to Choose a Health Plan

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Yo u h a v e
to Choose a
Health Plan

  This New York
  Medicaid CHOICE

    Choosing A Health Plan

From now on, most Medicaid
consumers must join a health
plan. Your regular Medicaid
benefits stay the same.
What changes is that you choose one health plan for
you and your family.
This guide tells you how to choose a health plan,
and how it works.

You have 60 days to choose
■   If you received a letter with this guide, the letter tells you
    the date by when you must choose a plan.
■   You can choose a health plan at any time before this date.
■   If you already have a health plan, you can stay in it or choose
    another one.
■   To join, fill out and sign the enclosed enrollment form. Mail
    it in the envelope that came with this guide.
■   Send the form back before 60 days, or New York Medicaid
    CHOICE will choose a plan for you.

Start now
Look through this guide for answers to any of your questions.
Or if you want to have a private, face-to-face meeting with a
New York Medicaid CHOICE counselor, call:
New York Medicaid CHOICE HelpLine:
For people with hearing
problems (TTY/TDD):                         Some Medicaid
                                            consumers are
1-888-329-1541                              not required
You may call Monday through Friday,         to join a health
8:30 a.m. to 8:00 p.m. and Saturdays        plan for special
10:00 a.m. to 6:00 p.m.
                                            reasons. To see
This call is free. Anything you say         if any of these
will be kept confidential.                  special reasons
                                            apply to you,
                                            turn to page 12
                                            of this guide.
In This Guide...

 How to Choose a Health Plan
          PAGE    2

   How Health Plans Work
          PAGE    6

     Health Plan Services
          PAGE    8

       Problem Solving
          P A G E 10

    Who Is Not Required
    to Join a Health Plan
         P A G E 12
How to choose
a Health Plan

Think About the
Doctors You Want

After you join a plan, you must
choose a doctor who works with
the plan. ■ If you want to keep
the doctors you see now, ask them
what health plans they work with.
■ If you don’t have a regular
doctor, you can choose one when
you join a plan. ■ To learn which
health plans have a doctor near
your home, or one who can serve
you in your language, you may
call the health plan directly.
Or call the New York Medicaid
CHOICE HelpLine.

Use the Plan Chart Get Ready to Join
and Hospital List   Choose one health plan

■ Health plans are not all the          and the doctors for you
  same. Use the Health Plan             and your family.
  Chart to learn about a plan’s       ■ Call the doctors, to
  special programs. You can             make sure they are in
  also learn if the plan offers         the plan you want and
  dental care and family                are taking new patients.
  planning. Use the Hospital          ■ Fill out and sign the
  List to see what hospitals
                                        enrollment form. Mail it
  work with each plan.
                                        in the enclosed envelope.
■ After you join a plan,
                                        No stamp is needed.
  you must use the hospitals,
  clinics and doctors that
  work with the plan.
■ Call the New York Medicaid

  CHOICE HelpLine to see
  what doctors work with
  your plan.

Think About
the Services Your
Family Needs
■ Everyone in your family
  must join the same plan,
  in most cases. So look
  for the health plans that
  have health care providers,
  clinics, and hospitals that
  meet your family’s needs.
■ You should confirm that

  the doctors you choose
  work with the hospitals
  you want.

How to Choose
a Health Plan

What Will                          Make Sure the
Happen Next?                       Plan you Picked is
■ New York Medicaid                Right for You!
  CHOICE will send you a           To see if your new health plan
  letter to confirm the plan       meets your needs, you should:
  you chose and the date that      ■ Call the health plan right
  you can begin using your           away. The phone number
  health plan.                       to the Member Services
■ Your new health plan will
                                     Department is on your
  send you a welcome letter          health plan card.
  and a member ID card. If         ■ Ask the people in the health
  you need care before your          plan’s Member Services
  ID arrives, use the plan’s         Department any questions
  welcome letter to show             that you have about the plan
  that you are a member.             and its services.
                                   ■ Choose a Primary Care

Keep Both Your                       Provider (PCP) and visit
Medicaid Card                        him or her as soon as you
and Your Health                      can. If you choose a new
Plan ID Card                         PCP, your first visit is very
                                     important. You will know if
■   You will need to use             the PCP’s office is easy for
    your Medicaid card to get        you to reach. And the PCP
    pharmacy services and other      can answer any questions
    services which may not be        about your future care.
    covered by your health plan,
    such as family planning and
    mental health services for
    people with SSI.

