VillageCareMAX Medicare Total Advantage (HMO-POS SNP): Summary of Benefits

Transcription

1 Advantage (HMO-POS SNP): Summary of Benefits H2168_MKT18_01 CMS Accepted Table of Contents Introduction to the Summary of Benefits...2 Things to Know about Advantage Plan (HMO-POS SNP)....4 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services....8 Summary of Medicare-Covered Benefits... 9 Summary of Medicaid-Covered Benefits 16 If you have questions, please call Advantage at (TTY: 711), 8:00 am to 8:00 pm, 7 days a week. The call is free. For more information, visit 1

2 SUMMARY OF BENEFITS January 1, 2018 December 31, 2018 INTRODUCTION TO SUMMARY OF BENEFITS This is a summary of health services covered by Advantage (HMO-POS SNP) for There are different types of Medicare health plans. Advantage is a Dual Eligible Special Needs Plan (D-SNP), which is a Health Maintenance Organization (HMO) for people with Medicare and Medicaid. This HMO plan offers Point of Service (POS) access to some out-of-network services. Advantage is approved by Medicare and Medicaid and run by a private company. This booklet is only a summary. It does not list every service that we cover or every limitation or exclusion. Please read the Evidence of Coverage (Member Handbook) for the full list of benefits. The Evidence of Coverage (Member Handbook) is provided upon enrollment and annually by December 31 st. You can also view it on our website at or call Member Services for a copy. You have choices about how to get your Medicare and Medicaid Benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare) or your Medicaid benefits through Medicaid fee-for-service. Original Medicare is run by the Federal government and Medicaid fee-for-service is run by New York State. Another choice is to get your Medicare and Medicaid benefits by joining a Medicare Advantage health plan like VillageCareMAX Medicare Total Advantage (HMO-POS SNP). Tips for comparing your Medicare choices If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call For more information, visit 2

3 This information is not a complete description of benefits. Contact the plan for more information. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. This plan is available to anyone who has both Medical Assistance from the State and Medicare. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 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: 711) Upon enrollment, we will request for the language that you prefer to get communications and information sent by mail. We will keep a record of your preference and you can request to change your preferred language by contacting Participant Services at during the hours of 8:00 am and 8:00 pm, 7 days of week. TTY users should call 711. The call is free. You can get this information for free in other formats, such as large print, Braille, or audio. Call and 711 for TTY users during the hours of 8:00 am to 8:00 pm, 7 days a week. The call is free. VillageCareMAX is an HMO plan with a Medicare and New York State Medicaid contracts. Enrollment in VillageCareMAX depends on contract renewal. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide members free, confidential assistance on any services offered by Advantage Plan. ICAN may be reached toll-free at or online at icannys.org. (TTY users call 711, then follow the prompts to dial ) For more information, visit 3

4 Things to Know About Advantage (HMO-POS SNP) Who should you contact if you have questions or need help CALL Calls to this number are free. 8:00 am to 8:00 pm, 7 days a week. On call service and nursing hotline available after business hours. Member Services also has free language interpreter services available for people who do not speak English. TTY 711 This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it. Calls to this number are free. 8:00 am to 8:00 pm, 7 days a week WRITE 112 Charles Street, New York NY WEBSITE What kind of plan is Advantage (HMO-POS SNP) Advantage is a Medicaid Advantage Plus (MAP) Dual Eligible Special Needs Plan that covers both Medicare and Medicaid benefits including long term services & supports. Our plan is designed for beneficiaries who require nursing home level of care. For more information, visit 4

5 Things to Know About Advantage (HMO-POS SNP) Who can join To join Advantage, you must be 18 or older and: Entitled to Medicare Part A, be enrolled in Medicare Part B Eligible for full Medicaid benefits Reside in our service area Eligible for nursing home level of care Require care management and be expected to need at least one of the following services for more than 120 days from the effective date of enrollment:» Nursing home services in the home» Therapies in the home» Home health aide services» Personal care services in the home» Private duty nursing» Adult day health care» Consumer-directed personal care services Our service area includes the following counties in New York: Bronx, Kings (Brooklyn), New York (Manhattan), and Queens. For more information, visit 5

