Transcription
2021 Summary of Companies, Lines of Business, Networks & Benefit PlansPlease use this chart to let your appointment schedulers know how you participate with EmblemHealth by checking the networks below covered by your contract(s).Provider:Service Address:Key: ER emergency room; fka formerly known as IN in-network; N/A not applicable; OON out-of-network; MOOP maximum out-of-pocket; PCP primary care provider;EH/CCI Reciprocity members may access providers in both EmblemHealth and ConnectiCare’s networks as noted. Service Areas where benefit plans may be sold, not wherecare may be received.2021 Company2021 Provider Network/Program2021 Member Benefit PlanEmblemHealth Plan, Inc., fkaGroup Health Incorporated(GHI)Commercial: CBP Network(Member ID cards may show: CBP,EPO, EPO1, EPO2, PPO, PPO1, orPPO4)GHI CBP plan (New York City Plan)No PCP or referrals required.Deductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) CoinsuranceDeductibles:IN: N/AOON: 200/ 500Copay: 15/ 30/ 150ACPNY and Monte: 0/ 0MOOP: 4,550/ 9,100Coinsurance: NoneOON Coverage Service AreaEH/CCI ReciprocityOON Coverage: YesService Area: NationalEH/CCI Reciprocity: No Benefit applies Specialist copay to dual PCP/Specialists.DC37 Med-Team (New York City Plan)No PCP or referrals required.Federal Employee Benefit (FEHB)(EPO)No PCP or referrals required.Deductibles:IN: N/AOON: 1,000/ 3,000Copay: 25/ 25/ 150MOOP: 7,150/ 14,300Coinsurance: 30% OON onlyOON Coverage: YesService Area: NationalEH/CCI Reciprocity: NoDeductibles: N/ACopay: 50/ 50/ 200MOOP: 8,150/ 16,300Coinsurance: NoneOON Coverage: NoService Area: NY & Northern NJEH/CCI Reciprocity: NoEmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC and Health Insurance Plan of Greater New York (HIP) are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrativeservices to the EmblemHealth companies.EMB PR OTH 54288 2021SummaryOfCompaniesNetBenPlans 4/21
2021 Company2021 Provider Network/Program2021 Member Benefit PlanEmblemHealth Plan, Inc., fkaGroup Health Incorporated(GHI) (Continued)Commercial: National Network Tristate Network Bridge Program(Prime Network, National Network,Choice Network, QualCare Network,and First Health Network)EmblemHealth EPODeductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) CoinsuranceNo PCP or referrals required.EmblemHealth PPONo PCP or referrals required.The Bridge Program gives membersaccess to multiple networks.Please refer to the member’s ID cardto see if the benefit plan accesses theBridge Program.EmblemHealth ConsumerDirect EPONo PCP or referrals required.EmblemHealth ConsumerDirect PPONo PCP or referrals required.EmblemHealth InBalance EPONo PCP or referrals required.EmblemHealth InBalance PPONo PCP or referrals required.EmblemHealth Health EssentialsPlus EPONo PCP or referrals required.Commercial: Network Access NetworkNetwork Access PlanNo PCP or referrals required2OON Coverage Service AreaEH/CCI ReciprocityDeductibles: N/ACopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: NoneOON Coverage: NoService Area: NationalEH/CCI Reciprocity: NoDeductibles:IN: N/AOON: VariousCopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: OON onlyOON Coverage: YesService Area: NationalEH/CCI Reciprocity: NoDeductibles: Various (includes Rx)Copay: NoMOOP: Up to 8,150/ 16,300Coinsurance: YesOON Coverage: NoService Area: NationalEH/CCI Reciprocity: NoDeductibles: Various (includes Rx)Copay: NoMOOP: Up to 8,150/ 16,300Coinsurance: YesOON Coverage: YesService Area: NationalEH/CCI Reciprocity: NoDeductibles: Various on-facility/non-preventivesurgical servicesCopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: YesOON Coverage: NoService Area: NationalEH/CCI Reciprocity: NoDeductibles:IN: Various on-facility/non-preventive surgicalservicesOON: VariousCopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: YesOON Coverage: YesService Area: NationalEH/CCI Reciprocity: NoDeductibles: N/ACopay: 40(limited to 3 outpatient visits only)MOOP: 3,000/ 6,000Coinsurance: NoneOON Coverage: NoService Area: NationalEH/CCI Reciprocity: NoDeductibles: VariousCopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance:EPO: NonePPO: YesOON Coverage:EPO: NoPPO: YesService Area: VariousEH/CCI Reciprocity: No
Deductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) Coinsurance2021 Company2021 Provider Network/Program2021 Member Benefit PlanEmblemHealth Plan, Inc., fkaGroup Health Incorporated(GHI) (Continued)Commercial: Network Access Network(continued)ArchCare Advantage HMO SNPMedicare: Medicare Choice PPO NetworkEmblemHealth Group Access Rx(PPO)No PCP or referrals required.No PCP or referrals required.EmblemHealth InsuranceCompany, fka HIP InsuranceCompany of New York (HIPIC)EmblemHealth Plan, Inc., fkaGroup Health Incorporated(GHI)ConnectiCareCommercial: Bridge Program(Prime Network, National Network,Choice Network, QualCare Network,and First Health Network)The Bridge Program gives membersaccess to multiple networks.First HealthMembers must follow the sameadministrative guidelines as memberswith plans under the EmblemHealthInsurance Company. Certain clientspecific exceptions may apply.Health Insurance Plan ofGreater New York (HIP)Commercial: Millennium NetworkQualCareBridge ASONo PCP or referrals required.Please refer to the member’s ID cardto see if the benefit plan accesses theBridge Program.EmblemHealth EPO Value(EmblemHealth/ConnectiCareEmployee Benefit Plan)No PCP or referrals required.EmblemHealth PPO Value(EmblemHealth/ConnectiCareEmployee Benefit Plan)No PCP or referrals required.HIP Prime HMO (Large Group)PCP and referrals needed.EmblemHealth HMO Plus (LargeGroup)PCP and referrals needed.EmblemHealth Silver Bold (IndividualDirect Pay – On Exchange)PCP and referrals needed.Deductibles: VariousCopay: VariousMOOP: VariousCoinsurance: VariousOON Coverage: VariousService Area: VariousEH/CCI Reciprocity: NoDeductibles: 0Copay: 15- 35/ 15- 35/ 50- 75MOOP: 3,400- 5,100Coinsurance: Up to 20%OON Coverage: YesService Area: NationalEH/CCI Reciprocity: NoDeductibles: VariousCopay: VariousMOOP: VariousCoinsurance: VariousOON Coverage:EPO: NoPPO: YesService Area: NationalEH/CCI Reciprocity: YesDeductibles: VariousCopay: VariousMOOP: VariousCoinsurance: VariousOON Coverage: NoService Area: NationalEH/CCI Reciprocity: YesDeductibles: VariousCopay: VariousMOOP: VariousCoinsurance: VariousOON Coverage: YesService Area: NationalEH/CCI Reciprocity: YesDeductibles: N/ACopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: NoneOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles: VariousCopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: NoneOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles: 6,500/ 13,000Copay: 50 / 70/ 0MOOP: Up to 6,500/ 13,000Coinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: No 3 free PCP visits. Benefit is not subject to deductible.3OON Coverage Service AreaEH/CCI Reciprocity
Deductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) Coinsurance2021 Company2021 Provider Network/Program2021 Member Benefit PlanHealth Insurance Plan ofGreater New York (HIP)(continued)Commercial: Millennium Network (continued)EmblemHealth Silver Bold CSR 1(Individual Direct Pay – On Exchange)PCP and referrals needed.EmblemHealth Silver Bold CSR 2(Individual Direct Pay – On Exchange)PCP and referrals needed.EmblemHealth Silver Bold CSR 3(Individual Direct Pay – On Exchange)PCP and referrals needed.EmblemHealth Platinum Premier-M(Small Group)PCP and referrals needed.OON Coverage Service AreaEH/CCI ReciprocityDeductibles: 5,500Copay:PCP: 3 free, 50 before deductibleSpecialist: 70 before deductibleMOOP: 5,500Coinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoDeductibles: 1,900Copay:PCP: 3 free, 50 before deductibleSpecialist: 70 before deductibleMOOP: 1,900Coinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoDeductibles: 650Copay:PCP: 3 free, 50 before deductibleSpecialist: 70 before deductibleMOOP: 650Coinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoDeductibles: 0Copay: 15/ 35/ 400MOOP: Up to 2,000/ 4,000Coinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: No 3 free PCP visits.EmblemHealth Platinum Value-M(Small Group)PCP and referrals needed.Deductibles: 250/ 500Copay: 15 / 35 / 400MOOP: Up to 2,500/ 5,000Coinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: No 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Gold Premier-M(Small Group)PCP and referrals needed.Deductibles: 450/ 900 Rx deductible 0Copay: 25 / 40 / 800MOOP: Up to 5,600/ 11,200Coinsurance: YesOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: No 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Gold Value-M(Small Group)PCP and referrals needed.Deductibles: 2,300/ 4,600Copay: 25 / 40 / 800MOOP: Up to 5,300/ 10,600Coinsurance: Yes 3 free PCP visits. Benefit is not subject to deductible.4OON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: No
Deductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) Coinsurance2021 Company2021 Provider Network/Program2021 Member Benefit PlanHealth Insurance Plan ofGreater New York (HIP)(continued)Commercial: Millennium Network (continued)EmblemHealth Silver Premier-M(Small Group)PCP and referrals needed.Deductibles: 3,600/ 7,200Rx deductible 0Copay: 35 / 65 /40%MOOP: Up to 7,800/ 15,600Coinsurance: YesOON Coverage Service AreaEH/CCI ReciprocityOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: No 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Silver Value-M(Small Group)PCP and referrals needed.Deductibles: 6,700/ 13,400Copay: 10 / 55 / 0MOOP: Up to 6,700/ 13,400Coinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: No 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Bronze Premier-M(Small Group)PCP and referrals needed.EmblemHealth Bronze Value-M(Small Group)PCP and referrals needed.Deductibles: 5,300/ 10,600Copay: 50% 3 free PCP visitsMOOP: Up to 8,450/ 16,900Co-insurance: YesOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoDeductibles: 8,550/ 17,100Copay: 0% (3 free PCP)MOOP: Up to 8,550/ 17,100Coinsurance: YesOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: No Benefit is not subject to deductible.Commercial: Select Care NetworkHIP Prime HMO (Large Group)PCP and referrals needed.EmblemHealth HMO Plus(Large Group)PCP and referrals needed.EmblemHealth Platinum(Individual On/Off Exchange)PCP and referrals needed.EmblemHealth Gold(Individual On/Off Exchange)PCP and referrals needed.EmblemHealth Gold Value(Individual On/Off Exchange)PCP and referrals needed.Deductibles: N/ACopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: NoneOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles: VariousCopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: NoneOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles: 0Copay: 15/ 35/ 100MOOP: Up to 2,000/ 4,000Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: NoDeductibles: 600/ 1,200Copay: 25/ 40/ 150MOOP: Up to 4,000/ 8,000Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: NoDeductibles: 3,300/ 6,600Copay: 45 / 65 / 0MOOP: Up to 3,300/ 6,600Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: No 3 free PCP visits. Benefit is not subject to deductible.5
Deductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) Coinsurance2021 Company2021 Provider Network/Program2021 Member Benefit PlanHealth Insurance Plan ofGreater New York (HIP)(continued)Commercial: Select Care Network (continued)EmblemHealth Silver(Individual On/Off Exchange)PCP and referrals needed.EmblemHealth Silver CSR 1(Individual On/Off Exchange)PCP and referrals needed.EmblemHealth Silver CSR 2(Individual On/Off Exchange)PCP and referrals needed.EmblemHealth Silver CSR 3(Individual On/Off Exchange)PCP and referrals needed.EmblemHealth Silver Value(Individual On/Off Exchange)PCP and referrals needed.OON Coverage Service AreaEH/CCI ReciprocityDeductibles: 1,300/ 2,600Copay: 30/ 50/ 300MOOP: Up to 8,500/ 17,000Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: NoDeductibles: 1,100/ 2,200Copay: 30/ 50/ 275MOOP: 6,500/ 13,000Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: NoDeductibles: 250/ 500Copay: 15/ 35/ 75MOOP: 2,200/ 4,400Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: NoDeductibles: 0Copay: 10/ 20/ 50MOOP: 1,000/ 2,000Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: NoDeductibles: 6,000/ 12,000Copay: 35 / 75 / 0MOOP: Up to 6,000/ 12,000Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: No 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Silver Value CSR 1(Individual On/Off Exchange)PCP and referrals needed.EmblemHealth Silver Value CSR 2(Individual On/Off Exchange)PCP and referrals needed.EmblemHealth Silver Value CSR 3(Individual On/Off Exchange)PCP and referrals needed.Deductibles: 5,150/ 10,300Copay: 35 / 75 / 0MOOP: 5,150/ 10,300Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: NoDeductibles: 1,700/ 3,400Copay: 35 / 75 / 0MOOP: 1,700/ 3,400Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: NoDeductibles: 550/ 1,100Copay: 35 / 75 / 0MOOP: 550/ 1,100Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: No Benefit is not subject to deductible.EmblemHealth Bronze(Individual On/Off Exchange)PCP and referrals needed.Deductibles: 4,700/ 9,400Copay: 3 visits 50 then 50/3 visits 75 then 75/50%MOOP: Up to 8,550/ 17,100Coinsurance: Yes Benefit is not subject to deductible.6OON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: No
Deductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) Coinsurance2021 Company2021 Provider Network/Program2021 Member Benefit PlanHealth Insurance Plan ofGreater New York (HIP)(continued)Commercial: Select Care Network (continued)EmblemHealth Catastrophic(Individual On/Off Exchange)PCP and referrals needed.EmblemHealth Platinum Premier-S(Small Group)No referrals required. PCP needed.OON Coverage Service AreaEH/CCI ReciprocityDeductibles: 8,550/ 17,100Copay: 0% 3 free PCP visitsMOOP: 8,550/ 17,100Coinsurance: YesOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: NoDeductibles: 0 Rx deductible 0Copay: 15/ 35/ 400MOOP: Up to 2,000/ 4,000Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: No 3 free PCP visits.EmblemHealth Platinum Value-S(Small Group)No referrals required. PCP needed.Deductibles: 250/ 500Copay: 15 / 35 / 400MOOP: Up to 2,500/ 5,000Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: No 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Gold