North Shore-LIJ Health Plan Member Handbook

Transcription

North Shore-LIJ Health Plan
Member Handbook
Your Complete Guide to Medicaid Long Term Care
www.nslijhealthplans.com
Blank Inside Front Cover
Member Handbook
HERE IS WHERE TO FIND INFORMATION YOU NEED
North Shore-LIJ Health Plan Telephone Numbers
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Help for People With Other Language Needs
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Help For People With Hearing and/or Vision Problems
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Welcome to North Shore-LIJ Health Plan
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Important Facts About North Shore-LIJ Health Plan
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Membership Eligibility for North Shore-LIJ Health Plan
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How Does My Health Coverage Change When I Become a Member?
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The Services Covered By North Shore-LIJ Health Plan
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Which Services Require/Do Not Require Authorization?
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The Services Not Covered By North Shore-LIJ Health Plan
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When You Have Other Health Insurance
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The Steps to Join/Enroll in North Shore-LIJ Health Plan
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How You Will Get the Services You Need
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How North Shore-LIJ Health Plan Handles Your Complaint/Grievance
and Grievance Appeal
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Ending Your Membership in North Shore-LIJ Health Plan
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Managed Long Term Care Enrollee Rights
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Other Information About North Shore-LIJ Health Plan
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Telephone Numbers
Business Hours are Monday through Friday
9:00 AM to 5:00 PM
All North Shore-LIJ Health Plan staff can be reached at one number –
Call: (855) 421-3066, TTY# is (855) 871-1665
After hours phone number: (855) 421-3066
Serves:
New York, Kings, Queens, and Richmond Counties in New York City
as well as Nassau and Suffolk Counties
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Free Customer Service Assistance
Servicios Gratis Para El Consumidor
If you do not speak English, North Shore-LIJ Health Plan is able to communicate with you
in whatever language you speak. We have staff whom are able to speak in English, Spanish,
and Russian. We also have a translation service available that will help us with telephone calls.
When your Care Manager visits you he/she will make arrangements to be sure that a translator
is available.
Para los individuos de habla español, La Guía de Miembro esta disponible en el español.
Por favor, pregunte para una copia del plan. Gracias.
If you have a problem hearing or seeing, North Shore-LIJ Health Plan staff will use whatever
means and tools available and preferred by you to communicate with us such as large print
materials, audio recordings, braille materials, etc.
This member handbook is available in other languages. In addition translation services are
available. Please contact us at (855) 421-3066, TTY # is (855) 871-1665 for additional
information.
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Welcome to North Shore-LIJ Health Plan
Your Partner in Managed Long Term Care
Thank you for choosing North Shore-LIJ Health Plan
We look forward to serving you.
North Shore-LIJ Health Plan is a Managed Long Term Care (MLTC) program for adults who
want to and are able to live safely at home. Our plan is available to you because you may need
health and long term care services and live in a County where the plan operates. We encourage
our members and their families to take an active role in their health care. North Shore-LIJ
Health Plan can offer you a variety of choices that will support you in taking care of your
health and long term care needs. This Member Handbook will help give you the information
you need to decide whether you want to become a Member of North Shore-LIJ Health Plan
It explains how the plan works and about the services covered by the plan. It also tells you
about how you need to work with your Care Manager to make the most of your Membership
benefits.
You can receive many services in your home. Other health and long term care services will
be offered to you within your neighborhood and throughout the County. When you join
North Shore-LIJ Health Plan you will have a Care Manager who will coordinate high quality
health and long term services for as long as you are a member, even if your health care needs
change. As a North Shore-LIJ Health Plan Managed Long Term Care member, you will receive
your covered long term care and health related services through providers who are part of
the North Shore-LIJ Health Plan network. The current Provider Directory as well as your
membership card will be provided to you in the membership folder.
We want you and your family to take an active role in your long term care. Your Care Manager
will work together with you and your doctor to see that all of your needs are met.
It is very important for you to review this Member Handbook carefully.
Please feel free to ask questions about our plan by calling or writing:
444 Merrick Rd., Suite 300
Lynbrook, NY 11563
(855) 421-3066, TTY # is (855) 871-1665
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Important Facts About
Membership
Membership in the North Shore-LIJ Health Plan is completely voluntary. You choose to
enroll in the program, and you may choose to disenroll for any reason. When you join/
enroll you will be sent a Membership identification card. Your North Shore-LIJ Health
Plan Membership card, plus your other insurance cards, should be shown to all of your
providers of care and services. Also, it is important to understand that this Member
Handbook is North Shore-LIJ Health Plan’s contract with you. This Member Handbook
explains the rights and obligations of both North Shore-LIJ Health Plan and you. It is
important that you keep it as part of your own records.
Freedom to Choose Your Own Doctor
Your Care Manager will assess your needs and talk with your doctor about the assessment.
With your input, we will work together to plan your care. If you do not have a doctor, your
Care Manager can help you in choosing one.
Care Management
You will be assigned a North Shore-LIJ Health Plan Care Manager. He/she is a professional
who is experienced with caring for adults 18 years and older. Your Care Manager will
work in cooperation with you to coordinate all of the care you will receive. Your Care
Manager will review your health and long term care needs with you, and your doctor on
an ongoing basis. If you choose, your family and/or significant other will be involved. Your
Care Manager will develop a long term care plan especially for you to make sure that you
receive all of the services that you need.
Preventive Health Care Services
Dental care, vision care and nutritional counseling are included among the covered benefits
of North Shore-LIJ Health Plan. We encourage check-ups and we will help you make and
get to your appointments.
Member Participation
You will be sent questionnaires asking what you think about the services offered by
North Shore-LIJ Health Plan and how we can make the plan work better for you. Plus,
Members may be invited to participate in focus groups to look at ways of making North
Shore-LIJ Health Plan the best plan it can be for our Members. North Shore-LIJ Health Plan
welcomes comments from Members at any time.
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Membership Eligibility for
To become a Member of North Shore-LIJ Health Plan you must meet all of
the following criteria:
1. You are at least 18 years of age;
2. You live in a North Shore-LIJ Health Plan service area: Manhattan, Brooklyn, Queens,
Staten Island, Nassau or Suffolk County;
3. You are eligible for Medicaid;
4. You are able, at the time of enrollment, of returning to, or remaining in your home/
community without risk to your health or safety, as determined by a North Shore-LIJ
Health Plan Care Manager;
5. You require long term care services from our program for more than 120 days. This
includes the assistance of a Care Manager, along with home care and/or adult day services.
A North Shore-LIJ Health Plan Care Manager will assess your needs to determine if you
need:
i. Nursing services in the home;
ii. Therapies in the home;
iii. Home health aide services;
iv. Personal care services in the home;
v. Adult day health care;
vi. Private duty nursing, or
vii.Social day care if used as a substitute for in-home personal care services.
Enrollment Process
You or a family member can call North Shore-LIJ Health Plan Managed Long Term Care and
request information about enrollment. The enrollment process will then begin as follows:
Step One
Once you contact us, a North Shore-LIJ Health Plan staff member will call you to talk about the
program to be sure that you are interested in the types of services offered by North Shore-LIJ
Health Plan. We also may check at this time to be sure you are eligible for Medicaid.
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If you are applying for Medicaid and need help, please let us know. The enrollment process will
take at least one or two months longer if you do not already have an active Medicaid number.
Step Two
If you are interested in becoming a member of North Shore-LIJ Health Plan, an Enrollment
Nurse will visit you in your home, at a time that is convenient for you to make a complete
assessment of your needs.
The Enrollment Nurse will ask you to sign a “Release of Medical and Health Information” form,
so that we can obtain input from your doctors and other health providers. Please be assured that
our staff will protect your health information to the full extent of the law.
During the assessment visit, the Nurse will give you a copy of the Member Handbook and
discuss with you how the program works.