6 Things to Know About Advantage (HMO-POS SNP) Which doctors, hospitals, and pharmacies can I use VillageCareMAX has a network of doctors, hospitals, pharmacies, and other providers. As a member, you will be able to get covered services from certain out-ofnetwork providers without prior authorization : Doctor Office Visits (Primary Care Provider and Specialists). Certain procedures may require authorization. Please refer to Chapter 4 of the Evidence of Coverage (Member Handbook) for details Outpatient Rehabilitation (Physical Therapy, Occupational Therapy, and Speech Language Therapy). Prior authorization is required after the first 20 visits Chiropractor Services. Prior authorization is required after the first 20 visits Podiatry Services Otherwise, if you use the providers that are not in our network for other services, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider and pharmacy directory on our website at Or, call us and we will send you a copy of the Provider & Pharmacy Directory. You do not need a referral from your primary care provider to see other providers in our network. However, prior authorization rules must be followed. For more information, visit 6

7 Things to Know About Advantage (HMO-POS SNP) What do we cover Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Members of our plan get all of the benefits covered by Original Medicare. Members of our plan also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. Members of our plan get most benefits covered by Medicaid Fee-for-Service We cover Part D drugs and also Part B drugs such as chemotherapy and some drugs administered by your provider.» You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at Or call us and we will send you a copy of the formulary. How will I determine my drug costs You pay nothing for covered generic and brand drugs during the two benefit stages: Initial Coverage and Catastrophic Coverage. For more information, call Member Services or view the Evidence of Coverage (Member Handbook) on our website at For more information, visit 7

8 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium $0 plan premium per month. You must continue to pay your Part B premium. How much is the deductible Is there any limit on how much I pay for my covered services Maximum Out-of-Pocket Responsibility (does not include prescription drugs) This plan does not have a deductible for in-network health services or Part D prescription drugs. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. For this plan, you pay nothing for Medicare-covered and Medicaid-covered services. Refer to the "Medicare & You 2018" handbook for Medicare-covered services. Your copy of Medicare & You 2017 gives information about these costs. Everyone with Medicare receives a copy of Medicare & You each year in the fall. For Medicaid-covered services, refer to the Medicaid Coverage section in this document. Is there a limit on how the plan will pay Our plan has a coverage limit every year for certain in-network benefits. Please refer to the Evidence of Coverage (Member Handbook) or contact us for the services that apply. For more information, visit 8

9 SUMMARY OF MEDICARE-COVERED BENEFITS The following chart is a quick overview of benefits, your costs and rules about the benefits. This section shows Medicare services and extra benefits covered by Benefits What you pay Benefit Rules Inpatient Hospital Care You pay nothing. You get an unlimited number of days for an inpatient hospital stay. Outpatient Hospital Care Observation services Outpatient Surgery Laboratory & diagnostic tests Medical supplies Certain drugs and biologicals Doctor Visits Preventive Care You pay nothing for the cost for each Medicare-covered outpatient hospital services You pay nothing for Medicare-covered primary care provider and specialist visits. $0 copay for preventive care visits $0 copay for annual wellness visit $0 copay for depression screening $0 copay for HIV screening $0 copay for flu shots, hepatitis B shots, pneumococcal shots. Prior authorization is required for some services. Prior authorization is not required for routine medical visits to in-network and out-of-network providers. Any additional preventive services approved by Medicare during the contract year will be covered. Prior authorization is not required for covered services from in-network and out-of-network providers. For more information, visit 9

10 Benefits What you pay Benefit Rules Emergency Care You pay nothing. You pay $0 if admitted to the hospital within 24 hours of the emergency room visit. Prior authorization is not required. Urgently Needed Services You pay nothing. Prior authorization is not required. Diagnostic Tests/ Labs/ Imaging» Diagnostic tests and procedures» Diagnostic radiology services (MRIs, CT scans)» Lab Services» Outpatient X- rays» Therapeutic radiology services (such You pay nothing. Prior authorization is required for some services. For more information, visit 10

11 Benefits What you pay Benefit Rules Hearing Services You pay nothing for Medicare-covered services. Prior authorization is required for some services. Dental Services You pay nothing for Medicare-covered services. Prior authorization is required for some services. Vision Services You pay nothing for Medicare-covered services. Prior authorization is required for some services. Mental Health Services» Inpatient Mental Health» Outpatient Group or Individual Therapy Visits You pay nothing. Prior authorization is required for inpatient mental health. Prior authorization is not required for outpatient mental health services for in-network and out-of-network providers. Skilled Nursing Facility You pay nothing. Plan covers up to 100 days in each benefit period. For more information, visit 11

