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Medicare Advantage Plans
MEDICARE ADVANTAGE PLANS
ConnectiCare and EmblemHealth Reciprocity for Network Access
Value-Based Insurance Design and New Benefits
Coordinating Care for Members
Health Survey for Medicare and Special Needs Plan Members
ConnectiCare Member Rewards Program
Care Management Plans for D-SNP Members
Medicare Connect Concierge
Claims and Billing
Medicare/Medicaid and Qualified Medicare Beneficiaries (QMBs)
Do Not Bill Dual Eligible and QMB Members for Any Medicaid Cost-Sharing
Dispute Resolution
Formularies
Help Members Stick with Their Medication Regimen by Using Our Mail Order Pharmacies and Free Pill Box
Fraud, Waste, and Abuse
Required: SNP MOC Training
Cultural Competency Education
Medicare Outpatient Observation Notice (MOON)
New Requirement for Medicare Providers Caring for Special Needs Plans Members
ConnectiCare and EmblemHealth Reciprocity for Network Access
Medicare members using ConnectiCare’s Medicare Choice Network (except members of dual eligible special needs plans (D-SNPs) and Passage plan members) can use EmblemHealth’s VIP Bold Network in New York. Some services are available through delegated networks and providers. These include behavioral health and chiropractic services (offered through Optum), vision care and eyewear (EyeMed Insight network), hearing aids (NationsHearing), and dental (Healthplex).
Similarly, EmblemHealth’s Medicare Advantage members using VIP Prime and VIP Bold networks (except members of D-SNPs) can use ConnectiCare’s Medicare Choice Network in Connecticut. Some services are only available through EmblemHealth’s delegated networks and providers. These include routine vision care and eyewear (EyeMed); behavioral health (Carelon Behavioral Health (formerly Beacon Health Options)), and dental (Healthplex).
For details on all our Medicare plans— including primary care provider (PCP) and specialist copay amounts, deductibles, maximum out-of-pocket expenses, service area where the plan will be offered, and whether there is reciprocity between ConnectiCare and EmblemHealth networks, see:
- 2025 Summary of Companies, Lines of Business, Networks, and Benefit Plans
- 2024 Summary of Companies, Lines of Business, Networks & Benefit Plans
Value-Based Insurance Design and New Benefits
The EmblemHealth family of companies has renewed the participation with the CMS-approved Value-Based Insurance Design (VBID) Model for 2024. This program promotes wellness and advance care planning to help ensure our Medicare members receive medical care that is consistent with their values, goals, and preferences. Plans participating in VBID include the following D-SNPs:
- ConnectiCare’s Choice Dual and Choice Dual Vista plans
- EmblemHealth’s VIP Dual and VIP Dual Reserve plans
ConnectiCare offers $0 copays on generic drugs in Tier 1, Tier 2, and Tier 6 (Select Care Drugs) for members enrolled in Choice Dual plans. Members pay no copayments for these drugs throughout the year, regardless of their level of extra help or the pharmacy they use. D-SNP members may also buy healthy foods using their over-the-counter (OTC) benefit. This valuable benefit helps some of our members with both Medicaid and Medicare address food insecurity and improve their health outcomes. In addition, D-SNP members can earn rewards for filling Select Care Drugs (Tier 6) medications for high blood pressure, high cholesterol, and diabetes if they are eligible to participate in the Medication Therapy Management Program and complete a Comprehensive Medication Review (CMR) with one of our pharmacists.
Many of our plans continue to offer OTC benefits. For more information, please visit connecticare.com/otc.
Advance Directives
We remind all our providers to discuss the importance of having executed advance directives at every visit and ensure that completed directives are included in the member’s medical record. The purpose of these directives is to ensure our Medicare members receive medical care that is consistent with their values, goals, and preferences, and that they designate a health care agent for a time the member is unable to make decisions on their own. D-SNP members can receive online help in completing draft advance directives and values statements.
Coordinating Care for Members
For helpful resources in coordinating care for ConnectiCare members, see Clinical Information and Coverage Guidelines. For EmblemHealth members, see Clinical Corner and the Utilization and Care Management chapter of the EmblemHealth Provider Manual
Health Survey for Medicare and Special Needs Plan Members
Special needs plan members will receive a call from ConnectiCare asking them to complete a health assessment (HA). Please encourage your patients to complete this survey. Members can complete the survey online by signing in to the member portal. This will help our Care Management team to better address members' needs and direct them to appropriate care and support services. Medicare members may be eligible for ConnectiCare’s Member Rewards Program when completing their HA within the first 90 days of enrollment. D-SNP members may also be eligible for a reward when completing an annual HA.