Enrollment in North Shore-LIJ Health Plan is voluntary. If you are interested in joining, the
nurse will ask you to sign an enrollment application and agreement. If you decide, for any
reason, that you do not want to be a Member of North Shore-LIJ Health Plan, you may withdraw
your application at any time prior to the start of enrollment.
Step Three
If you are eligible to join, we will work with you to complete an enrollment package to be
sent to New York Medicaid Choice (NYMC). In most cases, you will become a member of
North Shore-LIJ Health Plan on the first day of the month after you sign the enrollment
application and agreement. NYMC must verify your Medicaid eligibility prior to enrollment
in North Shore-LIJ Health Plan. We will confirm your actual enrollment date by telephone as
soon as possible. Once you are a member, your Care Manager will ensure that you get all of the
services that are outlined in your initial plan of care.
Reasons why your enrollment could be denied
1. You are currently receiving care in a hospital or residential facility operated by the State
office of Mental Health, the Office of Alcoholism and Substance Abuse Services or the
Office for People with Developmental Disabilities (OPWDD). An application to enroll in
North Shore-LIJ Health Plan may be accepted, but your enrollment may only begin upon
discharge to your home in the community.
2. You are already enrolled in another Medicaid managed care program, a Home and
Community based Services waivered program, a Day Treatment program sponsored by
the Office for People with Developmental Disabilities, or a Hospice program. If you
terminate your participation in these programs, you can then be considered for enrollment
in North Shore-LIJ Health Plan.
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How does my health coverage change when I become a
member of North Shore-LIJ Health Plan?
Once you are a member of North Shore-LIJ Health Plan you may receive a wide range of
services. They will be provided in your home, at community sites in your neighborhood, and
in local nursing homes. You have the right to be told where, when and how to get the services
you need.
North Shore-LIJ Health Plan uses a network of community providers to deliver the services
you need. You must receive all services covered by North Shore-LIJ Health Plan from the
providers in our Provider Network. This network is quite extensive. You will be provided with
a Provider Directory. You have the right to be told where, when and how to get the services
you need from North Shore-LIJ Health Plan, including how you can get covered benefits from
out-of-network providers if they are not available in the plan network.
In the event that North Shore-LIJ Health Plan is unable to provide necessary services, we will
provide timely access to out of network providers for as long as these services are required.
Your Care Manager is a nurse or social worker who will visit you periodically and stay in touch
by phone, depending on your medical needs. Your Care Manager will make sure that all of
your health care and long term services are closely coordinated. The services that you receive
from North Shore-LIJ Health Plan are based on a plan of care which is updated periodically,
based on the assessment of your health needs. This plan of care is developed by your nurse
and doctor, as well as with your input. Please talk with your Care Manager if you feel you need
a service covered by North Shore-LIJ Health Plan.
You do not lose any of your regular Medicaid or Medicare benefits. If a Medicaid or Medicare
service is not covered by North Shore-LIJ Health Plan, you may still receive the service outside
of North Shore-LIJ Health Plan, using your Medicaid and Medicare card. Your Care Manager
can assist you to receive these services.
If Medicaid determines that you have a Medicaid surplus (“or spend down”), you will be
responsible for paying this amount to North Shore-LIJ Health Plan. You will be billed monthly
for the amount that you owe. Please talk with your Care Manager or Social Worker about this
condition of your membership.
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The Services Covered by
When medically necessary (needed to protect and enhance your health)
the following services will be arranged for you by your Care Manager
He/she will provide:
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Comprehensive Care Management and coordination of your health care services
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Home Health Care
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Nursing Care
Home Health Aide
Physical Therapy (PT)
Occupational Therapy (OT)
Speech Therapy (ST)
Medical Social Services
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Personal Care/Assistance
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Housekeeping Services
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Adult Day Health Care
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Social Day Care
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Transportation (non-emergency to medical appointments)
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Eye Exam/Eyeglasses
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Hearing Exam/Hearing Aids
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Foot Care
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Dental Care
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Home-Delivered or Congregate Meals
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Rehabilitation Therapies (Physical Therapy, Occupational Therapy, Speech Therapy) in a
setting other than your home
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Nutrition Counseling
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Respiratory Therapy and Oxygen
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Medical and Surgical Supplies
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Durable Medical Equipment (wheelchair, hospital bed, etc.)
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Prosthetics and Orthotics
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Social and Environmental Supports such as home safety modifications or improvements
that are needed to safeguard your health
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Personal Emergency Response Systems (PERS)
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Nursing Home Care
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Private Duty Nursing
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Consumer Directed Personal Assistance Program
Medicare may cover some of these services. Coverage is based on certain Medicare rules. If you
have Medicare, and it covers any of these services, then Medicare will be billed first. If you have
any additional insurance (other than Medicare or Medicaid), which covers any of the services
listed on the previous page, the other insurance will be billed after Medicare. When using any of
the services listed on the previous page, which are paid for by Medicare, you have the freedom to
choose your own provider. When Medicare stops paying for those services, you will be required
to switch to one of our Network Providers. You can always call your Care Manager if you have
any questions regarding coverage for the services listed on the previous page.
From time to time, your needs change. You may require different types of services, or you may
need the same services more or less frequently. Because of this your Care Manager will update
your plan of care at least once every six months. When she/he updates your plan of care, your
needs will be reviewed with your physician and will always be discussed with you.
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The following is a brief explanation of the services
covered by North Shore-LIJ Health Plan
Comprehensive Care Management
North Shore-LIJ Health Plan will coordinate all of your home and community-based services as
well as your medical care. Your Care Manager is a health care professional (RN, Social Worker),
who works for North Shore-LIJ Health Plan. Your Care Manager will work closely with you
and your doctor to plan and arrange for you to get the medically necessary health and long
term care services you need and to make sure that your care is well coordinated. If you need to
receive care in a hospital or nursing home, your Care Manager will work with the staff of the
facility to make sure your needs are met.
Please remember to call (855) 421-3066, TTY # is (855) 871-1665 whenever you have
questions about North Shore-LIJ Health Plan. There is a nurse available by phone 24 hours
a day, 7 days a week.
Home Care Services
These are medically necessary services you receive in your home such as, nursing, medical
social services, and rehabilitation (physical, occupational & speech therapy).
Your Care Manager will work with you and your doctor to get you the care you need. These
services are provided by our Network Providers who are Certified Home Health Care Agencies
and Licensed Home Care Services Agencies. These services are provided based on a plan of
care that your physician approves. These services are provided to help prevent, rehabilitate,
guide, and/or support your health. All of these services are provided in your home.
Personal Care
The North Shore-LIJ Health Plan allows for help with eating, dressing, bathing, etc. as well as
home-environment support. Personal care must be medically necessary, and is based on a plan
of care that is approved by your physician.
North Shore-LIJ Health Plan determines the number of personal care hours you will receive
based on your health assessment and long term care needs.
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Consumer Directed Personal Assistance Program
You may also be eligible for the Consumer Directed Personal Assistance Program to help you
with your personal care such as feeding, dressing and other activities that may be included in
your plan of care and are medically necessary. If you are able to direct an adult who may be
a relative or friend who does not live with you, speak with your Care Manager to learn more
about this program.
Nutritional Counseling
Your Care Manager can arrange to have a dietitian speak to you by phone or come to your
home to help you with any nutritional problems you have. For example, if you have lost or
gained too much weight, or you do not understand your special diet, or have other dietary
problems, you may receive nutritional counseling.
Adult Day Health Care
This is a daytime program where you can receive therapeutic care, medical care, nursing care,
personal care, food and nutrition counseling, and other services. You may also take part in
physical, occupational and speech therapy. Plus, enjoy activities such as arts and crafts, music
and social events. Round trip transportation and meals are provided. You must not be homebound and require certain preventative or therapeutic services to attend an Adult Day Health
Center.
North Shore-LIJ Health Plan determines with you, your doctor and the Adult Day Health
Center the number of days you will go to the Adult Day Health Center. This is based on your
health care assessment and long term care needs.
