RiverSpring FIDA Plan

Transcription

1 201 Summary f Benefits RiverSpring FIDA Plan (Medicare Medicaid Plan) T cntact Participant Services, please call (TTY 711). We are available t take yur call 7 days a week frm 8 a.m. t 8 p.m. EST.

2 RiverSpring FIDA Plan: Summary f Benefits H6435_2018SummaryfBenefitsv2_Apprved RiverSpring FIDA Plan (Medicare-Medicaid Plan) 2018 Summary f Benefits If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 1

3 RiverSpring FIDA Plan: Summary f Benefits This is a summary f health services cvered by RiverSpring FIDA Plan fr This is nly a summary. Please read the Participant Handbk fr the full list f benefits. RiverSpring FIDA Plan 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 RiverSpring FIDA Plan yu can get yur Medicare and Medicaid services in ne managed care plan called a FIDA Plan. A RiverSpring FIDA Plan 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 RiverSpring FIDA Plan Participant Services r read the RiverSpring FIDA Plan Participant Handbk. This means that yu need t fllw certain rules t have RiverSpring FIDA Plan 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 Crele, French, Spanish, Krean, Chinese, Russian, r Italian, language assistance services, free f charge, are available t yu. Call (TTY 711), 7 days a week frm 8 a.m. t 8 p.m. EST. The call is free. Ou ka jwenn enfòmasyn sa a gratis nan lòt lang. Rele nan ak nan TTY/TDD: 711 ant 8:00 am ak 8:00 pm., Lè Zòn Lès, 7 ju pa semèn. Kutfil la gratis. Vus puvez btenir ces infrmatins gratuitement dans d autres langues. Appelez le u ntre numér TTY/TDD: jurs sur 7 de 8 a.m. à 8 p.m. EST. L appel est gratuit. Usted puede btener esta infrmacin en trs idimas de frma gratuita. Llame al y TTY/TDD: 711 8:00 am a 8:00 pm Hra del Este, ls 7 días de la semana. La llamada es gratuita. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 2

4 RiverSpring FIDA Plan: Summary f Benefits 이정보는다른언어로도제공됩니다 ( 무료 ). 주 7 일 8:00 am 8:00 pm(est) 중 나 TTY/TDD: 711 으로전화주십시오. 통화료는무료입니다. 您可免費取得以其他語言撰寫的資訊 請於週一至週日美國東部標準時間上午 8 時至下午 8 時致電 : ,TTY/TDD 使用者 : 711 每週 7 天服務 此為免付費電話 Данная информация доступна бесплатно на других языках. Звоните по номеру или 711 (линия TTY/TDD) с 8:00 до 20:00 по восточному поясному времени 7 дней в неделю. Звонок бесплатный. È pssibile ricevere queste infrmazini in altre lingue gratuitamente. Cntatta il e TTY/TDD: 711 dalle re 8:00 alle re 20:00 EST (ra standard rientale degli Stati Uniti), 7 girni su 7. Il servizi è gratuit. Yu can get this dcument fr free in ther frmats, such as large print, braille, r audi. Call (TTY 711), 7 days a week frm 8 a.m. t 8 p.m. EST. The call is free. If yu require any f the Plan materials, nw r in the future, in yur preferred language r alternative frmat, please call Participant Services at (TTY 711) -- we d be happy t help yu. ElderServe Health, Inc. cmplies with applicable Federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. 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 RiverSpring FIDA Plan. ICAN may be reached tll-free at r nline at icannys.rg. (TTY users call 711, then fllw the prmpts t dial ) If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 3

5 RiverSpring FIDA Plan: 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 RiverSpring FIDA Plan Care Manager and Interdisciplinary Team (IDT) What are lng-term services and supprts 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. RiverSpring FIDA Plan is a FIDA Plan that prvides benefits f Medicaid and Medicare t Participants in the FIDA Demnstratin. A RiverSpring FIDA Plan 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. 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. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 4

6 RiverSpring FIDA Plan: Summary f Benefits Frequently Asked Questins (FAQ) Can I direct my wn care r hire my wn aides Will yu get the same Medicare and Medicaid benefits in RiverSpring FIDA Plan that yu get nw Answers 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 RiverSpring FIDA Plan. 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 RiverSpring FIDA Plan, 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 RiverSpring FIDA Plan, 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 RiverSpring FIDA Plan, 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 RiverSpring FIDA Plan des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr RiverSpring FIDA Plan t cver yur drug, if medically necessary. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 5

7 RiverSpring FIDA Plan: 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 RiverSpring FIDA Plan s netwrk can prvide it Where is RiverSpring FIDA Plan available D yu pay a mnthly amunt (als called a premium) under RiverSpring FIDA Plan Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with RiverSpring FIDA Plan 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 RiverSpring FIDA Plan s netwrk, unless RiverSpring FIDA Plan 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 RiverSpring FIDA Plan's plan. T find ut if yur dctrs are in the plan s netwrk, call Participant Services r read RiverSpring FIDA Plan s Prvider and Pharmacy Directry. If RiverSpring FIDA Plan 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 RiverSpring FIDA Plan. Yes. If yu live in a nursing facility when yu enrll in RiverSpring FIDA Plan, yu can remain in that nursing facility fr the entire time that yu are in a FIDA Plan like RiverSpring FIDA Plan, even if that nursing facility is ut-f-netwrk and des nt participate with RiverSpring FIDA Plan. Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, RiverSpring FIDA Plan will pay fr the cst f an ut-f-netwrk prvider. The service area fr this plan includes: Brnx, Kings, Nassau, New Yrk, Queens, Richmnd, and Westchester Cunties, New Yrk. Yu must live in ne f these areas t jin the plan. Yu will nt pay any mnthly premiums t RiverSpring FIDA Plan fr yur cverage. Yu als will nt have any cpays r ther csts when yu get care frm netwrk prviders. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 6

8 RiverSpring FIDA Plan: Summary f Benefits Frequently Asked Questins (FAQ) What is prir authrizatin What is a referral Answers Prir authrizatin means that yu must get apprval frm RiverSpring FIDA Plan 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. RiverSpring FIDA Plan may nt cver the service, item, r drug if yu dn t get apprval frm RiverSpring FIDA Plan r yur IDT. A small number f services require prir authrizatin by a specialist and nt by RiverSpring FIDA Plan r yur IDT. Please refer t Chapter 4 f yur Participant Handbk fr mre infrmatin. RiverSpring FIDA Plan 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 RiverSpring FIDA Plan. 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 RiverSpring FIDA Plan and will nt be required. Hwever, prir authrizatin rules must be fllwed. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 7

9 RiverSpring FIDA Plan: 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 RiverSpring FIDA Plan Participant Services: CALL Calls t this number are free. 7 days a week frm 8 a.m. t 8 p.m., EST. Participant Services als has free language interpreter services available fr peple wh d nt speak English. TTY 711 Calls t this number are free. 7 days a week, 24 hurs a day. 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 a.m. t 8 p.m., EST. Participant Services als has free language interpreter services available fr peple wh d nt speak English. TTY 711 Calls t this number are free. 7 days a week, 24 hurs a day. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 8

10 RiverSpring FIDA Plan: 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 Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu want t see a dctr Visits t treat an injury r illness $0 Visits that d nt need prir authrizatin: - PCP - Emergency care - Urgent care - Out-f-area dialysis - Immunizatins - Palliative Care - Family planning Visits that may need prir authrizatin: - Specialist - Outpatient surgery r services Wellness visits, such as a physical $0 D nt need prir authrizatin. Transprtatin t a dctr s ffice $0 Need prir authrizatin at least 48 hurs befre yur appintment. Specialist care $0 D nt need prir authrizatin. Care t keep yu frm getting sick, such as flu shts Welcme t Medicare preventive visit (ne time nly) $0 D nt need prir authrizatin. $0 D nt need prir authrizatin. Yu need medical tests Lab tests, such as bld wrk $0 D nt need prir authrizatin. X-rays r ther pictures, such as CAT scans $0 Need prir authrizatin, unless they are emergent. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 9

11 RiverSpring FIDA Plan: Summary f Benefits Health need r prblem Services yu may need Screening tests, such as tests t check fr cancer Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Preventive screenings d nt need prir authrizatin. Diagnstic screenings may need prir authrizatin. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 10

12 RiverSpring FIDA Plan: 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 31-day supply $0 fr a 90-day supply There may be limitatins n the types f drugs cvered. Please see RiverSpring FIDA Plan s List f Cvered Drugs (Drug List) fr mre infrmatin. Sme drugs that yu take n a regular basis, fr a chrnic r a lng-term medical cnditin, are available thrugh mail-rder services r extended (90) day supply at a participating retail pharmacy. Brand name drugs $0 fr a 31-day supply $0 fr a 90-day supply There may be limitatins n the types f drugs cvered. Please see RiverSpring FIDA Plan s List f Cvered Drugs (Drug List) fr mre infrmatin. Sme drugs that yu take n a regular basis, fr a chrnic r a lng-term medical cnditin, are available thrugh mail-rder services r extended (90) day supply at a participating retail pharmacy. Yu need drugs t treat yur illness r cnditin (cntinued) Over-the-cunter drugs $0 RiverSpring FIDA Plan cvers sme OTC drugs when they are written as prescriptins by yur prvider. Please see RiverSpring FIDA Plan s List f Cvered Drugs (Drug List) fr mre infrmatin. Medicare Part B prescriptin drugs $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. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 11

13 RiverSpring FIDA Plan: Summary f Benefits Health need r prblem Yu need therapy after a strke r accident Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Occupatinal, physical, r speech therapy $0 Limited t 20 visits per year, per therapy. Need prir authrizatin. Yu need emergency care Emergency rm services $0 Yu may get cvered emergency medical care whenever yu need it, anywhere in the United States r its territries. D nt need prir authrizatin fr innetwrk and ut-f-netwrk emergency care. Emergency care is nt cvered utside the United States and its territries. Ambulance services $0 D nt need prir authrizatin fr innetwrk and ut-f-netwrk emergency ambulance services. Emergency ambulance services are nt cvered utside the United States and its territries. Nn-emergent ambulance services need prir authrizatin. Urgent care $0 D nt need prir authrizatin fr innetwrk and ut-f-netwrk urgent care. Urgent care is nt cvered utside f the United States and its territries. Yu need hspital care Hspital stay $0 Need prir authrizatin. Dctr r surgen care $0 Dctr r surgen care during a cvered hspital stay des nt need prir authrizatin. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 12

14 RiverSpring FIDA Plan: Summary f Benefits Health need r prblem Yu need help getting better r have special health needs Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Rehabilitatin services $0 Cardiac rehab, first curse f treatment, des nt need prir authrizatin. Other rehabilitatin services may need prir authrizatin. Medical equipment fr hme care $0 Need prir authrizatin. Skilled nursing care $0 Need prir authrizatin. Yu need eye care Eye exams $0 One rutine eye exam is cvered nce every 24 mnths and des nt need prir authrizatin. Additinal eye exams may need prir authrizatin. Glasses r cntact lenses $0 One pair every tw years. May need prir authrizatin. Yu need dental care Dental check-ups $0 One dental check-up every six mnths. May need prir authrizatin. Yu need hearing/auditry services Hearing screenings $0 Need prir authrizatin. Hearing aids $0 Need prir authrizatin. Yu have a chrnic cnditin, such as diabetes r heart disease Yu have a mental health cnditin Yu have a substance abuse prblem Yu need lng-term mental health services Services t help manage yur disease $0 Need prir authrizatin. Diabetes supplies and services $0 Need prir authrizatin. Mental r behaviral health services $0 Need prir authrizatin. Substance abuse services $0 Need prir authrizatin. Inpatient care fr peple wh need mental health care $0 Need prir authrizatin. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 13

15 RiverSpring FIDA Plan: Summary f Benefits Health need r prblem Yu need durable medical equipment (DME) Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Wheelchairs $0 Need prir authrizatin. Nebulizers $0 Need prir authrizatin. Crutches $0 Need prir authrizatin. Walkers $0 Need prir authrizatin. Oxygen equipment and supplies $0 Need prir authrizatin. 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 Meals brught t yur hme $0 Need prir authrizatin. 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 $0 Need prir authrizatin. $0 Need prir authrizatin. $0 Need prir authrizatin. $0 Need prir authrizatin. Services t help yu live n yur wn $0 Need prir authrizatin. Adult day services r ther supprt services $0 Need prir authrizatin. Assisted living r ther husing services $0 Need prir authrizatin. Nursing facility care $0 Need prir authrizatin. Respite care $0 Need prir authrizatin. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 14

