2018 AgeWell New York (Medicare-Medicaid) FIDA Plan Summary of Benefits

Transcription

1 H6308_FIDASB16700 Apprved AgeWell New Yrk (Medicare-Medicaid) FIDA Plan Summary f Benefits Brnx, Kings (Brklyn), Queens, Nassau, New Yrk (Manhattan), Sufflk and Westchester Cunties A wnderful wrld f memries and dreams. Nw make mre with AgeWell New Yrk.

2 H6308_FIDASB16700 Apprved AgeWell New Yrk FIDA: Summary f Benefits This is a summary f health services cvered by AgeWell New Yrk FIDA fr January This is nly a summary. Please read the Participant Handbk fr the full list f benefits. AgeWell New Yrk FIDA is a managed care plan that cntracts with bth Medicare and the New Yrk State Department f Health (Medicaid) t prvide benefits f bth prgrams t Participants thrugh the Fully Integrated Duals Advantage (FIDA) Demnstratin. It is fr peple with bth Medicare and Medicaid and wh meet ther eligibility requirements fr the FIDA Demnstratin. Under AgeWell New Yrk FIDA yu can get yur Medicare and Medicaid services in ne managed care plan called a FIDA Plan. A AgeWell New Yrk FIDA Care Manager will help manage yur care needs. This is nt a cmplete list. The benefit infrmatin is a brief summary, nt a cmplete descriptin f benefits. Fr mre infrmatin cntact the plan r read the Participant Handbk. Limitatins and restrictins may apply. Fr mre infrmatin, call AgeWell New Yrk FIDA Participant Services r read the AgeWell New Yrk FIDA Participant Handbk. This means that yu need t fllw certain rules t have AgeWell New Yrk FIDA pay fr yur services. The List f Cvered Drugs and/r pharmacy and prvider netwrks may change thrughut the year. We will send yu a ntice befre we make a change that affects yu. Benefits may change n January 1 f each year. If yu speak Spanish, language assistance services, free f charge, are available t yu. Call Participant Services at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Si habla españl, ls servicis de asistencia lingüística, de frma gratuita, están a su dispsición. Llame a Servicis para Participantes al (TTY: ), 7 días a la semana de 8:00 am a 8:00 pm. La llamada es gratuita. Yu can get this dcument fr free in ther frmats, such as large print, braille, r audi. Call Participants Services at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. If yu wuld like t request Participant materials in a preferred language and/r alternative frmat and keep the infrmatin as a standing request fr future mailings and cmmunicatins r if yu wuld like t change a standing request fr a preferred language and/r alternative frmat, call Participant Services at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 1

3 AgeWell New Yrk FIDA: Summary f Benefits The State f New Yrk has created a participant mbudsman prgram called the Independent Cnsumer Advcacy Netwrk (ICAN) t prvide Participants free, cnfidential assistance n any services ffered by AgeWell New Yrk FIDA. ICAN may be reached tllfree at r nline at icannys.rg. (TTY users call 711, then fllw the prmpts t dial ) If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 2

4 AgeWell New Yrk FIDA: Summary f Benefits The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) What is a Fully Integrated Duals Advantage (FIDA) Plan What is a AgeWell New Yrk FIDA Care Manager and Interdisciplinary Team (IDT) Answers A Fully Integrated Duals Advantage (FIDA) Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services, and ther prviders. It als has Care Managers and Interdisciplinary Teams t help yu plan and manage all yur prviders and services. They all wrk tgether t prvide the care yu need. AgeWell New Yrk FIDA is a FIDA Plan that prvides benefits f Medicaid and Medicare t Participants in the FIDA Demnstratin. A AgeWell New Yrk FIDA Care Manager is ne main persn that yu may cntact. This persn helps manage all yur prviders and services and makes sure yu get what yu need. This persn is part f yur Interdisciplinary Team (IDT), which als includes yu and yur designee(s). Yu may als chse t have any f the fllwing peple participate in any r all f yur IDT meetings: Yur Primary Care Prvider (PCP) r a designee frm yur PCP s ffice (r practice) wh has clinical experience and knwledge f yur needs; Yur Behaviral Health (BH) Prfessinal, if yu have ne, r a designee frm yur BH Prfessinal s ffice (r practice) wh has clinical experience and knwledge f yur needs; Yur hme care aide(s), r a designee with clinical experience frm the hme care agency wh has knwledge f yur needs, if yu are getting hme care; A clinical representative frm yur nursing facility, if getting nursing facility care; and Additinal individuals including:» Other prviders either as asked fr by yu r yur designee, r as recmmended by the IDT members as necessary fr adequate care planning and apprved by yu r yur designee; r» The registered nurse (RN) wh cmpleted yur assessment. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 3

