Frequently Asked Questions
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- Nathaniel McBride
- 5 years ago
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1 The Healthfirst Essential Plan 1. What is the Healthfirst Essential Plan? The Healthfirst Essential Plan (EP) provides federally subsidized, comprehensive health coverage for certain individuals previously eligible for Medicaid and Qualified Health Plans. The Healthfirst Essential Plan allows for new enrollment at any point throughout the year and improved continuity of care for people with income fluctuating above and below Medicaid eligibility levels. For more information, eligible individuals may call (TTY ) Monday to Friday, 9am 8pm, or visit 2. Who is eligible for the Healthfirst Essential Plan? Adult citizens or legal residents (ages 19 64) with incomes between $16,643 and $24,120. Adult legal residents (ages 21 64) with incomes at or below $16,643 and who are ineligible for Medicaid due to immigration status (i.e., Aliessa Population 1 ). The following individuals are NOT eligible for the Healthfirst Essential Plan: Individuals below age 19 and over age 65 Individuals in need of Long Term Care (Personal Care Services) Individuals in Custodial Nursing Home placement Individuals receiving Supplemental Security Income (SSI) benefits A member must report to the NYSOH any changes that could affect their eligibility. This requirement is especially relevant to EP members who become pregnant; they must report this life event to NYSOH if they are to obtain coverage for their unborn child. 3. When can people enroll in the Healthfirst Essential Plan? Individuals may enroll in the Healthfirst Essential Plan throughout the year (similar to Medicaid and Child Health Plus) by calling (TTY ), Monday to Friday, 9am 8pm, or by visiting 1 The term Aliessa Population refers to New York residents who are ineligible for Medicaid because they have not yet met the five-year residency requirement. 1
2 4. How is the Healthfirst Essential Plan different from Healthfirst Leaf Plans or Medicaid? The Healthfirst Essential Plan offers most of the same essential health benefits found within the Healthfirst Leaf Plans. These include: Ambulatory Patient Services Emergency Services Hospitalization Behavioral Health and Substance Use Disorder Services Treatment Prescription Drugs Rehab and Skill Development Services and Devices Laboratory Services Preventive, Wellness, and Chronic-Disease Management Maternity and Newborn Care (Mothers must go to the NYSOH website to report changes and gain coverage for newborn care.) Please Note: Essential Plan eligibility is limited to adults; therefore, pediatric dental and vision services are not covered under The Essential Plan. Legal residents who are ineligible for Medicaid due to immigration status (i.e., Aliessa Population), with incomes below $16,643 (Essential Plan 3 and Essential Plan 4), have additional benefits. These are: Non-Emergency Medical Transportation Non-Prescription Drugs Orthotic Devices, Orthopedic Footwear Adult Vision Care Adult Dental Care The Essential Plan does not include Personal Care Assistance benefits. 5. What are the member deductibles and monthly premiums? There are no deductibles for Healthfirst Essential Plan members. Healthfirst Essential Plan monthly premiums are based upon a member s income and residency status. Detailed information on copays and coinsurance for Essential Plans 1 to 4 can be found by going to our website at org/health-insurance/healthfirst-essential-plans and selecting the appropriate plan. 6. How can I confirm that I m a participating provider in the Healthfirst Essential Plan network? Providers can verify their participation in the Healthfirst Essential Plan network by reviewing their record in our online Provider Directory at 2
3 7. How can I become a participating provider in the Healthfirst Essential Plan network? For more information on how to become a participating provider in the Healthfirst Essential Plan network, please contact your Healthfirst Network Management Representative or call Healthfirst Provider Services at , Monday to Friday, 8:30am 5:30pm. 8. Are referrals required for Essential Plan members to see specialists? No, Essential Plan members do not require referrals for any in-network services. 9. How can I verify eligibility of an Essential Plan member? Member eligibility can be verified online, in the Healthfirst Provider Portal at by using the current Essential Plan member ID number or searching by the member name and date of birth. Providers may also verify member eligibility by calling Healthfirst Provider Services at with the member name and date of birth or Essential Plan member ID number. Essential Plan members may have had coverage under another plan before enrolling in The Essential Plan, so it is important to always check eligibility using their Essential Plan member ID, or the member name and date of birth, to ensure the most current eligibility is verified. 