Medicaid is health insurance for people with low incomes. There are two kinds of Medicaid:
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Soon. Most people on Medicaid will have to join a Managed Care Plan over the next few years. You will get a letter from the City when it is your turn to join. Some people will not have to join a Managed Care Plan.
Two groups of people do not have to join: People who are Exempt or Excluded.
You are exempt from Medicaid Managed Care if:
People who cannot join a Managed Care Plan even if they would like to are called excluded. You are excluded and cannot join a Medicaid Managed Care Plan if:
You will get a notice and an enrollment packet in the mail from New York Medicaid Choice when it is your turn to join.
What Is In the Enrollment Packet?
The information you need to enroll in a Managed Care Plan is in the enrollment packet. It also tells you when you have to join. It lists the Managed Care Plans in your neighborhood. It also gives you the phone number to apply for an exemption or exclusion. You can get an enrollment packet in English,Spanish, Russian, Chinese, and Haitian Creole.
You can enroll in three ways:
It takes a few weeks for New York Medicaid CHOICE to do your paperwork when you join a Plan. When you join a plan, you become a member. Your Plan must send you:
Your Plan must tell you how it works and its rules. You should choose a doctor, or Primary Care Provider, for each family member. Call your doctor and ask for your first appointment. This appointment will help you get to know your doctor. It will make it easier to get care if you are sick. Read your Managed Care Plan’s member handbook carefully. It will tell you how to use your Plan.
New York Medicaid CHOICE will automatically assign or enroll you in a Managed Care Plan if you do not choose a Plan and your time to enroll has ended. You will get 3 notices. The first notice will tell you to enroll in a Medicaid Managed Care Plan within 60 days. You will get a second notice 30 days later. It will be a “reminder notice” that says you only have 30 days to enroll. If you still do not choose a Plan you will get a third notice. This notice will say that the City will automatically enroll you in a Medicaid Managed Care Plan. The name of the Plan will be in that notice. On the 60th day, New York Medicaid CHOICE will send out a "confirmation" notice telling you that you have been automatically assigned to a Plan.
If you are automatically assigned to a Managed Care Plan, you have 90 days to change Plans. Your 90 days starts from the date you are enrolled in a Plan. To change Plans, call New York Medicaid CHOICE at 1-800-505-5678. If you do not change plans within this 90 day period, you cannot change your plan for 9 more months, unless you have a good reason.
Call New York Medicaid CHOICE at 1-800-505-5678 and ask to speak to an Exemption Counselor. They will send you a form. Fill out the form and send it back in the self-addressed envelope they mail you. You will get a decision in a week or two. In some cases, you will have to prove that you are exempt. For example, your doctor may have to fill out a "Chronic Medical Exemption Form" that asks questions about your health and your relationship with your doctor. You should receive a letter from New York Medicaid CHOICE which tells you if you are exempt or excluded. Ask for a Fair Hearing if you disagree with their decision.
You have the right to switch Plans for any reason during the first 90 days of your enrollment. After 90 days, you must stay in your Plan for 9 more months before you can change. But you can change Plans anytime if you have a good reason. Call New York Medicaid CHOICE at 1-800-505-5678 to help you change Plans.
Ask for a Fair Hearing if you have a problem changing Plans.
Maybe. Call New York Medicaid CHOICE at 1-800-505-5678 to quit Medicaid Managed Care. They will send you a form. You must sign and date the disenrollment form and send it back. You should get a confirmation letter. The letter will say that you are not in a Plan anymore. After 90 days, you must stay in your Plan for 9 more months before you can quit. But you can quit your Plan anytime if you have a good reason. Call New York Medicaid CHOICE at 1-800-505-5678 to quit. The only people who can quit a Medicaid Managed Care Plan are people who are exempt. Remember, only exempt people can choose to have regular Medicaid or be in a Medicaid Managed Care Plan.
Normally, it takes 45 days after you send in your disenrollment form to get out of your Plan. Sometimes, you can get out of the Plan in 10 days. This is called an expedited disenrollment. There are two ways you can get out in 10 days:
You must tell New York Medicaid CHOICE the reasons why you want a 10 day disenrollment.
Your regular Medicaid card will start working again when your disenrollment goes through. Unfortunately, Medicaid does not always tell you when this will happen. To find out if you are disenrolled, take your regular Medicaid card to your local doctor, clinic or pharmacy to see if your regular Medicaid is working. An expedited disenrollment means a fast disenrollment. Choosing a Managed Care Plan can be very confusing. New York City has many Plans. Be selective and don’t be afraid to ask for help! This is a very important decision.
There are a lot of outside agencies that can help you solve problems with your Plan. Some are listed here.
