CompleteCare (HMO D-SNP) - Member Handbook - Healthfirst

Page created by Jerome Manning
 
CONTINUE READING
CompleteCare (HMO D-SNP) - Member Handbook - Healthfirst
CompleteCare (HMO D-SNP)
                                Member Handbook

This handbook will tell you how to use your Healthfirst plan.
Keep this handbook where you can find it when you need it.

January 1–December 31, 2022
New York: Bronx, Kings, Nassau, New York, Orange, Queens,
Richmond, Rockland, Sullivan and Westchester Counties
                                                            H3359_MSD22_28 1066-21_C
CompleteCare (HMO D-SNP) - Member Handbook - Healthfirst
Important Phone Numbers
  HEALTHFIRST CORPORATE OFFICE: 100 Church Street, New York, NY 10007
                             •   change your PCP
                             •   with questions about benefits and services   1-888-260-1010
  Member Services            •   replace an ID card                           (TTY 1-888-542-3821)
  can help you:              •   report a birth                               8am–8pm, 7 days a week, Oct. to
                             •   with referrals                               Mar; Mon. to Fri., Apr. to Sept.
                             •   enroll in a medical management program
  HEALTHFIRST NETWORK PROVIDERS
                             • select a primary care dentist                  1-800-508-2047
  Dental                     • inquire about services covered
                                                                              Monday to Friday, 8am–8pm
                             • find a dentist’s location
                             • inquire about benefit coverage                 1-800-753-3311
                                                                              Monday to Friday, 8am–11pm
  Vision                     • locate participating eye doctors
                                                                              Saturday, 9am–4pm
                                (optometrists and opticians)                  Sunday, 12pm–4pm
  NationsHearing             • schedule hearing exams                         1-877-438-7251
  Hearing                    • get help purchasing hearing aids               Monday to Friday, 8am–8pm
                                                                              1-888-260-1010
                             • submit a pharmacy claim
  Pharmacy                   • inquire about drug coverage and
                                                                              (TTY 1-888-542-3821)
  Prescriptions                 prescription-related issues                   8am–8pm, 7 days a week, Oct. to
                                                                              Mar; Mon. to Fri., Apr. to Sept.
  GOVERNMENT OFFICES
                                             1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048)
  Medicare                                   24 hours a day, 7 days a week
  Elderly Pharmaceutical                     1-800-332-3742 (TTY 1-800-290-9138)
  Insurance Coverage Program                 Monday to Friday, 8am–5pm

  Local Department of Social Services (Please Fill In)
  Use this space to fill out you and your family’s provider information.
  Member Name:               PCP Name:
                             Phone Number:
                             Address:
  Member Name:               PCP Name:
                             Phone Number:
                             Address:
  Member Name:               PCP Name:
                             Phone Number:
                             Address:
  IMPORTANT COMPLETECARE PHONE NUMBERS
                                                                         1-888-260-1010 (TTY 1-888-542-3821)
  Member Services                                                        8am–8pm, 7 days a week, Oct. to Mar;
                                                                         Mon. to Fri., Apr. to Sept.
  New York State Health Dept. (Complaints)                               1-866-712-7197
  New York City - Human Resources Administration (HRA)
                                                                         1- 888-692-6116 or 1-718-557-1399
  Medicaid Helpline
  Nassau - Medicaid                                                      1-516-227-8000

  Orange - Medicaid                                                      1-845-291-4000

H3359_MSD21_13 1555-20_C1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org                                         i1
IMPORTANT COMPLETECARE PHONE NUMBERS
       Rockland - Medicaid Unit                                             1-845-364-3040
                                                                                                                      TABLE OF
       Sullivan - Medicaid                                                  1-845-292-0100 or 1-845-292-5910          CONTENTS
       Westchester - General Information/Case Management
                                                                            1-914-995-5000 or 1-914-995-3333
       Information Center (CMIC)                                                                                      Important Phone Numbers. . . . . . . . . . . . . . . . . . i                     Services not covered by the plan or
                                                                                                                                                                                                       by Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . .  15
       New York Medicaid CHOICE (For Long-Term Care Information)            1-888-401-6582 (TTY 1-888-329-1541)       Welcome to Healthfirst CompleteCare
                                                                                                                      (HMO D-SNP) Medicaid Advantage Plus Plan. . .  2                               How do I get approval for treatments or
       New York Medicaid CHOICE (All Other Reasons)                         1-800-505-5678 (TTY 1-888-329-1541)                                                                                      services?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  15
                                                                                                                      Membership Card. . . . . . . . . . . . . . . . . . . . . . . . .  2
       The Health Insurance Information                                                                                                                                                                Service Authorization Request (also known
                                                                            1-800-701-0501
       Counseling and Assistance Program (HIICAP)                                                                     Help from Member Services. . . . . . . . . . . . . . . .  2                      as Coverage Decision Request). . . . . . . . . . .  15
      For medical emergencies, please call 911, or go to the nearest emergency room, an urgent care center, or a      Who is eligible for enrollment in Healthfirst                                    Which services require prior authorization?. 15
      medical center. You will be asked to present your Healthfirst Member ID card when you receive emergency care.   CompleteCare Medicaid Advantage Plus Plan?.2
                                                                                                                                                                                                       What happens after we get your service
                                                                                                                      What is the enrollment process for Healthfirst                                   authorization request. . . . . . . . . . . . . . . . . . . .  16
                                                                                                                      CompleteCare Medicaid Advantage Plus?. . . . . 3
                                                                                                                                                                                                       If we are changing a service you are
                                                                                                                        Withdrawal of Enrollment .. . . . . . . . . . . . . . . .  4                   already getting . . . . . . . . . . . . . . . . . . . . . . . . .  16
                                                                                                                      What are my rights and responsibilities as                                     What To Do If You Want To Appeal
                                                                                                                      a Healthfirst CompleteCare member? . . . . . . 4                               A Decision About Your Care. . . . . . . . . . . . . . .  18
                                                                                                                        Responsibilities of Members. . . . . . . . . . . . . . . 5                     Level 1 Appeals (also known as
                                                                                                                                                                                                       a Plan Level Appeal). . . . . . . . . . . . . . . . . . . . .  18
                                                                                                                        Your Right to Use an Advance Directive . . . . . 5
                                                                                                                                                                                                       Timeframes for a “standard” appeal . . . . . . . 20
                                                                                                                        Notice of Information Available on Request . .6
                                                                                                                                                                                                       Timeframes for a “fast” appeal. . . . . . . . . . . . 20
                                                                                                                        We Will Treat You with Fairness and Respect
                                                                                                                        at all Times . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7     Level 2 Appeals. . . . . . . . . . . . . . . . . . . . . . . . .  21
                                                                                                                      Transitional Care. . . . . . . . . . . . . . . . . . . . . . . . . .  7          External Appeals for Medicaid Only. . . . . . . . 22
                                                                                                                      Monthly Surplus. . . . . . . . . . . . . . . . . . . . . . . . . .  7          What To Do If You Have A Complaint
                                                                                                                                                                                                     About Our Plan. . . . . . . . . . . . . . . . . . . . . . . . . . 23
                                                                                                                      Money Follows the Person (MFP)/Open Doors.  7
                                                                                                                                                                                                       How to File a Complaint. . . . . . . . . . . . . . . . . 23
                                                                                                                      Services Covered by Healthfirst CompleteCare. . 8
                                                                                                                                                                                                       Complaint Appeals. . . . . . . . . . . . . . . . . . . . . . 24
                                                                                                                        Deductibles and Copayments on Medicare
                                                                                                                        Covered Services. . . . . . . . . . . . . . . . . . . . . . . .  8             How to make a complaint appeal. . . . . . . . . 24
                                                                                                                        Who is part of my Healthfirst CompleteCare                                     What happens after we get
                                                                                                                        Care Team?. . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8         your complaint appeal. . . . . . . . . . . . . . . . . . . 24
                                                                                                                        What additional services are covered by                                      Disenrollment from Healthfirst CompleteCare 24
                                                                                                                        Healthfirst CompleteCare?. . . . . . . . . . . . . . . .  8
                                                                                                                                                                                                       Termination of Benefits from Voluntary
                                                                                                                      Can I get care outside of the Service Area?. .  13                               Disenrollment. . . . . . . . . . . . . . . . . . . . . . . . . . 24
                                                                                                                      Emergency Service. . . . . . . . . . . . . . . . . . . . . . .  13               Involuntary Disenrollment. . . . . . . . . . . . . . . .  25
                                                                                                                        If you have a medical emergency. . . . . . . . . 13                            Effective Date of Disenrollment and
                                                                                                                                                                                                       Coordination of Transfer to Other
                                                                                                                        What is covered if you have a medical                                          Service Providers . . . . . . . . . . . . . . . . . . . . . . . 26
                                                                                                                        emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14
                                                                                                                                                                                                       Re-Enrollment Provisions. . . . . . . . . . . . . . . . 26
                                                                                                                        What if it wasn’t a medical emergency? . . . . 14
                                                                                                                                                                                                     Notice of Non-Discrimination. . . . . . . . . . . . .  27
                                                                                                                        Payment of medical emergency services . . . 14
                                                                                                                                                                                                     Language Assistance Information. . . . . . . . . . 28
                                                                                                                      What Services are not covered by
                                                                                                                      Healthfirst CompleteCare?. . . . . . . . . . . . . . . .  14
                                                                                                                        Services covered by Original Medicare. . . . .  15

2ii    CompleteCare Member Handbook                                                                                                                       1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org                                                                          3
WELCOME to                                                                                                                                                            Who is eligible for                                         What is the enrollment process                          Step 3: Nurse Assessment

    Healthfirst CompleteCare                                                                                                                                              enrollment in Healthfirst                                   for Healthfirst CompleteCare                             ■    ur Clinical Eligibility Nurse will conduct a
                                                                                                                                                                                                                                                                                                   O
                                                                                                                                                                                                                                                                                                   telephonic or home assessment within 30 days
    (HMO D-SNP) Medicaid                                                                                                                                                  CompleteCare Medicaid                                       Medicaid Advantage Plus Plan?                                after you request to enroll in CompleteCare, or

    Advantage Plus Plan                                                                                                                                                   Advantage Plus Plan?                                        Step 1: Confirm Eligibility for long-term care               from CFEEC’s referral.
                                                                                                                                                                                                                                      services
                                                                                                                                                                          You are eligible to enroll in this plan if you meet the                                                              ■   Our Clinical Eligibility Nurse will ask you for
    Healthfirst CompleteCare (HMO D-SNP) Medicaid
                                                                                                                                                                          following criteria:                                         People who would like to join Healthfirst                    verbal consent to let him/her assess your
    Advantage Plus Plan is for people who have Medicare
                                                                                                                                                                                                                                      CompleteCare and who are new to Community                    healthcare needs and clinical eligibility.
    and full Medicaid, and who need long-term care                                                                                                                          ■   you are age 18 or older.
    services.                                                                                                                                                                                                                         Based Long-Term Care Services must call the              ■   Our nurse will ask you to provide verbal
                                                                                                                                                                                are Medicare Part A and B eligible                    Conflict-Free Evaluation and Enrollment Center
                                                                                                                                                                            ■                                                                                                                      consent that lets your healthcare providers
    This handbook tells you about the added benefits                                                                                                                                                                                  (CFEEC) at 1-855-222-8350, Monday to Friday,
                                                                                                                                                                                                                                                                                                   give us your medical information, where
    you get from CompleteCare. It also tells you how                                                                                                                        ■   Medicaid Community with Long Term Care eligible       8:30am–8pm; Saturday, 10am–6pm; or visit
                                                                                                                                                                                                                                                                                                   applicable. In this instance a blank copy
    to ask for a specific service, file a complaint, or                                                                                                                                                                               nymedicaidchoice.com to find out if they are
                                                                                                                                                                                live in the plan’s service area (Bronx, Kings                                                                     will be mailed to your home for a signature to:
    disenroll from the plan. The benefits in this handbook                                                                                                                  ■
                                                                                                                                                                                                                                      eligible to join. A conflict-free evaluation is only
    are in addition to the Medicare benefits in the                                                                                                                              (Brooklyn), Nassau, New York (Manhattan),            needed if you are new to long-term care services              ➤ identify your healthcare needs (also called
    CompleteCare Medicare Evidence of Coverage                                                                                                                                   Orange, Queens, Richmond (Staten Island),            and joining for the first time, or if you have not               an “initial assessment”).
    (EOC). Keep this handbook together with the EOC.                                                                                                                             Rockland, Sullivan, and Westchester counties).       been enrolled in a plan for 45 days. If you are
    You need both of them to know what services are                                                                                                                                                                                   transferring from a managed long-term care plan               ➤ find out if you are eligible for nursing
                                                                                                                                                                            ■    ave a long-term health problem or disability that
                                                                                                                                                                                h                                                                                                                      home level of care.
    covered, and how to get them.                                                                                                                                                                                                     (MLTC), mainstream Medicaid, or another Medicaid
                                                                                                                                                                                makes you eligible for nursing home level of care.
                                                                                                                                                                                                                                      Advantage Plus (MAP), you are not required to get
                                                                                                                                                                                                                                                                                                    ➤ find out if you require community-based
    Membership Card                                                                                                                                                         ■    re able to stay at home without jeopardy to
                                                                                                                                                                                a
                                                                                                                                                                                your health at the time you join the plan.
                                                                                                                                                                                                                                      a CFEEC evaluation.
                                                                                                                                                                                                                                                                                                       long-term care services offered by
                                                                                                                           H3359_GEN22_04 0812-21_C                                                                                   Step 2: Confirm Eligibility for Medicaid and                     CompleteCare for a continuous period
                                             CompleteCare (HMO D-SNP)
                                                                                      This card does not guarantee coverage. If an emergency exists, go to the
                                                                                      nearest Emergency Room or dial 911.
                                                                                                                                                                            ■    re expected to need one or more of the
                                                                                                                                                                                a                                                     Medicare                                                         of more than 120 days.
                                                                                      For Members
                                                                                      Member Services: 1-888-260-1010 (TTY: 1-888-542-3821)
    Member: JANE Q. SAMPLE                                   PCP           $0 Copay   Nurse Help Line: 1-855-687-7333 (TTY: 711)
                                                                                      Teladoc:          1-800-835-2362
                                                                                                                                                                                following Community Based Long-Term Care                                                                            ➤ provide and mail you information and a
     Health Plan (80840)
                                                             Specialist
                                                             ER
                                                                           $0 Copay
                                                                           $0 Copay
                                                                                      Dental:
                                                                                      Vision:
                                                                                                        1-800-508-2047
                                                                                                        1-800-753-3311
                                                                                                                                                                                Services (CBLTCS) for more than                       Enrolling in CompleteCare is voluntary. If you want
     CIN: XXXXXX
                                                             Urgent Care   $0 Copay   Website:
                                                                                      For Providers
                                                                                                        healthfirst.org/medicare
                                                                                                                                                                                                                                      to join, you (or someone on your behalf) can call               Health Care Proxy form (if you want to
                                                                                      Medical
                                                                                      Eligibility:         1-888-801-1660
                                                                                                                                    Pharmacy
                                                                                                                                                 1-866-693-4620
                                                                                                                                                                                120 days from the date that you join the plan:                                                                        assign someone you trust to make
     RxBIN 004336 RxPCN MEDDADV RxGrp Rx1110
     Provider Name:        Dr. John Doe                                               Prior Authorization: 1-888-394-4327
                                                                                      Electronic Claims: Payer ID 80141
                                                                                                                                    Help Desk:
                                                                                                                                    Claims:      CVS Caremark
                                                                                                                                                 P.O. Box 52066
                                                                                                                                                                                                                                      CompleteCare. Our team will help you contact
     Provider Phone:       1-212-123-4567
     Coverage provided by Healthfirst Health Plan, Inc. CMS: H3359-034
                                                                                      Paper Claims:        Healthfirst Claims Dept.
                                                                                                           P.O. Box 958438
                                                                                                           Lake Mary, FL 32795-8438
                                                                                                                                                 Phoenix, AZ 85072-2066
                                                                                                                                                                                 ➤ nursing services in the home                      New York Medicaid Choice to find out more about                 healthcare decisions for you).
     Visit MyHFNY.org to find a doctor, view your benefits, and more!                 HFNY22

