Open Enrollment on the NY State of Health Marketplace for 2018 coverage runs through

January 31, 2018.

If you want coverage that begins on January 1, 2018, you must enroll or renew your plan by December 15, 2017.

Check Your Mail for Next Steps to Renew Your Plan For more information about how to renew your plan, you will receive an official renewal letter from both the NY State of Health Marketplace and EmblemHealth. The letters will explain that you have two options:

• You don't need to do anything. Your plan will automatically renew. Still, this is a good time to check that your contact information is up-to-date on your Marketplace profile at nystateofhealth.ny.gov.

• You need to take action. You may be eligible for a different plan (maybe even at a lower cost) or for a different tax credit amount. You will need to update your Marketplace profile by visiting nystateofhealth.ny.gov. You can also review our plans at emblemhealth.com/individual.

Taking Care of Your Baby Blues

Flu Season is Here!

Get Your Plan Details Online

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Winter 2017

HEALTH MATTERS

Open Enrollment is Here!

Both letters will also tell you which plan you and any dependents will be enrolled in, the premium amount, any benefit changes, and the tax credit amount, if applicable.

Need help Call Hours

Renewing your plan? EmblemHealth at 800-233-1831 Daily, 8 am to 8 pm

With your current plan? EmblemHealth at 888-447-7703 Daily, 8 am to 6 pm

With your tax credits? NY State of Health Marketplace at 855-355-5777

Mon-Fri, 8 am to 8 pm Saturday, 9 am to 1 pm

2 Winter 2017

Health Matters is published by EmblemHealth to inform members of current health issues and improve the use of services. This publication should not replace the care and advice of your doctor. Always talk to your doctor about your personal health needs. HIP Health Plan of New York (HIP), HIP Insurance Company of New York (HIPIC) and Group Health Incorporated (GHI) are EmblemHealth companies.

Valued Customers on Our Value PlansEmblemHealth will once again offer our Value Plans for 2018 on the Individual Marketplace. This year, there are new benefits and great prices.

These plans come with adult dental and vision, acupuncture benefits, and a range of free services:

• Silver Value is one of the lowest priced Silver plans on the market.

– Free telemedicine, free labs, free preventive care, three free primary care physician visits, and no deductible for specialists, urgent care, and generic drugs.

• Bronze Value is one of the lowest priced Bronze plans on the market.

– Free telemedicine, free preventive care, and two free primary care physician visits.

For more information, visit emblemhealth.com/individual.

We’re upgrading our technology to better serve you As we put these changes into place, you may receive a new member ID card in the mail. Make sure that you give your doctor and pharmacist your NEW ID card at your next visit.

Taking Care of Your Baby BluesHaving a baby is such an exciting time in life, but caring for a newborn can be challenging and stressful at times and brings all sorts of changes.

Some women may develop “baby blues,” also known as postpartum depression. This condition is caused by the changes in women’s bodies and hormones after birth. Feeling down for weeks after pregnancy can be perfectly normal and a lot of women experience the “blues.” You should consider seeking help if your symptoms last longer than six weeks. EmblemHealth is here for you during that time:

• To find a doctor that meets your needs, call us at 888-447-7703 or visit emblemhealth.com/findadoctor. Once online, look for your plan in the provider search.

• Call the Postpartum Resource Center of New York at 855-631-0001 or visit postpartumny.org.

• Call 911 or 311 right away if you feel you may harm yourself or your baby.

Health Matters 3

WHO? WHICH SERVICE(S)?

Adults One preventive care visit.

Blood pressure measurement and cholesterol blood test.

Needed immunizations, including flu and tetanus vaccine.

Cancer screenings such as breast, cervical, colorectal, and skin.*

Help managing chronic conditions like asthma, diabetes, and high blood pressure, as applicable.

Help managing medications, like those for depression.

Monitoring the effects of certain medicine, like digoxin, diuretics, and angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), as applicable.

