Appendix E MAPMH
User Manual: MAPMH
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TABLE OF CONTENTS
WELCOME TO GUILDNET GOLD
-2-
WHAT THIS HANDBOOK IS FOR
-4-
OUR UNIQUE PLAN
-5-
HOW TO JOIN GUILDNET GOLD
-7-
DISENROLLMENT FROM GUILDNET GOLD
- 10 -
YOUR COVERAGE WHEN YOU ARE NO LONGER A GUILDNET GOLD MEMBER - 12 OUT OF POCKET EXPENSES
- 13 -
HOW TO GET SERVICES
- 14 -
COVERED SERVICES
- 17 -
PAYING PROVIDERS FOR COVERED SERVICES
- 29 -
SERVICES COVERED BY REGULAR MEDICARE OR MEDICAID FEE-FOR- SERVICE,
NOT BY GUILDNET GOLD
- 30 SERVICES NOT COVERED BY GUILDNET GOLD OR REGULAR MEDICARE OR
MEDICAID FEE-FOR-SERVICE
- 32 -
ACCESSING SERVICES IN SPECIAL SITUATIONS
- 33 -
SERVICE AUTHORIZATION AND ACTIONS
- 35 -
FAIR HEARINGS FOR SERVICES COVERED BY MEDICAID
- 43 -
GRIEVANCES
- 44 -
MEMBER RIGHTS AND RESPONSIBILITIES
- 47 -
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
-1-
WELCOME TO GUILDNET GOLD
Welcome to GuildNet Gold!
GuildNet Gold is designed for people who have Medicare and Medicaid, and who need longterm care services, medical care, and environmental and social supports in order to live in their
home and community safely, for as long as possible. Some examples of what GuildNet Gold
offers are: skilled nursing care in your home, personal care, visits to your doctors, and
prescription drugs. We also offer you ways to make your home safe, and your life easier.
As a member of GuildNet Gold, you will get a full benefit package consisting of the services that
you would normally get from regular Medicare, including Part D prescription drug coverage, and
most services that you would normally get from Medicaid fee-for-service. Plus, you can get
some extra services like nutritional training, smoking cessation, and respite for your family and
caregivers.
One of the things that makes GuildNet Gold different is that you can keep the doctors you see
now, including the specialists that you go to. You do not need a referral to see these doctors, and
you don’t need prior authorization.
As a member of GuildNet Gold, you may be able to take advantage of the social supports that we
offer. You may be able to go to a Social Day Center, or an Adult Day Health Care Center. At an
Adult Day Health Care Center, you can socialize, as well as get medical care. At both of these
Centers, you can participate in activities, and get meals and snacks. GuildNet Gold will arrange
transportation to and from the Center.
A great thing about joining GuildNet Gold is that you do not have any CO-PAYMENTS,
except for prescription drugs copayments.
Probably, the best thing about GuildNet Gold is that, within days of joining our program, you
will have a Case Manager assigned to you. This person will help you every step of the way to get
the care that you need. Your Case Manager will work with you, your family, and providers, to
develop a plan of care that meets your health care needs. Your plan of care will be reviewed on a
regular basis.
Your Case Manager will coordinate the services in your Care Plan for you, help you select
providers, and arrange for transportation to and from appointments. You can always call your
Case Manager to help you.
If you need to get in touch with your Case Manager or anyone else at GuildNet Gold, you
can call us at the Member Services number below:
1-800-932-4703
TTY Number 1-800-662-1220
Monday through Friday
8:00 am to 8:00 pm
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
-2-
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
-3-
WHAT THIS HANDBOOK IS FOR
This handbook tells you about the benefits that you get when you join GuildNet Gold. Along
with other things, this handbook tells you how to join GuildNet Gold.
This handbook and your Evidence of Coverage should be kept together. These two
documents will give you a full picture of your GuildNet Gold benefits, and how to get them.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
-4-
OUR UNIQUE PLAN
You Do Not Have To Change Doctors
When you join GuildNet Gold, you do not have to change your doctors. However, your doctor
must be willing to participate in your care plan, in order for you to keep him or her.
Network Providers
Using network providers is always the best thing to do because it makes it easier for your Case
Manager to coordinate your care, and to develop a plan of care that meets your needs, in the best
possible way.
GuildNet Gold allows you to go to out-of-network providers for services that you used to get
using your Medicare card. (See the “Covered Services” section of this Member Handbook.) In
this Member Handbook, we may refer to these services as services that you used to get through
regular Medicare.
You have to use Network Providers to get most of the services that you used to get using your
Medicaid card. (* See Covered Services Section of this Member Handbook.) In this Member
Handbook we may refer to these services as services that you used to get through Medicaid
fee- for-service.
You Do Not Need a Referral or Prior Authorization to See Your Doctors or To Receive
Many Services
You do not need a referral or prior authorization, to see your doctors, or to receive many
services. However, there are certain services that do require prior authorization. See the Covered
Services Section of this Handbook for further information.
World Wide Emergency
GuildNet Gold covers World Wide Emergency Care. For more information see the “Accessing
Services in Special Situations” section of this Member Handbook.
Out of Area Care Anywhere In the United States
GuildNet Gold covers out of area care anywhere in the United States. If the service that you want
is not vital to your health and well being, it is probably best for you to wait until you return to the
service area to get the care. If you wait, your Case Manager can help you get the service, and can
actively participate in coordinating your care.
For more information, see the “Accessing Services in Special Situations” section of this
Member Handbook.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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Our Relationship With GHI
GuildNet Gold and Group Health Inc. (GHI), have formed a business relationship to provide
you with a large network of providers that makes it possible for you to get the care you need,
quickly, easily, and close to home. This network is called the GHI Choice PPO Provider
Network. You can get the services that you used to receive using your Medicare card from the
GHI Choice PPO Provider Network.
This Handbook gives you information about the services that you will get through the GHI
Choice PPO Provider Network, but you should also look at your Evidence of Coverage for more
information about getting these services
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
-6-
HOW TO JOIN GUILDNET GOLD
It is simple to join GuildNet Gold. The only paperwork that you need to complete is a GuildNet
Gold enrollment form.
When you enroll in GuildNet Gold, you enroll in a Part D prescription drug program, a Medicare
Advantage plan, and a Medicaid managed long-term care plan. Medicaid calls this managed
long-term care plan Medicaid Advantage Plus. To you, the member, the combination of these
two plans provides you with an integrated managed long-term care program. This program is
GuildNet Gold. Through GuildNet Gold, you can get a full complement of medical services,
long-term care services, environmental and social supports, and prescription drugs.
Eligibility
To become a member of GuildNet Gold, you must:
• Have full Medicaid
• Have evidence of Medicare Part A & B coverage; or be enrolled in Medicare Part
C coverage; and
• Reside in Brooklyn, Queens, Manhattan or the Bronx; and
• Be 18 years of age or older; and
• Enroll in GuildNet Gold’s Medicare Advantage and Medicaid Advantage Plus
program; and
• Be eligible for nursing home level of care (as of the time of enrollment);
• Be capable, at the time of enrollment of returning to or remaining in your home
and community without jeopardy to your health and safety; and
• Require care management and be expected to need at least one of the following
services for at least 120 days from the effective date of enrollment;
¾ nursing services in the home;
¾ therapies in the home;
¾ home health aide services;
¾ personal care services in the home;
¾ adult day health care; or
¾ social day care if used as a substitute for in-home personal care services.
Not Eligible to Enroll in GuildNet Gold
You are not eligible to join GuildNet Gold if:
• You do not live in Brooklyn, the Bronx, Manhattan, or Queens.
• You are not eligible for Medicare Parts A and B AND Medicaid.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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•
You are medically determined to have End Stage Renal Disease (ESRD) at the time
of enrollment.
• You are a resident of a residential health care facility ("RHCF") at the time of
enrollment, and discharge back to the community is not expected within the first
month following effective date of enrollment.
