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.
How to Request a Coverage Determination
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.
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.
Contact Us:
Toll-Free: 1.844.269.3442
TTY: 711
Mailing Address:
Health Pointe of New York
810 Seventh Avenue – Suite 801
New York, New York 10019
Health Pointe of New York is an HMO I-SNP with a Medicare Contract. Enrollment in Health Pointe of New York depends on contract renewal.
CMS Material ID: H1722_HPweb2019 | Last updated 01/17/2020