5 AgeWell New Yrk FIDA: Summary f Benefits Frequently Asked Questins (FAQ) What are lng-term services and supprts Can I direct my wn care r hire my wn aides Will yu get the same Medicare and Medicaid benefits in AgeWell New Yrk FIDA that yu get nw Answers Lng-term services and supprts are help fr peple wh need assistance t d everyday tasks like taking a bath, getting dressed, making fd, and taking medicine. Mst f these services are prvided at yur hme r in yur cmmunity but culd be prvided in a nursing facility r hspital. Yu have the right t chse t direct yur wn care by selecting Cnsumer Directed Persnal Assistance Services (CDPAS). Thrugh CDPAS, yu can hire yur wn aides and make ther decisins abut hw t get services. Yu will get yur cvered Medicare and Medicaid benefits directly frm AgeWell New Yrk FIDA. Yu will wrk with a team f prviders wh will help determine what services will best meet yur needs. This means that sme f the services yu get nw may change. Yu will get almst all f yur cvered Medicare and Medicaid benefits directly frm AgeWell New Yrk FIDA, but yu will get fur benefits the same way yu d nw, utside f the plan. These benefits include: Hspice Services, Out-f-Netwrk Family Planning Services, Methadne Maintenance Treatment Prgram, and Directly Observed Therapy fr Tuberculsis Disease. When yu enrll in AgeWell New Yrk FIDA, yu and yur Interdisciplinary Team (IDT) will wrk tgether t develp a Persn-Centered Service Plan (PCSP) t address yur health and supprt needs. When yu first enrll in AgeWell New Yrk FIDA, yu can keep seeing yur dctrs and getting yur current services fr 90 days, r until yur PCSP is cmplete, whichever is later. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that AgeWell New Yrk FIDA des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr AgeWell New Yrk FIDA t cver yur drug, if medically necessary. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 4

6 AgeWell New Yrk FIDA: Summary f Benefits Frequently Asked Questins (FAQ) Can yu g t the same dctrs yu see nw Can yu remain in the same nursing facility yu live in nw What happens if yu need a service but n ne in AgeWell New Yrk FIDA s netwrk can prvide it Where is AgeWell New Yrk FIDA available Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with AgeWell New Yrk FIDA and have a cntract with us, yu can keep ging t them. Prviders with an agreement with us are in-netwrk. Yu must use the prviders in AgeWell New Yrk FIDA s netwrk, unless AgeWell New Yrk FIDA r yur IDT has authrized yu t see an ut-f-netwrk prvider. If yu need urgent r emergency care r ut-f-area dialysis services, yu can use prviders utside f AgeWell New Yrk FIDA's plan. T find ut if yur dctrs are in the plan s netwrk, call Participant Services r read AgeWell New Yrk FIDA s Prvider and Pharmacy Directry. If AgeWell New Yrk FIDA is new fr yu, yu can cntinue seeing the dctrs yu g t nw fr 90 days r until yur Persn-Centered Service Plan is cmplete, whichever is later. If yu currently get behaviral health services, yur Interdisciplinary Team (IDT) will review yur current episde f care t decide if yu can cntinue the services with the same prvider yu see nw. If they decide yu can see the same prvider yu see nw, yu will be able t see that prvider fr 24 mnths fllwing yur enrllment in AgeWell New Yrk FIDA. Yes. If yu live in a nursing facility when yu enrll in AgeWell New Yrk FIDA, yu can remain in that nursing facility fr the entire time that yu are in a FIDA Plan like AgeWell New Yrk FIDA, even if that nursing facility is ut-f-netwrk and des nt participate with AgeWell New Yrk FIDA. Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, AgeWell New Yrk FIDA will pay fr the cst f an ut-fnetwrk prvider. The service area fr this plan includes: Brnx, Kings (Brklyn), Nassau, New Yrk (Manhattan), Queens, Sufflk and Westchester Cunties, NY. Yu must live in ne f these areas t jin the plan. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 5

