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FIDA General Participant Information

  1. Your Rights & Responsibilities should you decide to leave Centers Plan for FIDA Care Complete
  2. Out of network coverage rules.
  3. Coverage Decisions

Your Rights & Responsibilities should you decide to leave Centers Plan for FIDA Care Complete

When can you end your participation in our FIDA Plan?

You can end your participation in Centers Plan for FIDA Care Complete at any time. Your participation will end on the last day of the month that we get your request to change your plan. For example, if we get your request on January 25, your coverage with our plan will end on January 31. Your new coverage will begin the first day of the next month.

These are ways you can get more information about when you can end your participation: 

  • Call the Enrollment Broker (New York Medicaid Choice) at 1-855-600-FIDA, Monday through Friday from 8:30 am to 8:00 pm and Saturday from 10:00 am to 6:00 pm. TTY users should call 1-888-329-1541.
  • Call the Health Insurance Information, Counseling and Assistance Program (HIICAP). The phone number for HIICAP is 1-800-701-0501.
  • Call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call 1-877-486-2048.

The Independent Consumer Advocacy Network (ICAN) can also give you free information and assistance with any issues you may have with your FIDA Plan. To contact ICAN, call 1-844-614-8800. (TTY users call 711, then follow the prompts to dial 844-614-8800.)

Your participation will end in certain situations (even if you haven’t asked for it to end)

These are the cases when the FIDA Program rules require that your participation must end:

  • If there is a break in your Medicare Part A and Part B coverage.
  • If you no longer qualify for Medicaid.
  • If you permanently move out of our service area.
  • If you are away from our service area for more than six consecutive months.
  • If you move or take a long trip, you need to call Participant Services to find out if the place you are moving or traveling to is in Centers Plan for FIDA Care Complete’s service area.
  • If you go to jail, prison, or a correctional facility for a criminal offense.
  • If you lie about or withhold information about other insurance you have for health care or prescription drugs.
  • If you are not a United States citizen or are not lawfully present in the United States.

In addition, we can ask that the FIDA Program remove you from Centers Plan for FIDA Care Complete for the following reasons:

  • If you intentionally give us incorrect information when you are enrolling in Centers Plan for FIDA Care Complete and that information affects your eligibility for our plan.
  • If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other Participants of Centers Plan for FIDA Care Complete even after we make and document our efforts to resolve any problems you may have.
  • If you knowingly fail to complete and submit any necessary consent or release form allowing Centers Plan for FIDA Care Complete and providers to access.

In any of the above situations, we will notify you of our concern before we ask for FIDA Program approval to have you disenrolled from Centers Plan for FIDA Care Complete. We will do this so that you have the opportunity to resolve the problems first. If the problems aren’t resolved, we will notify you again once we have submitted the request. If the FIDA Program approves our request, you will get a disenrollment notice. The Enrollment Broker will be available to explain your other coverage options.

We cannot ask that you be disenrolled from our FIDA Plan for any reason related to your health

If you feel that we are asking that you be disenrolled from Centers Plan for FIDA Care Complete for a health-related reason, you should call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call 1-877-486-2048. You should also call Medicaid at 1-800-541-2831.

  1. A.    You may have the right to ask for a fair hearing if the FIDA Program ends your participation in our FIDA Plan (Page

If the FIDA Program ends your participation in Centers Plan for FIDA Care Complete, the FIDA Program must tell you its reasons in writing. It must also explain how you can ask for a fair hearing about the decision to end your participation.

  1. B.    You have the right to file a grievance with Centers Plan for FIDA Care Complete if we ask the FIDA Program to end your participation in our FIDA Plan

If we ask the FIDA Program to end your participation in our plan, we must tell you our reasons in writing. We must also explain how you can file a grievance about our request to end your participation. You can see FIDA Grievances & Appeals for information about how to file a grievance.

Note: You can use the grievance process to express your dissatisfaction with our request to end your participation. However, if you want to ask that the decision be changed, you must file a fair hearing as described in Section B just above.

