NYS Provider & Health Plan Look-Up: Frequently Asked Questions

Below are answers to some Frequently Asked Questions about the NYS Provider & Health Plan Look-Up.

How should I use the information in the NYS Provider & Health Plan Look-Up?

Use the NYS Provider & Health Plan Look-Up when you are shopping for a health plan to see which providers participate with which plans. If you are already enrolled in a health plan, use the NYS Provider & Health Plan Look-Up to see which providers your plan works with.

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Why did NYS Department of Health develop the NYS Provider & Health Plan Look-Up?

Technology has changed the way consumers get information about important health care decisions, including how they pick health plans and providers. The NYS Provider & Health Plan Look-Up was developed to make it easier for consumers to get information about health plan provider networks. Previously, consumers who wanted to find information about health plan provider networks had to visit each health plan’s website. The NYS Provider & Health Plan Look-Up puts network information all in one place.

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What is a health plan network?

A health plan network is the group of providers, practices, and/or facilities that have entered into a contract with a specific health plan to provide covered health care services to the health plan’s members. Network providers, sometimes called participating providers, are providers who have agreed to accept specific reimbursement from health plans for covered services. Seeing an out-of-network provider, sometimes called a non-participating provider, may result in higher out-of-pocket costs for the consumer or may not be covered at all.

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What information is included in the NYS Provider & Health Plan Look-Up?

The NYS Provider & Health Plan Look-Up displays provider network information submitted by NYS licensed health plans for Qualified Health Plans (QHPs), Medicaid Managed Care plans, Child Health Plus plans, commercial health plans, Commercial Non-MCO medical plans, Commercial Non-MCO Dental plans and Commercial Non-MCO Vision plans.

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What is the difference between ‘commercial’ and ‘self-insured’ health plans?

A commercial health insurance plan is paid for by an individual or an organization other than the government and can take several different forms, including: health maintenance organizations (HMOs) / Managed Care Organizations (MCOs), preferred provider organizations (PPOs), exclusive provider organizations (EPOs), point-of-service plans (POS), and indemnity plans. Some employers are “self-insured” or “self-funded” which means that the employer organization assumes the financial risk of providing healthcare.

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What is the source of the information in the NYS Provider & Health Plan Look-Up?

The data in the NYS Provider & Health Plan Look-Up comes directly from health plans. The data currently includes provider network information for Qualified Health Plans (QHPs), Essential Plans, Child Health Plus, Medicaid Managed Care, and HIV Special Needs Plans offered on the NY State of Health Marketplace. The NYS Provider & Health Plan Look-Up also includes provider network information for other NYS Medicaid programs including Managed Long Term Care Plans, Health and Recovery Plans, and Fully Integrated Dual Advantage Plans, Commercial Non-MCO medical plans, Commercial Non-MCO Dental plans and Commercial Non-MCO Vision plans.

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How often is the provider network information updated?

Data in the NYS Provider & Health Plan Look-Up is updated at least every three months, or whenever health plans report a significant change in their network.

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I get health insurance coverage through my employer. Will the provider networks for my health plan be available in the NYS Provider & Health Plan Look-Up Tool?

If you are enrolled in a commercial health insurance plan through your employer, we expect that provider networks for your plan will be in the NYS Provider & Health Plan Look-Up in autumn of 2018. If you are in a self-insured group, information about participating providers and facilities will not be available in this tool.

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If the information is current, why do you suggest that I call my hospital or doctor to confirm participation?

The NYS Provider & Health Plan Look-Up will display the most recently submitted data from each health plan, which may not include changes made within the past 15 days. However, because provider networks can change and systems may not yet be updated, we recommend that consumers always confirm health plan participation with their provider.

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Do I have to do a separate search for each health care provider?

No. The NYS Provider & Health Plan Look-Up has been designed so that you can perform one search for all providers you are interested in seeing. For example, you can perform one search using your family’s three providers to get a list of health plans that network with all three providers.

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Why do two health plans show different specialties for the same doctor?

The NYS Provider & Health Plan Look-Up results page will display a provider’s specialty as submitted by the specific health plan. While in most cases a doctor’s specialty will be the same for all health plans, there are instances where a doctor may participate with health plans for only certain specialties.

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Why do two health plans show different locations for the same doctor?

In some instances, a provider practices in more than one location. Only those office/facility locations shown on the NYS Provider & Health Plan Look-Up results page are considered in-network. Since providers may practice at multiple locations and not all locations may be in network for a specific plan, contact the provider and be sure to verify network coverage at a certain location before making an appointment.

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Can I apply for health coverage through the NYS Provider & Health Plan Look-Up?

No. To apply for health coverage and enroll in a Qualified Health Plan, the Essential Plan, Child Health Plus, or Medicaid, please visit NY State of Health at nystateofhealth.ny.gov or by calling the NY State of Health Customer Service Center at 1-855-355-5777 (TTY 1-800-662-1220). To view the FAQs on the NY State of Health Marketplace, please click here

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Does the NYS Provider & Health Plan Look-Up include information for Medicare Advantage Plans?

No. Medicare Advantage is administered by the federal Centers for Medicare and Medicaid Services. To get information about Medicare Advantage plans, contact the specific health plan(s) or visit the health plans’ websites to search their networks.

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I am enrolled in Medicaid, but I am not in a managed care plan. Will the NYS Provider & Health Plan Look-Up show providers who accept Medicaid fee-for-service?

No, the NYS Provider & Health Plan Look-Up will not display information about providers or facilities that accept Medicaid fee-for-service. You should ask the provider if they accept Medicaid fee-for-service before receiving health care services.

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How does the NYS Provider & Health Plan Look-Up display networks for the plans?

The NYS Provider & Health Plan Look-Up will only provide information on the type of providers and services that participate with the plan. For example, there are no primary care physicians (PCPs) in managed long term care partial capitation plans, so you will not see any results if you search for PCPs for that plan type.

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What should I do if the data appears incorrect or if my provider says that they do not participate with my health plan, but the NYS Provider & Health Plan Look-Up tool says they do?

Report any concerns about potentially inaccurate information in the NYS Provider & Health Plan Look-Up by clicking ‘Contact Us’ at the top of the page, selecting the health plan the issue is about, and completing the required fields. Your concern will automatically be reported to the health plan selected.

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How do I know who will speak my preferred language at the facility?

Results will yield language spoken by a clinical staff member at the practice location.

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How are provider specialties displayed?

The NYS Provider & Health Plan Look-Up will display all specialties of a provider reported by the health plans, on the initial ‘Search by Provider’ results page. Health plans might contract with providers based on primary or secondary specialty at different locations. To view the provider specialty by location, click the “show health plans” button and a list will drop down to view the locations and specialties for that provider.

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How is a Primary Care Provider defined in the NYS Provider & Health Plan Look-Up?

Primary Care Providers (PCPs) are Medical Doctors (MDs), Doctors of Osteopathy (DOs), or Nurse Practitioners (NPs) with a specialty of Family Practice, Family Medicine, Internal Medicine, General Practice, or Pediatrics, who are reported by health plans as providing primary care. One health plan may consider a provider a PCP while another plan considers them a specialist, based on the health plan’s contract with the provider.

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