Frequently Asked Questions

A new experience that puts you first.

Welcome to the new EmblemHealth.com! We've made strides to help give you a new seamless digital experience.  Our website now features a streamlined navigation that makes it easy to find the content that is most relevant to you: whether you’re an existing EmblemHealth member looking for important documents; or you’re shopping for a health plan for yourself and your family.

 

If you’re a provider, broker or an employer, you can quickly switch to the appropriate section from the top left corner of any page. See the frequently asked questions below for more information.

How Do I...

Enrollment in one of our health plans is easy and simple. Depending on the plan or eligibility, you can enroll online, by mail, in person, on the New York State Marketplace, or by contacting us directly.

Select the type of plan you’re looking for below to get started.

Medicare Advantage
Available to people who have Medicare Parts A and B.

Individual & Family
Qualifying individuals, families, and young people age 21 or under living in one of 28 New York counties, including the five NYC boroughs, Long Island, Westchester, and regions stretching north of Albany. Children and young adults can stay on a parent’s plan until age 26, or through age 29 for an added cost.

Medicaid, HARP or Child Health Plus (CHPlus)
Eligibility requirements for these programs are established by New York State and include household income, residency, family size and age, as well as your citizenship or immigration status and whether you already have other insurance.

Medicare Supplement
These types of plans “supplement” Medicare by covering the bills that are only partially covered by Medicare Parts A and B.

Group plans
Start here if you're considering EmblemHealth insurance for your business or family.

Renewal or recertification is how Medicaid members renew their health care coverage and it is required by New York State annually. Depending on how you enrolled, the NYC Human Resources Administration (HRA), your Local Department of Social Services (LDSS), or the NY State of Health (NYSOH) Marketplace will send you a letter or an email with your renewal date.

Events such as marriage, divorce, birth of a child, change of income, or loss of employment may also change your renewal date. Look at the date on your letter or email. You must renew by the date provided.

If you don’t understand your letter, we can help. Call us at 888-432-8026 on weekdays from 8:30 am to 5 pm (excluding major holidays) or visit our Medicaid Renewal page for more information.

To learn if your prescription plan covers a specific drug, sign in to myEmblemHealth. Click on Pharmacy from the orange menu bar at the top of the page to access Express Scripts, our pharmacy benefit manager. On the Express Scripts website, click on the Prescriptions tab at the top and select Price a Medication.    

You can sign up for your own myEmblemHealth account and have full access to the tools and resources you need to manage your health benefits online.

You will need your member ID number, so be sure to have your member ID card handy. After you’ve successfully submitted your registration, you will immediately have access to your account to check claims, request member ID cards, update your information, and more.

You can request a new ID card directly from your myEmblemHealth account or call our member service line.

  • Sign in to myEmblemHealth and click on Tools that Help You from the orange menu bar at the top of the page. Then click on Print or Request ID Card. Your new ID card will arrive in the mail in five to seven business days. If you need an ID card right away, you can print a temporary version from the same page.

Call the Customer Service number listed for your plan on our contact page or use the secure message center in your account to email us.    

Our myEmblemHealth mobile app is available on iOS and Android devices, and provides useful benefit and plan information for members. Use the buttons below to download the appropriate version for your mobile device.

App Store Google Play

Visit our Behavioral Health section to find resources on various mental/behavioral health conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Bipolar disorder, and others.

You can also call Customer Service to speak to a representative now. Call the number on the back of your member ID card or contact us for more options.    

Understanding your Health Plan Payment Summary:
When you get care or send us a claim for services you got as a plan member, we send you a Health Plan Payment Summary. It is also sometimes called an Explanation of Benefits (EOB).

The Summary shows what was billed, what we paid, and what you have to pay, if anything. It is not a bill. Match this information to any health care bill you get to compare charges.

Definitions

Amount billed: The amount billed by the health care professional or facility (physician, hospital, etc.) for services that you or your covered dependents received.