Social Day Care
This is a daytime program where you can enjoy socialization and companionship. You may
take part in arts, crafts, music and other social activities. Nutritious lunches and snacks are
served. You may also receive services such as enhancement of daily living skills and caregiver
assistance. Round trip transportation and personal care may also be provided.
North Shore-LIJ Health Plan determines with you and the social day care center the number of
days you will go to the day program. This is based on your health care evaluation that is done
by North Shore-LIJ Health Plan’s Care Managers.
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Non-Emergency Transportation
North Shore-LIJ Health Plan will arrange and pay for your transportation to and from your
medical appointments. If you need transportation to any health related appointment, you will
need to call North Shore-LIJ Health Plan so we can schedule and arrange your transportation.
Taxi transportation may not be available in certain geographical areas therefore, ambulette service
will be arranged for you. When you need transportation, please contact your Care Manager at
least one (1) to two (2) days before your appointment unless you need urgent care. If you need
urgent care, call your Care Manager as soon as you know the time of your appointment and your
Care Manager will make their best efforts to help you get the transportation you need.
Eye Exams and Eyeglasses
North Shore-LIJ Health Plan recommends annual eye
examinations for all Members to prevent problems
from starting or getting worse. Please remember to
get your care at one of the eye centers listed in your
North Shore-LIJ Health Plan Provider Directory. Fully
credentialed optometrists provide eye exams and glasses.
You may receive one pair of glasses once every 2 years or more frequently if medically necessary.
Designer frames and sunglasses are not covered items. Requests to replace broken and/or lost
glasses will be reviewed on a case-by-case basis.
Hearing Aids and Hearing Exams
All medically necessary hearing exams are arranged by North Shore-LIJ Health Plan. Every exam
is performed by a fully licensed audiologist. If you have difficulty hearing in normal circumstances, North Shore-LIJ Health Plan will suggest that you have a hearing test. We will arrange for a
Network Provider Audiologist to perform the hearing tests. If medically necessary, you will be
fitted for hearing aids. Hearing aids will be replaced according to changes in your prescription.
Claims for lost or broken hearing aids will be reviewed on a case-by-case basis.
Podiatry/Foot Care
All medically necessary foot care services are arranged by North Shore-LIJ Health Plan and
provided by the licensed podiatrists listed in the North Shore-LIJ Health Plan Provider Directory.
Some examples of medical necessity are if you have diabetes, circulatory problems, foot ulcers,
or infections. Routine hygienic care of the feet, the treatment of corns and calluses, the trimming
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of nails, and other hygienic care such as cleaning or soaking feet may be covered if your Care
Manager deems it necessary.
Call your Care Manager to approve this service and assist you in scheduling an appointment
with a podiatrist. If it is difficult for you to visit an office, we have Network Provider Podiatrists
who makes home visits.
Dental Services
All medically necessary dental exams are arranged by North Shore-LIJ Health Plan. As part of
your dental benefit, you are entitled to twice yearly check ups including cleanings, x-rays, and
basic restorative services such as fillings, extractions, and dentures. You must get all of your
medically necessary dental services from our Network Provider Dentists. If you have dentures,
they may be replaced if needed, every 5 years unless there is a significant change in the way the
dentures fit. Call your Care Manager to assist you in scheduling an appointment. You may visit
the dentist as needed for any adjustments to dentures which may be required.
Home Delivered Meals/Congregate Meals
If you are unable to prepare your own meals,
congregate meals can be provided at local Senior
Centers. North Shore-LIJ Health Plan or the Senior
Center will provide transportation to the Senior
Center according to your Care Plan.
Members may also have meals delivered to their
homes. Typically one or two meals are provided per
day for individuals who are unable to prepare meals
and who do not have personal care services to assist
with meal preparation.
Physical Therapy, Occupational Therapy,
Speech Pathology (in a setting outside of the home)
Licensed therapists will provide you with the above services. All of these services must be
carried out under your doctor’s medical direction. These services include, but are not limited to:
exercises to increase the motion of your joints, exercises to increase your ability to dress, bathe,
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eat and/or exercise to improve your speech. There is a limit of 20 visits of each therapy type per
calendar year except for children under 21 and the developmentally disabled. The goal of these
services is to help you be as safe and independent as possible.
Medical Equipment, Supplies and Oxygen
North Shore-LIJ Health Plan will arrange for the delivery and installation of medically necessary
equipment you need such as canes, walkers, wheelchairs, commodes, shower chairs, etc.,
and medical supplies (such as compression stockings, enteral feedings, gauze pads, bandages,
diapers, hearing aid batteries, etc.) and oxygen. Your Care Manager will consult with your
doctor and set up delivery and installation as needed.
Items that may not be covered by Medicare and/or Medicaid may be covered by the plan. It is
always a good idea to ask your Care Manager if an item is covered or not. These items may
include, but are not limited to, products that will assist you with your activities of daily living
such as, hand held shower heads, feeding aids such as rocker knives, special cups, spoons, etc.
Medical equipment and oxygen need approval from your doctor(s).
Prosthetics and Orthotics
If it is medically necessary for you to use orthopedic shoes, braces, inserts for your shoes, or
other appliances such as artificial limbs, etc., North Shore-LIJ Health Plan will work with you
and your doctor to help you get what you need. Prosthetic appliances and devices are devices
that are used to replace any missing part of the body. Orthotic appliances and devices are used
to support weakness or to restrict or eliminate motion in a diseased or injured part of the body.
Prescription footwear is limited to (1) treatment of diabetes, or (2) when a shoe is part of a leg
brace or (3) for foot complications for members under 21.
Social and Environmental Support Services
In the event you require it, North Shore-LIJ Health Plan can provide you with social and environmental services and items that support your medical needs and are included in your plan of care.
These services and items include but are not limited to the following: pest control, housing
modifications to improve your safety, and respite care. You need approval from the plan to
receive any of these services.
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Personal Emergency Response System (PERS)
This is an electronic emergency alert system connected to your telephone. You will have an
emergency button to press to call for immediate help. When the equipment is installed in your
home, an emergency plan is developed with you and your family/caregiver. If, or when, you
experience an emergency, for example a fall, chest pain, difficulty breathing, severe anxiety,
etc., you would push the button and help is immediately sent to your home while a trained
operator stays in voice contact with you. Your Care Manager reviews the need for this device
after completing a health assessment with you. This system is recommended for those: who live
alone or who are alone for many hours, have a history of falls or sudden onsets of illnesses and
are capable of using the system.
Please call your Care Manager to find out if this system is medically necessary to help you
manage your care.
Nursing Home Care
Although we do our best to meet your needs at home, there may be times when it is more
appropriate for you to receive nursing care in a nursing home. Admission to one of our
participating nursing homes is made on an individual basis. This decision must be made by you,
your doctor, your family and your Care Manager. There are two types of Nursing Home stays:
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Short term rehabilitative stays following hospitalization
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Long term stays for ongoing care
If you require nursing home care, you must be eligible for this care under the Medicaid
program’s institutional eligibility rules. If your current Medicaid eligibility only allows you
to receive community services, you may be asked to complete an application for institutional
Medicaid. The application includes a review of your financial assets and income for the past
five years. A North Shore-LIJ Health Plan Social Worker will help you with this process. If you
have any questions about your Medicaid benefits, please speak with your Care Manager.
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These are just some of the services that North Shore-LIJ Health Plan offers. Your Care Manager
will be happy to discuss these or any other covered benefits with you.
Are there services I can obtain without first talking to my
Case Manager?
There are certain North Shore-LIJ Health Plan services that you can obtain without first talking
to your Care Manager. However, we still ask you to inform your Care Manager afterwards, so
that we are all working together.
The following covered services can be obtained without first talking to your Care Manager:
1. If you need to see a dentist, you may receive preventative and basic dental services from any
dentist listed in your Provider Directory without prior approval.