7 AgeWell New Yrk FIDA: Summary f Benefits Frequently Asked Questins (FAQ) D yu pay a mnthly amunt (als called a premium) under AgeWell New Yrk FIDA Answers Yu will nt pay any mnthly premiums t AgeWell New Yrk FIDA fr yur cverage. Yu als will nt have any cpays r ther csts when yu get care frm netwrk prviders. What is prir authrizatin What is a referral Prir authrizatin means that yu must get apprval frm AgeWell New Yrk FIDA r yur Interdisciplinary Team (IDT) befre yu can get a specific service, item, r drug r befre yu can see an ut-f-netwrk prvider. AgeWell New Yrk FIDA may nt cver the service, item, r drug if yu dn t get apprval frm AgeWell New Yrk FIDA r yur IDT. A small number f services require prir authrizatin by a specialist and nt by AgeWell New Yrk FIDA r yur IDT. Please refer t Chapter 4 f yur Participant Handbk fr mre infrmatin. AgeWell New Yrk FIDA can als prvide yu with a list f services r prcedures that require yu t get prir authrizatin frm a prvider ther than yur IDT. Sme services d nt require any prir authrizatin, such as emergency r urgently needed care, ut-f-area dialysis services, primary care prvider visits, and wmen s health specialist services. Fr the full list f services that d nt require prir authrizatin, please see Chapter 4 f yur Participant Handbk r call AgeWell New Yrk FIDA. A referral means that yur Primary Care Prvider gives yu apprval t see smene that is nt yur Primary Care Prvider. Referrals are nt necessary in AgeWell New Yrk FIDA and will nt be required. Hwever, prir authrizatin rules must be fllwed. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 6

8 AgeWell New Yrk FIDA: Summary f Benefits Frequently Asked Questins (FAQ) Wh shuld yu cntact if yu have questins r need help Answers If yu have general questins r questins abut ur plan, services, service area, billing, r Participant ID Cards, please call AgeWell New Yrk FIDA Participant Services: CALL Calls t this number are free. 7 days a week frm 8:00 am t 8:00 pm. Nte: Frm February 15 t September 30, We may use alternative technlgies n weekends and Federal hlidays. Participant Services als has free language interpreter services available fr peple wh d nt speak English. TTY This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. 7 days a week frm 8:00 am t 8:00 pm. If yu have questins abut yur health, please call the Nurse Advice Call line: CALL Calls t this number are free. 7 days a week frm 8:00 am t 8:00 pm. Nte: Frm February 15 t September 30, We may use alternative technlgies n weekends and Federal hlidays TTY This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. 7 days a week frm 8:00 am t 8:00 pm. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 7

9 AgeWell New Yrk FIDA: Summary f Benefits Frequently Asked Questins (FAQ) Wh shuld yu cntact if yu have questins r need help (cntinued) Answers If yu need immediate behaviral health services, please call the Behaviral Health Crisis Line: CALL Calls t this number are free. 7 days a week frm 8:00 am t 8:00 pm. Nte: Frm February 15 t September 30, We may use alternative technlgies n weekends and Federal hlidays. TTY This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. 7 days a week frm 8:00 am t 8:00 pm. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 8

10 AgeWell New Yrk FIDA: Summary f Benefits The fllwing chart is a quick verview f what services yu may need, yur csts and rules abut the benefits. Health need r prblem Yu want t see a dctr Yu need medical tests Services yu may need Visits t treat an injury r illness Wellness visits, such as a physical Transprtatin t a dctr s ffice Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Prir authrizatin is nt required t see yur PCP. $0 Prir authrizatin is nt required t see yur PCP. $0 Prir authrizatin is required. Specialist care $0 Prir authrizatin is nt required t see in-netwrk specialist. Care t keep yu frm getting sick, such as flu shts Welcme t Medicare preventive visit (ne time nly) Lab tests, such as bld wrk X-rays r ther pictures, such as CAT scans Screening tests, such as tests t check fr cancer $0 Prir authrizatin is nt required. $0 Prir authrizatin is nt required. $0 Prir authrizatin is nt required. $0 Prir authrizatin is nt required fr X- rays. Prir authrizatin is required fr CAT Scan, MRI. $0 Prir Authrizatin is nt required. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 9

