Empire announces changes to the Individual Health Benefit Plans

There will be a change to Empire’s ACA individual health benefit plans which impacts products sold on and off the New York State of Health Insurance Marketplace (also commonly called the Exchange) effective January 1,2019. 

 

Starting January 1, 2019:

• Members will be required to select a Primary Care Physician (PCP) when enrolling in one of the plans listed below.  You will be able to verify the member’s PCP on Availity (www.availity.com)
• Referrals will be required for all specialist visits. The referral form can be found on www.Empireblue.com-Download Commonly Used Forms and Quick Guides – General Forms
• No Out of Network coverage except in emergency.  Emergent care is covered in and out of network at the member in network cost share. For Out of Area urgent care, only services from a Blue Card provider will be covered.  In network member cost share applies.

 

Individual Health Benefit Plans utilizing the Pathway Network:

 

Network Name	Full Product Name	Prefix	PCP Required	Referral Required	Out-of-Network Benefits
Pathway Enhanced, Gated	Empire Gatekeeper Bronze Empire Gatekeeper Silver Empire Gatekeeper Gold Empire Gatekeeper Platinum Empire Gatekeeper Catastrophic	YAZ	YES	YES	NO
Pathway X Enhanced Gated	Empire Gatekeeper X Bronze Empire Gatekeeper X Silver Empire Gatekeeper X Gold Empire Gatekeeper X Platinum Empire Gatekeeper X Catastrophic	YCZ	YES	YES	NO