                                                                                                                                                                                 ➤ therapies in the home                             CompleteCare. If you qualify and have a completed
                                                                                                                                                                                                                                                                                                    ➤ talk about services you may need.
                                                                                                                                                                                                                                      New York Medicaid Choice review, if required,
    Your CompleteCare identification card (Member ID                                                                                                                             ➤ home health aide services
                                                                                                                                                                                                                                      a Healthfirst employee will check your Medicaid         Step 4: Sign Enrollment Agreement
    card) will be mailed to you. Carry this card with you
                                                                                                                                                                                 ➤ personal care services in the home                eligibility. We will give you a call to provide you
    at all times. You need to show it to your provider.                                                                                                                                                                                                                                        ■    fter the initial assessment, our nurse will ask
                                                                                                                                                                                                                                                                                                   A
                                                                                                                                                                                                                                      with more information about the plan and will
                                                                                                                                                                                 ➤ private duty nursing                                                                                           you to verbally consent to the Enrollment
                                                                                                                                                                                                                                      schedule a visit for one of our registered nurses
    Help from Member                                                                                                                                                             ➤ adult day health care                             to conduct a Community Health Assessment                     Agreement Transfer Attestation. By providing
                                                                                                                                                                                                                                                                                                   verbal consent to complete the Enrollment
    Services                                                                                                                                                                     ➤ Consumer Directed Personal Assistance
                                                                                                                                                                                    Services (CDPAS)
                                                                                                                                                                                                                                      for eligibility to the plan. We will also ask you for
                                                                                                                                                                                                                                      information about your healthcare needs.                     Agreement Transfer Attestation, you agree to:
    There is someone to help you at Member Services                                                                                                                                                                                                                                                 ➤ get all covered services from CompleteCare
                                                                                                                                                                          If you are a hospital inpatient, or live in a place          ■    our Medicaid eligibility must be reviewed
                                                                                                                                                                                                                                           Y
    7 days a week, 8am–8pm (October through March),                                                                                                                                                                                                                                                    and our network providers.
                                                                                                                                                                          licensed by the State Office of Mental Health (OMH),             and approved by the NYC Human Resources
    and Monday to Friday, 8am–8pm (April through
    September). Call 1-888-260-1010                                                                                                                                       the Office of Alcoholism and Substance Abuse                     Administration or Local Department of
                                                                                                                                                                                                                                                                                                    ➤ participate in CompleteCare according to
    (TTY 1-888-542-3821).                                                                                                                                                 Services (OASAS) or the State Office for People With             Social Services.
                                                                                                                                                                                                                                                                                                       the terms and conditions described in
                                                                                                                                                                          Developmental Disabilities (OPWDD), or are enrolled                                                                          this handbook.
    The State of New York has created a Participant                                                                                                                                                                                    ■    ou must have Medicare Parts A and B in order
                                                                                                                                                                                                                                           Y
                                                                                                                                                                          in another managed care plan managed by Medicaid,
    Ombudsman Program called the Independent                                                                                                                                                                                               to join CompleteCare.
                                                                                                                                                                          a Home and Community-Based Services waiver                                                                          Once New York Medicaid Choice and Healthfirst
    Consumer Advocacy Network (ICAN) to provide                                                                                                                           program, or OPWDD Day Treatment Program, or are             A licensed representative will schedule a home          CompleteCare decide that you are eligible to enroll,
    Participants/Members free, confidential assistance on                                                                                                                 getting services from hospice, you can enroll with          visit or telephone call and educate you about the       your Medicaid application will be sent to New
    any services offered by Healthfirst Health Plan, Inc.                                                                                                                 our plan upon discharge or termination.                     product and benefits and help you enroll into           York Medicaid Choice (NYMC) and your Medicare
    ICAN may be reached toll-free at 1-844-614-8800                                                                                                                                                                                                                                           application will be sent to Centers for Medicare &
                                                                                                                                                                                                                                      CompleteCare using the Medicaid Advantage Plus
    or online at icannys.org. (TTY users call 711, then                                                                                                                   The coverage explained in this handbook starts on                                                                   Medicaid Services (CMS) for approval.
                                                                                                                                                                                                                                      application.
    follow the prompts to dial 844-614-8800.)                                                                                                                             your enrollment date in Healthfirst CompleteCare.

2          CompleteCare Member Handbook                                                                                                                                                                                                                        1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org                                        3
Your start date will be given to you at the time of    You must join a MLTC to get these services. If you          ■    ame someone to speak for you about your care
                                                                                                                           n                                                        ■   Support Healthfirst CompleteCare
    enrollment. If the start date changes, Healthfirst     need to contact NYMC, please call 1-888-401-6582                and treatment.
                                                           (TTY 1-888-329-1541).                                                                                                         ➤ Tell your Care Team you have concerns about
    CompleteCare will let you know. You will get an
                                                                                                                       ■    ake advance directives and plans about
                                                                                                                           m                                                                your care or use the Healthfirst CompleteCare
    enrollment confirmation letter that shows your                                                                         your care.                                                       appeals and grievances process.
    enrollment date.
                                                           What are my rights                                          ■   s eek assistance from the Participant Ombudsman              ➤ Review this Member Handbook and follow
    After your application is approved, you will get       and responsibilities                                             program                                                         the steps to get proper care.
    a Member ID card within 10 calendar days.
    If you do not have your Member ID card and need        as a Healthfirst                                            ■    sk for an increase in your services, like your
                                                                                                                           a                                                             ➤ Respect the rights and safety of those involved
    to see a provider, call Member Services to check       CompleteCare member?                                            personal care services (PCS) and CDPAS.                          in your care and get help from us to keep your
                                                                                                                                                                                            home safe for your care needs.
    your coverage. They can fax your information to                                                                  *Our plan must obey laws that protect you from
    your provider. You can also use your confirmation      As a member of Healthfirst CompleteCare, you have          discrimination or unfair treatment. We do not                      ➤ Tell your Care Team the following:
    of coverage letter as proof of coverage until you      the right to:                                              discriminate based on age, sex (such as gender identity
                                                                                                                                                                                              y if you are leaving the service area
    get your Member ID card.                                ■   receive medically necessary care.                    or status of being transgender), race, creed, physical
                                                                                                                      or mental disability (such as gender dysphoria),                        y if you moved or have a new phone number
    During the initial assessment, you will be              ■   timely access to care and services.                  developmental disability, national origin, sexual
    evaluated by a registered nurse to determine if                                                                   orientation, type of illness or condition, or the need for              y if you changed providers
    you meet the clinical eligibility requirements to
                                                            ■    edical record privacy when you
                                                                m                                                     health services. If you want more information or have
                                                                get treatment.                                        concerns about discrimination or unfair treatment,                      y any changes in a health issue that may
    join CompleteCare. If your clinical assessment
                                                                                                                      please call the Department of Health and Human                            affect your current care
    determines that you are not eligible to join            ■   r eceive information on care choices in a way
    CompleteCare because of health and safety                    you want it and in a language you know.              Services’ Office for Civil Rights at 1-800-368-1019
    concerns, we will notify you of the denial of                                                                     (TTY 1-800-537-7697) or your local Office for Civil          Your Right to Use an Advance
                                                            ■   receive translation services free of charge.         Rights. If you have a disability and need help with
    enrollment which will then be sent to NYMC or
                                                                                                                      access to care, please call Healthfirst Member Services      Directive
    LDSS for final decision. You will be notified once      ■    gree to the care you are getting before the
                                                                a                                                     at 1-888-260-1010 (TTY 1-888-542-3821).
    NYMC or LDSS makes the final decision.                      start of treatment.                                                                                                You have the right to know your options and make
                                                                                                                                                                                   choices about your healthcare.
    If CMS or NYMC rejects your enrollment, you will        ■    e treated with respect and due consideration
                                                                b                                                    Responsibilities of Members
    get an enrollment denial letter. You can call us at         for your dignity.                                                                                                  You have the right to get full information from your
    1-888-260-1010 (TTY 1-888-542-3821) if you                                                                       To benefit from enrollment in Healthfirst CompleteCare,       providers and other healthcare providers when you
                                                            ■   r equest and receive a copy of your medical         you should try to:
    disagree with the decision. If NYMC or LDSS rejects                                                                                                                            go for medical care. Your providers must explain your
                                                                 records and ask that the records be changed
    your enrollment because you did not meet the                                                                                                                                   medical condition and your choices in a way that you
                                                                 or fixed.                                             ■    articipate Actively in Your Care and
                                                                                                                           P
                                                                                                                                                                                   can understand.
    eligibility requirements, NYMC or LDSS will tell us.                                                                   Care Decisions
    If we disagree with NYMC’s decision, we will follow
                                                            ■   t ake part in decisions about your healthcare
                                                                 or refuse treatment.                                                                                              You also have the right to make choices about your
                                                                                                                            ➤ Speak openly with your provider and Care
    the dispute resolution process that is approved by                                                                                                                             healthcare. To help you, we outlined your rights.
                                                                                                                               Team about your health and care.
    the State Department of Health (SDOH). If we do         ■    e free from any form of restraint or seclusion
                                                                b
    not dispute the rejection or you are found not to           used as a means of coercion, discipline,                    ➤ Ask questions to be sure you know, follow,
                                                                                                                                                                                    ■    now about all of your choices. You have the right
                                                                                                                                                                                        K
                                                                convenience or retaliation as specified in                     and review your service plan, and take part              to be told about all of the treatment options for
    meet the standards for enrollment after the dispute
                                                                federal regulations on the use of restraints and               in your care management calls.                           your condition, no matter what they cost or
    process is done, NYMC or LDSS will move on with
                                                                seclusion.                                                                                                              whether they are covered by our plan. This also
    your denial of enrollment. If you decide to withdraw                                                                    ➤ Share in care choices and be in charge of                includes being told about programs to help you
    your enrollment application before the start date of    ■    et care without regard to sex, gender identity,
                                                                g                                                              your own health.                                         safely manage your medications.
    enrollment, Healthfirst CompleteCare will tell NYMC         race, health status, color, age, national origin,
    or LDSS of the withdrawal by fax.                           sexual orientation, mental or physical disability,          ➤ Complete self-care as planned.                       ■    now about the risks. You have the right to be
                                                                                                                                                                                        K
                                                                marital status, or religion.*                                                                                           told about any risks involved in your care. You
                                                                                                                            ➤ Keep appointments and let the Care Team
                                                                                                                                                                                        must be told if any treatment is part of a research
    Withdrawal of Enrollment                                ■    e told where, when and how to get
                                                                b                                                              know of changes.
                                                                                                                                                                                        test. You always have the choice of saying no to
                                                                the services you need from us, such as                                                                                  experimental care.
    Your request for withdrawal must be received                                                                            ➤ Use network providers for care except in
                                                                how you can get covered benefits from
                                                                                                                               emergencies.
    the last day of the month prior to the enrollment           out-of-network providers.                                                                                           ■    ou have the right to say no. You can refuse any
                                                                                                                                                                                        Y
    month. Healthfirst CompleteCare will mail you a                                                                         ➤ Tell us if you get health services from                  care. This includes the right to leave a hospital or
    cancellation notice.
                                                            ■    omplain to New York State Department of
                                                                c
                                                                                                                               non-network healthcare providers.                        other healthcare place, even if your provider
                                                                Health (NYSDOH).
                                                                                                                                                                                        advises you not to leave. You also have the right
    Long-term care services are no longer covered by                                                                        ➤ Take part in policy development by writing               to stop taking your medication. But you will take
                                                            ■    omplain to your local department of social
                                                                c
    New York’s Fee-For-Service (FFS) Medicaid Program.                                                                         to us, or calling us.                                    full responsibility for what happens to your body
                                                                services and the right to use the New York State
                                                                Fair Hearing system and/or a New York State                 ➤ Take part in the six-month assessment                    as a result.
                                                                External Appeal where appropriate.                             visit or sooner as needed.

