The Medicaid Reference Guide is arranged in five sections: Categorical Factors; Income; Resources; Other Eligibility Factors; and Reference. endstream endobj 2624 0 obj <>/Metadata 186 0 R/Outlines 309 0 R/Pages 2612 0 R/StructTreeRoot 314 0 R/Type/Catalog>> endobj 2625 0 obj <. Your member handbook has information to help you get the care and services you need. The following treatments and services must be approved before you get them: Asking for approval of a treatment or service is called a service authorization request. Family Planning [Include here if family planning is not covered by the plan. The fee stays the same whether the patient needs one visit or many or even none at all. Tell us if you have problems with any health care staff Call Member Services. But, if for some reason you do not hear from us by that date, it is the same as if we denied your service authorization request. Tell you why the delay is in your best interest; Make a decision no later than 14 days from the day we asked for more information, the service was not medically necessary; or, the service was experimental or investigational; or, the outofnetwork service was not different from a service that is available in our network; and, Within ten days from being told that your request is denied, or care is changing; or. You are not happy about a decision we made that denied medical care you wanted. You may be able to enroll your children in Child Health Plus, even if you lose Medicaid. ], [Include here if dental services are not covered by the plan. Call Member Services at [Insert Member Services number] to find out how you can help. To enhance the electronic version of the Medicaid Reference Guide (MRG), all updates to the MRG have been filed/integrated into the document. 2651 0 obj <>stream hb```Il@(aHgTnlK8v0:yol~|CI[28@k>9{39~3i *Wx'3y4~p`F Be sure to call him or her whenever you have a medical question or concern. You can get HIV testing and counseling any time you have family planning services. Copyright 2023 DOH. You can call Member Services. Plans must indicate whether there are any limitations on accessing the entire approved network, if applicable, other than standard referral process. covered nursing home services include medical supervision, 24hour nursing care, assistance with activities of daily living, physical therapy, occupational therapy, and speechlanguage pathology. You can get these services from a provider who takes Medicaid by using your Medicaid Benefit card. TCM is a Medicaid service that is reimbursable through the School Supportive Health Services Program (SSHSP). Your PCP will take care of most of your health care needs, but you must have an appointment to see your PCP. the outofnetwork service was not different from a service that is available in our network; You must file an action appeal with the plan and get the plans final adverse determination; If you had a fast track action appeal and are not satisfied with the plans decision you can choose to file a standard action appeal with the plan or go directly to an external appeal; You and the plan may agree to skip the plans appeals process and go directly to external appeal. Last Updated: February 15, 2023. Call or go back to your PCP if you do not get better or ask for a second opinion. Individual updates can also be found in separate electronic files (see below). New York State provider manuals, tip sheets, important forms, and applications (NYS health insurance). You will also need to get prior authorization if you are getting one of these services now but need to continue or get more of the care. You can get these services by using your [Insert Plan Name] membership card. medicaid@health.state.ny.us. Call Member Services whenever these changes happen in your life: If you no longer get Medicaid, check with your local Department of Social Services. If you have a complaint, the handbook tells you what to do. If we deny payment for a service, we will send a notice to you and your provider the day the payment is denied. If you want HIV testing and counseling but. If you need HIV treatment after the testing and counseling service, your PCP will arrange it. To ask for an external appeal, fill out an application and send it to the State Insurance Department. You are always covered for emergencies.An emergency means a medical or behavioral condition: This would make a person with an average knowledge of health fear that someone will suffer serious harm to body parts or functions or serious disfigurement without care right away.Examples of an emergency are: Examples of nonemergencies are: colds, sore throat, upset stomach, minor cuts and bruises, or sprained muscles. If you want HIV testing and counseling as part of family planning services, you must use your Medicaid card to see a family planning provider outside that takes Medicaid. This handbook along with the Questions & Answers provides a step-by-step outline of the procedures that must be followed when claiming Medicaid reimbursement. PDF NEW YORK STATE - eMedNY Guidance for comprehensive health insurance policy forms. When a delay would risk your health, we will let you know our decision in 48 hours of when we have all the information we need to answer your complaint but you will hear from us in no more than 7 days from the day we get your complaint. If ever you cant keep an appointment, call to let your PCP know. This may be because you have more information to give the plan to help decide your case. You can also call the New York State Growing Up Healthy Hotline (18005225006) for nearby places to get these services. The titles are in bold print at the top of each page. Dental Services [Include here if dental services are not covered by the plan. As a member of [Insert Plan Name], you have a right to: As a member of [Insert Plan Name], you agree to: There may come a time when you cant decide about your own health care. Revised . If you can, prepare for your first appointment. This process is described earlier in this handbook. If you make an action appeal by phone, it must be followed up in writing. Your nearest Emergency Room . New eyeglasses (with Medicaid approved frames) are usually provided once every two years. You can also selfrefer to a dental clinic that is run by an academic dental center. If you have ideas tell us about them Maybe youd like to work with one of our member advisory boards or committees. ], [Insert plan