10. If I can t find a member s eligibility in the Provider Portal, or if there are multiple ID numbers for a member reflected, what should I do? If a member is not found or if there are multiple member ID numbers listed for a member when checking eligibility, providers should check each ID for current eligibility or call Healthfirst Provider Services at for assistance. 11. If a member seeks out-of-network coverage, are they covered under the Healthfirst Essential Plan? No, an Essential Plan member is not covered for out-of-network care except in situations when emergency care is needed. 12. What steps can my practice take to ensure proper billing of services? To ensure that members are accurately billed, provider practice staff should perform the following verifications before billing Healthfirst Essential Plan members for services rendered: Check member eligibility and Essential Plan coverage effective dates Verify MOOP status Verify and collect copayment amounts 13. Are a member s maximum out-of-pocket (MOOP) cost and eligibility status identified on the Healthfirst Provider Portal? Yes, a Healthfirst Essential Plan member s MOOP, coverage effective date, and copayment amounts can all be verified on the secure Healthfirst Provider Portal at 3
4 14. How are pharmacy benefits under the Healthfirst Essential Plan different from those under other Healthfirst plans? The prescription drug benefit for the Healthfirst Essential Plans uses the same formulary, network, and specialty medication management as our Healthfirst Leaf Plans. These can be referenced in the formularies on our website at For specialty medications, providers must contact CVS Caremark Specialty at Is the hospital network for the Healthfirst Essential Plan the same as for other Healthfirst plans? Healthfirst offers an extensive provider network similar to the Healthfirst Medicaid and Leaf Plan networks. To check whether a hospital is participating in the Healthfirst Essential Plan, visit our online Provider Directory at and select Healthfirst Essential Plan to view network hospitals and other care providers. 16. What are the authorization requirements for the Healthfirst Essential Plan? Providers should contact the Healthfirst Utilization Management department at to obtain authorization. Other than for emergency care, providers must obtain prior authorization for acute inpatient admissions, certain ancillary services, and all out-of-network care. 17. Do Healthfirst Essential Plan members have a unique member ID card? Yes, Healthfirst Essential Plan members have a member ID card specific to the Essential Plan that they are enrolled in. Depending on the member s income and eligibility, he/she will be enrolled in Essential Plan 1, Essential Plan 2, Essential Plan 3, or Essential Plan Is an Essential Plan member s copayment identified on their member ID card? Is it identified on the Healthfirst Provider Portal? Yes, this is listed on both. Healthfirst Essential Plan members copayments are identified on member ID cards for the following services: PCP Office Visits Emergency Room Specialist Office Visits Inpatient Hospital Urgent Care Prescriptions (Tier 1/Tier 2/Tier 3) Vision/Dental Office Visits (for members who purchased a vision and dental plan) 4
5 Member copay information is also available on the secure Healthfirst Provider Portal when checking eligibility. Below are sample images of Healthfirst Essential Plan member ID cards. Member Name Member ID: Essential Plan 1 Rx Bin: Rx PCN: ADV Rx Group: RX1108 Individual Deductible: $0 Copay PCP Office Visit: $15 Specialist Office Visit: $25 Urgent Care: $25 Emergency Room: $75 Inpatient Hospital: $150 Prescriptions: $6/$15/$30 Visit MyHFNY.org to find a doctor, view your benefits, pay your monthly premium and more! EP15_02 For Members Website healthfirst.org Member Services TTY: To avoid penalties and ensure timely care management, your provider must call Healthfirst at least 24 hours in advance for any services requiring prior authorization and within 48 hours of emergency admissions. Failure to call may reduce your benefits. Services requiring prior authorization are described in your benefit materials. This card does not guarantee coverage. You must comply with all terms and conditions of the plan. HFQEP17 For Providers / Medical Eligibility Prior Authorization Electronic Claims Payer ID Medical Claims Address Healthfirst Claims Department P.O. Box Lake Mary, FL Pharmacy Help Desk: Claims: CVS Caremark P.O. Box Phoenix, AZ Member Name Member ID: Essential Plan 1 Vision/Dental Rx Bin: Rx PCN: ADV Rx Group: RX1108 Individual Deductible: $0 Copay PCP Office Visit: $15 Specialist Office Visit: $25 Vision/Dental Office Visit: $15 Urgent Care: $25 Emergency Room: $75 Inpatient Hospital: $150 Prescriptions: $6/$15/$30 Visit MyHFNY.org to find a doctor, view your benefits, pay your monthly premium and