Amount not covered: Any part of the amount billed that was not eligible for payment based on the rules of your plan. For example, if the charges were for services or products that are not covered by your plan, if the health care professional or facility billed us more than once for the same service, or for charges submitted that are above the maximum amount your plan covers for out-of-network care. Some of these charges will not be your responsibility, but you may have to pay for others.

Coinsurance: After you pay your deductible, you and your plan may share the cost of your care. The percentage you pay is called coinsurance.

Copay: The flat fee you pay for certain services such as doctor visits or prescriptions.

Deductible: The amount you have to pay before the plan starts to pay for certain services.

EmblemHealth discount: The amount you save by using a health care professional or facility (doctor, hospital, etc.) that is part of an EmblemHealth network. EmblemHealth has contracts with its in-network doctors, hospitals, and other facilities to help you save money.

In-network: A group of health care professionals and facilities (doctors, hospitals, labs, etc.) that contract with EmblemHealth. They provide covered products and services to members. Using in-network services usually means you will pay a lot less.

Maximum out-of-pocket: The most you will pay for covered health services from in-network providers in any year. After that, we’ll pay for all your covered in-network health care.

Other insurance: You may have other insurance that is responsible to pay for a portion of this claim. The amount they owe or have paid is included on the claim detail page.

Out-of-network: Health care professionals and facilities (doctors, hospitals, labs, etc.) that do not contract with EmblemHealth. Depending on your plan, you may be able to use out-of-network services, but you may pay more for the same services, and you might have to file a separate claim for us to pay you back.

What EmblemHealth paid: The portion of the amount billed that was paid by your health care plan.

What you owe or may have already paid: The portion of the billed amount that you have to pay. This amount might include your deductible, coinsurance, copay, any amount over the maximum reimbursable charge, or charges for products or services not covered by your plan. Remember that you may have already paid some of this amount. For example, your doctor may have collected your copay at the time of the visit.

Unless you decide to go paperless, your EOB will be mailed to you. This information is also available under Claims when you sign in to your myEmblemHealth account.

If you are a member of a Qualified Health Plan or Essential Plan, learn more about your bill here.     

Sign in to myEmblemHealth and click the Find a Doctor link at the top of the page.  

You can schedule an appointment online with your AdvantageCare Physicians Primary Care Provider and select Specialists! Visit the AdvantageCare Physicians website (ACPNY.com) where you can choose a convenient appointment time at a location near you. 

Neighborhood Care offers many free classes such as Yoga, Zumba, Tai Chi, and more. You don’t have to be an EmblemHealth member to take advantage of these classes; just visit a Neighborhood Care near you.    

Visit our website often as we’re constantly adding relevant information to help you make the most out of your EmblemHealth plan. Take a look at our blog for health and wellness tips, member resources, and more.

You can also follow us on social media to stay up to date on the latest from us:

Facebook

Instagram

LinkedIn

Twitter

YouTube    

If you are a member, you can call the Customer Service number listed for your plan on our contact page or use the secure message center in your account to email us.

If you’re considering EmblemHealth or need general information, call us at 866-274-0060 or fill out the information request form

Date issued: January 11, 2016

What is Form 1095-B?
Form 1095-B is an IRS health coverage reporting form prepared by health insurers such as EmblemHealth. This form reports information about your health coverage and the type of coverage in which you were enrolled. EmblemHealth sends this information to you and the IRS.

What is it used for?
The Affordable Care Act requires health insurers filing electronically to submit Form 1095-B to the IRS by March 31 to report an individual’s health coverage during the prior tax year. (For 2015 reporting, the IRS granted an extension to June 30, 2016.) The IRS uses the information to help verify which taxpayers satisfied the Individual Shared Responsibility Mandate. This mandate requires nearly all Americans, including children, to have health coverage unless they qualify for an exemption.

Why am I receiving it?
Health insurers are required to send a copy of Form 1095-B to each subscriber by January 31. (For 2015 reporting, the IRS granted an extension to March 31, 2016.) You are receiving the form because you have been identified as a subscriber enrolled in one of EmblemHealth’s health plans. You will report the information on Form 1095-B on your federal income tax return in order to verify that you and any enrolled dependents had health coverage for some or all months during the tax year.