• You are enrolled in the NYS Medicaid Restricted Recipient Program.
• The New York City Human Resources Administration has determined that it is not
cost effective for you to enroll because you have other insurance.
• You were admitted to a Hospice program prior to time of enrollment (If you enter a
Hospice program while enrolled in GuildNet Gold you may remain enrolled).
• You are, and will continue to remain:
A resident of State-certified or voluntary treatment facility for children and youth.
A resident of a facility operated under the auspices of the State Office of Mental
Health (OMH), the Office of Alcoholism and Substance Abuse Services
(OASAS) or the Office of Mental Retardation and Developmental Disabilities
(OMRDD).
Enrolled in another Medicaid managed care plan
Enrolled in a home and community-based services waiver program.
Enrolled in an OMRDD Day Treatment Program.
For more information about the eligibility requirements for GuildNet Gold, please call:
Member Services
1-800-932-4703
TTY number 800-662-1220
Monday through Friday
8:00 am to 8:00 pm
Enrolling In GuildNet Gold
Enrolling in GuildNet involves you, your family, your doctor, the NYC Human Resources
Administration (HRA), Center for Medicare and Medicaid (CMS), and GuildNet Gold.
You, or your family, caregiver, or other referral source, may contact GuildNet Gold to notify us
of your interest in joining GuildNet Gold. To contact GuildNet Gold, call:
1-800-932-4703
TTY Number 1-800-662-1220
A GuildNet Gold Intake staff member will follow up on every referral, and you will be contacted
by telephone by our Intake staff who will provide you with basic information about our plan.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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Our Intake staff will ask you some questions to see if you are eligible to apply for coverage.
They will ask you if you live in the service area, and if you have Medicaid. If you appear to meet
basic eligibility for the plan, a Nurse Manager will arrange a meeting with you to conduct a
comprehensive social and health assessment, and will evaluate your medical care needs.
If you meet the clinical requirements and all other eligibility requirements for enrollment into
GuildNet Gold, the Nurse Manager will ask you if you would like to join the plan. If you do, you
will be asked to sign an enrollment agreement. If you sign the enrollment agreement, you are
agreeing to join a Medicare Advantage program and a Medicaid Advantage Plus program, which
together, make up the integrated managed long-term care plan, GuildNet Gold.
Once you have agreed to join GuildNet Gold, the Nurse Manager will contact your doctor to
notify him or her of your interest in joining GuildNet Gold, and to explain the services provided
through GuildNet Gold. Your doctor must be willing to work with us in planning and managing
your care. If your doctor is unwilling to work with us, and you still wish to enroll, we will assist
you in choosing another doctor. If you do not have a doctor, we will assist you with getting one.
GuildNet Gold will process your enrollment application by sending it to both HRA and CMS.
Once your enrollment has been approved by both HRA and CMS, we will notify you of the
effective date of your enrollment, which is known as your “effective date of coverage.” Your
enrollment into GuildNet Gold will not be effective, until your enrollment into both Medicare
Advantage and Medicaid Advantage Plus becomes effective.
Your enrollment into GuildNet Gold will usually be effective the 1st day of the month following
the month in which you completed your application.
Once you are enrolled in GuildNet Gold, you will receive a GuildNet Gold identification card.
You should use this card to get services covered by GuildNet Gold. For more information about
your GuildNet Gold identification card, please see your GuildNet Gold Medicare Advantage
Evidence of Coverage.
You need to keep your regular Medicaid card to get services that are not covered by GuildNet
Gold, but that are still covered by regular Medicaid, such as pharmaceuticals not covered by
GuildNet Gold.
If you change your mind about enrolling in GuildNet Gold, you can stop the process at any time.
Enrolling in GuildNet Gold is completely up to you. Please contact Member Services if you wish
to stop the enrollment process.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
-9-
Disenrollment from GuildNet GOLD
Voluntary Disenrollment
You can ask to leave GuildNet Gold at any time, for any reason.
To request disenrollment, call Member Services at 1-800-932-4703 for help or call TTY
Number 800-662-1220. Member Services will help you with the process. It could take up to six
weeks for your disenrollment to be effective, depending on when your request is received by
GuildNet Gold.
Involuntary Disenrollment
GuildNet Gold must disenroll you from its plan if:
• you are no longer a member of GuildNet Gold’s Medicare Advantage program or are no
longer a member of GuildNet Gold’s Medicaid Advantage Plus Program;
• you lose Medicaid eligibility;
• you no longer reside in the GuildNet Gold service area and refuse to voluntarily disenroll;
• you are absent from the GuildNet Gold service area for more than ninety (90) consecutive
days;
• you enter an OMH, OMRDD or OASAS residential program for forty-five (45) days or
longer;
• you join a home and community based waiver program;
• you clinically require nursing home care but are not eligible for such care under the
Medicaid institutional eligibility rules. In this event, GuildNet Gold will ensure your safe
discharge to an appropriate program;
• you lose Medicare Parts A and B; or
• you join another Medicare Advantage Product, Medicaid Managed Care Plan, or Part D
product.
•
GuildNet Gold may disenroll you from its plan if:
• You, your family member, or informal caregiver, engages in conduct or behavior that
seriously impairs GuildNet Gold’s ability to provide you or another member, with service.
Before we disenroll you, we must have made and documented reasonable efforts to resolve
the conduct or behavior.
• You provide fraudulent information on an enrollment form or permit abuse of an
identification card in the GuildNet Gold Program.
• You fail to pay or make arrangements satisfactory to GuildNet Gold to pay the amount that
the NYC HRA determined that you owe GuildNet Gold as spenddown/surplus or Net
Available Monthly Income (NAMI), within thirty (30) days from when the amount first
becomes due, provided that during the thirty (30) day period we made a reasonable effort to
collect the amount, including making a written request for payment, and advising you in
writing of your prospective disenrollment.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 10 -
•
You knowingly fail to complete and submit any necessary consent or release.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 11 -
YOUR COVERAGE WHEN YOU ARE NO LONGER A GUILDNET GOLD
MEMBER
GuildNet Gold is a plan that is made up of two programs. One is Medicare Advantage, and the
other is Medicaid Advantage Plus. If you disenroll from, or lose eligibility for our Medicare
Advantage program, or if you disenroll from, or lose eligibility for our Medicaid Advantage Plus
program, you will be disenrolled from GuildNet Gold. When your disenrollment is effective,
your coverage:
•
Will go back to regular Medicare and Medicaid fee-for-service; if you remain eligible for
Medicaid and Medicare, or
•
If you have joined another Medicaid or Medicare managed care plan, your coverage will
be through the plan or program that you have joined.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 12 -
OUT OF POCKET EXPENSES
Premiums, Deductibles, and Co-payments
When you join GuildNet Gold:
•
You DO NOT PAY THE MEDICARE PREMIUM IF you currently do not pay the
Medicare Part B premium.
•
You DO NOT HAVE TO PAY ANY DEDUCTIBLES.
•
There are NO CO-PAYMENTS for any services, other than prescription drugs.
•
There ARE CO-PAYS for prescription drugs. For more information on which drugs
have co-pays, please see your GuildNet Gold Medicare Evidence of Coverage.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 13 -
HOW TO GET SERVICES
Your Case Manager
When you join GuildNet Gold, you will be assigned a Case Manager who is a health care
professional who is usually either a nurse or a social worker. Your Case Manager is the person
who you should call, to help you get the care that you need.
When you join GuildNet Gold, and on a regular basis after that, your Case Manager will talk to
you, your family, caregivers, and doctors, and set up a plan of care for you that addresses your
health care, social, and environmental needs. When your plan of care is agreed to by you, your
family, caregivers, and doctors, your Case Manager will help you put the services you need in
place. Your Case Manager will help you to get prior authorization for services, when prior
authorization is needed. He or she can give you help in choosing providers, getting
transportation to and from appointments, and even getting home delivered meals.
If you, a family member, or a caregiver, thinks that you need a service that is not in your plan of
care, or that you need more service, or if you wish to discontinue a service, one of you should
speak to your Case Manager to see if he or she can help you to get the service.
To contact your Case Manager call Member Services at:
Call 1-800-932-4703
TTY Number 1-800-662-1220
A copy of your plan of care is available to you upon request.
Getting Services That You Previously Received Using Your Medicare Card
GuildNet Gold offers services that you used to get from Medicare before your joined GuildNet
Gold. When you got these services, you showed your provider your Medicare card. Now, you
can get these services from our GHI Choice PPO Network, using your GuildNet Gold ID card.
You should try to use providers in the GHI Choice PPO Provider Network to get the care that
you need. The providers in this network have been credentialed by us and we know that they
provide quality care. You can go to a provider out-of-network, but you should remember that
GuildNet Gold may not have experience with these providers, and we can not guarantee quality
care from them.
Choosing a provider in the GHI Choice PPO Network can help you get the best possible care.
This is because providers in the GHI Choice PPO Network have to work with our Case
Managers, and participate in your plan of care. Out of network providers are under no obligation
to do this. If you go to an out-of-network provider, it is possible that your Case Manager may not
be able to manage the care you receive in the best possible way.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 14 -
GuildNet Gold recommends that you use a GHI Choice PPO Provider instead of going out of
network. If you go to an out-of-network provider, please let your Case Manager know as soon as
you can, so he/she can work with the provider on giving you the best care possible.
Some of the services that you used to get using your Medicare card require prior authorization.
For these services, prior authorization is required whether or not the service is received through
the GHI Choice PPO Provider Network or out of network. Please refer to the “Covered Services”
section of this Member Handbook for more information.
If you need or want services:
Call Member Services and Ask to Speak to Your Case Manager
1-800-932-4703
TTY Number 1-800-662-1220
Getting Services That You Used To Get Using Your Medicaid Card
GuildNet Gold offers many services that you used to get from Medicaid, before you joined
GuildNet Gold. When you got these services, you showed your provider your Medicaid card.
Now, you will get these services from our GuildNet Gold Provider Network, using your
GuildNet Gold ID card. However, please remember, you will need your Medicaid card to get
Medicaid services not covered by GuildNet Gold.
You are free to choose any provider within the GuildNet Gold network, although you may need
prior authorization to get service.
There may be times when GuildNet Gold will approve you to use a provider outside of the
GuildNet Gold network. This can happen when GuildNet Gold does not have a provider with the
training and expertise to meet a specialized health care need included in your plan of care. It can
also happen when:
•
You are under the care of a health care provider when you enroll in GuildNet
Gold. You may continue treatment even if the provider is not in our network. (For
example, if you are receiving dental care and the treatment is not finished.) You
may continue treatment for up to sixty (60) days from when you join the plan.
Your provider must agree to accept payment at the plan rate, follow our policies,
and agree to provide us with medical information about your care.
•
A GuildNet Gold network provider that you are in an ongoing course of treatment
with, decides that they will no longer participate in the GuildNet Gold provider
network. We will allow you to continue to see the provider for ninety (90) days
until the transition to a new provider is in place. During that time, we will help
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 15 -
you to choose another provider from the GuildNet Gold provider network, and we
will transition your care to the new provider.
Your provider must agree to accept payment at the plan rate, follow our policies, and agree to
provide us with medical information about your care.
You should call your Case Manager if you have questions about going to an out-of-network
provider.
If you need or want a covered service that you used to get using your Medicaid card:
Call Member Services and Ask to Speak to Your Case Manager
1-800-932-4703
TTY Number 1-800-662-1220
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 16 -
COVERED SERVICES
The chart below describes the services covered by GuildNet Gold.
The easiest way for you to get one of these services is for you to call your Case Manager. Your
Case Manager can help with selecting a provider, making appointments, and getting prior
authorization, when prior authorization is needed. Of course, you can always make an
appointment directly with a provider, and have your provider assist you with gaining prior
authorization if it is needed. To reach your Case Manager please call:
1-800-932-4703
TTY Number 1-800-662-1220
Service and Description
Adult Day Health Care Center
•
•
•
•
•
You are covered for Adult Day Health Care Center services. The services that you
can receive at an Adult Day Health Center include: medical, nursing, food and
nutrition, social services, dental, and pharmacy.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
This is a service that you used to get using your Medicaid card. You will get this
service now through the GuildNet Gold Provider Network.
For purposes of appeals and grievances, this is a Medicaid only covered service.
Ambulance
•
•
•
•
•
You are covered for ambulance services to an institution such as a hospital and a SNF
and services dispatched from 911, where other forms of transportation would
endanger your health.
You do not have a co-payment or any out-of-pocket expense.
You do not require prior authorization, except for planned ambulance transport.
This is a service that you used to get using your Medicare card. You may get this
service now through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service covered by Medicare and
Medicaid.
Bone Mass Measurement
•
•
You are covered for Bone Mass Measurement procedures to identify bone mass,
detect bone loss, or determine bone quality, including a physician's interpretation
of the results, if you are at risk of losing bone mass or at risk of osteoporosis.
The following services are covered every two (2) years or more frequently, if
medically necessary: procedures to identify bone mass, detect bone loss, or
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 17 -
•
•
•
•
determine bone quality, including a physician's interpretation of the results.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is not required.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Cardiac Rehab (Outpatient)
•
•
•
•
•
Outpatient Cardiac rehabilitation therapy covered for patients who have had a heart
attack within the last twelve (12) months, have had coronary bypass surgery, and/or
have stable angina pectoris.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Certified Home Health Care
•
•
•
•
•
You are covered for medically necessary skilled nursing care, home health aide
services, social work, and rehabilitation services.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
This is a service that you used to get through Medicare and/or Medicaid. You may get
this service now through the GHI PPO Choice Provider Network or through the
GuildNet Gold provider network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Chiropractic Services
•
•
•
•
•
You are covered for Medicare Chiropractic services, which is manual manipulation of
the spine to correct subluxation.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required after the first eight (8) visits. Contact your Case
Manager.
This is a service that you used to get using your Medicare card. You may get this
service now through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicare.
Colorectal screening
•
•
You are entitled to all medically necessary services, as well as the following:
If you are 50 years old and older, you are covered for the following:
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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•
•
•
•
•
•
o Fecal occult blood test, every twelve (12) months.
o Flexible sigmoidoscopy (or screening barium enema as an alternative)
every forty-eight (48) months.
If you are at high risk of colorectal cancer, you are covered for:
o Screening colonoscopy (or screening barium enema as an alternative)
every twenty-four (24) months.
If you are not at high risk of colorectal cancer, you are covered for:
o Screening colonoscopy every ten (10) years, but not within forty-eight (48)
months of a screening sigmoidoscopy.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is not required.
This is a service that you used to get through Medicare and/or Medicaid. You may
now receive this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Dental
•
•
•
•
•
You are covered for dental services including preventive, prophylactic, and other
routine dental care, services and supplies, and dental prosthetics to alleviate a serious
health condition.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required, in some cases. Contact your Case Manager.
Some of these services are services that you used to get through Medicare and/or
Medicaid. The GuildNet Gold Network will now provide you with this service
through HealthPlex.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid only.
Diabetes Self-Monitoring
•
•
•
•
You are covered for Diabetes self-monitoring, self-management training and supplies
including coverage for glucose monitors, test strips, and lancets.
Prior authorization is not required.