Of course your Care Manager can help you select a dentist, and can always help with scheduling
appointments and arranging transportation. If you need more complicated dental work, your
dentist will be required to obtain approval before he/she begins the procedure.
2. You may receive one routine eye exam without prior approval each year at a vision care
center listed in your Provider Directory.
3. You do not need any prior approval from North Shore-LIJ Health Plan for emergency or
urgent care. In an emergency you should call “911” or get help at the closest hospital,
emergency room, or doctor’s office right away. Please let us know about such an event so
that we can help plan for your ongoing care.
Most of the services covered by North Shore-LIJ Health Plan have authorization requirements. This means that if you need any of the services listed below, you must get approval
in advance, before receiving care. The services that always require authorization in
advance are:
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Home Care Services, including nursing care, social work, rehabilitation, nutritional
counseling, and home health aides
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Personal Emergency Response System (PERS)
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Adult Day Health Care Services
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Home Delivered Meals
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Outpatient Rehabilitation Services
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Housekeeping Services
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Audiology (Hearing) Services
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Home Safety Modifications
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Respiratory Therapy and Oxygen
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Podiatry (Foot Care)
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Medical Equipment
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Medical and Surgical Supplies
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Nursing Home Care
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Social Day Care
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Transportation
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Private Duty Nursing
In addition, there are certain services that require an
authorization from North Shore-LIJ Health Plan only
in specific circumstances.
Dental Care- You do not need an authorization to see your dentist for a check up twice a year
and basic dental services. However, if you need more complex dental service, it will require
authorization in advance. Your dentist will obtain these authorizations for you.
Optometry and Eyeglasses- You do not need an authorization to have an eye exam from an
optometrist once a year or to get new glasses every two years. However, an authorization is
required if the services you need are not covered by Medicare.
Podiatry- For most members, podiatry is covered by Medicare. However, an authorization is
required if the services you require are not covered by Medicare.
Please talk with your Care Manager if you have any questions about your services and our
authorization procedures.
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Are there formal Service Authorization Procedures?
As listed in the previous pages of this handbook, most of the services covered by North Shore-LIJ
Health Plan Managed Long Term Care (MLTC) have authorization requirements, and all services
provided by North Shore-LIJ Health Plan are based on medical necessity. Please speak with your
Care Manager if you have any questions about our authorization process or to request services.
Your provider can also request services for you, and in addition, you can request services
by calling us. Either you or your provider can call us toll-free at (855) 421-3066, TTY # is
(855) 871-1665. If additional services are requested by you or your provider on your behalf,
we may ask your provider to explain to North Shore-LIJ Health Plan why the service is medically
necessary.
North Shore-LIJ Health Plan has made every effort to keep our authorization procedures as easy
as possible. Because it is important to us that you get the care that you need, we will provide
you with an answer as quickly as possible when a decision regarding medical necessity needs to
be determined.
Prior Authorization
A Prior Authorization is a request by you or a provider on your behalf for a new service (whether
for a new authorization period or within an existing authorization period) or a request to change
a service as determined in the plan of care for a new authorization period.
Concurrent Review
A Concurrent Review is a request by you or a provider on your behalf for additional services
(i.e., more of the same) that are currently authorized in the plan of care.
Expedited Review
Expedited — The plan determines or a provider indicates that a delay would seriously jeopardize
your life or health or ability to attain, maintain, or regain maximum function. You may request
an expedited review of a Prior Authorization or Concurrent Review. Appeals of actions resulting
from the concurrent review must be handled as expedited.
Any Action taken by North Shore-LIJ Health Plan regarding medical necessity or experimental or
investigational services must be made by a clinical peer reviewer as defined by PHL §4900 (2)(a).
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Adverse Determinations, other than those regarding medical necessity or experimental/
investigational services, must be made by a licensed, certified or registered health care
professional when such determination is based on an assessment of your health status or
of the appropriateness of the level, quantity or delivery method of care. This requirement
applies to determinations denying claims because the services in question are not a covered
benefit (where coverage is dependent on an assessment of your health status) and to Service
Authorization Requests including but not limited to: services included in the Benefit Package,
referrals and out-of-network services.
Time Frames for Review of Requested Service
1. North Shore-LIJ Health Plan must decide and notify you of decisions by phone and in
writing as fast as your condition requires but no more than:
Prior authorization:
i. Expedited – 3 business days from request for service.
ii. Standard – within 3 business days of receipt of necessary information, but no more than
14 days of receipt of request for services.
Concurrent review:
i. Expedited – within 1 business day of receipt of necessary information, but no more than
3 business days of receipt of request for services.
ii. Standard – within 1 business day of receipt of necessary information, but no more than
14 days of receipt of request for services.
iii. In the case of a request for Medicaid covered home health care services following an
inpatient admission, one (1) business day after receipt of necessary information; except
when the day subsequent to the request for services falls on a weekend or holiday,
seventy-two (72) hours after receipt of necessary information; but in any event, no more
than three (3) business days after receipt of the request for services.
2. Up to 14 calendar day extension. Extension may be requested by you or a provider on your
behalf (written or verbal). The North Shore-LIJ Health Plan also may initiate an extension if
we can justify need for additional information and if the extension is in your interest. In all
cases, the extension reason must be well documented.
3. You or a provider may appeal decision – see Appeal Procedures (pages 31-38).
4. If the North Shore-LIJ Health Plan denied your request for an expedited review, the
North Shore-LIJ Health Plan will handle it as standard review.
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Written Notices for Service Authorizations
Whenever you request services that require authorization, you will be notified of our decision
by phone and in writing. If you disagree with any of the authorization decisions made by
North Shore-LIJ Health Plan, you may discuss this with your Care Manager. However, if you
do not agree with our decision, you may appeal the decision. Please see pages 31-38 of this
handbook.
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The Services Not Covered by
North Shore-LIJ Health Plan does not cover the following services:
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Inpatient & Outpatient Hospital Care: Care you may receive while hospitalized or care
you may receive in a hospital clinic, physical therapy or rehabilitation department.
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Physician Services: Care given by a Doctor, Physician’s Assistant or Nurse Practitioner.
n
Laboratory and Diagnostic Tests: Includes such tests as blood tests, urine tests, and
electrocardiograms.
n
Radiology & Radio-Isotope X-rays: Includes X-rays, Bone Scans, Cat Scans and MRI’s.
n
Emergency Transportation: Ambulance trips to a hospital emergency room for emergency
care.
n
Hospital Emergency Room Care: Includes visits to the emergency room.
n
Renal Dialysis: Includes hemodialysis or peritoneal dialysis.
n
Mental Health Services: Includes inpatient and outpatient treatment for mental health
problems such as, but not limited to, depression and schizophrenia.
n
Alcohol & Substance Abuse: Includes care received for treatment of alcohol or drug abuse.
This would include hospitalization and outpatient treatment.
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Office of People With Developmental Disabilities (OPWDD): Services received through
the Office of People With Developmental Disabilities such as day programs & vocational
training.
n
Family Planning Services: Treatment or supplies such as birth control pills, condoms,
diaphragms, vasectomies or tubal ligation.
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Experimental or Investigational: Any individual drugs, medical devices or treatments in
clinical trials.
n
Pharmacy: This includes all prescription and non-prescription medications and compounded
medications. (Please note that if you have Medicare, you must fill your prescriptions at
a pharmacy that participates in your Medicare Prescription Plan. Remember to use your
pharmacy card for prescription medications and your Medicaid card for over-the-counter
medications.
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Will Medicaid and or Medicare still pay for services not
covered by North Shore-LIJ Health Plan?
Yes. Even though you have chosen to enroll in North Shore-LIJ Health Plan, your Medicaid
and Medicare benefits are still in effect.
As a Member of North Shore-LIJ Health Plan, you will continue to receive all of the same
Medicare/Medicaid benefits that you had before you became a Member. Your Care Manager
will help you use your Medicare/Medicaid benefits for services such as inpatient hospital stays,
outpatient hospital services, doctor visits, laboratory services, renal dialysis, and pharmacy.