Should I attach Form 1095-B to my income tax return?

No. Currently the IRS does not require you to submit Form 1095-B with your federal income tax return, but you will need the information on Part IV in order to report months of coverage for you and your family. After your tax return is filed, the IRS may conduct an inventory of filings and ask you to provide proof of coverage. Therefore you should keep the form with your tax records.

What information is on Form 1095-B?
Form 1095-B provides basic information about the health insurer, employer sponsoring the health coverage, and individuals covered by the health policy. Individual information includes:

  • Name of policy holder
  • Address of policy holder
  • Name, taxpayer identification number (usually a social security number), and months of coverage for each person on the policy

How will I receive the form?
Form 1095-B will be provided to you by January 31. If you consented to receive it electronically, you will receive an email notification with the subject line IMPORTANT TAX RETURN DOCUMENT AVAILABLE when it is available for download within your secure online account. Otherwise, a paper copy will be sent by first class mail to the address we have on file.

How do I consent to receive my 1095-B Form electronically?
Sign in to or register for your secure online account and select “Get Your 1095-B Tax Form” under Tools That Help You. Once you review the conditions to receive Form 1095-B electronically, click on the Consent button. Note that you can withdraw your consent at any time. When you withdraw consent, EmblemHealth will mail a paper copy of any future Form 1095-B to the address we have on file.

Will Form 1095-B be sent to my family members who are covered under my policy?
No. Form 1095-B will be sent only to each subscriber, not to each member. The form will list the names of each individual covered under the policy and will include information about each month of coverage. You can share your form with any family members who request a copy.

Why did I receive two different 1095-B forms?
Some members might receive two or more 1095-B forms if they were enrolled in a health plan through different employers at any time during the calendar year. For example, if a member was provided with health coverage while working for one company for the first half of the year, but then got a job with a different company, the health coverage provided through each company would be reported on separate 1095-B forms. Additionally, if an EmblemHealth member switches coverage from HIP to GHI, or vice versa, during the year, the member would receive one 1095-B reflecting coverage under HIP and another reflecting coverage under GHI. Members who receive multiple 1095-B forms should use the information from both forms to accurately report coverage on their annual income tax return.

Will I be able to get another copy if I lose the form?
You can view and print copies of the Form 1095-B by signing into your EmblemHealth Member Account and clicking on the “Get Your 1095-B Tax Form” under Tools That Help You. You may also call EmblemHealth Customer Service at 1-866-517-5804 to request a copy of the form.

Why can't I view/download Form 1095-B from my online EmblemHealth member account?
If EmblemHealth does not have your TIN/SSN information, you will not be able to view your Form 1095-B online. Please sign in to your secure online account and update your TIN/SSN in order to view your Form 1095-B. It may take two or three days for the update to be reflected in the EmblemHealth systems. You may also call EmblemHealth customer service at 1-866-517-5804 to request a copy of the form, but please be aware it may take a few days to receive your Form 1095-B by mail.

What if my Form 1095-B is not correct?
If any of the information on your Form 1095-B is incorrect or needs to be updated (for example, your name is misspelled or your social security number is missing) please call EmblemHealth Customer Service at 1-866-517-5804 to provide the correct information. A corrected Form 1095-B will be generated with the updated information with copies sent to you and the IRS.

Why does the IRS need my Tax Identification Number/Social Security Number (TIN/SSN)?
Under the Affordable Care Act, health insurers are required to file health coverage information with the IRS to help it determine whether individuals met the requirement to maintain minimum essential coverage and therefore are not liable for the Individual Shared Responsibility payment (tax penalty). The IRS will use the TIN/SSN reported on Form 1095-B to help match the health care information with the information reported on the member’s federal tax return.

Does EmblemHealth have my TIN/SSN?
EmblemHealth obtains TINs/SSNs for most members upon enrollment, but there are some records still missing TINs/SSNs, primarily for spouses and dependents of subscribers. If EmblemHealth is/was missing your TIN/SSN information, you will receive a letter from us requesting this information. To provide us with this information, follow the instructions in the letter. Note that you can also sign in to your online account and enter and/or update TINs/SSNs at any time.