If You’re Not                What Happens
Satisfied, You               After 90 Days?
Have 90 Days                 ■ After the 90-day trial
to Change                      period, you must stay
Plans                          with your new health
■ Your first few weeks in      plan for the next
  a new health plan are        9 months.
  like a trial period. You   ■ You can only switch

  have 90 days to decide       plans after the 90-day
  if that health plan          trial period when you
  will meet your family’s      have a special
  needs. You can change        reason to do so.
  health plans at any        ■ One example of a
  time during the 90           special reason is when
  day period.                  you have moved and
■ To change health             your health plan does
  plans, call the New          not offer services near
  York Medicaid                your home.
  CHOICE HelpLine
  at 1-800-505-5678.

                       To Change
                  Health Plans, Call the
                   New York HelpLine
                 1- 800 -505- 5678

How Health
Plans Work

You Have a                            You Can Get
Regular Doctor                        Regular Checkups
When you join a health plan,          ■ Your Primary Care Provider
you choose one doctor to                will give you regular check-
work as your regular health             ups to help prevent problems
care provider. Some plans let           from starting or getting
you choose a nurse practitioner         worse. Visit your PCP
as your regular provider. This          soon after you join a plan.
person is your Primary Care           ■ Your children will have
Provider (PCP).                         regular checkups as babies,
Your family members can                 small children, teenagers
each have a PCP who works               and young adults.
with the plan you join.               ■ You will get health care

You can reach your PCP’s                during pregnancy to keep
office or health plan                   you and your baby healthy.
24 hours a day, 7 days a week.        ■ With regular health care,

                                        you will have better health
                                        and miss out less on school
                                        and work.
If you become ill at
night or on the weekend,
your doctor or health
plan can help you get
the care you need.
You Can See
Your PCP will give you a              In Most Cases,
referral (permission) when            You’ll Have
you need to see a specialist.         Guaranteed
Your PCP will also talk to the        Eligibility
specialist about your health          This means that you are
problems.                             promised the services your
If you see a specialist often,        health plan covers along with
you can ask your plan to have         pharmacy and family planning
your specialist work as your          services, six months after you
PCP, or get a standing referral       join, even if you no longer
to visit him or her.                  qualify for Medicaid.

You Do Not Need                       You Can Learn
a Referral for                        How to Stay
Some Specialists                      Healthy
You do not need                       Most plans offer special
a referral for:                       health education programs,
■ Family planning visits              such as How to Quit
■ Pregnancy and
                                      Smoking or How to Lose
                                      Weight. These programs
  preventive care visits              can help you stay healthy.
  to your OB-GYN doctor.
You do not need
a referral for:
■ One visit a year for mental

  health services. The provider
  must be in your plan.
  (You must get a referral
  from your PCP for
  follow-up visits.)
■ One visit a year for drug

  and alcohol abuse services.
  The provider must be in
  your plan. (You must get a
  referral from your PCP for
  follow-up visits.)

Health Plan

Your Medicaid Benefits
and Health Plans
When you join a health plan,        ■ Short-term home health care
you keep the same Medicaid          ■ Emergency care
benefits. Most Medicaid
                                    ■ Transportation assistance
Health Benefits are included
in services provided by             ■ Mental health services

the health plans. Among             ■ Many other Medicaid
these services offered by the         services, such as eye care,
plans are:                            medical equipment and
■ Regular checkups and shots          HIV testing and counseling
■ Visits to the doctor when         ■ Preventive services

  you are sick                      Remember to keep your
■ Care during pregnancy             Medicaid card on hand. Use
■ Hospital care, lab tests,
                                    it at the drugstore to get med-
                                    icine; for family planning and
  X-rays                            other services not covered by
■ Referrals to specialists,         your plan, like mental health
  when you need them                services for people with SSI.

About Your                            Family Planning
Dental Care...                        Services
Look at the Health Plan list          Most health plans offer family
to see which plans offer dental       planning services. Every
care. If a plan offers dental         member of every plan can go
care, you must go to a dentist        to any Medicaid provider for
in the plan. If the plan does         family planning. You do not
not offer dental care, you may        need a referral from your
go to any dentist who takes           PCP for family planning.
Medicaid.                             Here is a list of family
                                      planning services:
                                      ■ Birth control pills, condoms,

Using the                               diaphragms, IUDs, Depo
Emergency Room                          Provera, Norplant and foam
                                      ■ Emergency contraception
Go to the Emergency Room
only when there is a real             ■ Pregnancy testing and

emergency. Do not use it for            counseling
routine care. Your PCP can            ■ Sterilization
treat problems that are not
                                      ■ Sexually transmitted disease
                                        testing and treatment.
Some examples of
                                      ■ HIV testing and counseling,
medical emergencies are:
■ Passing out
                                        when it is part of a family
                                        planning visit.
■ Convulsions (fits or spasms)
                                      ■ Abortions
■ Poisoning or drug overdose

■ Broken bones

■ Bad burns

■ A lot of pain

■ Bleeding that will not stop

■ Head or eye injuries

■ Trouble breathing

■ Miscarriage

■ Heart attack

■ High Fever

■ Chest pains

■ Rape

■ Any other serious problem

If you go to the emergency
room, call your health plan
as soon as possible afterwards.

Problem Solving

Use Your Plan’s
Member Services
Each plan has a
Member Services
Department to:
■ Tell you about the plan.

■ Send you a member

■ Invite you to an orientation

  session to learn about the
  plan, or tell you about it
  over the phone.
■ Send you a member ID card

  with the plan’s phone number
  on it and the name of your
  primary care provider.
■ Help you choose a primary

  care provider (PCP).
■ Answer questions and

  solve problems.

If You Have a       Know Your Rights
Problem with        In a Health Plan
Your Health Plan... You have the right to:
You can do any                         ■ Choose the health plan
of the following:                        that is right for you and
■ Call the plan’s Member                 your family.
  Services Department and              ■ Have all information about

  tell them your problem.                your health care kept confi-
  Often they can help. The               dential.
  number is on your plan               ■ Know how the plan works,
                                         and what services it offers.
■ Call the New York Medicaid
                                       ■ Choose a PCP who will give
  CHOICE HelpLine
                                         you regular checkups and
                                         keep track of all of your
■ Change Plans. Call the
                                         health care.
  New York Medicaid                    ■ An appointment within 48
  CHOICE HelpLine.
                                         to 72 hours if you are sick
■ Ask for a fair hearing
                                         and within 24 hours if you
  if your plan has denied,               need care right away.
  stopped, or reduced covered          ■ If you do not need care
  services you think you should
                                         right away, a checkup
  get. Call the New York
                                         within 12 weeks of
  Medicaid CHOICE
                                         joining the plan.
  HelpLine to find out more
                                       ■ A second opinion about
  about fair hearings.
■ Call the State Department
                                         certain medical conditions
                                         from another provider in
  of Health Complaint Line,
                                         your plan.
  Monday through Friday,
                                       ■ Change your primary
  8:30 a.m. to 4:30 p.m., at
  1-800-206-8125 if you have             care provider.
  a problem with your health           ■ Go to the emergency room

  services.                              for emergency care.
                                       ■ Be treated with dignity
If You Have                              and respect.
a Problem with
                                       ■ Complain to the health
Your Primary
Care Provider                            plan, State Department of
                                         Health, or to New York
(PCP)                                    Medicaid CHOICE.
Talk to your provider
about the problem first.
If that doesn’t work out,
you can:
■ Call your plan’s Member

  Services Department to talk
  about the problem.
■ Or you can ask to change

  providers. The phone num-
  ber to call is on your health
  plan card.

Who is not
Required to Join
a Health Plan

Some People                      Here is a list of persons who
Don’t Have to Join               can apply to be exempt and
Some Medicaid consumers          not join a health plan:
                                 ■ People with HIV infection.
have a special reason why
they do not have to join         ■ People in long-term alcohol

a health plan.                     or drug residential programs.
They can apply to be             ■ Pregnant women who are

exempt (ex-empt) and               getting prenatal care from
stay in regular Medicaid.          a provider who is not in
                                   any plan.
                                 ■ People who live in facilities

                                   for the mentally retarded and
                                   people with similar needs.
                                 ■ Some developmentally

                                   disabled people or physically
                                   disabled children who get
                                   care at home or in their
                                   community through waiver
                                   programs, and those who
                                   have the same needs.

The HelpLine has a special group
of counselors who can help you
apply for an exemption (ex-emp-shun).
Call us at 1-800-505-5678.
                                  Health Plans
                                  and HIV
                                  ■ People living with HIV may
                                    join a health plan, or keep
                                    the health care they have
                                    now. They may also join an
                                    HIV Special Needs Plan.
                                  ■ An HIV Special Needs Plan

