2025 Commercial Networks and Benefits Plan Changes
CLAIMS CORNER
Reimbursement Policies
CLINICAL CORNER
Preauthorization Updates
PHARMACY
Pharmacy Preauthorizations
MEDICAL POLICIES
Medical Policy Updates
TRAINING OPPORTUNITIES
Provider Portal Videos and Guides
Free Patient Management and ICD-10 Coding Webinars
Valuable Training Available
IN THE NEWS
Becker’s Payer Issues’ Podcast
IN EVERY ISSUE
WellSpark Success Story – Coaching Helped Lower A1C
EmblemHealth Neighborhood Care and ConnectiCare Centers
Keep Your Directory and Other Information Current
Consult EmblemHealth’s Online Provider Manual for Important Information
AUDIT REMINDERS
Episource Conducting Medical Record Requests
Feature Stories
Welcome 2025!
As we welcome 2025, we want to make sure our providers have a strong understanding of the plans we offer our members. Please review the following key resources we’ve prepared to give you and your patients an easier time navigating our plans.
First, our new 2025 Summary of Companies, Lines of Business, Networks, and Benefit Plans is a vital resource for helping your practice see which plans we are offering in 2025, and whether they are linked to a network or line of business for which you are contracted. We have also updated the following pages to give you the most updated information about our plans:
We look forward to partnering with you in 2025 as you deliver care to our members.
$15 Copay for CNY Senior Care
The $15 copayment for the EmblemHealth-GHI portion of the Senior Care Plan for City of New York (CNY) retirees resumed Jan. 1, 2025. As part of the benefit plan collectively bargained between the City and its unions, Senior Care members are now required to pay a $15 copay each time they use the health services listed below. Copays are limited to one copay per provider per date of service.
If you are a provider delivering the following services for Senior Care Plan members, you will need to collect the required $15 copay:
Primary care provider (PCP) office visits.
Specialist office visits.
Allergy testing/injections.
X-rays.
Laboratory tests.
Complex diagnostic and radiology services.
Radiation therapy.
Urgent care services.
Emergency care (professional component).
Mental health care (outpatient).
Substance use disorder services (outpatient).
Physical, occupational, and speech therapy.
Cardiac rehabilitation.
Pulmonary rehabilitation.
Chiropractic care.
Podiatry care.
Vision care.
Please note: Senior Care Plan members are responsible for the annual Medicare Part B deductible and $50 GHI Senior Care deductible.
New Guides for Quality Care
We are committed to making quality care available to our members. To help you and your billing staff correctly code your claims to include and exclude members from various measures, we are introducing two new resource guides:
Transitions of Care: Claims coding impacts quality scores. It is just as important to code your claims to exclude patients who do not meet a measure’s criteria as it is to include those who do.
Advanced Illness and Frailty Exclusions: Strong care coordination is vital for ensuring that patients successfully transition from an inpatient setting back to their home.
Coming Soon! Look for the 2025 versions of other quality guides and resources in a future edition.
February is American Heart Month
Hypertension is a leading risk factor for heart disease and stroke. During February, nationally recognized as American Heart Month, we take time to focus on conditions such as high blood pressure and other diseases and habits that affect heart health.
The American Heart Association recommends statins of moderate or high intensity for adults with clinical atherosclerotic cardiovascular disease to help reduce the risk of heart attack or stroke. See our website for information on statin therapy and more for patients with cardiovascular disease. You may also visit the Centers for Disease Control and Prevention for information on lifestyle choices and other ways that can help people can lead a longer, healthier life.
Medicare Updates
2025 Medicare Advantage Changes
To see which Medicare benefit plans we offer in 2025, see our updated Medicare Advantage pages:
If Medicare-Medicaid dual-eligible individuals have their Part A and Part B cost-share fully covered by their Medicaid plan or are Qualified Medicare Beneficiaries (QMB), they are not responsible for their Medicare Advantage cost-share for covered services. Please do not balance bill these members for any other costs. Any Medicare and Medicaid payments for services given to these members must be accepted as payment in full.
For EmblemHealth members, use ePACES to check whether the member has full or partial Medicaid benefits. For more details see EmblemHealth Medicare Advantage Plans.
