FULL ADVANTAGE FIDA PLAN A

Transcription

1 FULL ADVANTAGE FIDA PLAN A Medicare-Medicaid Fully Integrated Duals Advantage Plan Summary f Benefits January 1, December 31, 2016 H9345_ MKT16_01 CMS Apprved

2 VillageCareMAX Full Advantage FIDA Plan (Medicare-Medicaid Plan): Summary f Benefits H9345_MKT16_01 CMS Apprved This is a summary f health services cvered by VillageCareMAX Full Advantage FIDA Plan fr This is nly a summary. Please read the Participant Handbk fr the full list f benefits. VillageCareMAX Full Advantage FIDA Plan is a managed care plan that cntracts with bth Medicare and the New Yrk State Department f Health (Medicaid) t prvide benefits f bth prgrams t Participants thrugh the Fully Integrated Duals Advantage (FIDA) Demnstratin. It is fr peple with bth Medicare and Medicaid and wh meet ther eligibility requirements fr the FIDA Demnstratin. Yu are age 21 r lder at the time f enrllment Yu reside in the VillageCareMAX Full Advantage FIDA Plan s service area Yu require 120 r mre days f cmmunity-based r facility-based Lng Term Services and Supprts, are nursing facility clinically eligible and receive facility-based lng-term supprt services, r are eligible fr the Nursing Hme Transitin and Diversin (NHTD) 1915(c) waiver Under VillageCareMAX Full Advantage FIDA Plan yu can get yur Medicare and Medicaid services in ne managed care plan called a FIDA Plan. A VillageCareMAX Full Advantage FIDA Plan Care Manager will help manage yur care needs. This is nt a cmplete list. The benefit infrmatin is a brief summary, nt a cmplete descriptin f benefits. Fr mre infrmatin cntact the plan r read the Participant Handbk. Limitatins and restrictins may apply. Fr mre infrmatin, call VillageCareMAX Full Advantage FIDA Plan Participant Services r read the VillageCareMAX Full Advantage FIDA Plan Participant Handbk. The List f Cvered Drugs and/r pharmacy and prvider netwrks may change thrughut the year. We will send yu a ntice befre we make a change that affects yu. Benefits may change n January 1 f each year. Yu can get this infrmatin fr free in ther frmats, such as large print, braille, r audi. Call and 711 fr TTY users during the hurs f 8:00 am t 8:00 pm, 7 days a week. The call is free. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 1

3 Yu can get this infrmatin fr free in ther languages. Call , and 711 fr TTY users, during the hurs f 8:00 am t 8:00 pm, 7 days a week. The call is free. Puede btener esta infrmación gratis en Españl. Llame a Servicis del Participante al durante las hras de 8:00 am a 8:00pm, 7 días de la semana. Usuaris de TTY llamar al 711. La llamada es gratuita. Lei pu ttenere questi infrmazini in Italian gratuitamente. Chiama il Servizi Partecipanti a durante il perid da 8AM a 8PM, 7 girni alla settimana. TTY utilizzatri dvressi chiamare 711. La chiamata è gratis. Ou ka jwenn enfòmasyn sa a pu gratis nan kreyòl ayisyen. Rele sèvis patisipan nan les heures de 8:00 je pu 8:00 pm, 7 ju nan semenn nan. Utilisateurs TTY ta dwe rele 711. Apèl gratis. Вы можете получить эту информацию бесплатно на русском языке. Звоните в Отдел обслуживания участников плана по телефону с 8:00 утра до 8:00 вечера, 7 дней в неделю. Пользователи TTY звоните по телефону 711. Звонок бесплатный. 您可免費獲得到以上的中文資訊, 請致電參與者服務電話 , 辦公時間為上午 8 時到下午 8 時, 每週 7 天 聽力語言殘障服務專線 (TTY) 用戶請撥打 711 該電話為免付費通話 한국어로된정보를무료로얻을수있습니다. 주 7 일오전 8 시에서오후 8 시사이에 번 (TTY 사용자는 711 번 ) 으로문의해 주십시오. 통화는무료입니다. The State f New Yrk has created a participant mbudsman prgram called the Independent Cnsumer Advcacy Netwrk (ICAN) t prvide Participants free, cnfidential assistance n any services ffered by VillageCareMAX Full Advantage FIDA Plan. ICAN may be reached tll-free at r nline at icannys.rg. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 2

