NYCE PPO Bridge Program Network

Effective Jan 1, 2026 NYC employees, pre-Medicare eligibile retirees and their dependents will be offered the New York City Employees PPO plan (NYCE PPO), a health benefit plan delivered through a partnership between EmblemHealth and United Healthcare. The NYCE PPO Bridge Program will offer IN network coverage focused on providers within the 13 lower New York State counties of Bronx, Dutchess, Kings, Nassau, New York, Orange, Putnam, Queesn, Richmond, Rockland, Suffolk, Ulster and Westchester. Historically, all behavioral health services were managed and paid through the Carelon network. The NYCE PPO Bridge Program network replaces Carelon effective Jan 1. 2026. Members with Emblem GHI PPO will receive new insurance cards and providers should request those new cards before scheduling appointments. You can find more information on this new program at: https://www.emblemhealth.com/providers/resources/nyce-ppo/faqs

Medicare IN PERSON behavioral health session visit requirement

Beginning January 1, 2026, Medicare will require a mental health therapy session be conducted IN PERSON within six months of an initial session and then at least one session annually thereafter. This requirement was originally scheduled to begin 10/1/2025 but congress agreed to extend until January 2026.

Carelon EAP

Effective December 2, 2024 Carelon will discontinue the Case Activity Form (CAF) for submitting EAP services provided to Carelon members. Provider's will now be able to submit EAP claims via CMS 1500 forms. The CPT code to use is 99404 and the modifier to use is HJ.

Harvard Pilgrim Changes

Effective Jan. 1, 2025, non-contracted Harvard Pilgrim providers will no longer be considered IN network. Providers were considered participating if the provider was IN network with Optum/United Behavioral Health’s network. Harvard Pilgrim invites Optum/United providers that are seeing Harvard Pilgrim clients to join the Harvard Pilgrim network at https://www.harvardpilgrim.org/provider/resource-center/join-our-network/

BCBS of Michigan network participation changes for 2025

Starting Jan. 1, 2025, Blue Cross Blue Shield of Michigan and Blue Care Network will disenroll health care providers who haven’t submitted any claims for 24 consecutive months. Disenrollments will occur automatically and will be carried out on a quarterly basis. Blue Cross Blue Shield of Michigan and Blue Care Network notify the providers by letter 60 days in advance. Submitting claims regularly will prevent disenrollment from taking place.

NJ Medicaid FFS

Effective January 1st 2025, NJ Medicaid will be shifting behavioral health services from FFS(fee for service) to MCOs(managed care organizations). MCOs will be responsible for coordinating care and managing payments, rather than providers billing Medicaid directly. The main 5 MCOs are Aetna, Horizon NJ, United Healthcare Community Plan, Wellpoint and Fidelis. The process to credential providers through the MCOs has begun. You can get more information and credentialing contacts here: https://www.nj.gov/humanservices/dmhas/information/stakeholder/DMAHS_BHI/MCO%20BH%20Contact%20Resource%20Guide%20for%20Providers_7.22.2024.xlsx

My podcast episode with Leaders in Medical Billing