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GuildNet
Gold Plus FIDA Plan
MMP-POS

Participant Handbook 2017

For more information or other questions, please contact the Plan at 1-800-815-0000 or, for TTY users, 711,
hours of operation, Monday through Sunday, 8am to 8pm or visit www.guildnetny.org.

H0811_GN452_2017 Participant Handbook_Approved

GuildNet Gold FIDA Plus Plan MMP-POS
Participant Handbook
Table of Contents
Chapter 1: Getting started as a Participant........................................................................iii
Chapter 2: Important phone numbers and resources ...................................................... 13
Chapter 3: Using the plan’s coverage for your health care and other covered
services and items ......................................................................................... 28
Chapter 4: Covered Items and Services.......................................................................... 49
Chapter 5: Getting your outpatient prescription drugs and other covered
medications through the plan ....................................................................... 112
Chapter 6: Understanding the plan’s drug coverage ..................................................... 129
Chapter 7: Asking us to pay a bill you have gotten for covered services,
items, or drugs ............................................................................................. 136
Chapter 8: Your rights and responsibilities .................................................................... 142
Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances) .................................................. 164
Chapter 10: Ending your participation in our FIDA Plan ................................................ 214
Chapter 11: Legal notices.............................................................................................. 224
Chapter 12: Definitions of important words.................................................................... 228

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and
TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. For more information,
visit www.guildnetny.org.

CHAPTER 1
Getting Started as a Participant

iii

GuildNet Gold Plus FIDA Plan
Participant Handbook
January 1, 2017 – December 31, 2017

Your Health and Drug Coverage under GuildNet Gold Plus FIDA
Plan
This handbook tells you about your coverage under GuildNet Gold Plus FIDA Plan
(Medicare-Medicaid Plan) from the date you are enrolled with GuildNet Gold Plus FIDA Plan
through December 31, 2017. It explains how GuildNet Gold Plus FIDA Plan covers Medicare
and Medicaid services, including prescription drug coverage, at no cost to you. It explains the
health care services, behavioral health services, prescription drugs, and long-term services
and supports that GuildNet Gold Plus FIDA Plan covers. Long-term services and supports
include long-term facility-based care and long-term community-based services and supports.
Long-term community-based services and supports provide the care you need at home and
in your community, and can help reduce your chances of going to a nursing facility or
hospital.
This is an important legal document. Please keep it in a safe place.
GuildNet Gold Plus FIDA Plan is a Fully Integrated Duals Advantage (FIDA) Plan that is
offered by GuildNet, Inc. When this Participant Handbook says “we,” “us,” or “our,” it means
GuildNet, Inc. When it says “the plan” or “our plan,” it means GuildNet Gold Plus FIDA Plan.
You can get this handbook for free in other languages. Call 1-800-815-0000 and TTY/TDD
711, Monday through Sunday, 8am to 8pm. The call is free.
Usted puede obtener esta información en otros idiomas gratis. Llame al 1-800-815-0000 o TTY/TDD
al 711, de lunes a domingo de 8am a 8pm. La llamada es gratis.
Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare il numero verde 1-800815-0000 o 711 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)
711，星期一至星期日上午8 時至晚上8 時。撥打該電話免費。
Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang. Rele nimewo 1-800-815-0000 oswa
TTY/TDD 711, lendi jiska dimanch, depi 8am jiska 8pm. Koutfil la gratis.
다른 언어로 작성된 이 정보를 무료로 얻으실 수 있습니다. 월요일 - 일요일 오전 8시부터 오후 8시
사이에 1-800-815-0000번이나 TTY/TDD 711번으로 전화주세요. 통화는 무료입니다.

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

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 1: Getting started as a Participant

Вы можете бесплатно получить эту информацию на других языках. Позвоните по
телефону 1-800-815-0000 и TTY/TDD 711. Служба работает с понедельника по
воскресенье с 08:00 до 20:00 ч. Звонок бесплатный.
You can get this handbook for free in other formats, such as large print, braille, or audio. Call
1-800-815-0000 and TTY/TDD 711, Monday through Sunday, 8am to 8pm.
You can make a request now and in the future, for a language other than English or for an
alternate format by calling 1-800-815-0000 and TTY/TDD 711, during Monday through
Sunday, 8am to 8pm.

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.
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.
GuildNet Gold Plus FIDA Plan is an MMP-POS plan with a Medicare and New York State
Medicaid contract. Enrollment in GuildNet Gold Plus FIDA Plan depends on contract
renewal.
The State of New York has created a participant ombudsman program called the
Independent Consumer Advocacy Network (ICAN) to provide Participants free, 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. (TTY users call 711, then follow the
prompts to dial 844-614-8800.)

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 1: Getting started as a Participant

Chapter 1: Getting started as a Participant
Table of Contents
A. Welcome to GuildNet Gold Plus FIDA Plan ................................................................................... 4
B. What are Medicare and Medicaid? ................................................................................................ 4
Medicare ....................................................................................................................................... 4
Medicaid ........................................................................................................................................ 4
C. What are the advantages of this FIDA Plan? ................................................................................. 5
D. What is GuildNet Gold Plus FIDA Plan’s service area? ................................................................. 7
E. What makes you eligible to be a plan Participant?......................................................................... 7
F. What to expect when you first join a FIDA Plan ............................................................................. 8
G. What is a Person-Centered Service Plan?..................................................................................... 8
H. Does GuildNet Gold Plus FIDA Plan have a monthly plan premium? ............................................ 9
I. About the Participant Handbook .................................................................................................... 9
J. What other information will you get from us? ................................................................................. 9
Your GuildNet Gold Plus FIDA Plan Participant ID Card................................................................ 9
Provider and Pharmacy Directory ................................................................................................ 10
List of Covered Drugs .................................................................................................................. 11
The Explanation of Benefits ......................................................................................................... 12
K. How can you keep your Participant record up to date? ................................................................ 12
Do we keep your personal health information private? ................................................................ 12

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 1: Getting started as a Participant

A. Welcome to GuildNet Gold Plus FIDA Plan
GuildNet Gold Plus FIDA Plan is a Fully Integrated Duals Advantage (FIDA) Plan. A FIDA
Plan is an organization made up of doctors, hospitals, pharmacies, providers of long-term
services and supports, and other providers. It also has Care Managers and Interdisciplinary
Teams (IDTs) to help you manage all your providers and services. They all work together to
provide the care you need.
GuildNet Gold Plus FIDA Plan was approved by New York State and the Centers for
Medicare & Medicaid Services (CMS) to provide you services as part of the FIDA
Demonstration.
FIDA is a demonstration program jointly run by New York State and the federal government
to provide better health care for people who have both Medicare and Medicaid. Under this
demonstration, the state and federal government want to test new ways to improve how you
get your Medicare and Medicaid health care services. At present, this demonstration is
scheduled to last until December 31, 2017.
GuildNet Gold Plus FIDA Plan is a Point of Service Plan. This means that for services you
received under Medicare, you can see any Provider who accepts Medicare as long as the
Provider agrees to participate in the FIDA demonstration.

B. What are Medicare and Medicaid?
Medicare
Medicare is the federal health insurance program for:

 people 65 years of age or older,
 some people under age 65 with certain disabilities, and
 people with end-stage renal disease (kidney failure).
Medicaid
Medicaid is a program run by the federal government and New York State that helps people
with limited incomes and resources pay for long-term services and supports and medical
costs. It covers extra services and drugs not covered by Medicare.
Each state decides what counts as income and resources and who qualifies. Each state also
decides which services are covered and the cost for services. States can decide how to run
their programs, as long as they follow the federal rules.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 1: Getting started as a Participant

Medicare and New York State must approve GuildNet Gold Plus FIDA Plan each year. You
can get Medicare and Medicaid services through our plan as long as:

 You are eligible to participate in the FIDA Demonstration,
 We choose to offer the FIDA Plan, and
 Medicare and New York State approve GuildNet Gold Plus FIDA Plan to participate in
the FIDA Demonstration.
If at any time our plan stops operating, your eligibility for Medicare and Medicaid services will
not be affected.

C. What are the advantages of this FIDA Plan?
In the FIDA Demonstration, you will get all your covered Medicare and Medicaid services
from GuildNet Gold Plus FIDA Plan, including long-term services and supports (LTSS) and
prescription drugs. You do not pay anything to join or get services from this plan. However, if
you have Medicaid with a “spend-down” or “excess income,” you will have to continue to pay
your spend-down to the FIDA Plan.
GuildNet Gold Plus FIDA Plan will help make your Medicare and Medicaid benefits work
better together and work better for you. Here are some of the advantages of having GuildNet
Gold Plus FIDA Plan:

 You will have an Interdisciplinary Team that you help put together. An Interdisciplinary
Team (IDT) is a group of people that will get to know your needs and work with you to
develop and carry out a Person-Centered Service Plan specific to your needs. Your
IDT may include a Care Manager, doctors, service providers, or other health
professionals who are there to help you get the care you need.

 You will have a Care Manager. This is a person who works with you, with GuildNet
Gold Plus FIDA Plan, and with your care providers to make sure you get the care you
need.

 You will be able to direct your own care with help from your IDT and your Care
Manager.

 The IDT and Care Manager will work with you to come up with a Person-Centered
Service Plan specifically designed to meet your needs. The IDT will be in charge of
coordinating the services you need. This means, for example:
» Your IDT will make sure your doctors know about all medicines you take so they
can reduce any side effects.
» Your IDT will make sure your test results are shared with all your doctors and
other providers.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 1: Getting started as a Participant

» Your IDT will help you schedule and get to appointments with doctors and other
providers.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 1: Getting started as a Participant

D. What is GuildNet Gold Plus FIDA Plan’s service area?
The GuildNet Gold Plus FIDA Plan’s service area includes Bronx, Kings, New York, Queens,
Richmond, and Nassau Counties.
Only people who live in our service area can join GuildNet Gold Plus FIDA Plan.
If you move outside of our service area, you cannot stay in this plan.

E. What makes you eligible to be a plan Participant?
You are eligible for our plan as long as:

 you live in our service area;
 you are entitled to Medicare Part A, enrolled in Medicare Part B, and eligible for
Medicare Part D;

 you are eligible for Medicaid;
 you are a United States citizen or are lawfully present in the United States;
 you are age 21 or older at the time of enrollment;
 you require 120 or more days of community-based or facility-based LTSS or are
nursing facility clinically eligible and get facility-based long-term support services; and

 you are not excluded from enrollment based on one of the exclusions listed below.
You will be excluded from joining our plan if:

 you are a resident of a New York State Office of Mental Health (OMH) facility or a
psychiatric facility;

 you are getting services from the State Office for People with Developmental
Disabilities (OPWDD) system – whether getting services in an OPWDD facility or
treatment center, getting services through an OPWDD Waiver, whether you could be
getting services in an ICF/IID but you have chosen not to, or otherwise;

 you are expected to be Medicaid eligible for less than six months;
 you are eligible for Medicaid benefits only for tuberculosis related services, breast
cancer services, or cervical cancer services;

 you are getting hospice services (at time of enrollment);
 you are eligible for the family planning expansion program;
 you are a resident of an alcohol/substance abuse long-term residential treatment
program;

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 1: Getting started as a Participant

 you are eligible for Emergency Medicaid;
 you are enrolled in the 1915(c) waiver program for Traumatic Brain Injury (TBI);
 you participate in and reside in an Assisted Living Program; or
 you are in the Foster Family Care Demonstration.

F. What to expect when you first join a FIDA Plan
When you first join the plan, you will get a comprehensive assessment of your needs within
the first 90 days or within six months of your last assessment if you joined GuildNet Gold Plus
FIDA Plan from GuildNet MLTC Plan. The assessment will be conducted by a Registered
Nurse from GuildNet Gold Plus FIDA Plan.
If GuildNet Gold Plus FIDA Plan is new for you, you can keep seeing the doctors you go
to now and getting your current services for a certain amount of time. This is called the
“transition period.” In most cases, the transition period will last for 90 days or until your
Person-Centered Service Plan is finalized and implemented, whichever is later. Because
GuildNet Gold Plus FIDA Plan is a Point of Service plan, you may continue using an out-ofnetwork provider for Medicare-covered services after the transition period. However, you will
need to see doctors and other providers in GuildNet Gold Plus FIDA Plan’s network for
services covered by your Medicaid benefit. It is always best for you to see an in-network
provider. An in-network provider is someone who works with GuildNet Gold Plus FIDA Plan.
See Chapter 3 for more information on getting care.
After the transition period, you will need to see doctors and other providers in the GuildNet
Gold Plus FIDA Plan network for services covered by your Medicaid benefit. A network
provider is a provider who works with GuildNet Gold Plus FIDA Plan. See Chapter 3 for more
information on getting care.
There are three exceptions to the transition period described above:

 If you are a resident of a nursing facility, you can continue to live in that nursing facility
for the duration of the FIDA Demonstration, even if the nursing facility does not
participate in GuildNet Gold Plus FIDA Plan’s network.

 If you are getting services from a behavioral health provider at the time of your
enrollment, you may continue to get services from that provider until treatment is
complete, but not for more than two years. This is the case even if the provider does
not participate in GuildNet Gold Plus FIDA Plan’s network.

 You may continue to see out-of-network providers for services covered by Medicare.

G. What is a Person-Centered Service Plan?

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 1: Getting started as a Participant

Within the first 90 days after your enrollment effective date, you will meet with the members
of your Interdisciplinary Team (IDT) to talk about your needs and develop your PersonCentered Service Plan (PCSP). A PCSP is the plan for what health services, long-term
services and supports, and prescription drugs you will get and how you will get them.
You will have a comprehensive re-assessment when necessary, but at least every six
months. Within 30 days of the comprehensive re-assessment, your IDT will work with you to
update your PCSP. At any time, you may ask for a new assessment or an update to your
PCSP by calling your Care Manager.

H. Does GuildNet Gold Plus FIDA Plan have a monthly plan premium?
No. There is no monthly plan premium and there are no other costs for participating in
GuildNet Gold Plus FIDA Plan. However, if you have Medicaid with a “spend-down” or
“excess income,” you will have to continue to pay your spend-down to the FIDA Plan.

I. About the Participant Handbook
This Participant Handbook is part of our contract with you. This means that we must follow all
of the rules in this document. If you think we have done something that goes against these
rules, you may be able to appeal, or challenge, our action. For information about how to
appeal, see Chapter 9, call 1-800-MEDICARE (1-800-633-4227), or call the Independent
Consumer Advocacy Network at 1-844-614-8800. You may also complain about the quality
of the services we provide by calling Participant Services at 1-800-815-0000. TTY users call
711.
The contract is in effect for the months you are enrolled in GuildNet Gold Plus FIDA Plan
between January 1, 2017 and December 31, 2017.

J. What other information will you get from us?
You should have already gotten a GuildNet Gold Plus FIDA Plan Participant ID Card, a
Provider and Pharmacy Directory, and a List of Covered Drugs.

Your GuildNet Gold Plus FIDA Plan Participant ID Card
Under our plan, you will have one card for your Medicare and Medicaid services, including
long-term services and supports and prescriptions. You must show this card when you get
any services or prescriptions. Here’s a sample card to show you what yours will look like:

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 1: Getting started as a Participant

If your card is damaged, lost, or stolen, call Participant Services right away and we will send
you a new card.
As long as you are a Participant of our plan, you do not need to use your red, white, and
blue Medicare card or your Medicaid card to get services. Keep those cards in a safe place,
in case you need them later.

Provider and Pharmacy Directory
The Provider and Pharmacy Directory is a list of the providers and pharmacies in the
GuildNet Gold Plus FIDA Plan network. While you are a Participant of our plan, you must
use network providers to get covered services. There are some exceptions when you first
join our plan (see page 8). There are also some exceptions if you cannot find a provider in
our plan who can meet your needs. You will need to discuss this with your Interdisciplinary
Team (IDT).

You can ask for an annual Provider and Pharmacy Directory by calling Participant
Services at 1-800-815-0000. TTY users call 711. You can also see the Provider and
Pharmacy Directory at www.guildnetny.org or download it from this website.
The information available in the Provider and Pharmacy Directory list network provider’s
office hours and location, language(s) spoken, whether provider is accepting new patients,
wheelchair accessible and other important information.
What are “network providers”?

 GuildNet Gold Plus FIDA Plan’s network providers include:

Doctors, nurses, and other health care professionals that you can go to as a
Participant of our plan;

Clinics, hospitals, nursing facilities, and other places that provide health
services in our plan; and

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 1: Getting started as a Participant

Home health agencies, durable medical equipment suppliers, and others who
provide goods and services that you get through Medicare or Medicaid.

Personal care services, Adult Day Healthcare, non-emergency transportation
is some of your long-term supports and services covered by Medicaid. For
more information, see the benefit chart in chapter 4.

 Network providers have agreed to accept payment from our plan for covered services
as payment in full. By seeing these providers, you will not have to pay anything for
covered services.
What are “network pharmacies”?

 Network pharmacies are pharmacies (drug stores) that have agreed to fill
prescriptions for our plan Participants. Use the Provider and Pharmacy Directory to
find the network pharmacy you want to use.

 Except during an emergency, you must fill your prescriptions at one of our network
pharmacies if you want our plan to pay for them. There are no costs to you when you
get prescriptions from network pharmacies.

 It always is best for you to see an in-network provider, but you may go to a

provider outside of the Plan Network to get plan services covered by Medicare. A
referral is not required. Please note: If you go to an out-of-network provider, the
provider must be eligible to participate in Medicare. We cannot pay a provider who is
not eligible to participate in Medicare. If you go to a provider who is not eligible to
participate in Medicare, you must pay the full cost of the services you get. Providers
must tell you if they are not eligible to participate in Medicare.

Call Participant Services at 1-800-815-0000 (TTY users call 711) for more information. Both
Participant Services and GuildNet Gold Plus FIDA Plan’s website can give you the most up-to-date
information about changes in our network pharmacies and providers.

List of Covered Drugs
The plan has a List of Covered Drugs. We call it the “Drug List” for short. It tells which
prescription drugs are covered by GuildNet Gold Plus FIDA Plan.
The Drug List also tells you if there are any rules or restrictions on any drugs, such as a limit
on the amount you can get. See Chapter 5 for more information on these rules and
restrictions.
Each year, we will send you a copy of the Drug List, but some changes may occur during the
year. To get the most up-to-date information about which drugs are covered, visit
www.guildnetny.org or call 1-800-815-0000. TTY users call 711.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 1: Getting started as a Participant

The Explanation of Benefits
When you use your Part D prescription drug benefits, we will send you a summary report to
help you understand and keep track of payments for your Part D prescription drugs. This
summary report is called the Explanation of Benefits (or EOB).
The Explanation of Benefits tells you the total amount we have paid for each of your Part D
prescription drugs during the month. Chapter 6 gives more information about the Explanation
of Benefits and how it can help you keep track of your drug coverage.
An Explanation of Benefits is also available when you ask for one. To get a copy, please
contact Participant Services at 1-800-815-0000. TTY users call 711.