4   CompleteCare Member Handbook                                                                                                                    1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org                                           5
■    et a coverage denial reason. If you are denied
         G                                                     Notice of Information Available                            We Will Treat You with Fairness                           If you are                You will pay:
         coverage, you have the right to get a reason
                                                                                                                                                                                    eligible for:
         from us. To get the reason, you will need to ask      on Request                                                 and Respect at all Times
         us for a coverage decision.                                                                                                                                                Medicaid                  Nothing to Healthfirst
                                                               The following information is available upon request.       Healthfirst must obey laws that protect you from          (no monthly spend         CompleteCare
    You have the right to give orders about what is to be                                                                 discrimination or unfair treatment. We do not             down/ (NAMI))
    done if you are not able to make healthcare choices         ■    list of names, business addresses, and official
                                                                    a                                                     discriminate based on age, sex (such as gender
    for yourself.                                                   positions of the members of Healthfirst’s board                                                                 Medicaid                  A monthly surplus to
                                                                                                                          identity or status of being transgender), race,
                                                                    of directors, officers, controlling partners, and                                                               (with monthly spend       Healthfirst CompleteCare
    Sometimes people become unfit to make healthcare                                                                      creed, physical or mental disability (such as gender
                                                                    owners or partners                                                                                              down/ (NAMI))             as decided by New York
    choices for themselves due to accidents or serious                                                                    dysphoria), developmental disability, national origin,
                                                                                                                                                                                                              City Human Resources
    illness. You have the right to say what you want to         ■    copy of Healthfirst’s most recent annual
                                                                    a                                                     sexual orientation, type of illness or condition, or
                                                                                                                                                                                                              Administration/Local
    happen if you are in one of these situations. This              certified financial statement, balance sheet, and     the need for health services.
                                                                                                                                                                                                              District of Social Services
    means that, if you want to, you can:                            summary of receipts, and disbursements from
                                                                                                                          If you want more information or have concerns
                                                                    a certified public accountant                                                                                  If you are eligible for Medicaid with a surplus and
     ■   f ill out a written form to give someone the legal                                                              about discrimination or unfair treatment, please
          power to make healthcare choices for you.                                                                                                                                your surplus changes while you are a Healthfirst
                                                                ■   information about member complaints, and             call the Department of Health and Human Services’
                                                                                                                                                                                   CompleteCare member, your monthly payment will
          ive your providers written orders about how
         g                                                           aggregated information about grievances              Office for Civil Rights at 1-800-368-1019
     ■                                                                                                                                                                             be changed.
         you want them to handle your healthcare.                    and appeals                                          (TTY 1-800-537-7697) or your local Office for
                                                                                                                          Civil Rights. If you need to call NY Medicaid Choice,
    The legal documents that you can use to give
    your directions before these situations happen are
                                                                ■   s teps for protecting confidentiality of medical
                                                                     records, and other member information
                                                                                                                          please call 1-888-401-6582 (TTY 1-888-329-1541).         Money Follows the
    called advance directives. There are many types of
    advance directives and different names for them.            ■    description of the organizational arrangement
                                                                    a
                                                                                                                          If you have a disability and need help with access       Person (MFP)/Open
                                                                                                                          to care, please call Member Services at
    Documents called living will and power of attorney              and ongoing procedures of Healthfirst’s Quality
                                                                    Assurance Program
                                                                                                                          1-888-260-1010 (TTY 1-888-542-3821).                     Doors
    for healthcare are examples of advance directives.                                                                    If you have a complaint, Member Services can help.
                                                                                                                                                                                   MFP/Open Doors is a program that can help
    If you want to use an advance directive, here is what       ■    description of the steps followed by Healthfirst
                                                                    a                                                                                                              you move from a nursing home back into your
    to do.                                                          for experimental or investigational individual
                                                                    drugs, medical devices, or treatments in
                                                                                                                          Transitional Care                                        community. You can get MFP if you:
     ■    et the form. Get a form from your lawyer,
         G                                                          clinical trials                                       New members can get ongoing treatment from a               ■    ave lived in a nursing home for three (3)
                                                                                                                                                                                         h
         a social worker, or from an office supply store.
                                                                                                                          non-network provider for a transitional period of              months or longer.
         You can also get advance directive forms from          ■   s pecific clinical review criteria about a certain
         Medicare organizations or from Healthfirst                                                                       up to 60 days from enrollment. The provider must
                                                                     condition or disease, or other clinical                                                                         ■    ave health needs that can be met through
                                                                                                                                                                                         h
         Member Services.                                                                                                 accept our plan rate payment, agree to our policies,
                                                                     information, used during utilization review                                                                         services in your community.
                                                                                                                          and give us your medical information.
                                                                     (unless it’s proprietary to Healthfirst) when
     ■    ill it out and sign it. Remember that this is
         F
                                                                     checking covered services supplied by Healthfirst    If your provider leaves the network, you can get         MFP/Open Doors has people called Transition
         a legal document. Consider having a lawyer
         help you prepare it.                                                                                             ongoing treatment for a transitional period of up        Specialists and Peers who can meet with you in
                                                                     ➤ individual provider affiliations with                                                                      the nursing home and talk with you about moving
                                                                        participating hospitals or other places           to 90 days. The provider must accept our plan rate
     ■    ive copies to the right people. Give copies to
         G                                                                                                                                                                         back to the community. Transition Specialists
                                                                                                                          payment, agree to our policies, and give us your
         your provider and to the person who is making                                                                                                                             and Peers are different from Care Managers and
                                                                     ➤ licensure, certification, and accreditation       medical information.
         your decisions. You may also want to give copies                                                                                                                          Discharge Planners. They can help you by:
         to close friends or family members. Be sure to                 status of participating providers
         keep a copy for yourself.
                                                                     ➤ application, procedures, and minimum              Monthly Surplus                                            ■    iving you information about services and
                                                                                                                                                                                         g
                                                                        qualification requirements for Healthfirst                                                                       supports in the community.
    If you know that you are going to be hospitalized,                                                                    The surplus amount is money determined by the
    take a copy with you to the hospital.                               healthcare providers
                                                                                                                          New York City Human Resources Administration or            ■   f inding services offered in the community to
     ■   If you are admitted to the hospital, they will ask         ➤ information about the education, facility         Local District of Social Services and under the rules           help you be independent.
          you for your signed form.                                     affiliation, and participation in clinical        of the medical assistance program that a member
                                                                                                                                                                                     ■   v isiting or calling you after you move to make
                                                                        performance reviews conducted by the              must pay monthly to Healthfirst. Members with
     ■   If you have not signed it, the hospital has forms                                                                                                                               sure that you have what you need at home.
                                                                        DOH, of healthcare professionals who              a surplus will get an invoice on or about the 15th
          and will ask if you want to sign one.                         are licensed, registered, or certified under      of each month. The amount you pay depends on             For more information about MFP/Open Doors, or
    Remember, it is your choice whether you want to                     Article 8 of the State Education Law              your eligibility for Medicaid and Medicaid’s monthly     to set up a visit from a Transition Specialist or Peer,
    fill out an advance directive or whether you want                                                                     surplus program.                                         please call the New York Association on Independent
    to sign one if you are in the hospital. By law, no one                                                                                                                         Living at 1-844-545-7108, or email mfp@health.
    can deny you care or discriminate against you                                                                                                                                  ny.gov. You can also visit MFP/Open Doors on the
    based on whether or not you have signed an                                                                                                                                     web at health.ny.gov/mfp or ilny.org.
    advance directive.