For security reasons, I don’t feel comfortable giving my TIN/SSN to EmblemHealth. What will happen if Form 1095-B is filed without it?
You should know that EmblemHealth adheres to strict privacy rules. For security reasons, all TINs/SSNs recorded in our membership files are masked with only the last four numbers visible (for example, ***-**-7020). Only those Customer Service Advocates with unique security access are able to update a member’s TIN/SSN. If you do not respond to our letters requesting your TIN/SSN, EmblemHealth will instead report your date of birth on Form 1095-B. The IRS may not be able to match the health coverage information reported on your Form 1095-B with your income tax return with just your birthdate and therefore may be unable to verify you had health coverage during the tax year. You may receive a notice from the IRS that you are liable for a shared responsibility payment.

Where do I report my health coverage on my income tax return?
Most taxpayers who had health coverage for each month of the year will simply check a box on line 61 of the 1040 income tax form (line 38 of Form 1040A and line 11 of Form 1040EZ) to indicate they, their spouses and dependents had health care coverage for the entire year. You should use the same line to enter a payment amount if you did not have health coverage and therefore need to make an individual shared responsibility payment.

I had coverage only for part of the year. How do I calculate how much I owe?
If you and/or your spouse and dependents did not have health coverage for the full year and did not qualify for an exemption, calculate the amount you owe using the Shared Responsibility Payment Worksheet included in the instructions for Form 8965. Enter the payment amount on line 61 of Form 1040 (line 38 of Form 1040A or line 11 of Form 1040EZ). The penalty is calculated on a monthly basis – one-twelfth of the annual payment for each month that the individual did not have coverage. No payment is required if you or your family members were uninsured for less than three months of the year.

How much is the annual individual shared responsibility payment?
In 2015, the maximum penalty for not maintaining health coverage for the full year is $325 per person or 2 percent of the individual’s income, whatever is greater. The penalty per child under age 18 is $162.50. In 2016, the penalty will be 2.5 percent of income or $695 per person and $347.50 per child under age 18. After year 2016, the penalty amounts are based on the 2016 amounts, plus an inflation.

How will the payment be collected?
The Shared Responsibility Payment will be paid to the IRS when taxpayers file their federal income tax return. For example, the 2015 penalty payment would be paid when taxes are filed in 2016, and the 2016 penalty payment would be paid in 2017.

What will happen if I owe an Individual Shared Responsibility Payment, but cannot afford to make the payment when filing my tax return?
The IRS will hold back the amount of the fee from any future tax refunds. There are no liens, levies or criminal penalties for failing to pay the fee.

Questions?
For additional information about the Affordable Care Act individual shared responsibility provisions, please visit the Internal Revenue Service website or contact your tax advisor.

If you have questions about the Form 1095-B you receive from EmblemHealth, call 1-866-517-5804 from 9 am to 5 pm, Monday through Friday (excluding major holidays).

 

The FAQs above are current as of the date written and are subject to change based on updates and guidance from the Internal Revenue Service and other federal government agencies.

How Do I...

PPO

  • Medical, Member submitted claims: P.O. Box 3000, NY, NY 10116-3000

  • Medical, Provider submitted claims: P.O. Box 2832, NY, NY 10116-2832

  • Hospital Claims: P.O. Box 2833, NY, NY 10116-2833

  • Dental Claims: P.O. Box 2838, NY, NY 10116-2838

 

HMO

  • Medical Claims: P.O. Box 2845, NY, NY 10116-2845

  • Hospital Claims: P.O. Box 2803, NY, NY 10116-2803

 

Appeals

  • P.O. Box 2844 NY, NY 10116-2844

Questions?

We’re here to help

If you’re having trouble paying online or need other assistance, please call our Customer Service team at 1-855-283-2146, seven days a week (excluding major holidays), from 8 am to 8 pm.

Want to enroll in a health plan?  Go to the NY State of Health Marketplace.