2025 Commercial Networks and Benefits Plan Changes
Notable Changes for Diabetic Patients
Starting Jan. 1, 2025, there are two changes to be aware of that affect your patients with diabetes.
Upon issuance or renewal, prescription insulin will be covered with $0 cost-share. This applies to all New York commercial plans including Essential Plan, individual and family plans, and small and large group plans.
Copayments, coinsurance, and deductibles will be waived for members with a diabetes diagnosis who have an Essential Plan or an individual or family plan (excluding the Catastrophic plan) through the NY State of Health, for the following:
Primary care office visits for the diagnosis, management, and treatment of diabetes.
One office visit to perform an annual dilated retinal examination.
One office visit to perform an annual diabetic foot exam.
Diabetic self-management education services.
Laboratory procedures and tests for the diagnosis and management of diabetes.
Diabetic equipment and related supplies for the treatment of diabetes when prescribed by you or another provider who is legally authorized to prescribe including:
Acetone reagent strips.
Acetone reagent tablets.
Alcohol or peroxide by the pint.
Alcohol wipes.
All insulin preparations.
Automatic blood lance kit.
Cartridges for the visually impaired.
Diabetes data management systems.
Disposable insulin and pen cartridges.
Drawing-up devices for the visually impaired.
Equipment for use of the pump including batteries.
Glucagon for injection to increase blood glucose concentration.
Glucose acetone reagent strips.
Glucose kit.
Glucose monitor (with or without special features for visually impaired), control solutions, and strips for home glucose monitor.
Glucose reagent tape.
Glucose test or reagent strips.
Injection aides.
Injector (Busher) automatic.
Insulin cartridge delivery.
Insulin infusion devices.
Insulin pump.
Lancets.
Oral agents such as glucose tablets and gels.
Oral anti-diabetic agents used to reduce blood sugar levels.
Syringe with needle; sterile 1 cc box.
Urine testing products for glucose and ketones.
Additional supplies, as the New York State Commissioner of Health shall designate by regulation as appropriate for the treatment of diabetes.
Note: Cost-sharing may apply to other services provided during the same visit as diabetic services.
Notable Changes Pregnant and Postpartum Members
Beginning Jan. 1, 2025, pregnant and postpartum members who have individual and family plans (excluding the Catastrophic plan) through the NY State of Health will have copayments, coinsurance, and deductibles waived for:
Prescription drugs.
Urgent care services.
Outpatient mental health services.
Outpatient substance use services including partial hospitalization program services.
All services listed under preventive care.
All services and items listed under additional benefits, such as equipment and devices.
Outpatient services.
Professional services.
Cost-sharing will still apply to:
Inpatient hospital and birthing center services for delivery.
All inpatient services (e.g., hospital, rehabilitation, mental health/substance use disorder, and hospice).
Emergency care in a hospital.
Physician, nurse practitioner, and midwife services for delivery.
Ambulance services.
Pediatric vision and dental services for covered services.
Cost-sharing for all services has been waived for pregnant and postpartum Essential Plan members since April 4, 2024.
*Postpartum is defined as 12 months after delivery or other ending of pregnancy.
Claims Corner
Reimbursement Policies
Starting Jan. 1, 2025, we are introducing a new Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) Reimbursement Policy for both EmblemHealth and ConnectiCare
The following reimbursement policies have been updated. If the policy name does not have a company name shown, the policy applies to both EmblemHealth and ConnectiCare.
Laboratory Benefit Management policies are indicated by (LBM) after their names. See their revision histories for effective dates and applicable changes.
The Limitations section of the EmblemHealth Pain Management medical policy has been updated to reflect that genicular artery embolization for osteoarthritis pain of the knee is considered investigational.
Training Opportunities
Provider Portal Videos and Guides
If you need help navigating our provider portals, please see our videos, quick guides, and Frequently Asked Questions pages:
If you still have questions or need additional support, contact Provider Customer Service using the provider portal’s Message Center or live agent chat.
Free Patient Management and ICD-10 Coding Webinars
EmblemHealth works with Veradigm to offer free monthly webinars to help educate providers on best practices for the risk adjustment process. This includes accurate medical record documentation and claims coding to capture the complete health status of each patient.
