15. H0811_GN197_2016ANOC Annual Notice Of Change1

Annual-Notice-of-Change-FIDA Annual-Notice-of-Change-FIDA

User Manual: Annual-Notice-of-Change1

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H0811_GN197_2016ANOC_Approved

GuildNet Gold Plus FIDA Plan MMP-POS offered by
GuildNet, Inc.
Annual Notice of Changes for 2016
You are currently enrolled as a Participant of GuildNet Gold Plus FIDA Plan. Next
year, there will be changes to the plan’s benefits. Section B tells you about the
changes.
You can end your membership in GuildNet Gold Plus FIDA Plan at any time.

Additional Resources

 You can get this information for free in other languages. Call 1-800-8150000 and 1-800-662-1220 during 8am to 8pm, Monday through Sunday.
The call is free.

 Usted puede obtener esta información en otros idiomas gratis. Llame al
1-800-815-0000 o TTY/TDD al 1-800-662-1220, de lunes a domingo de
8am a 8pm. La llamada es gratis.

 Queste informazioni sono disponibili gratuitamente in altre lingue.
Chiamare il numero verde 1-800-815-0000 o 1-800-662-1220 mediante
un telefono testuale per non udenti (TTY/TDD), da lunedì a domenica,
dalle 8 alle 20. La chiamata è gratuita.

 您可以免費獲得本信息的其他語言版本。請撥打 1-800-815-0000 或聽障／
語障人士專線 (TTY/TDD) 1-800-662-1220，星期一至星期日上午 8 時至晚
上 8 時。撥打該電話免費。

 Вы можете бесплатно получить эту информацию на других языках.
Вы можете позвонить по телефону 1-800-815-000 и 1-800-662-1220
(TTY/TDD). Служба работает с понедельника по воскресенье с 8:00
до 20:00. Звонок бесплатный.

 Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang. Rele nimewo 1800-815-0000 oswa TTY/TDD 1-800-662-1220, lendi jiska dimanch, depi
8am jiska 8pm. Koutfil la gratis.

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000,
Monday through Sunday, 8am to 8pm (TTY 1-800-662-1220). The call is free. For more
information, visit www.guildnetny.org.
1

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016

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오전 8 시부터 오후 8 시 사이에 1-800-815-0000 번이나 TTY/TDD 1-800662-1220 번으로 전화주세요. 통화는 무료입니다.

 You can get this information for free in other formats, such as large print,
braille or audio. Call 1-800-815-0000 and 1-800-662-1220 during 8am to
8pm, Monday through Sunday. The call is free.

About GuildNet Gold Plus FIDA Plan

 GuildNet Gold Plus FIDA Plan is a managed care plan that contracts with
both Medicare and the New York State Department of Health (Medicaid)
to provide benefits of both programs to Participants through the Fully
Integrated Duals Advantage (FIDA) Demonstration.

 This GuildNet Gold Plus FIDA Plan is offered by GuildNet, Inc. When this
Annual Notice of Changes says “we,” “us,” or “our,” it means GuildNet,
Inc. When it says “the plan” or “our plan,” it means GuildNet Gold Plus
FIDA Plan.

Disclaimers
GuildNet Gold Plus FIDA Plan is a managed care plan that contracts with both
Medicare and the New York State Department of Health (Medicaid) to provide
benefits of both programs to Participants through the Fully Integrated Duals
Advantage (FIDA) Demonstration.
Limitations and restrictions may apply. For more information, call GuildNet Gold
Plus FIDA Plan Participant Services or read the GuildNet Gold Plus FIDA Plan
Participant Handbook. This means that you need to follow certain rules to have
GuildNet Gold Plus FIDA Plan pay for your services. If you don’t follow the rules
or exceed service limits, you may have to pay for the services.
The List of Covered Drugs and/or pharmacy and provider networks may change
throughout the year. We will send you a notice before we make a change that
affects you.
Benefits may change on January 1 of each year.
The State of New York has created a participant ombudsman program called the
Independent Consumer Advocacy Network (ICAN) to provide Participants free,

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016
confidential assistance on any services offered by GuildNet Gold Plus FIDA Plan.
ICAN may be reached toll-free at 1-844-614-8800 or online at icannys.org

Think about Your Medicare and Medicaid Coverage for Next Year
It is important to review your coverage now to make sure it will still meet your
needs next year. If it does not meet your needs, you can leave the plan at any
time.
If you leave our plan, you will still be in the Medicare and Medicaid programs.
You will have a choice about how to get your Medicare and Medicaid benefits (go
to section C starting on page 8 to see your options).

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016

Important things to do:

 Check if there are any changes to our benefits that may affect you. Are
there any changes that affect the services you use? It is important to review
benefit changes to make sure they will work for you next year. Look in section
B for information about benefit changes for our plan.

 Check if there are any changes to our prescription drug coverage that
may affect you. Will your drugs be covered? Are they in a different tier? Can
you continue to use the same pharmacies? It is important to review the
changes to make sure our drug coverage will work for you next year. Look in
section B for information about changes to our drug coverage.

 Check to see if your providers and pharmacies will be in our network
next year. Are your doctors in our network? What about your pharmacy?
What about the hospitals or other providers you use? Look in section A for
information about our Provider and Pharmacy Directory.

 Think about whether you are happy with our plan.
If you decide to stay with
GuildNet Gold Plus FIDA
Plan:
If you want to stay with us next
year, it’s easy – you don’t need to
do anything. If you don’t make a
change, you will automatically
stay enrolled in our plan.

If you decide to change plans:
If you decide other coverage will better
meet your needs, you can switch plans at
any time. If you enroll in a new plan, your
new coverage will begin on the first day of
the following month. Look in section C to
learn more about your choices.

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016

Table of Contents
Disclaimers ............................................................................................................................. 2
Think about Your Medicare and Medicaid Coverage for Next Year ....................................... 3
A. Changes to the network providers and pharmacies ........................................................... 6
B. Changes to benefits for next year ...................................................................................... 6
Changes to benefits for medical and long term care services ............................................ 6
Changes to prescription drug coverage ............................................................................. 7
C. Deciding which plan to choose ........................................................................................... 9
If you want to stay in GuildNet Gold Plus FIDA Plan .......................................................... 9
If you want to leave GuildNet Gold Plus FIDA Plan and still get your Medicare
and Medicaid services together from a single plan .......................................................... 10
If you want to leave GuildNet Gold Plus FIDA Plan and get your Medicare and
Medicaid services separately ........................................................................................... 10
D. Getting help ...................................................................................................................... 12
Getting help from GuildNet Gold Plus FIDA Plan ............................................................. 12
Getting help from the state enrollment broker .................................................................. 13
Getting help from the Independent Consumer Advocacy Network................................... 13
Getting help from the State Health Insurance Assistance Program ................................. 13
Getting help from Medicare .............................................................................................. 13
Getting help from Medicaid .............................................................................................. 14

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016

A. Changes to the network providers and pharmacies
Our network of providers and pharmacies has changed for next year.
An updated Provider and Pharmacy Directory is located on our website at
www.guildnetny.org. You may also call Participant Services at 1-800-815-0000
for updated provider information or to ask us to mail you a Provider and
Pharmacy Directory.
It is important that you know that we may also make changes to our network
during the year. If your provider does leave the plan, you have certain rights and
protections. For more information, see Chapter 3 of your Participant Handbook.

B. Changes to benefits for next year
Changes to benefits for medical and long term care services
We are changing our coverage for certain medical services next year. The table
below describes these changes.
2015 (this year)
Comprehensive Psychiatric
Emergency Programs (CPEPs)

CPEPs are not
covered.

$0
This service must be
obtained from an innetwork provider.

If you are having a mental health
crisis, GuildNet Gold Plus FIDA
Plan will pay for Office of Mental
Health licensed programs that
directly provide or help you get a
full range of psychiatric
emergency services. These
services are provided 24 hours a
day, seven days a week.

2016 (next year)

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016

Crisis Intervention Services
If you are having a mental health
crisis, GuildNet Gold Plus FIDA
Plan will pay for clinical
intervention through your crisis
intervention clinic.

Crisis Intervention
Services are not
covered.

Residential
Addiction Services
are not covered.

This service must be
obtained from an innetwork provider.

Crisis services do not need to be
in your treatment plan in order to
be covered. These services may
be provided by phone or in
person, with some exceptions.
At a minimum, each clinic will
have a clinician that can help
you by phone 24 hours a day,
seven days a week. At the
clinic's option, it may provide
face-to-face crisis services 24
hours a day, seven days a week.

Residential Addiction Services
GuildNet Gold Plus FIDA Plan
will pay for addiction treatment
services delivered by an
approved residential program.

This service must be
obtained from an innetwork provider.

Changes to prescription drug coverage
Changes to our Drug List

We sent you a copy of our 2016 List of Covered Drugs in this envelope. The List
of Covered Drugs is also called the “Drug List.”
We made changes to our Drug List, including changes to the drugs we cover and
changes to the restrictions that apply to our coverage for certain drugs. Review
the Drug List to make sure your drugs will be covered next year and to see
if there will be any restrictions.

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016
If you are affected by a change in drug coverage, we encourage you to:

 Work with your doctor (or other prescriber) to find a different drug
that we cover. You can call Participant Services at 1-800-815-0000 to ask
for a list of covered drugs that treat the same condition. This list can help
your provider find a covered drug that might work for you.


