There will be a change to Empire’s ACA individual health benefit plans which impacts products sold on and off the New York State of Health Insurance Marketplace (also commonly called the Exchange) effective January 1,2019. 


Starting January 1, 2019:

  • Members will be required to select a Primary Care Physician (PCP) when enrolling in one of the plans listed below.  You will be able to verify the member’s PCP on Availity (
  • Referrals will be required for all specialist visits. The referral form can be found on Commonly Used Forms and Quick Guides – General Forms
  • No Out of Network coverage except in emergency.  Emergent care is covered in and out of network at the member in network cost share. For Out of Area urgent care, only services from a Blue Card provider will be covered.  In network member cost share applies.


Individual Health Benefit Plans utilizing the Pathway Network:


Network Name

Full Product Name


PCP Required

Referral Required

Out-of-Network Benefits

Pathway Enhanced, Gated

Empire Gatekeeper Bronze

Empire Gatekeeper Silver

Empire Gatekeeper Gold

Empire Gatekeeper Platinum

Empire Gatekeeper Catastrophic





Pathway X Enhanced Gated

Empire Gatekeeper X Bronze

Empire Gatekeeper X Silver

Empire Gatekeeper X Gold

Empire Gatekeeper X Platinum

Empire Gatekeeper X Catastrophic






Featured In:
December 2018 Empire Provider Newsletter