Children/Adolescents One preventive care visit.

Needed immunizations, including flu and the human papillomavirus (HPV) vaccine series.*

Newborns (Birth to 15 Months) At least, six preventive care visits.

Needed immunizations, including flu vaccine for babies six months and older.

Needed immunizations, including flu vaccine for children older than six months.

*Ask your doctor when you should have these services done.

Do You Care for a Teen or Young Adult? If so, here are some questions to ask their doctor at the next visit:

• Are all immunizations up-to-date, including a yearly flu shot?

• How does their height and weight compare with other kids their age?

• What do you suggest for managing chronic conditions, like asthma or diabetes? (If applicable.)

• Any suggestions for managing medications, like those for attention deficit hyperactivity disorder (ADHD)? (If applicable.)

• Can you provide counseling on nutrition, physical activity, and risky behaviors like drug and alcohol abuse, tobacco use, and sexual activity?

Your To-Do List for Preventive Care It’s time to start keeping track of you and your family’s routine doctor visits and screenings for the year. Call your doctor to schedule your visits and get needed health services before the end of 2017. Below is a list of services you should receive annually. Make sure to check each one off to help you stay healthy and avoid getting sick.

Your Qualified Health Plan covers many of the services listed below at no cost-sharing (no copay, coinsurance, or deductible). Our new Bronze Value and Silver Value plans also offer a number of free wellness visits and dental check-ups. Check your member contract for details.

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Getting the right care is an important part of treating a child’s ADHD.

What is ADHD?ADHD is a behavioral health condition that often starts in childhood, but can continue on through adulthood. Symptoms vary and may include trouble focusing, being overly active, and acting without considering outcomes. The different paths of treatments address specific forms of ADHD because this condition may be experienced in different ways. Treatment usually combines counseling, lifestyle changes, and medicine.

Getting the Right TreatmentIf your child is prescribed medication, there will be follow-up visits for the doctor to check that the medication is working properly and there are no unusual side effects. Dosage (amount prescribed) can change depending on how your child responds to the ADHD medication.

Help at HomeYou play a big role in helping your child manage ADHD. Here are some tips:

• Have your child visit the doctor for a medicine check within three to four weeks of starting it. Continue with doctor visits every three to four months during the first year.

• Make sure your child takes the medicine every day, including weekends, holidays, and vacation. It is important to be consistent.

• Add talk therapy to your child’s care plan. A behavioral health professional can provide a safe space to talk about ADHD and help your child focus energy in positive ways!

4 Winter 2017

Following up on Attention Deficit Hyperactivity Disorder (ADHD)

AntibioticsAntibiotics are important to fight bacterial infections, which are otherwise hard to treat. But if taken incorrectly for illnesses such as cold, flu, ear infection, and sore throat, the bacteria can actually strengthen and medication becomes less effective.

If a doctor prescribes you an antibiotic:

• Don’t skip doses.

• Take all of the prescribed antibiotic unless your doctor says you can stop with medication.

• Make sure you understand how you should take them:– How many times a day?– How much time should pass between each dose?– Should they be taken with food?

When you take antibiotics the right way, you can get better, stay better, and make sure those around you stay healthy, too!

Drug CoverageCertain drugs may not be covered under your plan policy or may cost more out-of-pocket. To see what drugs are covered:

• Sign in to or register for your secure member account at emblemhealth.com.

• Go to emblemhealth.com/formulary.

• Review your member contract.

For more questions, call us at 888-447-7703, Monday to Friday, from 8 am to 6 pm

Learn About Home Delivery or Sign UpVisit our Pharmacy Services page at emblemhealth.com to learn how to register for home delivery and to review drugs covered under your plan.