Government Agencies:
Community Agencies:
To get other Booklets or Fact Sheets in about Medicaid, call The Legal Aid Society at (888) 218-6974 or visit www.legal-aid.org.
Bronx Health Plan, CenterCare, Community Premier Plus, Health First, Health Plus, HIP, Managed Health Systems (MHS), MetroPlus, Neighborhood Health Providers.
Start with your doctor. Talk to your doctor, therapists, or health care provider to see which Plans they belong to. Find out which Plan your child’s doctors belong to. See if your family doctors all belong to the same plan. You can also call a New York Medicaid CHOICE worker at 1-800-505-5678. They can also tell you about groups in your neighborhood that can help you choose a Plan. Remember you have a right to confidential counseling to help you choose a Managed Care Plan.
Ask yourself these questions when choosing a Plan for you and your family:
Ask your friends and family who are already in a Managed Care Plan about their Plans.
People who have been sick know alot about their Plans and may be good to talk to. Ask the Plan questions. You have the right to get a lot of information about the Plan before you join:
Medicaid Managed Care Plans have a lot of rules about how you get your care. Your Primary Care Provider is in charge of managing your health care. Your Primary Care Provider is supposed to make sure that you get all of the health care you need. Your Primary Care Provider can be a doctor or a nurse practitioner. For children, it can be a pediatrician or family doctor. For adults, it can be a doctor called an internist or general practitioner. Your Primary Care Provider is a doctor or nurse practitioner who is in charge of your care.
You choose a Primary Care Provider from your Plan’s list of doctors when you enroll in your Plan. If you do not, your Plan may choose one for you. Ask these questions when choosing a Primary Care Provider:
Many Plans let you change your Primary Care Provider at any time for any reason. But some Plans do not. You have the right to change your Primary Care Provider:
The law says that you can always change your Primary Care Provider if you have "good cause" or a good reason. For example, good cause is when you move far away from your doctor. Call your Plan and ask to change your Primary Care Provider. You can appeal if the Plan won’t let you change providers.
You cannot see a specialist without permission from your Primary Care Provider. Getting this permission is called a referral. Ask your Primary Care Provider for a referral if you think you need to see a specialist. You do not need a referral for some types of care. Women can see a gynecologist at least twice a year without a referral. Some people with serious, long term illnesses like HIV/AIDS can see their specialists without a referral. A specialist is a doctor you go to for special care like a dermatologist for a skin rash or a pulmonologist for asthma.
You must ask your Primary Care Provider for permission if you want to see a specialist or any other doctor besides your Primary Care Provider. The permission is called a referral.
Usually you must get health care from doctors and hospitals that are part of your Plan. But there are some benefits and services that are never covered by your Plan. You use your regular Medicaid card to get these services. Benefits and services from outside your plan are called carve-outs. You can get carve-out services with your regular Medicaid card. You can go to any doctor who accepts Medicaid, even if the doctor is not in your Plan. You do not need the permission from your Primary Care Provider to get these services. If you get SSI, you must use your regular Medicaid card to get mental health, alcohol and substance abuse services.
Use your regular Medicaid card to get these services:
Try your plan card if your regular Medicaid card doesn’t work. You can also use your regular Medicaid card to get family planning and HIV testing and counseling.
No. Some Plans do not cover dental services. Ask your Plan if it will pay for you to go to the dentist. If your Plan covers dental care, you must follow your Plan’s rules for going to the dentist. If your Plan does not cover dental care, use your regular Medicaid card to go to the dentist.
Go to any Medicaid doctor or clinic to get family planning and HIV testing and counseling. You don’t need permission from your Primary Care Provider or your Plan. Use your regular Medicaid card or your Plan card. The Family Planning services you can get without asking permission from your Managed Care Plan are:
Some Plans, like Fidelis, do not offer family planning, abortions, birth control, or HIV testing and counseling. If you join these Plans you can get these services only with your regular Medicaid card.
Yes. If you think you or your child’s life or health may be at risk, your Plan must pay. Your Plan may not pay for your emergency room visit if your medical problem was clearly not an emergency. For example, if you go to the emergency room for a cold, your Plan may not pay the bill and the hospital may try to bill you.
If you think that you or your child’s life or health may be at risk, get treatment immediately. Go straight to the nearest emergency room for care.
Call your Primary Care Provider if you have a medical problem that is not an emergency. Call your Plan’s 24-hour telephone number if you cannot reach your Primary Care Provider. If you go to the emergency room call your Plan as soon as you can. Most Plans ask you to call within 48 hours.
Hospitals are not supposed to bill Medicaid Managed Care patients directly. But they often do if your Plan refuses to pay them. An unpaid hospital bill can hurt your credit rating.
