GHI vs. HIP: How Your EmblemHealth Plan Works

Introduction

If you live in New York City, there's a good chance your health plan has the name EmblemHealth on it. Your card might also say GHI or HIP. Many people use these names as if they mean the same thing, and others aren't sure which one they have. That's easy to understand, since the names have been around for decades and the plans behind them have changed many times.

The difference matters, though. Whether your plan is a GHI plan, a HIP plan, or a state plan like Medicaid or the Essential Plan can decide whether you need a referral, whether you have to choose a primary care provider, and which clinicians you can see.

At Morningside Medical, we want you to feel sure about your coverage before you book. In this article, we explain where GHI and HIP came from, how to tell which plan you have, and what that means when you need care. We also cover EmblemHealth's Medicaid, Essential Plan, and Medicare plans, and how to check that a clinician is in your network.

Where GHI and HIP came from

GHI and HIP started as two separate health plans in New York. GHI stood for Group Health Incorporated. HIP stood for the Health Insurance Plan of Greater New York. According to EmblemHealth's history of the company, its roots go back to the 1930s, and the two plans later merged to become EmblemHealth.

The old names didn't disappear. Today, EmblemHealth still uses them in the names of its plans and networks. A network is the group of clinicians, hospitals, and labs a plan works with. If you stay in your plan's network, you pay less, and some plans don't cover care outside it at all.

Here's the simplest way to think about the two names:

• GHI is the name tied to EmblemHealth's PPO plans and network. PPO plans usually let you see specialists without a referral.
• HIP is the name on many of EmblemHealth's HMO plans, such as HIP HMO Preferred and HIP Prime HMO. HMO plans usually ask you to choose a primary care provider, and some need a referral before you see a specialist.

That's a general rule, not a promise for every plan. Some HIP plans don't need referrals, and some plans use more than one network. Your own plan documents are the final word.

What happened to GHI CBP?

For years, many City of New York workers had a plan called GHI CBP. On January 1, 2026, the City replaced it with a new plan called NYCE PPO. Many members were moved into it automatically.

NYCE PPO is offered by EmblemHealth and UnitedHealthcare together. It doesn't require referrals. If you used to have GHI CBP, read our guide to what NYC employees and retirees should know about NYCE PPO.

The GHI name is still in use for other City plans. GHI Senior Care is the plan many Medicare-eligible City retirees use. According to the City's 2025 retiree notice, Medicare-eligible retirees and their Medicare-eligible dependents continue to get their benefits through GHI Senior Care. So if you're a City retiree with Medicare and your card says GHI, you most likely have GHI Senior Care, not NYCE PPO.

How to tell which plan you have

Your member ID card is the best place to start. EmblemHealth tells clinicians to check the card to see which networks a member can use. Look for:

• The plan name, such as HIP HMO Preferred, EmblemHealth PPO, Enhanced Care, or Essential Plan.
• The network name, such as Prime, Select Care, or Enhanced Care Prime.
• A primary care provider's name, if your plan uses one.
• The member services phone number, usually on the back.

If you're not sure what a line on your card means, our article on how to read your insurance card explains the most common parts. You can also log in to your account at my.emblemhealth.com to see your plan details, or call the number on your card.

Keep in mind that a card doesn't guarantee coverage. Plans can end or change, and your card may be out of date. If you've changed jobs, aged into Medicare, or renewed your coverage through the state, check that your card is current.

Do you need a referral?

A referral is an OK from your primary care provider to see a specialist. Some plans require one before they'll pay for a specialist visit. Others let you book directly.

EmblemHealth's summary of its plans and networks shows which plans need one. Here's what it lists:

Usually no referral needed:

• Medicaid (Enhanced Care) and HARP (Enhanced Care Plus)
• Child Health Plus
• Essential Plan 1 through 4
• EmblemHealth PPO and EPO plans
• HIP Prime POS
• Individual and family plans in the Select Care and Millennium networks
• NYCE PPO
• Many VIP Medicare plans, such as VIP Gold

Referral usually needed:

• HIP Prime HMO and EmblemHealth HMO Plus through an employer
• HIP HMO Preferred, an HMO plan for City of New York employees
• Some VIP Medicare plans offered through an employer, such as VIP Premier

For HIP HMO Preferred, EmblemHealth's plan page says you need a referral from your primary care provider to see most specialists. It lists a few exceptions that don't need one: OB-GYN care, outpatient mental health visits, chiropractic care, and diabetes eye exams.

If your plan needs a referral, the easiest path is to have a primary care provider who can send you to the right specialist. Some practices can handle both steps. At Morningside, for example, a Morningside primary care provider can refer adults to our rheumatology team.

Do you need a primary care provider?

A primary care provider, or PCP, is the clinician who handles your everyday care. They do your yearly checkups, manage ongoing problems like high blood pressure, and help you decide when you need a specialist.

Some EmblemHealth plans ask you to choose a PCP and list them with the plan. HIP HMO Preferred is one. Its plan page says choosing a PCP is "one of the first things to do," and your PCP also affects what you pay. EmblemHealth's provider summary shows that Medicaid and HARP members, and members of many VIP Medicare plans, need a PCP too.

Other plans don't. NYCE PPO, for example, doesn't require one, according to its FAQ. Even so, it's a good idea to have a PCP. A clinician who knows your history can catch problems early and keep your care in one place.

