NY Manual
SHP Manual

New York Provider Manual
1.1 Introduction to the Provider Manual | 1.3 Network Management and Provider Services

1.2 About Healthfirst, Inc.

Healthfirst, Inc.

Healthfirst was founded in the early 1990’s by a consortium of hospitals under the auspices of the Greater New York Hospital Association.  An independent not-for-profit corporation since 1993, it has from its inception operated pursuant to a unique model that relies on population health management efforts on the part of its hospital sponsors and provider network supported by the infrastructure of an established and regulated health plan.  Funds saved through higher quality and better care management are returned to the provider delivery system.  Healthfirst has steadily expanded its product offerings from its start in Medicaid managed care to Medicare Advantage Prescription Drug (MAPD) plans, long term care, and commercial products offered on the New York State of Health (commonly known as the Exchange) branded at Healthfirst Leaf and Leaf Premier Plans.  With more than a million members and top quality and member satisfaction rankings, Healthfirst’s business model relies on empowering and partnering with the provider system and the community to achieve the superior outcomes and culturally competent healthcare for its customers.

Healthfirst PHSP, Inc.

Since 1994, Healthfirst has operated a Prepaid Health Services Plan (PHSP) serving Medicaid members in New York City under a certificate of authority granted by the State of New York. In 1995, the Healthfirst operating area was expanded to include Long Island. Healthfirst PHSP was developed to meet the objectives of New York State’s Managed Care Act, which changed the way healthcare was delivered for Medicaid recipients. In 1999, Healthfirst implemented its Child Health Plus (CHPlus) program to expand its ability to provide healthcare services to eligible children through participation in the state’s CHPlus Program. This offers reasonably priced healthcare coverage for the children of working parents who do not qualify for Medicaid and cannot afford unsubsidized health insurance.

Healthfirst Health Plan, Inc.

Healthfirst Health Plan, Inc. (HFHP) is the licensed HMO doing business as Healthfirst Medicare Plan and Healthfirst New York (commercial). Formerly known as Managed Health, Inc., HFHP was first managed by Healthfirst in July 1997 and then became a subsidiary of Healthfirst in August 1998. The service areas for the Healthfirst Medicare Plan include the Bronx, Brooklyn, Manhattan, Queens, Staten Island, Nassau and Westchester counties (not all plans are available in all counties). The service areas for Healthfirst New York include the Bronx, Kings, Manhattan, Queens, Richmond, Nassau and Suffolk counties.

Provider Participation

Healthfirst hospitals and their affiliated providers may be contracted to participate in one Healthfirst program or in a combination of programs (see Section 2). Because contracting differs among the programs, it is important to note that a provider who is contracted to provide services for one program is considered to be out-of-network for all of the other programs. Additionally, participation is office-site specific. While a contract may cover multiple locations, if an application has not been submitted or approved for a particular office, services rendered there are considered out-of-network. To confirm the programs that you participate in, contact Provider Services.

Each of the Healthfirst companies, Healthfirst, Inc., Healthfirst PHSP, Inc. and Healthfirst Health Plan, Inc. do business under the “Healthfirst” name. Throughout this provider manual the term “Healthfirst” refers to all three companies collectively. When referring to a specific company or a specific line of business, the specific company name is used, i.e., “Healthfirst Health Plan, Inc.” or “Healthfirst PHSP, Inc.”, and the specific product name if a specific product is used, i.e., “Medicare” or “Medicaid.”