4 English: We have free interpreter services t answer any questins yu may have abut ur health r drug plan. T get an interpreter, just call us at Smene wh speaks English can help yu. This is a free service. Spanish: Tenems servicis de intérprete sin cst algun para respnder cualquier pregunta que pueda tener sbre nuestr plan de salud medicaments. Para hablar cn un intérprete, pr favr llame al Alguien que hable españl le pdrá ayudar. Este es un servici gratuit. Chinese Mandarin: 我们提供免费的翻译服务, 帮助您解答关于健康或药物保险的任何疑问 如果您需要此翻译服务, 请致电 我们的中文工作人员很乐意帮助您 这是一项免费服务 Chinese Cantnese: 您對我們的健康或藥物保險可能存有疑問, 為此我們提供免費的翻譯服務 如需翻譯服務, 請致電 我們講中文的人員將樂意為您提供幫助 這是一項免費服務 Tagalg: Mayrn kaming libreng serbisy sa pagsasaling-wika upang masagt ang anumang mga katanungan niny hinggil sa aming planng pangkalusugan panggamt. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa Maaari kayng tulungan ng isang nakakapagsalita ng Tagalg. It ay libreng serbisy. French: Nus prpsns des services gratuits d'interprétatin pur répndre à tutes vs questins relatives à ntre régime de santé u d'assurance- médicaments. Pur accéder au service d'interprétatin, il vus suffit de nus appeler au Un interlcuteur parlant Français purra vus aider. Ce service est gratuit. Vietnamese: s s.. German: Unser kstenlser Dlmetscherservice beantwrtet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dlmetscher erreichen Sie unter Man wird Ihnen drt auf Deutsch weiterhelfen. Dieser Service ist kstenls. Krean: 당사는의료보험또는약품보험에관한질문에답해드리고자무료통역서비스를제공하고있습니다. 통역서비스를이용하려면전화 번으로문의해주십시오. 한국어를하는담당자가도와드릴것입니다. 이서비스는무료로영됩니다. Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону Вам окажет помо ь сотрудник, который говорит по- усски. Данная услуга бесплатная. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 3

5 وى ع يك ل يس ف وري م ترجم ع ى ل ح صول.ل دي نا األ دوي ة جدول او ب ال صحة ت ت ع ق ا ي ة اي عن إلل جاب ة ال مجان ية ال فوري ال م ترجم خدمات ن قدم ان نا Arabic: ال عرب ية ي تحدث ما مجان ية خدمة هذه.ب م اعدت ك. شخص ي قوم ع ى ب نا اال ت صال Hindi: हम र स व स य य दव क य जन क ब र म आपक ककस भ प रश न क जव ब द न क ल ए हम र प स म फ त द भ ष य स व ए उप ब ध ह. एक द भ ष य प र प त करन क ल ए, बस हम पर फ न कर. क ई व यक तत ज हहन द ब त ह आपक मदद कर सकत ह. यह एक म फ त स व ह. Italian: È dispnibile un servizi di interpretariat gratuit per rispndere a eventuali dmande sul nstr pian sanitari e farmaceutic. Per un interprete, cntattare il numer Un nstr incaricat che parla Italianvi frnirà l'assistenza necessaria. È un servizi gratuit. Prtugués: Dispms de serviçs de interpretaçã gratuits para respnder a qualquer questã que tenha acerca d nss plan de saúde u de medicaçã. Para bter um intérprete, cntacte-ns através d númer Irá encntrar alguém que fale idima Prtuguês para ajudar. Este serviç é gratuit. French Crele: Nu genyen sèvis entèprèt gratis pu repnn tut kesyn u ta genyen knsènan plan medikal swa dwòg nu an. Pu jwenn yn entèprèt, jis rele nu nan Yn mun ki pale Kreyòl kapab ede w. Sa a se yn sèvis ki gratis. Plish: s s s s, s. s s s, T s st. Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために 無料の通訳サービスがありますございます 通訳をご用命になるには にお電話ください 日本語を話す人者 が支援いたします これは無料のサービスです call is free. TTY users shuld call 711. Fr mre infrmatin, visit 4

6 The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) What is a Fully Integrated Duals Advantage (FIDA) Plan What is a VillageCareMAX Full Advantage FIDA Plan Care Manager and Interdisciplinary Team (IDT) Answers A Fully Integrated Duals Advantage (FIDA) Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services, and ther prviders. It als has Care Managers and Interdisciplinary Teams t help yu plan and manage all yur prviders and services. They all wrk tgether t prvide the care yu need. VillageCareMAX Full Advantage FIDA Plan is a FIDA Plan that prvides benefits f Medicaid and Medicare t Participants in the FIDA Demnstratin. A VillageCareMAX Full Advantage FIDA Plan Care Manager is ne main persn that yu may cntact. This persn helps manage all yur prviders and services and makes sure yu get what yu need. This persn is part f yur Interdisciplinary Team (IDT), which als includes: Yu and yur designee(s); Y P P (P P) s f P P s ff ( ) has clinical experience and knwledge f yur needs; Yur Behaviral Health (BH) Prfessinal, if yu have ne, r a designee frm yur BH P f ss s ff ( ) s f s; Yur hme care aide(s), r a designee with clinical experience frm the hme care agency wh has knwledge f yur needs, if yu are receiving hme care and apprve the hme / s s IDT; A clinical representative frm yur nursing facility, if receiving nursing facility care; and Additinal individuals including:» Other prviders either as requested by yu r yur designee, r as recmmended by the IDT members as necessary fr adequate care planning and apprved by yu r yur designee; r» The registered nurse (RN) wh cmpleted yur assessment, if apprved by yu r yur designee. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 5

7 Frequently Asked Questins (FAQ) What are lng-term services and supprts Can I direct my wn care r hire my wn aides Will yu get the same Medicare and Medicaid benefits in VillageCareMAX Full Advantage FIDA Plan that yu get nw Answers Lng-term services and supprts are help fr peple wh need assistance t d everyday tasks like taking a bath, getting dressed, making fd, and taking medicine. Mst f these services are prvided at yur hme r in yur cmmunity but culd be prvided in a nursing facility r hspital. Yu have the right t chse t direct yur wn care by selecting Cnsumer Directed Persnal Assistance Services (CDPAS). Thrugh CDPAS, yu can hire yur wn aides and make ther decisins abut hw t receive services. Yu will get yur cvered Medicare and Medicaid benefits directly frm VillageCareMAX Full Advantage FIDA Plan. Yu will wrk with a team f prviders wh will help determine what services will best meet yur needs. This means that sme f the services yu get nw may change. Yu will get almst all f yur cvered Medicare and Medicaid benefits directly frm VillageCareMAX Full Advantage FIDA Plan, but yu will get fur benefits the same way yu d nw, utside f the plan. These benefits include: Hspice Services, Out-f-Netwrk Family Planning Services, Methadne Maintenance Treatment Prgram, and Directly Observed Therapy fr Tuberculsis Disease. When yu enrll in VillageCareMAX Full Advantage FIDA Plan, yu and yur Interdisciplinary Team (IDT) will wrk tgether t develp a Persn-Centered Service Plan (PCSP) t address yur health and supprt needs. When yu first enrll in VillageCareMAX Full Advantage FIDA Plan, yu can keep seeing yur dctrs and getting yur current services fr 90 days, r until yur PCSP is cmplete, whichever is later. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that VillageCareMAX Full Advantage FIDA Plan des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr VillageCareMAX Full Advantage FIDA Plan t cver yur drug, if medically necessary. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 6

