Hub for Resources To Help You
Care for Our Medicare Members.

Please encourage any of your interested patients to visit our
Medicare Advantage plans page.

ConnectiCare and EmblemHealth Reciprocity for Network Access

Medicare members using ConnectiCare’s Medicare Choice Network (except members of dual eligible special needs plans (D-SNPs) and Passage plan members) can use EmblemHealth’s VIP Bold Network in New York. Some services are available through delegated networks and providers. These include behavioral health and chiropractic services (offered through Optum), vision care and eyewear (EyeMed Insight network), and dental (Healthplex).

Similarly, EmblemHealth’s Medicare Advantage members using VIP Prime and VIP Bold networks (except members of D-SNPs and VIP Reserve members) can use ConnectiCare’s Medicare Choice Network in Connecticut. Some services are only available through EmblemHealth’s delegated networks and providers. These include routine vision care and eyewear (EyeMed); behavioral health (Beacon Health Options); chiropractic, occupational, and physical therapy (Palladian); and dental (Healthplex).

See the 2022 Summary of Companies, Lines of Business, Networks & Benefit Plans for details on all of our Medicare plans, including primary care provider (PCP) and specialist copay amounts, deductibles, maximum out-of-pocket expenses, service area where the plan will be offered, and whether there is reciprocity between ConnectiCare and EmblemHealth networks.


ConnectiCare to Offer a New Medicare Plan in 2022

ConnectiCare Choice Dual Vista (HMO D-SNP) is a special needs plan for members with full Medicaid and Medicare that offers over-the-counter benefits, dental, vision, fitness, and hearing benefits in addition to Medicare-covered Part A and Part B services. Providers will need to coordinate the payment for covered services with the Connecticut Medicaid program and cannot balance bill members for any services without prior written notice.


Value-Based Insurance Design and New Benefits

The EmblemHealth family of companies is pleased to announce our participation in the CMS-approved Value-Based Insurance Design (VBID) Model. This program is designed to promote wellness and advance care planning to help ensure our Medicare members receive medical care that is consistent with their values, goals, and preferences. Plans participating in VBID include the following D-SNPs:  

  • ConnectiCare’s Choice Dual plan
  • EmblemHealth’s NY D-SNP (VIP Dual and VIP Dual Reserve) plans

Starting Jan. 1, 2022, as part of VBID, members of these dual plans can use their over-the-counter (OTC) allowance to buy healthy foods, fresh produce, and other groceries in participating pharmacies, retail locations, and online. This great benefit will help our vulnerable members with both Medicaid and Medicare to address food insecurity and will improve health outcomes. 

Many of our plans continue to offer OTC benefits and more plans will offer OTC benefits for the first time in 2022. For more information, please visit

Advance Directives

We remind all our providers to discuss the importance of having executed advance directives at every visit and ensure that completed directives are included in the member’s medical record. The purpose of these directives is to ensure our Medicare members receive medical care that is consistent with their values, goals, and preferences, and that they designate a health care agent for the time the member is unable to make decisions on their own. 

For helpful resources in coordinating care for ConnectiCare members, see Clinical Information and Coverage Guidelines; for EmblemHealth members, see Clinical Corner and the Utilization and Care Management chapter of the EmblemHealth Provider Manual


Health Survey for Medicare and Special Needs Plan Members

Medicare and special needs plan members will receive an automated call from ConnectiCare asking them to complete the health assessment (HA). Please encourage your patients to complete this survey. This will help our Care Management team to better address members' needs and direct them to appropriate care and support services.


Care Management Plans for D-SNP Members

Enrollees covered under our dual-eligible special needs plans (D-SNPs) have care plans on file with our Care Management Department. We make these care plans available to providers and are happy to share a copy. Please contact us to receive a copy for member(s) you are treating.

For ConnectiCare enrollees:
Phone: 800-390-3522


For EmblemHealth enrollees:
Phone: 800-447-0768


ConnectiCare Medicare Members – Optum/ProHEALTH Delegation

As of Oct. 1, 2021, providers caring for ConnectiCare Medicare Advantage members assigned or attributed to a primary care provider (PCP) who is part of the Optum Care Network of Connecticut IPA, which includes ProHealth Physicians, will need to contact Optum for preauthorization. Medicare Advantage members enrolled in ConnectiCare dual eligible special needs plans (D-SNPs) are excluded from this delegation and will continue to be managed by ConnectiCare. We will provide updates on our website as our agreement with Optum evolves.


Medicare Connect Concierge

Our Medicare members will have continued access to Medicare Connect Concierge in 2022. This is the one phone number members can call when they need help solving their health care needs. Medicare Connect Concierge can help:

  • Schedule a doctor’s appointment.
  • Coordinate preauthorizations.
  • Answer benefit questions.
  • Update mailing address.
  • Arrange transportation for members with Medicaid when covered.

To reach Medicare Connect Concierge, please call 800-224-2273 (TTY: 711), 8 a.m. to 8 p.m., seven days a week.

For helpful resources regarding claims for ConnectiCare members, see Billing and Claims and Our Policies; for EmblemHealth members, see Claims Corner and the Claims chapter of the EmblemHealth Provider Manual.

Contracted time frames in provider agreements will supersede time frames in this guide. For facility time frames, see the Provider Manual or applicable agreement.


Billing for Hospice Services

We remind our ConnectiCare providers that hospice services are not covered by the ConnectiCare Medicare Advantage plans and are instead covered by Original Medicare. Providers should submit claims for hospice care-related services to the terminal diagnosis directly to Original Medicare. ConnectiCare will continue to pay for care that is unrelated to the terminal condition or not covered by Original Medicare (like OTC benefit, routine dental, and vision).


Medicare/Medicaid and Qualified Medicare Beneficiaries (QMBs)

ConnectiCare offers several plans to members who have Medicaid (Choice Dual, Choice Dual Basic, Choice Dual Vista). In addition, many Qualified Medicare Beneficiaries (QMBs) enroll in our Medicare Advantage plans. Members with full Medicaid or QMBs are not responsible for paying any member cost-share for their plan-covered benefits.


Do Not Bill Dual Eligible and QMB Members for Any Medicaid Cost-Sharing

Medicare-Medicaid full dual eligible and QMB individuals who qualify to have their Medicare Parts A and B cost-share covered by their state Medicaid are not responsible for paying their Medicare Advantage plan cost-shares for Medicare-covered Part A and Part B services. Please do not balance bill these members.

Federal and State laws prohibit providers from balance billing Medicare-Medicaid dual eligible individuals for any Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments, if any, received for services provided to dual eligible individuals must be accepted as payment in full. To comply with this requirement, providers treating dual eligible and QMB individuals enrolled in ConnectiCare Medicare Advantage plans must do the following:

  • Verify plan and Medicaid/QMB eligibility prior to providing a service.
  • Do not bill the member or collect cost-sharing during the visit.
  • Bill Connecticut State Medicaid for the member’s cost-share.
  • Consider the claim as “paid in full,” regardless of the Medicaid or plan payment.
  • Notify member in writing if you do not accept Medicaid and member is not a QMB.

Federal law and provider contracts prohibit Medicare (ConnectiCare) providers from balance billing beneficiaries with Medicare and QMB, and Medicaid providers from balance billing dual eligibles. Providers may reference Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997.


For ConnectiCare members, you can contact the Connecticut Department of Social Services at 800-842-8440 or visit their website.


For EmblemHealth members, you can use eMedNY to check whether the member has full or partial Medicaid benefits. For more detail, see our EmblemHealth Medicare Advantage webpage or call the New York State eMedNY Call Center at 800-343-9000.


See Provider Appeals Process. Contracted time frames in provider agreements will supersede time frames in this guide.


See our Medicare Formularies for 2022.


New Cancer Drugs Require Preauthorization

As of Aug. 15, 2021, additional oncology-related chemotherapeutic drugs and supportive agents require preauthorization when delivered in the physician’s office, outpatient hospital, or ambulatory setting. See ConnectiCare’s Pharmacy Policies to determine where to submit the preauthorization request.


Help Members Stick With Their Medicine Regimen by Using Our Mail Order Pharmacy

Taking medicines as prescribed (medication adherence) is important for treating and controlling chronic conditions. Doctors play an important role in helping members stay adherent. Here are some steps as a doctor you can take to help members remain adherent:

  • Talk to members about the importance of taking their medicines on time as prescribed.
  • Remind members to track their refills and make an appointment for a new prescription before they run out.
  • Educate members on the side effects of the medicines and how to treat them.
  • Help identify and resolve barriers to members not taking their medicines as prescribed.
  • Consider prescribing 90-day supply prescriptions for maintenance medicines.
  • Consider prescribing generic drugs or less-expensive brand-name drugs on the member’s formulary if cost is a barrier.
  • Talk to the member about potential state drug assistance programs or pharmaceutical prescription assistance programs that may be able to help with the cost of medicines.
  • Educate members on pharmacy-based adherence tools that may help:
    • Medication synchronization (limit the member’s trip to the pharmacy for medications).
    • Compliance packing or blister packs.
    • Auto refills.
  • Encourage members to leverage available technologies (medication reminder apps on your phone or tablet, like the Express Scripts mobile app).


Starting Jan. 1, 2022, many of our plans will offer generic drugs (Tier 1 and Tier 2) for $0 copay for members who get their refills through Express Scripts Preferred Mail Order pharmacy. Please help your members stay adherent and save on their prescription drugs by recommending members switch to preferred mail order:

Express Scripts Home Delivery Service
PO Box 66577
St. Louis, MO 63166-6577


Call: 877-866-5828 (TTY: 711)

Fraud, Waste, and Abuse

EmblemHealth expects its contracted providers to prevent and address fraud, waste, and abuse and to meet their annual training requirement. To learn about this important topic, see Medicare Learning Network’s Web-Based Training:

  • Combating Medicare Parts C and D Fraud, Waste, & Abuse (Contact Hours 30 min.)
    Learn to spot fraud, waste, and abuse (FWA), identify methods to prevent FWA, identify how to report FWA, recognize how to correct FWA, and know potential consequences and penalties associated with violations.
  • Medicare Fraud & Abuse: Prevent, Detect, Report (Contact Hours 88 min.)
    Learn how to identify what Medicare considers fraud and abuse, provisions and penalties, prevention methods, and recognize how to report fraud and abuse.

If you have concerns about Compliance issues that you wish to bring to the attention of EmblemHealth/ ConnectiCare, please call toll free, 24/7, at 844-I-COMPLY (844-426-6759). You can also report online at

If you would specifically like to report concerns about fraud, waste, or abuse, please call 
888-4KO-FRAUD or send an email to the Special Investigations Unit by using this email address:

EmblemHealth/ConnectiCare will not retaliate against anyone who in good faith reports a compliance concern.


Required: SNP MOC Training

CMS requires Medicare providers to complete Special Needs Plan (SNP) Model of Care (MOC) training each year for each health plan’s MOC. Providers who care for ConnectiCare’s Medicare Advantage members with Choice Dual (HMO D-SNP) plans Training.


Cultural Competency Education

See these Cultural Competency Continuing Education and Resources to help you provide our members with care in the context of their cultural and linguistic needs.


Medicare Outpatient Observation Notice (MOON)

All hospitals and critical access hospitals are required by CMS to provide Medicare beneficiaries, including Medicare Advantage enrollees, with the OMB-approved Medicare Outpatient Observation Notice (MOON). The MOON and instructions for completing it are available on CMS’ website.


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