Medicaid: Frequently Asked Questions

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What is Medicaid and what's the difference between Regular Medicaid and Medicaid Managed Care?

Medicaid is health insurance for people with low incomes.  There are two kinds of Medicaid:

• Regular Medicaid
• In Regular Medicaid, you can go to any doctor, hospital or clinic that takes Medicaid. The doctor bills Medicaid, and Medicaid pays the bills
• Medicaid Managed Care
• Medicaid Managed Care is different from Regular Medicaid.  In Medicaid Managed Care you join a plan that is in charge of your medical care.  In Medicaid Managed Care there are many more rulesabout which doctors you can go to and how you get care.  Here are some rules:
• You Get a Personal Doctor.  When you join a Managed Care Plan you pick a doctor from yourPlan’s list.  The doctor will be in charge of your care.  This doctor is called your Primary CareProvider.  This doctor will give you regular care,like routine check-ups and shots.  Try to get to know your Primary Care Provider.  This doctor should know your medical history and your healthcare needs.
• Your Doctors Must Be On the Managed Care Plan’s List.  Your Managed Care Plan will only paydoctors, hospitals, and other health care providers that are on the Plan’s list. You could be stuck with the bill if you go to a doctor or hospital not on your Plan’s list.  Medicaid may not pay this bill.
• You Must Get Permission To See Other Doctors.  You must ask your Primary Care Provider forpermission to see a specialist or to go into the hospital unless you have an emergency.  This is called a referral.

When do I have to join a Managed Care plan?

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.

Does everyone have to join a Managed Care plan?

Two groups of people do not have to join:  People who are Exempt or Excluded.

• Exempt:  Some people have a choice to keep Regular Medicaid or to join a Medicaid Managed Care Plan.  These people are called "Exempt."
• Excluded: Some people are not allowed to join a Medicaid Managed Care Plan.  They are called "Excluded."  They stay in Regular Medicaid.

Who is exempt from Medicaid Managed Care?

You are exempt from Medicaid Managed Care if:

• You get SSI
• You get both Medicaid and Medicare
• You are homeless
• You are an adult or a child with a serious mental illness who had at least ten mental health appointments or hospital stays in a year
• You live at an alcohol or substance abuse program or a facility for the mentally retarded
• You are mentally retarded and get care from an intermediate care facility (or have health needs like a person in a facility)
• You have a developmental or physical disability and you are in a special treatment program
• You are in the “Care-at-Home” program (or have health needs like a person in that program)
• You are a Native American
• You are HIV+ or have AIDS, or have End Stage Renal Disease. Ask your doctor to fill out a Chronic Medical Exemption Form
• You have a chronic medical condition or have a major operation scheduled and you get care from a specialist doctor who is not in a Managed Care Plan. Ask your doctor to fill out a Chronic Medical Exemption Form
• You have to travel more than 30 minutes to get to a doctor in a Plan
• You are pregnant and get care for your pregnancy from a doctor who is not in a Plan. This exemption only lasts for 60 days after your baby is born
• You cannot get a doctor in a Plan who speaks your language
• You are temporarily living outside of New York City
• You have a “good cause” or good reason for not wanting to join

Who cannot join a Medicaid Managed Care plan?

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 are a foster child
• You are in the Medicaid "Spend-Down" or "Surplus Income" program
• You live in a nursing home or a hospice, or a long term home health care program, state-operated psychiatric facility, or residential treatment facility for children
• You get Medicare and are in a long term care program
• You are an infant living with a mother in jail
• You will get Medicaid for less than 6 months. For example, you get Emergency Medicaid
• You only use Medicaid for tuberculosis (T.B.) related services
• You are a blind or disabled child and live away from your parents
• You are in Medicaid’s Restricted Recipient program
• You have other insurance

How will I know when I need to join a Managed Care plan?

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.

How do I join a Managed Care plan?

You can enroll in three ways:

• Call New York Medicaid CHOICE at 1-800-505-5678.  New York Medicaid CHOICE has workers who can help you enroll.  They give information and advice about the different Managed Care Plans.  They do not work for a Managed Care Plan.  They have walk-in offices around the City.
• By Mail.  You will receive an enrollment form in your enrollment packet.  Fill it out and mail it back to New York Medicaid CHOICE to sign up for a Managed Care Plan.
• Call a Managed Care Plan.  You can join a Managed Care Plan directly with a Plan salesperson.  But remember, salespeople work for one Plan and will not tell you all your rights and options.  Choose carefully.  Don’t be afraid to look elsewhere for help.

What happens after I enroll?

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:

• A member handbook
• A list of doctors and other health care providers in the Plan
• A member card

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.

What happens if I do not enroll?

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.