How you will get Medicaid services  

If you leave the FIDA Plan, you will still be able to get your Medicaid services. You will have the opportunity to switch to a Medicaid Managed Long-Term Care plan for your long-term services and supports and to get your Medicaid physical and behavioral health services through Medicaid Fee-for-Service. You can choose to completely stop getting long-term services and supports. However, it may take extra time to complete a safe discharge process. If you choose to completely stop getting long-term services and supports, we must ensure that you will be safe without the receipt of these services. To do this, we will complete a safe discharge process. This might take a few weeks from the date you tell us you want to leave long-term services and supports. During this time, you will be enrolled into the Medicaid Managed Long-Term Care plan operated by the same company as Centers Plan for FIDA Care Complete. Your change request on your Medicare coverage will not be delayed and will take effect on the first day of the month after you ask for the change. 

Until your participation ends, you will keep getting your medical services and drugs through our FIDA Plan

If you leave Centers Plan for FIDA Care Complete, it may take time before your participation ends and your new Medicare and Medicaid coverage begins. See page 230 for more information. During this time, you will keep getting your services, items, and drugs through Centers Plan for FIDA Care Complete.

You should use our network pharmacies to get your prescriptions filled. Usually, your prescription drugs are covered only if they are filled at a network pharmacy, including through our mail-order pharmacy services.

If you are hospitalized on the day that your participation ends, your hospital stay will usually be covered by our plan until you are discharged. This will happen even if your new coverage begins before you are discharged.

 

Where can you get more information about ending your participation in our FIDA Plan?

If you have questions or would like more information on when we can end your participation, you can call Participant Services at 1-800-466-2745, seven days a week, 8 a.m. to 8 p.m. TTY users call 711 or 1-800-421-1220. 

The Independent Consumer Advocacy Network (ICAN) can also give you free information and assistance with any issues you may have with your FIDA Plan. ICAN may be reached toll-free at 1-844-614-8800 or online at icannys.org. (TTY users call 711, then follow the prompts to dial 844-614-8800

For additional information on disenrollment rights and responsibility please review Chapter 10 of your Participant Handbook.   

 

Out of Network Coverage Rules

With limited exceptions, while you are a Participant in Centers Plan for FIDA Care Complete, you must use network providers to get your medical care and services, so it is important to know which providers are part of our network. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which your Interdisciplinary Team (IDT) or our plan authorize use of out-of-network providers. For more information see the Centers Plan for FIDA Care Complete Participant Handbook.

Coverage Decisions
What is a Coverage Decision?
A coverage decision is an initial decision your Interdisciplinary Team (IDT), Centers Plan for FIDA Care Complete, or an authorized specialist makes about your benefits and coverage or about the amount Centers Plan for FIDA Care Complete will pay for your medical services, items, or drugs. Your IDT, Centers Plan for FIDA Care Complete, or your authorized specialist is making a coverage decision whenever it decides what is covered for you and how much Centers Plan for FIDA Care Complete will pay. Authorized specialists include dentists, optometrists, ophthalmologists, and audiologists.

If you or your provider is not sure if a service, item, or drug is covered by Centers Plan for FIDA Care Complete, either of you can ask for a coverage decision before the provider gives the service, item, or drug.

 

Asking for a Coverage Decision
How to ask for a coverage decision to get a medical, behavioral health or long-term care service:
If there is a service or item that you feel you need, ask your Interdisciplinary Team (IDT), Centers Plan for FIDA Care Complete, or authorized specialist to approve that service or item for you. You can do this by contacting your Care Manager and telling him/her that you want a coverage decision. Or you can call, write, or fax us, or ask your representative or provider to contact us and ask for a coverage decision.

You can call us at: 1-800-466-2745 (TTY users call: 1-800-421-1220)
You can fax us at: 1-718-581-5522
You can write to us at:

Centers Plan for FIDA Care Complete
Attn: Utilization Management Department
75 Vanderbilt Avenue
Staten Island, NY 10304-2604

Once you have asked, your IDT, Centers Plan for FIDA Care Complete, or authorized specialist will make a coverage decision.

