Individuals and Small Businesses

New York’s managed care health plans provide comprehensive health care services to nearly eleven million adults, children and seniors. These New Yorkers include those enrolled through their employers and individuals who shop for coverage through the state’s official Marketplace or directly from plans. The following member* stories offer real examples about how plans support the health care needs of their members.

* Some names have been changed to protect member privacy

Julie

Julie M. woke up in the middle of the night and found it difficult to breathe. She couldn’t take in air, and for the otherwise healthy 58-year-old, nothing like this had ever happened before. She was advised to go an emergency department, or a designated cardiac urgent care center like, Enhanced Cardiac Access at 1785 in Clifton Park.

A small wave of comfort washed over Julie to hear the numbers 1785. Julie, who worked in the field of mental and behavioral health care, was called upon in 2019 to serve on her health plan’s Member Advisory Committee to help design of the 1785 building—a joint venture between CDPHP and several local independent specialty medical practices.

Upon arriving, Julie says she was greeted by compassionate and caring staff and had no wait time before being seen. Julie is grateful for the quick, compassionate care she received. “I was able to get results right away and hear the comforting news that it wasn’t serious.”

Michael

“Can you feel lucky that you had a heart attack? I don’t know,” wondered Michael O. It may seem strange to say, but for the 57-year-old artist, college professor, the life-changing experience has not only amplified his artistic creativity, but also taught him more than a little about the importance of self-care and healthy habits.

Within days of his heart attack, clinical staff from CDPHP’s Hospital to Home team connected Michael with Movn, a unique virtual cardiac rehabilitation program developed by a California-based company and first introduced in the Capital Region by CDPHP in early 2021. While the number of patients completing cardiac rehab in a traditional setting has historically been low, Movn has impressive results, with over 80 percent of participants completing the program, 85 percent doing better controlling their blood pressure, and 95 percent adhering to their medications. CDPHP’s medical director says Movn is “a game-changer” when it comes to improving access to cardiac care for members.

For Michael, the convenience of the virtual program is most of what has kept him engaged in his rehab and helped him prioritize self-care overall. Now, a year after his heart attack, Michael feels stronger, has more energy, is eating better, and getting more sleep. And his creativity has grown as well. “A lot of my work has been about preserving objects, material culture, things that I find in archives to use in my art,” he explains. “So now, I guess, I’m in this new place of wanting to preserve myself.”

Simon

Simon W.* is member of United Healthcare. During a vacation in Mexico, Simon’s wife fell very ill and had to be transported to Florida. As her condition worsened, Simon worked with the hospital care coordinator to get his wife back to New York, and was told that transportation by medevac was approved.

He later found out that the care coordinator had made a mistake and the authorization was not approved, forcing him to cancel the medevac reservation. Wanting to get his wife back home so she could receive the care she needed at their local hospital, Simon turned to United Healthcare’s call center and was connected with a Health Advocate. The Health Advocate took immediate action to find a resolution, demonstrating empathy and care throughout the process. Keeping Simon informed every step of the way, the Health Advocate worked with the case manager to expedite the case and get the transportation approved, allowing him to safely get his wife home to receive much needed care.

Krista

Like most people who hear the words, “you’ve got cancer,” Krista G’s immediate thoughts were about treatment — surgery, chemotherapy, radiation, tests, and more. But that’s really just the beginning.

That’s why newly diagnosed Cigna members like Krista are referred to the plan’s Cancer Support Program that offers patients education on what to expect and setting up treatment plans and “sick day” plans, and addresses any gaps in care. When Krista began experiencing anxiety, the cancer program’s whole person care model that provides screenings for stress and depression spotted it quickly and helped connect her to emotional support services. Knowing there was a team to help coordinate providers and assist with her medical and other needs enables Krista to focus on her treatment and recovery.

Jeremy

Even though he had health insurance, when Jeremy D. learned he needed a liver transplant, he and his daughter told his plan, Cigna, they were worried about costs and the strain it might put on Jeremey’s finances.

The Cigna transplant case management team provided information to apply for grant and financial assistance through the American Liver Foundation. They also worked with the drug manufacturer to get a discount on a drug he’d need, reducing the cost by $1,000, which ensured that Jeremy stays in compliance with his medication. The team continued to monitor Jeremy after he was discharged to make sure he was following all appropriate therapies and to provide recovery support services including diabetes management and dietician recommendations.

Ron

After turning 50, Ron W. decided he wanted to lose weight and improve his health. He started some exercise, but needed help making lifestyle changes. Ron had participated in Highmark’s work-site wellness program at his job and was introduced to Highmark’s personalized care management program.

Working with his care manager, he set a modest short-term goal to get his weight down to 200 pounds (from 206 pounds) and a long-term goal of 190 pounds. The care manager suggested purchasing a scale, weighing in twice a week, and monitoring his progress — simple changes. Through education under the care management program, he started making better breakfasts and cooking at home more often, preparing meals ahead of time for the week. Together, Ron and his care manager came up with heathier snack options for work. He also limited his alcohol consumption to 1–2 drinks on occasion and started exercising regularly. After two years of care management, Ron lost 22 pounds — surpassing his long-term goal — and set a new goal to break 180 pounds. Thanks to Ron’s lifestyle changes, he also saw improvements in his work performance, sleep, and stress management — outcomes that have all contributed to a more positive sense of well-being.