more! EP15_02 For Members Website healthfirst.org Member Services TTY: To avoid penalties and ensure timely care management, your provider must call Healthfirst at least 24 hours in advance for any services requiring prior authorization and within 48 hours of emergency admissions. Failure to call may reduce your benefits. Services requiring prior authorization are described in your benefit materials. This card does not guarantee coverage. You must comply with all terms and conditions of the plan. HFQEP17 For Providers / Medical Eligibility Prior Authorization Electronic Claims Payer ID Medical Claims Address Healthfirst Claims Department P.O. Box Lake Mary, FL Pharmacy Help Desk: Claims: CVS Caremark P.O. Box Phoenix, AZ Do Healthfirst Essential Plan members have a grace period? Yes, Healthfirst Essential Plan members who owe a monthly premium have a 30-day grace period. Failure to pay the monthly premium will result in loss of coverage on the first day of the following month. Health insurers must pay claims for covered services incurred during that month. 20. What is the process for collecting deductibles and copayments? Healthfirst Essential Plan members do not have deductibles. The provider can collect copayments at each visit from the member. Detailed information on copays and coinsurance for the Healthfirst Essential Plan can be found on our website at 5
6 21. What resources are available? Healthfirst Provider Website Provider Alerts Claims & Billing ICD-10 Tools & Information Provider Forms Formularies Provider Newsletter, The Source Healthfirst Provider Portal Provider Services Utilization Management Verify Member Eligibility View Member Cost Sharing Look Up Authorization View Claims Status and Detail All Provider Inquiries Eligibility Inquiries Claims Inquiries Authorizations Ancillary Authorizations CVS Caremark Formulary Medications Specialty Pharmacy Davis Vision Routine Vision Care/Eyewear Superior Vision Surgical Procedures of the Eye DentaQuest Routine Dental Care evicore Radiology ASH Chiropractic Services Orthonet PT, OT, ST Pain Management, Spinal Surgery, Foot Surgery Plans are offered by affi liates of Healthfi rst, Inc. Plans contain exclusions and limitations HF Management Services, LLC EP17_33 6
Frequently Asked Questions
Corrected Claims Submissions 1. What is a corrected claim? If a claim was submitted to and accepted by Healthfirst but was later found to have incorrect information, certain data elements on the claim
Member Services
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Important Questions Answers Why this Matters:
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Important Questions Answers Why this Matters:
Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? $1,500 single / $3,000 family
Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?
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Important Questions Answers Why this Matters:
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$1,500 Individual/$3,000 Family for participating providers. $3,000 Individual/$6,000. Important Questions Answers Why this Matters:
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$0 See the chart starting on page 2 for your costs for services this plan covers.
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Blue Cross Blue Shield of Louisiana: Blue Max 2500 Maternity Summary of Benefits and Coverage: What this Plan Covers & What it Costs
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsla.com or by calling 1-800-599-2583. Important Questions
Open Access Plus (OAP1/OAP1N): University of Maine System Coverage Period: 01/01/ /31/2013
Open Access Plus (OAP1/OAP1N): University of Maine System Coverage Period: 01/01/2013 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Individual
Anthem Blue Cross University of the Pacific Student Health Plan PPO with Student Health Center (100/80/60) Coverage Period: 08/01/ /31/2016
Anthem Blue Cross University of the Pacific Student Health Plan PPO with Student Health Center (100/80/60) Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 08/01/2015-07/31/2016
2018 Summary of Benefits
2018 Summary of Benefits Benton, Crawford, Sebastian, Washington Counties, AR H9630--001 Benefits effective January 1, 2018 H9630_18_2913SB Accepted 09302017 This booklet provides you with a summary of
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.mhc.coop or by calling (855) 488-0622. Important Questions
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/ca or by calling 1-855-333-5730. Important
$500 Individual/$1,000 Family See the chart starting on page 2 for your costs for services this plan covers.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cvtrust.org or by calling 1-800-288-9870. Important Questions
National Guardian Life Insurance Company: Saint Anselm College Student Health Insurance Plan Coverage Period: 08/01/ /01/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.