Health Matters 5Health Matters 5

Rights and Responsibilities: Yours and Ours

Understanding your rights and responsibilities as a plan member helps you — and helps us help you — make the most of your membership. That’s why we ask that you go to emblemhealth.com/members/resources and read your Member Rights and Responsibilities. These outline what you can expect of us, as well as what we expect from you. When you know more about your rights and responsibilities as an EmblemHealth member, it’s easier for us to give you the best health care possible.

What Is Utilization Management? When a health plan uses medical guidelines to consider your need for health care services, this is known as utilization management. EmblemHealth makes these decisions based only on the right level of care, with the most appropriate health care professional, and in the proper medical setting for your health needs.

We never reward doctors or other individuals who conduct utilization management reviews for denying coverage of care.

Get Your Plan Details Online• Health benefits: Learn about covered services; primary, specialty,

hospital, and behavioral care (such as substance-use services); and emergency care, like when to call 911 or visit an urgent care center.

• Out-of-network policies: Look into limits on health care services received from out-of-network doctors. Note: your plan does not cover out-of-network care, except in emergencies. Also learn how to get care when you’re outside your plan’s New York service area.

• Provider network: Identify the network for your plan, get a list of in-network health care providers, and change your primary care physician, if you wish. Also check where you can get care after normal business hours, such as at urgent care centers.

• Prescription drug benefits: Review your plan’s formulary (list of covered drugs) and get details about our prescription drug policies, like preferred medications and certain limits.

• Plan costs: Understand your copays (the fixed amount you pay for health services each time you use them) or other costs for care.

• Claims: Find out how to submit claims for covered services.

• ID card: Download a temporary ID card and request a replacement card, if needed.

• Health resources: Create a personal health record and take a health risk assessment. Also look into our health and wellness programs and find information on health care reform.

• Plan services: Check how to voice a complaint or file an appeal to challenge a decision that impacts your health care coverage or relationship with EmblemHealth. Also see how to access language assistance and translation services, and learn how we assess new medical technology for coverage.

As Your Child GrowsWhen your child becomes an adolescent, it’s time to find the right doctor to help with the transition to adulthood. We’re here to help. Simply go to emblemhealth.com/findadoctor to see a list of doctors in our network suitable for your growing child’s needs. If you have questions, call Customer Service at the phone number on the back of your child’s member ID card and a representative will be happy to help.

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Asthma and Chronic Obstructive Pulmonary Disease (COPD)Colder weather can cause the lungs’ airways to swell and narrow, making breathing harder for someone with a lung condition like asthma or COPD.

Here are some simple ways to live better with asthma and COPD:

• Have an asthma or COPD action plan; take note of what makes your condition worse.

• Try to keep pets off furniture and areas dust-free.

• Do not smoke. Cigarette smoke contains thousands of toxic chemicals that irritate your airways and can lead to shortness of breath.

• Avoid wood burning stoves or fireplaces. People with lung problems are at risk for smoke-related health problems. To stay warm, try an energy-efficient electric heater instead.

• Wear protective gear and breathe through your nose. Cold air can dry out and irritate your airways and can lead to shortness of breath. Try wearing a scarf over your nose and mouth or a cold weather mask.

• Wash sheets in hot water once a week.

• Cut down on yard work and avoid exercising outdoors in cold weather.

If you have asthma, your doctor may prescribe two kinds of medicine:

• Controller: For long-term maintenance, taken every day.

• Reliever: For short-term relief, taken during an asthma attack.

Resources:• To develop your asthma action plan: emblemhealth.com/asthmaactionplan.

• Learn about your inhaler: emblemhealth.com/medicationsafety.

• National Heart, Lung and Blood Institute: nhlbi.nih.gov.

• Stay in touch with your local pharmacist to use your medication safely and effectively.

KEEP IT UP. Make sure you continue to take your prescribed medication.

Call your doctor first if you want to change or stop taking a medicine.

Looking for a Doctor? Provider Directories Are AvailableNeed to find a network pharmacy or medical provider near you? Our online directories are updated daily. Go to emblemhealth.com/findadoctor and follow the links to search our most up-to-date listings.

