Member Handbook New York Managed Long-Term Care …

1 ENY-MHB-0067-20 Member HandbookNew York Managed Long-Term care ProgramENY-MHB-0067-20 Member Handbook New York Managed Long-Term care Program 800-950-7679 (TTY 711) Services provided by HealthPlus HP, LLC, a licensee of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. ENY-MHB-0067-20 Dear Member : Welcome to the Empire BlueCross BlueShield HealthPlus Managed Long-Term care (MLTC) plan! We are delighted that you have selected Empire as your Managed Long-Term care plan and are confident that you will be very satisfied with your choice. You will receive your Empire Member ID card within 14 days of your enrollment effective date. Your ID card will tell you when your Empire MLTC membership starts. Please check your ID card right away. If any information is not right, we will send you a new ID card with the correct information. Please take some time to review your Member Handbook and the provider directory you received during your home visit with a care coordinator.

2 Para recibir esta informaci n en espa ol, llame a Servicios al Miembro al 800-950-7679 (TTY 711). 800-950-7679 (TTY 711) Once your enrollment has been approved, you will be assigned your own care manager, who is a registered nurse. Your care manager will assess your condition and adjust your services to meet your individual needs. Your care manager will also be available to answer your questions over the telephone and work with your providers to make sure that you have the right care at the right time. To reach your care manager, just call our Member Services department at 800-950-7679 (TTY 711). You can call us Monday through Friday, 8:30 to 5 Eastern time. We also have a 24/7 NurseLine. You can call toll free at 800-950-7679 (TTY 711) to talk to a nurse after normal business hours. This service is free. If you have any questions about Empire, the Member Handbook or the provider directory, or you need additional copies of the Handbook or directory, please call us.

3 Please also be sure to let us know if your address changes. You can also tell us about your ideas or concerns. Sincerely, Member Services Department Services provided by HealthPlus HP, LLC, a licensee of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Empire BlueCross BlueShield HealthPlus is a culturally diverse company. We welcome all eligible individuals into our health care programs, regardless of health status. If you have questions or concerns, please call Member Services at 800-950-7679 (TTY 711) or visit Table of Contents WELCOME TO THE EMPIRE Managed Long-Term care PLAN .. 2 HOW TO USE THIS Handbook .. 2 HOW Managed Long-Term care WORKS .. 2 THE EMPIRE Managed Long-Term care PLAN IS SPECIAL .. 3 YOUR PRIVACY IS IMPORTANT TO EMPIRE .. 3 Important Information about Advance Directives .. 3 JOINING EMPIRE .. 4 ELIGIBILITY CRITERIA .. 4 The Enrollment Process .. 5 Transfers.

4 5 Obtaining Information .. 6 The Enrollment Eligibility Assessment .. 6 Denial of Enrollment .. 7 YOUR care TEAM .. 8 care Manager .. 8 Reassessment Nurse .. 9 Medical Social Work Team .. 9 GETTING HELP .. 9 Member SERVICES DEPARTMENT .. 9 24/7 NURSELINE/AFTER HOURS ASSISTANCE .. 10 INTERPRETER SERVICES .. 10 SERVICES FOR VISUALLY IMPAIRED MEMBERS .. 10 SERVICES FOR HEARING IMPAIRED MEMBERS .. 10 KEEP US INFORMED .. 10 Help Improve Plan Policies .. 11 YOUR ID CARD .. 11 YOUR Managed Long-Term care BENEFITS .. 11 COVERED SERVICES .. 11 NON-COVERED SERVICES .. 12 Limitations .. 13 How to Obtain Covered Services .. 13 COORDINATION OF SERVICES .. 18 Person-Centered Service Plan (PCSP) Development and 18 REQUESTING NEW OR ADDITIONAL SERVICES .. 19 How Do I Make Requests for Services? .. 19 Prior Authorization/Service Authorization (New/Changes to Services) .. 19 Concurrent Review (More of the Same Services).. 19 Expedited Review .. 19 Extensions in Reviewing Requests.

5 20 Prior Authorization and Concurrent Review Request Approvals .. 20 Prior Authorization and Concurrent Review Request Denials .. 20 SELECTION OF PROVIDERS .. 20 CHOOSING YOUR OWN PRIMARY care PROVIDERS .. 20 SELECTION OF PROVIDERS FOR COVERED SERVICES .. 20 EFFECT ON MEMBERS WITH MEDICARE COVERAGE .. 20 CHANGING PROVIDER(S) .. 21 EMERGENCY care .. 21 Definition of an Emergency* .. 21 After An Emergency .. 21 IF YOU ARE HOSPITALIZED .. 22 PROVIDER TRANSITIONAL, OUT-OF-NETWORK AND OUT-OF-AREA care .. 22 Transitional care .. 22 CONTINUITY OF care .. 22 Out-of-Network care .. 22 If You Are Leaving the Empire Service Area .. 2 3 Out-of-area Emergency care .. 23 MEDICAID SERVICES NOT COVERED BY OUR PLAN .. 23 Pharmacy .. 23 SERVICES NOT COVERED BY EMPIRE Managed Long-Term care OR MEDICAID .. 24 SERVICE AUTHORIZATIONS, ACTIONS AND ACTION APPEALS .. 24 Prior Authorization .. 24 Concurrent Review .. 25 Retrospective Review .. 25 What happens after we get your service authorization request?

6 25 Timeframes for prior authorization requests .. 25 Timeframes for concurrent review requests .. 25 ACTIONS AND APPEALS OF ACTIONS .. 26 What is an Action? .. 26 Timing of Notice of Action .. 26 Contents of the Notice of Action .. 26 How Do I File an Appeal of an Action? .. 27 How Do I Contact Empire to File an Appeal? .. 27 For Some Actions You May Request to Continue Service during the Appeal Process .. 27 How long Will It Take Empire to Decide My Appeal of an Action? .. 28 EXPEDITED APPEAL PROCESS .. 28 If Empire Denies My Appeal, What Can I Do? .. 28 STATE FAIR HEARINGS .. 28 STATE EXTERNAL APPEALS .. 29 COMPLAINTS AND COMPLAINT APPEALS .. 30 What is a Complaint? .. 30 The Complaint Process .. 30 How do I Appeal a Complaint Decision? .. 31 Participant Ombudsman .. 31 IF YOU WISH TO DISENROLL (VOLUNTARY DISENROLLMENT) .. 32 MEMBERSHIP CANCELLATION (INVOLUNTARY DISENROLLMENT) .. 32 RIGHTS AND RESPONSIBILITIES AS AN EMPIRE Member .. 33 EMPIRE FUNDING AND PAYMENT.

7 34 PAYMENT OF NETWORK PROVIDERS BY EMPIRE .. 34 IF YOU HAVE A MEDICAID SURPLUS .. 35 INFORMATION EMPIRE WILL PROVIDE UPON REQUEST .. 35 IMPORTANT PHONE NUMBERS FOR EMPIRE Managed Long-Term care PLAN .. 36 2 ENY-MHB-0067-20 06/2020 Welcome to the Empire Managed Long-Term care Plan We are delighted that you have selected Empire as your Managed Long-Term care plan. We want to make sure your needs are addressed appropriately and any questions are answered promptly. The Empire enrollment specialists and care managers, experienced in caring for those with chronic illness, will work closely with you, your informal supports and your physician(s) to help develop a Person-Centered Service Plan (PCSP) that will effectively address your individual needs. If you have any questions or concerns, or want to speak with any Empire staff, please call our Member Services department at 800-950-7679 (TTY 711). A representative will be happy to connect you with the appropriate individual to answer all of your questions.

8 Once again, thank you for selecting Empire as your Managed Long-Term care plan. We are confident that you will be very satisfied with your choice. How to Use This Handbook Use this Member Handbook as an important resource to obtain information about Empire. This Member Handbook is issued to each Member in the Empire Managed Long-Term care plan. The information in this Member Handbook , along with any attachments or changes, is the entire contract between the Member and Empire. By enrolling, members agree to terms and conditions of membership as described in this Member Handbook . This contract describes the members rights and responsibilities in relation to receiving covered benefits and the steps you can take to make Empire work right for you. Keep this Handbook in a convenient place for future reference. If you cannot find the information that you are looking for, or need additional information or help, our Member Services department is available to assist you.

9 The Member Services department will put you in touch with your care manager. To contact Member Services, please use the following number: Member Services: 800-950-7679 (TTY 711) Hours of operation: Monday through Friday, 8:30 to 5 Eastern time After normal hours of operation, your call will automatically be transferred to the 24/7 NurseLine. This service is available 24 hours a day, seven days a week. How Managed Long-Term care Works A Managed Long-Term care plan is an entity that receives Medicaid funding to arrange, coordinate and pay for health and Long-Term care services for people who are chronically ill and/or have disabilities. Empire has been approved by the New York State Department of Health to offer you Managed Long-Term care . Through Empire, you will receive coordination of medical, specialty, and home- and community-based services, to help maintain or improve your quality of life and overall health, despite chronic illness.

10 Through our coordination and oversight, we will help you live fully and safely stay in your home and/or community for as long as possible. As a Member of Empire, you will also receive: A care manager, a registered nurse who will help ensure that you receive appropriate, timely care to meet your specific needs 3 ENY-MHB-0067-20 06/2020 A reassessment nurse, an RN who will visit you in your home or the nursing facility where you reside to assess your needs A personalized Person-Centered Service Plan (PCSP) that you, those you designate, the care manager and your primary care provider design just for you Extensive choices in providers that offer your Managed Long-Term care benefits Access to the Empire 24/7 NurseLine seven days a week to answer your questions The Empire Managed Long-Term care Plan Is Special Empire was established in the early 1990s. We currently provide health care coverage to over 415,000 New Yorkers across all of our product lines which include Medicaid Managed care , Child Health Plus, Essential Plan, Managed Long-Term care and Medicare Advantage.