This is a service that you used to get through Medicare and/or Medicaid. You may get
this service now through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Diagnostic testing (Outpatient)
•
You are covered for diagnostic tests that include, but are not limited to, the following:
o Laboratory tests.
o Radiation therapy.
o Surgical supplies, such as dressings.
o Supplies, such as splints and casts.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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•
•
•
•
o X-rays.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization for Magnetic Resonance Imaging (MRI), Magnetic Resonance
Angiography (MRA), Computerized Axial Tomography (CT scan), Positron
Emission Tomography (PET scan) and Nuclear Medicine Imaging is required.
Contact Your Case Manager.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Doctor Office Visits
•
•
•
•
•
You are covered for office visits, including medical and surgical care, in a doctor’s
office or ambulatory surgical center. This includes visits to Primary Care doctors.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is not required.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Durable Medical Equipment And Related Supplies
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You are covered for durable medical equipment, including devices and equipment
such as wheelchairs, crutches, hospital beds, IV infusion pumps, oxygen equipment,
nebulizers, and walkers, when medically necessary.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required for certain items. Contact your Case Manager.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Emergency Room
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You are covered for care provided in an emergency room anywhere in the world.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is not required.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Hearing Services
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You are covered for diagnostic hearing exams.
You are covered for medically necessary hearing services and products to alleviate
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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the loss or impairment of hearing. This includes hearing aid selecting, fitting, and
dispensing, conformity evaluations and hearing aid prescriptions, and hearing aid
products including hearing aids, hearing aid batteries, ear molds, special fittings, and
replacement parts.
You do not have a co-payment or any out-of-pocket expense.
Authorization is not required.
This is a service that you used to get through Medicare and/or Medicaid You may
now get this service through the GHI Choice PPO Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Home Delivered and Congregate Meals
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You are covered for meals delivered to you at your home, or meals you get in a
congregate setting, such as a senior center, if you are unable to prepare or have meals
prepared for you.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
You will get this service through the GuildNet Gold Network.
For purposes of appeals and grievances, this is a service covered by Medicaid only.
Immunizations
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You are covered for Hepatitis B vaccine if you are a person at risk.
You are covered for the Flu shot, once a year.
You are covered for the Pneumonia vaccine.
You are covered for other vaccines if you are at risk.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is not required.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Inpatient Hospital Care
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You are covered for unlimited days each benefit period.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required for non-emergency admissions. Contact your Case
Manager.
This is a service that you used to get through Medicare and/or Medicaid. You will
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Inpatient Mental Health Care
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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•
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You are covered for unlimited days each benefit period.
You are covered for Partial Hospitalization which is a structured program of active
treatment that is more intense than the care received in a doctor or therapist’s office
and is an alternative to inpatient hospitalization.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization may be required. Contact your Case Manager.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Mammograms
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You will be covered for all medically necessary mammograms, including an annual
screening if you are 40 years of age or older.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is not required.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Medical and Surgical Supplies, Enteral/Parenteral Formulas and
Supplements
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You are covered for medically necessary supplies, nutritional formula and
supplements.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
This is a service that you used to get through Medicaid.
You will now get this service through the GuildNet Gold Provider Network.
For purposes of appeals and grievances, this is a Medicaid-only covered service.
Medical Social Services
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You are covered for the assessment, arrangement, and provision of aid for social
problems that are the result of you living in your home.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
This is a service that is covered by Medicaid. You may get this service through the
GuildNet Gold Provider Network.
For purposes of appeals and grievances, this is a Medicaid-only covered service.
Nutrition
•
You are covered for assessment of your nutritional status and needs, nutrition
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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•
education, and nutritional counseling. Your cultural dietary needs will be considered
in the provision of these services.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
This is a service covered by Medicaid. You may get this through the GuildNet Gold
Provider Network.
For purposes of appeals and grievances, this is a Medicaid-only covered service.
Outpatient Drugs (Medicare Part B)
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You are covered for Medicare Part B covered prescription drugs and other drugs obtained
by a provider and administered in a physician’s office or clinic setting covered by
Medicare.
Prior authorization is not required.
This is a service that you previously got using your Medicare and/or Medicaid cards.
You may now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicare and Medicaid.
Outpatient Mental Health Care
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You are covered for Mental Health services, individual and group therapy, provided
by a doctor, clinical psychologist, clinical social worker, nurse practitioner, physician
assistant, or other mental health professional as allowed under applicable State laws.
You are covered for one (1) self-referral for an assessment, in a twelve (12) month
period.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Outpatient Rehab
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You are covered for Occupational, Speech/Language, and Physical Therapy delivered
on an outpatient basis.
You do not have a co-payment or any out-of-pocket expense
Prior authorization is required after twenty (20) visits for Physical Therapy, Speech
Therapy and Occupational Therapy. Contact your Case Manager.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Outpatient Substance Abuse
•
You are covered for individual and group visits to outpatient centers for substance
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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•
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abuse.
You are covered for one (1) self referral for an assessment, in a twelve (12) month
period.
You do not have a co-payment or any out-of-pocket expense
Prior authorization is required. Contact your Case Manager.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Outpatient Surgery
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•
You are covered for medically necessary visits to an ambulatory surgery center, or
outpatient hospital facility.
You are also covered for ambulatory dental services.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization may be required. Contact your Case Manager.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Pap Smears and Pelvic Exams
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Women are covered for Pap Smears and pelvic exams.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is not required.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Personal Emergency Response System (PERS)
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You are covered for a PERS which is an electronic device that you can use to get help
if you have a physical, emotional, or environmental emergency.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
This is a service that you used to receive using your Medicaid card. You will get this
service through the GuildNet Gold Provider Network.
For purposes of appeals and grievances, this is a Medicaid-only covered service.
Personal Care Services
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•
You are covered for medically necessary assistance with activities of daily living,
such as personal hygiene, dressing, and feeding.
You do not have a co-payment or any out-of-pocket expense.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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•
•
•
Prior authorization is required. Contact your Case Manager.
This is a service that you used to receive using your Medicaid card. You will get this
service through the GuildNet Gold Provider Network.
For purposes of appeals and grievances, this is a Medicaid-only covered service.
Podiatry Services
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You are covered for medically necessary foot care visits.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required in some instances. Contact your Case Manager.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Private Duty Nursing
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•
You are covered for medically necessary private duty nursing services when it is
ordered by a physician, physician assistant, or nurse practitioner.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
This is a service that you used to receive using your Medicaid card. You will now get
this service through the GuildNet Gold Provider Network.
For purposes of appeals and grievances, this is a Medicaid-only covered service.
Prostate Cancer Screening
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Medically necessary screening, including men aged 50 years and older. You do not
have a co-payment or any out-of-pocket expense.
Prior authorization is not required.
This is a service that you used to get through Medicare and/or Medicaid. You may get
this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Prosthetics
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•
You are covered for prosthetics that replace a body part or function. These include
colostomy bags and supplies directly related to colostomy care, pacemakers, braces,
prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere
after a mastectomy). Includes certain supplies related to prosthetic devices, and
repair and/or replacement of prosthetic devices. It includes some coverage following
cataract removal or cataract surgery.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required for certain items. Contact your Case Manager.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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•
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Routine Physical exams
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•
You are covered for one (1) routine physical exam each year.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is not required.
This is a service that you used to receive through Medicare and/or Medicaid. You
may now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Skilled Nursing Facility
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You are covered for unlimited days each benefit period for services received in a
Medicare certified skilled nursing facility, for short-term rehabilitation, or long-term
placement.
You do not have a co-payment or any out-of-pocket expense
Prior authorization is required. Contact your Case Manager.
This is a service that you used to get through Medicare and/or Medicaid. You may get
this service through the GHI PPO Choice Provider Network or the GuildNet Provider
Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Social Day Care
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•
You are covered for Social Day Care, which is a program that provides you with the
opportunity to go to a location on a regularly scheduled basis, where you can
socialize, receive meals, personal care, and monitoring, all under the supervision of
trained staff.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
This is a service covered by Medicaid. You will get this service through the GuildNet
Gold Provider Network.
For purposes of appeals and grievances, this is a service covered by Medicaid only.
Social and Environmental Supports
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•
You are covered for services and items that support your medical needs. These
services can include: home maintenance tasks, homemaker/chore services, housing,
improvement, and respite care.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
This is a service covered by Medicaid. You will get this service through the GuildNet
Gold Provider Network.
For purposes of appeals and grievances, this is a Medicaid-only covered service.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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Specialist Office Visits
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You are covered for specialist office visits that include:
o Medical and surgical care in a physician’s office or certified ambulatory
surgical center.
o Consultation, diagnosis, and treatment by a specialist.
o Second opinion prior to surgery.
o Outpatient hospital services.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is not required.
This is a service that you used to get through Medicare and/or Medicaid. You may
now get this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Transportation (non-emergency)
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You are covered for non-emergency transportation when you need to obtain medical
care and services. This includes ambulette, planned ambulance, invalid coach,
taxicab, livery, public transportation, or other means that are appropriate to your
medical condition and, if you need, a transportation attendant to accompany you. The
mode of transportation will be based on your medical condition.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is required. Contact your Case Manager.
This is a service that you used to receive using your Medicaid card. You will now get
this through the GuildNet Gold Provider Network.
For purposes of appeals and grievances, this is a service covered by Medicaid only.
Urgent Care
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You are covered for urgently needed care anywhere in the world.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization is not required.
This is a service that you used to get through Medicare and/or Medicaid. You may get
this service through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Vision Care Services
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•
If you are at high risk of glaucoma, (you have a family history of glaucoma, you have
diabetes, or are African-American aged 50 and older) you are covered for glaucoma
screening once per year.
You are covered for artificial eyes, low vision aids, and low vision services.
You are covered for medically necessary contact lenses, and polycarbonate lenses.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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•
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•
You are covered for one pair of eyeglasses or contact lenses, after each cataract
surgery that you have that includes insertion of an intraocular lens. You are also
covered for corrective lenses/frames (and replacements) that you need after a cataract
removal without a lens implant.
You are covered for one new pair of eyeglasses every year from the Davis Vision
eyewear collection, in addition to replacement of lost or destroyed glasses.
Replacement of lost, damaged, or destroyed eyeglasses/contact lenses are covered
under certain conditions.
You are covered for routine vision exams every year.
You are covered for outpatient physician services for eye care.
You do not have a co-payment or any out-of-pocket expense.
Prior authorization may be required. Contact your Case Manager.
Some of these services you used to get through Medicare and/or Medicaid. You
may access these services through the GHI PPO Choice Provider Network.
For the purpose of appeals and grievances, this is a service that is covered by
Medicaid and Medicare.
Health and Wellness Education Program
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General Education.
Parenting.
Smoking Cessation classes.
Childbirth education.
Nutritional counseling.
Health Advocate Counseling.
Contact your Case Manager for More Information.
PART D PRESCRIPTION DRUG COVERAGE: See your Evidence of
Coverage
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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PAYING PROVIDERS FOR COVERED SERVICES
Payment to all of our providers for approved covered services will be made by GuildNet Gold.
Providers are paid on a “fee-for-service” basis. This means that our providers get a GuildNet
Gold agreed-upon fee for each service he/she provides. This is true for providers in the GHI PPO
Choice Provider Network and the GuildNet Gold Provider Network.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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SERVICES COVERED BY REGULAR MEDICARE OR MEDICAID FEEFOR- SERVICE, NOT BY GUILDNET GOLD
There are some Medicare and Medicaid services that GuildNet Gold does not cover. You can
get these services from a provider using your Medicare or Medicaid Benefit Card.
•
Hospice: This is a coordinated program of home and inpatient care provided to people
who have been certified by a doctor as terminally ill, and expected to live six (6) months
or less. While this service is not covered by GuildNet Gold, you can receive Hospice
services from regular Medicare.
•
Certain Drugs, Pharmacy Items, and Vitamins:
o Medicaid fee-for-service covers barbiturates, benzodiazepines, some prescription
vitamins, and some non-prescription drugs and items. These are drugs, pharmacy
items, and vitamins that are not covered by GuildNet Gold’s Part D coverage.
o Under certain conditions, Medicaid fee-for-service pays for atypical
antipsychotics, antidepressants, anti-retrovirals used in the treatment of
HIV/AIDS, and anti-rejection drugs used in the treatment of tissue and organ
transplants. These drugs, which are normally covered by GuildNet Gold’s Part D
benefit, are paid for by Medicaid fee-for-service when you do not meet GuildNet
Gold’s utilization management requirements for these drugs, or there are quantity
limits on these drugs that exceed the amount that your doctor prescribed for you.
•
Out of Network Family Planning Services
You can go to any Medicaid doctor or clinic that provides family planning care. You do
not need a referral from your Primary Care Provider (PCP). The provider will be
reimbursed directly by Medicaid fee-for-service.
•
Methadone Maintenance Treatment Program (MMTP)
MMTP consists of drug detoxification, drug dependence counseling and rehabilitation
services which include chemical management of the patient with methadone. You can
get these services from Medicaid fee-for-service.
•
Certain Mental Health Services
You can get the following mental health services from Medicaid fee-for-service:
•
•
Intensive psychiatric rehabilitation treatment
Day treatment
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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•
•
•
•
Rehabilitation services to those in community homes or in family-based
treatment
Continuing day treatment
Assertive community treatment
Personalized recovery oriented services
•
Mental Retardation and Developmental Disabilities Services
You can get the following services from Medicaid fee-for-service:
• Long-term therapies
• Medicaid Service Coordination
•
Comprehensive Case Management Programs
These are programs that provide “social work” case-management referral services to
a targeted population. These services will be covered by Medicaid fee-for-service.
•
Directly Observed Therapy for Tuberculosis Disease
You can receive directly observed therapy, which is the direct oral ingestion of TB
medication to assure patient compliance with the physician’s prescribed medication
regimen. This service is covered under fee-for-service.
•
AIDS Adult Day Health Care
You can get Adult Day Health Care Programs that assist people with HIV disease to
live more independently in the community or eliminate the need for residential health
care services under fee-for-service.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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SERVICES NOT COVERED BY GUILDNET GOLD OR REGULAR
MEDICARE OR MEDICAID FEE-FOR-SERVICE
You must pay for services that are not covered by GuildNet Gold or by Medicaid if your
provider tells you in advance that these services are not covered, AND YOU AGREE, IN
WRITING, TO PAY FOR THEM. Examples of services not covered by GuildNet Gold or
Medicaid include, but are not limited to:
•
•
•
•
Cosmetic surgery if not medically needed
Personal and Comfort items
Infertility Treatment
Dental Implants
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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ACCESSING SERVICES IN SPECIAL SITUATIONS
What is an Emergency?
An emergency is a medical condition that has acute symptoms of sufficient severity, for
example, severe pain, such that a prudent lay-person with an average knowledge of health and
medicine could reasonably expect the absence of immediate medical attention to result in serious
jeopardy to the health of the individual, or in the case of a pregnant woman, to the health of the
woman or the unborn child; serious impairment to bodily functions; or serious dysfunction of
any body organ or part.
What to do in an Emergency
Call 911
You do not have to get prior authorization from GuildNet Gold in order to get emergency
medical help.
If you have an emergency medical condition, go to the nearest emergency room, or call 911 for
assistance.
Getting Care Outside of the Service Area
You may receive emergency care anywhere in the world.
You may receive all other out of area care anywhere in the United States. Prior authorization
rules described in this member handbook must be followed, when they apply.
Wherever you are, it is important that either you, a family member or a friend call your GuildNet
Case Manager as soon as possible. Your membership card lists the toll-free number that you can
call. Your Case Manager can rearrange any scheduled services that you might miss at this time,
and begin to make any necessary changes to your plan of care. He/she will help you to avoid any
unnecessary gaps in the services that you need.