12 Benefits Rehabilitation Services» Physical therapy visits» Occupational therapy visits» Speech and language therapy visits» Cardiac rehabilitation services What you pay You pay nothing. Benefit Rules Prior authorization is not required for outpatient rehabilitation services from in-network and out-of-network providers for the first 20 visits. Ambulance You pay nothing. Prior authorization is required for non-emergency ambulance trips. Medicare Part B drugs You pay nothing for chemotherapy drugs and all other Medicare Part B drugs Prior authorization required for certain injectable drugs. OUTPATIENT PRESCRIPTION DRUGS Phase 1: Initial Coverage Standard retail 30-day supply Mail-order costsharing (up to a 90-day supply) Long-term care (LTC) costsharing (up to a 98-day supply) You stay in the initial coverage stage until your total drug costs for the year reach $5,000 Tier 1: Generic Drugs $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay Tier 2: Brand Drugs For more information, visit 12

13 Benefits Phase 2: Catastrophic Coverage What you pay You pay nothing Benefit Rules You will stay in this stage until the end of the year. For more information, visit 13

14 ADDITIONAL HEALTH BENEFITS Over-the-Counter Items You pay nothing Covered for up to $1,320 per year ($110 per month) to purchase approved healthrelated items at participating locations. Acupuncture You pay nothing Covered for up to 15 visits per year when provided by a certified and licensed provider in the VillageCareMAX network. Home Health Care You pay nothing Outpatient Surgery You pay nothing Diabetes Supplies and Services» Diabetes selfmanagement training» Therapeutic shoes or inserts» Diabetic monitoring supplies Transportation (nonemergency services) You pay nothing You pay nothing for transportation to plan approved locations. Prior authorization required 2 days in advance of your trip. For more information, visit 14

15 Foot Care (Podiatry Services) You pay nothing. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions. Prior authorization is not required for podiatry services from in-network and out-of-network providers. Durable Medical Equipment and related supplies» Wheelchairs, crutches, hospital bed, IV infusion pump, oxygen equipment, nebulizer, and walker. You pay nothing. Wellness Programs» Member Newsletter» Nurse Advice Call Line You pay nothing. You can call the nurse advice line to speak to a registered nurse about your health-related concerns when our offices are closed, 7 days a week. For more information, visit 15

16 SUMMARY OF MEDICAID-COVERED BENEFITS The benefits described in the previous section of the Summary of Benefits are Medicare-covered services and extra benefits covered by The plan also covers most Medicaid benefits including long term services and supports. This section compares the Medicaid benefits covered by Advantage with those covered under New York State Medicaid Fee-for-Service. You must be eligible for full Medicaid benefits and meet the enrollment eligibility requirements for If you have questions about your Medicaid eligibility and what benefits you are entitled to call Member Services at (TTY: 711), 8:00 am to 8:00 pm, 7 days a week. For each benefit listed below, you can see what Advantage covers and what is covered by Medicaid. Medicaid Benefit Category New York State Medicaid Fee-for- Service (FFS) Advantage (HMO-POS SNP) MEDICAID BENEFITS AND SERVICES COVERED BY VILLAGECAREMAX MEDICARE TOTAL ADVANTAGE o Use your VillageCareMAX Member ID Card to access most of these services Adult Day Health Care» Medical, nursing, food and nutrition, social services, rehabilitation therapy, leisure-time activities (which are a planned program of diverse, meaningful activities), dental, pharmaceutical, and other ancillary services furnished in an approved SNF or extension site or residential health care facility. $0 copay for Medicaid-covered services. $0 copay for adult day health care services. For more information, visit 16

17 Medicaid Benefit Category Consumer Directed Personal Assistance Services (CDPAS)» Member or a person acting on a member s behalf (designated representative) self directs and manages the member s personal care services, home health aide services or skilled nursing tasks. Services are provided by a caregiver selected and supervised by the member or designated representative. New York State Medicaid Fee-for- Service (FFS) $0 copay for Medicaid-covered services. Dental Services» Medicaid-covered dental services include, but not be limited to, preventive, prophylactic and other dental care, services, supplies, routine exams, prophylaxis, oral surgery (when not covered by Medicare), and dental prosthetic and orthotic appliances required to alleviate a serious health condition. Advantage (HMO-POS SNP) $0 copay for consumer-directed personal assistance services. For more information, visit 17

