Major Changes Coming to NYC Employee Health Plan: What Providers Need to Know
Effective January 1, 2026, UnitedHealthcare and EmblemHealth are launching a new streamlined PPO plan for New York City employees. Here's what medical practices need to understand about network participation, claims submission, and reimbursement.
Overview of the NYCE PPO Plan
Starting in 2026, UnitedHealthcare and EmblemHealth will jointly offer the New York City Employees (NYCE) PPO plan, serving City of New York employees, non-Medicare retirees, and their dependents. This consolidation replaces the previous two-card system with a single unified ID card featuring UnitedHealthcare, EmblemHealth, and MAPFRE logos.
Critical Network Structure: Geography Determines Everything
The most important change for providers is the geographic split in network participation:
13 Downstate Counties Using EmblemHealth Network:
Bronx, Duchess, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Ulster, and Westchester
Members receiving care in these counties will use the EmblemHealth Bridge Program for professional and facility services at EmblemHealth contracted rates.
All Other Areas Using UnitedHealthcare Network: Outside the 13 downstate counties, members will use the UnitedHealthcare Choice Plus network at UnitedHealthcare contracted rates.
Contract and Reimbursement Rules
If you have contracts with both payers: Your EmblemHealth contract will be considered in-network if your practice is located in one of the 13 downstate counties. Outside those counties, your UnitedHealthcare contract applies.
If you only have an EmblemHealth contract: You'll be considered out-of-network for NYCE PPO members if your practice is outside the 13 downstate counties — even if you're an EmblemHealth participating provider.
Important exception for behavioral health: Behavioral health professionals are reimbursed based on their UnitedHealthcare contract regardless of location.
Claims Submission: Complete Overhaul
For services before January 1, 2026: Continue using your current submission process through EmblemHealth or Anthem, depending on claim type.
For services on or after January 1, 2026:
All medical claims must be submitted to:
Payer ID: 26992
Mailing address: NYCE PPO Plan, P.O. Box 21534, Eagan, MN 55121
Critical clearinghouse requirement: Any clearinghouse submitting transactions to Payer ID 26992 must route through Optum or an Optum-connected clearinghouse. All 835/ERAs will be sent under existing UMR Payer ID 39026. If you're not enrolled to receive ERAs from this Payer ID, you must complete enrollment now.
Appeals for 2026 services: Mail to CNY Post Service Appeals, P.O. Box 211381, Eagan, MN 55121, using Payer ID 26992.
New Provider Portal Access
A new secure provider portal will launch at nyceppo.com for managing 2026 services, including:
Claims activity review
Eligibility and benefits verification
Authorization request submission
Patient operations
Providers who already have a One Healthcare ID can use the same credentials. The previous portal will remain accessible for pre-2026 dates of service.
Authorization and Member Benefits
Prior authorization: Required for certain in-network services. Requests can be submitted through the new portal at nyceppo.com or by calling the customer service number on the member's ID card.
No PCP selection required: Members are not required to designate a primary care physician.
No referrals needed: Members can see specialists without referrals.
Cost-sharing: Providers may collect copays or coinsurance at the time of service. Balance billing is prohibited for in-network services.
Action Items for Practices
Verify your network status based on your practice location and existing contracts
Update your clearinghouse connections to ensure routing through Optum for the new Payer ID
Enroll for ERA receipt from UMR Payer ID 39026 if not already enrolled
Register for the new provider portal at nyceppo.com before January 1
Train front desk staff to recognize the new ID cards and verify eligibility correctly
Update your billing systems with the new Payer ID 26992 and mailing addresses
Questions and Support
For services before January 1, 2026: Contact EmblemHealth Provider Services at 866-447-9717 or use the EmblemHealth Provider Portal.
For services on or after January 1, 2026: Visit nyceppo.com for information and support.
Bottom Line: This consolidation aims to streamline services, but the geographic network split and new claims routing requirements demand immediate attention from billing departments. Practices must verify their network status and update systems well before the January 1 effective date to avoid claim denials and payment delays.
