PART C Information - Health Pointe of New York

Medicare Part C Information

Out-of-network Coverage

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Health Pointe Direct Complete Plan authorizes use of out-of-network providers.

Out-of-network/non-contracted providers are under no obligation to treat Health Pointe Direct Complete Plan members, except in emergency situations. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage. Please call our member services number or see your Evidence Of Coverage (PDF) for more information, including the cost-sharing that applies to out-of-network services.

If you don’t have your copy of the Provider Directory, you can request a copy from Member Services 1-844-269-3442. (TTY users should call 711). From October 1 to March 31, we are open 7 days a week, from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, from 8 a.m. to 8 p.m. EST. You may ask Member Services for more information about our network providers, including their qualifications.

Click here (PDF) to download the Provider Directory. Both Member Services and the website can give you the most up-to-date information about changes in our network providers.

How to Appoint a Representative

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal.

There may be someone who is already legally authorized to act as your representative under State law.
If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services at 1-844-269-3442 (TTY users should call 711). From October 1 to March 31, we are open 7 days a week, from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, from 8 a.m. to 8 p.m. EST.) and ask for the “Appointment of Representative” form.
Click here (PDF) to download the form from the CMS website.

The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.

How to get care from out-of-network providers

You generally must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. Here are two exceptions:

The plan covers emergency care or urgently needed care that you get from an out-of-network provider.
If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider.

Authorization should be obtained from the plan prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider.

Your PCP is responsible for contacting Health Pointe Direct Complete Plan to obtain an authorization for out-of-network services.
You are entitled to receive services from out-of-network providers for emergency or out of area urgently needed services.
The Plan is required to cover dialysis services for ESRD members who have traveled outside the plan's service area and are not able to access contracted ESRD providers.

Out-of-network/non-contracted providers are under no obligation to treat Health Pointe Direct Complete Plan members, except in emergency situations. Please call our member services number or see your Evidence Of Coverage (PDF) for more information, including the cost- sharing that applies to out-of-network services.

How to contact Social Security or Medicaid for Extra Help

People with limited income and resources may qualify for “Extra Help”. If you qualify, you get help paying for any Medicare drug plan’s monthly premium, yearly deductible, and prescription co-payments. This “Extra Help” also counts toward your out-of-pocket costs.

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:

1-800-MEDICARE (1-800-633-4227). TTY/TTD users should call 1-877-486-2024, 24 hours a day/7days a week; or

The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call, 1-800-325-0778; or Your State Medicaid Office.

How to Request a Coverage Determination

You may ask our plan to make a coverage decision on the medical care you are requesting. Start by calling or writing us using the information below to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this.

PHONE: 1-844-269-3442 (TTY users should call 711). From October 1 to March 31, we are open 7 days a week, from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, from 8 a.m. to 8 p.m. EST.

MAIL:

Health Pointe of New York

810 7th Ave, Suite 801

New York, NY 10019

If your health requires a quick response, you should ask us to make a “fast coverage decision.” More information can be found below.

Coverage Decisions

A coverage decision is a decision we make about your benefits and coverage, or about the amount we will pay for your medical services. You can ask us to make a coverage decision on the medical care you or your doctor is requesting. There are two kinds of coverage decisions – standard or fast.

A standard decision means we will give you an answer within 14 days after we receive your request. However, we can take up to 14 more days if you ask for more time, or if we need information (such as medical records) that may benefit you. If your health requires a quick response, you should ask us to make a “fast decision.”
A fast decision means we will answer within 72 hours. However, we can take up to 14 more days if we find that some information is missing that may benefit you, or if you need to get information to us for the review. If we decide to take extra days, we will tell you in writing. If you ask for a fast decision on your own, without your doctor’s support, our plan will decide whether your health requires that we give you a fast decision.

You or your physician can call our Medical Management Department at 1-844-269-3442. TTY users can contact the plan at 711.

If we say yes to your request, we will authorize or provide the care within 72 hours for a fast decision or within 14 days for a standard decision. If we say no to part or all of your request, we will send you a denial in writing that will explain your right to appeal the denial. Information on the aggregate number of Health Pointe Direct Complete Plan’s grievances, appeals and exceptions is available by contacting Health Pointe Direct Complete Plan’s Member Services at 1-844-269-3442.From October 1 to March 31, we are open 7 days a week, from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, from 8 a.m. to 8 p.m. EST. Please review the Evidence Of Coverage (PDF) (Chapter 9, Section 4 & Section 5) for your particular plan for more detailed information on coverage decisions and appeals requests.

A member appeal can be submitted when you want us to reconsider and change a decision we have made about what services are covered for you or what we will pay for a service. An appeal must be filed within 60 calendar days of the coverage decision. Two types of appeals are available to members –- a fast-track appeal and a standard appeal.