8 Frequently Asked Questins (FAQ) Can yu g t the same dctrs yu see nw Can yu remain in the same nursing facility yu live in nw What happens if yu need a service but n ne in VillageCareMAX Full Advantage FIDA Plan s netwrk can prvide it Where is VillageCareMAX Full Advantage FIDA Plan available Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with VillageCareMAX Full Advantage FIDA Plan and have a cntract with us, yu can keep ging t them. Prviders with an agree s -. Yu must use the prviders in VillageCareMAX Full Advantage FIDA Plan s, unless VillageCareMAX Full Advantage FIDA Plan r yur IDT has authrized yu t see an ut-f-netwrk prvider. If yu need urgent r emergency care r ut-f-area dialysis services, yu can use prviders utside f VillageCareMAX Full Advantage FIDA Plan's plan. T f f s s, Participant Services r read VillageCareMAX Full Advantage FIDA Plan s P P D. If VillageCareMAX Full Advantage FIDA Plan is new fr yu, yu can cntinue seeing the dctrs yu g t nw fr 90 days r until yur Persn-Centered Service Plan is cmplete, whichever is later. If yu currently receive behaviral health services, yur Interdisciplinary Team (IDT) will review yur current episde f care t decide if yu can cntinue the services with the same prvider yu see nw. If they decide yu can see the same prvider yu see nw, yu will be able t see that prvider fr 24 mnths fllwing yur enrllment in VillageCareMAX Full Advantage FIDA Plan. Yes. If yu live in a nursing facility when yu enrll in VillageCareMAX Full Advantage FIDA Plan, yu can remain in that nursing facility fr the entire time that yu are in a FIDA Plan like VillageCareMAX Full Advantage FIDA Plan, even if that nursing facility is ut-f-netwrk and des nt participate with VillageCareMAX Full Advantage FIDA Plan. Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, VillageCareMAX Full Advantage FIDA Plan will pay fr the cst f an ut-f-netwrk prvider. The service area fr this plan includes: Brnx, Kings (Brklyn), New Yrk (Manhattan) and Queens Cunties, New Yrk State. Yu must live in ne f these areas t jin the plan. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 7

9 Frequently Asked Questins (FAQ) D yu pay a mnthly amunt (als called a premium) under VillageCareMAX Full Advantage FIDA Plan What is prir authrizatin What is a referral Answers Yu will nt pay any mnthly premiums t VillageCareMAX Full Advantage FIDA Plan fr yur cverage. Yu als will nt have any c-payments r ther csts when yu get care frm netwrk prviders. Prir authrizatin means that yu must get apprval frm VillageCareMAX Full Advantage FIDA Plan r yur Interdisciplinary Team (IDT) befre yu can get a specific service, item, r drug r befre yu can see an ut-f-netwrk prvider. VillageCareMAX Full Advantage FIDA Plan may nt cver the service, item, f f VillageCareMAX Full Advantage FIDA Plan r yur IDT. A small number f services require prir authrizatin by a specialist and nt by VillageCareMAX Full Advantage FIDA Plan r yur IDT. Please refer t Chapter 4 f yur Participant Handbk fr mre infrmatin. VillageCareMAX Full Advantage FIDA Plan can als prvide yu with a list f services r prcedures that require yu t get prir authrizatin frm a prvider ther than yur IDT. Sme services d nt require any prir authrizatin, such as emergency r urgently needed care, ut-f-area dialysis services, primary care prvider visits, s s s services. Fr the full list f services that d nt require prir authrizatin, please see Chapter 4 f yur Participant Handbk r call VillageCareMAX Full Advantage FIDA Plan. A referral means that yur Primary Care Prvider gives yu apprval t see smene that is nt yur Primary Care Prvider. Referrals are nt necessary in VillageCareMAX Full Advantage FIDA Plan and will nt be required. Hwever, prir authrizatin rules must be fllwed. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 8

10 Frequently Asked Questins (FAQ) Wh shuld yu cntact if yu have questins r need help Answers If yu have general questins r questins abut ur plan, services, service area, billing, r Participant cards, please call VillageCareMAX Full Advantage FIDA Plan Participant Services: CALL TTY 711 Calls t this number are free. 8:00 am t 8:00 pm, 7 days a week. On call service and nursing htline available after business hurs. Participant Services als has free language interpreter services available fr peple wh d nt speak English. This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. 8:00 am t 8:00 pm, 7 days a week If yu have questins abut yur health, please call the Nurse Advice Call line: CALL TTY 711 Services are available 24 hurs daily, 7 days a week, at all times when ur ffice is clsed. This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. 8:00 am t 8:00 pm, 7 days a week call is free. TTY users shuld call 711. Fr mre infrmatin, visit 9

11 Frequently Asked Questins (FAQ) Wh shuld yu cntact if yu have questins r need help (cntinued) Answers If yu need immediate behaviral health services, please call the Behaviral Health Crisis Line: CALL Calls t this number are free. 8:00 am t 8:00 pm, 7 days a week. On call service and nursing htline available after business hurs. TTY 711 This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. 8:00 am t 8:00 pm, 7 days a week call is free. TTY users shuld call 711. Fr mre infrmatin, visit 10

12 The fllwing chart is a quick verview f what services yu may need, yur csts and rules abut the benefits. Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu want t see a dctr Visits t treat an injury r illness $0 Yu are cvered fr primary care physician visits. Yu must use a netwrk dctr fr services. Yu d nt need a referral t see a netwrk dctr. Wellness visits, such as a physical $0 Yu are cvered fr a yearly wellness visit and all preventive care services cvered by Medicare. Yu are als cvered fr the fllwing wellness benefits: Health Educatin Nutritinal Benefit Transprtatin t a dctr s ffice $0 Transprtatin includes taxi, bus r subway, van service r medical transprt. Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 11

13 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Specialist care, including chirpractic services and pdiatry $0 Yu must use a netwrk specialist fr services. Yu d nt need a referral t see a netwrk specialist. Chirpractic visits are fr manual manipulatin f the spine t crrect subluxatin f the spine (a displacement r misalignment f a jint r bdy part). Yu are cvered fr 4 rutine pdiatry visits every year fr ft care. In additin, yu are cvered fr medically necessary ft care t treat cnditins f the lwer limbs. Services may require prir authrizatin. Care t keep yu frm getting sick, such as flu shts $0 Cvered Medicare, Medicaid and Part D vaccines, including: Flu sht (ne sht per flu seasn in the fall r winter) Pneumcccal vaccine Hepatitis B vaccine fr participants with Medicare wh are at high risk call is free. TTY users shuld call 711. Fr mre infrmatin, visit 12

14 Health need r prblem Services yu may need Welcme t Medicare preventive visit (ne time nly) Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Yu are cvered fr the initial preventive physical exam Yu need medical tests Lab tests, such as bld wrk $0 Services may require prir authrizatin. X-rays r ther pictures, such as CAT scans, MRIs, EKGs $0 Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 13

15 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Screening tests, such as tests t check fr cancer $0 Yu are cvered fr the fllwing tests: Diagnstic tests and prcedures Therapeutic radilgy services (such as radiatin fr the treatment f cancer) Mammgrams Clnscpies and Clrectal Cancer screenings Cardivascular screenings Diabetes screenings Prstate cancer screenings Abdminal Artic Aneurysm screenings Cervical and Vaginal screenings HIV screenings Screening and behaviral cunseling interventins in primary care t reduce alchl misuse Screening fr depressin in adults Screening fr sexually transmitted infectins (STI) and high-intensity behaviral cunseling t prevent STIs. Services may require prir authrizatin, except fr preventive services. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 14

16 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need drugs t treat yur illness r cnditin Generic drugs (n brand name) $0 fr a 30-day supply. $0 fr a 90-day supply. There may be limitatins n the types f drugs cvered. Please see the VillageCareMAX Full Advantage FIDA Plan s List f Cvered Drugs (Drug List) fr mre infrmatin. An extended day supply f a medicatin is available thrugh retail and mail rder pharmacies. Please check the Prvider and Pharmacy Directry fr a list f pharmacies that ffer an extended day supply f medicatins. Brand name drugs $0 fr a 30-day supply. $0 fr a 90-day supply. There may be limitatins n the types f drugs cvered. Please see the VillageCareMAX Full Advantage FIDA Plan s List f Cvered Drugs (Drug List) fr mre infrmatin. An extended day supply f a medicatin is available thrugh retail and mail rder pharmacies. Please check the Prvider and Pharmacy Directry fr a list f pharmacies that ffer an extended day supply f medicatins. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 15

17 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Over-the-Cunter Drugs $0 VillageCareMAX Full Advantage FIDA Plan cvers sme OTC drugs when they are written as prescriptins by yur prvider. Please see VillageCareMAX Full Advantage FIDA Plan s List f Cvered Drugs (Drug List) fr mre infrmatin. Medicare Part B prescriptin drugs $0 Part B drugs include drugs given by yur dctr in his r her ffice, sme ral cancer drugs, and sme drugs used with certain medical equipment. Read the Participant Handbk fr mre infrmatin n these drugs. Services may require prir authrizatin. Yu need therapy after a strke r accident Occupatinal Therapy, Physical Therapy, r Speech Therapy $0 Services may require prir authrizatin. Outpatient Rehabilitatin $0 Outpatient Medicaid PT, OT, and ST are limited t twenty (20) visits per therapy per calendar year with sme exceptins Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 16