18 Medicaid Benefit Category Durable Medical Equipment (DME)» Medicaid-covered durable medical equipment including devices and equipment other than medical/surgical supplies, enteral formula and prosthetic or orthotic appliances having the following characteristics: can withstand repeated use for a protracted period time; are primarily and customarily used for medical purposes; are generally not useful to a person in the absence of illness or injury and are usually fitted, designed or fashioned for a particular individual's use. Must be ordered by a practitioner. No homebound prerequisite and including non-medicare DME covered by Medicaid (e.g. tub stool; grab bar). New York State Medicaid Fee-for- Service (FFS) Covered by New York State Medicaid $0 copay for Medicaid-covered services Advantage (HMO-POS SNP) $0 copay for durable medical equipment Prior authorization is required For more information, visit 18

19 Medicaid Benefit Category Hearing Services» Hearing services and products when medically necessary to alleviate disability caused by the loss or impairment of hearing. Services include hearing aid selecting, fitting, and dispensing; hearing aid checks following dispensing, conformity evaluations and hearing aid repairs; audiology services including examinations and testing, hearing aid evaluations and hearing aid prescriptions; and hearing aid products including hearing aids, hearing aid batteries, ear molds, special fittings and replacement parts. New York State Medicaid Fee-for- Service (FFS) $0 copay for Medicaid-covered services. Advantage (HMO-POS SNP) Home Delivered and Congregate Meals» Meals provided at home or in congregate settings, such as senior centers for individuals unable to prepare meals or have them prepared. $0 copay for Medicaid-covered services. $0 copay for home delivered and congregate meals. For more information, visit 19

20 Medicaid Benefit Category New York State Medicaid Fee-for- Service (FFS) Home Health Services (non-medicare covered)» Medically necessary, intermittent $0 copay for Medicaid-covered services. skilled nursing care, home health aide services, and rehabilitation services, etc. The provision of skilled services not covered by Medicare (e.g. physical therapist to supervise maintenance program for patients who have reached their maximum restorative potential or nurse to pre-fill syringes for disabled individuals with diabetes) and / or home health aide services as required by an approved plan of care developed by a certified home health agency. Advantage (HMO-POS SNP) $0 copay for home health services. Inpatient Mental Health» Unlimited inpatient mental health days beyond the 190-day lifetime Medicare limit as medically necessary. $0 copay for Medicaid-covered services. $0 deductible $0 copay per day Medical Social Services» Assessment, arranging and providing aid for social problems $0 copay for Medicaid-covered services. related to maintaining an individual at home. $0 copay for medical social services. For more information, visit 20

21 Medicaid Benefit Category Nutrition» Assessment of nutritional status/ needs, development and evaluation of treatment plans, nutritional education and counseling, in-service education. Includes cultural considerations. New York State Medicaid Fee-for- Service (FFS) $0 copay for Medicaid-covered services. Advantage (HMO-POS SNP) $0 copay for nutrition services. Outpatient Mental Health Care» Individual and group therapy visits$0 copay for Medicaid-covered services. Outpatient Rehabilitation Services» Occupational, Physical and Speech Therapists and are limited to (20) Medicaid visits per therapy per year, except for children under age 21 or if you have been determined to be developmentally disabled by the Office for People with Developmental Disabilities or if you have a traumatic brain injury. $0 copay for Medicaid-covered services. Outpatient Substance Abuse» Individual and group therapy visits Enrollee may self-refer for one assessment from a network provider in a 12 month period. $0 copay for outpatient rehabilitation services Prior authorization required after the first 20 visits. $0 copay for outpatient substance abuse services For more information, visit 21