Members who submit a fast-track appeal must meet criteria that the standard process time frame would jeopardize the member's health status. These fast reviews will be completed within 72 hours.
Standard appeal requests will be reviewed within 30 calendar days.

Members can make a fast-track appeal request by calling 1-844-269-3442 (TTY users should call 711). If the denial is reversed, we will authorize or provide care within 72 hours for a fast-track appeal or within 30 days for a standard appeal. If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have sent your appeal to the Independent Review Entity for a Level 2 Appeal.

To make an appeal in writing, you can mail to:

Health Pointe of New York

ATTN: Appeals and Grievances Department

810 7th Ave, Suite 801

New York, NY 10019

Please review the Evidence Of Coverage (PDF) (Chapter 9, Section 4 & Section 5) for more detailed information on coverage decisions or appeals.

Grievances

A grievance is any complaint other than one that involves a coverage decision. You would file a grievance if you have any type of problem with Health Pointe Direct Complete Plan or one of our network providers that does not relate to coverage for a service. If you have a grievance, we encourage you to call Member Services for a prompt response. We will try to resolve any complaint over the phone. You may also send your complaint in writing.

To submit a grievance in writing, please mail to:

Health Pointe of New York

ATTN: Appeals and Grievances Department

810 7th Ave, Suite 801

New York, NY 10019

We will notify you of a decision within 30 days of receipt of the written grievance. We may extend this time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. An expedited grievance can be made orally by calling 1-844-269-3442 for additional information, (TTY users should call 711). From October 1 to March 31, we are open 7 days a week, from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, from 8 a.m. to 8 p.m. EST.

Please review the Evidence Of Coverage (PDF) (Chapter 9, Section 10) for more detailed information on making complaints.

Eligibility

You are eligible for membership in our plan as long as:

You have both Medicare Part A and Medicare Part B (Section 2.2 tells you about Medicare Part A and Medicare Part B)
-- and -- you live in our geographic service area
-- and -- you are a United States citizen or are lawfully present in the United States
-- and --you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated.
-- and --you meet the special eligibility requirements described below.

Special eligibility requirements for our plan

Our plan is designed to meet the specialized needs of people who need a level of care that is usually provided in a nursing home.

To be eligible for our plan, you must live in a nursing home available through our plan. Please see the plan’s Provider Directory for a list of our contracted nursing homes or call Member Services at 1-844-269-3442 (TTY users should call 711). From October 1 to March 31, we are open 7 days a week, from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, from 8 a.m. to 8 p.m. EST) and ask us to send you a list.

To be eligible for our plan, you must meet one of the two requirements listed below.

You live in a nursing home available through our plan. Please see the plan’s Provider Directory for a list of our contracted nursing homes or call Member Services and ask us to send you a list.
If you lose your eligibility but can reasonably be expected to regain eligibility within 3-month(s), then you are still eligible for membership in our plan (Chapter 4, Section 2.1 of the Evidence Of Coverage (PDF) tells you about coverage and cost sharing during a period of deemed continued eligibility).

Member Rights & Responsibilities

As a Health Pointe Direct Complete Plan beneficiary, we must honor your rights as a member of our plan.

We must provide information in a way that works for you (in languages other than English that are spoken in the plan service area, in Braille, in large print, or other alternate formats, etc.)
We must treat you with fairness and respect at all times.We must ensure that you get timely access to your covered services and drugs.
We must protect the privacy of your personal health Information.
We must give you information about the plan, its network of providers, and your covered services.
We must support your right to make decisions about your care.

You have the right to know your treatment options and participate in decisions about your health care.

You have the right to get full information from your doctors and other health care providers when you go for medical care.

You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:

To know about all of your choices.
To know about the risks.
The right to say “no.”
To receive an explanation if you are denied coverage for care.

You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself.

You have the right to make complaints and to ask us to reconsider decisions we have made.

The following are your responsibilities as a Health Pointe Direct Complete Plan member:

Get familiar with your covered services and the rules you must follow to get these covered services.

If you have any other health insurance coverage or prescription drug coverage besides our plan, you are required to tell us.

Tell your doctor and other health care providers that you are enrolled in our plan.

Help your doctors and other providers help you, by giving them information, asking questions and following through on your care.
Be considerate.
Pay what you owe.
Tell us if you move.
Call Member Services at 1-844-269-3442 (TTY 711) for help if you have questions or concerns.

Please view the Evidence of Coverage (PDF) for your Health Pointe Direct Complete Plan for more detailed information on all Member Rights and Responsibilities. Click Here (PDF) for HIPAA Privacy Rules

Can’t find what you are looking for or need to check the status of your request?

For more information, please call us at:

Health Pointe Direct Complete Plan

1-844-269-3442 (TTY 711)

Our hours are 8:00 a.m.– 8:00 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30. Calls to this number are free.

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