6   CompleteCare Member Handbook                                                                                                                   1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org                                          7
Services Covered                                         be available to assist you in other needs that you
                                                             may have, including, but not limited to, arranging
                                                                                                                     or urgently needed care. To get approval for an out-
                                                                                                                     of-network provider, you or your provider must call
                                                                                                                                                                                disabled people) and/or home health aide services as
                                                                                                                                                                                needed by an approved plan of care. Home health care
    by Healthfirst                                           appointments and transportation. Your Care Team
                                                             will work with you and your provider to decide
                                                                                                                     Healthfirst Utilization Management at
                                                                                                                     1-888-394-4327 (TTY 1-888-542-3821).
                                                                                                                                                                                services not covered by Medicare need a doctor order,
                                                                                                                                                                                prior approval, and must be medically necessary.
    CompleteCare                                             the services you need and make a care plan. This
                                                             care plan is called a Person-Centered Service Plan      Personal Care                                              Nutrition
                                                             (PCSP). The PCSP will be developed with you and
    Deductibles and Copayments on                            anyone you want to help you with your plan of           You can get help with one or more activities of            Nutrition services include looking at your nutritional
    Medicare Covered Services                                care to meet your healthcare needs. The PCSP will       daily life: walking, cooking, cleaning, bathing, using     needs, food patterns, and planning nutrition fit for
                                                             include your goals, objectives, and special needs as    the bathroom, personal hygiene, dressing, feeding,         your physical, medical, and environmental needs.
    Many of the services that you get are covered                                                                    nutritional and environment support function tasks.        These services also include education and counseling,
                                                             well as services you receive. Your CT may contact
    by Medicare. They are described in the Healthfirst                                                               Personal care services need a physician’s order, prior     and the development of a nutritional treatment
                                                             your provider to talk about and develop your PCSP.
    CompleteCare Evidence of Coverage (EOC).                                                                         approval, and must be medically necessary.                 plan. Nutritional services need a doctor order, prior
                                                             This care plan will change as your needs change.                                                                   approval, and must be medically necessary.
    Chapter 3 of the EOC explains the rules for using
                                                             It will be re-evaluated at least every six (6) months   Consumer Directed Personal
    in-network providers and getting care in a medical
                                                             to ensure your care plan is up to date and we are
    emergency or if urgent care is needed. If there are
                                                             working towards helping you achieve your health
                                                                                                                     Assistance Services (CDPAS)                                Medical Social Services
    deductibles or copayments for benefits (see Chapter
                                                             goals. During the development of the PCSP, you and      This program lets you (also known as the “consumer’),      Medical social services include checking the need for,
    4 of the EOC, “What is Covered”), we will cover
                                                             the care manager will work together to establish        or the person acting for you, hire, train, supervise,      arranging for, and providing aid for social problems by
    the deductibles and copayments because you
                                                             goals based on what you both have together              arrange back-up coverage, keep payroll records, and        a trained social worker. These services will help you
    have Medicaid.
                                                             identified and prioritize your most important           fire the person giving you personal care services. You     with concerns about your illness, finances, housing,
    If there is a monthly premium for benefits (see          problems to work on.                                    can ask to use the CDPAS program at any time. You          or environment. They must be medically necessary
    Chapter 1 of the EOC), you will not have to pay                                                                  can disenroll from the program at any time. Healthfirst    before approved by Healthfirst.
                                                             Your care team will help you with any discharges
    that premium, since you have Medicaid. We will                                                                   will review the level of personal care services, home
                                                             from the hospital, or emergency room visits, making
    also cover many services that are not covered                                                                    health aide services, and/or skilled nursing services      Home-Delivered Meals and/or
                                                             sure you have your medications and follow-up
    by Medicare. The sections below explain what                                                                     you need and write you a plan of care.
    is covered.
                                                             appointments to keep you safe at home. Your                                                                        Meals in a Group Setting
                                                             care team will also help to educate you on your         Once we make your plan of care and tell you how
                                                             disease(s), medications, specialty appointments. If                                                                You can get meals given to you at home or in
    In-network providers will be paid in full directly                                                               many hours of services are needed, the next step will
                                                             your condition changes significantly, you may also                                                                 another setting (such as an adult home) if you do
    by Healthfirst CompleteCare for each service                                                                     be for you to find the sufficient number of personal
                                                                                                                                                                                not have cooking tools or if you have a special need.
    authorized and supplied to you, with no copayment        be assessed for changes in your care needs. By          assistants (PAs) needed to perform the services in
                                                                                                                                                                                Meals must be medically necessary before approval
    or cost to you. If you get a bill for covered services   helping you manage all parts of your care, your CT      your plan of care. A PA can be a family member,
                                                                                                                                                                                by Healthfirst.
    authorized by us, you are not responsible for paying     can find problems early, stop problems from getting     friend, neighbor, or former aide—but they must be
    the bill. Please call your Care Manager. You may be      worse, and help you avoid trips to the hospital and     trained to do the work you need. A PA cannot be a
    responsible for payment of covered services that         emergency room.                                         person legally in charge of your care (like your spouse    Social Day Care
    were not authorized by us or for covered services                                                                or designated representative). The consumer must
                                                                                                                                                                                Social day care gives members with limited
    that you got from providers out-of-network.                                                                      work with the Healthfirst team to arrange covered
                                                             What additional services                                services with providers or healthcare agencies.
                                                                                                                                                                                socialization functions, supervision, monitoring, and
                                                                                                                                                                                nutrition. This program takes place in a safe setting
    Who is part of my Healthfirst                            are covered by Healthfirst                                                                                         during any part of the day, but for less than a
                                                                                                                     The consumer is in charge of or responsible for
    CompleteCare Care Team?                                  CompleteCare?                                           scheduling their PAs. They need to make sure that          24-hour period. Other services may include,
                                                                                                                     there is coverage if a PA cannot make it to work.          but are not limited to, personal care help, teaching
                                                             We will arrange and pay for the extra health and                                                                   daily living skills, transportation, caregiver help,
    As a member of Healthfirst CompleteCare, you get                                                                 The consumer also needs to keep track of their
                                                             social services described below. You can get them                                                                  and case help. Social day care must be medically
    Care Management Services. You will be assigned                                                                   time worked and sign off on time sheets and other
                                                             as long as needed to stop or treat your illness or                                                                 necessary before it is approved by Healthfirst.
    a primary care manager (PCM) who will be a                                                                       important documents.
                                                             disability. Your care manager will help point out
    Registered Nurse (RN) or a Licensed Social Worker
                                                             the services and providers you need. You may
    (LSW) who is supported by a Care Team (CT) that
                                                             need a referral or an order from your provider for      Home Health Care Services Not                              Non-Emergency Transportation
    includes other support staff. This team collaborates
    with your primary care provider (PCP) to make up
                                                             these services, and you must get them from              Covered by Medicare                                        Healthfirst covers transportation costs for you to get
                                                             in-network providers.                                                                                              medical care and services. Transportation services are
    your personal Interdisciplinary Care Team (ICT).                                                                 Medicaid-covered home health services include
    Your CT will check changes in your health and help                                                                                                                          supplied by ambulance, ambulette, taxicab, public
                                                             If you cannot find an in-network provider, you          skilled services not covered by Medicare (e.g.,
    coordinate care and services. The CT can help you                                                                                                                           transit, or other means fit to your medical condition.
                                                             must get approval before using an out-of-network        physical therapist to supervise maintenance program
    with your medical, psychosocial, and environmental                                                                                                                          An aide can go with you to medical appointments
                                                             provider, except when it is for a medical emergency     for patients who have reached their maximum
    needs. Other members of the support team will                                                                                                                               if needed.
                                                                                                                     restorative potential, or nurse to pre-fill syringes for