You do not need approval from North Shore-LIJ Health Plan to use these services.
Please ask your Care Manager if you need help understanding the information you receive
from Medicare, Medicaid, or your Medicare prescription drug plan.
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The Steps to Join/Enroll in
Joining North Shore-LIJ Health Plan will require that some steps be taken by you, your
family/caregiver, your doctor, and Medicaid.
The following steps take place:
a) You, your family/caregiver or health care providers may call North Shore-LIJ Health
Plan and tell us of your interest in this plan.
b) Your eligibility to join the plan is reviewed with you to see if you qualify for
Membership.
c) We will check your Medicaid eligibility. If you do not have Medicaid but are Medicaid
eligible, our Medicaid Specialist will assist you with filling out the required Medicaid
application.
d) One of our Enrollment Nurses will contact you and arrange a meeting at a time
convenient for you, in your own home to explain and describe the plan to you.
e) The Enrollment Nurse will perform a comprehensive assessment to determine your
needs. This means you will need to take time to answer many questions about your
health and social situation.
During the enrollment visit you will receive an orientation to the plan and be asked to
sign consent for the plan to be able to get and give service providers information about
your health. This is called a Release of Medical and Health Information. Our staff will
protect your confidential health information to the full extent of the law. Also during
that visit, if you are interested and meet the eligibility requirements, you will be asked
to sign an enrollment application. Signing the enrollment application means you want
to voluntarily join/enroll in this plan and that you agree to the terms and conditions
set forth in the member handbook.
f) Enrollment into North Shore-LIJ Health Plan is subject to New York Medicaid Choice
(NYMC) approval. An enrollment package will be sent to NYMC and you will be
notified of any decisions that affect the status of your enrollment.
g) Once approved, you will be notified of your date of enrollment as soon as possible.
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How You Will Get the Services You Need
When you enroll, you, your doctor, your Care Manager and the other staff members of North
Shore-LIJ Health Plan will work together to develop a care plan that meets and supports your
health and long term care needs. The Member Care Plan is a written description of all the services
you receive. It is based on our assessment of your health and long term care needs and the plan’s
collaboration with your doctors. The initial care plan summary will be mailed to you after one of
North Shore-LIJ Health Plan’s Nurse Care Managers completes your health/social/environmental
assessment. Your Member Care Plan will be reviewed periodically and provide the basis for the
authorization period for your covered services. As your needs change, the Member Care Plan will
be changed along with the service authorization period.
Your Care Management Team (CMT) is responsible for the coordination and/or scheduling of
services for you. Your Care Manager will follow-up with you on a regular basis to check on
how you are doing. Your Care Manager will also work with your doctor, and other health care
providers, to make sure that you are getting all your needed services.
Requests for services should be made by calling your Care Manager. Your Care Manager will be
happy to discuss any request for changes in the services you receive with you and help you develop
the plan best suited to meet your needs. You may contact your Care Manager during our normal
business hours Monday through Friday from 9:00 am - 5:00 pm by calling (855) 421-3066,
TTY # is (855) 871-1665. Your Care Manager will speak with your doctor about changes to
your care plan that require his/her approval. In general, whenever you need new or additional
services or have a question regarding North Shore-LIJ Health Plan, you should call your
Care Manager.
North Shore-LIJ Health Plan will try its best to deal with your concerns or issues as soon as
possible, and to solve the problem to your satisfaction. If you are having a problem please use
either our grievance procedure or our appeal process as outlined below.
Please be assured of the following:
1. If you file a grievance or appeal there will be no change in services or the way you are
treated by North Shore-LIJ Health Plan staff or a health care provider because you have filed
a grievance or an appeal
2. We will maintain your privacy
3. We will give you any help you may need to file a grievance or appeal. This includes providing
you with interpreter services or help if you have vision and/or hearing problems.
4. You may choose someone (like a relative or friend or a provider) to act for you.
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If you are dissatisfied about anything to do with the plan or do not
agree with the services on your care plan you may use the Grievance
or Appeal process described on pages 31-38 of this handbook to satisfy
your concerns.
What to do if you need to reach North Shore-LIJ
Health Plan during non business hours
There is a Care Manager on call 7 days a week, 24 hours a day,
365 days a year.
Please call (855) 421-3066, TTY # is (855) 871-1665 and the operator
will be happy to take your message and will contact the Care Manager
on call. The Care Manager will return your call promptly.
What to do if your doctor makes changes in your treatment plan or
orders additional services or equipment
Call your Care Manager during normal business hours Monday through Friday between the
hours of 9:00 am-5:00 pm to tell her/him of the change.
However, if your doctor says that the service must begin right away, and it is after business
hours, please call and leave a message with the operator. A Care Manager will call you back
promptly.
When you can expect to receive requested services
The time frame for receiving approved services will be different depending upon the type of
service(s) needed. If there is an urgent need for any services, appointments will be arranged as
soon as possible. Your Care Manager will assist you in scheduling the services you need and
confirm the appointment(s) with you.
To receive covered services, you must use the North Shore-LIJ Health Plan Network
Providers listed in the North Shore-LIJ Health Plan Network Provider Directory, unless
otherwise authorized by your Care Manager.
Plan approvals
If you receive a covered service without getting approval from North Shore-LIJ Health Plan
before receiving the service, other than emergency care, the provider of that service may be
denied payment.
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In case of an emergency
Call 911 or go to the nearest hospital: An emergency is a medical or behavioral condition
which has a rapid onset and causes severe symptoms (such as chest pain or difficulty breathing).
You are entitled to emergency care 24 hours a day 7 days a week. Emergency services and/or
Emergency care do not require approval before you receive the care.
What to do if you are hospitalized
Whether you are discharged to home or hospitalized following an emergency room visit, you or
your family need to call your Care Manager as soon as possible. If you are going into the hospital
and it is not related to an emergency, please let your Care Manager know about it as soon as you
know the dates of your admission to the hospital. This will allow North Shore-LIJ Health Plan to
cancel scheduled appointments, or if you are hospitalized, to work with the hospital staff to plan
for your discharge and follow-up care.
If you are sick and it is not an emergency
If you feel ill and it is not an emergency, but you need same day medical care, directly notify your
Care Manager or call your physician. If necessary, the Care Manager will help you by contacting
your physician, dentist or other provider to arrange for any necessary appointment and/or transportation services.
If you plan to change where you are living
Whether you are moving permanently or for a short period of time within the service area, please
call your Care Manager as soon as you know the date you will be moving. This will let the Care
Manager help you in arranging where you will be receiving your services.
If you plan to be out of the service area
If you plan to leave the service area you live in to go on a short vacation or to visit friends/
relatives, please call your Care Manager. Your Care Manager will discuss your need for services
while you are away from your home, and if medically necessary, he/she will assist you in getting
services you need while you are away. To avoid any problems while you are out of your service
area, let your Care Manager know as soon as possible before you leave. Your Care Manager
can work with you to plan and arrange for the services that you need. However, if you require
emergent or urgent medical care, get the care you need and then contact your Care Manager.
If you leave the service area you live in for 60 days or longer you must be disenrolled from
North Shore-LIJ Health Plan.
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Use network providers
North Shore-LIJ Health Plan has contracts with many qualified service providers including home
care agencies, dentists, podiatrists, optometrists, audiologists, transportation and other providers.
The listing of the names, addresses and phone numbers can be found in the North Shore-LIJ
Health Plan Network Provider Directory. You will receive an up to date listing of the Network
Providers yearly. The listing will include new providers and any changes in the current providers.
Your Care Manager will have the most up to date information regarding the availability of a
particular provider and whether or not they are accepting new patients. North Shore-LIJ Health
Plan covered services are offered by North Shore-LIJ Health Plan’s Network Providers.
Members have the right to utilize benefits outside of the North Shore-LIJ Provider Network if
those necessary services are not available within our network of providers.
