Elderplan Medicaid Handbook

Transcription

1 Summary of Benefits Elderplan Medicaid Handbook H3347_EP15827

2 Elderplan Medicaid Handbook 2017 As a member of Elderplan you are entitled to Medicare Part A, are enrolled in Medicare Part B and live in our plan approved service area. If you are also a member of the New York State Medicaid program your Medicare cost-sharing amounts are subsidized and paid by the New York State Medicaid Program. Depending on your level of Medicaid coverage you may be entitled to a partial or full coverage which includes Medicare Part A and Part B premiums, deductibles and cost-sharing (excluding Part D co-payments). If you have any questions concerning what benefits you are entitled to under the Medicaid program, please call the New York City Medicaid staff at Human Resources Administration at (718) :00 a.m. to 5:00 p.m. Monday through Friday. Renewal of Medicaid Coverage The Human Resources Administration (HRA) has established a mail-in renewal program to assist you in maintaining your Medicaid health insurance coverage. When it is time for you to renew, you will receive a package in the mail that will include your renewal form and the necessary instructions to complete it. On the renewal form you will find the deadline by which HRA must receive your completed renewal form and necessary documentation. If your response is not received by the deadline, your Medicaid coverage will end. You can call the HRA Medicaid Helpline (call inside of New York City, call (212) outside of New York City.) toll-free or call 311 if you need help with your renewal form. If you prefer to drop off your renewal form and documentation in person and/or you need help in person, you can go to any Medical Assistance Program Community Office. Elderplan and Medicaid Cost-sharing As your primary insurance, Elderplan pays for Medicare covered services that you receive. Your provider will bill Elderplan directly for rendered services. If Elderplan does not cover the entire cost of that service, the remaining balance will be billed to Medicaid fee-for-service. It is important that you bring your Elderplan and Medicaid cards and any other health insurance cards to all appointments. H3347_EP15827

3 The provider is responsible to bill Elderplan and Medicaid for payment. It is unlawful for the provider to balance bill our members. Balance billing is the practice of hospitals, doctors offices and other medical Facilities billing patients for the balance between what they want to charge their patients for services and what the insurance company has already reimbursed them. If you receive a bill from a provider - do not pay the bill. Contact the provider s office and remind them that it is illegal to balance bill Medicaid beneficiaries. If you do not receive satisfaction at the provider s office please contact Elderplan Member Services at Elderplan Member Services is open 7 days a week from 8:00 a.m. to 8:00 p.m. (TTY/TTD 711) and we will contact the provider on your behalf. Elderplan and Care Management Elderplan members are automatically enrolled into the Care Management Program. Under this program you will receive care management services from our clinical team. This interdisciplinary team, consisting of nurses, social workers, support staff, and a pharmacist, can assist you in obtaining the services that you need, through the Elderplan benefits or community based services. If you experience changes in your health care requiring a hospitalization, nursing home stay, or home care, the team can assist you as you transition from any of those settings, so you can get the care that you need. You may contact Member Services with additional questions or concerns at , 7 days a week from 8:00 a.m. to 8:00 p.m. (TTY/TTD 711). Elderplan and Medicaid Appeals Your health and satisfaction are important to us. If you are dissatisfied with a coverage decision made by Elderplan you have the right to file an appeal. An appeal is a formal way of asking us to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. When we have completed the review we give you our decision. When you have a problem or concern, we hope you will try an informal approach first by calling Elderplan Member Services at Elderplan Member Services is open 7 days a week from 8:00 a.m. to 8:00 p.m. (TTY/TTD 711). We will work with you to try to find a satisfactory solution to

4 your problem. As a valued member of Elderplan you have rights and responsibilities as a member of our plan. This may include appeal rights under the Medicare and Medicaid process. We pledge to honor your rights, to take your problems and concerns seriously, and to treat you with respect. Your Elderplan Evidence of Coverage (Chapter 9) details your rights as a member of Elderplan and exactly what to do if you have a problem or complaint and/or how to file an appeal. If you have questions or need more guidance regarding the appeal process, please contact Elderplan Member Services and together with our Appeals Coordinators, we will be able to assist you through the process. We must treat you with fairness and respect at all times Our plan must obey laws that protect you from discrimination or unfair treatment. We do not discriminate based on a person s race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area. If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services Office for Civil Rights (TTY ) or your local Office for Civil Rights. If you have a disability and need help with access to care, please call us at Member Services (phone numbers are printed on the back cover of this booklet). If you have a complaint, such as a problem with wheelchair access, Member Services can help. Medicaid Benefits and Cost-sharing The chart on the next page, Medicaid Benefits and Cost-sharing, describes Medicaid benefits that you may be entitled to if you qualify for full Medicaid benefits under the New York State Medicaid program. The chart also explains if a similar benefit is available under Elderplan. In most cases, the benefits listed below are not covered by traditional Medicare If you have any questions concerning what benefits you are entitled to under the Medicaid program, please call the New York City Medicaid staff at Human Resources Administration at (718) , 8:00 AM to 5:00 PM Monday through Friday.

5 Inpatient Hospital Care including Substance Abuse and Rehabilitation Services Skilled Nursing Facility (SNF) Doctor Office Visits Podiatry Services Chiropractic Services Outpatient Substance Abuse Care Outpatient Mental Health Outpatient Services/Surgery Ambulance Services Emergency Care Urgently Needed Care Up to 365 days per year (366 days for leap year) Medicaid covers additional days beyond Medicare 100 day limit. copays and coinsurances (QMB and QMB- Plus Only) copays and coinsurances (QMB and QMB- Plus Only) copays and coinsurances copays and coinsurances copays, and coinsurances.

