Total Part D Premium: | $67.90 |
| Drug Deductible: | $250.0 |
| Tiers with No Deductible: | 1 |
| Gap Coverage: | No |
| Benchmark: | not below the regional benchmark |
| Type of Medicare Health: | Enhanced Alternative |
| Drug Benefit Type: | Enhanced |
| Similar Plan: | H3330-021 |
EmblemHealth VIP Go (HMO-POS) Part-C Premium
EmblemHealth Medicare HMO plan charges a $4.10 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
H3330-041 Part-D Deductible and Premium
EmblemHealth VIP Go (HMO-POS) has a monthly drug premium of $67.90 and a $250.0 drug deductible. This EmblemHealth Medicare HMO plan offers a $67.90 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0 this Premium covers any enhanced plan benefits offered by EmblemHealth Medicare HMO above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $67.90. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.
EmblemHealth Medicare HMO Gap Coverage
In 2021 once you and your plan provider have spent $4130 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA 'donut hole') You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This EmblemHealth Medicare HMO plan does not offer additional coverage through the gap.
Premium Assistance
The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The EmblemHealth VIP Go (HMO-POS) medicare insurance offers a $25.60 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $36.20 for 75% low income subsidy $46.80 for 50% and $57.30 for 25%.
| Full LIS Premium: | $25.60 |
|---|---|
| 75% LIS Premium: | $36.20 |
| 50% LIS Premium: | $46.80 |
| 25% LIS Premium: | $57.30 |
H3330-041 Formulary or Drug Coverage
EmblemHealth VIP Go (HMO-POS) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers.By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.
2021 EmblemHealth VIP Go (HMO-POS) Summary of Benefits
Additional Benefits
| No |
|---|
Comprehensive Dental
| Diagnostic services | Not covered |
|---|---|
| Endodontics | $0-20 copay |
| Extractions | $0-50 copay |
| Non-routine services | Not covered |
| Periodontics | $0-150 copay |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0-150 copay |
| Restorative services | $0-125 copay |
Deductible
| $500 In and Out-of-network |
|---|
Diagnostic Tests and Procedures
| Diagnostic radiology services (e.g., MRI) | $0-45 copay or 20% coinsurance (Out-of-Network) |
|---|---|
| Diagnostic radiology services (e.g., MRI) | 20% coinsurance |
| Diagnostic tests and procedures | $0-45 copay or 20% coinsurance (Out-of-Network) |
| Diagnostic tests and procedures | $0-45 copay |
| Lab services | $0-45 copay or 20% coinsurance (Out-of-Network) |
| Lab services | $0-15 copay |
| Outpatient x-rays | $40 copay |
| Outpatient x-rays | $0-45 copay or 20% coinsurance (Out-of-Network) |
Doctor Visits
| Primary | $10-100 copay per visit (Out-of-Network) |
|---|---|
| Primary | $10 copay per visit |
| Specialist | $45 copay per visit |
| Specialist | $10-100 copay per visit (Out-of-Network) |
Emergency care/Urgent Care
| Emergency | $90 copay per visit (always covered) |
|---|---|
| Urgent care | $50 copay per visit (always covered) |
Foot Care (podiatry services)
| Foot exams and treatment | $10-100 copay (Out-of-Network) |
|---|---|
| Foot exams and treatment | $40 copay |
| Routine foot care | $40 copay |
| Routine foot care | $10-100 copay (Out-of-Network) |
Ground Ambulance
| $250 copay or 20% coinsurance (Out-of-Network) |
|---|
| $250 copay |
Hearing
| Fitting/evaluation | $10 copay |
|---|---|
| Hearing aids | $0 copay |
| Hearing exam | $40 copay |
Inpatient Hospital Coverage
| $565 per day for days 1 through 5 $0 per day for days 6 through 90 (Out-of-Network) |
|---|
| $360 per day for days 1 through 5 $0 per day for days 6 through 90 |
Medical Equipment/Supplies
| Diabetes supplies | $0 copay |
|---|---|
| Diabetes supplies | 0-20% coinsurance per item (Out-of-Network) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Out-of-Network) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item |
| Prosthetics (e.g., braces, artificial limbs) | 0-20% coinsurance per item (Out-of-Network) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item |
Medicare Part B Drugs
| Chemotherapy | 10-20% coinsurance |
|---|---|
| Chemotherapy | 0-20% coinsurance (Out-of-Network) |
| Other Part B drugs | 10-20% coinsurance |
| Other Part B drugs | 0-20% coinsurance (Out-of-Network) |
Urgent Care Copay United Healthcare
Mental Health Services
| Inpatient hospital - psychiatric | $1,871 per stay |
|---|---|
| Inpatient hospital - psychiatric | Not Applicable (Out-of-Network) |
| Outpatient group therapy visit | $40 copay |
| Outpatient group therapy visit with a psychiatrist | $40 copay |
| Outpatient individual therapy visit | $40 copay |
| Outpatient individual therapy visit with a psychiatrist | $40 copay |
MOOP
| $11,300 In and Out-of-network $7,550 In-network |
|---|
Option
| No |
|---|
Optional supplemental benefits
| No |
|---|
Outpatient Hospital Coverage
| $495-565 copay per visit (Out-of-Network) |
|---|
| $360 copay per visit |
Preventive Care
| 0-20% coinsurance (Out-of-Network) |
|---|
| $0 copay |
Preventive Dental
| Cleaning | $0 copay |
|---|---|
| Dental x-ray(s) | $0 copay |
| Fluoride treatment | $0 copay |
| Oral exam | $0 copay |
Rehabilitation Services
| Occupational therapy visit | $40 copay |
|---|---|
| Occupational therapy visit | $10-100 copay (Out-of-Network) |
| Physical therapy and speech and language therapy visit | $10-100 copay (Out-of-Network) |
| Physical therapy and speech and language therapy visit | $40 copay |
Emblem Health Urgent Care Copays
Skilled Nursing Facility
| $0 per day for days 1 through 20 $184 per day for days 21 through 100 (Out-of-Network) |
|---|
| $0 per day for days 1 through 20 $184 per day for days 21 through 100 |
Transportation
| Not covered |
|---|
Vision
| Contact lenses | $0 copay |
|---|---|
| Eyeglass frames | $0 copay |
| Eyeglass lenses | $0 copay |
| Eyeglasses (frames and lenses) | $0 copay |
| Other | Not covered |
| Routine eye exam | $10 copay |
| Upgrades | Not covered |
Wellness Programs (e.g. fitness nursing hotline)
| Covered |
|---|
Advantage Health Urgent Care Locations
Reviews for EmblemHealth VIP Go (HMO-POS) H3330
| 2019 Overall Rating |
|---|
| Part C Summary Rating |
| Part D Summary Rating |
| Staying Healthy: Screenings, Tests, Vaccines |
| Managing Chronic (Long Term) Conditions |
| Member Experience with Health Plan |
| Complaints and Changes in Plans Performance |
| Health Plan Customer Service |
| Drug Plan Customer Service |
| Complaints and Changes in the Drug Plan |
| Member Experience with the Drug Plan |
| Drug Safety and Accuracy of Drug Pricing |
Staying Healthy, Screening, Testing, & Vaccines
| Total Preventative Rating |
|---|
| Breast Cancer Screening |
| Colorectal Cancer Screening |
| Annual Flu Vaccine |
| Improving Physical |
| Improving Mental Health |
| Monitoring Physical Activity |
| Adult BMI Assessment |
Managing Chronic And Long Term Care for Older Adults
| Total Rating |
|---|
| SNP Care Management |
| Medication Review |
| Functional Status Assessment |
| Pain Screening |
| Osteoporosis Management |
| Diabetes Care - Eye Exam |
| Diabetes Care - Kidney Disease |
| Diabetes Care - Blood Sugar |
| Rheumatoid Arthritis |
| Reducing Risk of Falling |
| Improving Bladder Control |
| Medication Reconciliation |
| Statin Therapy |
Member Experience with Health Plan
| Total Experience Rating |
|---|
| Getting Needed Care |
| Customer Service |
| Health Care Quality |
| Rating of Health Plan |
| Care Coordination |
Member Complaints and Changes in EmblemHealth VIP Go (HMO-POS) Plans Performance
| Total Rating |
|---|
| Complaints about Health Plan |
| Members Leaving the Plan |
| Health Plan Quality Improvement |
| Timely Decisions About Appeals |
Health Plan Customer Service Rating for EmblemHealth VIP Go (HMO-POS)
| Total Customer Service Rating |
|---|
| Reviewing Appeals Decisions |
| Call Center, TTY, Foreign Language |
EmblemHealth VIP Go (HMO-POS) Drug Plan Customer Service Ratings
| Total Rating |
|---|
| Call Center, TTY, Foreign Language |
| Appeals Auto |
| Appeals Upheld |
Va Health Care Copay
Ratings For Member Complaints and Changes in the Drug Plans Performance
| Total Rating |
|---|
| Complaints about the Drug Plan |
| Members Choosing to Leave the Plan |
| Drug Plan Quality Improvement |
Member Experience with the Drug Plan
| Total Rating |
|---|
| Rating of Drug Plan |
| Getting Needed Prescription Drugs |
Drug Safety and Accuracy of Drug Pricing
Emblem Health Urgent Care Locations
| Total Rating |
|---|
| MPF Price Accuracy |
| Drug Adherence for Diabetes Medications |
| Drug Adherence for Hypertension (RAS antagonists) |
| Drug Adherence for Cholesterol (Statins) |
| MTM Program Completion Rate for CMR |
| Statin with Diabetes |
Ready to Enroll?
Or Call
1-855-778-4180
Mon-Sat 8am-11pm EST
Sun 9am-6pm EST
Coverage Area for EmblemHealth VIP Go (HMO-POS)
(Click county to compare all available Advantage plans)
| State: | New York |
|---|---|
| County: | Albany,Bronx,Broome,Columbia,Delaware, Dutchess,Greene,Kings,Nassau, New York,Orange,Putnam,Queens, Rensselaer,Richmond,Rockland,Saratoga, Schenectady,Sullivan,Ulster,Warren, Washington,Westchester,Suffolk, |
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Source: CMS.
Data as of September 9, 2020.
Notes: Data are subject to change as contracts are finalized. For 2021, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit.Includes 2021 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.