What happens if I am 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.

How do I get an exemption or exclusion from joining a Managed Care Plan?

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.  To find out how to ask for a fair hearing, please click here.

Can I get out of Medicaid Managed Care entirely?

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.

How long does it take to leave my 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:

• If you have difficulties getting the medical care or services you need
• Someone lied to you to get you to sign up for the Plan

You must tell New York Medicaid CHOICE the reasons why you want a 10 day disenrollment.

How will I find out when I am disenrolled?

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.

Are there any agencies that can help me deal with my Plan?

There are a lot of outside agencies that can help you solve problems with your Plan.  Some are listed here.

Government Agencies:

• New York Medicaid CHOICE runs a toll-free hotline at: 1-800-505-5678.  They can help you choose, change, or leave a Plan.  They are open Mondays through Saturdays from 8:30 a.m. to 8:00 p.m.  Their workers speak English, Spanish, Russian, Chinese, Haitian Creole and many other languages.  They also have instant translation in 148 other languages and a TTD/TTY lines.
• New York’s Attorney General’s Health Care Bureau has a toll-free hotline to help people deal with their Plans at: 1-888-692-4422.
• The New York State Department of Health also runs a toll-free hotline at: 1-800-206-8125.  They take complaints and ask the local Department of Health office to look at your problem.  Sometimes they take a very long time to deal with complaints.  They will send you a letter when they get your complaint.
• The City Department of Health/Health Care Access Office is a special office to help handle the City’s Medicaid Managed Care program and monitor New York Medicaid CHOICE.  They have Account Executives who monitor each Plan.  Call the Office of Health Care Access and ask to speak to the Account Executive who is responsible for your Plan.  Medicaid’s Client Services Office can figure out if there is a problem with your Medicaid eligibility.  Their phone number is (212)273-0063.
• Women’s Health Line will give you information about family planning services.  Call: (718)230-1111 or (212) 230-1111.

Community Agencies:

• The Legal Aid Society's Public Benefits Education Project The Legal Aid Society can help you solve problems getting care with your Plan, Fair Hearings, Grievances, Utilization Review and External Review.  Call (212) 577-3575. You can get help in English, Spanish, and other languages or through a TTD/TTY.
• To get information about The Legal Aid Society or to find a Legal Aid office that serves your area, call (212) 440-4300.
• The Medicaid Managed Care Education Project can help you choose and use a Plan.  Call: (212) 614-5400.  They can help you in English and Spanish.
• The Patients’ Rights Hotline can help you file a quality of care complaint with the Department of Health about your health care services.  Call: (212) 316-9393.
• GMHC’s Office of Health Care Advocacy can help you with HIV and AIDS managed care problems.  Call: (212) 367-1125.
• Legal Action Center’s Managed Care Consumer Education Hotline can help you with Alcoholism and Substance Abuse Treatment problems.  Call: 1-800-299-4121.
• Medicare Rights Center can help you with Medicare Managed Care.  Call: (212) 869-3850.

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.

What are some examples of Plans in New York City?

Bronx Health Plan, CenterCare, Community Premier Plus, Health First, Health Plus, HIP, Managed Health Systems (MHS), MetroPlus, Neighborhood Health Providers.

What should I look for when choosing a Managed Care Plan?

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:

Can I continue to see all the doctors who are important to my family?  (These doctors may be pediatricians, obstetricians, gynecologists, therapists, specialists, clinics or hospitals.)
• Are there doctors who speak my language and understand my culture?
• Are there doctors in my neighborhood?  Is there a hospital in my neighborhood?
• How is the Plan set up?  (Plans give care differently.  Some give all care in one building.  Others use local doctor’s offices.  Decide which kind of Plan is best for you.)

Ask your friends and family who are already in a Managed Care Plan about their Plans.

• Do the Plan’s doctors and staff treat them with respect?
• Do they wait long for appointments?
• Can they reach their doctors by telephone when they need to?
• Does the Plan answer complaints quickly?
• Do they have problems seeing specialists or getting a second opinion?

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:

• What benefits are given by the Plan? Are there any limits on benefits?
• What doctors, hospitals, and other health care providers belong to the Plan?
• Do I need prior authorization before I can get treatments or services? (Prior authorization means that you need to ask permission from the plan before you get treatments.
• How do I complain about problems I have with the Plan?
• How are doctors in the Plan paid?
• What should I do in an emergency?
• How do I choose a Primary Care Provider?  How do I change my Primary Care Provider?
• How do I get specialty care?
• How do I get permission to go to a doctor who is not in my Plan?

How do I get care in a Managed Care Plan?

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.

How do I choose my Primary Care Provider?

