What does Medicaid Managed Care cover?
In this section, we explain the benefits HIP covers for all members, the ones HIP covers for some members, the ones that are available from both HIP and Medicaid, and the ones that are only covered by Medicaid.
Benefits covered for all HIP Medicaid Managed Care members.
Learn what the plan offers and how it can benefit you.
Routine and Preventive Medical Care
This type of care helps prevent health problems. It also helps find problems before they get serious. Care includes routine and sick visits to your PCP and other HIP network doctors for:
- Regular checkups
- Well-baby and well-child care (shots, checkups and developmental screenings)
- Eye and hearing exams
- Eyeglasses and other medically needed vision aids
- Regular gynecological exams
- Breast exams (including mammography)
- Allergy testing and treatment
- HIV counseling and testing services
- Smoking cessation counseling
- Four fluoride varnish applications (for children under 7 years of age)
- Lab work
- Specialty care
- Prenatal care
- Childbirth classes
- Doctor/midwife services
- Hospital delivery
- Newborn nursery care
We cover pharmacy benefit services for all our Medicaid managed care members. You must use our network pharmacies to fill all of your prescriptions and any covered over-the-counter medications, diabetic supplies, select durable medical equipment and medical supplies.
We offer a large network of well-known pharmacies, as well as many independent pharmacies. Ask your pharmacy if they are a network pharmacy. If they are, you can continue to use that pharmacy. If not, you will need to switch to a pharmacy that is in our network. This is easy to do; and it's important for getting your prescriptions filled in a timely manner and for avoiding out-of-pocket costs. To search for a list of participating pharmacies, click here.
Your Member ID Card
Please make sure to use your member ID Card when filling a prescription or obtaining other covered pharmacy benefits at a network pharmacy. It has information that your pharmacy needs to process your prescriptions. To locate a network pharmacy near you, go to www.emblemhealth.com/ssp-rx and click on “Pharmacy Locator.” You can also call our Pharmacy Customer Service department at 1-888-447-7364.
Our Drug Formulary
Our formulary is a list of medications that network doctors and other medical experts have approved for treating disease and maintaining the health of our Medicaid members. The main purpose of the formulary is to support the use of safe, effective and affordable drugs and treatments while providing our Medicaid members with quality care. Your doctors will prescribe medications listed on the formulary for your benefit plan unless there is a medical need to prescribe a drug that is not on the list. To see a list of drugs covered for Medicaid members, click here.
Home delivery of a new prescription
You may get home delivery of your maintenance drugs through our mail order pharmacy partner Express Scripts, Inc. (ESI). Maintenance drugs are used to treat chronic conditions and are usually prescribed in quantities greater than 30-day supplies. All you need to do is get a new written prescription from your doctor or other licensed health care provider, and mail it to ESI along with the completed order form. You may request an ESI order form to be mailed to you by calling our Pharmacy Customer Service at 1-888-447-7364. Mail the form and the original prescription(s) along with the required copayment to ESI as directed on the form. You may include multiple new prescriptions in your order.
If you prefer, your doctor or other licensed health care professional can assist you. You can bring your order form to them and they can fax it to ESI directly with your prescription. Or they can submit your prescription via the Web. In both cases, they must have your member ID number. Only doctors or other licensed health care providers may submit new prescriptions via fax or Web.
To use the Home Delivery tool, go to myEmblemHealth and register if you haven't already. After you sign in, click on “Pharmacy Services” and then select “Home Delivery”. You will be able to do things like check order status and request refills to existing prescriptions. You will need to register the first time you use the tool, and you will need your member ID to create an account. You or your doctor will still need to send ESI the actual written prescription when using the online option. Please allow 7 to 10 days for delivery from the day ESI receives the prescription(s) to receive your home delivery.
Check on the status of a home delivery prescription order
You can easily check the status of your order via the EmblemHealth/Express Scripts pharmacy benefits tool on this page. You will need to sign in using your member ID and password. You can also call ESI at 1-877-866-4165. If you have a hearing or speech impairment, and use a TDD, you can call 1-800-899-2114. You will need your member ID number and your prescription number(s) to access this information.
Specialty drugs are usually injectable, oral or inhaled drugs. They are used to treat chronic conditions such as multiple sclerosis, growth deficiencies, hepatitis C and cancer. They also require special storage and/or handling. You must have your specialty drug prescriptions filled through our select Specialty Pharmacy program. You cannot fill specialty drug prescriptions at a network retail pharmacy or through the ESI mail order program. Your doctor or other licensed health care provider will submit the prescription through our Specialty Pharmacy program. And similar to home delivery, your specialty prescriptions will be filled and sent directly to you at home.
For questions, please call EmblemHealth's Specialty Pharmacy program at 1-888-447-0295.
Medicaid Managed care pharmacy benefit includes:
- Prescription drugs
- Over-the-counter medicines (OTC)
- Insulin and diabetic supplies
- Smoking cessation agents, including OTC products
- Hearing aid batteries
- Enteral formula
- Emergency Contraception (six per calendar year)
- Medical and surgical supplies
This type of care includes:
- Inpatient care
- Outpatient care
- Emergency care
- Lab work and other tests
- Nursing services
- Inpatient and outpatient surgery, including dental surgery
- Inpatient detoxification services
- Emergency care services are procedures, treatments or services needed to evaluate or stabilize an emergency condition.