Premier-S(Small Group)No referrals required. PCP needed.Deductibles: 450/ 900 Rx deductible 0Copay: 25 / 40 / 800MOOP: Up to 5,600/ 11,200Coinsurance: YesOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: No 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Gold Value-S(Small Group)No referrals required. PCP needed.Deductibles: 2,300/ 4,600Copay: 25 / 40 / 800MOOP: Up to 5,300/ 10,600Coinsurance: YesOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: No Benefit is not subject to deductible.EmblemHealth Silver Premier-S(Small Group)No referrals required. PCP needed.Deductibles: 3,600/ 7,200Rx deductible 0Copay: 35 / 65 /40%MOOP: Up to 7,800/ 15,600Coinsurance: YesOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: No 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Silver Value-S(Small Group)No referrals required. PCP needed.Deductibles: 6,700/ 13,400Copay: 10 / 55 / 0MOOP: Up to 6,700/ 13,400Coinsurance: NoneOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: No 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Bronze Premier-S(Small Group)No referrals required. PCP needed.7Deductibles: 5,300/ 10,600Copay: 50% 3 free PCP visitsMOOP: Up to 8,450/ 16,900Coinsurance: YesOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: No
Deductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) Coinsurance2021 Company2021 Provider Network/Program2021 Member Benefit PlanHealth Insurance Plan ofGreater New York (HIP)(continued)Commercial: Select Care Network (continued)EmblemHealth Bronze Value-S(Small Group)No referrals required. PCP needed.Deductibles: 8,550/ 17,100Copay: 0% (3 free PCP)MOOP: Up to 8,550/ 17,100Coinsurance: YesOON Coverage Service AreaEH/CCI ReciprocityOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: No Benefit is not subject to deductible.Commercial: Prime NetworkChild Health PlusPCP and referrals needed.HIP Prime HMOPCP and referrals needed.HIP HMO Preferred (City of NY)PCP and referrals needed.EmblemHealth HMO PlusPCP and referrals needed.EmblemHealth HMO Preferred PlusPCP and referrals needed.HIP Prime POSPCP and referrals needed.HIP Prime POS (City of NY)PCP and referrals needed.8Deductibles: N/ACopay: NoMOOP: N/ACoinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoDeductibles: N/ACopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: NoneOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles: NoCopay: 10/ 10/ 150 ACPNY 0/ 0/ 150MOOP: 7,150/ 14,300Coinsurance: NoneOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles: VariousCopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: NoneOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles: VariousCopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: NoneOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles:IN: N/AOON: VariousCopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: OON onlyOON Coverage: YesService Area: TristateEH/CCI Reciprocity: YesDeductibles:IN: N/AOON: 750/ 2,250Copay: 10/ 15/ 100MOOP: 3,000/ 9,000Coinsurance: 30% OON onlyOON: YesService Area: TristateEH/CCI Reciprocity: Yes