Your Plan must give you health care near your home when you need it. Near your home means you do not have to travel more than 30 minutes by public transportation. You should not have to wait too long to get any care you need. For example, you are not supposed to wait more than one hour in a waiting room to see your doctors. You have a right to get an appointment in a certain amount of time:
If you have problems getting appointments within these time limits, write down the name of the person you spoke to at the doctor’s office or clinic and the time and date of the call.
You have important rights if you have a disability, a chronic condition, or disease. These rights are found in the New York State law called the Managed Care Bill of Rights:
THE MANAGED CARE BILL OF RIGHTS
You have the right to:
How Do I Get Special Care For My Disability, Condition,or Disease From My Managed Care Plan?
You have the right to get special care from your Plan if you have a disability, a chronic condition, or disease. This care includes:
What Are "Special Needs Plans"?
Soon there will be Special Needs Plans. Special Needs Plans are Managed Care Plans for people who are HIV+ or have AIDS. Special Needs Plans are sometimes called "SNPs" which sounds like the word "snips."
HIV Special Needs Plans are set up to meet the needs of people with HIV or AIDS. If you are HIV+ you can join a Special Needs Plan even if you don’t have symptoms of AIDS. Your HIV Special Needs Plan will give you all your regular health services and all HIV care, like referrals for necessary services, HIV counseling, testing, prevention and education. Your HIV Special Needs Plan must provide you with all new treatments, like protease inhibitors and viral load treatments. Your children can be enrolled with you if you want.
If you are HIV+ or have AIDS and you cannot get the treatment you need from either a regular Managed Care Plan or a Special Needs Plan, then you have the right to stay in Regular Medicaid. Special Needs Plans are still being formed.
Call your Plan’s Member Services Department first. All Plans are required to have a toll-free phone number to help you. The number is usually on your member card. Tell them about your problem. Your Plan must have someone who speaks Spanish and other languages to help you. They must also have a TTD/TTY for people who are deaf or hard of hearing.
What if My Plan’s Member Services Department Doesn’t Fix My Problem?
You have two options. First, you can ask for a Fair Hearing. Second, you can file a grievance with your Plan. A grievance is a complaint. You can also try a fair hearing and grievance at the same time. It is always best to put your complaints with your Managed Care Plan in writing and to keep a copy for your records.
Fair Hearings
A Fair Hearing is when you tell your problem to an independent State judge. The Plan gets to tell its side of the story too. The judge must make a decision within 90 days of the date you asked for a Fair Hearing. Often you can keep getting your benefits while you wait for the judge’s decision.
To request a Fair Hearing, call: (212) 417-6550 or (518) 474-8781. You can also request a Fair Hearing by writing to the State at: NYSDOH, Office of Administrative Hearings, P.O. Box 1930, Albany, NY 11201-1930. You can also fax in your written request to: 518-473-6735.
Grievances
A grievance is a complaint. Tell Member Services that you want to file a grievance. Try to put your grievance in writing. If you ask for a Fair Hearing within 10 days of the day that a service or benefit was cut off or reduced, you have the right to still get that service or benefit. This is called aid-to-continue.
How Do I File A Grievance with My Plan?
You can file a grievance over the phone or in writing. You can file a grievance over the phone if:
Example: Maria’s Plan refuses to pay for a blood test. She can file a grievance with her Plan to see if it will change its mind. All other grievances must be in writing. Your Plan must send you a letter within 15 days saying that it got your grievance.
Your Plan must send you a decision in writing. It has to give you a decision about your grievance within:
What if I Lose My Grievance?
You have the right to appeal your Plan’s decision. The Plan’s decision must be in writing and it must tell you how to appeal. All appeals must be in writing. Your Plan must decide your appeal within these times:
If you lose your appeal, and you still think you should have won, you should contact one of the government agencies listed below.
Ask your Plan for utilization review. Utilization review is a special appeal when your Plan or doctor thinks the medical care you want is not medically necessary. Medically necessary care is care that you need. Your Plan must decide your utilization review request within these times:
Example: Monica finds out that her son is having trouble hearing in school. The school nurse wants to send her son for a special hearing test. But her Plan says that the test is not medically necessary. Monica can ask for utilization review.
How Do I Ask For Utilization Review?
Your Plan must let you file a utilization review over the phone or in writing. You can leave a message after hours and they must call you back the next business day.
What If I Lose My Utilization Review?
Appeal! The Plan’s decision will tell you how to appeal. Your Plan must decide your appeal within 2 business days if it is about care that you are already getting or if your doctor thinks your case should be decided quickly. All other appeals take 30 days.