ConnectiCare Member Rewards Program
In 2024, ConnectiCare will continue to offer the ConnectiCare Member Rewards Program to encourage Medicare members to receive primary care and key health screenings. Members will receive a reloadable rewards card ranging from $10 to $100 for each of the eligible services they complete. Please reach out to your patients to schedule these important preventive exams. To get the list of rewards members may have earned or can earn, members must sign in to the ConnectiCare member portal and follow prompts for Wellness Rewards. Once they register for the rewards, they will be able to get their rewards loaded as they earn them.
Claims must be received by Dec. 31 of the calendar year for the incentive to be paid. Members must receive and use the reward before Dec. 31, 2024. Only one reward can be earned for each health service shown in the table below.
Activity |
Eligible Medicare Population |
Reward Trigger / Description |
Incentive Frequency |
Incentive Per Activity |
ConnectiCare Member Portal Registration |
Members who have not yet registered for ConnectiCare member portal |
Register for ConnectiCare member portal in the calendar year. |
Once a lifetime |
$25 |
Initial Medicare Annual Well Visit (AWV) (90 days) |
All new members |
Complete an Initial Medicare Annual Well Visit within 90 days of enrolling in the plan. |
Once a lifetime |
$50 |
Initial Health Assessment (HA) (90 days) |
All new members |
Complete HA within 90 days of enrollment. |
Once a year |
$50 |
Annual Health Assessment |
D-SNP members only |
Complete HA within calendar year by D-SNP member. |
Once a year |
$50 |
Sign-Up for Paperless Materials |
All members |
|
Once a lifetime |
$25 |
Colorectal Cancer Screening |
Medicare members, age 40+ |
Complete a fecal occult blood test (FOBT), flexible sigmoidoscopy, colonoscopy, FIT DNA test, or colonography. |
Once a year |
$25 |
Mammogram Exam |
Female members age 40+ |
Complete a mammogram. |
Once every two years |
$50 |
Diabetes A1C Test |
Diabetic members, ages 18+ |
Complete an A1C blood test. |
Once a year |
$25 |
Diabetes Eye Exam |
Diabetic members, ages 18+ |
Complete a retinal or dilated eye exam by an eye care professional. |
Once a year |
$25 |
Kidney Health Evaluation |
Diabetic members, ages 18+ |
Complete an estimated glomerular filtration rate (eGFR) test and a urine albumin-creative ratio. |
Once a year |
$25 |
Bone Mineral Density (BMD) Test |
Women with a fracture |
Complete a BMD within six months after fracture |
Once a year |
$100 |
Choice Dual and Choice Dual Vista D-SNP members can also earn rewards for filling Select Care Drugs (Tier 6) medications for high blood pressure, high cholesterol, and diabetes, if they are eligible to participate in the Medication Therapy Management Program and complete a Comprehensive Medication Review (CMR) with one of our pharmacists. Annual PCP visit reward is not offered in 2024.
Care Management Plans for D-SNP Members
Enrollees covered under our dual eligible special needs plans (D-SNPs) have care plans on file with our Care Management Department. We make these care plans available to providers and are happy to share a copy. Please contact us to receive a copy for member(s) you are treating.
For ConnectiCare enrollees:
Email: hmpreferrals@connecticare.com
Phone: 800-390-3522
For EmblemHealth enrollees:
Email: complexcasemgmt@emblemhealth.com
Phone: 800-447-0768
Medicare Connect Concierge
Our Medicare members will have continued support from Medicare Connect Concierge in 2024. This is the one phone number members can call when they need help solving their health care needs. Medicare Connect Concierge can help:
- Schedule a doctor’s appointment.
- Coordinate preauthorizations.
- Answer benefit questions.
- Update mailing address.
- Arrange transportation for members with Medicaid when covered.
To reach Medicare Connect Concierge, please call 800-224-2273 (TTY: 711), 8 a.m. to 8 p.m., seven days a week from Oct. 1 to March 31, and Monday to Saturday from April 1 to Sept. 30.
Claims and Billing
For helpful resources regarding claims for ConnectiCare members, see Billing and Claims and Our Policies. For EmblemHealth members, see Claims Corner and the Claims chapter of the EmblemHealth Provider Manual.
Contracted time frames in provider agreements will supersede time frames in this guide. For facility time frames, see the Provider Manual or applicable agreement.
