Yo u h a v e
to Choose a
This New York
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
■ 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.
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
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
How Health Plans Work
Health Plan Services
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
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
the Services Your
■ 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
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.
Health Plans, Call the
New York HelpLine
1- 800 -505- 5678
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
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
■ 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
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
■ 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
■ Convulsions (fits or spasms)
■ Poisoning or drug overdose
■ Broken bones
■ Bad burns
■ A lot of pain
■ Bleeding that will not stop
■ Head or eye injuries
■ Trouble breathing
■ Heart attack
■ High Fever
■ Chest pains
■ Any other serious problem
If you go to the emergency
room, call your health plan
as soon as possible afterwards.
Use Your Plan’s
Each plan has a
■ 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
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
you regular checkups and
keep track of all of your
■ Change Plans. Call the
New York Medicaid ■ An appointment within 48
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
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,
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
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,
■ 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
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
■ 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.
■ 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
■ People with end-stage
Call the New York
HelpLine for more
how to apply for
Who is not
Required to Join
Health Plans and
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
To get an exemption,
If you think that you, too, are
you must have one of
exempt (or don’t have to join),
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
■ 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
■ 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-
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
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.