11 AgeWell New Yrk FIDA: Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need drugs t treat yur illness r cnditin Generic drugs (n brand name) $0 fr a 30- day supply. $0 fr a 90- day supply There may be limitatins n the types f drugs cvered. Please see AgeWell New Yrk FIDA s List f Cvered Drugs (Drug List) fr mre infrmatin. Extended-day supplies are available with ur mail rder pharmacy EnvisinMail. Brand name drugs $0 fr a 30- day supply. $0 fr a 90- day supply There may be limitatins n the types f drugs cvered. Please see AgeWell New Yrk FIDA s List f Cvered Drugs (Drug List) fr mre infrmatin. Extended-day supplies are available with ur mail rder pharmacy EnvisinMail. Yu need drugs t treat yur illness r cnditin (cntinued) Yu need therapy after a strke r accident Yu need emergency care Over-the-cunter drugs $0 AgeWell New Yrk FIDA cvers sme OTC drugs when they are written as prescriptins by yur prvider. Please see AgeWell New Yrk FIDA s List f Cvered Drugs (Drug List) fr mre infrmatin. Medicare Part B prescriptin drugs Occupatinal, physical, r speech therapy $0 Part B drugs include drugs given by yur dctr in his r her ffice, sme ral cancer drugs, and sme drugs used with certain medical equipment. Read the Participant Handbk fr mre infrmatin n these drugs. $0 Prir authrizatin is required These services are limited t 20 therapy visits per year per therapy. Emergency rm services $0 Prir authrizatin is nt required. Emergency rm services are cvered within the United States nly. Ambulance services $0 Emergency Ambulance Services d nt require prir authrizatin. Scheduled ambulance trips require Prir Authrizatin. Urgent care $0 Prir authrizatin is nt required. Urgent care is cvered within the United States nly. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 10

12 AgeWell New Yrk FIDA: Summary f Benefits Health need r prblem Yu need hspital care Yu need help getting better r have special health needs Yu need eye care Yu need dental care Yu need hearing/auditry services Yu have a chrnic cnditin, such as diabetes r heart disease Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Hspital stay $0 Prir authrizatin is required. Dctr r surgen care $0 Prir authrizatin is required. Rehabilitatin services $0 Prir authrizatin is required. This service is limited t 20 visits per year. Medical equipment fr hme care $0 Prir authrizatin is required. Skilled nursing care $0 Prir authrizatin is required. Eye exams $0 Prir authrizatin is nt required. We cver ne rutine eye exam every tw years. Glasses r cntact lenses $0 Prir authrizatin is required. We cver a full set f cntact lenses and eye glasses (lenses and frames) nce every tw years. Dental check-ups $0 Prir authrizatin is required. We cver preventive dental: ne ral exam every 6 mnths, ne prphylaxis (cleaning) every 6 mnths, and ne set f dental x- rays every 6 mnths. We cver cmprehensive dental: nnrutine services, diagnstic services, restrative services, enddntics, peridntics, extractins, prsthdntics, and ther ral/maxillfacial surgery. Hearing screenings $0 Prir authrizatin is nt required fr rutine hearing exams. Hearing aids $0 Prir authrizatin is nt required fr fitting/evaluatin f hearing aids. Prir authrizatin is required fr hearing aids. Services t help manage yur disease Diabetes supplies and services $0 Prir authrizatin is nt required. $0 Prir authrizatin is required. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 11

13 AgeWell New Yrk FIDA: Summary f Benefits Health need r prblem Yu have a mental health cnditin Yu have a substance abuse prblem Yu need lngterm mental health services Services yu may need Mental r behaviral health services Substance abuse services Inpatient care fr peple wh need mental health care Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Prir authrizatin is nt required fr psychiatric services. Prir authrizatin is required fr mental r behaviral health services. $0 Prir authrizatin is nt required. $0 Prir authrizatin is required. There is n limit n the number f days cvered fr each inpatient psychiatric hspital stay. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 12

14 AgeWell New Yrk FIDA: Summary f Benefits Health need r prblem Yu need durable medical equipment (DME) Yu need help living at hme Yu need help living at hme (cntinued) Yu need a place t live with peple available t help yu Yur caregiver needs sme time ff Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Wheelchairs $0 Prir authrizatin is required. Nebulizers $0 Prir authrizatin is required. Crutches $0 Prir authrizatin is required. Walkers $0 Prir authrizatin is required. Oxygen equipment and supplies Meals brught t yur hme Hme services, such as cleaning r husekeeping Changes t yur hme, such as ramps and wheelchair access Persnal care assistant (Yu may be able t emply yur wn assistant. Call Participant Services fr mre infrmatin.) Training t help yu get paid r unpaid jbs Services t help yu live n yur wn Adult day services r ther supprt services Assisted living r ther husing services $0 Prir authrizatin is required. $0 Prir authrizatin is required. We cver a maximum f 3 meals per day fr 52 weeks. $0 Prir authrizatin is required. $0 Prir authrizatin is required. $0 Prir authrizatin is required. $0 Prir authrizatin is required. $0 Prir authrizatin is required. $0 Prir authrizatin is required. $0 Prir authrizatin is required. Nursing facility care $0 Prir authrizatin is required. Respite care $0 Prir authrizatin is required. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 13

15 AgeWell New Yrk FIDA: Summary f Benefits Other services that AgeWell New Yrk FIDA cvers This is nt a cmplete list. Call Participant Services r read the Participant Handbk t find ut abut ther cvered services. Other services cvered by AgeWell New Yrk FIDA AgeWell New Yrk FIDA ffers $50 per mnth fr Over-the-Cunter (OTC) benefit fr apprved nn-descriptin drugs and health related items purchased at participating lcatins. Yur csts fr in-netwrk prviders $0 Benefits cvered utside f AgeWell New Yrk FIDA This is nt a cmplete list. Call Participant Services t find ut abut ther services nt cvered by AgeWell New Yrk FIDA but available thrugh Medicare r Medicaid. Other services cvered by Medicare r Medicaid Yur csts Day treatment $0 Freestanding birth center services $0 Out f netwrk family planning services $0 Methadne Maintenance Treatment Prgram (MMTP) $0 Directly bserved therapy fr tuberculsis (TB) $0 Hspice services $0 Services that AgeWell New Yrk FIDA, Medicare, and Medicaid d nt cver This is nt a cmplete list. Call Participant Services t find ut abut ther excluded services. Services nt cvered by AgeWell New Yrk FIDA, Medicare, r Medicaid Services prvided t veterans in Veterans Affairs (VA) facilities. Hwever, when a veteran gets emergency services at a VA hspital and the VA cst sharing is mre than the cst sharing under AgeWell New Yrk FIDA, we will reimburse the veteran fr the difference. Participants are still respnsible fr their cst sharing amunts. Csmetic surgery r ther csmetic wrk, unless it is needed because f an accidental injury r t imprve a part f the bdy that is nt shaped right. Hwever, AgeWell New Yrk FIDA will pay fr recnstructin f a breast after a mastectmy and fr treating the ther breast t match it. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 14

16 AgeWell New Yrk FIDA: Summary f Benefits Services nt cvered by AgeWell New Yrk FIDA, Medicare, r Medicaid Experimental medical and surgical treatments, items, and drugs, unless cvered by Medicare r under a Medicare-apprved clinical research study r by AgeWell New Yrk FIDA. Experimental treatment and items are thse that are nt generally accepted by the medical cmmunity. Surgical treatment fr mrbid besity, except when it is medically needed and Medicare pays fr it. A private rm in a hspital, except when it is medically needed. Persnal items in yur rm at a hspital r a nursing facility, such as a telephne r a televisin. Fees charged by yur immediate relatives r members f yur husehld. Elective r vluntary enhancement prcedures r services (including weight lss, hair grwth, sexual perfrmance, athletic perfrmance, csmetic purpses, anti-aging and mental perfrmance), except when medically needed. Chirpractic care, ther than manual manipulatin f the spine cnsistent with Medicare cverage guidelines. Supprtive devices fr the feet, except fr rthpedic r therapeutic shes fr peple with diabetic ft disease. Radial kerattmy, LASIK surgery, visin therapy, and ther lw-visin aids. Reversal f sterilizatin prcedures and nnprescriptin cntraceptive supplies. Acupuncture. Naturpath services (the use f natural r alternative treatments). If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 15