2021 Company2021 Provider Network/Program2021 Member Benefit PlanHealth Insurance Plan ofGreater New York (HIP)(continued)Commercial: Prime Network (continued)HIPaccess IDeductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) CoinsuranceNo referrals required. PCP needed.HIPaccess IINo referrals required. PCP needed.GHI HMO (City of NY)PCP and referrals needed.Vytra HMO (City of NY)PCP and referrals needed.EmblemHealth Platinum Premier P(Small Group)No referrals required. PCP needed.OON Coverage Service AreaEH/CCI ReciprocityDeductibles: N/ACopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: NoneOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles:IN: N/AOON: VariousCopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: OON onlyOON Coverage: YesService Area: TristateEH/CCI Reciprocity: YesDeductibles: N/ACopay: 15/ 15/ 35MOOP: N/ACoinsurance: N/AOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles: N/ACopay: 5/ 5/ 25MOOP: N/ACoinsurance: N/AOON Coverage: NoService Area: NY 28 countyEH/CCI Reciprocity: YesDeductibles: 0 Rx, deductible 0Copay: 15/ 35/ 400MOOP: Up to 2,000/ 4,000Coinsurance: NoneOON Coverage: NoService Area: TristateEH/CCI Reciprocity: Yes 3 free PCP visits.EmblemHealth Platinum Value-P(Small Group)No referrals required. PCP needed.Deductibles: 250/ 500Copay: 15 / 35 / 400MOOP: Up to 2,500/ 5,000Coinsurance: NoneOON Coverage: NoService Area: TristateEH/CCI Reciprocity: Yes 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Gold Premier-P(Small Group)No referrals required. PCP needed.Deductibles: 450/ 900 Rx, deductible 0Copay: 25 / 40 / 800MOOP: Up to 5,600/ 11,200Coinsurance: YesOON Coverage: NoService Area: TristateEH/CCI Reciprocity: Yes 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Gold Value-P(Small Group)No referrals required. PCP needed.Deductibles: 2,300/ 4,600Copay: 25 / 40 / 800MOOP: Up to 5,300/ 10,600Coinsurance: Yes 3 free PCP visits. Benefit is not subject to deductible.9OON Coverage: NoService Area: TristateEH/CCI Reciprocity: Yes
Deductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) Coinsurance2021 Company2021 Provider Network/Program2021 Member Benefit PlanHealth Insurance Plan ofGreater New York (HIP)(continued)Commercial: Prime Network (continued)EmblemHealth Silver Premier-P(Small Group)No referrals required. PCP needed.Deductibles: 3,600/ 7,200 Rx, deductible 0Copay: 35 / 65 /40%MOOP: Up to 7,800/ 15,600Coinsurance: YesOON Coverage Service AreaEH/CCI ReciprocityOON Coverage: NoService Area: TristateEH/CCI Reciprocity: Yes 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Silver Value-P(Small Group)No referrals required. PCP needed.Deductibles: 6,700/ 13,400Copay: 10 / 55 / 0MOOP: Up to 6,700/ 13,400Coinsurance: NoneOON Coverage: NoService Area: TristateEH/CCI Reciprocity: Yes 3 free PCP visits. Benefit is not subject to deductible.EmblemHealth Silver Plus H.S.A.(Small Group)No referrals required. PCP needed.EmblemHealth Bronze Premier-P(Small Group)No referrals required. PCP needed.EmblemHealth Bronze Value-P(Small Group)No referrals required. PCP needed.EmblemHealth Bronze Plus H.S.A.(Small Group)No referrals required. PCP needed.Medicaid/Commercial: Enhanced Care Prime NetworkEmblemHealth Enhanced Care(Medicaid Managed Care plan forMedicaid-eligible individuals includingMedicaid children’s health andbehavioral health benefits)Deductibles: 3,000/ 6,000Copay: 30/ 50/40%MOOP: Up to 6,000/ 12,000Coinsurance: YesOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles: 5,300/ 10,600Copay: 50% 3 free PCP visitsMOOP: Up to 8,450/ 16,900Coinsurance: YesOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles: 8,550/ 17,100Copay: 0% 3 free PCP visitsMOOP: Up to 8,550/ 17,100Coinsurance: YesOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles: 6,300/ 12,600Copay: 50%MOOP: Up to 6,900/ 13,800Coinsurance: YesOON Coverage: NoService Area: TristateEH/CCI Reciprocity: YesDeductibles: N/ACopay: Rx 1/ 3 (with exceptions)MOOP: Rx 50 quarterlyCoinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoDeductibles: N/ACopay: Rx 1/ 3 (with exceptions)MOOP: Rx 50 quarterlyCoinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoDeductibles: N/ACopay: 15/ 25/ 75MOOP: 2,000Coinsurance: Yes, for certain servicesOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoPCP and referrals needed.SOMOS-managed members do notneed referrals.EmblemHealth Enhanced CarePlus (HARP for Medicaid-eligibleindividuals aged 21 and older)PCP and referrals needed.Essential Plan 1 (BHP)PCP and referrals needed.10