6 Outpatient Rehabilitation Services Prosthetic Devices Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Bone Mass Measurement Colorectal Screening Exams Immunizations Mammograms Pap Smears and Pelvic Exams Prostate Cancer Screening Exams End Stage Renal Disease Occupational, Physical and Speech therapies are limited to twenty (20) visits per therapy per year, except for children under age 21, or you have been determined to be developmentally disabled by the Office for People with Developmental Disabilities, or if you have a traumatic brain injury.

7 Prescription Drugs Over the Counter Drugs Dental Transportation (Routine) Inpatient Mental Health Services (over 190-day lifetime limit) Medicaid does not cover Part D covered drugs or copays. Medicaid Pharmacy Benefits allowed by State Law (select drug categories excluded from the Medicare Part D benefit). Certain Medical Supplies and Enteral Formula when not covered by Medicare. Certain Over the Counter medications are covered. copays and coinsurances Medicaid covered dental services including necessary preventive, prophylactic and other routine dental care, services, and supplies and dental prosthetics to alleviate a serious health condition. Ambulatory or inpatient surgical dental services subject to prior authorization. Includes ambulette, invalid coach, taxicab, livery, public transportation, or other means appropriate to the enrollee s medical condition. Medicaid covered Medicare deductibles, copays and coinsurances All inpatient mental health services, including voluntary or involuntary admissions for mental health services over the Medicare 190 day lifetime limit.

8 Non-Medicare Covered Home Health Services Non-Medicare Covered Durable Medical Equipment Medicaid covered Medicare deductibles, copays and coinsurances Medically necessary intermittent skilled nursing care, home health aide services and rehabilitation services. Also includes non-medicare covered home health services (e.g. home health aid services with nursing supervision to medically unstable individuals) 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)

9 Private Duty Nursing Services Non-Medicare Covered Hearing Services Private duty nursing services are covered when determined by the physician to be medically necessary. Nursing services can be provided through an approved certified home health agency, a licensed home care agency, or a private practitioner. Nursing services may be intermittent, part time or continuous and must be provided in an Enrollee s home in accordance wit the ordering physician, registered physician assistant or certified nurse practitioner s written treatment plan. Hearing services and products when medically necessary to alleviate disability caused by the loss or impairment of hearing. Services include hearing and 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, ear molds, special fittings and replacement parts.

10 Non-Medicare Covered Vision Services Hospice Physical Exams Health/Wellness Education Out-of-Network Family Planning services provided under the direct access provisions of the waiver Services of Optometrists, Ophthalmologists, and Ophthalmic dispensers including eyeglasses, medically necessary contact lenses and polycarbonate lenses, artificial eyes (stock or custom-made), low vision aids and low vision 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. copays and coinsurance. Medicaid covered Medicare deductibles, No coverage

11 Personal Care Services Certain Mental Health Services Methadone Maintenance Treatment Programs (MMTP) Rehabilitation Services Provided to Residents of OMH Licensed Community Residence (CRs) and Family Based Treatment Programs Office for People with Developmental Disabilities (OPWDD) Services Provides some or total assistance with such activities as personal hygiene, dressing and feeding and nutritional and environmental support function tasks. Services must be medically necessary and ordered by the enrollee s physician and provided by a qualified person. Medicaid coverage of Certain Mental Health Services includes: 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, Assertive Community Treatment (ACT), Personalized Recovery Oriented Services (PROS)

12 Comprehensive Medicaid Case Management Directly Observed Therapy for Tuberculosis (TB) Disease AIDS Adult Day Health Care HIV COBRA Case Management Assisted Living Program Adult Day Health Care Personal Emergency Response Services (PERS) An electronic device which enables certain high risk patients to secure help in the event of a physical, emotional or environmental emergency. A variety of electronic alert systems exist using different signaling devices. Such systems are usually connected to a patient s phone and signal a response center when a help button is activated. In the event of an emergency, the signal is received and appropriately acted on by a response center.

13 Elderplan/HomeFirst complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Elderplan, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Elderplan/HomeFirst.: Provides 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) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Civil Rights Coordinator. If you believe that Elderplan/HomeFirst has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you may file a grievance with: Civil Rights Coordinator th Ave Brooklyn, NY, Phone: , TTY 711 Fax: You may file a grievance in person or by mail, phone, or fax. If you need help filing a grievance, Civil Rights Coordinator, is available to help you. You may 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 Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW, Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at

14 ATTENTION: If you speak a non-english language or require assistance in ASL, 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). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). טפור.לאצפא ןופ יירפ סעסיוורעס ףליה ךארפש ךייא ראפ ןאהראפ ןענעז,שידיא טדער ריא ביוא :םאזקרעמפיוא (TTY: 711). লক ষ য কর ন যদ আপন ব ল, কথ বলত প র ন, ত হল ন খরচ য ভ ষ সহ য ত পর ষ ব উপলব ধ আছ ফ ন কর ন (TTY: 711) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). تامدخ نإف ASL يف ةدعاسم ىلإ جاتحت وأ ةيزيلجنإلا ريغ ةغل ثدحتت تنك اذإ :ةظوحلم (711 (TTY: مقرب لصتا.اناجم كل رفاوتت ةيوغللا ةدعاسملا ATTENTION: Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 711). لاک ںیہ بایتسد ںیم تفم تامدخ یک ددم یک نابز وک پآ وت ںیہ ےتلوب ودرا پآ رگا :رادربخ 711) (TTY: ںیرک PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: 711). KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711).

15 For more information, call us toll-free a.m. 8 p.m., 7 days a week. TTY/TDD users should call 711 Visit our website Elderplan.org Elderplan is an HMO plan with Medicare and Medicaid contracts. Enrollment in Elderplan depends on contract renewal. Anyone entitled to Medicare Parts A and B may apply. Enrolled members must continue to pay their Medicare part B premium if not otherwise paid for under Medicaid.