How to change your PCP. If your plan uses a PCP and you want to switch, you can call member services at the number on your card. An EmblemHealth member guide also describes a "Change PCP" link in the member portal. When you make the change, ask two questions:

1. When does the change take effect?
2. Can I have a reference number for the call?

Wait until the change takes effect before you book with your new PCP. If you see a different primary care clinician before then, your plan may not pay for the visit.

EmblemHealth Medicaid, HARP, and Child Health Plus

EmblemHealth runs three plans for New Yorkers who qualify for state coverage. According to EmblemHealth's overview of these plans:

• Enhanced Care is EmblemHealth's Medicaid plan. It's open to people of all ages, with no monthly premium and no copays for primary care, specialist, or telehealth visits.
• Enhanced Care Plus is EmblemHealth's HARP plan, for adults 21 and older. HARP stands for Health and Recovery Plan. It covers the same benefits as Medicaid, plus extra help with physical and behavioral health needs.
• Child Health Plus covers children under 19. Monthly premiums depend on family income and size.

None of these plans need a referral to see a specialist. EmblemHealth removed that rule on January 1, 2023. They do cover in-network care only, except in an emergency. So it's important to check that a clinician is in network before your visit.

To qualify, you must live in EmblemHealth's service area, which includes the five boroughs, Long Island, and Westchester County. Your eligibility is confirmed by NY State of Health or your local social services office. In New York City, that's the Human Resources Administration (HRA).

The Essential Plan

The Essential Plan is a state health plan for New Yorkers who earn too much for Medicaid but still need low-cost coverage. EmblemHealth is one of the insurers that offers it.

According to EmblemHealth's Essential Plan page, its Essential Plan has:

• $0 monthly premiums
• $0 preventive care, such as yearly checkups
• No referrals needed to see a specialist
• Adult dental and vision care included
• In-network care only

The plan comes in four levels, Essential Plan 1 through 4. Which one you get depends on your income and other factors.

A recent change. New York had expanded the Essential Plan to cover more people. That expansion ended on July 1, 2026. According to the New York State Department of Health, about 1.3 million New Yorkers with incomes below 200% of the federal poverty level keep their Essential Plan coverage. About 450,000 people with higher incomes became eligible for other plans instead, which may have monthly premiums and deductibles.

If you got a notice that your Essential Plan coverage is ending, or you aren't sure where you stand, contact NY State of Health at nystateofhealth.ny.gov or 1-855-355-5777. They can help you for free.

EmblemHealth Medicare plans

EmblemHealth's Medicare Advantage plans use the name VIP, such as VIP Gold and VIP Dual. Medicare Advantage plans replace Original Medicare with a private plan that follows Medicare's rules.

EmblemHealth's provider summary shows that many VIP plans don't need referrals but do use a PCP. Some VIP plans offered through an employer need both. Check your card, and call member services if you're not sure.

GHI Senior Care works differently. It's a Medicare supplement for City of New York retirees, which means it works alongside Original Medicare instead of replacing it.

How to check that a clinician is in network

Before your first visit, take two minutes to confirm the clinician is in your plan's network. EmblemHealth gives you two ways to check:

1. Search the Find a Doctor tool at emblemhealth.com.
2. Call the member services number on the back of your card.

Check even if a practice's website lists EmblemHealth. Some practices take part in one EmblemHealth network but not another. When you call, it helps to ask:

• Is this clinician in the network for my plan?
• Do I need a referral for this visit?
• Does my plan need me to choose a primary care provider first?
• What will I pay for this type of visit?

It's also worth asking the practice whether it's accepting new patients and how soon you can be seen.

Same-day care with EmblemHealth

When you get sick, a same-day visit with a primary care practice is often a good first step. You can be seen for things like a sore throat, a urinary tract infection, or a rash, and the same practice can handle your follow-up. If your plan has you choose a PCP, a primary care visit is usually covered only with the PCP listed on your plan. Call the number on your card before you book a sick visit with a different primary care practice.

For a medical emergency, don't wait. Call 911 or go to the nearest emergency room for severe chest pain or pressure, trouble breathing, signs of a stroke, or heavy bleeding. EmblemHealth's plan pages say emergency care is covered even outside the network.

Getting the most from your EmblemHealth plan

A few simple habits can make your plan easier to use:

• Know your plan's name. GHI, HIP, Medicaid, and the Essential Plan all work a little differently.
• Check your card. Make sure it's current, and look for a PCP's name if your plan uses one.
• Ask before you book. Confirm the clinician is in network for your plan.
• Use your preventive care. Yearly checkups and many screenings are covered at no cost on most plans.
• Have a primary care provider. Even when your plan doesn't require one, a clinician who knows you makes care simpler.

How Morningside can help

Morningside Medical is in network with EmblemHealth, including HIP and GHI plans, Enhanced Care (Medicaid), Enhanced Care Plus (HARP), Essential Plan 1 through 4, Child Health Plus, VIP Medicare plans, and GHI Senior Care. We're also a participating provider for NYCE PPO. You can see the full list on our EmblemHealth page.

All of our clinicians are accepting new patients. Same-day appointments are available during all open hours, Monday through Friday, and new patients can book them. We also offer telehealth visits, plus labs and ultrasound at our office. New rheumatology patients are being seen now. We don't take walk-ins, so please book first. Spanish translation is available.

Please confirm your coverage with EmblemHealth before your visit, since some details depend on your plan.

This article is for general information and is not a substitute for professional medical advice. Talk to your clinician about your specific situation.

You're always welcome to book an appointment.