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Restricted Recipients

Views: 4175
Posted: 30 Sep, 2011
by Sarina Master (Legal Aid Society)
Updated: 14 Oct, 2011
by Sarina Master (Legal Aid Society)
MEDICAID MANAGED CARE FACT SHEET
 
Restricted Recipients- the way you receive your Medicaid benefits is changing!
 
On August 1, 2011, Medicaid recipients who are restricted to certain providers will have to enroll in a Medicaid health plan. Before August 1, 2011, restricted recipients were “excluded” from managed care, which means that they could not join a Medicaid health plan even if they wanted to.
 
WHAT HAPPENS NEXT?
·        If you are a restricted recipient, you will receive a “heads up” notice from the State Department of Health on or around August 1, 2011, explaining the change.
·        If you live in New York City, you will also receive a mandatory enrollment notice from New York Medicaid Choice asking you to choose a Medicaid health plan . Residents of some upstate counties will receive this notice from The Local Department of Social Services. In some upstate counties restricted recipients will get the enrollment notice at recertification or after a change is made to their Medicaid case.
·        The notice will come with a brochure describing the managed care program, enrollment forms, a list of Medicaid health plans in the area and a letter explaining that the State Department of Health will choose a Medicaid health plan for you if you do not choose on your own.  
HOW LONG DO I HAVE TO CHOOSE A HEALTH PLAN?
·        Currently, non-disabled Medicaid recipients have 60 days to choose a plan; disabled recipients have 90 days to choose a plan. If you receive an enrollment package after October 1, 2011 you will only have 30 days to choose a plan.
·        If you do not choose a plan one will be chosen for you! This plan might not work with the providers you currently see!
·        After the first 90 days of enrollment you will be “locked-in” to your health plan and will not be allowed change plans during the remainder of that first year unless you have a very good reason for doing so.
 
HOW DO I CHOOSE A HEALTH PLAN?
Make a list of all your medical providers and figure out what Medicaid health plans each provider accepts. Some examples of Medical providers are your regular doctor, your specialist, your home care services provider, your physical therapist, and your durable medical equipment provider. Choose the Medicaid health plan that most of your providers accept, especially the providers that you do not want to give up. 
 
WILL MY HEALTH PLAN CONTINUE MY RESTRICTION?
Your new Medicaid healthplan will manage your current restrictions and will have the ability to make changes to them.
 
CAN MY HEALTH PLAN CHANGE OR EXTEND MY RESTRICTION?
Your new Medicaid health plan cancontinue your restriction or place a new restriction on your Medicaid case but only for specific reasons, such as: duplicative, excessive, contraindicated or conflicting services, drugs or supplies or Fraud or illegal activity.
 
WHAT ARE MY RIGHTS?
If your restriction is continued after the initial authorization period or if a new restriction is placed on your Medicaid case, you have the right to a notice of action from your Medicaid health plan and a Fair Hearing
Here are some steps you can take:
§       If your Medicaid case is restricted without notice, request a fair hearing immediately, and ask for aid continuing so your services can continue until the outcome of the hearing.
§       If you receive a notice advising you of a new restriction, request a fair hearing immediately. To be eligible for aid continuing you must request the hearing within 10 days of the date of the notice.
§       File a complaint with your Medicaid health plan by contacting member services.
§       File a complaint with the New York State Department of Health Managed Care hotline (see phone number below)
 
WHO CAN I CALL FOR HELP?
 
The Legal Aid Society’s Health Law Help-line
212-577-3575 ( NYC)
888-500-2544   (Outside NYC)
Open on Tuesdays
 
Community Health Advocates Hotline:   1-888-614-5400
 
NYS DOH Managed Care Complaint Line
1-800-206-8125,

Mon. - Fri. 8:30 am - 4:30 pm

Attached files
file Microsoft Word - RR Fact Sheet 9_20_11.pdf (57 kb)

Also listed in
folder Medicaid -> Medicaid Managed Care

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