Clinic Visit Policy
If you provide clinic visits to our Medicare members, and are owned and operated by a hospital, please review our clinic visit policy and correct coding requirements. ConnectiCare will monitor compliance with this policy and may recoup payment from providers for not following it.
Reminder: For services rendered in place of service (POS) 19, off-campus hospital-owned location, claims billed with the G0463 clinic code should include the Modifier PO.
Medicare/Medicaid and Qualified Medicare Beneficiaries (QMBs)
ConnectiCare offers two plans to members who have Medicaid (Choice Dual and Choice Dual Vista). In addition, many Qualified Medicare Beneficiaries (QMBs) enroll in our Medicare Advantage plans. Members with full Medicaid or QMBs are not responsible for paying any member cost-share for their plan-covered benefits.
Do Not Bill Dual Eligible and QMB Members for Any Medicaid Cost-Sharing
Medicare-Medicaid full dual eligible and QMB individuals who qualify to have their Medicare Parts A and B cost-share covered by their state Medicaid are not responsible for paying their Medicare Advantage plan cost-shares for Medicare-covered Part A and Part B services. Please do not balance bill these members.
Federal and State laws prohibit providers from balance billing Medicare-Medicaid dual eligible individuals for any Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments, if any, received for services provided to dual eligible individuals must be accepted as payment in full. To comply with this requirement, providers treating dual eligible and QMB individuals enrolled in ConnectiCare Medicare Advantage plans must do the following:
- Verify plan and Medicaid/QMB eligibility prior to providing a service.
- Do not bill the member or collect cost-sharing during the visit.
- Bill Connecticut State Medicaid for the member’s cost-share.
- Consider the claim as “paid in full,” regardless of the Medicaid or plan payment.
- Notify member in writing if you do not accept Medicaid and member is not a QMB.
Federal law and provider contracts prohibit Medicare (ConnectiCare) providers from balance billing beneficiaries with Medicare and QMB, and Medicaid providers from balance billing dual eligibles. Providers may reference Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997.
For ConnectiCare members, you can contact the Connecticut Department of Social Services at 800-842-8440 or visit their website.
For EmblemHealth members, you can use eMedNY to check whether the member has full or partial Medicaid benefits. For more detail, see our EmblemHealth Medicare Advantage webpage or call the New York State eMedNY Call Center at 800-343-9000.
Dispute Resolution
See Provider Appeals Process. Contracted time frames in provider agreements will supersede time frames in this guide.
Help Members Stick with Their Medication Regimen by Using Our Mail Order Pharmacies and Free Pill Box
Taking medicines as prescribed (medication adherence) is important for treating and controlling chronic conditions. Doctors play an important role in helping members stay adherent. Here are some steps as a doctor you can take to help members remain adherent:
- Talk to members about the importance of taking their medicines on time as prescribed.
- Remind members to track their refills and make an appointment for a new prescription before they run out.
- Educate members on the side effects of the medicines and how to treat them.
- Help identify and resolve barriers to members not taking their medicines as prescribed.
- Consider prescribing 90-day supply prescriptions for maintenance medicines.
- Consider prescribing generic drugs or less-expensive brand-name drugs on the member’s formulary if cost is a barrier.
- Talk to the member about potential state drug assistance programs or pharmaceutical prescription assistance programs that may be able to help with the cost of medicines.
- Educate members on pharmacy-based adherence tools that may help:
- Medicine synchronization (limit the member’s trip to the pharmacy for medicines).
- Compliance packing or blister packs.
- Auto refills.
- Encourage members to leverage available technologies (medicine reminder apps on their phone or tablet, like the Express Scripts mobile app).
Many of our plans, including D-SNPs, will offer generic drugs (Tier 1 and Tier 2) for $0 copay for members who get their refills through Express Scripts Preferred Mail Order pharmacy. Please help your members stay adherent and save on their prescription drugs by recommending members switch to preferred mail order:
Express Scripts Home Delivery Service
PO Box 66577
St. Louis, MO 63166-6577
or
Call: 877-866-5828 (TTY: 711)
Sortpak – new mail delivery pharmacy
We have added a new compliance packaging pharmacy, SortPak, to help our Medicare providers and members organize medication refills and support medication adherence.
Sortpak’s services include:
- Coordinating prescription and nonprescription maintenance medication refills, up to a 90-day supply, to ensure member receives all medicines at one time.
- Sorting medications into individual pouches organized by the day and hour.
- Delivering medications to the member’s doorstep with no additional delivery cost.