                                    (HIV SNP) is a special
                                    managed care plan for people
■ People with long-term             living with HIV/AIDS and
  health problems being             their children up to age 19,
  treated by a specialist who       whether or not they have
  is not in any plan.               HIV or AIDS. HIV SNP
■ Adults who have serious           providers have special training
  mental illness and children       to treat people with HIV.
  who have serious emotional        If you want to know more
  problems.                         about HIV SNPs please call
■ Native American persons.
                                  ■ If you have HIV and want to
■ Homeless persons.
                                    join a health plan or an HIV
■ People who cannot find
                                    SNP, you can keep seeing your
  providers in any plan who         doctor only if he or she is in
  can serve them in their lan-      the plan you join. Ask your
  guage.                            doctors what plans they are in.
■ People who live where a         ■ To keep the health care you

  provider is not accessible.       have now, you must apply for
■ People with Supplemental          an exemption. To apply for
  Security Income (SSI)             an exemption please call
  or Medicaid-only                  1-800-505-5678.
  Supplemental Security           For more information on HIV,
  Income (MA-SSI).                call 1-800-732-9503, Monday
■ People temporarily living
                                  through Friday, 9:00 a.m. to
  outside of New York City.       5:00 p.m.
■ People scheduled for major

  surgery in the next 30 days
  whose provider is not in a
  health plan.
■ People with end-stage

  renal disease.

                                      Call the New York
                                      Medicaid CHOICE
                                      HelpLine for more
                                      information about
                                       exemptions and
                                       how to apply for
                                        an exemption.

Who is not
Required to Join
aHealth Plan

Health Plans and
Native Americans
Native Americans may join a            ■ Documentation of roll or
health plan or keep the health           band number, documenta-
care they have now. If you are           tion of parents’ or grandpar-
a Native American and you                ents’ roll or band number,
join a health plan, you can              together with birth certifi-
still go to your tribal health           cate(s) or baptismal record
center for care. You can also            indicating descent from the
go to your health plan doctor.           parent or grandparent.
If you have been seeing a              ■ Notarized letter from a
Medicaid doctor that is not              federal or state recognized
part of a health plan, and who           American Indian/Alaska
is not working in a tribal cen-          Native/Tribe Village Office
ter, you will not be able to             stating heritage or a birth
keep seeing that doctor if you           certificate indicating heritage.
join a plan. If you want to
keep seeing that doctor ask for        Call the New York Medicaid
an exemption so you won’t              CHOICE HelpLine
have to join a health plan.            (1-800-505-5678) for
                                       more information.
To get an exemption,
                                       If you think that you, too, are
you must have one of
                                       exempt (or don’t have to join),
the following:
                                       call a HelpLine counselor
■ Bureau of Indian Affairs,
                                       (1-800-505-5678) and ask
  Tribal Health, Resolution,           for an Exemption Application.
  Long House or Canadian               Anything you say to a counselor
  Department of Indian                 is kept confidential.
  Affairs Identification cards.

                                Call a HelpLine
                           counselor if you think you
                           are excluded from joining
                                 a health plan.

Some People                            ■ People with other health
Must Stay with                           insurance (if that insurance
Regular Medicaid                         costs less than Medicaid).
                                       ■ Babies under six months
Some Medicaid consumers
are not allowed to join a                who can get Supplemental
health plan. This means they             Security Income.
are “excluded” from joining            ■ Infants living with their

a health plan and must stay              mothers in jail or prison.
with regular Medicaid.                 ■ People in the recipient

Medicaid consumers who                   restriction program.
cannot join a health plan are:         ■ People eligible for both

■ People in nursing homes,               Medicaid and Medicare.
  hospices, or long term               ■ Blind or disabled children
  health care programs and               living apart from parents
  in demonstration programs.             for 30 days or more.
■ Children or adults in state
                                       ■ Foster care children.
  psychiatric or residential treat-    ■ People eligible for TB
  ment facilities.
                                         services only.
■ People who live in Family

  Care Homes licensed by the           If you become excluded for
  Office of Mental Health.             managed care after you join
                                       a health plan, you must disen-
■ People who will get
                                       roll from the health plan.
  Medicaid for less than
  6 months except for
  pregnant women.
■ People who are on Medicaid
                                       You Have the
                                       Right to a Fair
  only after they spend some           Hearing...
  of their own money for
  medical needs (spenddown             If you request an exemption
  cases).                              or exclusion, and do not get it.
                                       For more information about
                                       fair hearings, speak to a Help-
                                       Line counselor.


102301NYMANBRO   16
For Questions, Problems, or Complaints

Call the New York Medicaid CHOICE HelpLine:
Or you may also call: The New York State
Department of Health Complaint Line:
You may call to complain about your medical care, your
health plan, or about New York Medicaid CHOICE.
             New York Medicaid CHOICE HelpLine:






Telefone nimewo 1-888-329-1539, si-w bezwen yo ede-w
Haitian Creole








Llame al (1-888-329-1467), si necesita asistencia

Upang matulungan namin kayo,
tawagang lamang ang numeron nakalista sa itaas




New York Medicaid CHOICE is a program of the State of New York and New York City.
New York Medicaid CHOICE is operated by MAXIMUS.