16 RiverSpring FIDA Plan: Summary f Benefits Other services that RiverSpring FIDA Plan 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 RiverSpring FIDA Plan Over-the-cunter supplies benefit Yur csts fr in-netwrk prviders $0. Yu are cvered fr up t $25 a mnth fr ver-the-cunter prducts. OTC items may nly be purchased fr the participant. Please cntact the plan fr specific instructins fr using this benefit. Benefits cvered utside f RiverSpring FIDA Plan This is nt a cmplete list. Call Participant Services t find ut abut ther services nt cvered by RiverSpring FIDA Plan but available thrugh Medicare r Medicaid. Other services cvered by Medicare r Medicaid Yur csts Day treatment $0 Freestanding birth center services As determined under Medicare/Medicaid fee-frservice. Out f netwrk family planning services As determined under Medicare/Medicaid fee-frservice. Methadne Maintenance Treatment Prgram (MMTP) As determined under Medicare/Medicaid fee-frservice. Directly bserved therapy fr tuberculsis (TB) Hspice services As determined under Medicare/Medicaid fee-frservice. As determined under Medicare/Medicaid fee-frservice. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 15

17 RiverSpring FIDA Plan: Summary f Benefits Services that RiverSpring FIDA Plan, 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 RiverSpring FIDA Plan, Medicare, r Medicaid Services that are nt medically necessary accrding t the standards f Medicare and New Yrk Medicaid unless therwise apprved r entered in yur Persn-Centered Service Plan (PCSP). 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. Services prvided t veterans in Veterans Affairs (VA) facilities. Hwever, when emergency services are received at a VA hspital and the VA cst sharing is mre than the cst sharing under ur plan, we will reimburse veterans fr the difference. LASIK surgery. Services that yu get withut prir authrizatin, when prir authrizatin is required fr getting that service. Naturpath services (uses natural r alternative treatments). Emergency facility services fr nn-authrized, rutine cnditins that are nt a medical emergency. Services prvided utside the United States and its territries. Private rm in a hspital, except when it is cnsidered medically necessary. Persnal items in yur rm at a hspital r a skilled nursing facility, such as a telephne r a televisin. Csmetic surgery r prcedures, unless because f an accidental injury r when medically necessary. Hwever, all stages f recnstructin fr a breast are cvered after a mastectmy, as well as fr the unaffected breast t prduce a symmetrical appearance. Acupuncture. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 16

18 RiverSpring FIDA Plan: Summary f Benefits Yur rights as a Participant f the plan As a Participant f RiverSpring FIDA Plan, yu have certain rights. Yu can exercise these rights withut being punished. Yu can als use these rights withut lsing yur services frm RiverSpring FIDA Plan. 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: Yu have the right t make decisins abut yur care, including refusing treatment. 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 RiverSpring FIDA Plan r yur prvider treats yu 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 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. RiverSpring FIDA Plan 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 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 If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 17

19 RiverSpring FIDA Plan: Summary f Benefits Have interpreters t help with cmmunicatin with yur dctrs and yur health plan 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 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 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 Get a detailed reasn fr why services were denied Fr mre infrmatin abut yur rights, yu can read the RiverSpring FIDA Plan Participant Handbk. If yu have questins, yu can als call RiverSpring FIDA Plan Participant Services. If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 18

20 RiverSpring FIDA Plan: Summary f Benefits If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think RiverSpring FIDA Plan shuld cver smething we denied, call RiverSpring FIDA Plan at Yu may be able t appeal ur decisin. Fr questins abut grievances (cmplaints) and appeals, yu can read Chapter 9 f the RiverSpring FIDA Plan Participant Handbk. Yu can als call RiverSpring FIDA Plan 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 RiverSpring FIDA Plan, 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 ) Fr additinal infrmatin abut cmplaints, grievances, r appeals, talk t yur Care Manager r call Participant Services at 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 RiverSpring FIDA Plan 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. Or, call the New Yrk State Office f the Medicaid Inspectr General at FRAUD ( ). If yu have questins, please call RiverSpring FIDA Plan at (TTY 711), 7 days a week, 8 a.m. t 8 p.m. EST. The call is free. Fr mre infrmatin, visit 19

21 RiverSpring Health Plans (TTY 711) 8 a.m. t 8 p.m. EST. 7 days a week. RiverSpringFIDA.rg