specific process for how members request care from a specialist outside the network. Give your OK to any treatment or plan for your care after that plan has been fully explained to you. You can also get a DNR form to carry with you and/or a bracelet to wear that will let any emergency medical provider know about your wishes. Fast track action appeals: If we have all the information we need, fast track action appeal decisions will be made in 2 work days from your action appeal. Its purpose is to assist districts in determining Medicaid eligibility for applicants/recipients. We will write you and will tell you the reasons for our decision. CPR and DNR You have the right to decide if you want any special or emergency treatment to restart your heart or lungs if your breathing or circulation stops. (You should still keep the first appointment. Plans should either list academic dental centers within a (30) thirtymile radius or include toll free member services number for members to call. You do not have to use a lawyer, but you may wish to speak with one about this. refuse to work with your PCP in regard to your care. ]You can go to any Medicaid doctor or clinic that provides family planning. Youll find a list in our provider directory. Medicaid Managed Care - Fidelis Care Medicaid Information | NY State of Health By the date the change in services is scheduled to occur. Any changes that occur after the release of this version of Handbook #7 will be posted on this site with effective dates for implementation. We will call you back the next work day. NYS Medicaid in Education - New York State Education Department Enrollees diagnosed with diabetes may selfrefer for a dilated eye (retinal) examination once in any twelve (12) month period. Medicaid Service Coordination (MSC) program, Services received under the Home and Community Based Services Waiver, Medical Model (CareatHome) Waiver Services, Outpatient chemical dependence for youth programs, Chemical dependence (including alcohol and substance abuse) services ordered by the LDSS, All covered alcohol and substance abuse services (except detox) are available for people who receive SSI or who are certified blind or disabled by using their Medicaid benefit card. Use it for reference or check it out a bit at a time. Your PCP will call you back as quickly as possible. You should know that you have a choice. The decision you receive from the fair hearing officer will be final. We can help you understand or get these documents. This can be done by calling [Insert appropriate health plan tollfree number] or writing. These services include pharmacy benefits (include dental if not covered by the plan). Questions concerning the Medicaid Reference Guide may be addressed by sending an e-mail message to Your [Insert Plan Name] ID card should arrive within 14 days after your enrollment date. Targeted Case Management (TCM) is a comprehensive service that includes coordinating medical and non-medical procedures for the student. PDF Coordination of Benefits and Third Party Liability (COB/TPL - Medicaid We will not treat you any differently or act badly toward you because you file an action appeal. We want to be sure you get off to a . The documents listed below can help. This could be a child with an ear ache who wakes up in the middle of the night and wont stop crying. No doubt you have seen or heard about the changes in health care. Current as of 3/18/2021 . You should keep your Medicaid benefit card. After your call, we will send you a form which is a summary of your phone appeal. You and the plan will be told the final decision within two days after the decision is made. Emergency care services are procedures, treatments or services needed to evaluate or stabilize an emergency. When you have a question, check this Handbook or call our Member Services unit. If you require an attendant to go with you to your doctors appointment or if your child is the member of the plan, transportation is also covered for the attendant or parent or guardian. In order to get to know you better, we will get in touch with . In all cases, we will review your request as fast as your medical condition requires us to do so but no later than mentioned below. This ensures all questions or complaints submitted can be reviewed and responded to by appropriate staff within OMH and/or the Department of Health. Also, check the back of your drivers license to let others know if and how you want to donate your organs. PDF NEW YORK STATE DENTAL POLICY AND PROCEDURE MANUAL - eMedNY Certain medications may require that your doctor get prior authorization from Medicaid before writing your prescription. Medicaid Preferred Drug List and Managed Care Plan Information. When you visit your dentist, you should show your plan ID card or; You will receive a separate Dental ID card with the name of your assigned dentist. The site is updated regularly to meet the ever-growing needs of the New York State provider community. MEDICAID MANAGED CARE MODEL MEMBER HANDBOOK REVISED FOR 2010. All Rights Reserved. We will notify you by the date our time for review has expired. Read the Medicaid Managed Care Member Handbook to learn more about your benefits, as well as utilization management procedures, and specific benefit inclusions and exclusions. [For Medicaid in NYC, use "New York City Department of Health and Mental Hygiene" instead of State Department of Health] to meet the health care needs of people with Medicaid. First, let family, friends and your doctor know what kinds of treatment you do or dont want. You can change your mind and these documents at any time. To assist school districts and counties in obtaining Medicaid Reimbursement for certain diagnostic and health support services provided to students with disabilities. Note: State which one of the following 2 bullets applies. This is a list of all the doctors, clinics, hospitals, labs, and others who work with. However, if you want an external appeal, you must still file the application with the State Department of Insurance within 45 days from the time the plan gives you the notice of final adverse determination or when you and the plan agreed to waive the plans appeal process. Although we do not cover dental services in our benefit package, you can still get dental care using your Medicaid Benefit Card Medicaid covers regular and routine dental services such as preventive dental checkups, cleaning, xrays, fillings