If the service that you want when you are out of area is not vital to your health and well being, it
might be best for you to wait until you return home to get the service. This will allow your Case
Manager to be more actively involved in your care. If it is a long-term care service that you are
seeking, remember that you will be disenrolled from GuildNet Gold if you do not return to the
service area within ninety (90) days.
How to Get Help after Business Hours
It is always best for you to discuss your questions directly with your Case Manager, who knows
you best, during business hours.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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However, you might have an urgent need for help, or questions that cannot wait until business
hours. If you need help after hours, on a weekend, or on a holiday, contact us at our 24-hour tollfree number, and a GuildNet representative will help you.
1-800-932-4703
TTY Number 1-800-662-1220
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 34 -
SERVICE AUTHORIZATION AND ACTIONS
When you ask for approval of a treatment or service, it is called a service authorization
request. To get a service authorization you should call your Case Manager or Member
Services at:
1-800-932-4703
TTY Number 1-800-662-1220
Services will be authorized in a certain amount and for a specific period of time. This is called
an authorization period.
Some of the services you receive from GuildNet Gold are covered only by Medicare, some only
by Medicaid and some are covered by both Medicare and Medicare, (See the Covered Services
section of this Member Handbook for more information.) The way GuildNet Gold makes
decisions about services depends on whether the service is covered by Medicaid and/or
Medicare.
When GuildNet Gold determines that services are covered by Medicaid we will make decisions
about your care following the rules described below. For the rules about GuildNet Gold service
authorization process for services covered by Medicare, please refer to your Evidence of
Coverage.
Medicaid Service Authorization Rules
Prior Authorization
Some of the GuildNet Gold covered services described in this Member Handbook, in
particular the services that you used to get using your Medicaid card, need prior
authorization (approval in advance), from your Case Manager, before you receive them,
or in order to be able to continue receiving them. (See the Covered Services Section of
this Member Handbook for information about which services require prior authorization.)
Concurrent Authorization
You will also need to get prior authorization if you are receiving a service now that is
only covered by Medicaid, but need to get more of the care during an authorization
period. This is called concurrent authorization.
What happens after we get your service authorization request?
When GuildNet Gold gets your service authorization request, we evaluate your request against
established clinical review criteria.
Any decision to deny a service authorization request, to approve it for an amount or time period
that is less than requested, or reduce, suspend, or terminate a service, that we have already
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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approved, is called an ACTION. These decisions will be made by a qualified health care
professional. If we decide that the service is not medically necessary, the decision will be made
by a clinical peer reviewer, who may be a doctor, a nurse or a health care professional who
typically provides the care you requested. You can request the specific criteria, called clinical
review criteria, used to make the decision for actions related to medical necessity.
After we get your request, we will review it under a standard or expedited (fast track) process.
You or your doctor can ask for an expedited review if it is believed that a delay will cause
serious harm to your health. If your request for an expedited review is denied, we will tell you in
writing and let you know your request will be handled under the standard review time frames. In
all cases, we will review your request as fast as your medical condition requires us to do so, but
no later than the time frame identified below.
We will tell you and your provider by phone and in writing, and let you know whether your
request is approved or denied. We will also tell you the reason for the decision. We will explain
what options for appeals or fair hearings you will have if you don’t agree with our decision.
Time Frames for Prior Authorization Requests
•
Standard review: We will make a decision about your request within three (3)
business days of receiving all the information we need, but you will hear from us no
later than fourteen (14) days after we receive your request. We will tell you by the
14th day if we need more information.
•
Expedited review: We will make a decision and you will hear from us within three
(3) business days. We will tell you by the third business day if we need more
information.
Time Frames for Concurrent Authorization Requests
•
Standard review: We will make a decision within one (1) business day after we have
received all of the information we need, but you will hear from us no later than
fourteeen (14) days after we have received your request.
•
Expedited review: We will make a decision within one (1) business day after we
have received all of the information we need, but you will hear from us no later than
three (3) business days after we have received your request.
If we need more information to make either a standard or expedited decision about
your service request, the time frames above can be extended up to fourteen (14)
days. We will:
•
Write and tell you what information is needed. If your request is for an expedited
review, we will call you right away and send a written notice later.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 36 -
•
Tell you why the delay is in your best interest.
•
Make a decision as quickly as we can, when we have received the necessary
information, but no later than fourteen (14) days from the original request.
You, your provider, or someone you trust, may also ask us to take more time to make a decision.
This may be because you have more information to give us that will help us to decide your case.
This can be done by calling Member Services at 1-800-932-4703, TTY Number 1-800-6621220 or by writing to us at the address on the letter that we sent you.
You or someone you trust can file a grievance with the plan if you don’t agree with our decision
to take more time to review your request. You or someone you trust can also file a complaint
about the review time with the New York State Department of Health by calling 1-866-7127197.
We will notify you of any decision we make about your request for services in writing. If you are
not satisfied with our decision about a Medicaid service, you have the right to file a Medicaid
Action Appeal (See the Action Appeal Section of this Member Handbook for further
information.)
OTHER DECISIONS ABOUT YOUR MEDICAID SERVICES
Sometimes we will do a review on the care you are receiving to see if you still need the care. If
we find that you do not need the services you are currently receiving, this can result in a
termination, suspension or reduction of benefits. In most cases, we will tell you in writing, at
least ten (10) days before we change your services. You may also file a Medicaid Action Appeal
if you disagree with our decision.
Reconsiderations
If we made a decision about your service authorization request without talking to your health
care provider, your health care provider may ask to speak with the plan’s Medical Director. The
Medical Director will talk to your health care provider within one (1) business day.
ACTION APPEALS
As a Dually-Eligible (Medicare and Medicaid) member of our plan, the way in which you make
appeals our decisions about your services will depend on whether the services are covered by
Medicare and/or Medicaid (See the “Covered Services” section of this Member Handbook for
more information.)
•
Medicare Services: For appeals about a service that is covered only by Medicare
(Chiropractic services and Part D Prescription Drug Benefits), you will follow the rules
outlined in your Evidence of Coverage. You will also follow these rules if you think that
you are being discharged from the hospital too soon, or if you think your coverage for
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
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Skilled Nursing Facility, Certified Home Health Care, or Comprehensive Outpatient
Rehabilitation is ending too soon, and we told you the decision we made was based on
Medicare rules.
•
Medicaid Services: For appeals about a service that is covered only by Medicaid,
examples of which are: personal care services, private duty nursing, non-emergency
transportation, dental services, see the Covered Benefits Section of this Member
Handbook for more information, You will follow the Medicaid rules listed below.
•
Medicaid and Medicare Services: For appeals about all other services covered by
GuildNet Gold (for services covered by Medicare and Medicaid see the Covered Services
section of this Member Handbook), you may choose to follow either the Medicare rules
outlined in your Evidence of Coverage, or the Medicaid rules described below. If you
choose to follow the Medicare rules, you cannot use your Medicaid appeal rights,
including the right to a NYS Medicaid Fair Hearing. But if you choose to follow the
Medicaid rules, you will have up to sixty (60) days from the day of GuildNet Gold’s
notice of denial of coverage to use your Medicare appeal rights.
•
If you don’t make a choice between the Medicare and Medicaid rules, we will follow
the Medicaid rules.
We understand that the Appeals process may be confusing to you. GuildNet Gold will explain
the appeals processes available to you depending on your issue. Call Member Services at 1800-932-4703, TTY Number 800-662-1220 to get more information on your rights and the
options available to you.
How to File a Medicaid Appeal
• If you are not satisfied with the action we have taken concerning the services that you are
currently receiving or with our decision about your service authorization request, you
have forty-five (45) business days, after receiving our written decision, to file an appeal.
You can do this yourself or ask someone you trust to file the appeal for you.
