File A Complaint: Your Right If You Receive Medicaid

Your Right if you Receive Medicaid

New York State law requires many people who receive Medicaid to enroll in an MCO. In some areas of the state, people on Medicaid will be required to join MCOs. Some people will not be required to join MCOs.

For some people on Medicaid, joining an MCO is voluntary:

You live in an area where there are not at least 2 MCOs.

You are in a residential alcohol/substance abuse treatment facility.

Most people with mental retardation or developmental disabilities (contact your local ARC or UCP for specifics).

You are disabled and in a special home care waiver program.

You are a Native American.

You receive both Medicaid and Medicare.

You have a chronic medical condition and are receiving ongoing care from a specialist who is not in any Medicaid MCOs’ network.

You have HIV/AIDS.

You receive SSI.

You are homeless.

You are an adult or child with serious mental illness.

If plans can’t provide a PCP who speaks your language.

If there are no PCPs within 30 minutes travel from your home.

For good cause.

Some groups of Medicaid recipients will not be able to join MCOs:

You receive care through a Long-Term Home Health Care Program.

You are in a state psychiatric facility or residential facility for children.

You are in a nursing home or hospice facility.

You are expected to be Medicaid eligible for less than six months.

Foster Children.

Contact the organizations listed at the end of this section for up-to-date information—the categories of people who either may or may not join an MCO could change over the next year.

If you join a Medicaid MCO, hold on to your Medicaid card. You will need it to get prescription drugs, medical supplies, over-the-counter medications when a doctor prescribes them and certain other benefits which may include family planning, transportation and dental care.

For people with HIV who receive Medicaid:

Currently Medicaid recipients with HIV and their children are not required to enroll in MCOs. Soon there will be Special Needs Plans (SNPs) in some parts of the State for people with HIV. SNPs will have to provide comprehensive services for HIV. If there is an HIV SNP in your part of the State, you and your children will have to choose between an HIV Special Needs Plan (SNP) and a
regular Medicaid MCO. If you live in a part of the State where there are no HIV SNPs, you won’t have to join a Medicaid managed care plan.

If you do enroll in a Medicaid MCO SNP you have the same rights that all consumers have as described in this guide.

For More Information about HIV SNPs contact:

NYS AIDS Coalition: 518-426-2396

NYS Department of Health AIDS Institute: 518-486- 1383.

People on Medicaid who are enrolled in MCOs have the same rights as all consumers under the
Managed Care Consumer’s Bill of Rights described in this guide.

In addition, there are other rules that apply to people on Medicaid enrolled in MCOs:

You have the right to change your MCO.

The rules for when and how often you can switch from one MCO to another vary based on where you live and whether you picked a plan or were assigned to one. Contact the organizations listed at the end of this section to find out which time frames apply to you.

You have the right to change your PCP:

Within 30 days of your first visit with that PCP. However, most MCOs let you change your PCP whenever you want to.

After that initial time period, only once every 6 months.

You have the right to see your HCP within 1 hour of your scheduled appointment time.

Medicaid MCOs cannot discriminate against you because of your health problems or disabilities, or because you are on Medicaid. Also, MCOs can not discriminate against you for filing complaints or grievances.

Your Right to Information: Along with the information that MCOs must give all consumers in the member handbook or member contract, MCOs that serve people on Medicaid must also provide the following information to Medicaid recipients:

How the plan addresses the needs of people who are visually or hearing impaired.

Notice of your right to a Medicaid Fair Hearing and to Aid Continuing whenever a health service or benefit is denied.

For women, notice of your right to self-refer for women’s health needs, at no additional cost to you, to any women’s health care provider of your choice whether that HCP is in your MCO’s network or outside that network.

Your right to a health care provider who will meet your needs:

The Commissioner of Health has established specific standards that Medicaid MCOs must meet.These standards are included in the contracts Medicaid MCOs sign with the Department of Social Services. These standards spell out acceptable:

Ratios of HCPs to patients.

Travel distances and travel times to HCPs.

Waiting times to get an appointment or a referral to an HCP.

Medicaid managed care consumer complaint rights:

People on Medicaid have the same rights as other consumers as outlined in the sections on Grievance Procedures and Utilization Review. In addition, people receiving Medicaid have the right to have their complaints resolved through the Medicaid Fair Hearing process which is external to all health insurance plans. When you request a Fair Hearing you can request Aid Continuing, that is, that ongoing care continue during the Fair Hearing process.

Here is how the process works:

Your MCO notifies you that a Medicaid service or benefit has been denied, suspended or discontinued.

You have 60 days to request a Fair Hearing, but

If you want Aid Continuing you must request a Fair Hearing within 10 days of the date on the notice from your MCO. If you do not get a written notice, you can get Aid Continuing at any time.

Request a Fair Hearing even if you think that your MCO made a mistake. You can always cancel your request later if your complaint is resolved to your satisfaction before the hearing date. Most Medicaid notices say you can request a conference or a hearing. Always request a hearing, because you can only get Aid Continuing if you request a hearing.

To ask for a Fair Hearing contact:

NYS Dept. of Health,
PO Box 1930, Albany, NY 12201,
518-474-8781 or 212-417-6550.

If you are disabled or too ill to attend a Fair Hearing, you can request a home hearing. The Department of Health (DOH) will schedule either:

A hearing that your representative attends, or

A telephone hearing, or

A paper hearing.

You get to choose which type of hearing.If you don’t get everything you asked for from that hearing, DOH will automatically schedule a home hearing in your home with Aid Continuing.

For More Information About Medicaid & MCOs contact:

Dept. of Health Managed Care Hot line: 800-206-8125

Legal Aid Society’s Health Law Unit, 212-577-3575, TTY/TDD 212-577-3581, or upstate call toll free: 888- 500-2455

New York Legal Assistance Group: 212-750-0800, ext. 153

NYC Managed Care Helpline: 800-505-5678

Greater Upstate Law Project: 800-724-0490

Community Service Society Helpline: 212-614-5400

Legal Action Center (for questions about alcohol and drug treatment): 800-299-4121.

Your local legal services or legal aid office.