Appendix B: New York State Managed Care Bill of Rights Policy and Statement on Working With Maximus

NEW YORK STATE MANAGED CARE BILL OF RIGHTS

YOU HAVE A RIGHT TO INFORMATION—IF YOU ASK FOR IT

The managed care plan must give you a list of drugs they will pay for, and tell you whether a certain drug is on that list. The plan must give you benefit approval guidelines, if you ask for them in writing. The managed care plan must tell you which hospitals its providers are affiliated with, as well as the procedures it uses to decide whether drugs, devices or treatments in clinical trials are "investigational" or "experimental".

YOU HAVE A RIGHT TO INFORMATION—IF YOU DON'T ASK FOR IT

Even without your having to ask, managed care plans must disclose benefits for which they will or won't pay, including dollar amounts and visit limits. The plan must tell you if you need their approval before you receive a given service. The managed care plan must tell you how to file a complaint or challenge a denial of benefits.

YOU HAVE A RIGHT TO INFORMATION FROM YOUR DOCTOR

No health plan may punish or forbid a health care provider from informing you of all treatments that apply to your medical condition.

YOU HAVE A RIGHT TO CHALLENGE DECISIONS

The plan must inform you how to use the appropriate procedure, how long the process will take, and your right to have someone represent you. You also have the right to appeal the reviewer's findings to another plan official, and to an independent outside reviewer. There are three ways to challenge a decision or practice of your plan:

• Utilization review allows patients to questions the plan's decision to deny a benefit based on lack of "medical necessity."
• Internal grievance procedures-which are mandatory only for managed care plans-allow a review of complaints regarding all other types of care.
• External appeal procedures allow patients to ask for an impartial reviewer's decision when a managed care plan denies care because they consider it "not medically necessary" or "experimental or investigational".

YOU HAVE A RIGHT TO RECEIVE EMERGENCY CARE

All health insurance plans must cover an emergency room visit, even without prior approval. Your symptoms, however, must be sudden, severe, or painful enough that a "prudent layperson" could expect that not receiving immediate medical attention would cause serious health problems.

YOU HAVE A RIGHT TO CHOOSE YOUR PROVIDERS

Every managed care plan must have enough providers within a reasonable distance from where their members live. You must have a choice of at least three primary care physicians.

YOU HAVE A RIGHT TO DECIDE WHEN AND WHERE TO RECEIVE WOMEN'S HEALTH SERVICES

A female member of a managed care plan can go to any women's health specialist (ob/gyn) in the plan's network without a referral from her primary care doctor, for two routine checkups a year, plus any pregnancy-related care and treatment of acute conditions and problems found during an ob/gyn visit.

YOU HAVE A RIGHT TO CHILD IMMUNIZATION

No health plan may charge a copayment for immunizations or any other preventative health services for children under 19 years old. 

YOU HAVE A RIGHT TO RECEIVE SPECIALTY CARE

If a managed care plan decides that it does not have an adequate provider for your condition, the plan must refer you to an appropriate provider outside the network at no additional cost. Also, you have a right to receive standing referrals to specialists.

YOU HAVE A RIGHT TO RECEIVE CONTINUING CARE

If you join a managed care plan, the managed care plan must pay for your continuing treatment with a provider, even if the provider does not belong to the managed care plan, as long as the provider meets the managed care plan's requirements and agrees to their payment rates, and:

• You are undergoing a course of treatment for a life-threatening or disabling and degenerative disease, in which case you may continue to see the provider for up to 60 days, or
• You are in the second or third trimester of pregnancy, in which case you may continue to see the provider through delivery and up to 60 days thereafter.

If your provider leaves your managed care plan, the plan must pay for continued treatment (unless the provider left for reasons of fraud, imminent harm to patient care or State sanctions) as long as the provider meets the plan's requirements and agrees to their payment rates, and:

• You are receiving ongoing treatment, in which case you may continue to see the provider for up to 90 days after you have been notified that the provider is no longer with the managed care plan, or
• You are in your second or third trimester of pregnancy and receiving ongoing treatment from the provider, in which case you may continue to see the provider until up to 60 days after delivery.

POLICY STATEMENT ON WORKING WITH CONSUMERS' REPRESENTATIVES

MAXIMUS enrollment counselors will cooperate with representatives of consumers for issues related to enrollment, disenrollment, expedited disenrollments, and exemptions or exclusions, including providing information on status of exemptions or exclusions and sending exemption or exclusion forms to consumers.

Enrollment counselors will not identify or confirm any medical or other consumer information to the representative. MAXIMUS enrollment counselors will not identify AIDS/HIV or mental health status or application for exemption due to AIDS/HIV or SPMI/SED other than in general terms (chronic illness).

Representatives of consumers include:

• Representatives designated by a written statement indicating the consumer's allowing the representative to act on their behalf, the duration of time the consumer is authorizing, the topics the representative can address on behalf of the consumer, and whether the authorization is for an individual or any representative of an organization. The statement must be signed by the consumer and sent (hard copy or via fax) to MAXIMUS.
• Representatives legally designated to represent consumers as verified by a copy of documentation (such as guardianship papers) sent (hard copy or via fax) to MAXIMUS.
• Social workers, case workers, or health care representatives of shelters, residential agencies, hospitals, institutional placements, and institutions in which the consumer resides.
• Representatives of consumers when the consumer remains on the phone, so long as the representative allows the consumer to speak if they desire. The enrollment counselor will verify the consumer's identity by matching key information on MAXSTAR and will obtain the consumer's verbal authorization to be represented prior to working with the representative.
• Representatives of consumers when the consumer identifies the representative and indicates over the phone that they want the representative to act on their behalf without the consumer remaining on the line. The enrollment counselor will verify the consumer's identity by matching key information on MAXSTAR and obtain the consumer's verbal authorization to be represented prior to working with the representative. If the designation is to last beyond the phone call, the enrollment counselor will obtain from the consumer the length of time for which they are authorizing the representative to act on their behalf. Subsequent to initial verbal authorization, the representative must submit by mail or fax to MAXIMUS written notice from the consumer indicating the time frame and whether the designation is for an individual or anyone in the organization.
• Parent, guardian, or members of a household when representing any other member of the household.

Notification that a consumer has authorized a representative to act on their behalf or that documents authorizing representation have been received will be entered into the comments section in MAXSTAR. Upon additional contact from a designated consumer representative, an Enrollment Counselor will verify the consumer authorization of representation prior to working with the representative.

Employees of health plans contracted by the New York Medicaid program cannot serve as representatives of consumers unless they are members of their Medicaid case. Consumers must indicate that a representative is not an employee of a health plan contracted by New York Medicaid CHOICE for phone designations.

Translators are not to be considered representatives. Enrollment Counselors should verify that the translators inform the consumer and receive input from the consumer prior to providing information.

MAXIMUS will mail any material requested by consumer's representatives to consumers, their parents, or legal guardians.