2021 Company2021 Provider Network/Program2021 Member Benefit PlanHealth Insurance Plan ofGreater New York (HIP)(continued)Medicaid/Commercial: Enhanced Care Prime Network(continued)Essential Plan 1 PlusDeductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) CoinsurancePCP and referrals needed.Essential Plan 2PCP and referrals needed.Essential Plan 2 PlusPCP and referrals needed.Essential Plan 3PCP and referrals needed.Essential Plan 4PCP and referrals needed.Medicare: VIP Prime NetworkEmblemHealth VIP Premier (HMO)(Group Plan)PCP and referrals needed, exceptduring COVID-19 State of Emergency.EmblemHealth VIP Rx Carve-Out(HMO) (Group Plan)PCP and referrals needed, exceptduring COVID-19 State of Emergency.Health Insurance Plan ofGreater New York (HIP)(continued)Medicare: VIP Bold Network (New for 2021)EmblemHealth VIP Dual(HMO D-SNP - Individual Medicareplan. Special needs plan limited toindividuals with both Medicare andfull Medicaid coverage.)No referrals required.PCP needed.11OON Coverage Service AreaEH/CCI ReciprocityDeductibles: N/ACopay: 15/ 25/ 75MOOP: 2,000Coinsurance: Yes, for certain servicesOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoDeductibles: N/ACopay: 0MOOP: 200Coinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoDeductibles: N/ACopay: 0MOOP: 200Coinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoDeductibles: N/ACopay: 0MOOP: 200Coinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoDeductibles: N/ACopay: 0MOOP: 0Coinsurance: NoneOON Coverage: NoService Area: NY 8 countyEH/CCI Reciprocity: NoDeductibles: N/ACopay: VariousMOOP: Up to 7,550Coinsurance: Up to 20%OON Coverage: NoService Area: NY 24EH/CCI Reciprocity: YesMay access CCI Choice Network formost services.Deductibles: N/ACopay: VariousMOOP: 3,400Coinsurance: Up to 20%OON Coverage: NoService Area: NY 24 countyEH/CCI Reciprocity: YesMembers may access CCI ChoiceNetwork for most services.Deductibles: 0 (Provider must bill Medicaid)Copay: 0/ 0/ 0MOOP: 0Coinsurance: 0Individuals with full Medicaid coverage are notrequired to pay cost-sharing. Providers must billCOB to Medicaid or Medicaid plan and cannotbalance bill members.OON Coverage: NoService Area: NY 24 countyEH/CCI Reciprocity: No
Deductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) Coinsurance2021 Company2021 Provider Network/Program2021 Member Benefit PlanHealth Insurance Plan ofGreater New York (HIP)(continued)Medicare: VIP Bold Network (New for 2021)(continued)EmblemHealth VIP Gold (HMO)No referrals required. PCP needed.EmblemHealth VIP Gold Plus (HMO)No referrals required. PCP needed.EmblemHealth VIP Rx Saver (HMO)No referrals required. PCP needed.EmblemHealth VIP Part B Saver(HMO) (Optional dental and fitnessbenefit riders are available at alow cost)Deductibles: 0Copay: 0/ 25/ 90MOOP: 7,550Coinsurance: Up to 20%OON Coverage: NoService Area: NY 14 countyEH/CCI Reciprocity: YesMember may access CCI ChoiceNetwork for most services.Deductibles: 0Copay: 0/ 0/ 90MOOP: 7,550Coinsurance: Up to 20%OON Coverage: NoService Area: NY 14 countyEH/CCI Reciprocity: YesMembers may access CCI ChoiceNetwork for most services.Deductibles: 0Copay: 5/ 35/ 90MOOP: 