NYCE PPO: What NYC Employees and Retirees Should Know

Introduction

If you work for the City of New York, your health plan may have changed in the last year. On January 1, 2026, a new plan called NYCE PPO took the place of the GHI CBP plan that many City workers had used for years. Plenty of people were moved into it automatically. So you may be using a plan you never picked and have never read much about.

You don't need to learn every rule to use your plan well. You just need a few facts: who the plan covers, what a visit costs, whether you need a referral, and how to tell if a clinician is in your network.

At Morningside Medical, we want you to feel sure about your coverage before you book. In this article, we explain how NYCE PPO works in plain language. We also cover what to do if your doctor isn't in the network, and how to use the City's yearly transfer period if you're thinking about changing plans.

What is NYCE PPO?

NYCE PPO stands for NYC Employees PPO. According to the plan's FAQ, it's a premium-free health plan offered jointly by EmblemHealth and UnitedHealthcare. It covers medical care, such as doctors and hospitals, under one plan and one member ID card.

PPO stands for preferred provider organization. In general, a PPO gives you a network of clinicians and hospitals. You pay less when you stay in that network, but you can still go outside it and pay more.

Who does the plan cover?

NYCE PPO is available to three groups enrolled in the NYC Health Benefits Program:

• City of New York employees
• Retirees who aren't yet eligible for Medicare
• Eligible dependents of those employees and retirees

Dependents get their own member ID cards. If you've retired and you're eligible for Medicare, NYCE PPO isn't written for you. The City's Office of Labor Relations can tell you which plans apply at nyc.gov/hbp.

What happened to GHI CBP?

The City's fall 2025 notice explained the change. The GHI CBP/Anthem plan was replaced by NYCE PPO on January 1, 2026. Members of the old plan were enrolled in NYCE PPO automatically unless they chose a different plan.

If you still have an old GHI CBP card, it's worth finding your new one. You can view or download your NYCE PPO card from the member portal or mobile app. You can also ask for a copy by calling Customer Service at 212-501-4444 (TTY 711).

The name GHI hasn't gone away, which can be confusing. EmblemHealth still lists other plans with that name, such as GHI Senior Care. If you aren't sure which plan you have, look at your ID card or call the number on the back.

How the network works

NYCE PPO uses two networks, and the one that applies depends on where you get care.

In the downstate area. EmblemHealth's network covers New York City, Long Island, and the Hudson Valley counties of Dutchess, Orange, Putnam, Rockland, Ulster, and Westchester. The plan says this network includes 78,000 doctors, health care professionals, and hospitals.

Everywhere else. Outside that area, you use the UnitedHealthcare Choice Plus network. The plan says it has more than 1.6 million in-network providers across the country. It also covers nearby places outside the downstate area, such as Bergen County in New Jersey and Fairfield County in Connecticut. Mental and behavioral health care uses UnitedHealthcare's network.

Here's a detail that's easy to miss. Inside the downstate area, a UnitedHealthcare provider is in network only if they're also in EmblemHealth's network. If they aren't, the plan treats them as out of network. So a doctor who says "we take UnitedHealthcare" may not be in network for you. Always check using NYCE PPO's own search tool.

Preferred, participating, and out-of-network care

NYCE PPO has three levels of care. What you pay depends on which level your clinician falls into. The numbers below come from the plan's summary for July 2026 through June 2027. Plans can change, so check your own documents too.

Preferred providers. These are a smaller group of clinicians and facilities where you'll likely pay less, or even nothing, for certain services. The plan lists AdvantageCare Physicians, NYC Health + Hospitals, Memorial Sloan Kettering, and Hospital for Special Surgery among them. Preferred status applies only in the downstate area. Primary care and specialist visits are listed at no charge.

Participating providers. These are the rest of the in-network clinicians. The summary lists a $15 copay for a primary care visit and a $30 copay for a specialist visit. It also lists a $20 copay per visit for blood work and for X-rays. A copay is a set amount you pay for a service. Morningside Medical is a participating provider.

Out-of-network providers. If you see someone outside the network, you first meet a deductible of $200 per person or $500 per family. After that, you pay the difference between what the plan allows and what the provider charges. That can add up, and the plan warns that you may get a bill for the difference.

In network, the plan has no overall deductible. Preventive care, such as a yearly checkup, is listed at no charge for both preferred and participating providers. The summary also notes that you may have to pay for services that aren't preventive, so ask if you're not sure.

Do you need a referral?

No. The plan's FAQ is direct on this point: NYCE PPO does not require referrals. Its summary says you can see the specialist you choose without one.

That makes a real difference if you need a specialist. If your joints keep swelling or you have a blood test that needs follow-up, you can book with a rheumatologist directly. You don't have to get a primary care visit first, though your primary care clinician can still help you decide where to go.

