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 1-844-553-9055 (TTY 1-888-542-3821) Monday to Friday, 9am 8pm, or visit http://hfchoice.org/essential-plans. 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 1-844-553-9055 (TTY 1-888-542-3821), Monday to Friday, 9am 8pm, or by visiting http://hfchoice.org/essential-plans/. 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
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 www.healthfirst. 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 www.hfdocfinder.org. 2
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 1-888-801-1660, 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 www.healthfirst.org, 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 1-888-801-1660 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 1-888-801-1660 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 www.healthfirst.org/providers. 3
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 www.healthfirst.org/formulary. For specialty medications, providers must contact CVS Caremark Specialty at 1-866-814-5506. 15. 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 www.hfdocfinder.org 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 1-888-394-4327 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 4. 18. 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
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: 0000000000000 Essential Plan 1 Rx Bin: 004336 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 1-888-250-2220 TTY: 1-888-542-3821 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 1-888-801-1660 Prior Authorization 1-888-394-4327 Electronic Claims Payer ID 80141 Medical Claims Address Healthfirst Claims Department P.O. Box 958438 Lake Mary, FL 32795-8438 Pharmacy Help Desk: 1-800-364-6331 Claims: CVS Caremark P.O. Box 52136 Phoenix, AZ 85072-2136 Member Name Member ID: 0000000000000 Essential Plan 1 Vision/Dental Rx Bin: 004336 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 1-888-250-2220 TTY: 1-888-542-3821 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 1-888-801-1660 Prior Authorization 1-888-394-4327 Electronic Claims Payer ID 80141 Medical Claims Address Healthfirst Claims Department P.O. Box 958438 Lake Mary, FL 32795-8438 Pharmacy Help Desk: 1-800-364-6331 Claims: CVS Caremark P.O. Box 52136 Phoenix, AZ 85072-2136 19. 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 www.healthfirst.org/health-insurance. 5
21. What resources are available? Healthfirst Provider Website Provider Alerts Claims & Billing ICD-10 Tools & Information Provider Forms Formularies Provider Newsletter, The Source www.healthfirst.org/alerts www.healthfirst.org/providers/claims-billing www.healthfirst.org/icd10 www.healthfirst.org/providerforms www.healthfirst.org/formulary www.hfnysource.org 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 www.healthfirst.org/providers 1-888-801-1660 Authorizations 1-888-394-4327 Ancillary Authorizations CVS Caremark Formulary Medications 1-855-582-2022 Specialty Pharmacy 1-866-814-5506 Davis Vision Routine Vision Care/Eyewear 1-800-773-2847 Superior Vision Surgical Procedures of the Eye 1-888-273-2121 DentaQuest Routine Dental Care 1-855-343-4267 evicore Radiology 1-877-773-6964 ASH Chiropractic Services 1-800-972-4226 Orthonet PT, OT, ST 1-844-641-5629 Pain Management, Spinal Surgery, Foot Surgery 1-844-504-8091 Plans are offered by affi liates of Healthfi rst, Inc. Plans contain exclusions and limitations. 2017 HF Management Services, LLC 2047-17 EP17_33 6