- Care you need after you have received emergency care to make sure you remain in stable condition. Depending on the need, you may be treated in the emergency room, in an inpatient hospital room, or in another setting. These are called Post Stabilization Services.
This type of care includes but is not limited to medically needed care:
- Occupational, physical and speech therapy – Limited to twenty (20) visits per therapy per calendar year. Children under age 21, members that have a developmental disability as determined by the Office for People with Developmental Disabilities and members that have a traumatic brain injury do not have a limit on the number of visits for these services.
- Durable medical equipment (DME), including hearing aids, artificial limbs and orthotics
- Renal and Hemodialysis
- HIV/AIDS treatment services
- Midwife services
- Cardiac rehabilitation
- Outpatient detoxification services.
- Other covered services as medically needed
Home Health Care
These services are generally provided so that you do not have to stay in a hospital. Your doctor or case manager must agree that your medical needs can be met at home with this help, and request prior approval from you plan. Services also include:
- One medically necessary post partum home health visit, additional visits as medically necessary for high-risk women.
- At least 2 visits to high-risk infants. (newborns)
- Other home health care visits as needed and ordered by your PCP/specialist.
Personal Care Services (PCS)
- Must be medically needed and arranged by us
- Provide some or total assistance with personal hygiene, dressing and feeding and assist in preparing meals and housekeeping.
Personal Emergency Response System (PERS) Services
PERS is an in-home health emergency alert system available only to members receiving home health and/or personal care services.
This type of care includes:
- Services of an ophthalmic dispenser, ophthalmologist and optometrist.
- Low-vision eye exams and vision aids ordered by a network doctor (every two years, but more often if medically needed).
- Medically needed contact lenses.
- Eyeglasses (a new pair of Medicaid-approved frames every two years, or more often if medically needed). Progressive lenses are not covered.
- Scratch-resistant, break-resistant and polycarbonate eyeglass lenses.
- Artificial eyes (when ordered by a HIP network doctor).
- Replacement of lost or destroyed glasses, including repairs, when medically needed.
- Specialist referrals for eye diseases and defects.
- Members diagnosed with diabetes may self-refer for a dilated eye (retinal) examination once in any 12-month period.
Family Planning Services
These services include:
- Birth control
- Medically necessary abortions
- Screening for anemia, cervical cancer, sexually transmitted diseases, hypertension, breast disease, pelvic abnormality and pregnancy
You can get these services from HIP network OB/GYN doctors. Or, you can use your Medicaid card if you want to go to doctors or clinics out of our network. Either way, no approval or referral from a HIP network doctor is needed to get these services. Just make an appointment.
Residential Health Care Facility Care (Nursing Home Services)
When a temporary stay is ordered by your network doctor and approved by your health plan, services include:
- Medical supervision
- 24-hour nursing care
- Assistance with activities of daily living
- Physical and occupational therapy and speech language pathology
When your local Department of Social Services (DSS) determines that a stay in a nursing home is permanent, you will be disenrolled from Medicaid managed care and get your care through regular Medicaid.
Emergency Transportation Services
These services include land and air ambulance transportation. Call 911 for emergency transportation.
These services are covered for members under 21 years of age who are receiving hospice services from regular Medicaid.
Nutritional Counseling and Assessment
Includes assessment and nutritional counseling sessions with a network registered dietician. The result of the initial assessment will determine the number of sessions required. Both the assessment and the counseling sessions require a referral by your primary care physician. Members who particularly benefit from these services include those who are pregnant; newly diagnosed or living with diabetes, heart disease and/or kidney disease; have an eating disorder or other digestive problems; or have been diagnosed as overweight or obese by their physician.
Case Management Services
These services include the coordination of benefits and services for members that have complex or serious diseases or conditions. Members may be assigned to a case management nurse who will work with you and your doctors to ensure that you get the care and services you need, when you need them. You could be in the program for weeks, months or years depending on your condition and circumstances. The purpose of case management is to achieve the best health care outcome.
Social Work Services
These services include help in getting any community services you may need.
Experimental and Investigational Treatments
These types of treatments are covered on a case-by-case basis according to New York State law.
These services include any HIP-covered services ordered by a judge.
Benefits HIP Covers for Some Members.
HIP covers the following services for some, but not all, members. Check to see if we cover these benefits for you or in the county where you get Medicaid:
Nonemergency Transportation Services for New York City (All Five Boroughs) Members Only
We cover the following forms of transportation to and from appointments for services covered by HIP and Medicaid, but only for our New York City members:
- Public bus and train trips. No prior approval is needed. At the time of the appointment, you will be reimbursed for your round-trip fare by the network medical center, dentist, PCP or OB/GYN with whom you have the appointment or who is making a referral.