7,550Coinsurance: Up to 20%Comprehensive dental and fitness benefitswith no maximumsOON Coverage: NoService Area: NY 18 countyEH/CCI Reciprocity: YesMembers may access CCI ChoiceNetwork for most services.Deductibles: 1,000 applies to some servicesCopay: 25/ 50/ 90MOOP: 7,550Coinsurance: Up to 20%OON Coverage: NoService Area: NY 24 countyEH/CCI Reciprocity: YesMay access CCI Choice Network formost services.Deductibles: 500 applies to some servicesCopay: 10- 30/ 45- 65/ 90MOOP: 7,550/OON combined 11,300Coinsurance: Up to 20%OON Coverage: Yes. Out-ofnetwork coverage allowed formany benefitsService Area: NY 24 countyEH/CCI Reciprocity: YesMembers may access CCI ChoiceNetwork for most services.Deductibles: 0Copay: 0/ 45/ 90MOOP: 7,550Coinsurance: Up to 20%OON Coverage: NoService Area: NY 14 countyEH/CCI Reciprocity: YesMembers may access CCI ChoiceNetwork for most services.Deductibles: 0Copay: 15/ 50/ 90MOOP: 6,700Coinsurance: Up to 20%OON Coverage: NoService Area: NY 12 countyEH/CCI Reciprocity: YesMembers may access CCI ChoiceNetwork for most services.Deductibles: 0Copay: 5/ 35/ 90MOOP: 7,550Coinsurance: Up to 20%OON Coverage: NoService Area: NY 9 countyEH/CCI Reciprocity: YesMembers may access CCI ChoiceNetwork for most services.No referrals required. PCP needed.EmblemHealth VIP Go (HMO-POS)No referrals required. PCP not required.EmblemHealth VIP Essential (HMO)No referrals required. PCP needed.EmblemHealth VIP Value (HMO)No referrals required. PCP needed.EmblemHealth VIP Passport (HMO)(Dental, Vision and Hearing Coverage,Fitness Program (SilverSneakers))No referrals required. PCP needed.12OON Coverage Service AreaEH/CCI Reciprocity
2021 Company2021 Provider Network/Program2021 Member Benefit PlanDeductible (Individual/Family)Copay (PCP/Specialist/ER)MOOP (Individual/Family) CoinsuranceHealth Insurance Plan ofGreater New York (HIP)(continued)Medicare: VIP Bold Network (continued)EmblemHealth VIP Passport NYC(HMO) (Dental, Vision and HearingCoverage, Fitness Program(Silver Sneakers))Deductibles: 0Copay: 10/ 40/ 90MOOP: 7,550Coinsurance: Up to 20%OON Coverage: NoService Area: NY 5 countyEH/CCI Reciprocity: YesMembers may access CCI ChoiceNetwork for most services.Deductibles: 0 (Providers must bill Medicaid)Copay: 0/ 0/20% Up to 90MOOP: 0- 7,550Coinsurance: 0Members with full Medicaid coverage. Providersmust bill COB to Medicaid or Medicaid plan andcannot balance bill members.OON Coverage: NoService Area: NY 14 countyEH/CCI Reciprocity: NoDeductibles: 0- 295Copay: 0/ 25/ 90MOOP: 0- 7,550Coinsurance: Up to 20%Individuals with full or partial Medicaid coverageor QMB. Providers must bill COB to Medicaid orMedicaid plan and cannot balance bill members.OON Coverage: NoService Area: NY 24 countyEH/CCI Reciprocity: NoDeductibles: 0Copay: 0/ 25/ 90MOOP: 0- 7,550Coinsurance: 20%OON Coverage: NoService Area: NY Medicare 4countyEH/CCI Reciprocity: NoDeductibles: 0Copay: 0/ 0/ 0MOOP: 0- 7,550Coinsurance: 0Individuals with full Medicaid coverage. Providersmust bill COB to Medicaid or Medicaid plan andcannot balance bill members.OON Coverage: NoService Area: NY Medicare 4countyEH/CCI Reciprocity: NoDeductibles: VariousCopay: VariousMOOP: Up to 8,150/ 16,300Coinsurance: Yes. InpatientOON Coverage: NoService Area: Na
Choice Network, QualCare Network, and First Health Network) The Bridge Program gives members access to multiple networks. Please refer to the member's ID card to see if the benefit plan accesses the Bridge Program. EmblemHealth EPO No PCP or referrals required. Deductibles: N/A Copay: Various MOOP: Up to 8,150/ 16,300 Coinsurance: None OON .