22 Medicaid Benefit Category Over-the-Counter Items New York State Medicaid Fee-for- Service (FFS) New York State Medicaid covers certain over-the-counter medications with prescription. Personal Care Services» Medically necessary assistance with activities such as personal $0 copay for Medicaid-covered services. hygiene, dressing and feeding, and nutritional and environmental support function tasks. Personal Emergency Response Services (PERS)» Electronic devices that enable individuals to secure help in a physical, emotional or environmental emergency Podiatry» Medically necessary foot care for medical conditions affecting lower limbs. Visits for routine foot care up to 4 visits per year $0 copay for Medicaid-covered services. $0 copay for Medicaid-covered services. Advantage (HMO-POS SNP) Advantage (HMO SNP) provides an OTC card with a maximum limit of up to $1,440 per year ($120 per month) to purchase approved healthrelated items at participating locations. $0 copay for personal care services. $0 copay for personal emergency response services. $0 copay for podiatry services. For more information, visit 22

23 Medicaid Benefit Category New York State Medicaid Fee-for- Service (FFS) Private Duty Nursing» Medically necessary private duty nursing services in accordance $0 copay for Medicaid-covered services. with the ordering physician, registered physician assistant or certified nurse practitioner s written treatment plan. Private duty nursing services may be intermittent, part-time or continuous and may be provided through an approved certified home health agency, a licensed home care agency, or a private Practitioner. Prosthetic Devices» Prosthetics, orthotics and orthopedic footwear $0 copay for Medicaid-covered services. Advantage (HMO-POS SNP) $0 copay for private duty nursing services Prior authorization is required $0 copay for prosthetic devices. Skilled Nursing Facility» Days beyond Medicare 100 day limit» No prior hospital stay required. $0 copay for Medicaid-covered services. $0 copay for skilled nursing facility services. For more information, visit 23

24 Medicaid Benefit Category Social and Environmental Supports» Services and items to support medical needs, including home maintenance tasks, homemaker/chore services, housing improvement, and respite care. Social Day Care» Structured comprehensive program providing socialization; supervision, monitoring; personal care, and nutrition in a protective setting. New York State Medicaid Fee-for- Service (FFS) Not covered by New York State Medicaid.. Not covered by New York State Medicaid. Advantage (HMO-POS SNP) $0 copay for social and environmental supports services. $0 copay for social day care services. Transportation (non-emergency)» Transportation essential to obtain necessary medical care and services covered as part of the plan s benefits and/or by Medicaid Fee-for-Service. Transportation services include transportation by ambulance, ambulette, taxicab, livery, public transportation, or other means appropriate to the enrollee s medical condition. $0 copay for Medicaid-covered services. $0 copay for non-emergency transportation services to plan approved locations. Prior authorization is required 2 days in advance of trip. For more information, visit 24

25 Medicaid Benefit Category New York State Medicaid Fee-for- Service (FFS) Vision Services (non-medicare covered)» Services of optometrists, $0 copay for Medicaid-covered services. ophthalmologists, and ophthalmic dispensers, including eyeglasses, medically necessary contact lenses, and poly carbonate lenses, artificial eyes (stock or custommade), low-vision aids, and lowvision services. Coverage also includes the repair or replacement of parts. Coverage also includes examinations for diagnosis and treatment for visual defects and/or eye disease. Examinations for refraction are limited to every two (2) years unless otherwise justified as medically necessary. Eyeglasses do not require changing more frequently than every two (2) years unless medically necessary or unless the glasses are lost, damaged, or destroyed. Advantage (HMO-POS SNP) $0 copay for vision services. For more information, visit 25

26 Medicaid Benefit Category AIDS Adult Day Health Care (ADHCP) Designed to assist individuals with HIV disease to live more independently in the community or eliminate the need for residential health care services. New York State Medicaid Fee-for- Service (FFS) Advantage (HMO-POS SNP) $0 copay for ADHCP services. For more information, visit 26

27 Medicaid Benefit Category New York State Medicaid Fee-for- Service (FFS) Advantage (HMO-POS SNP) MEDICAID BENEFITS AND SERVICES NOT COVERED BY VILLAGECAREMAX MEDICARE TOTAL ADVANTAGE o Use your Medicaid card issued by New York State to access these benefits. Certain Mental Health Services» Intensive Psychiatric Rehabilitation Treatment Programs» Day Treatment» Continuing Day Treatment» Case Management for Seriously and Persistently Mentally Ill (sponsored by state or local mental health units)» Partial Hospitalizations (services not covered by Medicare)» Assertive Community Treatment (ACT)» Personalized Recovery Oriented Services (PROS) Comprehensive Medicaid Case Management (CMCM)» Provides social work case management referral services to a targeted population. A CMCM case manager will assist a client in accessing necessary services in accordance with goals outlined in a written case management plan. Not covered by VillageCareMAX Medicare Total Covered under Medicaid Fee-for-Service. Not covered by VillageCareMAX Medicare Total Covered under Medicaid Fee-for-Service. For more information, visit 27

