Emblem Health is a Medicaid managed care plan, not Medicaid itself

Emblem Health is a private insurance company that contracts with state Medicaid programs to deliver coverage. If you are enrolled in Emblem Health, you have Medicaid — but Emblem Health is the organization that processes your claims, manages your doctors, and handles your benefits day-to-day. Think of it this way: Medicaid is the government program that pays for your care; Emblem Health is the company running that program on the state's behalf.

Emblem Health operates primarily in New York and New Jersey. In New York, it is one of several Medicaid managed care plans available to people who may have access to for Medicaid. The state assigns you to a plan, or you may be able to choose one during your enrollment period. If you receive a card that says "Emblem Health" on it, you are covered by Medicaid through Emblem Health's network.

Key Takeaways

  • Emblem Health is a managed care company that administers Medicaid benefits on behalf of New York and New Jersey, not a separate program.
  • Having an Emblem Health card means you have Medicaid coverage, and Emblem Health decides which doctors and hospitals are in your network.
  • You do not pay Emblem Health premiums directly — Medicaid pays Emblem Health to cover you, and your care is free or low-cost at the point of service.
  • If you are assigned to Emblem Health but prefer a different Medicaid plan, you may be able to switch during open enrollment or if you have a may have access to life event.

How Emblem Health's Medicaid coverage works

When you enroll in Medicaid in New York, the state assigns you to a managed care plan — Emblem Health is one option. Emblem Health then becomes your primary contact for coverage questions, referrals, and claims. You choose doctors from Emblem Health's network, and those doctors bill Emblem Health directly. You typically pay nothing at the doctor's office.

Emblem Health covers the same services that Medicaid covers: doctor visits, hospital care, prescription drugs, mental health services, and other medically necessary care. The coverage itself comes from Medicaid; Emblem Health is the intermediary. If you need a service, you check Emblem Health's provider directory or call their member services line to confirm the doctor or facility is in-network.

What Emblem Health covers under Medicaid

Emblem Health's Medicaid plans cover preventive care, emergency services, hospitalization, prescription medications, mental health and substance use treatment, and dental and vision services for children. Coverage details vary slightly depending on which Medicaid category you fall into — for example, coverage for adults differs from coverage for children or pregnant people.

To find out exactly what is covered under your specific Emblem Health plan, call the member services number on your card or visit the Emblem Health website. You can also ask your doctor's office whether a specific service requires prior approval from Emblem Health. Some treatments need advance authorization before you receive them.

Emblem Health member services and how to reach them

Emblem Health has a member services phone line available during business hours. The number is on your insurance card. You can call to ask about coverage, find in-network doctors, request a referral, or report a problem with a claim. Many questions can also be answered through the Emblem Health website or mobile app.

If you have a dispute with Emblem Health — for example, if they deny a claim you believe should be covered — you have the right to file a grievance or appeal. Emblem Health must respond within a set timeframe, usually 30 days. If you disagree with their decision, you can request an independent external review through the state.

Changing from Emblem Health to another Medicaid plan

If you are assigned to Emblem Health but want to switch to a different Medicaid managed care plan, you can do so during the annual open enrollment period, which typically runs from November through January. You can also request a change if you have a may have access to life event, such as moving out of state, losing your job, or having a significant change in your household.

To switch plans, contact your local Medicaid office or the New York State Department of Health (if you are in New York). You can also call 1-800-541-2831 to speak with someone who can help you change plans. The change usually takes effect on the first day of the following month.

If you think you may have access to for Medicaid

Medicaid income and resource limits vary by state and by category — for example, limits for children differ from limits for adults or seniors. To find out whether you meet the requirements, contact your local Medicaid office or visit your state's Medicaid website. You can also call 211 to be connected to a local enrollment counselor who can walk you through the process.

When you apply for Medicaid, the state will tell you which managed care plan you are assigned to, or you may be given a choice. Emblem Health is available in some areas but not all. If you live in an area where Emblem Health operates and are assigned to them, you will receive an Emblem Health card in the mail within a few weeks of your approval.

Frequently Asked Questions

Does Emblem Health cost money?

No. Emblem Health is a Medicaid plan, and Medicaid is free or very low-cost. The state pays Emblem Health to cover you. You do not pay Emblem Health a premium. You may have small copays for some services, but these are set by Medicaid, not by Emblem Health.

What if my doctor is not in Emblem Health's network?

If your current doctor is not in Emblem Health's network, you will need to find an in-network doctor or request a referral to an out-of-network provider. Emblem Health may cover out-of-network care in certain situations, such as emergency services or if no in-network provider is available. Call member services to ask about your specific situation.

Can I use Emblem Health outside of New York or New Jersey?

Emblem Health's network is limited to New York and New Jersey. If you move out of state, you will need to enroll in your new state's Medicaid program and will be assigned to a different managed care plan. If you travel temporarily, Medicaid covers emergency services anywhere in the country.

How do I know if I am enrolled in Emblem Health?

Check your Medicaid card. It will have the name of your managed care plan printed on it. If it says "Emblem Health," you are enrolled with them. You can also call the member services number on your card to confirm your plan.

What happens if Emblem Health denies a claim?

You have the right to appeal. Emblem Health must send you a written explanation of why the claim was denied. You can request an appeal within 60 days of the denial. If you disagree with their decision after the appeal, you can request an independent external review through the state.