- Conducting medication adherence assessments.
- Contacting prescriber(s) at least one month in advance to check on the need for refills and sending refill reminders to the members.
If you have a member who could benefit from this type of service, you can:
- Call: 877-570-7787
- Fax: 877-475-2382
- Send e-scripts using:
- NCPDP/NABP: 0524733
- NPI number: 1063407252
- Mail: 124 S. Glendale Ave., Glendale, CA 91205
Free pill boxes
If you have a patient who needs help keeping their pills organized, let them know we offer free pill boxes to everyone, regardless of coverage.
A form for ordering the pill boxes along with a helpful video on medication adherence can be found on these web pages:
Fraud, Waste, and Abuse
EmblemHealth expects its contracted providers to prevent and address fraud, waste, and abuse and to meet their annual training requirement. To learn about this important topic, see Medicare Learning Network’s Web-Based Training:
- Combating Medicare Parts C and D Fraud, Waste, & Abuse (Contact hours 30 min.)
Learn to spot fraud, waste, and abuse (FWA), identify methods to prevent FWA, identify how to report FWA, recognize how to correct FWA, and know potential consequences and penalties associated with violations. - Medicare Fraud & Abuse: Prevent, Detect, Report (Contact hours 88 min.)
Learn how to identify what Medicare considers fraud and abuse, provisions and penalties, and prevention methods and recognize how to report fraud and abuse.
If you have concerns about compliance issues that you wish to bring to the attention of EmblemHealth/ ConnectiCare, please call toll free, 24/7, at 844-I-COMPLY (844-426-6759). You can also report online at emblemhealth.alertline.com.
If you would specifically like to report concerns about fraud, waste, or abuse, please call
888-4KO-FRAUD (888-456-3728) or send an email to the Special Investigations Unit by using this email address: kofraud@emblemhealth.com.
EmblemHealth/ConnectiCare will not retaliate against anyone who in good faith reports a compliance concern.
Required: SNP MOC Training
CMS requires Medicare providers to complete Special Needs Plan (SNP) Model of Care (MOC) training each year for each health plan’s MOC. Providers who care for ConnectiCare’s Medicare Advantage members with Choice Dual and Choice Dual Vista (HMO D-SNP) plans must complete this training.
Notices are sent to providers in advance of the training due date. Providers who do not complete the training by due date will be referred to the ConnectiCare Credentialing Committee.
Cultural Competency Education
See these Cultural Competency Continuing Education and Resources to help you provide our members with care in the context of their cultural and linguistic needs.
Medicare Outpatient Observation Notice (MOON)
All hospitals and critical access hospitals are required by CMS to provide Medicare beneficiaries, including Medicare Advantage enrollees, with the OMB-approved Medicare Outpatient Observation Notice (MOON). The MOON and instructions for completing it are available on CMS’ website.
New Requirement for Medicare Providers Caring for Special Needs Plans Members
Beginning Jan. 1, 2023, EmblemHealth and ConnectiCare Special Needs Plan (SNP) member benefits will include coverage for face-to-face encounters between members and providers for the delivery of health care, care management, or care coordination services. Face-to-face encounters must occur, as practical and with the member’s consent, on at least an annual basis beginning within the first 12 months of SNP enrollment.
A face-to-face encounter must be either in-person or through a virtual (visual, real-time, and interactive) encounter. Medicare providers caring for SNP members will be required to obtain the member’s consent for face-to-face virtual encounters.
When a provider reaches out to conduct a face-to-face virtual encounter with a SNP member, consent must be obtained from the SNP member prior to, or when scheduling, the encounter. At the time of the scheduled virtual encounter, the provider must inform the member on the purpose and intended outcomes of the visit.
At least annually, EmblemHealth and ConnectiCare care managers will review member usage history data to identify members who require outreach and face-to-face scheduling. All data collected will be reviewed with providers during the interdisciplinary care team (ICT) meetings.
Additional requirements
As a reminder, when caring for SNP members, providers must also:
- Actively participate in the SNP member’s ICT and individualized care plan (ICP) development and implementation.
- Follow care transitions protocol.
- Use guidance from:
- ConnectiCare’s medical coverage criteria and clinical practice guidelines.
- EmblemHealth’s medical policies and clinical practice guidelines.
- Complete SNP model of care training annually for ConnectiCare and EmblemHealth.
- Encourage SNP members to complete their surveys:
- Health assessment
- Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
- Health Outcomes Survey (HOS)
Below are some additional resources to help you manage the health of your SNP patients:
