Resource Hub to Help You
Care for Our Medicare Members.

Please encourage interested patients to view our  Medicare Advantage plans.

 

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), hearing aids (NationsHearing), and dental (Healthplex).

Similarly, EmblemHealth’s Medicare Advantage members using VIP Prime and VIP Bold networks (except members of D-SNPs and VIP Reserve Classic 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).

For details on all 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, see:

Value-Based Insurance Design and New Benefits

The EmblemHealth family of companies is pleased to share that we will renew participation with the CMS-approved Value-Based Insurance Design (VBID) Model for 2023 (based on our success in 2022). This program promotes 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, Choice Dual Basic, and Choice Dual Vista plans
  • EmblemHealth’s VIP Dual and VIP Dual Reserve plans

Starting Jan. 1, 2023, ConnectiCare will offer $0 copays on generic drugs in Tier 1, Tier 2, and new Tier 6 (Select Care Drugs) for the members enrolled in Choice Dual plans. Members pay no copayments for these drugs throughout the year, regardless of their level of extra help or the pharmacy they use. Members of ConnectiCare Choice Dual (HMO D-SNP) can continue to use their over-the-counter (OTC) allowance to buy healthy foods and fresh produce in participating pharmacies, retail locations, and online. This valuable benefit helps some of our members with both Medicaid and Medicare address food insecurity and improve their health outcomes.

Many of our plans continue to offer OTC benefits. For more information, please visit connecticare.com/OTC.

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. Choice Dual members can receive online help in completing draft advance directives and values statements.

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. Medicare members may also be eligible for ConnectiCare’s Member Rewards Program when completing their HA within the first 90 days of enrollment. D-SNP members may also be eligible for a reward when completing an annual HA.

ConnectiCare Member Rewards Program

Starting January 2023, we are pleased to offer the ConnectiCare Member Rewards Program to encourage Medicare members to receive primary care and key health screenings. Members will receive a reloadable rewards card ranging from $10 to $50 for each of the eligible services they complete (earning up to $275 per calendar). Please reach out to your patients to schedule these important preventive exams. To get the list of rewards members may have earned or can earn, members must sign in to the ConnectiCare member portal and follow prompts for Wellness Rewards. Once they register for the rewards, they will be able to get their rewards loaded as they earn them.

Claims must be received by Dec. 31 of the calendar year for the incentive to be paid. Members must receive and use the reward before Dec. 31, 2023. Only one reward can be earned for each health service shown in the table below.

Activity

Eligible Medicare Population​

Reward Trigger/Description

Incentive Frequency​

Incentive Per Activity

ConnectiCare Member Portal Registration

Members who have not yet registered for ConnectiCare Member Portal

Register for ConnectiCare Member portal in the calendar year.

Once a lifetime

$25

Reward Portal Registration​

All members​

Member registration within reward portal.

Once a lifetime​

$10​

Initial Medicare Annual Well Visit (AWV) (90 days) ​

All new members

Complete an Initial Medicare Annual Well Visit within 90 days of enrolling in the plan.

Once a lifetime

$50​

Annual Visit with Primary Care Provider (PCP) ​

All members​

Complete an office visit with PCP.

Once a year​

$25​

Initial Health Assessment (HA) (90 days) ​

All new members

Complete HA within 90 days of enrollment.

Once a year​

$25 ​

Annual Health Assessment​

D-SNP members only​

Complete HA within calendar year by D-SNP member.

Once a year​

$25​

Sign-Up for Paperless Materials

All members


Complete process to sign up for paperless materials.

Once a lifetime

$15

Colorectal Cancer Screening​

Medicare members, age 40+

Complete a fecal occult blood test (FOBT), flexible sigmoidoscopy, colonoscopy, FIT DNA test, or colonography.

Once a year​

$25 ​

Mammogram Exam​

Female members age 40+

Complete a mammogram.

Once every two years​

$50 ​

Diabetes A1c Test​

Diabetic members, ages 18+

Complete an A1c blood test.

Once a year​

$25 ​

Diabetes Eye Exam​

Diabetic members, ages 18+

Complete a retinal or dilated eye exam by an eye care professional.

Once a year​

$25 ​

Kidney Health Evaluation

Diabetic members, ages 18+

Complete an estimated glomerular filtration rate (eGFR) test and a urine albumin-creative ratio.

Once a year

$25

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:
Email: hmpreferrals@connecticare.com
Phone: 800-390-3522

For EmblemHealth enrollees:
Email: complexcasemgmt@emblemhealth.com
Phone: 800-447-0768

ConnectiCare Medicare Members – Optum/ProHEALTH Delegation

As of April 1, 2023, 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 submit claims to Optum for payment. 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. The new claims address is on the ID cards we will send members before April. 

Medicare Connect Concierge

Our Medicare members will have continued support from Medicare Connect Concierge in 2023. 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.

Clinic Visit Policy

If you provide clinic visits to our Medicare members, and are owned and operated by a hospital, please review our clinic visit policy and correct coding requirements. ConnectiCare will monitor compliance with this policy and may recoup payment from providers for not following it.

Reminder: For services rendered in place of service (POS) 19, off-campus hospital-owned location, claims billed with the G0463 clinic code should include the Modifier PO.

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.

Formularies

See our Medicare Formularies for 2023.

For 2023, we added a new Select Care Drugs tier on most of our plan formularies. The drugs on this tier are available to members with Part D coverage without a deductible at $0 copay and are covered through the coverage gap. Select Care Drugs include maintenance drugs for diabetes, hypertension, and hyperlipidemia.

As required by the Inflation Reduction Act of 2022, Medicare members with prescription drug coverage will pay no deductible and no more than $35 copay for a one-month supply of covered insulins (or less for members receiving extra help), and $0 copay for most Part D vaccines in both preferred and standard pharmacies in our network.

Help Members Stick to Their Medicine Routine 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:
    • Medicine synchronization (limit the member’s trip to the pharmacy for medicines).
    • Compliance packing or blister packs.
    • Auto refills.
  • Encourage members to leverage available technologies (medicine reminder apps on your phone or tablet, like the Express Scripts mobile app).

 

Many of our plans, including D-SNPs, 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

or

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 emblemhealth.alertline.com.

If you would specifically like to report concerns about fraud, waste, or abuse, please call 
888-4KO-FRAUD (888-456-3728) or send an email to the Special Investigations Unit by using this email address: kofraud@EmblemHealth.com.

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, Choice Dual Basic, and Choice Dual Vista (HMO D-SNP) plans must complete this training.

Notices are sent to providers months in advance of the due date. However, some providers have still not completed their training. Providers who do not complete the 2022 training by Nov. 30, 2022, will be referred to the ConnectiCare Credentialing Committee.

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.

 

EMB_PR_WEB_60082_2023Mcare 11/22

Beginning Jan. 1, 2023, EmblemHealth and ConnectiCare Special Needs Plan (SNP) member benefits will include coverage for face-to-face encounters between members and providers for the delivery of health care, care management, or care coordination services. Face-to-face encounters must occur, as practical and with the member’s consent, on at least an annual basis beginning within the first 12 months of SNP enrollment.

A face-to-face encounter must be either in-person or through a virtual (visual, real-time, and interactive) encounter. Medicare providers caring for SNP members will be required to obtain the member’s consent for face-to-face virtual encounters.

When a provider reaches out to conduct a face-to-face virtual encounter with a SNP member, consent must be obtained from the SNP member prior to, or when scheduling, the encounter. At the time of the scheduled virtual encounter, the provider must inform the member on the purpose and intended outcomes of the visit.

At least annually, EmblemHealth and ConnectiCare care managers will review member usage history data to identify members who require outreach and face-to-face scheduling. All data collected will be reviewed with providers during the interdisciplinary care team (ICT) meetings.

Additional Requirements

As a reminder, when caring for SNP members, providers must also:

Below are some additional resources to help you manage the health of your SNP patients: