MEMBER HANDBOOK Managed Long Term Care

Transcription

1 MEMBER HANDBOOK Managed Long Term Care Revised June 2016

2 Important names and phone numbers Names, addresses and phone numbers of doctors: What to do in an emergency: Call 911 immediately, and notify VNSNY CHOICE within 24 hours if possible. For VNSNY CHOICE MLTC Member Services call toll free Monday Friday, 9 am 5 pm TTY users please call i

3 We speak your language As a VNSNY CHOICE Managed Long Term Care (MLTC) member, you can get important information about the program in the language you understand best. For example, this Member Handbook and other health information are available in English, Spanish, Chinese, Korean and Russian. If you need a translated version of the Member Handbook, please call us at to ask for a copy in your language. Hablamos su idioma Como miembro del programa de atención médica supervisada a largo plazo de VNSNY CHOICE, usted puede obtener información importante sobre el programa en el idioma que entiende mejor. Por ejemplo, este Manual de los Miembros y otra información sobre la salud están disponibles en Inglés, Español, Chino, Coreano y Ruso. Si necesita una versión traducida del Manual de los Miembros, por favor llámenos al para pedir una copia en su idioma. 我們講您的語言 ( 中文 ) 作為 VNSNY CHOICE 管理下長期護理 (MLTC) 會員, 您可以通過自己最熟悉的語言來獲得有關本計劃的重要資訊 例如, 本會員手冊和其他健康資訊有英文 西班牙文 中文 韓文和俄文 如果您需要會員手冊的翻譯版本, 請致電 來索取所需語言的翻譯本 Мы говорим на вашем языке Участники программы по оказанию долгосрочной медицинской помощи VNSNY CHOICE могут получать необходимую информацию на удобном для них языке. Например, данный справочник и другие документы, касающиеся вашего здоровья, доступны на английском, испанском, китайском, корейском и русском языках. Если вам нужен перевод справочника участника, свяжитесь с нами по телефону и попросите копию на нужном языке. 해당언어지원 ( 한국어 ) 해당언어지원 ( 한국어 VNSNY CHOICE) 관리형장기간호멤버께서사용하시는언어로프로그램에대한주요정보를받아보실수있습니다. 예를들어멤버안내책자와건강정보를영어, 스페인서, 중국어, 한국어, 러시아어로받다볼수있습니다. 멤버안내번역서가필요하신면, 에문의하여원하는번역서를요청하십시요. ii

4 Congratulations on becoming a member of VNSNY CHOICE s Managed Long Term Care (MLTC) Plan. Your membership lets us know that home is your first choice for long term care. This Member Handbook, along with your signed Enrollment Application and Agreement, now become your contract with VNSNY CHOICE, your managed long term care program. It describes the benefits of membership, eligibility for the program, and our policies and procedures. It will help you understand what you need to do to obtain services and how best to work with your Care Manager and other VNSNY CHOICE staff to ensure that your needs are being met. Please review this Handbook carefully. If you would like more information on anything covered in this Handbook or if you have any questions, please call Member Services at the number below. You will find the telephone number for Member Services at the end of each page of this handbook. Our member service representatives are here to help you. We encourage you and your family to be involved in your long term care. We want you to have an ongoing relationship with your Care Manager and your doctor(s), who, working together, will help you receive the home, community, and facility-based long term care services you need. Thank you for choosing VNSNY CHOICE MLTC for your long term care. We look forward to serving you. Thank You Thank you for choosing VNSNY CHOICE! We are ready to serve you. We want you to be satisfied with the services you receive from us. Please call Member Services at Monday through Friday from 9:00 am to 5:00 pm whenever you have suggestions or concerns. (TTY users call 711). Wishing you well, Hany Abdelaal, DO President, VNSNY CHOICE Health Plans iii

5 Welcome to VNSNY CHOICE Managed Long Term Care VNSNY CHOICE is committed to helping our members continue to live independently in their homes and communities for as long as possible. Our goal is to promote choice in long term health care. We achieve our goal by directly involving you in planning your care and by offering a wide range of flexible services and schedules to fit your everyday needs. This program provides innovative long term care solutions that are beneficial and cost effective for each member. iv

6 Table of Contents Section A: What is VNSNY CHOICE MLTC?... 1 Section B: Who is eligible to enroll and the enrollment process for VNSNY CHOICE MLTC?..2 Section C: How does my health care change when I become a member of VNSNY CHOICE MLTC?...6 Section D: What are the benefits and services covered by VNSNY CHOICE MLTC?...8 Section E: How do I obtain these services? Section F: Are there formal authorization procedures?...17 Section G: Who is part of my VNSNY CHOICE MLTC Team?...20 Section H: Who is in the VNSNY CHOICE provider network? Section I: What are my responsibilities as a VNSNY CHOICE MLTC member?...22 Section J: What are my rights as a VNSNY CHOICE MLTC member?...23 Section K: Can I continue to use my own doctor? Section L: What happens if I am hospitalized?...28 Section M: Will Medicaid and/or Medicare still pay for services not covered by VNSNY CHOICE MLTC?...29 Section N: What should I do in an emergency? Section O: How do I get help during non-business hours if my needs change, but it is not an emergency?...32 Section P: What if I leave the VNSNY CHOICE Managed Long Term Care area?...33 Section Q: What if I decide to end my membership in VNSNY CHOICE Managed Long Term Care?...34 Section R: Can my membership be cancelled? Section S: The VNSNY CHOICE MLTC Grievance and Appeal Process Section T: More Information Section U: About The Visiting Nurse Service of New York...46.

7 Section A: What is VNSNY CHOICE MLTC? VNSNY CHOICE Managed Long Term Care (MLTC) is a managed long term care program for adults who wish to and are able to live safely at home but need assistance with day-to-day activities. VNSNY CHOICE MLTC is designed to provide you with the very best care, so you can remain safely at home for as long as possible. We encourage our members to take an active part in their own health care, and we offer many choices in services and locations. Once you choose to join VNSNY CHOICE MLTC, you will work closely with a Care Manager whose job it is to understand all of your health needs and coordinate all the care you receive. Your Care Manager will talk with you, offer professional advice and make sure you receive the right level of quality services you need. Your Care Manager will assess your needs and talk with your health care professionals about the assessment. Together, with your input, they will collaborate on the plan for your care. Your Care Manager will be there to help you whether you are at home, in the hospital, or if you require nursing home care. As a VNSNY CHOICE MLTC member, you will receive your covered long term care and health-related services through providers who are part of the VNSNY CHOICE Provider Network. The current network Provider Directory is in your membership folder. For as long as you are a member, you will receive high quality long term care, even if your health care needs change. Our goal is to help you live independently in your own home for as long as possible. We have the people and resources to provide you with a wide range of rehabilitation services and community based services. We can even make improvements to your home so that you are safe. In addition, we will coordinate all VNSNY CHOICE MLTC services with other services that are paid for by Medicaid and Medicare. VNSNY CHOICE is affiliated with the Visiting Nurse Service of New York and has been providing managed long term care services to residents of New York since

8 Section B: Who is eligible to enroll and the enrollment process for VNSNY CHOICE MLTC? VNSNY CHOICE Managed Long Term Care (MLTC) is for individuals who need long term care services and would like to receive these services at home and in the community for as long as possible. Your membership in VNSNY CHOICE is voluntary. You choose to enroll in the program, and you may choose to disenroll for any reason. To enroll in VNSNY CHOICE MLTC, you must meet the following requirements: You must be at least 18 years old. You must be eligible for Medicaid. You are eligible for MLTC as determined by an eligibility assessment tool developed by the New York State Department of Health. You must need at least one (1) of the following Community Based Long Term Care services covered by VNSNY CHOICE MLTC for more than 120 days from the effective date of enrollment: a. Nursing services in the home; b. Therapies in the home; c. Home health aide services d. Personal care services in the home, including bathing, dressing, grooming, toileting, ambulation, transferring, feeding, administration of medications, routine skin care, using medical supplies such as walkers and wheelchairs, meal preparation (complex, modified diets) e. Adult day health care; f. Private duty nursing; or g. Consumer Directed Personal Assistance Services Your health care needs can be safely met in your home. You live in the VNSNY CHOICE service area which includes the following counties: Albany, Bronx, Columbia, Delaware, Dutchess, Erie, Fulton, Greene, Herkimer, Kings (Brooklyn), Madison, Monroe, Montgomery, Nassau, New York (Manhattan), Oneida, Onondaga, Orange, Otsego, Putnam, Queens, Rensselaer, Richmond (Staten Island), Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington and Westchester. You or a member of your family can call VNSNY CHOICE Managed Long Term Care (MLTC) directly to discuss enrollment in the program. Sometimes, another health care provider (such as a nurse, social worker, or physician) may also refer an individual to VNSNY CHOICE. 2

9 If you are interested in VNSNY CHOICE MLTC and new to receiving MLTC services, you will be referred to the Conflict-Free Evaluation and Enrollment Center (CFEEC) to schedule an eligibility evaluation. A Registered Professional Nurse from the CFEEC will come to your home and perform the evaluation within about 5-7 business days from the time you make the call. Once the evaluation is completed, you will receive a letter from New York Medicaid Choice indicating your eligibility for a Managed Long Term Care Plan. If you are determined to be eligible, you will have the option of selecting a plan. The CFEEC will provide assistance with connecting you to the plan of your choice. Regardless of how we learn about your need for long term care services, the enrollment process is the same: Step 1 First, a VNSNY CHOICE Registered Professional Nurse will contact you to talk about the program and to be sure that you are interested in the types of services offered by VNSNY CHOICE MLTC. We also may check at this time to be sure that you are eligible for Medicaid. If you need help applying for Medicaid, please let us know. A Registered Professional Nurse can direct you to someone who will help you with this application. If you are applying for Medicaid at the same time that you enroll in VNSNY CHOICE MLTC, the enrollment process may take at least one or two months longer than if you already have an active Medicaid number. Step 2 If you are interested in VNSNY CHOICE MLTC, a Registered Professional Nurse will come to your home at a time that is convenient for you to complete an assessment of your needs. This assessment will help develop your plan of care. Step 3 The Registered Professional Nurse will also ask you to sign a New York State Department of Health form, an Authorization for Release of Health Information pursuant to HIPAA, so that VNSNY CHOICE MLTC can obtain information and input from your doctor and other health providers. We want to know as much as possible about your health needs so that we can provide the services that are best for you. Please be assured that our staff will protect your confidential health information to the full extent of the law. Step 4 The assessment may take more than 1 home visit to complete. During these visits, the Registered Professional Nurse will discuss the program with you and your family to be sure that you understand how VNSNY CHOICE MLTC works. She/he will give you a copy of your Member Handbook and Provider Directory and will discuss with you the information about our policies and procedures that you can find in it. 3

10 The Registered Professional Nurse will also work with you to develop a proposed care plan. The Care Manager will work with your health care professionals to develop a care plan. This Care Plan includes the services you will receive once you are a member of VNSNY CHOICE MLTC. If your condition changes, your Registered Professional Nurse will modify the Care Plan so that we can continue to meet your long term care needs. Step 5 Enrollment in VNSNY CHOICE MLTC is voluntary. If you are interested in the program, the Registered Professional Nurse will ask you to sign an enrollment application and agreement. If you choose not to enroll in the program, you can withdraw your application by noon on the 20th day of the month prior to the effective date of your enrollment by contacting us orally or in writing. We will send you an acknowledgment in writing confirming your withdrawal. Step 6 VNSNY CHOICE MLTC will send your enrollment information to Medicaid. In most cases, you will become a member of VNSNY CHOICE MLTC on the first day of the month after you sign the enrollment application and agreement. We will confirm your actual enrollment date by telephone as soon as possible usually a few days before your membership begins. Once you are a member, your Care Manager will ensure that you get all the services that are outlined in your Care Plan. Please see Section C for more information about your Care Manager and how she/he will work with you to make sure that you receive all of the services you need. Step 7 Upon enrollment in VNSNY CHOICE, you may continue an ongoing course of treatment, with a non-network health care provider, for a transitional period of up to (60) sixty days from enrollment for any treatment relating to a life threatening disease or condition or a degenerative or disabling disease or condition. If your provider accepts payment at VNSNY CHOICE s rate, adheres to VNSNY CHOICE s quality assurance and other policies, and provides medical information about your care to VNSNY CHOICE, VNSNY CHOICE will be responsible for payment to the non-network provider. Should your health care provider leave the VNSNY CHOICE network, your ongoing course of treatment may be continued for a transitional period of up to (90) ninety days if your provider accepts payment at VNSNY CHOICE s rate, adheres to VNSNY CHOICE s quality assurance and other policies, and provides medical information about your care to VNSNY CHOICE. If you feel you have a condition that meets the criteria for transitional care services, please notify your Care Manager. If you are currently receiving Medicaid fee-for-service Community Based Long Term Care (CBLTC) services, you will continue to receive those services under your pre-existing service plan for at least 90 days after enrollment. 4

11 Step 8 Medicaid must verify your Medicaid eligibility prior to enrollment in VNSNY CHOICE MLTC. In addition to the criteria listed at the beginning of this chapter, your enrollment in VNSNY CHOICE MLTC would be denied in the following circumstances: You are currently receiving care in a hospital or residential facility operated by the State Office of Mental Health, the Office of Alcoholism and Substance Abuse Services or the Office for People with Developmental Disabilities (OPWDD). An application to enroll in VNSNY CHOICE MLTC may be accepted, but your enrollment may only begin upon discharge to your home in the community. You are already enrolled in another Medicaid managed care program, a Day Treatment program sponsored by the Office for People with Developmental Disabilities, or a Hospice program. If you terminate your participation in these programs, you can then be considered for enrollment in VNSNY CHOICE MLTC. You were involuntarily disenrolled from VNSNY CHOICE in the past, and the situation that led to your disenrollment has not been resolved. 5

12 Section C: How does my health care change when I become a member of VNSNY CHOICE MLTC? The decision to join VNSNY CHOICE Managed Long Term Care (MLTC) is important because it affects how you receive many of the health care services you need on a regular basis. When you become a member of VNSNY CHOICE MLTC, your Care Manager will talk to you to be sure you understand how your health care has changed and how to use your Medicaid benefits. Your Care Manager is a Registered Professional Nurse with experience caring for people with long term care needs. The major changes are listed below for your information, and many of these topics are discussed in more detail later in this Member Handbook. You may receive a wide range of covered services from VNSNY CHOICE MLTC. These services are listed on pages They are provided to you in your home, at community sites in your neighborhood, and in local nursing homes. As a VNSNY CHOICE MLTC member, one call can connect you to all the services you need. VNSNY CHOICE uses a network of community providers to deliver many of the services you need. You must receive all services covered by VNSNY CHOICE MLTC from the providers in our Provider Network. (Please see page 21 for information on the circumstances when we will make an exception to this rule.) The network includes programs, agencies and professionals who provide each of the services covered by VNSNY CHOICE MLTC. For many health services, the VNSNY CHOICE network is quite extensive so that you have many providers to choose from. Please check your Provider Directory to see if your local provider is in our network Your Care Manager is a Registered Professional Nurse with experience caring for people with long term care needs. Your Care Manager will stay in touch with you by telephone. She/he will make sure that all of your health care and long term care services are closely coordinated. Your Care Manager will talk with your health care professionals about your medical needs as needed. If you need a service that is not covered by VNSNY CHOICE MLTC, but is paid for by Medicare, Medicaid, or other insurance, your Care Manager also will help you arrange for these services if you wish. Please call Member Services if you need to speak to your Care Manager. Your Care Manager will be sure you get all the services that are outlined in your Care Plan. The services you get from VNSNY CHOICE MLTC are based on a Care Plan (which is discussed in detail on pages 15-16). This plan is updated periodically, based on a comprehensive assessment of your health needs. You play an important part in this process. If you feel you need a service that is covered by VNSNY CHOICE MLTC, please talk with your Care Manager. You do NOT have to change your Primary Care Physician to remain enrolled in the plan. Your Care Manager will talk with him/her about VNSNY CHOICE MLTC and the services we can provide to you. Your Care Manager will talk to your health care professionals about your care plan. 6

13 You will use your Medicaid and/or Medicare card only for specific services. As a VNSNY CHOICE MLTC member, you are still eligible for all the services you normally get from Medicaid. And, if you are covered by Medicare, the services that Medicare pays for do not change when you enroll in VNSNY CHOICE MLTC. Now you will only use your Medicare card, your Medicaid card, and/or your identification card from your Medicare Prescription Drug Plan when you go for certain services. Some examples of these services are the physician, the hospital, the emergency room, prescriptions and over-the-counter drugs, a mental health program, or substance abuse service. A complete list of the services that are still covered by Medicare and/or Medicaid appears on pages of this Handbook. If Medicaid determines that you have a Medicaid surplus (or spend down ), you will be responsible for paying this amount to VNSNY CHOICE. You will get a bill from the Visiting Nurse Service of New York (VNSNY) each month for the amount you owe. (As an affiliated company, VNSNY provides this billing service on behalf of VNSNY CHOICE.) If you have questions regarding your Medicaid surplus, please call Member Services at the phone number listed below. Please read this Handbook carefully for more information on these topics. This Handbook includes information on the key policies and procedures of VNSNY CHOICE MLTC and is an important part of your agreement to enroll in this program. You should keep it in a handy location so that you can refer to it whenever you have questions about the services you receive. Member Services is also available to answer any questions you have about VNSNY CHOICE MLTC. Please do not hesitate to call them. The Member Services phone number is listed below. 7

14 Section D: What are the benefits and services covered by VNSNY CHOICE MLTC? VNSNY CHOICE Managed Long Term Care (MLTC) offers a wide range of home, community, and facility-based long term care and health-related services. One call connects you to all the services of the program. We will provide or arrange for services that are medically necessary. This means any health service that is needed to prevent, diagnose, correct, or cure (when possible) your health problems. Health problems may cause pain, illness, injury, or disability. They can interfere with normal activities, and in some cases, could endanger one s life. At VNSNY CHOICE MLTC, we want to understand your health needs, so that we can provide specific services to help you. Your Care Manager will work with you to develop a Care Plan that uses the following services as medically necessary to meet your needs: Adult day health care Chore service and housekeeping Comprehensive care management and coordination of your health care services Consumer Directed Personal Assistance Services (CDPAS) Dental care Durable medical equipment Environmental supports, such as home safety modifications or improvements that are needed to safeguard your health Eye exams and glasses Foot care Hearing exams and hearing aids (including hearing aid batteries) Home-delivered meals Medical and surgical supplies Nursing home care Nutritional Services Personal care Personal Emergency Response System (PERS) Preventive services Private Duty Nursing Professional Home Health Care Services - Home health aide services - Medical social services - Nursing care - Occupational therapy (OT) - Physical therapy (PT) - Speech therapy (ST) 8

15 Prosthetics and orthotics Registered Nurse availability by telephone - 24 hours a day, 7 days a week Rehabilitation therapies (PT, OT, ST) provided in settings other than the home Respiratory therapy and oxygen Scheduled transportation to medical appointments (non-emergent) Social Day Care Veterans Home Services All of the services are provided by VNSNY CHOICE MLTC and the VNSNY CHOICE Provider Network. If you are a veteran, you may access Veteran s Home Services. To find the network providers in your neighborhood, please check the current Provider Directory. Member Services can help you find the most convenient locations and can tell you which providers are taking new patients. Just call Member Services at the number below. More about the services and benefits of VNSNY CHOICE MLTC. The Consumer Directed Personal Assistance Services (CDPAS) is a self-directed home care model available to Medicaid eligible consumers who are chronically ill or physically disabled and in need of home care services. Consumers who are in need of personal care services, home health aide services or skilled nursing tasks may request that these services be provided by a consumer directed personal care assistant under the direction of the enrollee or enrollee s designated representative. A Registered Professional Nurse will complete an assessment to determine your eligibility for CDPAS. The assessment determines the level of assistance with personal care services, home health aide services and/or skilled nursing services you are eligible to receive. To find out more about CDPAS and determine if it is right for you, please speak with you Care Manager. Comprehensive Care Management: VNSNY CHOICE MLTC coordinates all of your home and community-based services as well as all of your medical care. Your Care Manager will provide or arrange for these services, and she/he will be sure that all the care you receive is carefully coordinated. As your needs change, you and your Care Manager, along with your doctor, may decide to change your Care Plan. In addition to home and community based services, your Care Manager will oversee all of your services and work with the health care professionals to make sure your overall Care Plan meets all of your health care needs. If you become hospitalized or need to stay in a skilled nursing facility, your Care Management Team will work with the staff of the named facility to be sure that your needs are met. Professional Home Health Care Services: VNSNY CHOICE MLTC will coordinate the provision of services, which may include care from nurses, social workers, nutritionists, physical therapists, occupational therapists and speech therapists. These services are provided to help prevent, rehabilitate, guide and/or support your health. 9

16 Personal Care: VNSNY CHOICE MLTC will coordinate the provision of personal care and help you with such activities as personal hygiene, dressing and eating, and home-environment support as determined by an assessment of your needs. Private Duty Nursing: Skilled nursing care provided in your home by properly licensed registered professional or licensed practical nurses. Nutritional Services: VNSNY CHOICE s in-network nutritionists can assess your dietary needs and help you to be sure that your diet is consistent with your personal needs. Home Delivered Meals: VNSNY CHOICE MLTC can provide you with home-delivered or congregate meals provided in accordance with your Care Plan. Typically, one or two meals are provided per day for individuals who are unable to prepare meals and who do not have personal care services to assist with meal preparation. Rehabilitation Therapy: VNSNY CHOICE MLTC Rehabilitation services may be provided at outpatient locations, based on your needs. These services include: Physical Therapy, Occupational Therapy, and Speech-Language Pathology which are rehabilitation services provided by licensed registered physical therapists, occupational therapists, or speech language pathologists for the purpose of maximum reduction of physical or mental disability and restoration to your best functional level Physical, occupational and speech therapy are limited to twenty (20) visits per therapy per year for each discipline. If you receive benefits from both Medicare and Medicaid through VNSNY CHOICE MLTC, PT, OT or ST visits that are paid for as part of your Medicare benefit do not count as part of the 20 rehabilitation visit limit. These Medicaid limits apply to rehabilitation therapy visits that you receive in a private practitioner s office as well as visits received in a certified hospital outpatient department or a diagnostic and treatment center (free-standing clinic). These service limits do not apply to visits that take place in a hospital inpatient setting, a skilled nursing facility or through a certified home health agency (CHHA). Additionally, these service limits do not apply to VNSNY CHOICE members if additional services are authorized by your Care Manager, if you are younger than 21 years of age, if you have a traumatic brain injury, or you have been determined to be developmentally disabled by the Office for People with Developmental Disabilities. Non-Emergency Transportation: VNSNY CHOICE MLTC will arrange and pay for your transportation to and from your doctor, as well as other providers for non-emergency healthrelated services. Services will be provided by ambulette or car services depending on your individual need. If you need transportation, please call Member Services at least 2 business days in advance, if possible, so that it can be scheduled with a participating transportation company. If public transportation is available and you are well enough to travel to your medical appointments, VNSNY CHOICE MLTC will reimburse you for the cost. 10

17 If a family member or other caregiver accompanies you, that person will also be reimbursed for public transportation. Dental Services: After you enroll in VNSNY CHOICE MLTC, you will receive a dental card from the dental network for VNSNY CHOICE MLTC. The dental card is accepted by hundreds of fully qualified dentists in New York. All dental services are provided through this network, and you can select any dentist listed in your Provider Directory for your care. Member Services can help you with selecting a dentist or making an appointment, if you wish. As part of your dental benefit, you are entitled to twice yearly check ups including cleanings, x-rays, and basic restorative services such as fillings, extractions, and dentures. Personal Emergency Response System (PERS): PERS is an electronic device that enables members to secure help in the event of an emergency (including a physical, emotional or environmental emergency). Such systems are usually connected to a member s phone and signal a response center once a help button is activated. In the event of an emergency, the signal is received and appropriately acted on by our contracted response center. Eye Exams and Glasses: Fully credentialed optometrists provide eye exams and glasses. You can get a routine eye exam once every two years and eyeglasses every 2 years or more frequently if medically necessary. Please remember to get your care at one of the eye care centers listed in your VNSNY CHOICE MLTC Provider Directory. Member Services can help you with selecting an optometrist or making an appointment, if you wish. Foot Care: Foot care is provided by the licensed podiatrists listed in the VNSNY CHOICE MLTC Provider Directory. Routine hygienic care of the feet, the treatment of corns and calluses, the trimming of nails, and other hygienic care such as cleaning or soaking feet may be covered if your Care Manager deems it necessary. If you need to see a podiatrist, please discuss this with your Care Manager. Durable Medical Equipment: VNSNY CHOICE MLTC coordinates the provision of durable medical equipment (DME). DME includes Medical/Surgical Supplies, Enteral and Parenteral Formula, Hearing Aid Batteries, Prosthetics, Orthotics and Orthopedic Footwear. Hearing Exams and Hearing Aids: Hearing exams and hearing aids are provided by a network of local, independent audiologists. Every exam is performed by a fully licensed audiologist. Several offices are located in the VNSNY CHOICE MLTC service area. If you think you need a hearing exam, we may ask you to see your doctor first, in order to be sure that another health problem is not affecting your ability to hear. VNSNY CHOICE also covers batteries for your hearing aids. Please talk with your Care Manager about this service. Prosthetics and Orthotics: VNSNY CHOICE MLTC will coordinate the provision of prosthetic appliances and devices. Prosthetic appliances and devices are devices that replace any missing part of the body. Orthotic appliances and devices are devices used to support a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body. Orthopedic footwear are shoes, shoe modifications or shoe additions which are used 11

18 to correct, accommodate or prevent a physical deformity or range of motion malfunction in a diseased or injured part of the ankle or foot; to support a weak or deformed structure of the ankle or foot or to form an integral part of a brace. VNSNY CHOICE covers orthopedic footwear and compression stockings prescribed as medically necessary by your doctor. Your Care Manager can help with coordinating the coverage of these items. Medical Equipment, Medical and Surgical Supplies, Respiratory Therapy and Oxygen: VNSNY CHOICE MLTC will coordinate with your health care professionals on required medical equipment, supplies, respiratory therapy, and oxygen. Your Care Manager will identify the need for enteral or oral supplement based on the following Medicaid Criteria: You have a documented diagnostic condition where caloric and dietary nutrients cannot be absorbed or metabolized. There are clinical findings related to malnutrition; requires supplemental nutrition; demonstrates documented compliance with an appropriate medical and nutritional Care Plan. There is laboratory data related to malnutrition. There has been failure to increase or maintain body weight with usual solid or oral liquid intake. You are on tube feedings. Social and Environmental Supports: In the event you require it, VNSNY CHOICE MLTC can provide you with social and environmental supports services and items that support your medical needs and are included in your Care Plan. These services and items include but are not limited to the following: home maintenance tasks, chore services, pest control, housing modifications to improve your safety and respite care. Social Day Care: Social day care is a structured program that provides you with socialization, supervision, monitoring and nutrition in a protective setting. You may also receive services such as enhancement of daily living skills, personal care, transportation and caregiver assistance. If interested, please consult with your Care Manager. Adult Day Health Care: VNSNY CHOICE MLTC can arrange for you to receive adult day health care in a residential health care facility or State-approved site supervised by a physician. The services provided at an adult day health care include: medical, nursing, food and nutrition, social services, rehabilitation therapy, leisure time activities, dental, pharmaceutical and other services. You must not be homebound and must require certain preventive or therapeutic services to attend an adult day health care center. 12

19 Nursing Home Care: Although we do our best to meet your needs at home, there may be times when it is more appropriate for you to receive care in a nursing home. Admission to one of our participating nursing homes is made on an individual basis. The decision to receive care in a nursing home must be made by you, your doctor, your family and your Care Manager. There are two types of nursing home stays. They are short term or rehabilitation stays following hospitalization and long term stays for ongoing care. One of the ways we can be helpful is to see if you are eligible for institutional care under Medicaid. If your current Medicaid eligibility only allows you to receive community services, you may be asked to complete an application for institutional Medicaid. The application includes a review of your financial assets and income for the past five years. Staff from our Membership and Eligibility Unit will help you with this process. This is important because it can affect your ability to receive care in a nursing home. Please call Member Services if you need assistance completing the application for institutional Medicaid. We speak your language As a VNSNY CHOICE MLTC member, you can get important information in the language you understand best. For example, this Member Handbook and other health information are available in English, Spanish, Chinese, Korean and Russian. We have staff, providers and translators who speak many languages. Hearing Impaired If you are deaf or hearing impaired, you can contact VNSNY CHOICE by calling the Telecommunications Relay Services (TRS). You can reach them at 711. Visually Impaired If you are visually impaired, we will assist you by discussing all of the information about VNSNY CHOICE MLTC with you. We will also provide written information so that your caregivers can assist you. Your Health and Safety Your health and safety is our primary concern. If you feel that you are being abused or in danger of being abused or neglected, please do not hesitate to speak to your Care Manager about Adult Protective Services (APS). APS is a state-mandated program that helps adults who are mentally and/or physically impaired and: Due to these impairments, are unable to manage their own resources, carry out the activities of daily living, or protect themselves from abuse, neglect, exploitation or other hazardous situations without assistance from others; and Have no one available who is willing and able to assist them responsibly. 13

20 Your Care Manager can refer you to an APS caseworker and they will work together to promptly resolve your risks by arranging for services and support that will enable you to live independently and safely. If you prefer to self-refer please call: For NYC: APS Central Intake 1(212) , or call 311 For Upstate members: 1(844) Questions about covered services? Just pick up the phone and call our Member Services Department. The Member Services phone number is listed below. 14

21 Section E: How do I obtain these services? It is really quite easy. When you enroll in VNSNY CHOICE Managed Long Term Care (MLTC), your Care Management Team will work together with you, your family, and your health care professional team to develop a Care Plan that meets your needs. Your Care Plan is a list of all the services you need, based on the assessment by a health care team (Registered Professional Nurse and Health Care Professionals). To develop your Care Plan, your Care Manager also talks with you and your family about your needs and personal preferences. Your Care Plan will be in writing, and your Care Manager will inform you of the services that are listed in your Care Plan. (Please see Section F for more information on VNSNY CHOICE MLTC s authorization procedures.) You will receive a form that outlines the services that have been authorized to meet your needs. This form will include information about how frequently the services will be provided and how long you can expect them to continue. You are an important member of your health care team, and it is important that you let us know what you need and whether you are satisfied with the care you are receiving from VNSNY CHOICE MLTC. Can I get additional services or change my Care Plan? From time to time, your needs may change. You may require different types of services, or you may need the same services more or less frequently. Because of this, your Care Manager will review and update your Care Plan at least once every six months. When she/he updates your Care Plan, she/he will review your needs with your health care professionals and will always discuss your services with you. If you believe that your Care Plan needs to be changed, please discuss your needs with your Care Manager. VNSNY CHOICE staff will talk with you about the changes you have requested and may discuss your request with your health care professionals. If VNSNY CHOICE MLTC determines that the changes in services are medically necessary, your Care Manager will inform you of the changes in advance. (Please see pages for more information on the timeframes that will be followed when you request a change to the services you receive.) We have also set up a toll free phone number that you may call to request additional services. The number is , and staff are available Monday through Friday between 9 a.m. to 5 p.m. to assist you. If you call this number, the staff member who takes your request will discuss your needs with your Care Manager and/or other VNSNY CHOICE staff who are involved in your care. When you request additional services, we might ask your physician or other health care provider to explain to VNSNY CHOICE MLTC the reasons why the service is medically necessary. 15

22 If you are ever dissatisfied with a service you are receiving, or disagree with the types of services that are included in your Care Plan, we ask that you first discuss your concerns with your Care Manager. You can file an appeal and/or a fair hearing, if you believe that VNSNY CHOICE MLTC has not authorized services that you need. You can also file a formal complaint (known as a Grievance ) if you are dissatisfied with the services that you receive, by following the procedures outlined on pages of this Handbook Are there services I can obtain without first talking with my Care Manager? There are certain VNSNY CHOICE MLTC services that you can obtain without first talking with your Care Manager. However, if you use any of these services, we still ask that you inform your Care Manager afterwards, so that we are all working together. The following covered services can be obtained without first talking with your Care Manager about your Care Plan: Whenever you need transportation to an appointment with your doctor or another healthrelated service, please call Member Services to make all arrangements. To ensure that transportation is available, please call us at least 2 business days before your appointment, if possible, to arrange for your transportation. If you need to see a dentist, you may receive preventive care and basic dental services from any dentist listed in your Provider Directory without prior approval. Of course, Member Services can help you select a dentist, and Member Services can always help with scheduling appointments or arranging transportation. (Please also see Section F for important information on dental care. If you need more complicated dental work, your dentist will be required to obtain approval before he begins the procedure.) You may receive one routine eye exam without prior approval each year at a vision care center listed in your Provider Directory. Member Services can help you to schedule an appointment or arrange transportation. You do not need any prior approval from VNSNY CHOICE MLTC for emergency or urgent care. In an emergency, you should call 911 or get help at the closest hospital, emergency room, or doctor s office right away. (For more information, please see page 31). What if I receive a bill from a provider? As a member of VNSNY CHOICE MLTC, you are not responsible for paying for the medically necessary care that you receive from the program and its providers as long as you follow the procedures in this Member Handbook. These services are covered by VNSNY CHOICE MLTC, Medicare and/or Medicaid. However, once in awhile, a provider may send you a bill for the services you receive. If you receive a bill for services that were authorized by the program, please let us know. VNSNY CHOICE is responsible to cover the cost of the program s services, and we can help to ensure that all services are billed appropriately. Remember, VNSNY CHOICE MLTC staff is available to assist you. Whenever you have questions, please call Member Services. You will find the Member Services phone number listed below. 16

23 Section F: Are there formal authorization procedures? Most of the services covered by VNSNY CHOICE Managed Long Term Care (MLTC) have authorization requirements. This means that if you need any of the services listed below, you must get approval in advance, before receiving care. The services that always require authorization in advance are: Adult Day Health Care Services Audiology Services Chore or Housekeeping Services Consumer Directed Personal Assistance Services Home Care Services, including nursing care, social work services, rehabilitation therapies, nutritional counseling, and home health aide services/personal care services Home Delivered Meals Home Safety Modifications Medical Equipment Medical and Surgical Supplies Nursing Home Care Nutrition Services Nutritional Supplements Outpatient Rehabilitation Therapy Personal Emergency Response System (PERS) Podiatry (also see below) Private Duty Nursing Prosthetics and Orthotics Respiratory Therapy and Oxygen Social Day Care Services In addition, there are certain services that require an authorization from VNSNY CHOICE MLTC only in specific circumstances. These services are described below, along with any special procedures that you must follow when you need them. Dental care - You do not need an authorization to see your in-network dentist for a check-up twice a year and basic dental services. However, if you need a more complex dental service, it will require authorization in advance. Your dentist will obtain these authorizations for you. Optometry and eyeglasses - You do not need an authorization to have an eye exam from an in-network optometrist once a year or to get new glasses every two years. However, an authorization is required if you need these services more frequently. Podiatry - For most members, podiatry care is covered by Medicare. However, an authorization is required if the services you need are not covered by Medicare or you do not have Medicare. 17

24 Please talk with your Care Manager if you have any questions about your services and our authorization procedures. As described earlier in this Handbook, VNSNY CHOICE MLTC provides all services based on medical necessity. If you believe you need any of the services that require approval in advance, you must get authorization from VNSNY CHOICE MLTC. Please contact Member Services for assistance. You can also request additional services from VNSNY CHOICE MLTC by telephone, by calling us toll-free at Your provider can also request services on your behalf. If you (or your provider) call this number, the staff member who takes your request will discuss your needs with your Care Manager and/or other VNSNY CHOICE staff who are involved in your care. When you request additional services, we might ask your physician or other health care provider to explain to VNSNY CHOICE MLTC the reasons why the service is medically necessary. (The only exception to this is dental care. In this case, your dentist will obtain all needed authorizations for you.) We have tried to keep our authorization procedures as simple as possible. Because your health is important, VNSNY CHOICE MLTC will make sure you get a quick answer when the medical necessity of a service needs to be determined. For example: Prior Authorizations: Whenever you ask for a new service that requires authorization, you will be informed of the authorization decision within 3 business days after VNSNY CHOICE MLTC gets all the information that is needed to make the decision. We will always make our decision within 14 days of your request for services, unless it is in your best interest for us to extend this timeframe. If your health would be put in danger by taking the amount of time listed above to make our decision, we will treat your request as an expedited request and will make our decision as quickly as possible. In this situation, we will not take longer than 3 business days from your request for services to make a decision unless it is in your best interest for us to extend this timeframe. If you or your provider thinks that your request should be treated as an expedited request, you may request it. Concurrent Reviews: When you make a request for additional services that are currently authorized in your plan of care, this is called a Concurrent Review. You will be informed of the authorization decision within 1 business day after VNSNY CHOICE MLTC gets all the information that is needed to make the decision. We will always make our decision within 14 days of your request for service, unless it is in your best interest for us to extend this timeframe. For an expedited concurrent review you will be informed of the authorization decision within 1 business day after VNSNY CHOICE MLTC receives the information we need to make a decision, but no more than 3 business days from your request for services. 18

25 In the case of a request for Medicaid covered home health care services following an inpatient admission, one (1) business day after receipt of necessary information; except when the day subsequent to the request for services falls on a weekend or holiday, seventy-two (72) hours after receipt of necessary information; but in any event, no more than three (3) business days after receipt of the request for services. o If you have already received care that requires an authorization in advance, please talk with your Care Manager before you receive additional services from this provider. If this provider continues to provide services, the provider might not be paid by either Medicaid or VNSNY CHOICE. Instead, if you continue to receive services that have not been authorized by VNSNY CHOICE MLTC, you may be responsible for paying for them. Whenever you ask for services that require authorization, it is our policy to tell you our decisions both by telephone and in writing. If you disagree with any of the authorization decisions made by VNSNY CHOICE MLTC, please feel free to discuss the situation with us. However, if you do not agree with our decision, you may always appeal the decision, following the process described on pages of this Handbook. Please note that VNSNY CHOICE MLTC may extend these timeframes by up to 14 calendar days, if we need additional information in order to make a decision and we believe that an extension is in your best interest. If you have any questions about whether a service requires an authorization, please call Member Services for assistance. 19

26 Section G: Who is part of my VNSNY CHOICE MLTC team? At VNSNY CHOICE Managed Long Term Care (MLTC), there are many people working together to ensure that you receive the services you need. Some of these individuals will visit you in your home, some may talk with you on the telephone, and some work behind the scenes to provide assistance to the professionals who care for you. The VNSNY CHOICE team is made up of highly qualified individuals, including: Care Manager: Your Care Manager is a Registered Professional Nurse who is experienced in caring for adults with long term health care needs. Your Care Manager will talk to you about your needs and preferences, and she/he will coordinate all the care you receive. She/he will work with you and develop a plan of long term care especially for you. She/he will coordinate with your health care professionals (for instance, social workers and therapists) to make sure you receive the services you need. Member Services: VNSNY CHOICE MLTC is designed so that there is always someone available to help you. Our Member Services Department will assist you whenever our offices are open. Member Services is just a phone call away when you need services, wish to request any changes in your service plan, or if you encounter any problems. Our Member Services Department works together with your Care Manager and other team members to ensure that your needs are being met. If necessary, Member Services can assist with contacting your Care Manager. Home Health Aide or Personal Care Aide: For most members, this is the person who comes to the house most frequently to ensure that your day-to-day needs are met. The Home Health Aide or Personal Care Aide might help you take a bath or prepare your food. He or she might also assist you with dressing, housekeeping, or getting to a medical appointment. Registered Professional Nurse: Registered Professional Nurses are additional members of your care management team. They help manage your illness and your medications. Your Registered Professional Nurse will coordinate your care with your health care professionals. Social Worker: "The Social Worker can provide guidance and support with concerns that may be affecting your well being. The Social Worker can also help connect you with public benefits, community based resources, and support services. Let your Care Manager know if you would like to speak with a Social Worker." 20