18 Health need r prblem Yu need emergency care Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Emergency rm services $0 Yu d nt need prir authrizatin fr emergency rm services prvided innetwrk and ut-f-netwrk. Emergency care is nt cvered utside the United States and its territries, except under limited circumstances. Ambulance services $0 Services may require prir authrizatin, except in an emergency. Urgent care $0 Yu d nt need prir authrizatin fr urgent care services prvided in-netwrk and ut-f-netwrk. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 17

19 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need hspital care Hspital stay $0 Yu are cvered fr an unlimited number f days. Yu may g t any netwrk hspital. Except in an emergency, yur dctr shuld tell the VillageCareMAX Full Advantage FIDA Plan that yu are ging t be admitted t the hspital. Services may require prir authrizatin. Dctr r surgen care $0 Yu are cvered fr utpatient surgery at the fllwing facilities: Ambulatry surgical centers Outpatient hspitals Freestanding birthing centers Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 18

20 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need help getting better r have special health needs Rehabilitatin services $0 Yu are cvered fr the fllwing: Cardiac Rehabilitatin, including up t 36 supplemental rehabilitatin services Intensive Cardiac Rehabilitatin services Pulmnary Rehabilitatin Services Services may require prir authrizatin. Medical equipment fr hme care $0 Yu are cvered fr Durable Medical Equipment including tub stl, grab bars, tilet cmmdes and shwer chairs. Services may require prir authrizatin Skilled nursing care $0 Yu are cvered fr the fllwing: Private duty nursing services Skilled nursing visits thrugh a hme health agency Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 19

21 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need eye care Eye exams $0 Yu are cvered fr the fllwing: One rutine eye exam every tw years Eye exams t diagnse and treat diseases and cnditins f the eye, including a yearly glaucma screening with n cst. Glasses r cntact lenses $0 Yu are cvered fr the fllwing: One set f cntact lenses every tw years One pair f eyeglasses (frames and lenses) every tw years One pair f Medicare-cvered eyeglasses r cntact lenses after cataract surgery. Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 20

22 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need dental care Dental check-ups $0 Yur are cvered fr the fllwing preventive dental services: One ral exam every six mnths One cleaning every six mnths One set f dental X-rays every six mnths One fluride treatment every six mnths Yu are als cvered fr cmprehensive dental care. Services may require prir authrizatin. Yu need hearing/auditry services Hearing screenings $0 Yu are cvered fr the fllwing: Exams t diagnse and treat hearing and balance issues Rutine hearing exams Hearing aids and fitting $0 Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 21

23 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu have a chrnic cnditin, such as diabetes r heart disease Services t help manage yur disease $0 Yu are cvered fr the fllwing: Case Management Services Medicatin Therapy Management Services Kidney disease educatin services and renal dialysis Diabetes supplies and services $0 Yu are cvered fr the fllwing: Diabetic mnitring supplies Diabetes Self-Management training Therapeutic shes r inserts Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 22

24 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu have a mental health cnditin Mental r behaviral health services $0 Yu are cvered fr the fllwing: Individual and grup therapy visits Partial hspitalizatin prgram services Assertive Cmmunity Treatment Mbile Mental Health Treatment Psitive Behaviral Interventins and Supprt Other services t supprt yur behaviral health needs Services may require prir authrizatin. Yu have a substance abuse prblem Substance abuse services $0 Yu are cvered fr the fllwing: Individual and grup treatment visits Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 23

25 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need lng-term mental health services Inpatient care fr peple wh need mental health care $0 Yu are cvered fr the fllwing: An unlimited number f days fr an inpatient hspital stay fr mental r behaviral health services, Except in an emergency, yur dctr must tell VillageCareMAX Full Advantage FIDA plan that yu are ging t be admitted t the hspital. Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 24

26 Health need r prblem Yu need durable medical equipment (DME) Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Wheelchairs $0 Services may require prir authrizatin. Canes $0 Services may require prir authrizatin. Crutches $0 Services may require prir authrizatin. Walkers $0 Services may require prir authrizatin. Oxygen $0 Services may require prir authrizatin. Prsthetic Devices $0 Services may require prir authrizatin. Yu need help living at hme Meals brught t yur hme r prvided in cngregate settings (e.g. senir centers) $0 Services may require prir authrizatin. Hme services, such as cleaning, husekeeping r mving assistance $0 Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 25