If you need help filing an appeal you can call:
Member Services
1-800-932-4703
TTY Number 1-800-662-1220
•
We will not treat you any differently or act badly toward you because you file an appeal.
•
The appeal can be made by phone or in writing.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 38 -
Your Medicaid action appeal will be reviewed under the expedited (fast track) process if:
• You or your health care provider ask to have your appeal reviewed under the expedited
process. Your health care provider will have to explain how a delay in making our
decision will cause harm to your health. If your request for review under the expedited
process is denied, we will tell you in writing, and let you know that your appeal will be
reviewed under the standard process;
•
Your request was denied when you asked to continue receiving care that you are now
getting, or need to extend a service that has been provided.
Expedited appeals can be made by phone and do not have to be followed up in writing.
What happens after we get your Medicaid Appeal
• Within fifteen (15) days, we will send you a letter to let you know we are working on
your appeal. We will let you know if we need additional information to make our
decision.
•
Action Appeals of clinical matters will be decided by qualified health care professionals
who did not make the first decision, at least one of whom will be a clinical peer reviewer.
•
Non-clinical decisions will be handled by a person other than the one that made your first
decision.
•
Before and during the appeal, you or your designee can see your case file, including
medical records and any other documents and records being used to make a decision on
your case.
•
You can also provide information to be used in making the decision in person or in
writing.
•
We will give you the reasons for our decision and our clinical rationale, if it applies, in
writing. We will also let you know about appeal rights that are available to you, if you are
not satisfied with our decision.
•
You or someone you trust can always file a complaint with the New York State
Department of Health at 1-800-206-8125, TTY Number 1-800-662-1220. However, you
should know that this is not the same as filing a request for a NYS Medicaid Fair
Hearing. (See the Fair Hearings section for instructions on how to file a NYS Medicaid
Fair Hearing request.)
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 39 -
Time Frames for Medicaid Action Appeals
• Standard appeals: If we have all the information we need, we will tell you our decision
within thirty (30) days from the date of your appeal. A written notice of our decision will
be sent within two (2) business days from the day we made the decision.
•
Expedited appeals: If we have all the information we need, expedited appeal decisions
will be made within two (2) business days from your appeal. We will tell you within
three (3) business days after we receive your appeal if we need more information. We
will tell you our decision by phone and send a written notice later.
If we do not have the information we need to make either a standard or expedited decision
about your Medicaid action appeal we will
• Write to tell you that we need more time to collect the information. If your request is an
expedited review, we will call you right away, and send a written notice later.
•
Tell you why the delay is in your best interest.
•
Take no more than fourteen (14) additional days to make a decision.
Asking for more time
You, your provider, or someone you trust may also ask us to take more time to make a decision.
This may be because you have more information to give the plan which will help to decide your
case. This can be done by calling 1-800-932-4703, TTY Number 1-800-662-1220 or by writing
to the address on the letter that you received from us.
You or someone you trust can file a grievance with the plan if you don’t agree with our decision
to take more time to review your action appeal. You or someone you trust can also file a
complaint about the review time with the New York State Department of Health by calling 1866-712-7197, but that will not allow you to request a Medicaid Fair Hearing.
If your original denial was because we said the Medicaid service was not medically necessary or
was experimental or investigational, and we do not tell you our decision about your appeal
within the time frames above, the original denial against you will be reversed. This means your
service authorization request will be approved.
Aid to Continue while appealing a decision about your Medicaid services
In some cases you may be able to continue receiving the services you are currently receiving
while you wait for your Medicaid appeal to be decided. You may be able to continue the
services that are scheduled to end or be reduced if you ask for an appeal:
•
•
Within ten (10) days from our notice to you that care is changing; or
By the date the change in services is scheduled to occur.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 40 -
If your appeal results in another denial, you may have to pay for the cost of any continued
benefits that you received as a result of requesting an appeal about those benefits.
If we deny your appeal and you are not satisfied, you can appeal further using the NYS External
Appeals process or the NYS Medicaid Fair Hearing process described below.
New York State External Appeals
If the plan decides to deny coverage for a Medicaid service you and your doctor asked for
because it is not medically necessary or because it is experimental or investigational, you can ask
New York State for an independent external appeal. This is called an external appeal because it
is decided by reviewers who do not work for the health plan or the State. These reviewers are
qualified people approved by New York State. The service must be in the plan’s benefit package
or be an experimental treatment. You do not have to pay for an external appeal.
Before you appeal to New York State:
1. You must file an Action Appeal with the plan and get the plan’s final adverse
determination; or
2. If you had an Expedited Action Appeal and are not satisfied with the plan’s decision,
you can choose to file a Standard Action Appeal with the plan or go directly to a
NYS external appeal; or
3. You and the plan may agree to skip the plan’s appeals process and go directly to a
NYS External Appeal.
You have forty-five (45) days after you receive the plan’s final decision to ask for a NYS
External Appeal. If you and the plan agreed to skip the plan’s appeals process, then you must
ask for the Medicaid External Appeal within forty-five (45) days of the date when you made that
agreement.
You will lose your right to a NYS External Appeal if you do not file an application for a
NYS External Appeal on time.
To ask for an External Appeal, you will need to fill out an application and send it to the State
Insurance Department. You can call Member Services at 1-800-932-4703, TTY Number 800662-1220 if you need help filing an appeal. You and your doctors will have to give information
about your medical problem.
Here are some ways to get an application:
•
•
•
Call the State Insurance Department, 1-800-400-8882
Go to the State Insurance Department’s website at www.ins.state.ny.us
Contact the health plan at 1-800-932-4703
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 41 -
Your NYS External Appeal will be decided in thirty (30) days from the date the State Insurance
Department receives your application. More time (up to five business days) may be needed if the
external appeal reviewer asks for more information. You and the plan will be told the final
decision within two (2) days after the decision is made.
You can get a faster decision if your doctor says that a delay will cause serious harm to your
health. This is called an Expedited External Appeal. The external appeal reviewer will decide
an expedited appeal in three (3) days or less. The reviewer will tell you and the plan the decision
right away by phone or by fax. Later, a letter will be sent that tells you the decision.
You may also ask for a Medicaid Fair Hearing if we deny your appeal. You may request both a
NYS Medicaid Fair Hearing and a NYS External Appeal, as well. If you ask for a Fair Hearing
and an External Appeal, the decision of the NYS Fair Hearing officer will be the one that counts.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 42 -
FAIR HEARINGS FOR SERVICES COVERED BY MEDICAID
You may ask for a New York State Medicaid Fair Hearing if we deny your appeal. You may ask
for both a NYS External Appeal and a NYS Medicaid Fair Hearing. However, if you ask for
both, it will be the decision of the Fair Hearing officer that counts. If you filed an appeal under
Medicare rules, you may not then request a Fair Hearing about the same appeal.
You may also request a Fair Hearing if you are not happy with a decision your local Department
of Social Services made about your enrollment in, or disenrollment from, GuildNet Gold.
In some cases, you may be able to keep getting care in the same way while waiting for your Fair
Hearing. This is called “aid to continue”.
If we decide to change the Medicaid services that we previously authorized, you may be able to
continue receiving services while you wait for your NYS Medicaid Fair Hearing decision. You
may be able to continue the services that are scheduled to end or be reduced if you ask for a NYS
Medicaid Fair Hearing:
•
•
Within ten (10) days from the date you received our decision about your appeal and
we told you in the appeal decision that we were still intending to change your care or
service; or
By the date the change in care or services is scheduled to occur.
If the Fair Hearing decision is not in your favor, you may have to pay the costs of any continued
benefits you received solely as a result of requesting a Fair Hearing about those benefits.
To request a Fair Hearing, fill out the Fair Hearing Notice that we send you with our decision, if
the decision is not in your favor. You can call Member Services at 1-800-932-4703, TTY
Number 1-800-662-1220, if you need help filing your request for a Fair Hearing.