- Taxi and van trips. Your network doctor (or dentist) must approve taxi or van transportation based on medical necessity. Your doctor will fill out the medical necessity form and fax it to the number on the form. You can then call our Customer Service Department at 1-800-447-8255 to reach a customer services representative who will provide you with the phone number of a network taxi or van service so that you can schedule your trip. The network taxi or van service will bill us for the trip. If we give you permission to use a non network service, you must pay for the taxi directly and we will tell you how to get reimbursed.
- Ambulette trips. When medically needed, prior approval is required. To obtain prior approval, your doctor (or dentist) must call us at 1-866-447-9717. Once the trip is approved, we will arrange the trip with the ambulette company. The ambulette company will bill us for the trip.
Please note: Network taxi and van services are only authorized to transport to and from medical services.
When you need an attendant to go with you to a medical appointment, the attendant's transportation is covered. When your child is the member of the plan, transportation is covered for you or someone else who takes him/her to the appointment.
Members in Nassau, Suffolk, and Westchester counties should refer to the section Benefits Using Your Medicaid Card Only of your handbook for instructions on how to obtain nonemergency services.
To learn more about your HIP covered transportation benefits and the rules we have for them, please call 1-800-447-8255, Monday through Friday, from 8 am to 6 pm.
Mental Health and Chemical Dependence Care (for non-SSI and non-MA-SSI members only)
We cover these services for non SSI and non MA-SSI members only. Coverage includes:
For members in receipt of SSI and MA-SSI benefits (members 65 years of age or older and those who are disabled), we cover detoxification services on an inpatient or outpatient basis. All other inpatient and outpatient mental health and chemical dependence services are covered by general Medicaid and you must use providers that will accept your Medicaid Card.
This type of care is covered for all children under 21 years of age and members (regardless of age) with physical conditions that pose a hazard due to the presence of localized illness, injury or symptoms involving the foot, or when performed as a necessary and integral part of otherwise covered services such as the diagnosis and treatment of diabetes, ulcers and infections.
Services include routine hygienic care of the feet, the treatment of corns and calluses, the trimming of nails, and other hygienic care such as cleaning or soaking feet.
Benefits you can get from HIP or through regular Medicaid with your Medicaid card.
You can choose where to get the following services — from a HIP network doctor, or any doctor who will accept your Medicaid card — without a referral:
You can get these services from HIP network doctors, or you can get them from any doctor or clinic that will take your Medicaid card. No approval or referral from network doctors is needed.
All members must use HIP network doctors for hysterectomies, routine gynecological exams, prenatal care, delivery and postpartum (after-delivery) care.
HIV Counseling and Testing
You can get these services from HIP network providers, or you can get them from any doctor or clinic that will take your Medicaid card if they are part of a family planning visit.
TB Diagnosis and Treatment (Tuberculosis)
You can get these services from HIP network providers, or you can get them from a county public health clinic.
Benefits using your Medicaid card only.
The following services are covered by Medicaid, but not HIP. You can get these services from any provider who will take your Medicaid card:
Nonemergency Transportation Services (Nassau, Suffolk and Westchester County members only)
We do not cover nonemergency rides for our Nassau, Suffolk or Westchester County members. These members must call:
- Nassau County members: Nassau County Department of Social Services at 1-516-433-1660.
- Suffolk County member: Suffolk County Department of Social Services at 1-866-952-1564.
- Westchester County members: Medical Answering Services (MAS) at 1-866-883-7865.
If possible, you or your provider should call the above numbers at least three days prior to your medical appointment and give the representative:
- Your Medicaid ID number (for example, AB12345C).
- Appointment date and time.
- Address where your appointment will take place.
- Your doctor's name.
Non-emergency medical transportation includes: personal vehicle, bus, taxi, ambulette and public transportation. If you have an emergency and need an ambulance, you must call 911.
Mental Health Services
- Intensive psychiatric rehabilitation treatment
- Day and continuing day treatment
- Intensive case management
- Depression disease management
- Partial hospital care
- Rehab services to those in community homes or in family-based treatment
- Clinic services for children with a diagnosis of Serious Emotional Disturbance (SED) at mental health clinics certified by the State Office of Mental Health
- All covered mental health services for members who receive SSI or who are certified blind or disabled are available by using their Medicaid benefit card
Mental Retardation and Developmental Disabilities Services
- Long-term therapies
- Day treatment
- Housing services
- Medicaid service coordination (MSC) program
- Home and community-based waiver program services
- Medical model (Care-at-Home) waiver services
Chemical Dependence (Alcohol and Substance Abuse) Services
- Methadone treatment
- Outpatient substance abuse treatment
- Outpatient alcohol rehabilitation
- Outpatient alcohol clinic services
- Outpatient chemical dependence for youth programs
- Chemical dependence (including alcohol and substance abuse) services ordered by the LDSS
All covered alcohol and substance abuse services (except detox) are available for people who receive SSI or who are certified blind or disabled by using their Medicaid benefit card. Detox services are available using your HIP member ID card.
Other services you can get using your Medicaid card
- Preschool and school services programs (early intervention)
- Early Start programs
- Comprehensive Medicaid case management
- Directly Observed Therapy (DOT) for tuberculosis
- Adult day treatment for persons with HIV
- Long-term health care
- Hospice services