All covered mental health services for people who receive SSI or who are certified blind or disabled are available by using the Medicaid benefit card. You feel the decision limits your Medicaid benefits or that we did not make the decision in a reasonable amount of time. 2 NOTICE OF NON-DISCRIMINATION. New lenses may be ordered more often, if, for example, your vision changes more than onehalf diopter. Your nearest Emergency Room . At the time you join, you have a lifethreatening disease or condition that gets worse with time. Copyright 2023 DOH. Medicaid Reference Guide - New York State Department of Health You must get these services from the providers who are in [Insert Plan Name]. The electronic version of the MRG is in Portable Document Format (PDF). There are some treatments and services that you need to get approval for before you receive them or in order to be able to continue receiving them. Transportation [Include if covered by plan. The Medicaid Reference Guide (MRG) was designed for local social services districts in New York State. View rights & responsibilities, provider info and more. 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 that case, you can ask to keep your doctor for up to 60 days. Generally, you can get these once every two years, or more often if medically needed. After you enroll, well send you a welcome letter. You do not have to use a lawyer, but you may wish to speak with one about this. . You or someone you trust can also file a complaint about the review time with the New York State Department of Health by calling 1800206 8125. Medicaid The New York State Medicaid Managed Care Plan is offered through UnitedHealthcare Community Plan. We will tell you in 3 work days after giving us your action appeal, if we need more information. These services are provided through a large network of health care providers that you can access directly using . Copyright 2023 DOH. If you have questions, call your PCP or [Insert Plan Name] at [Insert Member Services Number]. The titles are in bold print at the top of each page. HIV counseling and testing [Only include here if Family Planning is covered by the plan]. After we get your request we will review it under a standard or fast track process. With this enhancement, users will no longer have to review the material in the MRG as well as each update to assure that the most current information has been consulted. hb```Il@(aHgTnlK8v0:yol~|CI[28@k>9{39~3i *Wx'3y4~p`F Action appeals of clinical matters will be decided by qualified health care professionals who did not make the first decision, at least one of whom will be a clinical peer reviewer. You will not have to pay for any care you received that was covered by the plan or by Medicaid even if we later deny payment to the provider. 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. . You can get these services from a provider who takes Medicaid by using your Medicaid Benefit card. Any changes that occur after the release of this version will be posted on this site with effective dates for implementation. We will tell you by the 14th day if we need more information. You can get an appointment for an urgent care visit for the same or next day. You can call Member Services at [Insert Member Services number] if you have specific concerns. 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. You will be given the reasons for our decision and our clinical rationale, if it applies. If your PCP refers you to another doctor, we will pay for your care. If you do not leave in the first 90 days, however, you must stay in [Insert Plan Name] for nine more months, unless you have a good reason (good cause). If you need emergency transportation, call 911. If you have a longlasting illness, like HIV/AIDS or other longterm health problems, you may be able to. They do this by checking your treatment plan against medically acceptable standards. We will tell you which hospitals our health providers work with. You or someone you trust can ask for this. (You should still keep the first appointment. Provider Contract Guidelines for MMCOs and IPAs. You can get these services by using your [Insert Plan Name] membership card. The external appeal application says what information will be needed. Your PCP will provide a DNR (Do Not Resuscitate) order for your medical records. We do not offer a Medicaid managed care service that you can get from another health plan in your area. Be sure to let them know you are disenrolling from [Insert Plan Name] and you want to reenroll in a new plan. The Medicaid Reference Guide is arranged in five sections: Categorical Factors; Income; Resources; Other Eligibility Factors; and Reference. Guidance for comprehensive health insurance policy forms. As soon as you choose a PCP, call to make a first appointment. In most cases, we will provide the care you need until then. The Medicaid Reference Guide (MRG) is available only as a portable document format (PDF) file. You will get a letter to follow up our communication in 3 work days. You can ask someone you trust (such as a legal representative, a family member, or friend) to file the complaint for you. This process is described earlier in this handbook. We can help you understand or get these documents. 2642 0 obj <>/Filter/FlateDecode/ID[]/Index[2623 29 2653 1]/Info 2622 0 R/Length 103/Prev 764015/Root 2624 0 R/Size 2654/Type/XRef/W[1 2 1]>>stream Work with your PCP to guard and improve your health. Both programs, though, allow for some people to keep getting care through regular Medicaid. The only purpose is to let others know what you want if you cant speak for yourself. Treat health care staff with the respect you expect yourself. [Include if covered by plan.] PDF Medicaid Select Plan Member Handbook - CDPHP We will write you and will tell you the reasons for our decision. Current as of 3/18/2021 . However, if you choose to ask for services to be continued, and the fair hearing is decided against you, you may have to pay the cost for the services you received while waiting for a decision. This is a list of all the doctors, clinics, hospitals, labs, and others who work with. Whether you are at home or away, call your PCP any time, day or night. Call the managed care unit of your local Social Services Department or New York Medicaid CHOICE to get a transfer or disenrollment packet. If you need HIV treatment after the testing and counseling service, your PCP will arrange it. If we have all the information we need you will know our decision in 30 work days. Click on the link to the Department of Health's Medicaid Update website. Revised . If you break your glasses, they can be repaired. ********************************************. If you have a complaint, the handbook tells you what to do. Appendix XII: Child Health Plus Member Handbook. This is called retrospective review. You can use your [Insert Plan Name] ID card to see one of [Insert Plan Name]s family planning providers. Your PCP will take care of most of your health care needs, but you must have an appointment to see your PCP. Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an action. If you need HIV treatment after the testing and counseling service, your PCP will help you get followup care. We will notify you by the date our time for review has expired. To assist school districts and counties in obtaining Medicaid Reimbursement for certain diagnostic and health support services provided to students with disabilities. The date on the top left of each page indicates the date of printing or revision. ], [For Medicaid in NYC, use "New York City Department of Health and Mental Hygiene" instead of State Department of Health], [For Health Plans that serve counties and/or New York City that use the enrollment broker, use the following language:]. 0 The Preschool/School Supportive Health Services Program Handbook (Update 9) was developed by the NYS Department of Health in conjunction with the NYS Department of Education. 2022 Elderplan Plus Long-Term Care (HMO D-SNP) Medicaid Member Handbook . You may have already picked your PCP (Primary Care Provider) to serve as your regular doctor. These doctors and specialists, hospitals, labs and other health care facilities make up our provider network. Call or go back to your PCP if you do not get better or ask for a second opinion. If you have questions, call Member Services at 1-855-456-9126. 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. We will call you with our decision or try to reach you to tell you. Individual updates can also be found in separate electronic files (see below). Besides primary and specialty care, FQHCs have social support services, case management, and classes to help you stop smoking, control diabetes, or lose weight. Asking for approval of a treatment or service is called a service authorization request. You can get these services from any doctor or clinic that provides them and who takes Medicaid. Health Care Proxy With this document, you name another adult that you trust (usually a friend or family member) to decide about medical care for you if you are not able to do so. Rehab services to those in community homes or in familybased treatment, Clinic services for children with a diagnosis of Serious Emotional Disturbance (SED), at mental health clinics certified by the State Office of Mental Health. Some people want to get their care from FQHCs because the centers have a long history in the neighborhood. 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. It will tell you how your new health care system will work and how you can get the most from, The first several pages will tell you what you need to know. There is no differential in levels of reimbursement between general practitioners and specialists. Be sure to call him or her whenever you have a medical question or concern. Call Member Services whenever these changes happen in your life: If you no longer get Medicaid, check with your local Department of Social Services. Any changes that occur after the release of this version will be posted on this site with effective dates for implementation. If we need more information to make either a standard or fast track decision about your action appeal, we will: You, your provider, or someone you trust may also ask us to take more time to make a decision. We may also review other treatments and services you have already received. When your county lets you decide to join a Medicaid health plan or not (a voluntary county): You can ask to leave the plan at any time for any reason. 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. Ask your PCP or call Member Services at [Insert Member Services Number] for a list of places to go to get these services. This is called concurrent review. The documents listed below can help. The Member Handbook also explains how to get care using our provider network. You can use one of the following ways to request a Fair Hearing: Remember, you can complain anytime to the New York State Department of Health by calling 18002068125. Call us if you have questions at [Insert Member Services Number]. [Insert Member Services TollFree Number], [Plans using one handbook for multiple service areas should be specific regarding the enrollment status of each service area. Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints. The Medicaid Reference Guide is intended only to express Department policies and interpretations. We will tell you by the third work day if we need more information. You can call Member Services. You will not receive a separate dental ID card. Medicaid Eligibility Verification System (MEVS) Reference Material. ], [insert if required by health plan for UR appeal], [Insert Member Services number and the appropriate hours], [For plans that serve the enrollment broker counties, insert the phone number for New York Medicaid CHOICE. Community Oriented Recovery and Empowerment (CORE) Services, Adult Behavioral Health Home and Community Based Services (BH HCBS), Adult BH HCBS Provider Application & Designation, Licensed Behavioral Health Practitioner (LBHP) Benefit, Behavioral Health Service Advisory Council, Contact Your Local Mental Hygiene Department. 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. endstream endobj startxref NYSED::FAQs - New York State Education Department We will tell you our decision by phone and send a written notice later. This may be because you have more information to give the plan to help decide your case. It provides very low-cost health insurance coverage for individuals and families who are eligible. Blue Choice Option | Excellus BlueCross BlueShield We want to be sure you get off to a . See doctors and pick up prescriptions close to home. Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an action. We will tell you and your provider both by phone and in writing if your request is approved or denied. If you do not want special treatment, including cardiopulmonary resuscitation (CPR), you should make your wishes known in writing. You can help us develop policies that best serve our members. RememberYou do not need prior approval for emergency services. You can write us with your complaint or call the Member Services number and request a complaint form. If you have a problem, talk with your PCP, or call or write Member Services. Medicaid Preferred Drug List and Managed Care Plan Information. You do not need a referral from your PCP to get these services. If you need more visits, your PCP will help you get a referral. If you do this, you should talk with the person, so they know what you want. %%EOF If you have any problems accessing the content on this web site, please contact MedinEd@nysed.gov . .x(Ek] @p/ #8'D)"n> D@z17g -q0p/b` j) You can also call the managed care staff at your local Department of Social Services. Fast track review: We will make a decision and you will hear from us within 3 work days. Visit the NY State Department . If your request for a fast track review is denied, we will tell you and your case will be handled under the standard review process. You should know that you have a choice. For help in finding a Medicaid family planning provider, call Member Services at [Insert Member Services Number]. With this Handbook, you should have a provider directory. To get approval for these treatments or services you need to: [Insert instructions for submitting a service authorization request: e.g., You or your doctor may call our tollfree Member Services number at [Insert Member Services Number] or send your request in writing to [Insert Plan Address]]. Enrolled Practitioners SEARCH (including OPRA), National Diabetes Prevention Program (NDPP), Edit/Error Knowledge Base (EEKB) Search Tool, Choosing which MEVS method is right for you, Department of Health's Medicaid Update website, Personal Care and Consumer Directed Personal Assistance Program, Child/Teen Health Program (C/THP) - Early Periodic Screening Diagnosis and Treatment (EPSDT), Free Standing or Hospital Based Ordered Ambulatory, Licensed Mental Health Counselor (LMHC) & Licensed Marriage and Family Therapist (LMFT), Personal Emergency Response System (PERS), School Supportive Health Services Program. Your PCP can help you if you need to see a different specialist. Medicaid | Highmark Blue Cross Blue Shield of Western New York Our health plan does not meet New York State requirements and members are harmed because of it. Services for which you need a referral (approval) in advance and you did not get it. [List plans service areas that are served by New York Medicaid CHOICE] County(ies), you can also call the New York Medicaid CHOICE HelpLine at 1-800-505-5678. Our health plan cannot provide a suitable primary care provider for you within acceptable travel times (if providers are routinely within 30 minutes or 30 miles from where you live). medicaid@health.state.ny.us. Questions concerning the Medicaid Reference Guide may be addressed by sending an e-mail message to [NOTE: Use if plan allows separate selection of OB/GYN], [Insert member services toll free number]. Handbook also available in Portable Document Format (PDF) Medicaid Managed Care Model Member Handbook. Include information needed to file a UR appeal for a decision that the outofnetwork service requested is not materially different from an alternate innetwork service. You can also selfrefer to a dental clinic that is run by an academic dental center. You do not need a referral from your PCP to see a dentist! Additional appeals to your health plan may be available to you if you want to use them. 