NY Manual
SHP Manual

New York Provider Manual
2.3 Healthfirst Commercial Programs | 3.1 Description of the Networks

​2.4 Benefits/Covered Services

Members who participate under a government-sponsored program (Medicaid, Child Health Plus, and Medicare) are entitled to receive all services covered by that program. Benefits among the programs vary. For example, Medicaid members are entitled to receive all the services covered under the Medicaid program, but some services are covered directly by Medicaid Fee-for-Service. Medicare members are entitled to receive all the services under the Medicare program. Further, for Medicare members, the Healthfirst Medicare Plan offers a variety of products that not only cover the services available under Original Medicare, but also offer additional benefits such as dental and vision. Commercial health plan members are entitled to receive all services covered by their plan.

To view a detailed summary of the benefits offered by the Medicaid and CHPlus programs, please refer to the Healthfirst Provider Portal or to our member handbooks located on our website, www.healthfirst.org. For the Medicare programs, please refer to the applicable Summary of Benefits. Any changes to a particular benefit package will be noted in The Source, our provider newsletter, or in other mailings. Copies of these materials are located on our website at www.healthfirst.org/providerservices.  

To view a detailed summary of the benefits offered by the Healthfirst Leaf or HMO A–D plans, please refer to the Summary of Benefits available on our website at www.healthfirst.org/health-insurance/healthfirst-leaf-plans.

Consent to Receive Noncovered Services

If you are unsure whether a requested service is covered by Healthfirst, you must do the following:

  • Determine if the member has coverage through one of the Healthfirst Medicare programs. If they do, refer to Section 15 for instructions.

  • For non-Medicare programs, inform the member that their Healthfirst program may not cover the service. You should contact Member Services directly to confirm whether the service is covered. You should explain to the member that they may also contact Member Services.

  • If Member Services confirms that the service is not covered, advise the member that, they may file a grievance if they disagree with Healthfirst’s interpretation. Information on the process for filing grievances may be obtained by calling Member Services.

  • If Member Services confirms that the service is not covered and the member asks that you provide the noncovered service anyway, you must tell the member the cost of the noncovered service.  You must also explain that the member will be billed directly for, and must pay for, the noncovered service, and that Healthfirst will not be financially responsible for the cost of any noncovered service.

  • You must obtain the member’s written consent, acknowledging that they were advised of the cost of the noncovered service and agreeing to be financially responsible for it. A general consent signed by the member accepting financial responsibility for any services not paid for by Healthfirst is insufficient. The written consent must indicate the specific services and costs for the noncovered service that will be provided.