8   CompleteCare Member Handbook                                                                                                               1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org                                           9
Healthfirst will cover Non-Emergency Medicaid-            ■    edical/Surgical Supplies. Items for medical
                                                                   M                                                    Hearing Services                                          Members must get all vision care through Davis
     covered transportation provided that it is included           use other than drugs, which treat a                                                                            Vision. All covered vision services must be
     as a Managed Long-Term Care benefit by the New                specific condition.                                  Members get Medicaid-covered hearing services,            medically necessary.
     York State Department of Health.                                                                                   such as hearing services and products to ease
                                                               ■    edical Equipment. Adaptive devices and
                                                                   M                                                    disability caused by the loss of hearing.
     Transportation by an approved car service or                  equipment prescribed by a healthcare provider.
                                                                                                                                                                                  Dental
     ambulette services must be arranged by Healthfirst                                                                 Services include hearing aids, fitting, and dispensing;
                                                                                                                                                                                  We offer members dental care through DentaQuest.
     two (2) days before needed. We will send                  ■    nteral and parenteral nutritional supplements.
                                                                   E                                                    ear molds and replacement parts; hearing aid
                                                                                                                                                                                  Covered services include routine dental services
     authorization to the transportation vendor. All non-          Liquid nutritional supplements.**                    checks, evaluations, and repairs; audiology exams
                                                                                                                                                                                  such as preventive dental checkups, cleaning,
     emergency transportation should be arranged by                                                                     and testing; and prescriptions.
                                                               ■    rosthetics. Artificial substitute or replacement
                                                                   P                                                                                                              X-rays, fillings, and other services. You do not need
     calling Member Services at 1-888-260-1010
                                                                   of a limb.                                           Members must get all Medicaid-covered hearing             a referral from your primary care provider to see
     (TTY 1-888-542-3821), 7 days a week, 8am–8pm
                                                                                                                        care from providers through NationsHearing.               a dentist.
     (October through March), and Monday to Friday,            ■    rthotics. Appliances and devices that support
                                                                   O
                                                                                                                        All covered hearing services must be medically
     8am–8pm (April through September).                            or fix a movable part of the body.                                                                             How to Access Dental Services:
                                                                                                                        necessary but may need prior authorization.
     If you do not get pre-approval from Healthfirst           ■    rthopedic Footwear. Shoes, shoe additions,
                                                                   O                                                                                                              You must get dental treatment from providers
     for non-emergent transportation, you will be                  or braces used to fix, help, or prevent a            Podiatry                                                  through DentaQuest. All covered dental services
     responsible for the full cost. If you take public             deformity or range-of-motion issue in a                                                                        must be medically necessary. Individual dental
     transportation (i.e., MTA transit, Long Island Rail           diseased or injured part of the ankle or foot.       Members get Medicaid-covered podiatry services            procedures may need pre-approval.
     Road, and/or Metro-North Rail Road, etc.), you                                                                     for medically necessary foot care. This includes care
     must submit a Member Reimbursement Form to                lease note: The plan limits incontinence supplies
                                                              P                                                         for medical conditions affecting lower limbs; up to       If you need to find a dentist or change your dentist,
     Healthfirst to get reimbursed.                           to those manufacturers listed below. We will              four routine foot care visits per year.                    call 1-800-508-2047. They have language services
                                                              not cover other incontinence supply brands                                                                          if needed, too.
     This form is on our website at                           and manufacturers unless your doctor or other             Added podiatry benefits include routine foot care
     HFMedicareMaterials.org, or you can call Member                                                                    for other conditions (up to 12 visits per year) and        ■    how your Member ID card when you visit
                                                                                                                                                                                       S
                                                              provider tells us that the brand is appropriate for
     Services to ask for one. Fill out the form and mail it                                                             diagnosis and the medical or surgical treatment of             your dentist. You will not get a separate dental
                                                              your medical needs. However, if you are new to
     to the address below. Reimbursement will be mailed                                                                 injuries and diseases of the feet (such as hammer              ID card.
                                                              Healthfirst CompleteCare and are using a brand
     to you.                                                  of incontinence supplies that is not listed below,        toe or heel spurs).
                                                              we will continue to cover your brand for you for
                                                                                                                                                                                  Social/Environmental Supports
         Healthfirst Medicare Plan
         Member Services                                      up to 90 days. During this time, you should talk          Vision                                                    Social and environmental supports are services
         P.O. Box 5165                                        with your doctor to decide what brand is medically                                                                  and items that support your healthcare needs and
                                                                                                                        Members get Medicaid-covered vision services as
         New York, NY 10274                                   appropriate for you after this 90-day period. (If you                                                               are included in your plan of care. These services
                                                                                                                        services of optometrists, ophthalmologists, and
                                                              disagree with your doctor, you can ask him or her to                                                                and items include but are not limited to: home
                                                                                                                        ophthalmic dispensers such as eyeglasses, medically
     Private Duty Nursing                                     refer you for a second opinion.)
                                                                                                                        necessary contact lenses, and polycarbonate               maintenance tasks, homemaker/chore services,
                                                                                                                        lenses, artificial eyes (stock or custom-made),           housing improvement, and respite care. Social
     Private duty nursing services are medically necessary    Incontinence supplies are limited to Attends,
                                                                                                                        low-vision aids, and low-vision services. Coverage        and environmental supports must be medically
     services given to you at your permanent or               Comfees, Cuties, Comfortwear, Inspire, Covidien,
                                                                                                                        also includes the repair or replacement of parts,         necessary before approval by Healthfirst.
     temporary home by a licensed registered professional     SureCare, and K2 Health.
     or licensed practical nurses (RNs or LPNs). The                                                                    examinations for diagnosis and treatment for visual
                                                              **Enteral formula limited to nasogastric,                defects and/or eye disease. Medicaid-covered              Personal Emergency Response
     services may be ongoing. Private duty nursing
     services need a doctor’s order and prior approval.
                                                                jejunostomy, or gastrostomy tube feeding, or            examinations for refraction are limited to every          Services
                                                                treatment of an inborn error of metabolism.             two (2) years unless otherwise justified as medically
                                                                Enteral formula and nutritional supplements             necessary. Medicaid-covered eyeglasses do not             Personal Emergency Response Services (PERS)
     Non-Medicare Covered Durable                               are limited to people who cannot get nutrition          require changing more frequently than every two           is a personal electronic device that lets high-risk
     Medical Equipment (DME) and                                through any other means, and to these                   (2) years unless medically necessary or unless the        patients get help in an emergency. These devices
                                                                                                                                                                                  alert response centers once a “help” button on
     Related Supplies                                           conditions: 1) tube-fed people who cannot chew          glasses are lost, damaged, or destroyed.
                                                                or swallow food and must get nutrition through                                                                    the device is activated. PERS must be medically
     Healthfirst CompleteCare covers any DME covered            formula by tube; and 2) people with rare inborn         Added vision benefits include one (1) yearly routine      necessary before approval by Healthfirst.
     by Original Medicare. We will not cover specific           metabolic disorders requiring specific medical          eye exam, one (1) yearly glaucoma screening (for
     brands and manufacturers unless your provider asks         formulas to give vital nutrients not available          those at high risk), and one (1) pair of eyeglasses       Adult Day Health Care
     us and provides medical reason. As a dual-eligible         through any other means. Coverage of certain            (standard lenses and frames) every year or a $400
                                                                                                                        allowance for non-plan collection frames and              Adult day health care includes: medical, nursing,
     member, you also get Medicaid-covered DME. New             inherited disease of amino acid and organic acid
                                                                                                                        contact lenses.                                           food and nutrition, social services, rehabilitation
     York State Medicaid covers additional prosthetics,         metabolism that include low-protein or modified
                                                                                                                                                                                  therapy, leisure time activities (planned meaningful
     orthotics, and orthopedic footwear that Medicare           protein solid food products.
     doesn’t cover. DME supplies are:

10   CompleteCare Member Handbook                                                                                                                 1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org                                         11
programs), dental, pharmaceutical, and other
     ancillary services. Adult day health care needs
                                                             Can I get care outside of                                 Worldwide emergency/urgent care services,
                                                                                                                       including transportation are subject to a maximum
                                                                                                                                                                                    What Services are not
     a physician’s order, prior approval, and must be        the Service Area?                                         plan benefit allowance of $200,000 per year.                 covered by Healthfirst
     medically necessary.
                                                             When you are outside the service area and cannot          If you have an emergency, we will talk with the              CompleteCare?
                                                                                                                       providers who are giving you emergency care to help
     Nursing Home Care Not Covered by                        get care from an in-network provider, we will
                                                                                                                                                                                    There are some Medicaid services that the plan
                                                             cover urgently needed care from any provider.             manage and follow up on your care. The providers
     Medicare (only if you are eligible for                                                                            who are giving you emergency care will decide when           does not cover. You can get these services from
                                                             These services are non-emergency, unforeseen
     institutional Medicaid)                                 medical illnesses, injuries, or conditions that require   your condition is stable and the medical emergency           any provider who takes Medicaid by using your
                                                                                                                       is over.                                                     Medicaid Benefit Card. Call Member Services at
     To get nursing home care services not covered by        immediate medical care.
                                                                                                                                                                                    1-888-260-1010 (TTY 1-888-542-3821) if you
     Medicare, the services must follow the treatment                                                                  After the emergency is over, you can get follow-up           have a question about a benefit. Some of the
                                                             You are also covered for emergency care and
     plan written by the ordering provider, registered                                                                 care. It is covered by the plan. If your emergency care is   services covered by Medicaid using your Medicaid
                                                             urgent care worldwide. But Healthfirst will not
     physician assistant, certified nurse practitioner,                                                                given by out-of-network providers, we will try to arrange    benefit card include:
                                                             cover any Part D prescription drugs that you get
     or certified home health agency. It requires prior                                                                for in-network providers to take over your care.
                                                             as part of your emergency or urgent care visit
     approval and must be medically necessary.                                                                                                                                       ■   Assisted Living Program
                                                             in another country.
     Inpatient Mental Healthcare over the                                                                              What if it wasn’t a                                           ■   Certain Mental Health Services, including

     190-day Lifetime Medicare Limit                         Emergency Service                                         medical emergency?                                                 ➤ Intensive Psychiatric Rehabilitation
                                                             A medical emergency is when you, or someone               If it turns out that your medical emergency was not                   Treatment Programs
     Inpatient mental health care over the 190-day
     lifetime Medicare limit needs a doctor order, prior     with an average knowledge of health and medicine,         actually an emergency, as long as you reasonably                   ➤ Day Treatment
     approval, and must be medically necessary.              believe that you have medical symptoms that               thought your health was in serious danger, we will
                                                             require immediate medical attention to prevent loss       cover your care. But after the provider said that it was           ➤ Case Management for Seriously and
                                                             of life, loss of a limb, or loss of function of a limb.   not an emergency, we will cover additional care only if:              Persistently Mentally Ill (sponsored by
     Outpatient Mental Health and                            The health symptoms may be a sickness, injury,                                                                                  state or local mental health units)
     Substance Abuse                                         severe pain, or a medical condition that is quickly         ■   y ou go to an in-network provider to get the
                                                                                                                              additional care, or                                         ➤ Continuing Day Treatment
                                                             getting worse or may cause death.
     Members can get outpatient mental health and
     substance abuse services from any in-network                                                                        ■   t he additional care you get is considered                  ➤ Assertive Community Treatment (ACT)
     provider. You can self-refer for one assessment         If you have a medical emergency:                                 urgently needed care, and you follow the rules
                                                                                                                                                                                          ➤ Partial Hospitalization (not covered
     for each benefit from an in-network provider in a                                                                        for getting this urgent care.
                                                               ■    et help as quickly as possible. Call 911 or
                                                                   G                                                                                                                         by Medicare)
     12-month period. Pre-approval is only needed for
                                                                   go to the nearest emergency room, hospital,                                                                            ➤ Personalized Recovery Oriented
     out-of-network service requests, electroconvulsive
                                                                   or urgent care center. Call for an ambulance
                                                                                                                       Payment of medical
     therapy (ECT), and neuropsychological testing.                                                                                                                                          Services (PROS)
                                                                   if you need it. You do not need to get approval     emergency services
                                                                   or a referral.                                                                                                    ■   Comprehensive Medicaid Case Management
     Outpatient Rehabilitation                                                                                         You can get emergency services from any provider.
                                                               ■    s soon as possible, call Healthfirst about
                                                                   A                                                   But when you get emergency or urgently needed                 ■    irectly Observed Therapy for
                                                                                                                                                                                         D
     Healthfirst CompleteCare (HMO D-SNP) removed                  your emergency.                                     care from an out-of-network provider, you should                  Tuberculosis Disease
     service limits on physical therapy (PT), occupational                                                             ask the provider to bill the plan.                            ■    ome and Community Based Waiver Program
                                                                                                                                                                                         H
     therapy (OT), and speech therapy (ST). Healthfirst             ➤ You (or someone else) should call us to
                                                                                                                         ■   If you paid the entire amount yourself when you            Services
     CompleteCare (HMO D-SNP) will cover medically                     tell us about your emergency care within
     necessary PT, OT, and ST visits that are ordered by               48 hours. Call Member Services at                      got the care, you need to send us the bill, along      ■    edicaid Pharmacy Benefits as allowed by
                                                                                                                                                                                         M
     a doctor or other licensed professional.                          1-888-260-1010 (TTY 1-888-542-3821),                   with documentation of any payments you have                State Law (select drug categories excluded
                                                                       7 days a week, 8am–8pm (October                        made.                                                      from Medicare Part D benefit)
     To learn more about these services, call Member                   through March), and Monday to Friday,             ■    ou may also get a bill from the provider. Send
                                                                                                                             Y                                                       ■   Methadone Maintenance Treatment Programs
     Services at 1-888-260-1010 (TTY 1-888-542-3821),                  8am–8pm (April through September).
     7 days a week, 8am–8pm (October through                                                                                 us this bill, along with documentation of any           ■    ffice for People with Developmental
                                                                                                                                                                                         O
     March), and Monday to Friday, 8am–8pm                                                                                   payments you have already made.                             Disability Services
     (April through September).                              What is covered if you have
                                                                                                                         ■   If the provider is owed anything, we will pay               ut-of-network Family Planning services under
                                                                                                                                                                                         O
                                                             a medical emergency?                                            them.
                                                                                                                                                                                     ■
                                                                                                                                                                                         the direct access provisions
                                                             Emergency medical care is covered whenever
                                                                                                                              ➤ If you have already paid the bill, we will          ■    ehabilitation Services Provided to Residents of
                                                                                                                                                                                         R
                                                             you need it, worldwide. This includes                                                                                       OMH Licensed Community Residences (CRs)
                                                                                                                                 pay you back.
                                                             ambulance services.
                                                                                                                                                                                     ■   Family Based Treatment Programs