K. How can you keep your Participant record up to date?
You can keep your Participant record up to date by letting us know when your information
changes.
The plan’s network providers and pharmacies need to have the right information about you.
They use your Participant record to know what services and drugs you get. Because of
this, it is very important that you help us keep your information up-to-date.
Let us know the following:

 If you have any changes to your name, your address, or your phone number
 If you have any changes in any other health insurance coverage, such as from your
employer, your spouse’s employer, or workers’ compensation

 If you have any liability claims, such as claims from an automobile accident
 If you are admitted to a nursing facility or hospital
 If you get care in an out-of-area or out-of-network hospital or emergency room
 If your caregiver or anyone responsible for you changes
 If you are part of a clinical research study
If any information changes, please let us know by calling Participant Services at 1-800-8150000. TTY users call 711.

Do we keep your personal health information private?
Yes. Laws require that we keep your medical records and personal health information
private. We make sure that your health information is protected. For more information about
how we protect your personal health information, see Chapter 8.

CHAPTER 2
Important phone numbers and resources

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 2: Important phone numbers and resources
Table of Contents
A.How to contact GuildNet Gold Plus FIDA Plan Participant Services ..............................................16
Contact Participant Services about: ............................................................................................... 15
Questions about the plan ..................................................................................................... 16
Questions about claims, billing or Participant ID Cards ........................................................ 16
Coverage decisions about your services and items ............................................................. 16
Appeals about your services and items ............................................................................... 16
Grievances about your services and items .......................................................................... 17
Coverage decisions about your drugs.................................................................................. 17
Appeals about your drugs .................................................................................................... 17
Grievances about your drugs ............................................................................................... 17
Payment for health care or drugs you already paid for ......................................................... 18
B. How to contact your Care Manager ...............................................................................................19
Contact your Care Manager about:................................................................................................ 19
Questions about your care and covered services, items, and drugs .................................... 19
Assistance in making and getting to appointments .............................................................. 19
Questions about getting behavioral health services, transportation, and long-term
services and supports (LTSS).............................................................................................. 19
Requests for services, items, and drugs .............................................................................. 19
Requests for a Comprehensive Reassessment or changes to a Person-Centered
Service Plan ........................................................................................................................ 19
C. How to contact the Nurse Advice Call Line ....................................................................................20
Contact the Nurse Advice Call Line about: .................................................................................... 20
Immediate questions about your health ............................................................................... 20

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and
TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711.
For more information, visit www.guildnetny.org.
14

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 2: Important phone numbers and resources

D. How to contact the Behavioral Health Crisis Line ..........................................................................21
Contact the Behavioral Health Crisis Line about: ........................................................................... 21
Questions about behavioral health services......................................................................... 21
Any issues you might be having .......................................................................................... 21
E. How to contact the Enrollment Broker ...........................................................................................22
Contact New York Medicaid Choice about:.................................................................................... 22
Questions about your FIDA Plan options ............................................................................. 22
F. How to contact the State Health Insurance Assistance Program (SHIP) .......................................23
Contact HIICAP about: ................................................................................................................ 23
Questions about your Medicare health insurance .............................................................. 23
G.How to contact the Quality Improvement Organization (QIO) .......................................................24
Contact Livanta about:................................................................................................................. 24
Questions about your health care ...................................................................................... 24
H.How to contact Medicare ..............................................................................................................25
I. How to contact Medicaid .............................................................................................................26
J. How to contact the Independent Consumer Advocacy Network ...................................................27
K.How to contact the New York State Long-Term Care Ombudsman Program ................................27

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 2: Important phone numbers and resources

A. How to contact GuildNet Gold Plus FIDA Plan Participant Services
CALL

1-800-815-0000 This call is free.
Hours are Monday through Sunday, 8am to 8pm.
We have free interpreter services for people who do not speak English.

TTY

711 This call is free.
Hours are Monday through Sunday, 8am to 8pm.

FAX

1-212-769-1621

WRITE

GuildNet Gold Plus FIDA Plan
15 West 65th Street
New York, NY 10023

guildnetinfo@lighthouseguild.org

WEBSITE

www.guildnetny.org

Contact Participant Services about:

 Questions about the plan
 Questions about claims, billing or Participant ID Cards
 Coverage decisions about your services and items
A coverage decision is a decision about whether you can get certain covered services and
items or how much you can have of certain covered services and items.
Call us or your Care Manager if you have questions about a coverage decision GuildNet
Gold Plus FIDA Plan or your Interdisciplinary Team (IDT) made about your services and
items.
 To learn more about coverage decisions, see Chapter 9.

 Appeals about your services and items
An appeal is a formal way of asking us to review a decision we or your IDT made about
your coverage and asking us to change it if you think we or your IDT made a mistake.
 To learn more about making an appeal, see Chapter 9.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 2: Important phone numbers and resources

 Grievances about your services and items
You can file a grievance (also called “making a complaint”) about us or any provider
(including a non-network or network provider). A network provider is a provider who works
with GuildNet Gold Plus FIDA Plan. You can also file a grievance about the quality of the
care you got to us or to the Quality Improvement Organization (see Section G below).
 Note: If you disagree with a coverage decision that GuildNet Gold Plus FIDA Plan or
your IDT made about your services or items, you can file an appeal (see the section
above).
You can also send a grievance about GuildNet Gold Plus FIDA Plan right to Medicare.
You can use an online form at
https://www.medicare.gov/MedicareComplaintForm/home.aspx. Or you can call 1-800MEDICARE (1-800-633-4227) to ask for help.
 To learn more about filing a grievance, see Chapter 9.

 Coverage decisions about your drugs
A coverage decision is a decision about whether you can get certain covered drugs or
how much you can have of a certain covered drug. This applies to your Part D drugs,
Medicaid prescription drugs, and Medicaid over-the-counter drugs as covered by GuildNet
Gold Plus FIDA Plan. See Chapter 5 and the List of Covered Drugs for more information
on your drug benefits and how to get covered drugs.
 For more on coverage decisions about your prescription drugs, see Chapter 9.

§ Appeals about your drugs
An appeal is a way to ask us to change a coverage decision.
If you would like to appeal a coverage determination or file a grievance, please call 1-888447-6855 (TTY please use 711) or write to us at
GuildNet Gold Plus FIDA Plan
Attn: Grievance and Appeals
PO Box 2807
New York, NY 10116-2807.
Our fax number is 1-866-350-2168.
 For more on making an appeal about your prescription drugs, see Chapter 9.

 Grievances about your drugs

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Chapter 2: Important phone numbers and resources

You can file a grievance (also called “making a complaint”) about us or any pharmacy.
This includes a grievance about your prescription drugs.
 Note: If you disagree with a coverage decision about your prescription drugs, you can
file an appeal (see the section above).
You can also send a grievance about GuildNet Gold Plus FIDA Plan right to Medicare.
You can use an online form at
https://www.medicare.gov/MedicareComplaintForm/home.aspx. Or you can call 1-800MEDICARE (1-800-633-4227) to ask for help.
 For more on filing a grievance about your prescription drugs, see Chapter 9.

 Payment for health care or drugs you already paid for
To learn how to ask us to pay you back, see Chapter 7.

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Chapter 2: Important phone numbers and resources

B. How to contact your Care Manager
When you enroll in GuildNet Gold Plus FIDA Plan, you will be assigned a Care Manager.
Your Care Manager will work with you, the Plan and your providers to make sure that you get
the care you need. You may request to change your Care Manager at any time.

CALL

1-800-815-0000 This call is free.
Hours are Monday through Sunday, 8am to 8pm.
We have free interpreter services for people who do not speak English.

TTY

711 This call is free.
Hours are Monday through Sunday, 8am to 8pm.

FAX

1-212-769-1621

WRITE

GuildNet Gold Plus FIDA Plan
15 West 65th Street
New York, NY 10023

guildnetinfo@lighthouseguild.org

WEBSITE

www.guildnetny.org

Contact your Care Manager about:

 Questions about your care and covered services, items, and drugs
 Assistance in making and getting to appointments
 Questions about getting behavioral health services, transportation, and long-term
services and supports (LTSS)

 Requests for services, items, and drugs
 Requests for a Comprehensive Reassessment or changes to a Person-Centered
Service Plan

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Chapter 2: Important phone numbers and resources

C. How to contact the Nurse Advice Call Line
GuildNet Gold Plus FIDA Plan’s Nurse Advice Call Line is a service available to you 24 hours
a day/7 days a week. You can contact the Nurse Advice Call Line for any health-related
questions you may have.

CALL

1-800-815-0000 This call is free.
The Nurse Advice Call Line is available 24 hours a day, 7 days a week.
We have free interpreter services for people who do not speak English.

TTY

711 This call is free.
The Nurse Advice Call Line is available 24 hours a day, 7 days a week.

Contact the Nurse Advice Call Line about:

 Immediate questions about your health

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Chapter 2: Important phone numbers and resources

D. How to contact the Behavioral Health Crisis Line
CALL

1-855-517-3480 This call is free.
Monday through Sunday, 24 hours a day.
We have free interpreter services for people who do not speak English.

TTY

1-855-825-2166 This call is free.
This number is for people who have hearing or speaking problems. You
must have special telephone equipment to call it.
Monday through Sunday, 24 hours a day.

Contact the Behavioral Health Crisis Line about:

 Questions about behavioral health services
 Any issues you might be having

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Chapter 2: Important phone numbers and resources

E. How to contact the Enrollment Broker
New York Medicaid Choice is New York State’s Enrollment Broker for the FIDA program.
New York Medicaid Choice provides free counseling about your FIDA Plan options and can
help you enroll or disenroll in a FIDA Plan.
New York Medicaid Choice is not connected with any insurance company, managed care
plan, or FIDA Plan.

CALL

1-855-600-FIDA This call is free.
The Enrollment Broker is available Monday through Friday from 8:30
am to 8:00 pm, and Saturday from 10:00 am to 6:00 pm.

TTY

1-888-329-1541 This call is free.
This number is for people who have hearing or speaking problems.
You must have special telephone equipment to call it.

WRITE

New York Medicaid Choice
P.O. Box 5081
New York, NY 10274

WEBSITE

http://www.nymedicaidchoice.com

Contact New York Medicaid Choice about:

 Questions about your FIDA Plan options
New York Medicaid Choice counselors can:
» help you understand your rights,
» help you understand your FIDA Plan choices, and
» answer your questions about changing to a new FIDA Plan.

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Chapter 2: Important phone numbers and resources

F. How to contact the State Health Insurance Assistance Program (SHIP)
The State Health Insurance Assistance Program (SHIP) gives free health insurance
counseling to people with Medicare. In New York State, the SHIP is called the Health
Insurance Information, Counseling, and Assistance Program (HIICAP).
HIICAP is not connected with any insurance company, managed care plan, or FIDA Plan.
CALL

1-800-701-0501 This call is free.

WEBSITE

http://www.aging.ny.gov/healthbenefits

You may also contact your local HIICAP office directly:
LOCAL OFFICE

CALL

WRITE

Nassau County

516-485-3754

Office of Children and Family Services
400 Oak Street
Garden City, New York 11530

New York City

212-602-4180

Department for the Aging
Two Lafayette Street, 16th Floor
New York, NY 10007-1392

Suffolk County

631-979-9490

RSVP Suffolk
811 West Jericho Turnpike, Suite 103W
Smithtown, NY 11787

Westchester County

914-813-6651

Department of Senior Programs & Services
9 South First Avenue, 10th Floor
Mt. Vernon, NY 10550

Contact HIICAP about:

 Questions about your Medicare health insurance
HIICAP counselors can:
» help you understand your rights,
» help you understand your Medicare plan choices, and
» answer your questions about changing to a new Medicare plan.

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Chapter 2: Important phone numbers and resources

G. How to contact the Quality Improvement Organization (QIO)
Our state has an organization called Livanta. This is a group of doctors and other health care
professionals who help improve the quality of care for people with Medicare. Livanta is not
connected with our plan.

CALL

1-866-815-5440 This call is free.
Livanta is available Monday through Friday from 9:00 am to 5:00 pm,
and Saturday through Sunday from 11:00 am to 3:00 pm.

TTY

1-866-868-2289
This number is for people who have hearing or speaking problems.
You must have special telephone equipment to call it.

WRITE

BFCC-QIO Program
9090 Junction Dr., Suite 10
Annapolis Junction, MD 20701

BFCCQIOArea1@livanta.com

WEBSITE

http://bfccqioarea1.com

Contact Livanta about:

 Questions about your health care
You can make a complaint about the care you got if:
» You have a problem with the quality of care,
» You think your hospital stay is ending too soon, or
» You think your home health care, skilled nursing facility care, or comprehensive
outpatient rehabilitation facility (CORF) services are ending too soon.

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Chapter 2: Important phone numbers and resources

H. How to contact Medicare
Medicare is the federal health insurance program for people 65 years of age or older, some
people under age 65 with disabilities, and people with end-stage renal disease (permanent
kidney failure requiring dialysis or a kidney transplant).
The federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services,
or CMS.

CALL

1-800-MEDICARE (1-800-633-4227)
Calls to this number are free, 24 hours a day, 7 days a week.

TTY

1-877-486-2048 This call is free.
This number is for people who have hearing or speaking problems.
You must have special telephone equipment to call it.

WEBSITE

http://www.medicare.gov
This is the official website for Medicare. It gives you up-to-date
information about Medicare. It also has information about hospitals,
nursing facilities, physicians, home health agencies, and dialysis
facilities. It includes booklets you can print right from your computer.
You can also find Medicare contacts in your state by selecting “Forms,
Help & Resources” and then clicking on “Phone numbers & websites.”
The Medicare website has the following tool to help you find plans in
your area:
Medicare Plan Finder: Provides personalized information about
Medicare prescription drug plans, Medicare health plans, and
Medigap (Medicare Supplement Insurance) policies in your area.
Select “Find health & drug plans.”
If you don’t have a computer, your local library or senior center may be
able to help you visit this website using its computer. Or, you can call
Medicare at the number above and tell them what information you are
looking for. They will find the information on the website, print it out, and
send it to you.

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Chapter 2: Important phone numbers and resources

I. How to contact Medicaid
Medicaid helps with medical and long-term services and supports costs for people with
limited incomes and resources.
You are enrolled in Medicare and in Medicaid. If you have questions about the help you get
from Medicaid, call the Medicaid Helpline.

CALL

1-800-541-2831 This call is free.
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.

TTY

1-877-898-5849 This call is free.
This number is for people who have hearing or speaking problems. You
must have special telephone equipment to call it.

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Chapter 2: Important phone numbers and resources

J. How to contact the Independent Consumer Advocacy Network
The Independent Consumer Advocacy Network (ICAN) helps people enrolled in a FIDA Plan
with access to covered services and items, questions about billing, or other questions and
problems. ICAN can help you file a grievance or an appeal with our plan.
CALL

1-844-614-8800 This call is free.
ICAN is available Monday through Friday from 8:00 am to 8:00 pm.

TTY

Call 711, then follow the prompts to dial 844-614-8800

ican@cssny.org

WEBSITE

www.icannys.org

K. How to contact the New York State Long-Term Care Ombudsman
The Long-Term Care Ombudsman Program helps people learn about nursing facilities and
other long-term care settings. It also helps solve problems between these settings and
residents or their families.

CALL

1-800-342-9871 This call is free.

WEBSITE

http://www.ltcombudsman.ny.gov

You may also contact your local long-term care ombudsman directly. The contact information
for the ombudsman in your county can be found in the directory at the following website:
http://www.ltcombudsman.ny.gov/Whois/directory.cfm.

CHAPTER 3
Using the plan’s coverage for your health care and
other covered services and items

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Chapter 3: Using the plan’s coverage for your health care
and other covered services and items

Table of Contents
A. About “services and items,” “covered services and items,” “providers,” and “network
providers” ...................................................................................................................................... 31
B. General rules for getting your health care, behavioral health, and long-term services and
supports covered by GuildNet Gold Plus FIDA Plan ...................................................................... 31
C.Your Interdisciplinary Team (IDT) ................................................................................................... 33
D.Your Care Manager ........................................................................................................................ 34
What is a Care Manager? .............................................................................................................. 34
Who gets a Care Manager?........................................................................................................... 34
How can I contact my Care Manager? ........................................................................................... 34
How can I change my Care Manager? .......................................................................................... 34
E. Getting care from Primary Care Providers, specialists, other network providers, and out-ofnetwork providers .......................................................................................................................... 35
Getting care from a Primary Care Provider (PCP) ......................................................................... 35
How to get care from specialists and other network providers ....................................................... 36
What if a network provider leaves our plan? .................................................................................. 36
How to get care from out-of-network providers .............................................................................. 37
F. Getting approval for services and items that require prior authorization ......................................... 37
G.How to get long-term services and supports (LTSS) ....................................................................... 38
H.How to get behavioral health services ............................................................................................ 39
I. How to get self-directed care ......................................................................................................... 40
J. How to get transportation services................................................................................................. 41

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Chapter 3: Using the plan’s coverage for your health care
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K. How to get covered services when you have a medical emergency or urgent need for
care, or during a disaster ............................................................................................................. 41
Getting care when you have a medical emergency ..................................................................... 41
Getting urgently needed care ...................................................................................................... 43
Getting care during a disaster...................................................................................................... 43
L. What if you are billed directly for the full cost of services and items covered by GuildNet
Gold Plus FIDA Plan?.................................................................................................................. 44
What should you do if services or items are not covered by our plan?......................................... 44
M.How are your health care services covered when you are in a clinical research study?............... 44
What is a clinical research study? ............................................................................................... 45
When you are in a clinical research study, who pays for what? ................................................... 45
Learning more ............................................................................................................................. 46
N. How are your health care services covered when you are in a religious non-medical health
care institution? ........................................................................................................................... 46
What is a religious non-medical health care institution?............................................................... 46
What care from a religious non-medical health care institution is covered by our plan? ............... 46
O.Rules for owning durable medical equipment ............................................................................... 47
Will you own your durable medical equipment? ........................................................................... 47
What happens if you lose your Medicaid coverage? .................................................................... 47
What happens if you change your FIDA Plan or leave FIDA and join an MLTC Plan? ................. 48

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Chapter 3: Using the plan’s coverage for your health care
and other covered services and items

A. About “services and items,” “covered services and items,”
“providers,” and “network providers”
Services and items are health care, long-term services and supports, supplies, behavioral
health, prescription and over-the-counter drugs, equipment and other services. Covered
services and items are any of these services and items that GuildNet Gold Plus FIDA Plan
pays for. Covered health care and long-term services and supports include those listed in the
Covered Items and Services Chart in Chapter 4 and any other services that GuildNet Gold
Plus FIDA Plan, your IDT, or an authorized provider decides are necessary for your care.
Providers are doctors, nurses, and other people who give you services and care. The term
providers also includes hospitals, home health agencies, clinics, and other places that give
you services, medical equipment, and long-term services and supports.
Network providers are providers who work with the health plan. These providers have
agreed to accept our payment as full payment. Network providers bill us directly for care they
give you. When you see a network provider, you pay nothing for covered services or items.

B. General rules for getting your health care, behavioral health, and longterm services and supports covered by GuildNet Gold Plus FIDA Plan
GuildNet Gold Plus FIDA Plan covers all services and items covered by Medicare and
Medicaid plus some additional services and items available through the FIDA Program.
These include behavioral health, long term supports and services, and prescription drugs.
GuildNet Gold Plus FIDA Plan will generally pay for the services and items you need if you
follow the plan rules for how to get them. To be covered:

 The care you get must be a service or item covered by the plan. This means that it
must be included in the plan’s Covered Items and Services Chart. (The chart is in
Chapter 4 of this handbook). Other services and items that are not listed in the chart
may also be covered if your Interdisciplinary Team (IDT) determines they are
necessary for you.

 The care must be medically necessary. Medically necessary means those services

and items necessary to prevent, diagnose, correct, or cure conditions you have that
cause acute suffering, endanger life, result in illness or infirmity, interfere with your
capacity for normal activity, or threaten some significant handicap. This includes care
that keeps you from going into a hospital or nursing facility. It also means the services,
supplies, or drugs meet accepted standards of medical practice.

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Chapter 3: Using the plan’s coverage for your health care
and other covered services and items

§ You will have and are expected to cooperate with an Interdisciplinary Team (IDT).

Your IDT will assess your needs, work with you and/or your designee to plan your care
and services, and make sure that you get the necessary care and services. You can
find more information about the IDT in Section C.
»

In most cases, you must get approval from GuildNet Gold Plus FIDA Plan, your
IDT, or an authorized provider before you can access covered services and items.
This is called prior authorization. To learn more about prior authorization, see
page 37.

You do not need prior authorization for emergency care or urgently needed care
or to see a woman’s health provider. You can get other kinds of care without
having prior authorization. To learn more about this, see page 38.

§ You will have a Care Manager who will serve as your primary point of contact with your
IDT. You can find more information about the Care Manager in Section D.

§ You may choose a network provider to serve as your Primary Care Provider (PCP).

You may also choose to have your PCP be a member of your IDT. To learn more about
choosing or changing a PCP, see page 35. If you choose an out-of-network Medicare
provider as your PCP, providers are encouraged to participate in your Interdisciplinary
Team (IDT), but they do not have to agree to participate in order to be someon's PCP.

§ You must get your Medicaid-covered services and items from network providers.
Usually, GuildNet Gold Plus FIDA Plan will not cover Medicaid-covered services or
items from a provider who has not joined GuildNet Gold Plus FIDA Plan’s network.
GuildNet Gold Plus FIDA covers out-of-network care for all Medicare-covered services.
Here are some cases when this rule does not apply:
» The plan covers emergency or urgently needed care from an out-of-network
provider. To learn more and to see what emergency or urgently needed care
means, see page 41.
» If you need care that our plan covers and our network providers cannot give it to
you, you can get the care from an out-of-network provider. In this situation, we will
cover the care as if you got it from a network provider and at no cost to
you. To learn about getting approval to see an out-of-network provider, see page
37.
» The plan covers services and items from out-of-network providers and
pharmacies when a provider or pharmacy is not available within a reasonable
distance from your home.
» The plan covers kidney dialysis services when you are outside the plan’s service
area for a short time. You can get these services at a Medicare-certified dialysis
facility.

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Chapter 3: Using the plan’s coverage for your health care
and other covered services and items

» When you first join the plan, you can continue seeing the providers you see now
during the “transition period.” In most cases, the transition period will last for 90
days or until your Person-Centered Service Plan is finalized and implemented,
whichever is later. However, your out-of-network provider must agree to provide
ongoing treatment and accept payment at our rates. After the transition period,
we will no longer cover your care if you continue to see out-of-network providers
for Medicaid-covered services.
» If you are a resident of a nursing facility, you can continue to live in that nursing
facility for the duration of the FIDA Program, even if the nursing facility does not
participate in GuildNet Gold Plus FIDA Plan’s network.
» If you are getting services from a behavioral health provider at the time of your
enrollment, you may continue to get services from that provider until treatment is
complete, but not for more than two years.
» The Plan covers Medicare-covered services provided by out-of-network Medicare
providers. Your out-of-network provider must agree to bill our Plan for services.

C. Your Interdisciplinary Team (IDT)
Every Participant has an Interdisciplinary Team (IDT). Your IDT will include the following
individuals:
 You and your designee(s) and
 Your Care Manager.
You may also choose to have any of the following people participate in any or all of your IDT
meetings:
 Your Primary Care Provider (PCP), including a physician, nurse practitioner, physician
assistant, or specialist who has agreed to serve as your PCP, or a designee from your
PCP’s practice who has clinical experience (such as a registered nurse, nurse
practitioner, or physician assistant) and knowledge of your needs;
 Your Behavioral Health (BH) Professional, if you have one, or a designee from your BH
Professional’s practice who has clinical experience and knowledge of your needs;
 Your home care aide(s), or a designee with clinical experience from the home care
agency who has knowledge of your needs, if you are getting home care;
 A clinical representative from your nursing facility, if getting nursing facility care; and
 Additional individuals including:

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Chapter 3: Using the plan’s coverage for your health care
and other covered services and items

» Other providers either as asked for by you or your designee, or as recommended
by the IDT members as necessary for adequate care planning and approved by
you or your designee; or
» The registered nurse (RN) who completed your assessment.
The FIDA Plan Care Manager is the IDT lead. Your IDT conducts your service planning and
develops your Person-Centered Service Plan (PCSP). Your IDT authorizes services some or
all of the services in your PCSP, depending on whether your PCP participated in the process
for developing your PCSP. These decisions cannot be changed by GuildNet Gold Plus FIDA
Plan.

D. Your Care Manager
What is a Care Manager?
The FIDA Plan Care Manager coordinates your Interdisciplinary Team (IDT). The Care
Manager will ensure the integration of your medical, behavioral health, substance use,
community-based or facility-based long-term services and supports (LTSS), and social
needs. The Care Manager will coordinate these services as specified in your PersonCentered Service Plan.

Who gets a Care Manager?
All Participants have a Care Manager. Your Care Manager assignment or selection first
occurs when you are enrolled in GuildNet Gold Plus FIDA Plan.

How can I contact my Care Manager?
When a Care Manager is assigned or selected, GuildNet Gold Plus FIDA Plan will provide
you with contact information for your Care Manager. Participant Services can also provide
this information to you at any time during your participation in GuildNet Gold Plus FIDA Plan.

How can I change my Care Manager?
You may change your Care Manager at any time, but you will have to choose from a list of
GuildNet Gold Plus FIDA Plan Care Managers. If you have an existing Care Manager (from
Managed Long-Term Care, or MLTC, for example), you may ask to have the same person be
your FIDA Plan Care Manager. If the Care Manager is also available in the FIDA Plan and
the Care Manager’s caseload permits, GuildNet Gold Plus FIDA Plan must honor your
request. To change Care Managers, contact Participant Services at 1-800-815-0000 and
TTY/TDD 711, Monday through Sunday, 8 am to 8 pm.

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Chapter 3: Using the plan’s coverage for your health care
and other covered services and items

E. Getting care from Primary Care Providers, specialists, other network
providers, and out-of-network providers
Getting care from a Primary Care Provider (PCP)
You must choose a Primary Care Provider (PCP) to provide and manage your care. GuildNet
Gold Plus FIDA Plan will offer you the choice of at least three Primary Care Providers to
select from. If you do not choose a PCP, one will be assigned to you. You can change your
PCP at any time by contacting Participant Services at 1-800-815-0000, Monday through
Sunday, 8am to 8pm. TTY users call 711.
What is a “PCP,” and what does the PCP do for you?
Your Primary Care Provider (PCP) is your main doctor and will be responsible for providing
many of your preventive and primary care services. Your PCP will be a part of your
Interdisciplinary Team (IDT), if you so choose. If your PCP is part of your IDT, your PCP will
participate in developing your Person-Centered Service Plan, making coverage
determinations as a member of your IDT, and recommending or requesting many of the
services and items your IDT or GuildNet Gold Plus FIDA Plan will authorize.
How will I get a PCP?
We will give you a choice of at least three PCPs. If you don’t choose a PCP, we will assign
one to you. In assigning a PCP to you, we will consider how far the PCP is from your home,
any special health care needs you have, and any special language needs you have.
If you already have a PCP when you join the plan, you will be able to continue seeing that
PCP during the transition period (see page 8 for more information). After the transition
period, you can continue to see that PCP if he/she participates in Medicare, agrees to bill the
Plan for Medicare covered services agrees and participates in coordinating your services
through your IDT.
Can a clinic be my PCP?
No. Your PCP may not be a clinic and must be a specific type of provider that meets certain
requirements. If the PCP works at a clinic and otherwise meets all criteria, that provider can
be designated as a PCP.
Changing your PCP
You may change your PCP for any reason, at any time. Simply call GuildNet Gold Plus FIDA
Plan and ask for a new PCP. The plan will process your request and tell you the effective
date of the change, which will be within five business days of your request.

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Chapter 3: Using the plan’s coverage for your health care
and other covered services and items

If your current PCP leaves our network or otherwise becomes unavailable, GuildNet Gold
Plus FIDA Plan will provide you with an opportunity to select a new PCP.

How to get care from specialists and other network providers
A specialist is a doctor who provides health care for a specific disease or part of the body.
There are many kinds of specialists. Here are a few examples:

 Oncologists care for patients with cancer.
 Cardiologists care for patients with heart problems.
 Orthopedists care for patients with bone, joint, or muscle problems.
GuildNet Gold Plus FIDA Plan or your IDT will authorize specialist visits that are appropriate
for your conditions. Access to specialists must be approved by GuildNet Gold Plus FIDA Plan
or your IDT through a standing authorization or through pre-approval of a fixed number of
visits to the specialist. This information will be included in your Person-Centered Service
Plan (PCSP).

What if a network provider leaves our plan?
A network provider you are using might leave our plan. If one of your providers does leave
our plan, you have certain rights and protections that are summarized below:

 Even though our network of providers may change during the year, we must give you
uninterrupted access to qualified providers.

 When possible, we will give you at least 15 days’ notice so that you have time to
select a new provider.

 We will help you select a new qualified provider to continue managing your health
care needs.

 If you are undergoing medical treatment, you have the right to ask, and we will work
with you to ensure, that the medically necessary treatment you are getting is not
interrupted.

 If you believe we have not replaced your previous provider with a qualified provider or
that your care is not being appropriately managed, you have the right to file an appeal
of our decision.

 If a provider of Medicare-covered services leaves the network, you may continue
seeing that provider as long as the provider continues participating with Medicare and
agrees to bill the Plan.
If you find out one of your providers is leaving our plan, please contact us so we can assist
you in finding a new provider and managing your care. Please call Participant Services at
1-800-815-0000 (TTY users call 711), Monday through Sunday, 8am to 8pm.

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Chapter 3: Using the plan’s coverage for your health care
and other covered services and items

How to get care from out-of-network providers
If you need care that our plan covers and our network providers cannot give it to you, you
can get permission from GuildNet Gold Plus FIDA Plan or your IDT to get the care from an
out-of-network provider. In this situation, we will cover the care as if you got it from a network
provider and at no cost to you. You do not need approval to continue seeing an out-ofnetwork Medicare provider. However, if you wish to continue seeing an out-of-network
Medicaid provider, please call your care manager at 1-800-815-0000 (TTY users call 711) to
make your request.
Remember, when you first join the plan, you can continue seeing the providers you see now
during the “transition period.” In most cases, the transition period will last for 90 days or until
your Person-Centered Service Plan is finalized and implemented, whichever is later. During
the transition period, our Care Manager will contact you to help you find and switch to
providers that are in our network. After the transition period, we will no longer pay for your
care if you continue to see out-of-network providers for Medicaid-covered services, unless
GuildNet Gold Plus FIDA Plan or your IDT has authorized you to continue to see the out-ofnetwork provider.

 Please note: If you need to go to an out-of-network provider for a Medicaid-covered

service, please work with GuildNet Gold Plus FIDA Plan or your IDT to get approval to see
an out-of-network provider and to find one that meets applicable Medicare or Medicaid
requirements. If you go to an out-of-network provider for your Medicaid-services without
first getting Plan or IDT approval, you may have to pay the full cost of the services you
get.

 You do not need authorization for an out-of-network Medicare-covered services.

F. Getting approval for services and items that require prior authorization
Your Interdisciplinary Team (IDT) is responsible for authorizing all services and items that
can be anticipated during the development of your Person-Centered Service Plan (PCSP).
However, your IDT may not be able to authorize all of your services if your PCP does not
participate on the IDT. For example, if there is no PCP or other physician participating in a
given IDT meeting, the IDT cannot authorize new prescription medications. In those cases,
your IDT will add the list of requested prescription medications to the PCSP. GuildNet Gold
Plus FIDA Plan will then review and approve the prescription medications if they are
medically necessary.
In addition, GuildNet Gold Plus FIDA Plan and certain authorized providers are responsible
for authorizing most of the health care services and items you might need in between IDT

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and other covered services and items

service planning meetings and PCSP updates. These are services and items that could not
have been planned or predicted and therefore were not included in your PCSP.
Services you can get without first getting authorization
In most cases, you will need approval from GuildNet Gold Plus FIDA Plan, your IDT, or
certain authorized providers before seeing other providers. This approval is called “prior
authorization.” You can get services like the ones listed below without first getting approval:

 Emergency services from network providers or out-of-network providers.
 Urgently needed care from network providers or out-of-network providers.
 Urgently needed care from out-of-network providers when you can’t get to network
providers because you are outside the plan’s service area.

 Kidney dialysis services that you get at a Medicare-certified dialysis facility when you
are outside the plan’s service area. (Please call Participant Services before you leave
the service area. We can help you get dialysis while you are away.)

 Immunizations, including flu shots hepatitis B vaccinations, and pneumonia.
 Routine women’s health care and family planning services. This includes breast
exams, screening mammograms (x-rays of the breast), Pap tests, and pelvic exams.

 Primary Care Provider (PCP) visits.
 Palliative care.
 Other preventive services.
 Services from public health agency facilities for tuberculosis screening, diagnosis and
treatment, including Directly Observed Therapy (TB/DOT).

 Vision services through Article 28 clinics that provide optometry services and are
affiliated with the College of Optometry of the State University of New York to obtain
covered optometry services.

 Dental services through Article 28 clinics operated by Academic Dental Centers.
 Cardiac rehabilitation for the first course of treatment (a Physician or RN authorization
is required for courses of treatment following the first course).

 Supplemental education, wellness, and health management services.
 Additionally, if you are eligible to get services from Indian health providers, you may
see these providers without approval from GuildNet Gold Plus FIDA Plan or your IDT.

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G. How to get long-term services and supports (LTSS)
Community-based LTSS are a range of medical, habilitation, rehabilitation, home care, or
social services a person needs over months or years in order to improve or maintain function
or health. These services are provided in the person’s home or a community-based setting
such as assisted-living facilities. Facility-based LTSS are services provided in a nursing
facility or other long-term residential care setting.
As a Participant in GuildNet Gold Plus FIDA Plan, you will get a comprehensive assessment
of your needs, including your need for community-based or facility-based LTSS. All of your
needs, as identified in your assessment, will be addressed in your Person-Centered Service
Plan (PCSP). Your PCSP will outline which LTSS you will get, from whom, and how often.
If you have a pre-existing service plan prior to your enrollment into GuildNet Gold Plus FIDA
Plan, you will continue to get any community-based or facility-based LTSS included in the
pre-existing plan. Your pre-existing service plan will be honored for 90 days or until your
PCSP is finalized and implemented, whichever is later.



If you have questions about LTSS, contact Participant Services or your Care Manager.

H. How to get behavioral health services
Behavioral health services are a variety of services that can support mental health and
substance abuse needs you may have. This support can include emotional, social,
educational, vocational, peer support and recovery services, in addition to more traditional
psychiatric or medical services.
As a Participant in GuildNet Gold Plus FIDA Plan, you will get a comprehensive assessment
of your needs, including your need for behavioral health services. All of your needs, as
identified in your assessment, will be addressed in your Person-Centered Service Plan
(PCSP). Your PCSP will outline which behavioral health services you will get, from whom,
and how often.
If you are getting services from a behavioral health provider at the time of your enrollment in
GuildNet Gold Plus FIDA Plan, you may continue to get services from that provider until
treatment is complete, but not for more than two years. This is the case even if the provider
does not participate in GuildNet Gold Plus FIDA Plan’s network. If the services you receive
are covered by Medicare, you may continue to receive services from your out-of-network
Medicare provider as long as you are enrolled in the Plan.



If you have questions about behavioral health services, contact Participant Services or
your Care Manager.

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Chapter 3: Using the plan’s coverage for your health care
and other covered services and items

I. How to get self-directed care
You have the opportunity to direct your own services through the Consumer Directed
Personal Assistance Services (CDPAS) program.
If you are chronically ill or physically disabled and have a medical need for help with activities
of daily living (ADLs) or skilled nursing services, you can get services through the CDPAS
program. Services can include any of the services provided by a personal care aide (home
attendant), home health aide, or nurse. You have flexibility and freedom in choosing your
caregivers.
You must be able and willing to make informed choices about the management of the
services you get, or have a legal guardian or designated relative or other adult able and
willing to help make informed choices.
You or your designee must also be responsible for recruiting, hiring, training, supervising and
terminating caregivers, and must arrange for back-up coverage when necessary, arrange
and coordinate other services, and keep payroll records.
Your Care Manager and Interdisciplinary Team (IDT) will review the CDPAS option with you
during your IDT meetings. You can select this option at any time by contacting your Care
Manager.

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Chapter 3: Using the plan’s coverage for your health care
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J. How to get transportation services
GuildNet Gold Plus FIDA Plan will provide you with emergency and non-emergency
transportation. Your Interdisciplinary Team (IDT) will discuss your transportation needs and
will plan for how to meet them. Call your Care Manager any time you need transportation to a
provider in order to get covered services and items.
Transportation coverage includes a transportation attendant to accompany you somewhere,
if necessary.
Transportation is also available to non-medical events or services such as religious services,
community activities, or supermarkets.

K. How to get covered services when you have a medical emergency or
urgent need for care, or during a disaster
Getting care when you have a medical emergency
What is a medical emergency?
A medical or behavioral health emergency is a condition with severe symptoms, severe pain,
or serious injury. The condition is so serious that, if it doesn’t get immediate medical
attention, you or anyone with an average knowledge of health and medicine could expect it to
result in:

 placing your health (or, with respect to a pregnant woman, your health or that of your
unborn child) in serious jeopardy, or in the case of a behavioral condition, placing your
health or the health of others in serious jeopardy; or

 serious harm to bodily functions; or
 serious dysfunction of any bodily organ or part; or
 serious disfigurement; or
 in the case of a pregnant woman, an active labor, meaning labor at a time when either
of the following would occur:
» There is not enough time to safely transfer you to another hospital before
delivery.
» The transfer may pose a threat to your health or safety or to that of your unborn
child.

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What should you do if you have a medical emergency?
If you have a medical emergency:

 Get help as fast as possible. Call 911 or go to the nearest emergency room or

hospital. Call for an ambulance if you need it. You do not need to get approval from
GuildNet Gold Plus FIDA Plan or your IDT.

