- EmblemHealth VIP Passport (HMO) 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.
- EmblemHealth VIP Rx Saver EmblemHealth VIP Go EmblemHealth VIP Part B Saver EmblemHealth VIP Dual (Dual Eligible SNP) Primary Doctor Visit: $5 copay per visit: $10 copay per visit (in-network) $10-100 copay per visit (out-of-network) $25 copay per visit: $0 copay: Specialist Visit: $35 copay per visit.
The GHI Comprehensive Benefits Plan (CBP) gives you the freedom to choose in-network or out-of-network doctors. You can see any network doctor without a referral. In most cases, when you see a network doctor, your cost will just be a copay. Using an Out-of-Network Health Care Professional.
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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.
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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) |
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 |
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 |
|---|
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
Emblem Health Payer Id In Nyc
| 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 |
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
| 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.
Date Issued: 1/23/2019
Last Revised: 1/1/2021
The Affordable Care Act (ACA) requires non-grandfathered health plans in the individual and group markets to cover certain preventive/screening care services received from in-network providers, in full, without member cost-sharing (i.e., without copay, deductible and/or coinsurance). In general, eligible services include preventive/screening care services which have received an “A” or “B” rating from the United States Preventive Services Task Force (USPSTF) or have been set forth in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA), as well as immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics “Bright Futures” guidelines. For additional information about these guidelines and recommendation, please click on the link(s) below:
Instructions to Providers for Coding Claims for ACA Mandated Preventive Care Services:
In order to help EmblemHealth properly identify and accurately process claims for ACA-mandated preventive/screening care services, providers are asked to follow the coding guidelines and instructions below when submitting claims for these services to EmblemHealth.
I) Annual Preventive Care Medical Evaluation
A. Preventive Medicine Visits should be reported with the appropriate patient age and gender specific procedure code from the 99381 through 99397 AMA CPT Coderange.
B. The associated preventive/screening ICD-10 diagnosis code (e.g., Z00.00, Z00.01) should be entered into the first claim diagnosisfield.
II) Preventive/Screening Colonoscopy
A. Services provided by the in-network endoscopist, anesthesiologist and pathologist associated with an in-network preventive/screening colonoscopy are eligible for coverage without membercost-sharing.
B. With the understanding that a preventive/screening colonoscopy may become diagnostic or therapeutic due to unforeseen findings, the AMA CPT Code that most accurately represents the procedure performed should be reported.
C. The appropriate preventive/screening ICD-10 diagnosis code (e.g., Z12.11) should be entered into the first claim diagnosisfield.
D. Anesthesia services should be reported with any specific findings entered into the first claim diagnosis field. The second claim diagnosis code should be reported with the appropriate preventive/screening ICD diagnosis code (e.g., Z12.11). CPT code 00812 MUSTbe used if the screening colonoscopy becomes a diagnostic colonoscopy and/or if the screening colonoscopy is stopped due to poor preparation and a sigmoidoscopy is done. While modifier 33 may be reported along with the anesthesia CPT code, it is not used in making preventive care benefit determinations; EmblemHealth considers the procedure and diagnosis codes when determining whether preventive care benefits apply. Pathology services should be reported with the appropriate screening ICD diagnosis code (e.g., Z12.11) entered into the first claim diagnosisfield.
III) All Other Preventive/Screening Services (e.g., Screening Mammography, LipidProfile)
Emblem Health Payer Id 13551
A. Eligible preventive screening services should be reported with the appropriate screening ICD diagnosis code(e.g., Z12.39, Z00.00, and Z00.01) and entered into the first claim diagnosisfield.
EmblemHealth Preventive Care/Screening Services Table:
Emblem Health Payments
Important Notes |
|
Emblemhealth Covid Copay
For more information, view the EmblemHealth Preventive Care/Screening Services table.