17 AgeWell New Yrk FIDA: Summary f Benefits Yur rights as a Participant f the plan As a Participant f AgeWell New Yrk FIDA, yu have certain rights. Yu can exercise these rights withut being punished. Yu can als use these rights withut lsing yur services frm AgeWell New Yrk FIDA. We will tell yu abut yur rights at least nce a year. Fr mre infrmatin n yur rights, please read the Participant Handbk. This is nt a cmplete list f all yur rights. Yur rights include, but are nt limited t, the fllwing: Yu have a right t respect, fairness and dignity. This includes the right t: Get cvered services withut cncern abut race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, sexual rientatin, genetic infrmatin, ability t pay, r ability t speak English Ask fr infrmatin in ther frmats (e.g., large print, braille, r audi) Be free frm any frm f physical restraint r seclusin Nt be billed by netwrk prviders Have yur questins and cncerns answered cmpletely and curteusly Freely apply yur rights withut any negative effect n the way AgeWell New Yrk FIDA r yur prvider treats yu Chse a Primary Care Prvider (PCP) and yu can change yur PCP at any time Participate in Interdisciplinary Team meetings abut yur care Get yur cvered services and drugs quickly Knw abut all treatment ptins, n matter what they cst r whether they are cvered Refuse treatment, even if yur dctr advises against it Stp taking medicine Ask fr a secnd pinin. AgeWell New Yrk FIDA will pay fr the cst f yur secnd pinin visit Create and apply an advance directive, such as a living will r health care prxy Yu have the right t get infrmatin abut yur health care. This includes infrmatin n treatment and yur treatment ptins. This infrmatin shuld be in a frmat yu can understand. These rights include getting infrmatin n: Descriptin f the services we cver Hw t get services Hw much services will cst yu Names f prviders and care managers Yu have the right t make decisins abut yur care, including refusing treatment. This includes the right t: Yu have the right t timely access t care that des nt have any cmmunicatin r physical access barriers. This includes the right t: Get medical care timely Get in and ut f a health care prvider s ffice. This means barrier free access fr peple with disabilities, in accrdance with the Americans with Disabilities Act Have interpreters t help with cmmunicatin with yur dctrs and yur health plan If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 16

18 AgeWell New Yrk FIDA: Summary f Benefits Yu have the right t seek emergency and urgent care when yu need it. This means yu have the right t: Get emergency services withut prir apprval in an emergency Have yur persnal health infrmatin kept private Direct yur wn care r hire yur wn aides thrugh Cnsumer-Directed Persnal Assistance Services See an ut f netwrk urgent r emergency care prvider, when necessary Yu have the right t make cmplaints abut yur cvered services r care. This includes the right t: Yu have a right t cnfidentiality and privacy. This includes the right t: File a cmplaint r grievance against us r ur prviders Ask fr and get a cpy f yur medical recrds in a way that yu can understand and ask fr yur recrds t be changed r crrected Get a detailed reasn fr why services were denied Fr mre infrmatin abut yur rights, yu can read the AgeWell New Yrk FIDA Participant Handbk. If yu have questins, yu can als call AgeWell New Yrk FIDA Participant Services. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 17

19 AgeWell New Yrk FIDA: Summary f Benefits If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think AgeWell New Yrk FIDA shuld cver smething we denied, call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. Yu may be able t appeal ur decisin. Fr questins abut grievances (cmplaints) and appeals, yu can read Chapter 9 f the AgeWell New Yrk FIDA Participant Handbk. Yu can als call AgeWell New Yrk FIDA Participant Services. Additinally, yu can get help frm the Independent Cnsumer Advcacy Netwrk (ICAN). ICAN can give yu free, cnfidential assistance n any services ffered by AgeWell New Yrk FIDA, including any prblems getting quality care. ICAN may be reached at r nline at icannys.rg. (TTY users call 711, then fllw the prmpts t dial ) Yu have the right t file an appeal with ur plan fr any adverse determinatin (denial f services). Yu will nt have t pay fr any pf these prceedings. T start yur appeal, yu, yur prvider, r yur representative must cntact us. Yu can call (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. Or, yu may appeal in writing and submit the request t the fllwing address: AgeWell New Yrk FIDA, Appeals & Grievance Department, 1991 Marcus Ave Suite M201, Lake Success, NY If yu suspect fraud Mst health care prfessinals and rganizatins that prvide services are hnest. Unfrtunately, there may be sme wh are dishnest. If yu think a dctr, hspital r ther pharmacy is ding smething wrng, please cntact us. Call us at AgeWell New Yrk FIDA Participant Services. Phne numbers are n the cver f this summary. Or, call Medicare at MEDICARE ( ). TTY users shuld call Yu can call these numbers fr free, 24 hurs a day, 7 days a week. If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 18