and other services to check for any changes or abnormalities that may require treatment and/or followup care for you. The letter will tell you: Your complaint appeal will be reviewed by one or more qualified people at a higher level than those who made the first decision about your complaint. Your doctor would have to explain how a delay will cause harm to your health. Keep this handbook handy for when you need it. You can also call the New York State Growing Up Healthy Hotline (18005225006) for the names of family planning providers near you. Write you and tell you what information is needed. If your request is in a fast track review, we will call you right away and send a written notice later. The handbook has other information you may find useful. Infrastructure Application Form B - Lead Agency Information. If your request for fast track is denied, we will tell you and your action appeal will be reviewed under the standard process; If your request was denied when you asked to continue receiving care that you are now getting or need to extend a service that has been provided; If your request was denied when you asked for home health care after you were in the hospital. Be cared for with respect, without regard for health status, sex, race, color, religion, national origin, age, marital status or sexual orientation. This may be because you have more information to give the plan to help decide your case. We will not make things hard for you or take any action against you for filing a complaint. HIV counseling and testing [Only include here if Family Planning is covered by the plan]. %PDF-1.7 % RememberYou do not need prior approval for emergency services. Both programs, though, allow for some people to keep getting care through regular Medicaid. Member Resources - Fidelis Care Asking for approval of a treatment or service is called a service authorization request. It should be mailed to [Insert appropriate health plan address]. Or you can use your [Insert Plan Name] ID card and ask your PCP to arrange it. If we are unable to make a decision about your Complaint because we dont have enough information, we will send a letter and let you know. New York City as a result of litigation commence d by a whistleblower under the federal False Claims Act. medicaid@health.state.ny.us. connect you with the New York Medicaid CHOICE Conlict Free Evaluation and Enrollment Center (CFEEC) or you can call directly to 1-855-222-8350 TTY This section also contains billing instructions, as well as pertinent procedure codes and fee schedules. This is called prior authorization. You just choose one of our participating providers. ](Plan Name) believes that providing you with good dental care is important to your overall health care. Here is information you can get by calling Member Services at [Insert Member Services number]. Affinity by Molina Healthcare Medicaid Managed Care (MMC) The Medicaid Managed Care program offered through Affinity ranks among the largest in the New York metropolitan area. Covered services include regular and routine dental services such as preventive dental checkups, cleaning, xrays, fillings and other services to check for any changes or abnormalities that may require treatment and/or followup care for you. H3347_EP16563_C . 2 NOTICE OF NON-DISCRIMINATION. Detox services are available using your, Preschool and school services programs (early intervention), Comprehensive Medicaid Case Management program ("CMCM" program), Routine foot care (for those 21 years and older), Services from a provider that is not part of. Second, you can appoint an adult you trust to make decisions for you. As soon as you choose a PCP, call to make a first appointment. If we made a decision that your service authorization request was not medically necessary or was experimental or investigational; and we did not talk to your doctor about it, your doctor may ask to speak with the plans Medical Director. You and your doctors will have to give information about your medical problem. The action appeal can be made by phone or in writing. If you need emergency transportation, call 911. Handbook #7 is effective September 1, 2009. With this Handbook, you should have a provider directory. 2022 Elderplan Plus Long-Term Care (HMO D-SNP) Medicaid Member Handbook . You may also ask for a fair hearing if the plan decided to deny, reduce or end coverage for a medical service You may request a fair hearing and ask for an external appeal. NEW YORK STATE MEDICAID MANAGED CARE MEMBER HANDBOOK November 2022 22-23065 CDPHP Select Plan (518) 641-3800 or 1-800-388-2994, TTY/TDD 711, Behavioral Health Crisis 1-888-320-9584. . Ask your PCP for a list of places to get these services or call Member Services at [Insert Member Services Number]. Enrolled Practitioners SEARCH (including OPRA), National Diabetes Prevention Program (NDPP), Edit/Error Knowledge Base (EEKB) Search Tool, NYS Department of Health Rules and Regulations, Title 10, NYS Department of Health Rules and Regulations, Title 18, Preferred Diabetic Supply List (PDSL) - Magellan, Wearable Automatic External Defibrillator Guidelines, Enteral Formula Prior Authorization webinar. Medicaid pays for a wide-range of services, depending on your age, financial circumstances, family situation, or living arrangements. We will let you know our decision in 45 days of when we have all the information we need to answer your complaint but you will hear from us in no more than 60 days from the day we get your complaint. CSNY20MC4888315_000. We want to be sure you get off to a good start as a new member . Infrastructure Program Extension Guidance. The State Medicaid Manual | CMS This is called an expedited external appeal. Medicare Resources Exhausted Benefits Fidelis Care offers case management services to members by phone. 3. This allows users to rapidly identify updated sections. ), adult baseline and routine physicals: within 12 weeks, first prenatal visit: within 3 weeks during 1nt trimester (2 weeks during 2nd, 1 week during 3rd), first newborn visit: within 2 weeks of hospital discharge, first family planning visit: within 2 weeks, followup visit after mental health/substance abuse ER or inpatient visit: 5 days, nonurgent mental health or substance abuse visit: 2 weeks, If you need care that your PCP cannot give, he or she will REFER you to a specialist who can.
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