Some services may still need prior authorization. That means the plan has to approve them first. The summary lists certain imaging services as one example. Your provider is responsible for getting these approvals, but the plan says it's your job to confirm they were obtained before treatment. A quick question at the office can save you a surprise later.

Do you need a primary care provider?

The plan doesn't require you to have one. But the FAQ makes the case for choosing one anyway, and we agree. A primary care clinician knows you and your health. They can help with everyday care, preventive checkups, and ongoing conditions. They can also help coordinate your care if you see a specialist.

It's also a good use of your benefits. If you haven't had a checkup in a while, preventive care is listed at no charge. If you also bring up a new problem, that part of the visit may not count as preventive, and a copay may apply. It's fine if it's been years since you saw a doctor. A first visit is simply a chance to go over your health history, your medications, and any screenings you're due for.

How to find an in-network clinician

The plan gives you two ways to check:

1. Search the provider tool at nyceppo.com.
2. Call Customer Service at 212-501-4444 (TTY 711).

Check before your first visit, even if a clinician's website lists the plan. Networks can change. Some clinicians also take part in one network but not another. When you call, you can ask these questions:

• Is this clinician in the NYCE PPO network?
• Are they a preferred or a participating provider?
• What will I pay for this type of visit?
• Does this visit need prior authorization?

It also helps to ask the office whether new patients are welcome and how soon you can be seen.

What if your doctor isn't in the network?

You have a few choices. According to the FAQ, your doctor can ask to join the EmblemHealth or UnitedHealthcare network. You can also keep seeing your doctor using the plan's out-of-network benefit, which generally costs more. Or you can use the search tool to find a new clinician in the network.

If you're joining NYCE PPO while under active treatment for certain medical conditions, the plan also describes transition of care coverage. If approved, it can let you keep seeing a doctor for up to 90 days from the day you start on the plan, or through delivery and related postpartum care if you're pregnant. You need to ask before your first visit as a NYCE PPO member. If you moved to the plan in January 2026, that 90-day window has passed. Call Customer Service to find out if this applies to you.

Same-day care, urgent care, or the ER?

When you get sick, where you go can change what you pay. The plan's summary lists these amounts for participating providers:

• A primary care visit: $15 copay
• Urgent care: $50 copay, or $100 at CityMD and ProHealth in the downstate area
• The emergency room: $150 copay, which is waived if you're admitted within 24 hours

For a sore throat, a urinary tract infection, or a rash, a same-day primary care visit keeps your care with a practice that can handle your follow-up. If the office is closed and the problem can't wait, urgent care is there for you. The right choice depends on what's wrong. Cost should never keep you from emergency care. Call 911 or go to the nearest emergency room for severe chest pain or pressure, trouble breathing, signs of a stroke, or heavy bleeding.

Many practices offer same-day visits, but they don't all use the same rules. Before you count on one, ask whether new patients can book it and whether you need an appointment first.

Prescriptions and your union

Drug coverage is where City plans can feel the most complicated, because it depends on your union. If you get prescription coverage through EmblemHealth, it runs through Prime Therapeutics, and you use your NYCE PPO card. If your coverage comes through your union, you use that card instead.

The plan's FAQ covers common questions about pharmacies and home delivery. If you take a medicine regularly, it's worth checking your drug list on the member portal, since the list can change.

Thinking about changing plans?

City employees can change health plans during the yearly fall transfer period. According to the Office of Labor Relations, the 2026 period runs from November 1 through November 30, and changes take effect in January 2027.

If you're happy with NYCE PPO, you may not need to do anything. If you're comparing plans, these questions can help:

• Is your current clinician in the plan's network?
• Do you want to see specialists without a referral?
• Does the plan require you to choose a primary care provider?
• What will you pay for the visits you make most often?

The rules for each group can differ, so check the current notice at nyc.gov/hbp or ask your benefits office before you decide.

Getting the most from your plan

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

• Keep your card handy. You can find it in the member portal or app.
• Check before you book. A two-minute search can save you a bill you didn't expect.
• Use your preventive care. Yearly checkups and many screenings are there for a reason.
• Ask what's preventive. If a visit covers a new problem, part of it may not count as preventive.
• Choose a primary care clinician. Even when your plan doesn't require one, it helps to have someone who knows you.

How Morningside can help

Morningside Medical is a participating provider with NYCE PPO. All of our clinicians are accepting new patients and are in network for the plan, including for rheumatology and telehealth. Being in network doesn't mean every service is covered. For example, the plan's summary lists weight loss programs as not covered, so check before you book. Same-day appointments are available during all open hours, Monday through Friday, and new patients can book them.

If you're new to NYCE PPO or haven't seen a clinician in a while, we'd be glad to help you get started. Please confirm your coverage with NYCE PPO 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.