Work with your doctor (or other prescriber) and ask the plan to make
an exception to cover the drug. You can ask for an exception before next
year and we will give you an answer within 72 hours after we receive your
request (or your prescriber’s supporting statement). To learn what you
must do to ask for an exception, see Chapter 9 of the 2016 Participant
Handbook or call Participant Services at 1-800-815-0000. If you need
help asking for an exception, you can contact Participant Services or your
Care Manager.



CURRENT FORMULARY EXCEPTIONS ARE ONLY VALID THROUGH
THE END OF 2015. YOU WILL NEED TO REQUEST A NEW EXCEPTION
IF ONE IS STILL NEEDED IN 2016.

Changes to prescription drug costs
There are no changes to the amount you pay for prescription drugs in 2016.
Read below for more information about your prescription drug coverage.
We moved some of the drugs on the Drug List to a lower or higher drug tier. To
see if your drugs will be in a different tier, look them up in the Drug List.
The table below shows your costs for drugs in each of our four drug tiers.
2015 (this year)
Drugs in Tier 1
(Part D generic drugs)

Your co-pay for a onemonth (30-day) supply
is $0 per prescription.

2016 (next year)
Your co-pay for a onemonth (30-day) supply
is $0 per prescription.

Cost for a one-month supply
of a drug in Tier 1 that is
filled at a network pharmacy

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016

Drugs in Tier 2
(Part D brand drugs)

Your co-pay for a onemonth (30-day) supply
is $0 per prescription.

Cost for a one-month supply
of a drug in Tier 2 that is
filled at a network pharmacy
Drugs in Tier 3
(Medicaid covered
prescription drugs)
Cost for a one-month supply
of a drug in Tier 3 that is
filled at a network pharmacy
Drugs in Tier 4
(Medicaid covered over-thecounter drugs & items)
Cost for a one-month supply
of a drug in Tier 4 that is
filled at a network pharmacy

C. Deciding which plan to choose
If you want to stay in GuildNet Gold Plus FIDA Plan
We hope to keep you as a Participant next year.
To stay in our plan you don’t need to do anything. If you do not sign up for a
different plan or change to Original Medicare, you will automatically stay enrolled
as a Participant of our plan for 2016.

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016
If you want to leave GuildNet Gold Plus FIDA Plan and still get your
Medicare and Medicaid services together from a single plan
If you want to keep getting your Medicare and Medicaid services together from a
single plan, you can join a different FIDA Plan. You can enroll in the new FIDA
Plan by calling New York Medicaid Choice at 1-855-600-FIDA, Monday through
Friday from 8:30 am to 8:00 pm and Saturday from 10:00 am to 6:00 pm. TTY
users should call 1-888-329-1541.
If you don’t want a different FIDA Plan but you still want to get your Medicare and
Medicaid services together from a single plan, you may be able to enroll in the
Program of All-Inclusive Care for the Elderly (PACE) or the Medicaid Advantage
Plus (MAP) Program. For more information, call New York Medicaid Choice.
If you want to leave GuildNet Gold Plus FIDA Plan and get your Medicare
and Medicaid services separately
If you do not want to enroll in a different FIDA, PACE, or MAP Plan after you
leave GuildNet Gold Plus FIDA Plan, you will go back to getting your Medicare
and Medicaid services separately.
How you will get Medicare services
You will have three options for getting your Medicare services. By choosing one
of these options, you will automatically end your membership in our FIDA Plan:

1. You can change to:

Here is what to do:

A Medicare health plan, such as a
Medicare Advantage plan

Call Medicare at 1-800-MEDICARE (1800-633-4227), 24 hours a day, seven
days a week. TTY users should call 1877-486-2048.
If you need help or more information,
call the Health Insurance Information,
Counseling and Assistance Program
(HIICAP) at 1-800-701-0501.
You will automatically be disenrolled
from GuildNet Gold Plus FIDA Plan
when your new plan’s coverage begins.

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016

2. You can change to:

Here is what to do:

Original Medicare with a separate
Medicare prescription drug plan

3. You can change to:

Here is what to do:

Original Medicare without a
separate Medicare prescription
drug plan

Call Medicare at 1-800-MEDICARE (1800-633-4227), 24 hours a day, seven
days a week. TTY users should call 1877-486-2048.

NOTE: If you switch to Original
Medicare and do not enroll in a
separate Medicare prescription drug
plan, Medicare may enroll you in a
drug plan, unless you tell Medicare
you don’t want to join.

If you need help or more information,
call the Health Insurance Information,
Counseling and Assistance Program
(HIICAP) at 1-800-701-0501.
You will automatically be disenrolled
from GuildNet Gold Plus FIDA Plan
when your Original Medicare coverage
begins.

You should only drop prescription
drug coverage if you get drug
coverage from an employer, union or
other source. If you have questions
about whether you need drug
coverage, call the Health Insurance
Information, Counseling and
Assistance Program (HIICAP) at 1800-701-0501.