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:

• Does the doctor speak my language?
• Does the doctor understand my culture?
• Is there a doctor’s office near my home?
• What are the office hours?
• How long will I have to wait for an appointment?
• Will I usually see my doctor on appointments, or will I see an assistant?

How do I change my 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:

• 30 days after your first visit, and
• once every 6 months

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.

Can I see doctors besides my Primary Care Provider?

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.

What is a referral?

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.

How do I get services not covered by my Plan?

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.

When do I use my Medicaid Card?

Use your regular Medicaid card to get these services:

• Pharmacy benefits
• Methadone maintenance benefits
• Some benefits for SSI recipients
• Day treatment services for people with developmental disabilities
• Comprehensive Medicaid case management services for people with developmental disabilities
• Early Intervention Services for children with learning problems
• Certain special education services
• Certain long term services for people with developmental disabilities at specified licensed facilities
• TB directly observed therapy
• AIDS adult day health care
• HIV COBRA case management

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.

Do all plans cover dental services?

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.

How do I get Family Planning or HIV Testing and counseling services?

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:

• Birth control (including pills, condoms, diaphragms, and other forms)
• Abortions
• Yearly pap smears
• Testing and treatment for sexually transmitted diseases
• HIV testing and counseling
• Pregnancy testing and counseling

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.

Does my Plan have to pay for emergency room visits?

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.

What are my rights to get Health Care quickly in my neighborhood?

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:

• Emergency Care.  You have a right to emergency care 24 hours a day at any emergency room.
• Urgent Care.  You have a right to an appointment for an urgent medical or mental health problems within 24 hours.
• Sick Visits.  You have a right to an appointment with your Primary Care Provider within 48 to 72 hours if you are sick.
• Preventive Care.  You have a right to an appointment for routine or non-urgent care within 4 weeks.
• Specialist Visits.  You have a right to an appointment with a specialist within 48 to 78 hours for urgent care and 4 to 6 weeks for regular care.
• Prenatal Care.  You have a right to your first prenatal appointment within 3 weeks until you are 4 months pregnant.  Later in your pregnancy you get your first appointment within 1 to 2 weeks.
• Newborn Visit.  Your newborn has a right to an appointment with a doctor within 2 weeks of leaving the hospital.
• Family Planning Visit.  You have a right to an appointment within 2 weeks.
• Mental Health or Substance Abuse Hospital Follow-Up.  You have a right to a follow-up visit within 5 days of an emergency or hospital discharge.
• Mental Health or Substance Abuse Visits.  You have a right to an appointment for non-urgent mental health or substance abuse visit within 2 weeks.

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.

What are my rights if I have special Health Care needs?

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:

• Information about your Plan
• Access to Emergency Care
• Access to Specialty Care
• File a grievance with your Plan
• Challenge medical decisions you don’t agree with
• As a Medicaid recipient, you also have the right to a Fair Hearing and Aid Continuing

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:

• You can go “Out-of-Network” for Speciality Care.  Your Plan must pay for you to go to a doctor not in the Plan if your Plan does not have a doctor who is qualified to treat your condition.  When you go to a doctor who is not in your Plan, you are going out-of-network.
• Standing Referrals.  A standing referral allows you to go to your specialist doctors more often.  You do not have to get a referral from your Primary Care Provider.  Your Plan must tell you how to get a standing referral.
• You can have a Specialist as your Primary Care Provider.  If you have a life-threatening or degenerative and disabling condition, you can get a specialist who knows how to treat your condition as your Primary Care Provider.  Your specialist will be in charge of managing your health care.  Your Plan must tell you how to get a specialist to handle your care.
• Right to Go to a Center of Excellence.  If you have a life-threatening or degenerative and disabling condition your Plan can send you to a Center of Excellence.  This is a place that is expert at treating your condition.
• Right to Case Management Services.  Your Plan must have case managers who are trained to help people with disabilities and chronic conditions.  A case manager is your own personal advocate within your Plan.  She or he should help you get the care you need, like specialty care, home health care, or medical equipment.

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.

How do I solve a problem with my Plan?

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:

• You cannot get health care that you need
• You have a billing problem

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:

• 48 hours if your health is in danger
• 30 days for grievances about referrals, health care benefits or services
• 45 days for all other issues (like billing problems)

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:

• 2 business days if your health is in danger
• 30 business days for everything else

If you lose your appeal, and you still think you should have won, you should contact one of the government agencies listed below.

What should I do if my Plan or doctor says that the care I need is not "medically necessary"?

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:

• 1 business day if you want to continue treatment or services you are already getting
• 3 business days if you need pre-authorization ahead of time.  Pre-authorization means you need to get permission from your Plan for a treatment, service or surgery
• 30 business days if you have already received the treatment, service or surgery

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.