 

How long does it take to get a coverage decision?

It usually takes up to 3 business days after you asked. If you do not receive a decision within 3 business days, you can appeal.

  • Sometimes the IDT, Centers Plan for FIDA Care Complete, or authorized specialist needs more time to make a decision. In this case, you will receive a letter telling you that it could take up to 14 more calendar days. The letter will explain why more time is needed.

There are three exceptions to the decision deadline described above:

  • For coverage decisions about continuing or adding to your current health care services, you will receive a decision within 1 business day.
  • For coverage decisions about home health care services after an inpatient hospital stay, you will receive a decision within 1 business day. However, if the day after your request is a weekend or holiday, you will receive a decision within 72 hours.
  • For coverage decisions on a service or item that you already received, you will receive a decision within 14 calendar days.

 

Can I get a coverage decision faster?

Yes. If you need a response faster because of your health, you should ask for a “fast coverage decision.” If the IDT, Centers Plan for FIDA Care Complete, or authorized specialist approves the request, you will receive a decision within 24 hours.

However, sometimes the IDT, Centers Plan for FIDA Care Complete, or authorized specialist need more time. In this case, you will receive a letter telling you that it could to take up to 14 more calendar days. The letter will explain why more time is needed.

 

If you want to ask for a fast coverage decision, you can do one of three things:

  • Call your Care Manager;
  • Call Participant Services at 1-800-466-2745 or fax us at 1-718-581-5522; or
  • Have your provider or your representative call Participant Services.

 

Here are the rules for asking for a fast coverage decision:

You must meet the following two requirements to get a fast coverage decision:

  • You can get a fast coverage decision only if you are asking for coverage for medical care or an item you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care or an item you have already received.)
  • You can get a fast coverage decision only if the standard 3 business day deadline could seriously jeopardize your life, health, or ability to attain, maintain or regain maximum function.
    • If your provider says that you need a fast coverage decision, you will automatically get one.
      • If you ask for a fast coverage decision without your provider’s support, the IDT, Centers Plan for FIDA Care Complete, or authorized specialist will decide if you get a fast coverage decision.
        • If the IDT, Centers Plan for FIDA Care Complete, or authorized specialist decides that your health does not meet the requirements for a fast coverage decision, you will receive a letter. The IDT, Centers Plan for FIDA Care Complete, or authorized specialist will also use the standard 3 business day deadline instead.
        • This letter will tell you that if your provider asks for the fast coverage decision, you will automatically get a fast coverage decision.
        • The letter will also tell how you can file a “fast grievance” about the decision to give you a standard coverage decision instead of the fast coverage decision you requested. (For more information about the process for making grievances, including fast grievances, see Chapter 9, Section 10 of your Participant Handbook.)

 

If the coverage decision is Yes, when will I get the service or item?

If the coverage decision is Yes, that means you have been approved to get the service or item. If possible, you will receive or start to receive the approved service or item within 3 business days from the date of our decision. If the service or item cannot reasonably be provided within 3 business days, your IDT will work with the provider to make sure you get the approved service or item as quickly as possible.

 

If the coverage decision is No, how will I find out?

If the answer is No, you will receive a letter explaining why. The plan or your IDT will also notify you by phone.

  • If the IDT, Centers Plan for FIDA Care Complete, or authorized specialist says no, you have the right to ask us to reconsider – and change – the decision. You can do this by making (or “filing”) an appeal. Making an appeal means asking Centers Plan for FIDA Care Complete to review the decision to deny coverage.
  • If you decide to make an appeal, it means you are going on to Level 1 of the appeals process as described in Chapter 9, Section 5.3, of your Participant Handbook.

Centers Plan for FIDA Care Complete Disclaimers

Centers Plan FIDA Care Complete (Medicare-Medicaid Plan) is a managed care plan that contracts with both Medicare and New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.

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Last modified: Apr 4, 2019