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. Benefits and Services | Billing and Rates | Care Management | Clinical Resources Download the Aetna Better Health of New York Medicaid Managed Long Term Care handbook today. You feel the doctors decision stops or limits your Medicaid benefits. a written statement that the service you asked for is different from the service we have in our network; and. This handbook should replace any guidebook you are currently using. You do not need a referral from your PCP to get these services. Data and Planning | Federal Authority | Health and Recovery Plans (HARPs) | Whether you have to join or you choose to join a managed care plan, this handbook will help. Tell us if you have problems with any health care staff Call Member Services. Your PCP will call you back as quickly as possible. 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. Includes the services of other practitioners, including. See if You Qualify View Covered Services - In Spanish Blue Choice Option Member Handbook Pharmacy Benefit Change - Effective 4/1/23 Your Choice of Doctors & Hospitals ](Plan Name) believes that providing you with good dental care is important to your overall health care. You can visit an anonymous testing and counseling site. you need to have a breast or pelvic exam. Here are some ways to get an application: Your external appeal will be decided in 30 days. [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. You can make any needed changes before sending the form back to us. ](Plan Name), believes that providing you with good dental care is important to your overall health care. We will not treat you any differently or act badly toward you because you file an action appeal. Information from the State Insurance Department about consumer complaints about. We offer dental care through a contract with (Name of Dental Vendor), an expert in providing high quality dental services; or We offer dental care through contracts with individual dentists who are experts in providing high quality dental services. Most problems can be solved right away. Such counties operate a mandatory managed care program. tell you to go to the nearest emergency room. Requests for the MRG in an alternate format should be made by sending an e-mail note to: They will tell you what to do. It should be mailed to [Insert appropriate health plan address]. This website is provided as a service for providers and the general public, as part of the offerings of the electronic Medicaid system of New York State. You can also call the managed care staff at your local Department of Social Services. If you ask for a fair hearing and an external appeal, the decision of the fair hearing officer will be the one that counts. Welcome! This handbook will be your . The Medical Director will talk to your doctor within one work day. You may be able to continue the services that are scheduled to end or be reduced if you ask for a fair hearing: If your fair hearing results in another denial you may have to pay for the cost of any continued benefits that you received. Be sure that your medical record is private and will not be shared with anyone except as required by law, contract, or with your approval. If you want HIV testing and counseling but. Its purpose is to assist districts in determining Medicaid eligibility for applicants/recipients. You can also lose your [Insert Plan Name] membership, if you often: There are some treatments and services that you need to get approval for before you receive them or in order to be able to continue receiving them. The decision you receive from the fair hearing officer will be final. hbbd``b` @`$ j $_ N6-bEL76yD`ud#? ` = Your Provider Manual to the New York Medicaid Program offers you a wealth of information about Medicaid, as well as specific instructions on how to submit a claim for rendered services. Medicaid Managed Care - Fidelis Care Dental Services [Include here if dental services are not covered by the plan. If you disagree with a decision we made about your complaint, you or someone you trust can file a complaint appeal with the plan. You and your doctors will have to give information about your medical problem. We will tell you by the 14th day if we need more information. Call Member Services at [Insert Member Services number] to find out how you can help. MMCO Guidance and Standards | Pharmacy | Utilization Management | Value Based Payment, Adult Behavioral Health (BH) Home and Community Based Services (BH HCBS), Licensed Behavioral Health Practitioner (LBHP) Benefit | (FAQs), Medicaid Managed Care Cost-Effective Alternative Services (In-Lieu of Services), Personalized Recovery-Oriented Services (PROS), Behavioral Health Guidance for Managed Care Organizations Carving Behavioral Health into Medicaid Advantage Plus (MAP), Billing Behavioral Health (BH) Medicaid Services under Managed Care, Opioid Use Disorder Identification and Treatment for Patients with Mental Illnesses, Tobacco and SMI: Bending the Deadly Curve, County and Regional Data Planning Resources, MMCO Transition Monitoring Reports: Service