27 Health need r prblem Services yu may need Changes t yur hme, such as ramps and wheelchair access Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Yu are cvered fr envirnmental mdificatins, adaptive devices and assistive technlgy t imprve yur safety at hme. Services may require prir authrizatin. Persnal care assistant (Yu may be able t emply yur wn assistant. Call Participant Services fr mre infrmatin.) $0 Yu are cvered fr persnal care services prvided by a persnal care assistant t help with activities such as persnal hygiene, dressing and feeding. Yu can chse t direct yur wn care by selecting yur assistant thrugh Cnsumer Directed Persnal Assistance Services (CDPAS). Services may require prir authrizatin. Training t help yu get paid r unpaid jbs $0 Yu are cvered fr Independent Living Skills Training and Develpment (ILST) Services. Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 26

28 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Hme health care services $0 Yu are cvered fr the fllwing: Intermittent skilled nursing Rehabilitatin services Hme Health Aide services Medicaid-cvered hme health services that are nt cvered by Medicare Services may require prir authrizatin. Services t help yu live n yur wn $0 Yu are cvered fr the fllwing: Persnal Emergency Respnse Services (PERS) Hme visits by medical persnnel Hme Maintenance Services Hme and Cmmunity Supprt Services Cmmunity Transitinal Services Structured Day Prgram Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 27

29 Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Adult day services r ther supprt services $0 Yu are cvered fr the fllwing: Adult Day Health Care AIDS Adult Day Health Care Scial Day Care including transprtatin services Services may require prir authrizatin. Yu need a place t live with peple available t help yu Assisted living r ther husing services $0 Services may require prir authrizatin. Nursing facility care $0 N prir hspital stay is required. There is n limit t the number f days cvered by the plan fr each skilled nursing facility stay. Services may require prir authrizatin. Yur caregiver needs sme time ff Respite care $0 Services may require prir authrizatin. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 28

30 Benefits cvered utside f VillageCareMAX Full Advantage FIDA Plan This is nt a cmplete list. Call Participant Services t find ut abut ther services nt cvered by VillageCareMAX Full Advantage FIDA Plan but available thrugh Medicare r Medicaid. Other services cvered by Medicare r Medicaid Yur csts Directly bserved therapy fr tuberculsis (TB) $0 Hspice services $0 Methadne Maintenance Treatment Prgram (MMTP) $0 Out f netwrk family planning services $0 Over-the-Cunter (OTC) Drugs (sme OTC drugs are cvered when they are written as prescriptins by yur prvider) $0 when cvered by the plan call is free. TTY users shuld call 711. Fr mre infrmatin, visit 29

31 Services that VillageCareMAX Full Advantage FIDA Plan, Medicare, and Medicaid d nt cver This is nt a cmplete list. Call Participant Services t find ut abut ther excluded services. Services nt cvered by VillageCareMAX Full Advantage FIDA Plan, Medicare, r Medicaid Acupuncture Chirpractic care, ther than manual manipulatin f the spine cnsistent with Medicare cverage guidelines. Radial kerattmy, LASIK surgery, visin therapy, and ther lw-visin aids. A private rm in a hspital, except when it is medically needed. Csmetic surgery r ther csmetic wrk, unless medically necessary Experimental medical and surgical treatments, items, and drugs, unless cvered by Medicare r under a Medicare-apprved clinical research study r by VillageCareMAX Full Advantage FIDA Plan. Surgical treatment fr mrbid besity, except when medically necessary call is free. TTY users shuld call 711. Fr mre infrmatin, visit 30