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016

How you will get Medicaid services
You will have the opportunity to switch to a Medicaid Managed Long-Term Care
plan for your long-term services and supports and to receive your Medicaid
physical and behavioral health services through Medicaid Fee-for-Service.

 Note: You can choose to completely stop receiving long-term services and
supports. However, it may take extra time to complete a safe discharge
process. During that time, you will be enrolled into the Medicaid Managed
Long-Term Care plan operated by the same company as GuildNet Gold
Plus FIDA Plan. Your change request on your Medicare coverage will not
be delayed and will take effect on the first day of the month after you
request the change.
If you were receiving services through the Nursing Home Transition & Diversion
(NHTD) 1915(c) waiver prior to enrolling in a FIDA Plan, you will have the
opportunity to re-apply for the waiver. You will continue to receive any existing
Nursing Home Transition & Diversion services from GuildNet Gold Plus FIDA
Plan or enroll in a Medicaid Managed Long-Term Care plan to receive your
Medicaid services until your NHTD application is approved. New York Medicaid
Choice can help you with your NHTD application.

D. Getting help
Getting help from GuildNet Gold Plus FIDA Plan
Questions? We’re here to help. Please call Participant Services at 1-800-8150000 (TTY only, call 1-800-662-1220). We are available for phone calls Monday
through Sunday, 8am to 8pm. Calls to these numbers are free
Read your 2016 Participant Handbook
The 2016 Participant Handbook is the legal, detailed description of your plan
benefits. It has details about next year's benefits. It explains your rights and the
rules you need to follow to get covered services and prescription drugs.
We will send you a copy of the 2016 Participant Handbook by December 31. An
up-to-date copy of the 2016 Participant Handbook is always available on our
website at www.guildnetny.org. You may also call Participant Services at 1-800815-0000 to ask us to mail you a 2016 Participant Handbook.

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016
Visit our website
You can also visit our website at www.guildnetny.org. As a reminder, our website
has the most up-to-date information about our provider and pharmacy network
(Provider and Pharmacy Directory) and our Drug List (List of Covered Drugs).
Getting help from the state enrollment broker
New York Medicaid Choice is New York State's managed care enrollment
program. New York Medicaid Choice counselors can tell you about all your
managed care options. You can call New York Medicaid Choice at 1-855-600FIDA, Monday through Friday from 8:30 am to 8:00 pm and Saturday from 10:00
am to 6:00 pm. TTY users should call 1-888-329-1541.
Getting help from the Independent Consumer Advocacy Network
The Independent Consumer Advocacy Network (ICAN) can help you if you are
having a problem with GuildNet Gold Plus FIDA Plan. ICAN is not connected with
us or with any insurance company or health plan. The phone number for ICAN is
1-844-614-8800. The services are free.
Getting help from the State Health Insurance Assistance Program
You can also call the State Health Insurance Assistance Program (SHIP). In New
York State, the SHIP is called the Health Insurance Information, Counseling, and
Assistance Program (HIICAP). The HIICAP counselors can help you understand
your FIDA Plan choices and answer questions about switching plans. HIICAP is not
connected with us or with any insurance company or health plan. The HIICAP
phone number is 1-800-701-0501.
Getting help from Medicare
To get information directly from Medicare:
Call 1-800-MEDICARE (1-800-633-4227).
You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week. TTY users should call 1-877-486-2048.
Visit the Medicare Website
You can visit the Medicare website (http://www.medicare.gov). If you choose to
disenroll from your FIDA Plan and enroll in a Medicare Advantage plan, the
Medicare website has information about costs, coverage, and quality ratings to
help you compare Medicare Advantage plans. You can find information about

GuildNet Gold Plus FIDA Plan ANNUAL NOTICE OF CHANGES FOR 2016
Medicare Advantage plans available in your area by using the Medicare Plan
Finder on the Medicare website. (To view the information about plans, go to
http://www.medicare.gov and click on “Find health & drug plans.”)
Read Medicare & You 2016
You can read Medicare & You 2016 Handbook. Every year in the fall, this booklet
is mailed to people with Medicare. It has a summary of Medicare benefits, rights
and protections, and answers to the most frequently asked questions about
Medicare. If you don’t have a copy of this booklet, you can get it at the Medicare
website (http://www.medicare.gov) or by calling 1-800-MEDICARE
(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call
1-877-486-2048.
Getting help from Medicaid
To get information directly from Medicaid, call the Medicaid Helpline at 1-800541-2831 (TTY: 1-877-898-5849). The Medicaid Helpline is available Monday
through Friday from 8:00 am to 8:00 pm and Saturday from 9:00 am to 1:00 pm.

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15. H0811_GN197_2016ANOC Annual Notice Of Change1

Annual-Notice-of-Change-FIDA Annual-Notice-of-Change-FIDA

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