Summary of Benefits. Allwell Medicare Premier (HMO) Duval, Pinellas, Polk, Hernando, Pasco and Volusia Counties, Florida H
2018 Summary of Benefits Duval, Pinellas, Polk, Hernando, Pasco and Volusia Counties, Florida H9276-002 Benefits effective January 1, 2018 H9276_18_2859SB_B_Accepted 10032017 This booklet provides you
Total Health Care USA, Inc.: Total Saver Complete Summary of Benefits and Coverage: What this Plan Covers & What it Costs
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.thcmi.com or by calling 1-800-826-2862 Important Questions
Vantage Health Plan, Inc: Summary of Benefits and Coverage: What this Plan Covers & What It Costs
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.vantagehealthplan.com or by calling 1-888-823-1910. Important
What is the overall deductible? Are there other deductibles for specific services? Is there an out-ofpocket
Association of Washington Cities HealthFirst 250 Medical Plan Coverage Period: 01/01/2016 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible
Important Questions Answers Why this Matters: Network: $3,500 Individual $7,000 Family Non-Network: $10,000 Individual $20,000 Family
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.inhealthohio.org or by calling 1-800-580-8502. Important
Important Questions Answers Why this Matters: In-network: $0/Individual; $0/Family Out-of-network: $500/Individual; $1,000/Family
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://eoc.anthem.com/eocdps/aso or by calling 1-800-445-7490.
See the chart starting on page 2 for your costs for services this plan covers. $0 deductible? Are there other deductibles
HUMANA HEALTH BENEFIT PLAN OF LOUISIANA, INC. (HBPLA): Ochsner Humana HMO 142041 Coverage Period: Beginning on or after: 01/01/2018 Summary of Benefits and Coverage: What this Plan Covers & What it Costs
BlueCross BlueShield of WNY: Platinum 250 Coverage Period: 01/01/ /31/2015
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbswny.com or by calling 1-855-344-3425. Important Questions
Important Questions Answers Why this Matters: What is the overall deductible?
HMO Blue New England Premier Value with HCCS Coverage Period: on or after 01/01/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type:
Regence BlueShield: Choice HSA 1500 Coverage Period: 01/01/ /31/2016
Regence BlueShield: Choice HSA 1500 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016-12/31/2016 Coverage for: Individual & Eligible Family Plan Type:
Important Questions Answers Why this Matters: $300 Single/$600 Family for Network Providers. $500 Single/$1,000 Family for Non- What is the overall
Bellefontaine City Schools: Blue Access (PPO) Coverage Period: 04/01/2015-03/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO
BridgeSpan Health Company: BridgeSpan Bronze Essential 6850 Value PPO
BridgeSpan Health Company: BridgeSpan Bronze Essential 6850 Value PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Questions: Call 1 (855) 857-9943 or visit us at www.bridgespanhealth.com.
Schedule of Benefits
Schedule of Benefits NHP Prime HMO plan for GIC members Exclusively for members of the Group Insurance Commission health plan meets Minimum Creditable Coverage standards and will satisfy the individual
EverydayHealth 5000/100 Alliance Summary of Benefits and Coverage: What this Plan Covers & What it Costs
EverydayHealth 5000/100 Alliance Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: On and after 10/18/16 Coverage for: Individual Plan Type: PPO This is only a summary.
You must pay all the costs up to the deductible amount before this plan. covered services after you meet the deductible.
Secure Choice Health Savings Account Partner Coverage Period: Beginning on or after 01-01-2016 Summary of Benefits and Coverage: What this Plan covers & What it Costs Coverage for: S, S+1, and Family coverage
Anthem Blue Cross: Anthem Silver DirectAccess, a Multi-State Plan Coverage Period: 01/01/ /31/2014
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/ca or by calling 1-855-333-5730. Important
Some of the services this plan doesn t cover are listed on page 6. See your policy Yes. plan doesn t cover?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan s Summary Plan Description (SPD) at www.mycoresource.com (login required) or on
Important Questions Answers Why this Matters: In-network: $2,100 person /
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.mhc.coop or by calling (855) 488-0622. Important Questions
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthcomp.com or by calling 1-855-727-5267. Important