When you agree to become a Member of North Shore-LIJ Health Plan, you agree to use our
Network Providers.
You may change your Network Provider at any time during your Membership in North Shore-LIJ
Health Plan. To do so just call your Care Manager before receiving any services from your
new Network Provider. The change in Network Providers will be effective usually within 1-2
business days of your Care Manager getting your call.
New members who are receiving treatment from a provider who is not a
North Shore-LIJ Health Plan provider
If you are being treated for a life threatening or degenerative and disabling disease or condition,
you may continue treatment with the provider who is not a North Shore-LIJ Health Plan Network
Provider for a temporary (transitional) period of up to 60 days from your date of enrollment.
This will be approved by North Shore-LIJ Health Plan only if the non-participating provider
agrees to:
a) accept payment in full from North Shore-LIJ Health Plan at the rate the plan pays
b) follow North Shore-LIJ Health Plan’s quality assurance requirements and grievance and
appeals procedures, if applicable
c) provide necessary medical information about the care you are receiving to North Shore-LIJ
Health Plan
d) follow North Shore-LIJ Health Plan’s rules about getting approvals from our plan when
needed
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If your provider leaves North Shore-LIJ Health Plan’s network
Sometimes a professional health care provider, for example, your dentist, optometrist or
podiatrist, may leave the North Shore-LIJ Health Plan Network while you are getting care.
That professional health care provider may continue your care for a period of up to 90 days
after North Shore-LIJ Health Plan notified you that the Network Provider was leaving North
Shore-LIJ Health Plan. The provider must:
a) continue to meet and follow all the rules and regulations for their profession
b) accept payment from North Shore-LIJ Health Plan at the rate the plan pays
c) follow North Shore-LIJ Health Plan’s quality assurance requirements and grievance and
appeal procedures, if applicable
d) provide medical information about the care you are receiving to North Shore-LIJ Health Plan
e) follow North Shore-LIJ Health Plan’s rules about getting approvals from the plan when needed
If North Shore-LIJ Health Plan does not have the type of provider you need
North Shore-LIJ Health Plan will speak with your doctor about your special needs. If North
Shore-LIJ Health Plan does not have a provider with appropriate training or experience to meet
the special care you may need you will get a referral to a health care provider outside of the
North Shore-LIJ Health Plan Network of Providers.
Membership costs to you
There are no costs to you to be a Member of this plan, unless the member has been determined
to have a monthly “spend down” (see page 30). North Shore-LIJ Health Plan and its Network of
Providers may not bill you for any services covered (paid for) by the plan.
The Network of Providers are paid by North Shore-LIJ Health Plan. It is the responsibility of our
plan and our Network Providers to coordinate the benefits you receive from any other plan such
as, but not limited to, Medicare, or other third party health insurers such as Blue Cross, HIP,
AARP, etc.
It is very important that we know about any other health plan coverage you may have in addition
to Medicaid. If you receive a bill from any of our Network Providers or anyone else for a covered
service of the plan, please call your Care Manager for help. Even if the service is not covered by
the plan and you need help, please call your Care Manager and he/she will assist you in solving
the problem.
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What to do if you have a Medicaid “spend down”
North Shore-LIJ Health Plan enrolls Members who are considered by the County Medicaid
Program to have a “spend down”. The term “spend down” is used by the Local County
Department of Social Services to describe the part of your income that is above the amount of
income allowed by Medicaid rules for you to be eligible for the Medicaid Program. A “spend
down” can also be called a “surplus”. As a Member of North Shore-LIJ Health Plan, you are
required to make the assigned “spend down” payment determined by the NYMC directly
to North Shore-LIJ Health Plan at the beginning of every month.
If you do not pay the “spend down” owed to North Shore-LIJ Health Plan within 30 days that
the overage is first due, North Shore-LIJ Health Plan has the right to begin disenrollment
proceedings (as described under the disenrollment section of this Handbook on pages 39-40).
There are no other payments to North Shore-LIJ Health Plan. If you have any questions
regarding your Medicaid “spend down”, please contact the appropriate County Department
of Social Services.
The address is:
Nassau County Department of Social Services
Attention: Overage Unit
60 Charles Lindbergh Boulevard
Uniondale, New York 11553
Phone: (516) 571-1734
Suffolk County Department of Social Services
Overage Unit
Attention: Medicaid Overage Unit
P.O. Box 18100
Hauppauge, NY 11788-8900
Phone: (631) 584-5879
New York City Medical Assistance Program
330 34th St. 5th floor
NY, NY 10001
Attention: DARB Pay Coordinator
If you have any questions about paying your “spend down” to North Shore-LIJ Health Plan
please, speak with your Care Manager so that we can help work out any problems you may have.
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How North Shore-LIJ Health Plan
Handles Your Complaint/Grievance
and Grievance Appeal
North Shore-LIJ Health Plan will try its best to deal with your concerns or issues as quickly
as possible and to your satisfaction. If you are having a problem please use either our
grievance procedure or our appeal process as outlined below.
Please be assured of the following:
If you file a grievance or appeal there will be no change in services or the way you
are treated by North Shore-LIJ Health Plan staff or a health care provider because
you have filed a grievance or an appeal
We will maintain your privacy
We will give you any help you may need to file a grievance or appeal. This includes
providing you with interpreter services or help if you have vision and/or hearing
problems.
You may choose someone (like a relative or friend or a provider) to act for you.
To file a grievance or to appeal a plan action, please call us toll free at: (855) 421-3066,
TTY # is (855) 871-1665, or write to:
Attention: Grievances and Appeals
Lynbrook, NY 11563
When you contact us, you will need to give us your name, address, telephone number and
the details of the problem.
A grievance form is included in the enrollment packet for you and/or your representative’s
convenience.
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What is a Grievance?
A grievance is any communication by
you to us of dissatisfaction about the care
and treatment you receive from our staff
or providers of covered services. For
example, if someone was rude to you
or you do not like the quality of care or
services you have received from us, you
can file a grievance with us.
The Grievance Process
You may file a grievance orally or in writing with us. The person who receives your grievance will
record it, and appropriate staff will oversee the review of the grievance. We will send you a letter
telling you that we received your grievance and a description of our review process. We will
review your grievance and give you a written answer within one of two timeframes.
1. If a delay would significantly increase the risk to your health, we will decide within 48 hours
after receipt of all necessary information.
2. For all other types of grievances, we will notify you of our decision within 45 days of receipt
of necessary information, but the process must be completed within 60 days of the receipt
of the grievance. The review period can be increased up to 14 days if you request it or if we
need more information and the delay is in your interest.
Our answer will describe what we found when we reviewed your grievance and our decisions
about your grievance.
How do I Appeal a Grievance Decision?
If you are not satisfied with the decision we make concerning your grievance, you may request
a second review of your issue by filing a grievance appeal. You must file a grievance appeal in
writing. It must be filed within 60 business days of receipt of our initial decision about your
grievance. Once we receive your appeal, we will send you a written acknowledgement telling
you the name, address and telephone number of the individual we have designated to respond
to your appeal. All grievance appeals will be conducted by appropriate professionals, including
health care professionals for grievances involving clinical matters, who were not involved in the
initial decision.
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For standard appeals, we will make the appeal decision within 30 business days after we receive
all necessary information to make our decision. If a delay in making our decision would significantly increase the risk to your health, we will use the expedited grievance appeal process. For
expedited grievance appeals, we will make our appeal decision within 2 business days of receipt
of necessary information. For both standard and expedited grievance appeals, we will provide
you with written notice of our decision. The notice will include the detailed reasons for our
decision and, in cases involving clinical matters, the clinical rationale for our decision.
What is an Action?
When North Shore-LIJ Health Plan:
n
Denies or limits services requested by you or your provider
n
Denies a request for a referral
n
Decides that a requested service is not a covered benefit
n
Reduces, suspends or terminates services that we already authorized
n
Denies payment for services
n
Doesn’t provide timely services
n
Doesn’t make grievance or appeal determinations within the required timeframes
Those are considered Plan actions.
An action is subject to appeal. (See How do I File an Appeal of an Action? See below for more
information)
Timing of Notice of Action
If we decide to deny or limit services you requested or decide not to pay for all or part of a
covered service, we will send you a notice when we make our decision. If we are proposing to
reduce, suspend or terminate a service that is authorized, our letter will be sent at least 10 days
before we intend to change the service.
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Contents of the Notice of Action
Any notice we send to you about an action will:
n
Explain the action we have taken or intend to take
n
Cite the reasons for the action, including the clinical rationale, if any
n
Describe your right to file an appeal with us (including whether you may also have a right to
the State’s external appeal process)
n
Describe how to file an internal appeal and the circumstances under which you can request
that we speed up (expedite) our review of your internal appeal
n
Describe the availability of the clinical review criteria relied upon in making the decision,
if the action involved issues of medical necessity or whether the treatment or service in
question was experimental or investigational
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Describe the information, if any, that must be provided by you and/or your provider in order
for us to render a decision on appeal
If we are reducing, suspending or terminating an authorized service, the notice will also tell you
about your right to have services continue while we decide on your appeal, how to request that
services be continued, and the circumstances under which you might have to pay for services if
they are continued while we were reviewing your appeal.
What is an Appeal?
If you do not agree with an action that we have taken, you may appeal that action. When you
file an appeal, it means that we must look again at the reason for our action to decide if we were
correct.
How do I File an Appeal of an Action?
You can file an appeal of an action with the plan orally or in writing. When the plan sends you a
letter about an action it is taking (like denying or limiting services, or not paying for services), you
must file your appeal request within 45 calendar days of the date on our letter notifying you of the
action.
If you call us to file your request for an appeal, you must send a written request unless you ask
for an expedited review.
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How do I Contact North Shore-LIJ Health Plan
to file an Appeal?
There are several ways you can file your appeal with us:
Call us toll free at (855) 421-3066, TTY # is (855) 871-1665
Write to us at:
Lynbrook, NY 11563
Send us a fax at: (516) 881-7152
The person who receives your appeal will record it, and
appropriate staff will oversee the review of the appeal. We
will send a letter telling you that we received your appeal,
and how we will handle it. Your appeal will be reviewed by knowledgeable clinical staff who
were not involved in the plan’s initial decision or action that you are appealing.
For Some Actions You May Request to Continue Service During
the Appeal Process
If you are appealing a reduction, suspension or termination of services you are currently
authorized to receive, you may request to continue to receive these services while we are
deciding your appeal. We must continue your service if you make your request to us no later
than 10 days from our mailing of the notice to you about our intent to reduce suspend or
terminate your services, or by the intended effective date of our action, and the original period
covered by the service authorization has not expired. Your services will continue until you
withdraw the appeal, the original authorization period for your services has been met or until
10 days after we mail your notice about our appeal decision, if our decision is not in your favor
unless you have requested a New York State Medicaid Fair Hearing with continuation of services.
(See Fair Hearing Section on page 36 of this Member Handbook).
Although you may request a continuation of services while your appeal is under review, if your
appeal is not decided in your favor, we may require you to pay for these services if they were
provided only because you asked to continue to receive them while your appeal was being
reviewed.
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How Long Will It Take the Plan to Decide My Appeal of an Action?
Unless you ask for an expedited review, we will review your appeal of the action taken by us as
a standard appeal and send you a written decision as quickly as your health condition requires,
but no later than 30 days from the day we receive an appeal. (The review period can be increased
up to 14 days if you request an extension or we need more information and the delay is in your
interest.) During our review you will have a chance to present your case in person and in writing.
You will also have the chance to look at any of your records that are part of the appeal review.
We will send you a notice about the decision we made about your appeal that will identify the
decision we made and the date we reached that decision.
If we reverse our decision to deny or limit requested services, or reduce, suspend or terminate
services and services were not furnished while your appeal was pending, we will provide you
with the disputed services as quickly as your health condition requires. In some cases you may
request an “expedited” appeal. See Expedited Appeal Process below.
Expedited Appeal Process
If you or your provider feels that taking the time for a standard appeal could result in a serious
problem to your health or life, you may ask for an expedited review of your appeal of the action.
We will respond to you with our decision within 2 business days after we receive all necessary
information. In no event will the time for issuing our decision be more than 3 business days
after we receive your appeal. (The review period can be increased up to 14 days if you request
an extension or we need more information and the delay is in your interest).
If we do not agree with your request to expedite your appeal, we will make our best efforts to
contact you in person to let you know that we have denied your request for an expedited appeal
and will handle it as a standard appeal. Also, we will send you a written notice of our decision to
deny your request for an expedited appeal within 2 days of receiving your request.
If the North Shore-LIJ Health Plan Denies My Appeal, What Can I Do?
If our decision about your appeal is not totally in your favor, the notice you receive will explain
your right to request a Medicaid Fair Hearing from New York State and how to obtain a Fair
Hearing, who can appear at the Fair Hearing on your behalf, and for some appeals, your right
to request to receive services while the Hearing is pending and how to make the request. If we
deny your appeal because of issues of medical necessity or because the service in question was
experimental or investigational, the notice will also explain how to ask New York State for an
“external appeal” of our decision.
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State Fair Hearings
If we did not decide the appeal totally in your favor, you may request a Medicaid Fair Hearing
from New York State within 60 days of the date we sent you the notice about our decision on
your appeal.
If your appeal involved the reduction, suspension or termination of authorized services you are
currently receiving, and you have requested a Fair Hearing, you may also request to continue
to receive these services while you are waiting for the Fair Hearing decision. You must check
the box on the form you submit to request a Fair Hearing to indicate that you want the services
at issue to continue. Your request to continue the services must be made within 10 days of the
date the appeal decision was sent by us or by the intended effective date of our action to reduce,
suspend or terminate your services, whichever occurs later. Your benefits will continue until
you withdraw the appeal; the original authorization period for your services ends; or the State
Fair Hearing Officer issues a hearing decision that is not in your favor, whichever occurs first.
If the State Fair Hearing Officer reverses our decision, we must make sure that you receive the
disputed services promptly, and as soon as your health condition requires. If you received the
disputed services while your appeal was pending, we will be responsible for payment for the
covered services ordered by the Fair Hearing Officer.
Although you may request to continue services while you are waiting for your Fair Hearing
decision, if your Fair Hearing is not decided in your favor, you may be responsible for paying
for the services that were the subject of the Fair Hearing.
State External Appeals
If we deny your appeal because we determine the service is not medically necessary or is
experimental or investigational, you may ask for an external appeal from New York State.
The external appeal is decided by reviewers who do not work for us or New York State. These
reviewers are qualified people approved by New York State. You do not have to pay for an
external appeal.
When we make a decision to deny an appeal for lack of medical necessity or on the basis that
the service is experimental or investigational, we will provide you with information about how
to file an external appeal, including a form on which to file the external appeal along with our
decision to deny an appeal. If you want an external appeal, you must file the form with the
New York State Department of Financial Services within 4 months from the date we denied
your appeal.
Member Handbook
n
37
Your external appeal will be decided within
30 days. More time (up to 5 business days)
may be needed if the external appeal reviewer
asks for more information. The reviewer will
tell you and us of the final decision within two
business days after the decision is made.
You can get a faster decision if your doctor
can say that a delay will cause serious harm
to your health. This is called an expedited
external appeal. The external appeal reviewer
will decide an expedited appeal in 3 days or
less. The reviewer will tell you and us the
decision right away by phone or fax. Later, a
letter will be sent that tells you the decision.
You may ask for both a Fair Hearing and an
external appeal. If you ask for a Fair Hearing
and an external appeal, the decision of the Fair
Hearing Officer will be the one that counts.