32 Yur rights as a Participant f the plan As a Participant f VillageCareMAX Full Advantage FIDA Plan, yu have certain rights. Yu can exercise these rights withut being punished. Yu can als use these rights withut lsing yur services frm VillageCareMAX Full Advantage FIDA Plan. We will tell yu abut yur rights at least nce a year. Fr mre infrmatin n yur rights, please read the Participant Handbk. This is nt a cmplete list f all yur rights. Yur rights include, but are nt limited t, the fllwing: Yu have a right t respect, fairness and dignity. This includes: The right t get cvered services withut cncern abut race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, sexual rientatin, genetic infrmatin, ability t pay, r ability t speak English The right t request infrmatin in ther frmats (e.g., audi CD ROM, large print, cassette, Braille) The right t be free frm any frm f restraint r seclusin The right nt t be billed by netwrk prviders The right t have yur questins and cncerns answered cmpletely and curteusly The right t freely apply yur rights withut any negative effect n the way VillageCareMAX Full Advantage FIDA Plan r yur prvider treats yu Yu have the right t get infrmatin abut yur health care. This includes infrmatin n treatment and yur treatment ptins. This infrmatin shuld be in a frmat yu can understand. These rights include getting infrmatin n: Descriptin f the services we cver Hw t get services Hw much services will cst yu Names f prviders and care managers call is free. TTY users shuld call 711. Fr mre infrmatin, visit 31 Yu have the right t make decisins abut yur care, including refusing treatment. This includes the right: T chse a Primary Care Prvider (PCP) and yu can change yur PCP at any time T participate in Interdisciplinary Team meetings abut yur care T get yur cvered services and drugs quickly T knw abut all treatment ptins, n matter what they cst r whether they are cvered T refuse treatment, even if yur dctr advises against it T stp taking medicine T ask fr a secnd pinin. VillageCareMAX Full Advantage FIDA Plan will pay fr the cst f yur secnd pinin visit T create and apply an advance directive, such as a living will r health care prxy Yu have the right t timely access t care that des nt have any cmmunicatin r physical access barriers. This includes the right t: Get medical care timely G f s ff. T s means barrier free access fr peple with disabilities, in accrdance with the Americans with Disabilities Act

33 Have interpreters t help with cmmunicatin with yur dctrs and yur health plan Yu have the right t seek emergency and urgent care when yu need it. This means: Yu have the right t get emergency services withut prir apprval in an emergency Yu have the right t see an ut f netwrk urgent r emergency care prvider, when necessary Yu have a right t cnfidentiality and privacy. This includes: The right t ask fr and get a cpy f yur medical recrds in a way that yu can understand and t ask fr yur recrds t be changed r crrected The right t have yur persnal health infrmatin kept private The right t direct yur wn care r hire yur wn aides thrugh Cnsumer-Directed Persnal Assistance Services Yu have the right t make cmplaints abut yur cvered services r care. This includes the right t: File a cmplaint r grievance against us r ur prviders Get a detailed reasn fr why services were denied Fr mre infrmatin abut yur rights, yu can read the VillageCareMAX Full Advantage FIDA Plan Participant Handbk. If yu have questins, yu can als call VillageCareMAX Full Advantage FIDA Plan Participant Services. call is free. TTY users shuld call 711. Fr mre infrmatin, visit 32

34 If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think VillageCareMAX Full Advantage FIDA Plan shuld cver smething we denied, call VillageCareMAX Full Advantage FIDA Plan at Yu may be able t appeal ur decisin. Fr questins abut grievances (cmplaints) and appeals, yu can read Chapter 9 f the VillageCareMAX Full Advantage FIDA Plan Participant Handbk. Yu can als call VillageCareMAX Full Advantage FIDA Plan Participant Services. Additinally, yu can get help frm the Independent Cnsumer Advcacy Netwrk (ICAN). ICAN can give yu free, cnfidential assistance n any services ffered by VillageCareMAX Full Advantage FIDA Plan, including any prblems getting quality care. ICAN may be reached at r nline at icannys.rg. T file a cmplaint, grievance r appeal, please call Participant Services at TTY users shuld call 711 fr assistance. Our hurs are 8:00 am t 8:00 pm, 7 days a week. Yu can als write t: VillageCareMAX Quality Management 112 Charles Street New Yrk, NY If yu suspect fraud Mst health care prfessinals and rganizatins that prvide services are hnest. Unfrtunately, there may be sme wh are dishnest. If yu think a dctr, hspital r ther pharmacy is ding smething wrng, please cntact us. Call us at VillageCareMAX Full Advantage FIDA Plan Participant Services. Phne numbers are n the cver f this summary. Or, call Medicare at MEDICARE ( ). TTY users shuld call Yu can call these numbers fr free, 24 hurs a day, 7 days a week. Or, call the Office f the Medicaid Inspectr General (OMIG) tll free at FRAUD ( ). call is free. TTY users shuld call 711. Fr mre infrmatin, visit 33

35 Tll-free TTY days a week, 8:00 am t 8:00 pm