12   CompleteCare Member Handbook                                                                                                                  1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org                                          13
Services covered by Original                                      Healthfirst Medicare Plan                            Concurrent Review                                            Standard Process
                                                                       Provider Service Intake
     Medicare:                                                         P.O. Box 5166                                        You can also ask Healthfirst Provider Service Intake         Generally, we use the standard timeframe for giving
                                                                       New York, NY 10274-5166                              to get more of a service than you are getting now.           you our decision about your request for a medical
       ■    ospice services provided to Medicare
           H
                                                                                                                            This is called concurrent review.                            item or service, unless we have agreed to use the fast
           Advantage members
                                                                 We will authorize services in a certain amount                                                                          track deadlines.
                                                                 and for a specific period of time. This is called an       Retrospective Review                                               standard review for a prior authorization
                                                                                                                                                                                              A
     Services not covered by the plan                            authorization period.
                                                                                                                                                                                          ■

                                                                                                                            Sometimes we will do a review on the care you are                 request means we will give you an answer within
     or by Medicaid                                                                                                         getting to see if you still need the care. We may also            three (3) work days of when we have all the
                                                                 Which services require prior                               review other treatments and services you already got.             information we need, but no later than 14
     These services are not covered by the plan or by
     Medicaid:                                                   authorization?                                             This is called retrospective review. We will tell you if          calendar days after we get your request. If your
                                                                                                                            we do these reviews.                                              case is a concurrent review where you are
       ■   Conversion or Reparative Therapy                     Some covered services require prior authorization                                                                            asking for a change to a service you are already
                                                                 (approval in advance) from Healthfirst Provider                                                                              getting, we will make a decision within one (1)
     If you have any questions, call Member Services             Service Intake before you get them. You or someone         What happens after we get your                                    work day of when we have all the information we
     at 1-888-260-1010 (TTY 1-888-542-3821).                     you trust can ask for prior authorization. The following   service authorization request                                     need, but will give you an answer no later than
                                                                 treatments and services must be approved before                                                                              14 calendar days after we get your request.
                                                                                                                            The health plan has a review team to be sure you get
     How do I get approval for                                   you get them:
                                                                                                                            the services we promise. Doctors and nurses are on            ■    e can take up to 14 more calendar days
                                                                                                                                                                                              W
                                                                       Elective (non-emergency) inpatient admissions
     treatments or services?                                                                                                                                                                  if you ask for more time or if we need
                                                                   ■
                                                                                                                            the review team. Their job is to be sure the treatment
                                                                                                                            or service you asked for is medically needed and right            information (such as medical records from
                                                                   ■   Residential health care facility care
                                                                                                                            for you. They do this by checking your treatment plan             out-of-network providers) that may benefit you.
     Service Authorization Request                                 ■   Home health care                                     against acceptable medical standards.                             If we decide to take extra days to make the
     (also known as Coverage                                                                                                                                                                  decision, we will tell you in writing what
                                                                   ■   Personal care services                               We may decide to deny a service authorization                     information is needed and why the delay is in
     Decision Request)                                             ■   Personal Emergency Response System (PERS)            request or to approve it for an amount that is less than          your best interest. We will make a decision as
                                                                                                                            you asked for. A qualified healthcare professional will           quickly as we can when we receive the necessary
     You have Medicare and get assistance from Medicaid.           ■   Adult and Social Day Care                            make these decisions. If we decide that the service               information, but no later than 14 days from
     Information in this section covers your rights for all of                                                              you asked for is not medically necessary, a clinical
                                                                   ■   Nutritional Services                                                                                                   the day we asked for more information.
     your Medicare and most of your Medicaid benefits.                                                                      peer reviewer will make the decision. A clinical peer
     In most cases, you will not use one process for your          ■    ocial and environmental services (chore
                                                                       S                                                    reviewer may be a doctor, a nurse, or a healthcare            ■   If you believe we should not take extra days, you
     Medicare benefits and a different process for your                services, home modifications or respite)             professional who typically provides the care you asked             can file a “fast complaint.” When you file a fast
     Medicaid benefits. You will usually use one process for                                                                for. You can ask for the specific medical standards,               complaint, we will give you an answer to your
     both. This is sometimes called an “integrated process”        ■   Durable medical equipment (DME)
                                                                                                                            called clinical review criteria, used to make the                  complaint within 24 hours. (The process for
     because it integrates Medicare and Medicaid processes.        ■   Inpatient mental health care                         decision about medical necessity.                                  making a complaint is different from the process
                                                                                                                                                                                               for service authorizations and appeals. For more
     However, for some of your Medicaid benefits, you              ■   Bunionectomy and hammer toe repair                   After we get your request, we will review it under                 information about the process for making
     may also have the right to an additional External                                                                      either a standard or a fast track process. You or your
                                                                   ■   Partial hospitalization services                                                                                        complaints, including fast complaints, see What
     Appeals process. See page 21 for more information                                                                      provider can ask for a fast track review if you or your            To Do If You Have A Complaint About Our Plan.)
     on the External Appeals process.                              ■   Outpatient surgery, if cosmetic                      provider believes that a delay will cause serious harm
                                                                                                                            to your health. If we deny your request for a fast track     If we do not give you our answer within 14 calendar
     Information in this section applies to all of your            ■    on-emergency transportation, including
                                                                       N
                                                                                                                            review, we will tell you and handle your request under       days (or by the end of the extra days if we take them),
     Medicare and most of your Medicaid benefits.                      ambulance services
                                                                                                                            the standard review process. In all cases, we will review    you can file an appeal.
     This information does not apply to your Medicare
                                                                   ■   Prosthetic devices and related supplies              your request as fast as your medical condition requires
     Part D prescription drug benefits.                                                                                                                                                   ■   I f our answer is yes to part or all of what you
                                                                                                                            us to do so, but no later than mentioned below. More
                                                                   ■    utpatient diagnostic tests and therapeutic
                                                                       O                                                                                                                       asked for, we will authorize the service or give
     When you ask for approval of a treatment or service,              services – (i.e., PET scans and radiation therapy)   information on the fast track process is below.
                                                                                                                                                                                               you the item that you asked for.
     it is called a service authorization request (also
     known as a coverage decision request).                            Comprehensive Dental Services                        We will tell you and your provider both by phone and in
                                                                   ■                                                                                                                      ■   I f our answer is no to part or all of what you
     To get a service authorization, you or your provider                                                                   writing if we approve or deny your request. We will also
                                                                   ■   Private Duty Nursing                                                                                                    asked for, we will send you a written notice that
     must call Member Services at 1-888-260-1010                                                                            tell you the reason for the decision. We will explain what
                                                                                                                                                                                               explains why we said no. Level 1 Appeals (also
     (TTY 1-888-542-3821) or write to us at:                                                                                options you have if you don’t agree with our decision.
                                                                   ■   Consumer Directed Personal Assistance (CDPAS)                                                                           known as Level 1) later in this chapter tells how
                                                                                                                                                                                               to make an appeal.

14   CompleteCare Member Handbook                                                                                                                     1-888-260-1010 | TTY 1-888-542-3821 | MyHFNY.org                                             15
You can also read