We hope you will always discuss your concerns with us. However, if you are dissatisfied with
North Shore-LIJ Health Plan, or if you disagree with the way we handled your complaint, you
also have the right to file a complaint with the New York State Department of Health. You can
call them or write to them at the following location:
New York State Department of Health
Bureau of Managed Long Term Care
Empire State Plaza
Corning Tower, Rm. 1911
Albany, New York 12237
Telephone: (866) 712-7197
38
n
Ending Your Membership in
When You Can End Your Membership:
Membership (enrollment) is voluntary so you may choose to end your Membership in North
Shore-LIJ Health Plan. Ending Membership is called disenrolling. If you decide to end your
Membership due to a complaint or concern, please contact your Care Manager or the Social
Services Coordinator. Your Membership in North Shore-LIJ Health Plan is very important to us.
We would welcome a chance to work on the problem to try and work it out to your satisfaction.
You may begin ending your membership at any time, for any reason, by calling the plan. We
will send you a letter to confirm your request to end your membership. We will ask you to sign
the letter and return it to us to keep in your record or, if you wish, you may send us a letter in
your own words telling us why you want to end your membership in the plan. The letters will
not delay ending your membership since the process to end your membership begins at
the time of your request.
If you continue to need long term care services you must join another MLTC or Managed Care
Program. Our Care Management Team will assist you in your application and transfer to the
MLTC or Managed Care Plan. You will receive a letter from North Shore-LIJ Health Plan telling
you the date of your disenrollment. North Shore-LIJ Health Plan will continue to manage the
services you need until your Membership has ended or you enroll in another MLTC or Managed
Care Plan.
Also, you need to know that if you decide to join or receive services from another Medicaid
managed care plan, a hospice program, a home or community based services waivered
program, an Office of People With Developmental Disabilities (OPWDD) Day Treatment or a
Comprehensive Medicaid Case Management (CMCM) program, you will be considered to have
voluntarily disenrolled from North Shore-LIJ Health Plan. You will no longer be able to get
services from the plan.
If North Shore-LIJ Health Plan believes it is necessary to disenroll a member, we must
obtain the approval of New York Medicaid Choice.
Only under certain conditions does North Shore-LIJ Health Plan have the right to end
(disenroll) your Membership.
Member Handbook
n
39
North Shore-LIJ Health Plan must cancel your membership if:
1.
2.
3.
4.
You moved out of your service area
Left service area for any reason for 60 consecutive days or longer
Lost your right to receive Medicaid
Are hospitalized or enter a State inpatient mental health, substance abuse, rehabilitation
program or a program for retardation or developmental disabilities for 45 days or longer
5. Are admitted into a Skilled Nursing Home and you are not eligible for Institutional
Medicaid
6. Are no longer in need of Nursing Home level of care
7. You are incarcerated
You may have your Membership ended by North Shore-LIJ Health Plan if:
1. You, or any others present in your home show behaviors or conduct that seriously impairs
our ability to have services given to you.
2. You or your representative give North Shore-LIJ Health Plan false information, otherwise
deceives the plan or engages in fraudulent conduct with respect to any part of the plan.
3. You knowingly fail to complete and submit any necessary consent or release, or other
document reasonably requested by North Shore-LIJ Health Plan.
4. If applicable, you fail to make efforts to pay your spend down/surplus to meet Medicaid
eligibility within 30 days after it is due.
North Shore-LIJ Health Plan will work with you to try and solve any of these problems. If these
problems cannot be worked out between you and North Shore-LIJ Health Plan, we will send you
a letter telling you of our plan to disenroll you.
North Shore-LIJ Health Plan will continue to arrange for the covered services you need until
your Membership is ended.
North Shore-LIJ Health Plan staff will help you to arrange for future services from other
providers, if necessary. In order to prevent a lapse in the delivery of services you get, services
from the new provider will be started on the day following your disenrollment from North
Shore-LIJ Health Plan.
40
n
Managed Long Term Care Member Rights
North Shore-LIJ Health Plan will uphold members’ rights and responsibilities as outlined
below:
As a member of North Shore-LIJ Health Plan
n
You have the Right to receive medically necessary care.
n
You have the Right to timely access to care and services.
n
You have the Right to privacy about your medical record and when you get treatment.
n
You have the Right to appoint someone to speak for you about your care and treatment.
n
You have the Right to get information in a language you understand; you can get oral
translation services free of charge.
n
You have the Right to get information necessary to give informed consent before the
start of treatment.
n
You have the Right to be treated with respect and dignity.
n
You have the Right to get a copy of your medical records and ask that the records be
amended or corrected.
n
You have the Right to take part in decisions about your health care, including the right
to refuse treatment.
n
You have the Right to be free from any form of restraint or seclusion used as a means of
coercion, discipline, convenience or retaliation.
n
You have the Right to get care without regard to sex, race, health status, color, age,
national origin, sexual orientation, marital status or religion.
n
You have the Right to be told where, when and how to get the services you need from
your managed long term care plan, including how you can get covered benefits from
out-of-network providers if they are not available in the plan network.
n
You have the Right to complain to the New York State Department of Health or your
Local Department of Social Services; and, the Right to use the New York State Fair
Hearing System and/or a New York State External Appeal, where appropriate.
n
You have the Right to get information on available treatment options and alternatives
presented in a manner and language you understand.
Member Handbook
n
41
You are Responsible to:
n
Enter into the plan with the aim of following the rules and procedures talked about in
your Member Handbook
n
Give correct and complete information concerning illnesses, hospitalizations,
medications, allergies, changes in your health and long term care needs, and other
important information
n
Take part in making, following and keeping up-to-date your agreed upon Member
Care Plan
n
Get approval for services and treatments covered by North Shore-LIJ Health Plan from
your Care Manager or doctor before receiving the service
n
Choose service providers within the North Shore-LIJ Health Plan Network of
Providers for covered services
n
Understand that services are made available within the plan’s policies
n
Call North Shore-LIJ Health Plan whenever you have a question about the plan and/or
the services
n
Accept services without regard to the race, color, religion, age, sex, national origin or
disability of the caregiver
n
When applicable, make payment to North Shore-LIJ Health Plan of any “spend down”
payment owed the plan
n
To keep appointments or notify the program if an appointment cannot be kept
n
Help in making and keeping a safe environment in your home
n
Notify North Shore-LIJ Health Plan when you are going away or are out of town, and
if you are moving
If you have any questions about any of this information please call North Shore-LIJ
Health Plan’s Care Management Department for assistance
42
n
Other Information About
Annual Notice
As a Member of North Shore-LIJ
Health Plan every year you will
receive:
n
Your Disenrollment Rights
n
Privacy Practices
n
Network Directory
n
When needed, an updated
Member Handbook
Member Handbook
n
43
North Shore-LIJ Health Plan is committed to
working with you as your partner in health care
Mission Statement
The mission of North Shore-LIJ Health Plan is to provide
quality care with dignity and compassion. We assist
members to live independently in their home and
communities as long as possible. We encourage members
and their families to be involved in the development and
implementation of the member’s individualized care plan.
We provide education, advocacy and treatment to support
members in reaching the highest possible level of wellness
and independence. We are committed to member
satisfaction, quality and respect.
Our Values
Compassion
Efficiency
n
Member Safety
44
n
Dignity
n
Diversity
Excellence
n
Integrity
Respect
n
Team work
n
n
Blank Inside Back cover
Important Names and
Phone Numbers
Care Manager
Name______________________________________
Number____________________________________
Member Service Coordinator
Name______________________________________
Number____________________________________
North Shore-LIJ Health Plan Office Address
___________________________________________
___________________________________________
___________________________________________
Names, addresses and phone numbers of doctors
___________________________________________
___________________________________________
___________________________________________
In an emergency call 911 immediately, and notify
North Shore-LIJ Health Plan within 24 hours if
possible.
MLTC_C028780_memhandbook_0913

North Shore-LIJ Health Plan Member Handbook

Transcription

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