28 Medicaid Benefit Category Directly Observed Therapy for Tuberculosis (TB) Disease» Direct observation of oral ingestion of TB medications to assure patient compliance with the physician s prescribed medication regimen. New York State Medicaid Fee-for- Service (FFS) Advantage (HMO-POS SNP) Not covered by VillageCareMAX Medicare Total Covered under Medicaid Fee-for-Service. HIV Cobra Case Management» Provides intensive, family-centered case management and community follow-up activities by case managers, case management technicians, and community followup workers including assessment, service plan development, monitoring and crisis intervention. Not covered by VillageCareMAX Medicare Total Covered under Medicaid Fee-for-Service. For more information, visit 28

29 Medicaid Benefit Category New York State Medicaid Fee-for- Service (FFS) Home-and-Community Based Waiver Program Services» Personal care services to a participant who requires assistance with personal care services tasks and whose health and welfare in the community is at risk because oversight and supervision of the participant is required when no personal care task is being performed. These services are provided under the direction and supervision of a Registered Professional Nurse. Medicaid Pharmacy Benefits» Select drug categories excluded from the Medicare Part D benefit. For a full list of Medicaid reimbursable drugs, visit formfile.aspx. Methadone Maintenance Treatment Programs (MMTP)» Drug detoxification, drug dependence counseling, and rehabilitation services which include chemical management with methadone. Advantage (HMO-POS SNP) Not covered by VillageCareMAX Medicare Total Covered under Medicaid Fee-for-Service. Not covered by VillageCareMAX Medicare Total Covered under Medicaid Fee-for-Service. Not covered by VillageCareMAX Medicare Total Covered under Medicaid Fee-for-Service. For more information, visit 29

30 Medicaid Benefit Category New York State Medicaid Fee-for- Service (FFS) Office for People with Developmental Disabilities (OPWDD) Services» Medicaid covers the following OPWDD services: Long Term Therapy Services Provided by Article 16-Clinic Treatment Facilities or Article 28 Facilities. Day Treatment. Medicaid Service Coordination (MSC). Home- and Community- Based Services Waivers (HCBS). Services Provided Through the Care At Home Program (OMRDD) Advantage (HMO-POS SNP) Not covered by VillageCareMAX Medicare Total Covered under Medicaid Fee-for-Service. Out-of-Network Family Planning Services» Health services to prevent or reduce the incidence of unwanted pregnancy. These include: diagnosis and all medically necessary treatment, sterilization, screening and treatment for sexually transmissible diseases and screening for disease and pregnancy. Not covered by VillageCareMAX Medicare Total Covered under Medicaid Fee-for-Service. For more information, visit 30

31 Medicaid Benefit Category New York State Medicaid Fee-for- Service (FFS) Rehabilitation Services Provided to Residents of OMH-Licensed Community Residences (CRs) and Family-Based Treatment Programs» Medicaid covers rehabilitation services provided to residents of the Office of Mental Health (OMH)- licensed community residences (CRs) and family-based treatment programs. Advantage (HMO-POS SNP) Not covered by VillageCareMAX Medicare Total Covered under Medicaid Fee-for-Service. For more information, visit 31

32 Notice of Non-discrimination VillageCareMAX complies with Federal civil rights laws. VillageCareMAX does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. VillageCareMAX provides the following: Free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Free language services to people whose first language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact VillageCareMAX Member Services Department at For TTY/TDD services, call 711. If you believe that VillageCareMAX has not given these services or treated you differently because of race, color, national origin, age, disability, or sex, you can file a grievance with VillageCareMAX by: Mail: Grievances Coordinator, VillageCareMAX, 112 Charles Street, New York, NY Phone: , TTY 711 Fax: In person: Grievances Coordinator, VillageCareMAX, 112 Charles Street, New York, NY complaints@villagecare.org You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights by: Web: Office of Civil Rights Complaint Portal at Mail: U.S. Department of Health and Human Services 200 Independence Avenue, SW, Room 509F, HHH Building Washington, D.C Complaint forms are available at Phone: , (TDD) For more information, visit 32