Health Matters 7

Rights to External Appeal

You have the right to an external appeal for review of a decision when health care services are denied. Services can be denied if they are considered not medically necessary, experimental/investigational, a clinical trial, a rare disease treatment or, in certain cases, as out-of-network. Providers also have their own rights to an external appeal when health care services that you are currently getting or already received are denied. External appeal requests must be submitted to the New York State Department of Financial Services (DFS). DFS will assign an independent medical expert to review the appeal.

This medical expert may overturn your plan’s decision in whole or in part. Or, they may uphold your plan’s denial of coverage. Their decision is binding on both you and your plan.

To appeal to DFS, you first request your plan’s internal or first-level appeal. You have 180 days to request an internal or first-level appeal from your plan after receiving your Adverse Determination (denial). If your plan upholds the original denial, you will receive a letter known as a “Final Adverse Determination.”

You have four months after you receive your final adverse decision on your appeal to ask for an external appeal. If you and your plan agree to skip the plan’s appeal process, you must ask for the external appeal within four months after the agreement with your plan is made.

When we issue a final adverse decision of denial, you will receive instructions on how to file an external appeal along with an external appeal application.

If you have questions or if you need help with an external appeal application, call DFS at 800-400-8882 or visit their website, dfs.ny.gov.

Understand your rights. If you disagree with any coverage decisions we make about your care, you can take steps to appeal our decision.

Flu Season Is Here — Hurry to Get Your VaccineFlu prevention starts with the flu shot. It’s especially important if you have a chronic health condition like asthma, diabetes, or heart disease, if you’re over age 65, or if you’re pregnant. After getting the shot, your body can take about two weeks to start building the antibodies it needs to protect you from the flu. So call your doctor today to schedule your vaccination.

Your plan covers a yearly flu shot at no cost-sharing (no copay, coinsurance, or deductible), as long as you get it from an in-network primary care physician, pharmacy, or retail clinic.

55 Water Street, New York, New York, 10041-8190Presort

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HOW TO CONTACT USEmblemHealth: 888-447-7703 Mon-Fri, 8 am-6 pm (excluding major holidays)

myEmblemHealth app: Download from iTunes or Google Play

NY State of Health Marketplace: 855-355-5777 Mon-Fri, 8 am-8 pm, and Sat, 9 am-1 pm (Call for questions about your tax credits and subsidies.)

Lab Services — Quest Diagnostics:• 888-277-8772 (appointments)• 866-697-8378 (customer service)

Emblem Behavioral Health Services: 888-447-2526

Healthy Beginnings PATH: 877-736-2229 (one-on-one support before and after pregnancy)

Web Resources:• emblemhealth.com• acpny.com (AdvantageCare Physicians)• ehnc.com (EmblemHealth

Neighborhood Care)• emblemhealth.com/familycaregiver

(EmblemHealth’s Care for the Family Caregiver program)

• nystateofhealth.ny.gov (NY State of Health Marketplace)

• questdiagnostics.com/patient (lab services)

Paying Your Monthly Bill Each month you will need to pay EmblemHealth a premium (monthly plan cost). You have four payment options:

1. Auto bill-pay (online). Sign up for this EmblemHealth service, which automatically withdraws your premium from your bank account.

2. Online. Pay through your secure online member account.

3. By phone. Call 888-447-7703 and choose the option to pay by phone — through your checking or savings account, or with your Visa or MasterCard.

4. By mail. Send in a check with the bill you get in the mail.

Visit emblemhealth.com/paymybill for details.

Go Paperless!Going paperless is a great way to reduce clutter, stay organized and store your information in

one safe place. By choosing this option, you’ll receive EmblemHealth communications in your secure online message center at emblemhealth.com, instead of by mail.

Just go to emblemhealth.com and sign in to or register for your secure online account. Once you get to your account home page, select “Go Paperless” under “Tools That Help You.”

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