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  • Fully Integrated Dual Advantage (FIDA) - closed effective 12/31/18 > Participant Rights and Responsibilities

    The rights and responsibilities listed below indicate what participants can expect of FIDA plans and what responsibilities participants have to FIDA plans.

    FIDA Plan participants have the right to:

    • To receive medically necessary items and services as needed to meet the participant's needs, in a manner that is sensitive to the participant's language and culture and that is provided in an appropriate care setting, including the home and community.
    • To receive timely access to care and services.
    • To request and receive written and oral information about the FIDA Plan, its participating providers, its benefits and services and the participants’ rights and responsibilities in a manner the participant understands.
    • To receive materials and/or assistance in a foreign language and in alternative formats, if necessary.
    • To be provided qualified interpreters free of charge if a participant needs interpreters during appointments with providers and when talking to the FIDA Plan.
    • To be treated with consideration, respect and full recognition of his or her dignity, privacy, and individuality.
    • To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
    • Not to be neglected, intimidated, physically or verbally abused, mistreated or exploited.
    • To not be discriminated against on the basis of and to get care without regard to sex, race, health status, disability, color, age, national origin, sexual orientation, marital status or religion.
    • To be told where, when and how to get the services the participant needs, including how to get covered benefits from out-of-network providers if they are not available in the FIDA Plan network.
    • To complain to NYSDOH or the Local Department of Social Services, and the right to use the New York State Fair Hearing System and/or a New York State External Appeal, where appropriate.
    • To be advised in writing of the availability of the NYSDOH toll-free hotline, the telephone number, the hours of its operation and that the purpose of the hotline is to receive complaints or answer questions about home care agencies.
    • To appoint someone to speak for him/her about the care he/she needs.
    • To be informed of all rights, and the right to exercise such rights, in writing prior to the effective date of enrollment.
    • To participate in his/her care planning and participate in any discussions around changes to the person-centered service plan, if/when they are warranted.
    • To recommend changes in policies and services to agency personnel, NYSDOH or any outside representative of the participant's choice.
    • To have telephone access to a nursing hotline and on-call participating providers 24/7 in order to obtain any needed emergency or urgent care or assistance.
    • To access care without facing physical barriers. This includes the right to be able to get in and out of a provider’s office, including barrier-free access for participants with disabilities or other conditions limiting mobility, in accordance with the Americans with Disabilities Act.
    • To receive reasonable accommodations in accessing care, in interacting with the FIDA Plan and providers, and in receiving information about one’s care and coverage.
    • To see a specialist and request to have a specialist serve as primary care provider.
    • To talk with and receive information from providers on all conditions and all available treatment options and alternatives, regardless of cost, and to have these presented in a manner the participant understands. This includes the right to be told about any risks involved in treatment options and about whether any proposed medical care or treatment is part of a research experiment.
    • To choose whether to accept or refuse care and treatment, after being fully informed of the options and the risks involved. This includes the right to say yes or no to the care recommended by providers, the right to leave a hospital or other medical facility, even if against medical advice, and to stop taking a prescribed medication.
    • To receive a written explanation if covered items or services were denied, without having to request a written explanation.
    • To have privacy in care, conversations with providers, and medical records such that:
      • Medical and other records and discussions with providers will be kept private and confidential.
      • Participant gets to approve or refuse to allow the release of identifiable medical or personal information, except when the release is required by law.
      • Participant may request that any communication that contains protected health information from the FIDA Plan be sent by alternative means or to an alternative address.
      • Participant is provided a copy of the FIDA Plan’s Privacy Practices, without having to request the same.
      • Participant may request and receive a copy of his or her medical records and request that they be amended or corrected, if the privacy rule applies.
      • Participant may request information on how his/her health and other personal information has been released by the FIDA Plan.
    • To seek and receive information and assistance from the independent, conflict-free Participant Ombudsman.
    • To make decisions about providers and coverage, which includes the right to choose and change providers within the FIDA Plan’s network and to choose and change coverage (including how one receives his/her Medicare and/or Medicaid coverage – whether by changing to another FIDA Plan or making other changes in coverage).
    • To be informed at the time of enrollment and at PCSP update or revision meetings of the explanation of what is an advance directive and the right to make an advance directive – giving instructions about what is to be done if the participant is not able to make medical decisions for him/herself - and to have the FIDA Plan and its participating providers honor it
    • To access information about the FIDA Plan, its network of providers, and covered items and services.

      IMPORTANT: State and federal laws give adults in New York State the right to accept or refuse medical treatment, including life-sustaining treatment, in the event of catastrophic illness or injury. FIDA Plans make available materials on advance directives with written instructions, such as a living will or health care proxy containing the members’ wishes relating to health care should they become incapacitated. If members live in another state, they should check with their local state insurance department, if available, for information on additional rights they may have.

      FIDA Plan participants have the responsibility to:

      • To try to understand covered items and services and the rules around getting covered items and services.
      • To tell providers that they are enrolled in a FIDA Plan and show their FIDA Plan ID card.
      • To treat providers and employees of the FIDA Plan with respect.
      • To communicate problems immediately to the FIDA Plan.
      • To keep appointments or notify the interdisciplinary team if an appointment cannot be kept.
      • To supply accurate and complete information to the FIDA Plan’s employees.
      • To actively participate in PCSP development and implementation.
      • To notify the State and the FIDA Plan of any changes in income and assets. Assets include bank accounts, cash in hand, certificates of deposit, stocks, life insurance policies and any other assets.
      • To ask questions and request further information regarding anything not understood.
      • To use the FIDA Plan’s participating providers for services included in the FIDA Plan benefit package.
      • To notify the FIDA Plan of any change in address or lengthy absence from the area.
      • To comply with all policies of the FIDA Plan as noted in the Participant Handbook.
      • If sick or injured, to call their doctors or care coordinators for direction right away.
      • In case of emergency, to call 911.
      • If emergency services are required out of the service area, to notify the FIDA Plan as soon as possible.

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      Glossary terms found on this page:

      Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

      Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

      Initial oral or written communication from a member or their designee or provider that expresses discontent with any aspect of their care or coverage with EmblemHealth. Specifically, it is dissatisfaction with:

      • A determination made by the plan, other than a determination of medical necessity or a determination that a service is considered experimental or investigational
      • Treatment experienced through the plan, its providers or contractors
      • Any concern with the plan, its benefits, employees or providers.

      An individual other than the subscriber who is eligible to receive health care services under the member's Certificate of Insurance. Generally, dependents are limited to the subscriber's spouse and eligible children.

      The date on which the coverage of an insurance policy goes into effect at 12:01 am.

      Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

      A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

      Written request for an independent entity that has been certified by the State to conduct a review of a denial of coverage, based on lack of medical necessity or that the service requested is experimental and investigational.

      A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

      A managed care plan under contract with the Centers for Medicare & Medicaid Services and the State to provide the fully-integrated Medicare and Medicaid benefits under the FIDA demonstration. Also called fully-integrated duals advantage plan.

      An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

      • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
      • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
      • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
      • Maintains medical records for all patients
      • Has a requirement that every patient be under the care of a member of the medical staff
      • Provides 24-hour patient services
      • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

      A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.

      The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.

      An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

      A city or county social services district as constituted by Section 61 of the New York State Social Services Law (SSL). Also called a LDSS.

      Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

      A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

      Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.

      Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

      • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
      • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
      • It is in accordance with accepted standards of good medical practice in the community.
      • It is furnished in a setting commensurate with the member's medical needs and condition.
      • It cannot be omitted under the standards referenced above.
      • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
      • It is not furnished primarily for the convenience of the member, the member's family or the provider.
      • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

      The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

      Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

      A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

      An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

      The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

      A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A network provider is a member of the EmblemHealth network of network providers applicable to the member's certificate. Therefore, they are sometimes referred to as participating providers. Payment is made directly to a network provider. Please consult the EmblemHealth Directory or go online to search for network providers.

      The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called the New York State Department of Health.

      The use of health care providers who have not contracted with the health plan to provide services. Depending on the member's contract, out-of-network services may not be covered.

      A health care provider, such as a physician, skilled nursing facility, home health agency or laboratory, that does not have an agreement with EmblemHealth plans to provide covered services to members. Also called a Non-Participating Provider.

      A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A participating provider is a member of the EmblemHealth network of providers applicable to the member's certificate. Therefore, they are more commonly referred to as network providers. Payment is made directly to a participating provider. Please consult the EmblemHealth Directory or go online to search for participating providers.

      A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

      A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

      A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

      • Doctor of medicine
      • Doctor of osteopathy
      • Dentist
      • Chiropractor
      • Doctor of podiatric medicine
      • Physical therapist
      • Nurse midwife
      • Certified and registered psychologist
      • Certified and qualified social worker
      • Optometrist
      • Nurse anesthetist
      • Speech-language pathologist
      • Audiologist
      • Clinical laboratory
      • Screening center
      • General hospital
      • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

      A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

      New York State Department of Health. This agency provides information for consumers, doctors, researchers and health care providers.

      The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.

      Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or severe pain, such as a high fever.


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