20 AgeWell New Yrk FIDA: Summary f Benefits Ntice f Nn-Discriminatin AgeWell New Yrk FIDA cmplies with applicable Federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. AgeWell New Yrk FIDA des nt exclude peple r treat them differently because f race, clr, natinal rigin, age, disability, r sex. AgeWell New Yrk FIDA prvides free aids and services t peple with disabilities t cmmunicate effectively with us, such as: Qualified sign language interpreters Written infrmatin in ther frmats (large print, audi, accessible electrnic frmats, ther frmats) Free language services t peple whse primary language is nt English, such as qualified interpreters and infrmatin written in ther languages If yu need these services, cntact AgeWell New Yrk FIDA Participant Services at If yu believe that AgeWell New Yrk FIDA has failed t prvide these services r discriminated in anther way n the basis f race, clr, natinal rigin, age, disability, r sex, yu can file a grievance with: AgeWell New Yrk FIDA Civil Rights Crdinatin Unit 1991 Marcus Avenue Suite M201 Lake Success, New Yrk TTY/TDD: Fax: civilrightsunit@agewellnewyrk.cm Yu can file a grievance in persn r by mail, fax, r . If yu need help filing a grievance, the Civil Rights Crdinatin Unit is available t help yu. Yu can als file a civil rights cmplaint with the U.S. Department f Health and Human Services, Office fr Civil Rights electrnically thrugh the Office fr Civil Rights Cmplaint Prtal, available at r by mail r phne at: U.S. Department f Health and Human Services, 200 Independence Avenue SW., Rm 509F, HHH Building, Washingtn, DC 20201, , TDD: Cmplaint frms are available at If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 19

21 AgeWell New Yrk FIDA: Summary f Benefits Multi-language Insert English: ATTENTION: If yu d nt speak English, language assistance services, free f charge, are available t yu. Call (TTY: ). Spanish: ATENCIÓN: si habla españl, tiene a su dispsición servicis gratuits de asistencia lingüística. Llame al (TTY: ). Chínese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). French Crele: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pu lang ki dispnib gratis pu u. Rele (TTY: ). Krean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Italian: ATTENZIONE: In cas la lingua parlata sia l'italian, sn dispnibili servizi di assistenza linguistica gratuiti. Chiamare il numer (TTY: ). Yiddish: אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופ ) (TTY: Bengali: লkয ক ন য দ আপ ন ব ল, কথ বল ত প রন, ত হ ল ন খরচ য় ভ ষ সহ য়ত প র ষব uপলb আ ছ ফ ন ক ন (TTY: ) Plish: UWAGA: Jeżeli mówisz p plsku, mżesz skrzystać z bezpłatnej pmcy językwej. Zadzwń pd numer (TTY: ). Arabic: ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: ). If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 20

22 AgeWell New Yrk FIDA: Summary f Benefits French: ATTENTION : Si vus parlez français, des services d'aide linguistique vus snt prpsés gratuitement. Appelez le (ATS : ). Urdu : خبردار: اگر آپ اردو بولتے ہيں تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں کال کريں.(TTY: ) Taglg: PAUNAWA: Kung nagsasalita ka ng Tagalg, maaari kang gumamit ng mga serbisy ng tulng sa wika nang walang bayad. Tumawag sa (TTY: ). Greek: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: ). Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispzicin shërbime të asistencës gjuhësre, pa pagesë. Telefnni në (TTY: ). If yu have questins, please call AgeWell New Yrk FIDA at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. Fr mre infrmatin, visit 21

23 We re here fr yur c all. AgeWell New Yrk FIDA is a managed care plan that cntracts with bth Medicare and the New Yrk State Department f Health (Medicaid) t prvide benefits f bth prgrams t Participants thrugh the Fully Integrated Duals Advantage (FIDA) Demnstratin. Yu can get this dcument fr free in ther frmats, such as large print, braille, r audi. Call Participant Services at (TTY: ), 7 days a week frm 8:00 am t 8:00 pm. The call is free. agewellnewyrk.cm TTY/TDD