The Veradigm webinars are held on Tuesdays and Thursdays; one in the morning and one in the afternoon. View topics and dates here. Click the Register button, then the Public Event List link, and search by webinar date or title of interest.
Here are the upcoming topics:
Jan. 28/30: 2025 Coding Updates: New Year, New Codes!
Feb. 25/27: The ABCs of Coding for Common Pediatric Conditions
EmblemHealth also works with Veradigm to promote risk adjustment and gap-closure education for primary care providers caring for EmblemHealth members enrolled in these products:
NY State of Health, The Official Health Plan Marketplace plans.
Medicare HMO.
Medicaid.
If you have any questions, or you would like to set up a private session for your practice, please email Veradigm at providerengagement@veradigm.com or call Veradigm's Customer Support team at 410-928-4218, option 7, from 8 a.m. to 8 p.m., Monday through Friday.
Abdou Bah shares his unique insights on equity-focused solutions to improve patient outcomes on a recent Becker's Healthcare podcast. Listen as Bah, EmblemHealth’s Senior Vice President of Medical Management and Chief Health Equity Officer, discusses strategies for controlling and managing ongoing health care costs. He also addresses the invisible barriers that prevent patients from accessing the care they need. Bah highlights the importance of equity-focused solutions to improve patient outcomes and reduce disparities in health care.
In Every Issue
WellSpark Success Story – Coaching Helped Lower A1C
WellSpark Health’s broad range of well-being resources are helping our members achieve positive behavioral and lifestyle changes. One member, a 45-year-old female living with diabetes, used the coaching services offered to create healthy habits and saw positive results. “My A1C went down and I’m feeling more and more motivated! I’ve been going outside for walks three to four times week. I’m impressing myself!”
To see which of our benefit plans offer WellSpark’s resources, review the 2025 Summary of Companies, Lines of Business, Networks & Benefit Plans. We ask that you encourage eligible members to sign in to the member portal to see what is available to them and to take advantage of the support offered.
Learn more about WellSpark resources that may be available to your EmblemHealth and ConnectiCare members:
EmblemHealth Neighborhood Care and ConnectiCare Centers
Our EmblemHealth Neighborhood Care locations and ConnectiCare Centers provide one-on-one customer support to help members understand their health plan, provide connection to community resources, and offer free health and wellness events to help the entire community learn healthy behaviors. Our virtual and on-demand events are available to you and all your patients. View locations and upcoming events for EmblemHealth Neighborhood Care and ConnectiCare Centers.
Keep Your Directory and Other Information Current
Let Us Know When Directory Information Changes
If a provider in your practice is leaving, please inform us as soon as possible. See how to submit data changes as required by our participation agreements for EmblemHealth and ConnectiCare.
If you participate with us under a delegated credentialing agreement, please have your administrator submit these changes.
Remember to review your CAQH application every 120 days and ensure you have authorized EmblemHealth as an eligible plan to access your CAQH information.
Consult EmblemHealth’s Online Provider Manual for Important Information
The EmblemHealth Provider Manual is a valuable online resource and an extension of your Provider Agreement. It applies to all EmblemHealth plans and includes details about your administrative responsibilities and contractual and regulatory obligations. You can also find information about best practices for interacting with our plans and how to help our members navigate their health care. A key resource is the Access & Availability Standards which set up the expected time frames for appointment availability, appointment wait times, and after hours coverage. You can find the EmblemHealth Provider Manual in the top navigation menu of our provider website, emblemhealth.com/providers.
Audit Reminders
Episource Conducting Medical Record Requests
EmblemHealth and ConnectiCare partner with Episource to conduct Medicare and NY State of Health (NYSOH)/Access Health CT chart reviews required by the Centers for Medicare & Medicaid Services (CMS).
The purpose of the chart review is to capture proper ICD-10 coding and identify any areas of improvement. Instances of improper coding will be identified during the review and shared with you. Proper coding helps us better serve our members.
If you receive a medical record request from Episource, please follow the instructions and send the requested documentation directly to Episource as required by your participating provider agreement. Medical record requests will occur throughout the year. We appreciate your prompt response to all Episource medical record requests.