You can use one of the following ways to request a Fair Hearing:
• By phone. Call toll free 1-800-342-3334
• By fax at 518-473-6735
• By Internet at www.otda.state.ny.us/oah/forms.asp
• By mail:
Fair Hearing Section
NYS Office of Temporary and Disability Assistance
P.O. Box 1930
Albany, New York 12201
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 43 -
Remember, you can file a complaint at any time with the New York State Department of Health
by calling 1-866-712-7197. Call Member Services at 1-800-932-4703, TTY Number 1-800662-1220 if you have any questions.
GRIEVANCES
We hope our plan serves you well. If there are unfortunate circumstances where you have a
problem with the care or treatment you receive from our staff or providers, or you do not like the
quality of care or services you receive from us, call Member Services:
1-800-932-4703
TTY Number 1-800-662-1220
Most problems can be solved right away if you call us promptly. Problems that are not solved
the same day will be handled according to the process described below.
You can always ask someone you trust to file the grievance for you. If you need our help
because of a hearing or vision impairment or if you need translation services, we can help you.
We will not make things hard for you or take any action against you for filing a grievance.
If you chose to make a grievance in writing, your grievances must be sent to the following
addresses, as described below:
GuildNet Gold
Appeals Department
P.O. Box 4296
Kingston, NY 12402
Grievances About Prescription Drug Program Should Be Sent To:
P.O. Box 4296
Kingston, NY 12402
Or Call
1-866-557-7300.
TTY number 1-866-248-0640
Grievances about services that are only a benefit under Medicare (Chiropractic or Part D
Prescription Drugs): will follow the GuildNet Gold Medicare grievance process. (Please see your
Evidence of Coverage for instructions.)
Grievances about services covered only by Medicaid (those services such as personal care,
private duty nursing, and other services that you used to get using your Medicaid card): will
follow the GuildNet Gold Medicaid grievance process, described below.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 44 -
Grievances about all other services (those covered by both Medicare and Medicaid): you
can choose to use either the Medicare or Medicaid grievance process. If you need assistance
choosing which grievance process to follow, our Member Services staff can answer any
questions that you may have. If you don’t make a choice between the Medicare and Medicaid
rules, we will follow the Medicaid rules.
We understand that the grievance process may be confusing to you. GuildNet Gold will explain
the grievance processes available to you depending on your issue. Call Member Services at 1800-932-4703, TTY Number 1-800-662-1220 to get more information on your rights and the
options available to you.
Medicaid Grievance Process
If we don’t solve the problem to your satisfaction right away over the phone - or after we get
your written grievance - we will send you a letter within fifteen (15) business days. The letter
will tell you:
•
•
•
who is working on your grievance;
how to contact this person and
if we need more information to resolve your grievance.
Your grievance will be reviewed by one or more qualified people. If your grievance involves
clinical matters it will be reviewed by one or more qualified health care professionals.
We will let you know our decision in forty-five (45) days of the date when we have all the
information we need to answer your grievance, but you will hear from us in no more than sixty
(60) days from the day we get your grievance. We will write to you and will tell you the reasons
for our decision.
When a delay would be a risk to your health, we will expedite (fast track) our review and let you
know our decision in 48 hours of the date when we have all the information we need to answer
your grievance, but you will hear from us in no more than seven (7) days from the day we get
your grievance. We will call you with our decision. You will get a letter within three (3) business
days of when we make our decision.
If we do not have the information we need to make a decision about your Medicaid
grievance we will
• Write to tell you that we need more time to collect the information. If your grievance is
being expedited, we will call you right away to tell you what information we need, and
send a written notice later.
•
Tell you why the delay is in your best interest;
•
Take no more than fourteen (14) additional days to make a decision.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 45 -
You will be told how to appeal our decision if you are not satisfied and we will include any
forms you may need in order to appeal our decision.
Medicaid Grievance Appeals
If you disagree with a decision we made about your grievance, you or someone you trust can file
a Medicaid Grievance Appeal with the plan.
•
You have sixty (60) business days after receiving our written decision to file an
appeal.
•
You can file the appeal yourself or ask someone you trust to file the appeal for you.
•
The appeal can be made in writing, or you can call Member Services. After your call,
we will send you a form which is a summary of your phone appeal. If you agree with
our summary, you must sign and return the form to us. You can make any needed
changes before sending the form back to us.
After we get your Grievance Appeal we will send you a letter within fifteen (15) business days.
The letter will tell you:
•
who is working on your Grievance Appeal
•
how to contact this person
•
if we need more information to make a decision about your appeal.
Your Grievance Appeal will be reviewed by one or more qualified people at a higher level than
those who made the first decision about your grievance. If your Grievance Appeal involves
clinical matters, your case will be reviewed by one or more qualified health professionals with at
least one clinical peer reviewer, who were not involved in making the first decision about your
grievance.
We will let you know our decision within thirty (30) business days from the time we have all the
information needed. If a delay would risk your health, you will get our decision in two (2)
business days of the day when we have all the information we need to decide the appeal. You
will be given the reasons for our decision and our clinical rationale, if it applies. If you are still
not satisfied, you or someone on your behalf can file a complaint at any time with the New York
State Department of Health at 1-866-712-7197.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 46 -
MEMBER RIGHTS AND RESPONSIBILITIES
Your rights as a GuildNet Gold Member, at a minimum, include the right to:
• Receive medically necessary care.
• Privacy about your medical record and when you get treatment.
• Timely access to care and services.
• Get information on available treatment options and alternatives presented in a manner
and language you understand
• Get information in a language you understand; you can get oral translation services
free of charge.
• Get information necessary to give informed consent before the start of treatment.
• Be treated with respect and dignity.
• Get a copy of your medical records and ask that the records be amended or corrected.
• Tell GuildNet about your care needs and concerns and work with your Case Manager
in addressing them.
• Take part in decisions about your health care, including the right to refuse treatment.
• Be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience or retaliation.
• Get care without regard to sex, race, health status, color, age, national origin, sexual
orientation, marital status or religion.
• Be told where, when, and how, to get the services you need from GuildNet, including
how you can get covered benefits from out-of-network providers.
• Complain to GuildNet, the New York State Department of Health or the New York
City Human Resources Administration, and in some instances, the right to use the
New York State Fair Hearing System, to request a NYS External Appeal, or appeal to
the CMS designated agency.
• Appoint someone to speak for you about your care and treatment.
• Make advance directives and plans about your care.
Your responsibilities as a GuildNet Gold member, at a minimum, include your
responsibility to:
• Get approval from your physician and your Case Manager before receiving a covered
service that requires prior approval.
• Notify GuildNet Gold when you are out of the service area.
• Make all required payments to GuildNet Gold; and,
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 47 -
•
Cooperate with any requests for documentation related to maintaining your Medicaid
eligibility.
You may have additional rights and responsibilities through your Medicare coverage. Please see
your Evidence of Coverage for more information.
Getting Information about GuildNet and GuildNet Gold
GuildNet Gold is one of the health care programs offered by GuildNet. You can get more
information about GuildNet and GuildNet Gold whenever you wish. For more information you
should call Member Services at:
1-800-932-4703
TTY Number 1-800-662-1220
Monday through Friday
8:00 am to 8:00 pm
The following information is available upon request:
•
Names, addresses, and positions of the Officers and Board of Directors.
•
Most recent GuildNet annual certified financial statement.
•
Information on consumer grievances.
•
Procedures for confidentiality of member information.
•
Quality management program and procedures.
•
Clinical review criteria that is used in utilization review. (This information must be
requested in writing.)
•
Application procedures and minimum qualification requirements for GuildNet Gold
health care providers, including providers in the GHI Choice Network.
Member Service Number 1-800-932-4703
TTY Number 1-800-662-1220
- 48 -
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