Access, Use and Denials, County-Level BH HCBS and CORE Access Data, NYS Mental Health Parity and Addiction Equity Act Report - April 2019, NYS Section 1115 Medicaid Redesign Team (MRT) Waiver, NYS Section 1115 MRT Waiver - Special Terms and Conditions, Assisting Eligible Individuals with HARP Enrollment, Information for Medicaid Managed Care Organizations (MMCOs), Adult and Childrens Behavioral Health Mainstream and HARP Staff Requirements, Language Assistance Services for Adult BH HCBS, Provider Contract Guidelines for MMCOs and IPAs, Telehealth Reimbursement and Credentialing for Article 31 and 32 Providers, Infrastructure Program Extension Guidance, Infrastructure Application Form A - Agency Information and Funding Request, Infrastructure Application Form B - Lead Agency Information, Infrastructure Application Form C - Provider Attestation, Infrastructure Application Budget Template, Ambulatory Health Services Prior Authorization Guidelines, ACT Continuity of Care Expectations for Inpatient Settings, Behavioral Health (BH) Home and Community Based Services (BH HCBS), Outpatient Appointment Requirements: BH Discharge Planning, Personalized Recovery Oriented Services (PROS), Behavioral Health Value Based Payment Readiness Program, VBP University from the Department of Health. If you agree with our summary, you should sign and return the form to us. New York's Medicaid program provides comprehensive health insurance to lower-income New Yorkers. Plans should either list academic dental centers within a (30) thirtymile radius or include toll free member services number for members to call. Targeted Case Management - New York State Education Department Or, you can sign up with a primary care physician at one of the FQHCs that we work with, listed below. If you ask, we will tell you: 1) whether our contracts or subcontracts include physician incentive plans that affect the use of referral services, and, if so, 2) information on the type of incentive arrangements used; and 3) whether stop loss protection is provided for physicians and physicians groups. If you need our help because of a hearing or vision impairment, or if you need translation services, or help filing the forms we can help 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. Use our 24/7 NurseLine to get reliable medical advice any time, day or night. Information for All Providers gives you pertinent policy and resource information! If you call us after hours, leave a message. We are glad that you chose [Insert Plan Name]. You may leave [Insert Plan Name] and join another health plan at any time during that time. MEDICAID MANAGED CARE MODEL MEMBER HANDBOOK REVISED FOR 2010. If you are not satisfied with this answer, you have the right to file an action appeal with us See the Action Appeal section later in this handbook. Use the emergency room only for real emergencies. Include the timeframes for resolving the request for outofnetwork specialists, the process for appeal, the required documentation, and a phone number for the member to use to contact the plan regarding the request. A copy of the most recent individual direct pay subscriber contract. Welcome! You may have an injury or an illness that is not an emergency but still needs prompt care. Getting prior authorization is a simple process for your doctor and does not prevent you from getting medications that you need. Click on your provider manual below, and read about specific rules governing the provision of your care and service to Medicaid recipients. [Insert Plan Name] does not provide family planning services. You will need the card to get services that [Insert plan name] does not cover. Handbook #7 is effective September 1, 2009. Your PCP will need to know as much about your medical history as you can tell him or her. All questions or complaints regarding Behavioral Health Medicaid Managed Care should be submitted to the OMH Division of Managed Care using the OMH MC Question/Complaint Form. If ever you cant keep an appointment, call to let your PCP know. ], [Include here if transportation services are not covered through the plan. You just choose one of our participating providers. You'll be able to find helpful manuals and reference material, and get answers to questions about New York Medicaid. You do not need a referral from your PCP to see one of our providers if: Family Planning [Only include here if Family Planning is covered by the plan.]. If you ask us in writing, we will tell you the guidelines we use to review conditions or diseases that are covered by, If you ask in writing, we will tell you the qualifications needed and how health care providers can apply to be part of. A written notice of our decision will be sent within 2 work days from when we make the decision. These services include pharmacy benefits (include dental if not covered by the plan). Insert days, hours and tollfree phone number for member services. For some services, you can choose where to get the care. This is called prior authorization. This may be because you have more information to give the plan to help decide your case. Many counties in New York State, including New York City, offer a choice of managed care health plans. This handbook along with the Questions & Answers provides a step-by-step outline of the procedures that must be followed when claiming Medicaid reimbursement.
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