 As soon as possible, make sure that you tell our plan about your emergency. We
need to follow up on your emergency care. You or someone else should call to tell us
about your emergency care, usually within 48 hours. However, you will not have to pay
for emergency services because of a delay in telling us. Please call Participant
Services at 1-800-815-0000, Monday through Sunday, 8am to 8pm. TTY users call
711.

What is covered if you have a medical emergency?
You may get covered emergency care whenever you need it, anywhere in the United States
or its territories. If you need an ambulance to get to the emergency room, GuildNet Gold Plus
FIDA Plan covers that. To learn more, see the Covered Items and Services Chart in Chapter
4.
GuildNet Gold Plus FIDA Plan does not cover emergency care outside of the United States
or its territories.
If you have an emergency, your Care Manager will talk with the doctors who give you
emergency care. Those doctors will tell your Care Manager when your medical emergency is
over.
After the emergency is over, you may need follow-up care to be sure you get better. Your
follow-up care will be covered by GuildNet Gold Plus FIDA Plan. If you get your emergency
care from out-of-network providers, your Care Manager will try to get network providers to
take over your care as soon as possible.
What if it wasn’t a medical emergency after all?
Sometimes it can be hard to know if you have a medical emergency. You might go in for
emergency care and have the doctor say it wasn’t really a medical emergency. As long as
you reasonably thought your health was in serious danger, we will cover your care.
However, after the doctor says it was not an emergency, we will cover your additional care
only if:

 you go to a network provider for Medicaid-covered services,
 you go to an out-of-network Medicare provider for Medicare-covered services, or

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and other covered services and items

 the additional care you get is considered “urgently needed care” and you follow the
rules for getting this care. (See the next section.)

Getting urgently needed care
What is urgently needed care?
Urgently needed care is care you get for a sudden illness, injury, or condition that isn’t an
emergency but needs care right away. For example, you might have a flare-up of an existing
condition and need to have it treated.
Getting urgently needed care when you are in the plan’s service area
In most situations, we will cover urgently needed care only if:

 you get this care from a network provider or an out-of-network Medicare provider for
Medicare-covered services, and

 you follow the other rules described in this chapter.
However, if you can’t get to a network provider, we will cover urgently needed care you get
from an out-of-network provider.
GuildNet Gold Plus FIDA Plan also has a 24-hour nurse line, where a nurse is available to
answer your health questions 24 hours a day, seven days a week. You can access this
service by calling 1-800-815-0000. TTY users call 711.
Getting urgently needed care when you are outside the plan’s service area
When you are outside the service area, you might not be able to get care from a network
provider. In that case, our plan will cover urgently needed care you get from any provider.

Our plan does not cover urgently needed care or any other care that you get outside
theUnited States.

Getting care during a disaster
If the Governor of your state, the U.S. Secretary of Health and Human Services, or the
President of the United States declares a state of disaster or emergency in your geographic
area, you are still entitled to care from GuildNet Gold Plus FIDA Plan.
Please visit our website for information on how to obtain needed care during a declared
disaster: www.guildnetny.org.
During a declared disaster, if you cannot use a network provider, we will allow you to get care
from out-of-network providers at no cost to you. If you cannot use a network pharmacy during
a declared disaster, you will be able to fill your prescription drugs at an out-of-network
pharmacy. Please see Chapter 5 for more information.

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and other covered services and items

L. What if you are billed directly for the full cost of services and items
covered by GuildNet Gold Plus FIDA Plan?
Providers should only bill GuildNet Gold Plus FIDA Plan for the cost of your covered services
and items. If a provider sends you a bill instead of sending it to GuildNet Gold Plus FIDA
Plan, you can send it to us to pay. You should not pay the bill yourself. But if you do,
GuildNet Gold Plus FIDA Plan may pay you back.



If you have paid for your covered services or items, or if you have gotten a bill for covered
services or items, see Chapter 7 to learn what to do.

What should you do if services or items are not covered by our plan?
GuildNet Gold Plus FIDA Plan covers all services and items:

 that are medically necessary, and
 that are listed in the plan’s Covered Items and Services Chart or that your
Interdisciplinary Team (IDT) determines are necessary for you (see Chapter 4), and

 that you get by following plan rules.

 If you get services or items that aren’t covered by GuildNet Gold Plus FIDA Plan, you
must pay the full cost yourself.

If you want to know if we will pay for any services or items, you have the right to ask us. You
also have the right to ask for this in writing. If we say we will not pay for your services or
items, you have the right to appeal our decision.
Chapter 9 explains what to do if you want the plan to cover a medical service or item. It also
tells you how to appeal a coverage decision. You may also call Participant Services to learn
more about your appeal rights.
If you disagree with a decision made by the plan, you may contact the Independent
Consumer Advocacy Network (ICAN) to help you appeal the decision. ICAN provides free
information and assistance. You can call ICAN at 1-844-614-8800, Monday through Friday
from 8:00 am to 8:00 pm. (TTY users call 711, then follow the prompts to dial 844-614-8800.)

M. How are your health care services covered when you are in a clinical
research study?

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Chapter 3: Using the plan’s coverage for your health care
and other covered services and items

What is a clinical research study?
A clinical research study (also called a clinical trial) is a way doctors test new types of health
care or drugs. They ask for volunteers to help with the study. This kind of study helps doctors
decide whether a new kind of health care or drug works and whether it is safe.
Once Medicare approves a study you want to be in, someone who works on the study will
contact you. That person will tell you about the study and see if you qualify to be in it. You
can be in the study as long as you meet the required conditions. You must also understand
and accept what you must do for the study.
While you are in the study, you may stay enrolled in our plan. That way you continue to get
care from our plan not related to the study.
If you want to participate in a Medicare-approved clinical research study, you do not need to
get approval from GuildNet Gold Plus FIDA Plan, your IDT, or your Primary Care Provider.
The providers that give you care as part of the study do not need to be network providers.
You do need to tell us before you start participating in a clinical research study.
Here’s why:

 We can tell you if the clinical research study is Medicare-approved.
 We can tell you what services you will get from clinical research study providers
instead of from our plan.
If you plan to be in a clinical research study, you or your Care Manager should contact
Participant Services.

When you are in a clinical research study, who pays for what?
If you volunteer for a clinical research study that Medicare approves, you will pay nothing for
the services covered under the study and Medicare will pay for services covered under the
study as well as routine costs associated with your care. Once you join a Medicare-approved
clinical research study, you are covered for most items and services you get as part of the
study. This includes:

 Room and board for a hospital stay that Medicare would pay for even if you weren’t
in a study.

 An operation or other medical procedure that is part of the research study.
 Treatment of any side effects and complications of the new care.
If you are part of a study that Medicare has not approved, you will have to pay any costs
for being in the study.

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Learning more
You can learn more about joining a clinical research study by reading “Medicare & Clinical
Research Studies” on the Medicare website
(http://www.medicare.gov/publications/pubs/pdf/02226.pdf). You can also call
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should
call 1-877-486-2048.

N. How are your health care services covered when you are in a religious
non-medical health care institution?
What is a religious non-medical health care institution?
A religious non-medical health care institution is a place that provides care you would
normally get in a hospital or skilled nursing facility. If getting care in a hospital or a skilled
nursing facility is against your religious beliefs, we will cover care in a religious non-medical
health care institution. You may choose to get health care at any time for any reason. This
benefit is only for Medicare Part A inpatient services (non-medical health care services).
Medicare will only pay for non-medical health care services provided by religious non-medical
health care institutions.

What care from a religious non-medical health care institution is covered by
our plan?
To get care from a religious non-medical health care institution, you must sign a legal
document that says you are against getting medical treatment that is “non-excepted.”

 “Non-excepted” medical treatment is any care that is voluntary and not required by any
federal, state, or local law.

 “Excepted” medical treatment is any care that is not voluntary and is required under
federal, state, or local law.
To be covered by our plan, the care you get from a religious non-medical health care
institution must meet the following conditions:

 The facility providing the care must be certified by Medicare.
 GuildNet Gold Plus FIDA Plan’s coverage of services is limited to non-religious aspects
of care.

 If you get services from this institution that are provided to you in a facility, the following
applies:

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and other covered services and items

You must have a medical condition that would allow you to get covered services
for inpatient hospital care or skilled nursing facility care.

You must get approval from GuildNet Gold Plus FIDA Plan or your IDT before
you are admitted to the facility or your stay will not be covered.

Your hospital coverage will be covered as we described in the Benefits Chart in Chapter 4.
The coverage for this benefit chart is unlimited.

O. Rules for owning durable medical equipment
Will you own your durable medical equipment?
Durable medical equipment means certain items ordered by a provider for use in your own
home. Examples of these items are oxygen equipment and supplies, wheelchairs, canes,
crutches, walkers, and hospital beds.
You will always own certain items, such as prosthetics. Other types of durable medical
equipment will be rented for you by GuildNet Gold Plus FIDA Plan. Examples of items that
must be rented are wheelchairs, hospital beds, and continuous positive airway pressure
(CPAP) devices.
In Medicare, people who rent certain types of durable medical equipment own it after 13
months. As a Participant of GuildNet Gold Plus FIDA Plan, however, you usually will not own
the rented equipment, no matter how long it is rented for you.
In certain situations, we will transfer ownership of the durable medical equipment item. Call
Participant Services to find out about the requirements you must meet and the papers you
need to provide.

What happens if you lose your Medicaid coverage?
If you lose your Medicaid coverage and leave the FIDA Program, you will have to make 13
payments in a row under Original Medicare to own the equipment if:

 you did not become the owner of the durable medical equipment item while you were in
our plan and

 you get your Medicare benefits in the Original Medicare program.
If you made payments for the durable medical equipment under Original Medicare before you
joined GuildNet Gold Plus FIDA Plan, those Medicare payments do not count toward the 13
payments you would have to make after your Medicaid ends. You will have to make 13 new
payments in a row under Original Medicare to own the item.

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 There are no exceptions to this case when you return to Original Medicare. If you join a
Medicare health plan (such as a Medicare Advantage plan) instead of Original Medicare,
you should check with the plan about its coverage of durable medical equipment.

What happens if you change your FIDA Plan or leave FIDA and join an MLTC
Plan?
If you join another FIDA Plan or a Managed Long-Term Care (MLTC) Plan, your Care
Manager at your new plan will work with you to ensure that you continue to have access to
the durable medical equipment you are getting through GuildNet Gold Plus FIDA Plan.

CHAPTER 4
Covered Items and Services

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Chapter 4: Covered Items and Services
Table of Contents

A.Understanding your covered items and services ............................................................................51
B. GuildNet Gold Plus FIDA Plan does not allow providers to charge you for covered items or
services .........................................................................................................................................51
C.About the Covered Items and Services Chart .................................................................................51
D.The Covered Items and Services Chart ..........................................................................................53
E.Benefits covered outside of GuildNet Gold Plus FIDA Plan ..........................................................108
Day treatment .............................................................................................................................. 108
Freestanding birth center services ............................................................................................... 108
Out of network family planning services ...................................................................................... 108
Methadone Maintenance Treatment Program (MMTP) ................................................................ 108
Directly observed therapy for tuberculosis (TB) ........................................................................... 108
Hospice services ......................................................................................................................... 108
F. Benefits not covered by GuildNet Gold Plus FIDA Plan, Medicare, or Medicaid ..........................109

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Chapter 4: Covered Items and Services

A. Understanding your covered items and services
This chapter tells you what items and services GuildNet Gold Plus FIDA Plan pays for. You
can also learn about services that are not covered. Information about drug benefits is in
Chapter 5.
Because you are a FIDA Participant, you pay nothing for your covered items and services as
long as you follow GuildNet Gold Plus FIDA Plan’s rules. See Chapter 3 for details about the
plan’s rules.
If you need help understanding what services are covered, call your Care Manager and/or
Participant Services at 1-800-815-0000 (TTY 711).

B. GuildNet Gold Plus FIDA Plan does not allow providers to charge you
for covered items or services
We do not allow GuildNet Gold Plus FIDA Plan providers to bill you for covered items or
services. We pay our providers directly, and we protect you from any charges. This is true
even if we pay the provider less than the provider charges for a service.



You should never get a bill from a provider. If you do, see Chapter 7 or call
Participant Services.

C. About the Covered Items and Services Chart
This Covered Items and Services Chart tells you which items and services GuildNet Gold
Plus FIDA Plan pays for. It lists items and services in alphabetical order and explains the
covered items and services.
We will pay for the items and services listed in the Covered Items and Services Chart
only when the following rules are met. You do not pay anything for the items and
services listed in the Covered Items and Services Chart, as long as you meet the
coverage requirements described below.

 Your Medicare and Medicaid covered items and services must be provided according
to the rules set by Medicare and Medicaid.

 The items and services (including medical care, services, supplies, equipment, and
drugs) must be medically necessary. Medically necessary means you need items and
services to prevent, diagnose, correct, or cure conditions that cause acute suffering,

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Chapter 4: Covered Items and Services

endanger your life, result in illness or infirmity, interfere with your capacity for normal
activity, or threaten some significant handicap.

 You get your Medicaid-covered care from a network provider. A network provider is a
provider who works with GuildNet Gold Plus FIDA Plan. In most cases, GuildNet Gold
Plus FIDA Plan will not pay for care you get from an out-of-network provider for your
Medicaid-covered services, unless it is approved by your Interdisciplinary Team (IDT)
or GuildNet Gold Plus FIDA Plan. Chapter 3 has more information about using
network and out-of-network providers. You may use out-of-network Medicare
providers for your Medicare-covered services.

 You have an Interdisciplinary Team (IDT) that will arrange and manage your care.
For more information on your IDT, see Chapter 3.

 Most of the items and services listed in the Covered Items and Services Chart are
covered only if your IDT, GuildNet Gold Plus FIDA Plan, or an authorized provider
approves them. This is called prior authorization. The Covered Items and Services
Chart tells you when an item or service does not require prior authorization.
All preventive services are covered by GuildNet Gold Plus FIDA Plan. You will see this apple
next to preventive services in the benefits chart.

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Chapter 4: Covered Items and Services

D. The Covered Items and Services Chart
Services that GuildNet Gold Plus FIDA Plan pays for
Abdominal aortic aneurysm screening
A one-time ultrasound screening for people at risk. The plan
only covers this screening if you have certain risk factors and
if you get a referral for it from your physician, physician
assistant, nurse practitioner, or clinical nurse specialist.

What you must pay
$0
This service may be
obtained from an outof-network Medicare
provider.

Adult day health care

GuildNet Gold Plus FIDA Plan will pay for adult day health
care for Participants who are functionally impaired, not
homebound, and who require certain preventive, diagnostic,
therapeutic, rehabilitative, or palliative items or services.

This service must be
obtained from an innetwork provider.

Adult day health care includes the following services:

 Medical
 Nursing
 Food and nutrition
 Social services
 Rehabilitation therapy
 Leisure time activities, which are a planned program of
diverse meaningful activities

 Dental
 Pharmaceutical
 Other ancillary services

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Services that GuildNet Gold Plus FIDA Plan pays for
AIDS adult day health care
GuildNet Gold Plus FIDA Plan will pay for AIDS adult day
health care programs (ADHCP) for Participants with HIV.
ADHCP includes the following services:

 Individual and group counseling/education provided in a

Chapter 4: Covered Items and Services

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

structured program setting

 Nursing care (including triage/assessment of new
symptoms)

 Medication adherence support
 Nutritional services (including breakfast and/or lunch)
 Rehabilitative services
 Substance abuse services
 Mental health services
 HIV risk reduction services
Alcohol misuse screening and counseling
The plan will pay for one alcohol-misuse screening for adults
who misuse alcohol but are not alcohol dependent. This
includes pregnant women.
If you screen positive for alcohol misuse, you can get up to
four brief, face-to-face counseling sessions each year (if you
are able and alert during counseling) with a qualified primary
care provider or practitioner in a primary care setting.

$0
This service may be
obtained from an outof-network Medicare
provider.

This service does not require prior authorization.

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Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Ambulance services

Covered ambulance services include fixed-wing, rotary-wing,
and ground ambulance services. The ambulance will take you
to the nearest place that can give you care.

Emergency
services may be
obtained from an
out-of-network
Medicare provider.

Your condition must be serious enough that other ways of
getting to a place of care could risk your life or health.
Ambulance services for other cases must be approved by
your IDT or GuildNet Gold Plus FIDA Plan.
In cases that are not emergencies, your IDT or GuildNet Gold
Plus FIDA Plan may authorize use of an ambulance. Your
condition must be serious enough that other ways of getting to
a place of care could risk your life or health.

Check with Plan if your
non-emergency
ambulance service
must be obtained from
an in-network provider.

Ambulatory surgical center services

GuildNet Gold Plus FIDA Plan will pay for covered surgical
procedures provided at ambulatory surgical centers.

This service may be
obtained from an outof-network Medicare
provider.

Annual wellness visit / routine physical exam

If you have been in Medicare Part B for more than 12 months,
you can get an annual wellness checkup. This is to develop or
update a prevention plan based on your current health and
risk factors. GuildNet Gold Plus FIDA Plan will pay for this
once every 12 months.

This service may be
obtained from an outof-network Medicare
provider.

Note: You cannot have your first annual checkup within
12 months of your “Welcome to Medicare” preventive visit.
You will be covered for annual checkups after you have had
Part B for 12 months. You do not need to have had a
“Welcome to Medicare” visit first.
This service does not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Assertive community treatment (ACT)

GuildNet Gold Plus FIDA Plan will pay for ACT services. ACT
is a mobile team-based approach to delivering comprehensive
and flexible treatment, rehabilitation, case management and
support services to individuals in their natural living setting.

This service must be
obtained from an innetwork provider.

Assisted living program

GuildNet Gold Plus FIDA Plan will pay for Assisted Living
Program services provided in an adult home or enriched
housing setting.
Services include:

This service must be
obtained from an innetwork provider.

 Personal care
 Housekeeping
 Supervision
 Home health aides
 Personal emergency response services
 Nursing
 Physical, occupational, and/or speech therapy
 Medical supplies and equipment
 Adult day health care
 A range of home health services
 Case management services of a registered professional
nurse

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Assistive technology

GuildNet Gold Plus FIDA Plan will pay for physical
adaptations to the private residence of the Participant or the
Participant’s family. The adaptations must be necessary to
ensure the health, welfare, and safety of the Participant or
enable the Participant to function with greater independence
in the home.

This service must be
obtained from an innetwork provider.

Covered adaptations include:

 Installation of ramps and grab bars
 Widening of doorways
 Modifications of bathrooms
 Installation of specialized electric and plumbing systems
Bone mass measurement
GuildNet Gold Plus FIDA Plan will pay for certain procedures
for Participants who qualify (usually, someone at risk of losing
bone mass or at risk of osteoporosis). These procedures
identify bone mass, find bone loss, or find out bone quality.
GuildNet Gold Plus FIDA Plan will pay for the services once
every 24 months, or more often if they are medically
necessary. GuildNet Gold Plus FIDA Plan will also pay for a
doctor to look at and comment on the results.

$0
This service may be
obtained from an outof-network Medicare
provider.

This service does not require prior authorization.
Breast cancer screening (mammograms)
GuildNet Gold Plus FIDA Plan will pay for the following
services:

 One baseline mammogram between the ages
of 35 and 39

 One screening mammogram every 12 months

$0
This service may be
obtained from an outof-network Medicare
provider.

for women age 40 and older

 Clinical breast exams once every 24 months
This service does not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Cardiac (heart) rehabilitation services

GuildNet Gold Plus FIDA Plan will pay for cardiac
rehabilitation services such as exercise, education, and
counseling. Participants must meet certain conditions with a
provider’s order. GuildNet Gold Plus FIDA Plan also covers
intensive cardiac rehabilitation programs, which are more
intense than cardiac rehabilitation programs.

This service may be
obtained from an outof-network Medicare
provider.

This service does not require prior authorization.
Cardiovascular (heart) disease risk reduction visit
(therapy for heart disease)

GuildNet Gold Plus FIDA Plan pays for one visit a year with
your Primary care Provider (PCP) to help lower your risk for
heart disease. During this visit, your doctor may:

This service may be
obtained from an outof-network Medicare
provider.

 discuss aspirin use,
 check your blood pressure, or
 give you tips to make sure you are eating well.
This service does not require prior authorization.
Cardiovascular (heart) disease screening and testing
GuildNet Gold Plus FIDA Plan pays for blood tests to check
for cardiovascular disease once every five years (60 months).
These blood tests also check for defects due to high risk of
heart disease.

This service does not require prior authorization.

This service may be
obtained from an outof-network Medicare
provider.

Care management (service coordination)

Care management is an individually designed intervention
that helps the Participant get access to needed services.
These care management interventions are designed to
ensure the Participant’s health and welfare and increase the
Participant’s independence and quality of life.

This service is provided
directly by GuildNet
Gold Plus FIDA Plan.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Cervical and vaginal cancer screening
GuildNet Gold Plus FIDA Plan will pay for the following
services:

 For all women: Pap tests and pelvic exams once every
24 months

 For women who are at high risk of cervical cancer: one

Chapter 4: Covered Items and Services

What you must pay
$0
This service may be
obtained from an outof-network Medicare
provider.

Pap test and pelvic exam every 12 months

 For women who have had an abnormal Pap test and are
of childbearing age: one Pap test and pelvic exam every
12 months

This service does not require prior authorization.
Chemotherapy
GuildNet Gold Plus FIDA Plan will pay for chemotherapy for
cancer patients. Chemotherapy is covered when it is provided
in an inpatient or outpatient unit of a hospital, a provider’s
office, or a freestanding clinic.

This service may be
obtained from an outof-network Medicare
provider.

Chiropractic services

GuildNet Gold Plus FIDA Plan will pay for the following
services:

This service may be
obtained from an outof-network Medicare
provider.

 Adjustments of the spine to correct alignment

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Colorectal cancer screening

Chapter 4: Covered Items and Services

What you must pay
$0

GuildNet Gold Plus FIDA Plan will pay for the following:

 Barium enema
» Covered once every 48 months if you're 50 or over
and once every 24 months if you're at high risk for
colorectal cancer, when this test is used instead of a
flexible sigmoidoscopy or colonoscopy.

This service may be
obtained from an outof-network Medicare
provider.

 Colonoscopy
» Covered once every 24 months if you're at high risk
for colorectal cancer. If you aren't at high risk for
colorectal cancer, Medicare covers this test once
every 120 months, or 48 months after a previous
flexible sigmoidoscopy.

 DNA based colorectal screening
» Covered once every 3 years if you’re 50 or over.

 Fecal occult blood test
» Covered once every 12 months if you're 50 or older.

 Guaiac-based fecal occult blood test or fecal
immunochemical test

» Covered once every 12 months if you’re 50 or over.

 Flexible sigmoidoscopy
» Covered once every 48 months for most people 50 or
older. If you aren't at high risk, Medicare covers this
test 120 months after a previous screening
colonoscopy.
This service does not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Community integration counseling

GuildNet Gold Plus FIDA Plan will pay for community
integration counseling. This is a counseling service provided
to Participants who are coping with altered abilities and skills,
a revision of long term expectations, or changes in roles in
relation to significant others.

This service must be
obtained from an innetwork provider.

This service is primarily provided in the provider’s office or
the Participant’s home. Community integration counseling
services are usually provided in one-to-one counseling
sessions. However, there are times when it is appropriate to
provide this service to the Participant in a family counseling
or group counseling setting.
Community transitional services

GuildNet Gold Plus FIDA Plan will pay for Community
Transitional Services (CTS). These services help a
Participant transition from living in a nursing facility to living in
the community.

This service must be
obtained from an innetwork provider.

CTS includes:

 The cost of moving furniture and other belongings
 Buying certain essential items such as linen and dishes
 Security deposits, including broker’s fees required to
obtain a lease on an apartment or home

 Buying essential furnishings
 Set-up fees or deposits for utility or service access (for
example, telephone, electricity, or heating)

 Health and safety assurances such as pest removal,

allergen control, or one time cleaning prior to occupancy

CTS cannot be used to purchase diversional or recreational
items, such as televisions, VCRs/DVDs, or music systems.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Comprehensive Psychiatric Emergency Programs
(CPEPs)
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.
Consumer directed personal assistance services
(CDPAS)
GuildNet Gold Plus FIDA Plan will pay for CDPAS, which
provides services to chronically ill or physically disabled
individuals who have a medical need for help with activities of
daily living (ADLs) or skilled nursing services. Services can
include any of the services provided by a personal care aide
(home attendant), home health aide, or nurse.

Chapter 4: Covered Items and Services

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

$0
For more information
on obtaining this
benefit, please call
Participant Services.

Participants who choose CDPAS have flexibility and freedom
to choose their caregivers. The Participant or the person
acting on the Participant's behalf (such as the parent of a
disabled or chronically ill child) is responsible for recruiting,
hiring, training, supervising, and, if necessary, terminating
caregivers providing CDPAS services.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Continuing day treatment

GuildNet Gold Plus FIDA Plan will pay for continuing day
treatment. This service helps Participants maintain or
enhance current levels of functioning and skills, maintain
community living, and develop self-awareness and selfesteem.

This service must be
obtained from an innetwork provider.

Services include:

 Assessment and treatment planning
 Discharge planning
 Medication therapy
 Medication education
 Case management
 Health screening and referral
 Rehabilitative readiness development
 Psychiatric rehabilitative readiness determination and
referral

 Symptom management
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 services do not need to be in your
treatment plan in order to be covered.

This service must be
obtained from an innetwork provider.

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.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Defibrillator (implantable automatic)

GuildNet Gold Plus FIDA Plan will pay for defibrillators for
certain people diagnosed with heart failure, depending on
whether the surgery takes place in a hospital inpatient or
outpatient setting.

This service may be
obtained from an outof-network Medicare
provider.

Dental services

GuildNet Gold Plus FIDA Plan will pay for the following dental
services:

 Oral exams once every six months
 Cleaning once every six months
 Dental x-rays once every six months
 Diagnostic services

This service must be
obtained from an innetwork provider or by
an Article 28 Clinic
operated by Academic
Dental Centers.

 Restorative services
 Endodontics, periodontics, and extractions
 Dental prosthetics and orthotic appliances required to

alleviate a serious condition, including one that affects a
Participant’s employability

 Other oral surgery
 Dental emergencies
 Other necessary dental care
Oral exams and cleanings require prior authorization by
GuildNet Gold Plus FIDA Plan or your IDT. X-rays and other
dental services must be authorized by your dentist. However,
dental services provided through Article 28 Clinics operated
by Academic Dental Centers do not require prior
authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Depression screening

GuildNet Gold Plus FIDA Plan will pay for one depression
screening each year. The screening must be done in a
primary care setting that can give follow-up treatment and
recommendations for additional treatments.

This service may be
obtained from an outof-network Medicare
provider.

This service does not require prior authorization.
Diabetes screening

GuildNet Gold Plus FIDA Plan will pay for this screening
(includes fasting glucose tests) if you have any of the
following risk factors:

This service may be
obtained from an outof-network Medicare
provider.

 High blood pressure (hypertension)
 History of abnormal cholesterol and triglyceride levels
(dyslipidemia)

 Obesity
 History of high blood sugar (glucose)
Tests may be covered in some other cases, such as if you are
overweight and have a family history of diabetes.
Depending on the test results, you may qualify for up to two
diabetes screenings every 12 months.
This service does not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Diabetic self-management training, services, and
supplies
GuildNet Gold Plus FIDA Plan will pay for the following
services for all people who have diabetes (whether they use
insulin or not):

Chapter 4: Covered Items and Services

What you must pay
$0
This service may be
obtained from an outof-network Medicare
provider.

 Supplies to monitor your blood glucose, including
the following:
»
»
»
»

A blood glucose monitor
Blood glucose test strips
Lancet devices and lancets
Glucose-control solutions for checking the accuracy of
test strips and monitors

 For people with diabetes who have severe diabetic foot
disease, GuildNet Gold Plus FIDA Plan will pay for the
following:

» One pair of therapeutic custom-molded shoes
(including inserts) and two extra pairs of inserts each
calendar year, or
» One pair of depth shoes and three pairs of inserts
each year (not including the non-customized
removable inserts provided with such shoes)
GuildNet Gold Plus FIDA Plan will also pay for fitting the
therapeutic custom-molded shoes or depth shoes.

 GuildNet Gold Plus FIDA Plan will pay for training to help
you manage your diabetes, in some cases.

Diagnostic testing

See “Outpatient diagnostic tests and therapeutic services and
supplies” in this chart.

This service may be
obtained from an outof-network Medicare
provider.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

What you must pay

Durable medical equipment and related supplies

Durable medical equipment includes items such as:

Medicare covered
items may be obtained
from an out-of-network
Medicare provider.

 Wheelchairs

 Oxygen equipment

 Crutches

 IV infusion pumps

 Hospital beds

 Walkers

 Nebulizers

 Speech generating devices

We will pay for all medically necessary durable medical
equipment that Medicare and Medicaid usually pay for. If our
supplier in your area does not carry a particular brand or
maker, you may ask them if they can special-order it for you.

Chapter 4: Covered Items and Services

Medicaid covered items
must be obtained from
an in-network provider.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Emergency care

Emergency care means services that are:

If you get emergency
care at an out-ofnetwork hospital and
need inpatient care
after your emergency is
stabilized, you must
have your inpatient
care at the out-ofnetwork hospital
authorized.

 given by a provider trained to give emergency services,
and

 needed to treat a medical or behavioral health
emergency.

A medical or behavioral health emergency is a condition with
severe symptoms, severe pain, or serious injury. The
condition is so serious that, if it doesn’t get immediate medical
attention, you or anyone with an average knowledge of health
and medicine could expect it to result in:

 placing your health (or, with respect to a pregnant

woman, your health or that of your unborn child) in
serious jeopardy, or in the case of a behavioral condition,
placing your health or the health of others in serious
jeopardy;

This service may be
obtained from an outof-network Medicare
provider.

 serious harm to bodily functions; or
 serious dysfunction of any bodily organ or part; or
 serious disfigurement; or
 in the case of a pregnant woman, an active labor,

meaning labor at a time when either of the following
would occur:
» There is not enough time to safely transfer you to
another hospital before delivery.
» The transfer may pose a threat to your health or safety
or to that of your unborn child.

Coverage is within the U.S. and its territories.
This service does not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Environmental modifications and adaptive devices
GuildNet Gold Plus FIDA Plan will pay for internal and
external physical adaptations to the home that are necessary
to ensure the health, welfare, and safety of the Participant.
Environmental modifications may include:

Chapter 4: Covered Items and Services

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

 Installation of ramps and grab bars
 Widening of doorways
 Modifications of bathroom facilities
 Installation of specialized electrical or plumbing systems
to accommodate necessary medical equipment

 Any other modification necessary to ensure the
participant’s health, welfare or safety

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Family planning services
The law lets you choose any provider to get certain family
planning services from. This means any doctor, clinic,
hospital, pharmacy or family planning office.
GuildNet Gold Plus FIDA Plan will pay for the following
services:

Chapter 4: Covered Items and Services

What you must pay
$0
These services may be
obtained from an outof-network provider.

 Family planning exam and medical treatment
 Family planning lab and diagnostic tests
 Family planning methods (birth control pills, patch, ring,
IUD, injections, implants)

 Family planning supplies with prescription (condom,
sponge, foam, film, diaphragm, cap, emergency
contraception, pregnancy tests)

 Counseling and diagnosis of infertility, and related
services

 Counseling and testing for sexually transmitted infections
(STIs), AIDS, and other HIV-related conditions, as part of
a family planning visit

 Treatment for sexually transmitted infections (STIs)
 Voluntary sterilization (You must be age 21 or older, and

you must sign a federal sterilization consent form. At least
30 days, but not more than 180 days, must pass between
the date that you sign the form and the date of surgery.)

 Abortion
These services do not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Health and wellness education programs
GuildNet Gold Plus FIDA Plan will pay for health and wellness
education for Participants and their caregivers, which
includes:

 Classes, support groups, and workshops
 Educational materials and resources

Chapter 4: Covered Items and Services

What you must pay
$0
This service must
be obtained from
an in-network
provider.

 Website, email, or mobile application communications
These services are provided on topics including, but not
limited to: heart attack and stroke prevention, asthma, living
with chronic conditions, back care, stress management,
healthy eating and weight management, oral hygiene, and
osteoporosis.
This benefit also includes annual preventive care reminders
and caregiver resources.
This service does not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Hearing services
GuildNet Gold Plus FIDA Plan pays for hearing and balance
tests done by your provider. These tests tell you whether you
need medical treatment. They are covered as outpatient care
when you get them from a physician, audiologist, or other
qualified provider.
Hearing services and products are covered when medically
necessary to alleviate disability caused by the loss or
impairment of hearing.
Services include:

Chapter 4: Covered Items and Services

What you must pay
$0
Hearing and balance
evaluations may be
obtained from an outof-network Medicare
provider. All other
hearing services must
be obtained from an innetwork provider.

 Hearing aid selecting, fitting, and dispensing
 Hearing aid checks following dispensing
 Conformity evaluations and hearing aid repairs
 Audiology services, including examinations and testing
 Hearing aid evaluations and hearing aid prescriptions
 Hearing aid products, including hearing aids, earmolds,
special fittings, and replacement parts when authorized
by an audiologist

HIV screening

GuildNet Gold Plus FIDA Plan pays for one HIV screening
exam every 12 months for people who:

This service may be
obtained from an outof-network Medicare
provider.

 ask for an HIV screening test, or
 are at increased risk for HIV infection.
For women who are pregnant, GuildNet Gold Plus FIDA Plan
pays for up to three HIV screening tests during a pregnancy.
This service does not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Home and community support services (HCSS)

GuildNet Gold Plus FIDA Plan will pay for HCSS for
Participants who:

This service must be
obtained from an innetwork provider.

 require assistance with personal care services tasks, and
 whose health and welfare in the community is at risk

because supervision of the Participant is required when
no personal care task is being performed.

Home delivered and congregate meals

GuildNet Gold Plus FIDA Plan will pay for congregate and
home delivered meals. This is an individually designed
service that provides meals to Participants who cannot
prepare or obtain nutritionally adequate meals for themselves,
or when providing such meals will decrease the need for more
costly supported in-home meal preparation. This benefit
includes three meals a day for 52 weeks a year.

This service must be
obtained from an innetwork provider.

Home health services

Before you can get home health services, a provider must tell
us you need them, and they must be provided by a home
health agency.
GuildNet Gold Plus FIDA Plan will pay for the following
services, and maybe other services not listed here:

 Part-time or intermittent skilled nursing and home health
aide services

 Physical therapy, occupational therapy, and speech
therapy

 Medical and social services
 Medical equipment and supplies

Medicare covered
services may be
obtained from an outof-network Medicare
provider.
Services not covered
by Medicare must be
obtained from an innetwork provider.
For more information
on network rules for
home health services,
please call Participant
services.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Home infusion

GuildNet Gold Plus FIDA Plan will pay for the administration
of home infusion drugs and supplies.

This service must be
obtained from an innetwork provider.

Home maintenance services

GuildNet Gold Plus FIDA Plan will pay for home maintenance
services. Home maintenance services include household
chores and services that are required to maintain an
individual’s home environment in a sanitary, safe, and viable
manner. Chore services are provided on two levels:

This service must be
obtained from an innetwork provider.

 Light chores – Cleaning and/or washing of windows,

walls, and ceilings; snow removal and/or yard work;
tacking down loose rugs and/or securing tiles; and
cleaning of tile work in bath and/or kitchen. Light chores
are provided when needed.

 Heavy-duty chores – limited to one-time-only, intensive

cleaning/chore efforts, except in extraordinary situations.
Heavy-duty chore services may include (but are not
limited to) tasks such as scraping and/or cleaning of floor
areas.

Home visits by medical personnel

GuildNet Gold Plus FIDA Plan will cover home visits by
medical personnel to provide diagnosis, treatment, and
wellness monitoring. The purpose of these home visits is to
preserve the Participant’s functional capacity to remain in the
community. Wellness monitoring includes disease prevention,
health education, and identifying health risks that can be
reduced.

Medicare covered
services may be
obtained from an outof-network Medicare
provider.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 4: Covered Items and Services

Services that GuildNet Gold Plus FIDA Plan pays for
Hospice care

What you must pay
$0

You can get care from any hospice program certified by
Medicare. You have the right to elect hospice if your provider and
hospice medical director determine you have a terminal
prognosis. This means you have a terminal illness and are
expected to have six months or less to live. Your hospice doctor
can be a network provider or an out-of-network provider.
The plan will pay for the following while you are getting
hospice services:

 Drugs to treat symptoms and pain
 Short-term respite care
 Home care
Hospice services and services covered by Medicare Part
A or B are billed to Medicare.

 See Section F of this chapter for more information.
For services covered by GuildNet Gold Plus FIDA Plan
but not covered by Medicare Part A or B:
GuildNet Gold Plus FIDA Plan will cover plan-covered
services not covered under Medicare Part A or B. The plan
will cover the services whether or not they are related to your
terminal prognosis. You pay nothing for these services.
For drugs that may be covered by GuildNet Gold Plus
FIDA Plan’s Medicare Part D benefit:

 Drugs are never covered by both hospice and our plan at

the same time. For more information, please see Chapter
5.

Note: If you need non-hospice care, you should call your
Care Manager at 1-800-815-0000 (TTY 711) to arrange the
services. Non-hospice care is care that is not related to your
terminal prognosis.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Immunizations

GuildNet Gold Plus FIDA Plan will pay for the following
services:

This service may be
obtained from an outof-network Medicare
provider.

 Pneumonia vaccine
 Flu shots, once a year, in the fall or winter
 Hepatitis B vaccine if you are at high or intermediate risk
of getting hepatitis B

 Other vaccines if you are at risk and they meet Medicare
Part B coverage rules

GuildNet Gold Plus FIDA Plan will pay for other vaccines that
meet the Medicare Part D coverage rules. Read Chapter 6 to
learn more.
These services do not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Independent living skills and training

Independent Living Skills Training and Development (ILST)
services are individually designed to improve or maintain the
ability of the Participant to live as independently as possible in
the community. ILST may be provided in the Participant’s
residence and in the community.

This service must be
obtained from an innetwork provider.

Services may include assessment, training, and supervision
of or assistance with:

 Self-care
 Medication management
 Task completion
 Communication skills
 Interpersonal skills
 Socialization
 Sensory/motor skills
 Mobility
 Community transportation skills
 Reduction/elimination of maladaptive behaviors
 Problem solving skills
 Money management
 Pre-vocational skills
 Ability to maintain a household

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Inpatient acute hospital care, including substance abuse
and rehabilitative services
GuildNet Gold Plus FIDA Plan will pay for the following
services, and maybe other services not listed here:

 Semi-private room (or a private room if it is medically
necessary)

 Meals, including special diets
 Regular nursing services
 Costs of special care units, such as intensive care or
coronary care units

 Drugs and medications

Chapter 4: Covered Items and Services

What you must pay
$0
You must get approval
from GuildNet Gold
Plus FIDA Plan to keep
getting inpatient care at
an out-of-network
hospital after your
emergency is under
control.
This service may be
obtained from an outof-network Medicare
provider.

 Lab tests
 X-rays and other radiology services
 Needed surgical and medical supplies
 Appliances, such as wheelchairs
 Operating and recovery room services
 Physical, occupational, and speech therapy
 Inpatient substance abuse services
 Blood, including storage and administration
 Physician services
 In some cases, the following types of transplants:

corneal, kidney, kidney/pancreatic, heart, liver, lung,
heart/lung, bone marrow, stem cell, and
intestinal/multivisceral.
This benefit is continued on the next page

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Inpatient acute hospital care, including substance abuse
and rehabilitative services
(continued)
If you need a transplant, a Medicare-approved transplant
center will review your case and decide whether you are a
candidate for a transplant. Transplant providers may be local
or outside of the service area. If local transplant providers are
willing to accept the Medicare rate, then you can get your
transplant services locally or at a distant location outside the
service area. If GuildNet Gold Plus FIDA Plan provides
transplant services at a distant location outside the service
area and you choose to get your transplant there, we will
arrange or pay for lodging and travel costs for you and one
other person.
Inpatient mental health care

GuildNet Gold Plus FIDA Plan will pay for mental health care
services that require a hospital stay, including days in excess
of the Medicare 190-day lifetime maximum.

This service may be
obtained from an outof-network Medicare
provider.

Intensive psychiatric rehabilitation treatment programs

GuildNet Gold Plus FIDA Plan will pay for time limited, active
psychiatric rehabilitation designed to:

This service must be
obtained from an innetwork provider.

 Help a Participant form and achieve mutually agreed
upon goals in living, learning, working, and social
environments

 Intervene with psychiatric rehabilitative technologies to
help a Participant overcome functional disabilities

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Kidney disease services and supplies, including EndStage Renal Disease (ESRD) services

GuildNet Gold Plus FIDA Plan will pay for the following
services:

This service may be
obtained from an outof-network Medicare
provider.

 Kidney disease education services to teach kidney care

and help Participants make good decisions about their
care. You must have stage IV chronic kidney disease,
and your IDT or GuildNet Gold Plus FIDA Plan must
authorize it. GuildNet Gold Plus FIDA Plan will cover up
to six sessions of kidney disease education services per
lifetime.

 Outpatient dialysis treatments, including dialysis

treatments when temporarily out of the service area, as
explained in Chapter 3

 Inpatient dialysis treatments if you are admitted as an
inpatient to a hospital for special care

 Self-dialysis training, including training for you and

anyone helping you with your home dialysis treatments

 Home dialysis equipment and supplies
 Certain home support services, such as necessary visits
by trained dialysis workers to check on your home
dialysis, to help in emergencies, and to check your
dialysis equipment and water supply

Your Medicare Part B drug benefit pays for some drugs
for dialysis. For information, please see “Medicare Part B
prescription drugs” in this chart.
Kidney disease education services do not require prior
authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 4: Covered Items and Services

Services that GuildNet Gold Plus FIDA Plan pays for
Lung cancer screening
The plan will pay for lung cancer screening every 12 months if
you:
 Are aged 55-77, and
 Have a counseling and shared decision-making visit with
your doctor or other qualified provider, and
 Have smoked at least 1 pack a day for 30 years with no
signs or symptoms of lung cancer or smoke now or have quit
within the last 15 years.

What you must pay
$0
This service may be
obtained from an outof-network Medicare
provider

After the first screening, the plan will pay for another
screening each year with a written order from your doctor or
other qualified provider.
Medical nutrition therapy
This benefit is for Participants with diabetes or kidney disease
without dialysis. It is also for after a kidney transplant when
ordered by your provider.
GuildNet Gold Plus FIDA Plan will pay for three hours of oneon-one counseling services during your first year that you get
medical nutrition therapy services under Medicare. (This
includes GuildNet Gold Plus FIDA Plan, a Medicare
Advantage plan, or Medicare.) We pay for two hours of oneon-one counseling services each year after that. If your
condition, treatment, or diagnosis changes, you may be able
to get more hours of treatment with a provider’s request and
approval by your IDT or GuildNet Gold Plus FIDA Plan. A
provider must prescribe these services and renew the request
to the IDT or to GuildNet Gold Plus FIDA Plan each year if
your treatment is needed in the next calendar year.

$0
This service may be
obtained from an outof-network Medicare
provider.

This service does not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Medical social services

GuildNet Gold Plus FIDA Plan will pay for medical social
services, which includes the assessment of social and
environmental factors related to the Participant’s illness and
need for care.

This service must be
obtained from an innetwork provider.

Services include:

 Home visits to the individual, family, or both
 Visits to prepare to transfer the Participant to the
community

 Patient and family counseling, including personal,
financial, and other forms of counseling services

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Medicare Part B prescription drugs
These drugs are covered under Part B of Medicare. GuildNet
Gold Plus FIDA Plan will pay for the following drugs:

 Drugs you don’t usually give yourself and are injected or

infused while you are getting provider, hospital outpatient,
or ambulatory surgery center services

Chapter 4: Covered Items and Services

What you must pay
$0
This service may be
obtained from an outof-network Medicare
provider.

 Drugs you take using durable medical equipment (such
as nebulizers) that were authorized by your IDT or
GuildNet Gold Plus FIDA Plan

 Clotting factors you give yourself by injection if you have
hemophilia

 Immunosuppressive drugs, if you were enrolled in

Medicare Part A at the time of the organ transplant

 Osteoporosis drugs that are injected. These drugs are

paid for if you are homebound, have a bone fracture that
a provider certifies was related to post-menopausal
osteoporosis, and cannot inject the drug yourself

 Antigens
 Certain oral anti-cancer drugs and anti-nausea drugs
 Certain drugs for home dialysis, including heparin, the

antidote for heparin (when medically needed), topical
anesthetics, and erythropoiesis-stimulating agents (such
as Procrit)

 IV immune globulin for the home treatment of primary
immune deficiency diseases



Chapter 5 explains the outpatient prescription drug
benefit. It explains rules you must follow to have
prescriptions covered.



Chapter 6 provides additional information about your
outpatient prescription drug coverage.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Medication therapy management (MTM) services

GuildNet Gold Plus FIDA Plan provides medication therapy
management (MTM) services for Participants who take
medications for different medical conditions. MTM programs
help Participants and their providers make sure that
Participants’ medications are working to improve their health.

This service is provided
directly by GuildNet
Gold Plus FIDA Plan.



Chapter 5 provides additional information about MTM
programs.

Mobile mental health treatment

GuildNet Gold Plus FIDA Plan will pay for mobile mental
health treatment, which includes individual therapy that is
provided in the home. This service is available to Participants
who have a medical condition or disability that limits their
ability to come into an office for regular outpatient therapy
sessions.

This service must be
obtained from an innetwork provider.

Moving assistance

GuildNet Gold Plus FIDA Plan will pay for moving assistance
services. These are individually designed services intended to
move a Participant’s possessions and furnishings when the
Participant must be moved from inadequate or unsafe
housing to an environment which more adequately meets the
Participant’s health and welfare needs and reduces the risk of
unwanted nursing facility placement.

This service must be
obtained from an innetwork provider.

Moving assistance does not include items such as security
deposits, including broker’s fees required to obtain a lease on
an apartment or home; set-up fees or deposits for utility or
service access (for example, telephone, electricity, heating);
and health and safety assurances such as pest removal,
allergen control, or cleaning prior to occupancy.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
New York State Office of Mental Health Licensed
Community Residences
GuildNet Gold Plus FIDA Plan will pay for behavioral health
residential programs in these settings that provide
rehabilitative and supportive services. These services focus
on intensive, goal-oriented intervention, within a structured
program setting, to address residents’ needs regarding
community integration. These services also include goaloriented interventions which focus on improving or
maintaining resident skills to enable living in community
housing.

Chapter 4: Covered Items and Services

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

Nurse advice call line

GuildNet Gold Plus FIDA Plan has a nurse advice line which
is a toll-free phone service that Participants can call 24 hours
a day, 7 days a week. Participants can call the nurse advice
line for answers to general health related questions and for
assistance in accessing services through GuildNet Gold Plus
FIDA Plan.

This service is provided
directly by GuildNet
Gold Plus FIDA Plan.

Nursing facility care

GuildNet Gold Plus FIDA Plan will pay for nursing facilities for
Participants who need 24-hour nursing care and supervision
outside of a hospital.

This service must be
obtained from an innetwork provider.

Nutrition (includes nutritional counseling and educational
services)

GuildNet Gold Plus FIDA Plan will pay for nutrition services
provided by a qualified nutritionist. Services include:

 Assessment of nutritional needs and food patterns

This service may be
obtained from an outof-network Medicare
provider.

 Planning for providing food and drink appropriate for the
individual’s physical and medical needs and
environmental conditions

These services do not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Obesity screening and therapy to keep weight down

If you have a body mass index of 30 or more, GuildNet Gold
Plus FIDA Plan will pay for counseling to help you lose
weight. You must get the counseling in a primary care setting.
That way, it can be managed with your full prevention plan.
Talk to your Care Manager or Primary Care Provider (PCP) to
find out more.

This service may be
obtained from an outof-network Medicare
provider.

This service does not require prior authorization.
Other supportive services the IDT determines are
necessary

GuildNet Gold Plus FIDA Plan will pay for additional
supportive services or items determined by the Participant’s
IDT to be necessary for the Participant. This is meant to cover
items or services that are not traditionally included in the
Medicare or Medicaid programs but that are necessary and
appropriate for the Participant. One example is GuildNet Gold
Plus FIDA Plan paying for a blender to puree foods for a
Participant who cannot chew.

Outpatient blood services

Blood, including storage and administration, beginning with
the first pint you need.

This service may be
obtained from an outof-network Medicare
provider.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Outpatient diagnostic tests and therapeutic services and
supplies

GuildNet Gold Plus FIDA Plan will pay for the following
services, and maybe other services not listed here:

These services may be
obtained from an outof-network Medicare
provider.

 CT scans, MRIs, EKGs and X-rays when a provider

orders them as part of treatment for a medical problem

 Radiation (radium and isotope) therapy, including
technician materials and supplies

 Surgical supplies, such as dressings
 Splints, casts, and other devices used for fractures and
dislocations

 Medically necessary clinical lab services and tests

ordered by a provider to help diagnose or rule out a
suspected illness or condition

 Blood, including storage and administration
 Other outpatient diagnostic tests

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Outpatient hospital services

GuildNet Gold Plus FIDA Plan pays for medically necessary
services you get in the outpatient department of a hospital for
diagnosis or treatment of an illness or injury.

This service may be
obtained from an outof-network Medicare
provider.

GuildNet Gold Plus FIDA Plan will pay for the following
services, and maybe other services not listed here:

 Services in an emergency department or outpatient clinic,
such as observation services or outpatient surgery

 Labs and diagnostic tests billed by the hospital
 Mental health care, including care in a partial-

hospitalization program, if a provider certifies that
inpatient treatment would be needed without it

 X-rays and other radiology services billed by the hospital
 Medical supplies, such as splints and casts
 Some screenings and preventive services
 Some drugs that you can’t give yourself
Note: Unless the provider has written an order to admit you
as an inpatient to the hospital, you are an outpatient. Even if
you stay in the hospital overnight, you might still be
considered an “outpatient.” If you are not sure if you are an
outpatient, you should ask the hospital staff.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Outpatient mental health care

GuildNet Gold Plus FIDA Plan will pay for mental health
services provided by:

This service may be
obtained from an outof-network Medicare
provider.

 a state-licensed psychiatrist or doctor,
 a clinical psychologist,
 a clinical social worker,
 a clinical nurse specialist,
 a nurse practitioner,
 a physician assistant, or
 any other Medicare-qualified mental health care

professional as allowed under applicable state laws.

GuildNet Gold Plus FIDA Plan will pay for the following
services:

 Individual therapy sessions
 Group therapy sessions
 Clinic services
 Day treatment
 Psychosocial rehab services
Participants may directly access one assessment from a
network provider in a twelve (12) month period without getting
prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Outpatient rehabilitation services

GuildNet Gold Plus FIDA Plan will pay for Physical Therapy
(PT), Occupational Therapy (OT), and Speech Therapy (ST).

This service may be
obtained from an outof-network Medicare
provider.

You can get outpatient rehabilitation services from hospital
outpatient departments, independent therapist offices,
comprehensive outpatient rehabilitation facilities (CORFs),
and other facilities.
OT, PT, and ST services are limited to twenty (20) visits per
therapy per calendar year except for individuals with
intellectual disabilities, individuals with traumatic brain injury,
and individuals under age 21.
Outpatient surgery

GuildNet Gold Plus FIDA Plan will pay for outpatient surgery
and services at hospital outpatient facilities and ambulatory
surgical centers.

This service may be
obtained from an outof-network Medicare
provider.

Over-the-Counter Drugs and Health-Related Items

GuildNet Gold Plus FIDA Plan will pay for over-the-counter
health related items. You can purchase approved items for
any OTC network pharmacy and use the GuildNet OTC card
to pay for these items up to $50 per month. The GuildNet
OTC card will automatically refill any amount used in the prior
month so that $50 is available each month. Unused amounts
do not carry over from one month to the next.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Palliative care

GuildNet Gold Plus FIDA Plan will pay for interdisciplinary
end-of-life care and consultation with the Participant and
his/her family members. These services help to prevent or
relieve pain and suffering and to enhance the Participant's
quality of life.

This service must be
obtained from an innetwork provider.

Services include:

 Family palliative care education
 Pain and symptom management
 Bereavement services
 Massage therapy
 Expressive therapies
These serviced do not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Partial hospitalization

Partial hospitalization is a structured program of active
psychiatric treatment provided in a hospital outpatient setting
or by a community mental health center. Partial hospitalization
is more intense than the care you get in a provider or
therapist’s office and is an alternative to inpatient
hospitalization.

This service may be
obtained from an outof-network Medicare
provider.

GuildNet Gold Plus FIDA Plan will pay for partial
hospitalization to serve as an alternative to inpatient
hospitalization, or to reduce the length of a hospital stay within
a medically supervised program. Services include:

 Assessment and treatment planning
 Health screening and referral
 Symptom management
 Medication therapy
 Medication education
 Verbal therapy
 Case management
 Psychiatric rehabilitative readiness determination
 Referral and crisis intervention
Note: Because there are no community mental health centers
in our network, we cover partial hospitalization only in a
hospital outpatient setting.

Peer-delivered services

GuildNet Gold Plus FIDA Plan will pay for peer support
services provided by a peer support provider. This is a person
who assists individuals with their recovery from mental illness
and substance abuse disorders.

This service must be
obtained from an innetwork provider.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

What you must pay

Peer mentoring

GuildNet Gold Plus FIDA Plan will pay for peer mentoring for
Participants who have recently transitioned into the
community from a nursing facility or during times of crisis.
This is an individually designed service intended to improve
the Participant’s self-sufficiency, self-reliance, and ability to
access needed services, goods, and opportunities in the
community. This will be accomplished through education,
teaching, instruction, information sharing, and self-advocacy
training.

This service must be
obtained from an innetwork provider.

Personal care services (PCS)

GuildNet Gold Plus FIDA Plan will pay for PCS to assist
Participants with activities such as personal hygiene,
dressing, feeding, and nutritional and environmental support
function tasks (meal preparation and housekeeping). PCS
must be medically necessary, ordered by the Participant’s
physician, and provided by a qualified person according to a
plan of care.
Personal emergency response services (PERS)
GuildNet Gold Plus FIDA Plan will pay for PERS, which is an
electronic device that enables certain high-risk Participants to
reach out for help during an emergency.

Chapter 4: Covered Items and Services

This service must be
obtained from an innetwork provider.

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

Personalized recovery oriented services (PROS)

GuildNet Gold Plus FIDA Plan will pay for PROS to assist
individuals in recovery from the disabling effects of mental
illness. This includes the coordinated delivery of a customized
array of rehabilitation, treatment, and support services in
traditional settings and in off-site locations.

This service must be
obtained from an innetwork provider.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Pharmacy benefits (outpatient)

GuildNet Gold Plus FIDA Plan will pay for certain generic,
brand, and non-prescription drugs to treat a Participant’s
illness or condition. Chapters 5 and 6 provide additional
information about your pharmacy benefits.

This service must be
obtained from an innetwork pharmacy.

Physician/provider services, including Primary Care
Provider (PCP) office visits

GuildNet Gold Plus FIDA Plan will pay for the following
services:

This service may be
obtained from an outof-network Medicare
provider.

 Medically necessary health care or surgery services
given in places such as:

» physician’s office
» certified ambulatory surgical center
» hospital outpatient department

 Consultation, diagnosis, and treatment by a specialist
 Basic hearing and balance exams given by your PCP or a
specialist, if your doctor orders it to see whether you need
treatment

 Second opinion before a medical procedure
Participants may see PCPs and specialists without first
getting prior authorization.
Podiatry services
GuildNet Gold Plus FIDA Plan will pay for the following
services:

 Care for medical conditions affecting lower limbs,

including diagnosis and medical or surgical treatment of
injuries and diseases of the foot (such as hammer toe or
heel spurs)

$0
This service may be
obtained from an outof-network Medicare
provider.

 Routine foot care for Participants with conditions affecting
the legs, such as diabetes

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Positive behavioral interventions and support (PBIS)

GuildNet Gold Plus FIDA Plan will pay for PBIS for
Participants who have significant behavioral difficulties that
jeopardize their ability to remain in the community. The
primary focus of this service is to decrease the intensity
and/or frequency of the targeted behaviors and to teach safer
or more socially appropriate behaviors.

This service must be
obtained from an innetwork provider.

Examples of PBIS include:

 Comprehensive assessment of the Participant
 Development and implementation of a holistic structured
behavioral treatment plan

 Training of family, natural supports, and other providers
 Regular reassessment of the effectiveness of the
Participant’s behavioral treatment plan

Preventive services

GuildNet Gold Plus FIDA Plan will pay for all preventive tests
and screenings covered by Medicare and Medicaid to help
prevent, find, or manage a medical problem. This includes,
but is not limited to, all the preventive services listed in this
chart. You will see this apple
next to preventive services in
this chart.

These services may be
obtained from an outof-network Medicare
provider.

Private duty nursing services

GuildNet Gold Plus FIDA Plan will pay for private duty nursing
services covered for continuous or intermittent skilled nursing
services. These services are provided in the Participant’s
home and are beyond what a certified home health agency
can provide.

This service must be
obtained from an innetwork provider.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Prostate cancer screening exams
For men age 50 and older, GuildNet Gold Plus FIDA Plan will
pay for the following services once every 12 months:

 A digital rectal exam
 A prostate specific antigen (PSA) test

Chapter 4: Covered Items and Services

What you must pay
$0
This service may be
obtained from an outof-network Medicare
provider.

This service does not require prior authorization.
Prosthetic devices and related supplies
Prosthetic devices replace all or part of a body part or
function. GuildNet Gold Plus FIDA Plan will pay for the
following prosthetic devices, and maybe other devices not
listed here:

 Colostomy bags and supplies related to colostomy care

$0
This service may be
obtained from an outof-network Medicare
provider.

 Pacemakers
 Braces
 Prosthetic shoes
 Artificial arms and legs
 Breast prostheses (including a surgical brassiere after a
mastectomy)

 Orthotic appliances and devices
 Support stockings
 Orthopedic footwear
GuildNet Gold Plus FIDA Plan will also pay for some supplies
related to prosthetic devices. They will also pay to repair or
replace prosthetic devices.

Pulmonary rehabilitation services

GuildNet Gold Plus FIDA Plan will pay for pulmonary
rehabilitation programs for Participants who have moderate to
very severe chronic obstructive pulmonary disease (COPD).
The Participant must have an order approved by the IDT or
GuildNet Gold Plus FIDA Plan for pulmonary rehabilitation
from the provider treating the COPD.

This service must be
obtained from an innetwork provider.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

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

Chapter 4: Covered Items and Services

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

Respiratory care services

GuildNet Gold Plus FIDA Plan will pay for respiratory therapy,
which is an individually designed service provided in the
home. Respiratory therapy includes preventive, maintenance,
and rehabilitative airway-related techniques and procedures.

This service must be
obtained from an innetwork provider.

Respite care services

GuildNet Gold Plus FIDA Plan will pay for respite care
services to provide scheduled relief to non-paid supports who
provide primary care and support to a Participant. The service
may be provided in a 24-hour block of time as required.

This service must be
obtained from an innetwork provider.

The primary location for this service is in the Participant’s
home, but respite services may also be provided in another
community dwelling or facility acceptable to the Participant.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Sexually transmitted infections (STIs) screening and
counseling

GuildNet Gold Plus FIDA Plan will pay for screenings for
chlamydia, gonorrhea, syphilis, and hepatitis B. These
screenings are covered for pregnant women and for some
people who are at increased risk for an STI. A PCP or other
primary care practitioner must order the tests. We cover these
tests once every 12 months or at certain times during
pregnancy.

This service may
be obtained from
an out-of-network
Medicare provider.

GuildNet Gold Plus FIDA Plan will also pay for up to two faceto-face, high-intensity behavioral counseling sessions each
year for sexually active adults at increased risk for STIs. Each
session can be 20 to 30 minutes long. GuildNet Gold Plus
FIDA Plan will pay for these counseling sessions as a
preventive service only if they are given by a PCP. The
sessions must be in a primary care setting, such as a doctor’s
office.
This service does not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Skilled nursing facility care
GuildNet Gold Plus FIDA Plan covers an unlimited number of
days of Skilled Nursing Facility Care and there is no prior
hospital stay required.
GuildNet Gold Plus FIDA Plan will pay for the following
services, and maybe other services not listed here:

Chapter 4: Covered Items and Services

What you must pay
$0
This service may
be obtained from
an out-of-network
Medicare provider.

 A semi-private room, or a private room if it is medically
needed

 Meals, including special diets
 Nursing services
 Physical therapy, occupational therapy, and speech
therapy

 Drugs you get as part of your plan of care, including

substances that are naturally in the body, such as bloodclotting factors

 Blood, including storage and administration
 Medical and surgical supplies given by nursing facilities
 Lab tests given by nursing facilities
 X-rays and other radiology services given by nursing
facilities

 Appliances, such as wheelchairs, usually given by
nursing facilities

 Physician/provider services
You will usually get your care from network facilities.
However, you may be able to get your care from a facility not
in our network. You can get care from the following places if
they accept GuildNet Gold Plus FIDA Plan amounts for
payment:

 A nursing facility or continuing care retirement community
where you lived before you went to the hospital (as long
as it provides nursing facility care)

 A nursing facility where your spouse lives at the time you
leave the hospital

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Smoking and tobacco cessation (counseling to stop
smoking or tobacco use)

If you use tobacco but do not have signs or symptoms of
tobacco-related disease, you use tobacco and have been
diagnosed with a tobacco-related disease, or you are taking
medicine that may be affected by tobacco:

This service may
be obtained from
an out-of-network
Medicare provider.

 GuildNet Gold Plus FIDA Plan will pay for two counseling
quit attempts in a 12 month period as a preventive
service. This service is free for you. Each counseling
attempt includes up to four face-to-face visits.

GuildNet Gold Plus FIDA Plan will pay for smoking cessation
counseling for pregnant women and women up to six months
after birth. This smoking cessation counseling is in addition to
benefits for prescriptions and over-the-counter smoking
cessation products.
This service does not require prior authorization.
Social and environmental supports
GuildNet Gold Plus FIDA Plan will pay for services and items
to support a Participant’s medical needs. Services may
include:

 Home maintenance tasks

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

 Homemaker/chore services
 Housing improvement
 Respite care
Social day care
GuildNet Gold Plus FIDA Plan will pay for social day care for
functionally impaired Participants for less than 24 hours per
day.
The services included in this benefit provide Participants with
socialization, supervision and monitoring, personal care, and
nutrition in a protective setting.

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

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Social day care transportation

GuildNet Gold Plus FIDA Plan will pay for transportation
between a Participant’s home and the social day care
facilities.

This service must be
obtained from an innetwork provider.

Structured day program

GuildNet Gold Plus FIDA Plan will pay for structured day
program services provided in an outpatient congregate setting
or in the community. Services are designed to improve or
maintain the Participant’s skills and ability to live as
independently as possible in the community.

This service must be
obtained from an innetwork provider.

Services may include:

 Assessment
 Training and supervision to an individual with self-care
 Task completion
 Communication skills
 Interpersonal skills
 Problem-solving skills
 Socialization
 Sensory/motor skills
 Mobility
 Community transportation skills
 Reduction/elimination of maladaptive behaviors
 Money management skills
 Ability to maintain a household

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Substance abuse services: Opioid treatment services

GuildNet Gold Plus FIDA Plan will pay for opioid treatment
services to help Participants manage addiction to opiates
such as heroin. Opioid treatment programs administer
medication, generally methadone by prescription, along with a
variety of other clinical services.

This service may be
obtained from an outof-network Medicare
provider.

These programs help Participants control the physical
problems associated with opiate dependence and provide the
opportunity for Participants to make major lifestyle changes
over time. This service does not include Methadone
Maintenance, which is available through Medicaid but not
through GuildNet Gold Plus FIDA Plan.
Substance abuse services: Outpatient medically
supervised withdrawal

GuildNet Gold Plus FIDA Plan will pay for medical supervision
of Participants that are:

This service may be
obtained from an outof-network Medicare
provider.

 Undergoing mild to moderate withdrawal
 At risk of mild to moderate withdrawal
 Experiencing non-acute physical or psychiatric

complications associated with their chemical dependence

Services must be provided under the supervision and
direction of a licensed physician.
Substance abuse services: Outpatient substance abuse
services

GuildNet Gold Plus FIDA Plan will pay for outpatient
substance abuse services including individual and group
visits.

This service may be
obtained from an outof-network Medicare
provider.

Participants may directly access one assessment from a
network provider in a twelve (12) month period without getting
prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Substance abuse services: Substance abuse program

GuildNet Gold Plus FIDA Plan will pay for substance abuse
program services to provide individually designed
interventions to reduce/eliminate the use of alcohol and/or
other substances by the Participant, which, if not effectively
dealt with, will interfere with the individual’s ability to remain in
the community.

This service may be
obtained from an outof-network Medicare
provider.

Telehealth services

GuildNet Gold Plus FIDA Plan will pay for telehealth services
for Participants with conditions that require frequent
monitoring and/or the need for frequent physician, skilled
nursing, or acute care services to reduce the need for in-office
visits.

This service must be
obtained from an innetwork provider.

Participants eligible for this service include those with the
following conditions: congestive heart failure, diabetes,
chronic pulmonary obstructive disease, wound care,
polypharmacy, mental or behavioral problems limiting selfmanagement, and technology-dependent care such as
continuous oxygen, ventilator care, total parenteral nutrition or
enteral feeding.
These services do not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for
Transportation services (emergency and non-emergency)
GuildNet Gold Plus FIDA Plan will pay for emergency and
non-emergency transportation. Transportation is provided for
medical appointments and services. Transportation is also
available for non-medical events or services, such as religious
services, community activities, or supermarkets, through
transportation modes including but not limited to:

 Taxi
 Bus
 Subway
 Van
 Medical transport

Chapter 4: Covered Items and Services

What you must pay
$0
Non-emergency
transportation
services must be
obtained from an
in-network
provider.
For emergency
transportation services,
please see Ambulance
section.

 Ambulance
 Fixed wing or airplane transport
 Invalid coach
 Livery
 Other means
Urgently needed care

Urgently needed care is care given to treat:

 a non-emergency, or
 a sudden medical illness, or
 an injury, or

This service may be
obtained from an outof-network Medicare
provider.

 a condition that needs care right away.
If you require urgently needed care, you should first try to get
it from a network provider. However, you can use out-ofnetwork providers when you cannot get to a network provider.
Urgent care does not include primary care services or
services provided to treat an emergency medical condition.
This coverage is within the U.S. and its territories only.
These services do not require prior authorization.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Vision care: Eye and vision exams and eye care

GuildNet Gold Plus FIDA Plan will pay for the diagnosis and
treatment of visual defects, eye disease, and eye injury. For
example, this includes annual eye exams for diabetic
retinopathy for people with diabetes and treatment for agerelated macular degeneration. Examinations for refraction are
limited to once a year unless medically necessary.

This service must be
obtained from an innetwork provider.

For people at high risk of glaucoma, GuildNet Gold Plus FIDA
Plan will pay for one glaucoma screening each year. People
at high risk of glaucoma include:

 people with a family history of glaucoma,
 people with diabetes,
 African-Americans who are age 50 and older, and
 Hispanic Americans who are 65 or older.
Article 28 Clinic services may be directly accessed without
prior authorization from GuildNet Gold Plus FIDA Plan or your
IDT.

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Services that GuildNet Gold Plus FIDA Plan pays for

Chapter 4: Covered Items and Services

What you must pay

Vision Care: Eyeglasses (lenses and frames) and contact
lenses

GuildNet Gold Plus FIDA Plan will pay for eyeglasses,
medically necessary contact lenses and poly-carbonate
lenses, artificial eyes (stock or custom-made), low vision aids
and low vision services, when authorized by an optometrist or
ophthalmologist. Coverage also includes the repair or
replacement of parts.

This service must be
obtained from an innetwork provider.

Eyeglasses and contact lenses are provided once every two
years unless it is medically necessary to have them more
frequently or unless the glasses or contact lenses are lost,
damaged or destroyed.
GuildNet Gold Plus FIDA Plan will pay for one pair of glasses
or contact lenses after each cataract surgery when the doctor
inserts an intraocular lens. (If you have two separate cataract
surgeries, you must get one pair of glasses after each
surgery. You cannot get two pairs of glasses after the second
surgery, even if you did not get a pair of glasses after the first
surgery.) GuildNet Gold Plus FIDA Plan will also pay for
corrective lenses, frames, and replacements if you need them
after a cataract removal without a lens implant.
Article 28 Clinic services may be directly accessed without
prior authorization from GuildNet Gold Plus FIDA Plan or your
IDT.

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Services that GuildNet Gold Plus FIDA Plan pays for
“Welcome to Medicare” Preventive Visit
GuildNet Gold Plus FIDA Plan covers the one-time “Welcome
to Medicare” preventive visit. The visit includes:

 a review of your health,
 education and counseling about the preventive services
you need (including screenings and shots), and

Chapter 4: Covered Items and Services

What you must pay
$0
This service may be
obtained from an outof-network Medicare
provider.

 referrals for other care if you need it.
Important: We cover the “Welcome to Medicare” preventive
visit only during the first 12 months that you have Medicare
Part B. When you make your appointment, tell your doctor’s
office you want to schedule your “Welcome to Medicare”
preventive visit.
Wellness counseling
GuildNet Gold Plus FIDA Plan will pay for wellness counseling
to help medically stable Participants maintain their optimal
health status.
A Registered Professional Nurse (RN) works with the
Participant to reinforce or teach healthy habits such as the
need for daily exercise, weight control, or avoidance of
smoking. The RN is also able to offer support for control of
diseases or disorders such as high blood pressure, diabetes,
morbid obesity, asthma or high cholesterol. The RN can help
the Participant to identify signs and symptoms that may
require intervention to prevent further complications from the
disease or disorder.

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

These services do not require prior authorization.

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Chapter 4: Covered Items and Services

E. Benefits covered outside of GuildNet Gold Plus FIDA Plan
The following four services are not covered by GuildNet Gold Plus FIDA Plan but are available
through Medicare or Medicaid. Your Interdisciplinary Team (IDT) will help you access these
services.
Day treatment
Day treatment is a combination of diagnostic, treatment, and rehabilitative procedures that
provide the services of the clinic treatment program, as well as social training, task and skill
training, and socialization activities.
Freestanding birth center services
Services at freestanding birth centers are covered by Medicaid.
Out of network family planning services
Out of network family planning services are paid directly by Medicaid. Services include
diagnosis and all medically necessary treatment, sterilization, screening and treatment for
sexually transmissible diseases, and screening for disease and pregnancy. Also included is
HIV counseling and testing when provided as part of a family planning visit. Additionally,
reproductive health care includes coverage of all medically necessary abortions. Fertility
services are not covered.
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. This does not
include opioid treatment services, which are covered by GuildNet Gold Plus FIDA Plan (see
the Covered Items and Services Chart above). Facilities that provide methadone
maintenance treatment do so as their principal mission and are certified by the Office of
Alcohol and Substance Abuse Services (OASAS) under Title 14 NYCRR, Part 828.
Directly observed therapy for tuberculosis (TB)
Tuberculosis directly observed therapy (TB/DOT) is the direct observation of oral ingestion of
TB medications to ensure patient compliance with the physician's prescribed medication
regimen. While the clinical management of TB is covered under GuildNet Gold Plus FIDA
Plan, TB/DOT is covered by Medicaid when provided by an approved TB/DOT provider.
Hospice services
Hospice services provided to Participants by Medicare approved hospice providers are paid
directly by Medicare. Hospice is a coordinated program of home and inpatient care that provides
non-curative medical and support services. A Participant has the right to elect hospice if his/her
provider and hospice medical director determine that the Participant has a terminal prognosis.

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Chapter 4: Covered Items and Services

This means that the Participant has a terminal illness and is expected to have six months or less
to live. Hospice programs provide Participants and families with palliative and supportive care to
meet the special needs arising out of physical, psychological, spiritual, social, and economic
stresses which are experienced during the final stages of illness and during dying and
bereavement.
Hospices are organizations which must be certified under Article 40 of the New York State Public
Health Law and approved by Medicare. All services must be provided by qualified employees and
volunteers of the hospice or by qualified staff through contractual arrangements to the extent
permitted by Federal and State requirements. All services must be provided according to a written
plan of care, which must be incorporated into the Person-Centered Service Plan (PCSP) and
reflect the changing needs of the Participant/family.
If a Participant in the FIDA Plan gets Hospice services, he or she may remain enrolled and
continue to access the FIDA Plan’s benefit package. See the Covered Items and Services Chart
in Section D of this chapter for more information about what GuildNet Gold Plus FIDA Plan pays
for while you are getting hospice care services. Hospice services and services covered by
Medicare Parts A and B that relate to the Participant’s terminal prognosis are paid for by Original
Medicare.
For hospice services and services covered by Medicare Part A or B that relate to a
Participant’s terminal prognosis:

 The hospice provider will bill Medicare for a Participant’s services. Medicare will pay for
hospice services related to your terminal prognosis. Participants pay nothing for these
services.
For services covered by Medicare Part A or B that are not related to a Participant’s
terminal prognosis (except for emergency care or urgently needed care):

 The provider will bill Medicare for a Participant’s services. Medicare will pay for the services
covered by Medicare Part A or B. Participants pay nothing for these services.
For drugs that may be covered by GuildNet Gold Plus FIDA Plan’s Medicare Part D benefit:

 Drugs are never covered by both hospice and our plan at the same time. For more
information, please see Chapter 5.

Note: If you need non-hospice care, you should call your Care Manager at 1-800-815-0000
(TTY 711) to arrange the services. Non-hospice care is care that is not related to your
terminal prognosis.

F. Benefits not covered by GuildNet Gold Plus FIDA Plan, Medicare, or
Medicaid

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Chapter 4: Covered Items and Services

This section tells you what kinds of benefits are excluded by GuildNet Gold Plus FIDA Plan.
Excluded means that GuildNet Gold Plus FIDA Plan does not pay for these benefits.
Medicare and Medicaid will not pay for them either.
The list below describes some services and items that are not covered by GuildNet Gold Plus
FIDA Plan under any conditions and some that are excluded by GuildNet Gold Plus FIDA
Plan only in some cases.
GuildNet Gold Plus FIDA Plan will not pay for the excluded medical benefits listed in this
section (or anywhere else in this Participant Handbook) except under the specific conditions
listed. If you think that we should pay for a service that is not covered, you can file an appeal.
For information about filing an appeal, see Chapter 9.
In addition to any exclusions or limitations described in the Covered Items and Services
Chart, the following items and services are not covered by GuildNet Gold Plus FIDA
Plan:

§ Services considered not medically
necessary according to the standards of
Medicare and Medicaid, unless these
services are listed by our plan as
covered services.

§ Experimental medical and surgical
treatments, items, and drugs, unless
covered by Medicare or under a
Medicare-approved clinical research
study or by GuildNet Gold Plus FIDA
Plan. See page 44 for more information
on clinical research studies.
Experimental treatment and items are
those that are not generally accepted by
the medical community.

§ Surgical treatment for morbid obesity,
except when it is medically needed and
Medicare pays for it.

§ A private room in a hospital, except when
it is medically needed.

 Fees charged by your immediate
relatives or members of your household.

 Elective or voluntary enhancement
procedures or services (including weight
loss, hair growth, sexual performance,
athletic performance, cosmetic
purposes, anti-aging and mental
performance), except when medically
needed.

 Cosmetic surgery or other cosmetic
work, unless it is needed because of an
accidental injury or to improve a part of
the body that is not shaped right.
However, GuildNet Gold Plus FIDA Plan
will pay for reconstruction of a breast
after a mastectomy and for treating the
other breast to match it.

 Chiropractic care, other than manual
manipulation of the spine consistent with
Medicare coverage guidelines.

§ Personal items in your room at a hospital

 Supportive devices for the feet, except

or a nursing facility, such as a telephone
or a television.

for orthopedic or therapeutic shoes for
people with diabetic foot disease.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

 Radial keratotomy, LASIK surgery,
vision therapy, and other low-vision aids.

 Reversal of sterilization procedures and
non-prescription contraceptive supplies.

 Acupuncture.
 Naturopath services (the use of natural
or alternative treatments).

Chapter 4: Covered Items and Services

when a veteran gets emergency
services at a VA hospital and the VA
cost sharing is more than the cost
sharing under GuildNet Gold Plus
FIDA Plan, we will reimburse the
veteran for the difference. Participants
are still responsible for their cost sharing
amounts.

 Services provided to veterans in
Veterans Affairs (VA) facilities. However,

CHAPTER 5
Getting your outpatient prescription drugs and
other covered medications through the plan

112

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Chapter 5: Getting your outpatient prescription drugs and other
covered medications through the plan

Table of Contents
Introduction ........................................................................................................................................115
Rules for the plan’s outpatient drug coverage ................................................................................ 115
A.Getting your prescriptions filled ......................................................................................................116
Fill your prescription at a network pharmacy.................................................................................. 116
Show your Participant ID Card when you fill a prescription ............................................................ 116
What if you want to change to a different network pharmacy? ....................................................... 116
What if the pharmacy you use leaves the network? ....................................................................... 116
What if you need a specialized pharmacy?.................................................................................... 117
Can you use mail-order services to get your drugs? ...................................................................... 117
Can you get a long-term supply of drugs? ..................................................................................... 118
Can you use a pharmacy that is not in the plan’s network? ........................................................... 119
Will the plan pay you back if you pay for a prescription at a pharmacy not in the plan’s
network?........................................................................................................................................ 119
B.The plan’s Drug List .......................................................................................................................120
What is on the Drug List? .............................................................................................................. 120
How can you find out if a drug is on the Drug List? ........................................................................ 120
What is not on the Drug List? ........................................................................................................ 120
What are tiers? .............................................................................................................................. 121
C.Limits on coverage for some drugs .................................................................................................121
Why do some drugs have limits? ................................................................................................... 122
What kinds of rules are there? ....................................................................................................... 122

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

Do any of these rules apply to your drugs?.................................................................................. 123
D.Why your drug might not be covered ............................................................................................123
You can get a temporary supply .................................................................................................. 123
E.Changes in coverage for your drugs .............................................................................................124
F. Drug coverage in special cases ...................................................................................................125
If you are in a long-term care facility ............................................................................................ 125
If you are in a long-term care facility and become a new Participant of the plan .......................... 126
If you are in a Medicare-certified hospice program ...................................................................... 126
G.Programs on drug safety and managing drugs .............................................................................126
Programs to help Participants use drugs safely ........................................................................... 126
Programs to help Participants manage their drugs ...................................................................... 127

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

Introduction
This chapter explains rules for getting your outpatient prescription drugs and other covered
medications. These are drugs that your provider orders for you that you get from a pharmacy
or by mail order. They include drugs covered under Medicare Part D and Medicaid.
GuildNet Gold Plus FIDA Plan also covers the following drugs, although they will not be
discussed in this chapter:

 Drugs covered by Medicare Part A. These include some drugs given to you while you
are in a hospital or nursing facility.

 Drugs covered by Medicare Part B. These include some chemotherapy drugs, some
drug injections given to you during an office visit with a doctor or other provider, and
drugs you are given at a dialysis clinic. To learn more about what Medicare Part B
drugs are covered, see the Covered Items and Services Chart in Chapter 4.

Rules for the plan’s outpatient drug coverage
The plan will usually cover your drugs as long as you follow the rules in this section.
1. You must have a doctor or other provider write your prescription. A written prescription is
required for both prescription and over-the-counter (OTC) drugs.
2. You generally must use a network pharmacy to fill your prescription unless GuildNet Gold
Plus FIDA Plan or your Interdisciplinary Team (IDT) has authorized you to use an out-ofnetwork pharmacy.
3. Your prescribed drug must be on the plan’s List of Covered Drugs. We call it the “Drug
List” for short.

§ If it is not on the Drug List, we may be able to cover it by giving you an exception. See
page 187 Chapter 9 to learn about asking for an exception.
4. Your drug must be used for a medically accepted indication. This means that the use of
the drug is either approved by the Food and Drug Administration or supported by certain
reference books.

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

A. Getting your prescriptions filled
Fill your prescription at a network pharmacy
In most cases, the plan will pay for prescriptions only if they are filled at the plan’s network
pharmacies. A network pharmacy is a drug store that has agreed to fill prescriptions for our
plan Participants. You may go to any of our network pharmacies.

 To find a network pharmacy, you can look in the Provider and Pharmacy Directory, visit
our website, or contact Participant Services or your Care Manager.

Show your Participant ID Card when you fill a prescription
To fill your prescription, show your Participant ID Card at your network pharmacy. The
network pharmacy will bill the plan for your covered prescription or over-the-counter (OTC)
drug.
If you do not have your Participant ID Card with you when you fill your prescription, ask the
pharmacy to call the plan to get the necessary information.
If the pharmacy is not able to get the necessary information, you may have to pay the full
cost of the prescription when you pick it up. You can then ask GuildNet Gold Plus FIDA Plan
to pay you back. If you cannot pay for the drug, contact Participant Services right away. We
will do what we can to help.

 To learn how to ask us to pay you back, see Chapter 7.
 If you need help getting a prescription filled, you can contact Participant Services or your
Care Manager.

What if you want to change to a different network pharmacy?
If you change pharmacies and need a refill of a prescription, you can ask your pharmacy to
transfer the prescription to the new pharmacy.

 If you need help changing your network pharmacy, you can contact Participant Services or
your Care Manager.

What if the pharmacy you use leaves the network?
If the pharmacy you use leaves the plan’s network, you will have to find a new network
pharmacy.

 To find a new network pharmacy, you can look in the Provider and Pharmacy Directory,
visit our website, or contact Participant Services or your Care Manager.

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

What if you need a specialized pharmacy?
Sometimes prescriptions must be filled at a specialized pharmacy. Specialized pharmacies
include:

 Pharmacies that supply drugs for home infusion therapy.
 Pharmacies that supply drugs for residents of a long-term care facility, such as a
nursing facility. Usually, long-term care facilities have their own pharmacies. If you are
a resident of a long-term care facility, we must make sure you can get the drugs you
need at the facility’s pharmacy. If your long-term care facility’s pharmacy is not in our
network, or you have any difficulty accessing your drug benefits in a long-term care
facility, please contact your Care Manager or Participant Services.

 Pharmacies that serve the Indian Health Service/Tribal/Urban Indian Health Program.
Except in emergencies, only Native Americans or Alaska Natives may use these
pharmacies.

 Pharmacies that supply drugs requiring special handling and instructions on their use.

 To find a specialized pharmacy, you can look in the Provider and Pharmacy Directory, visit
our website, or contact Participant Services or your Care Manager.

Can you use mail-order services to get your drugs?
For certain kinds of drugs, you can use the plan’s network mail-order services. Generally, the
drugs available through mail-order are drugs that you take on a regular basis for a chronic or
long-term medical condition. The drugs available through our plan’s mail-order service are
marked as mail-order drugs in our Drug List.
Our plan’s mail-order service allows you to order up to a 90-day supply.

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

How do I fill my prescriptions by mail?
To get order forms and information about filling your prescriptions by mail, call the Plans
Prescription Benefit Managers (PBM) Express Scripts at 1-877-866-5828, Monday through
Sunday, 8am to 8pm (TTY users, please call 1-800-899-2114) or you can ask your Care
Manager for assistance.
Usually, a mail-order prescription will get to you within 14 days. If your medication does not
arrive in time, you can call your physician and request a prescription for your local pharmacy
or call Participant Services for assistance in getting the prescription filled locally. We will
arrange for a temporary supply from your local pharmacy.
How will the mail-order service process my prescription?
The mail-order service has different procedures for new prescriptions it gets from you, new
prescriptions it gets directly from your provider’s office, and refills on your mail-order
prescriptions:
1. New prescriptions the pharmacy gets from you
The pharmacy will automatically fill and deliver new prescriptions it gets from you.
2. New prescriptions the pharmacy gets directly from your provider’s office
After the pharmacy gets a prescription from a health care provider, it will contact you to
see if you want the medication filled immediately or at a later time. This will give you an
opportunity to make sure the pharmacy is delivering the correct drug (including strength,
amount, and form) and, if needed, allow you to stop or delay the order before it is shipped.
It is important that you respond each time you are contacted by the pharmacy, to let them
know what to do with the new prescription and to prevent any delays in shipping.
3. Refills on mail-order prescriptions
For refills, please contact your pharmacy 14 days before you think the drugs you have on
hand will run out to make sure your next order is shipped to you in time.
So the pharmacy can reach you to confirm your order before shipping, please make sure to
let the pharmacy know the best ways to contact you. You can call the mail-order pharmacy at
1-877-866-5828 to let them know how to reach you.

Can you get a long-term supply of drugs?
You can get a long-term supply of maintenance drugs on our plan’s Drug List. Maintenance
drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.
Some network pharmacies allow you to get a long-term supply of maintenance drugs. The
Provider and Pharmacy Directory tells you which pharmacies can give you a long-term

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

supply of maintenance drugs. You can also call Participant Services or your Care Manager
for more information.
For certain kinds of drugs, you can use the plan’s network mail-order services to get a longterm supply of maintenance drugs. See the section above to learn about mail-order services.

Can you use a pharmacy that is not in the plan’s network?
Generally, we pay for drugs filled at an out-of-network pharmacy only when you are not able
to use a network pharmacy. We have network pharmacies outside of our service area where
you can get your prescriptions filled as a Participant of our plan.
We will pay for prescriptions filled at an out-of-network pharmacy in the following cases:

 If you are unable to obtain a covered drug in a timely manner within our service area
because there are no network pharmacies within a reasonable driving distance that
provides 24 hour services.

 If there is a declared disaster, and you are unable to fill your prescription at a network
pharmacy.

 If you are trying to fill a prescription drug that is not regularly stocked at an accessible
network, retail or mail-order pharmacy (including high-cost and unique drugs).

 If you are getting a vaccine that is medically necessary but not covered by Medicare
Part B or some covered drugs that are administered in your doctor’s office.

 In these cases, please check first with Participant Services to see if there is a network
pharmacy nearby.

Will the plan pay you back if you pay for a prescription at a pharmacy not in the
plan’s network?
Sometimes a pharmacy that is not in the plan’s network will require you to pay the full cost for
the drug and seek payment from us. You can ask GuildNet Gold Plus FIDA Plan to pay you
back.

 To learn more about this, see Chapter 7.

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

B. The plan’s Drug List
The plan has a List of Covered Drugs. We call it the “Drug List” for short.
The drugs on the Drug List are selected by the plan with the help of a team of doctors and
pharmacists. The Drug List also tells you if there are any rules you need to follow to get your
drugs.
We will generally cover a drug on the plan’s Drug List as long as you follow the rules
explained in this chapter.

What is on the Drug List?
The Drug List includes the drugs covered under Medicare Part D and some prescription and
over-the-counter (OTC) drugs and items covered under your Medicaid benefits.
The Drug List includes both brand-name (e.g., SYNTHROID); and generic drugs (e.g.,
atenolol). Generic drugs have the same active ingredients as brand-name drugs. Generally,
they work just as well as brand-name drugs and usually cost less.
Our plan also covers certain over-the-counter drugs and products. Some over-the-counter
drugs cost less than prescription drugs and work just as well. For more information, call
Participant Services or your Care Manager.

How can you find out if a drug is on the Drug List?
To find out if a drug you are taking is on the Drug List, you can:

 Check the most recent Drug List we sent you in the mail.
 Visit the plan’s website at www.guildnetny.org. The Drug List on the website is always
the most current one.

 Call Participant Services to find out if a drug is on the plan’s Drug List or to ask for a
copy of the list.

What is not on the Drug List?
The plan does not cover all prescription drugs or all over-the-counter (OTC) drugs. Some
drugs are not on the Drug List because the law does not allow the plan to cover those drugs.
In other cases, we have decided not to include a drug on the Drug List.
GuildNet Gold Plus FIDA Plan will not pay for the drugs listed in this section. These are
called excluded drugs. If you get a prescription for an excluded drug, you must pay for it
yourself. If you think we should pay for an excluded drug because of your case, you can file
an appeal. (To learn how to file an appeal, see Chapter 9).

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

Here are three general rules for excluded drugs:

 Our plan’s outpatient drug coverage (which includes Part D and Medicaid drugs)
cannot pay for a drug that would already be covered under Medicare Part A or Part B.
Drugs covered under Medicare Part A or Part B are covered by GuildNet Gold Plus
FIDA Plan for free, but they are not considered part of your outpatient prescription drug
benefits.

 Our plan cannot cover a drug purchased outside the United States and its territories.
 The use of the drug must be either approved by the Food and Drug Administration or
supported by certain reference books as a treatment for your condition. Your doctor
might prescribe a certain drug to treat your condition, even though it was not approved
to treat the condition. This is called off-label use. Our plan usually does not cover drugs
when they are prescribed for off-label use.
Also, by law, the types of drugs listed below are not covered by Medicare or Medicaid.

 Drugs used to promote fertility
 Drugs used for cosmetic purposes or to promote hair growth
 Drugs used for the treatment of sexual or erectile dysfunction, such as Viagra®,
Cialis®, Levitra®, and Caverject®

 Drugs used for treatment of anorexia, weight loss, or weight gain
 Outpatient drugs when the company who makes the drugs say that you have to have
tests or services done only by them

What are tiers?
Every drug on the plan’s Drug List is in one of four tiers. A tier is a group of drugs of generally
the same type (for example, brand name, generic, or over-the-counter drugs.)


Tier 1 – Medicare Part D generic drugs



Tier 2 – Medicare Part D brand drugs



Tier 3 – Medicaid covered (non-Part D) prescription drugs



Tier 4 –over-the-counter (OTC) drugs and items

All drugs and items on our Drug List have a $0 copayment.
To find out which tier your drug is in, look for the drug in the plan’s Drug List.

C. Limits on coverage for some drugs

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

Why do some drugs have limits?
For certain prescription and covered over-the-counter (OTC) drugs, special rules limit how
and when the plan covers them. In general, our rules encourage you to get a drug that works
for your medical condition and is safe and effective. When a safe, lower-cost drug will work
just as well as a higher-cost drug, the plans expects your provider to prescribe the lower-cost
drug.
If there is a special rule for your drug, it usually means that the prescribing provider
will have to give us or your Interdisciplinary Team (IDT) extra information, or you or
your provider will have to take extra steps for us to cover the drug. For example, your
provider may have to tell us your diagnosis or provide results of blood tests first. If you or
your provider thinks the rule should not apply to your situation, you should ask GuildNet Gold
Plus FIDA Plan or your IDT to make an exception. GuildNet Gold Plus FIDA Plan or your IDT
may or may not agree to let you use the drug without taking the extra steps.

To learn more about asking for exceptions, see Chapter 9.
What kinds of rules are there?
1. Limiting use of a brand-name drug when a generic version is available
Generally, a generic drug works the same as a brand-name drug and usually costs less. In
most cases, if there is a generic version of a brand-name drug, our network pharmacies will
give you the generic version. We usually will not pay for the brand-name drug when there is
a generic version. However, if your provider has told us or your IDT the medical reason that
the generic drug and other covered drugs that treat the same condition will not work for you
and has written “DAW” (Dispense as Written) on your prescription for a brand-name drug,
then GuildNet Gold Plus FIDA Plan or your IDT will approve the brand-name drug.
2. Getting plan or IDT approval in advance
For some drugs, you or your doctor must get approval from the plan or your IDT before you
fill your prescription. If you don’t get approval, we may not cover the drug. Your IDT may
approve drugs as part of your Person-Centered Service Plan (PSCP), or you can ask
GuildNet Gold Plus FIDA Plan for approval.
During the first 90 days of your membership in the plan, you do not need the plan or your
IDT to approve a refill request for an existing prescription, even if the drug is not on our Drug
List or is limited in some way. See page 123 for more information about getting a temporary
supply.
3. Trying a different drug first
In general, the plan wants you to try lower-cost drugs (that often are as effective) before the
plan covers drugs that cost more. For example, if Drug A and Drug B treat the same medical

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

condition, and Drug A costs less than Drug B, GuildNet Gold Plus FIDA Plan’s rules may
 you
wasto
never
on the
plan’s
Drug A
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or not work for you, the plan will then cover Drug
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try Drug
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4. Quantity limits
For some drugs, we limit the amount of the drug you can have. This is called a quantity limit.
For example, the plan might limit how much of a drug you can get each time you fill your
prescription.

Do any of these rules apply to your drugs?
To find out if any of the rules above apply to a drug you take or want to take, check the
Drug List. For the most up-to-date information, call Participant Services or check our website
at www.guildnetny.org.

D. Why your drug might not be covered
We try to make your drug coverage work well for you, but sometimes a drug might not be
covered in the way that you would like it to be. For example:

 The drug you want to take is not covered by the plan. The drug might not be on the
Drug List. A generic version of the drug might be covered, but the brand name version
you want to take is not. A drug might be new and we have not yet reviewed it for safety
and effectiveness.

 The drug is covered, but there are special rules or limits on coverage for that

drug. As explained in the section above, some of the drugs covered by the plan have
rules that limit their use. In some cases, you or your prescriber may want to ask
GuildNet Gold Plus FIDA Plan or your Interdisciplinary Team (IDT) for an exception to
a rule.

There are things you can do if your drug is not covered in the way that you would like it to be.

You can get a temporary supply
In some cases, the plan can give you a temporary supply of a drug when the drug is not on
the Drug List or when it is limited in some way. This gives you time to talk with your provider
about getting a different drug or to ask GuildNet Gold Plus FIDA Plan or your IDT to approve
the drug.
To get a temporary supply of a drug, you must meet the two rules below:
1. The drug you have been taking:

§ is no longer on the plan’s Drug List, or
§ was never on the plan's Drug List, or
§ is now limited in some way

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

2. You must be in one of these situations:
§

Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

You were in the plan last year and do not live in a long-term care facility.
We will cover a temporary supply (or supplies) of your drug during the first 90 days of
the calendar year. This temporary supply or supplies will be for up to 90 days. If your
prescription is written for fewer days, we will allow multiple fills to provide up to a
maximum of 90 days of medication. You must fill the prescription at a network
pharmacy.

§ You are new to the plan and do not live in a long-term care facility.
We will cover a temporary supply (or supplies) of your drug during the first 90 days of
your membership in the plan. This temporary supply will be for up to 90 days. If your
prescription is written for fewer days, we will allow multiple fills to provide up to a
maximum of 90 days of medication. You must fill the prescription at a network
pharmacy.

§ You were in the plan last year and live in a long-term care facility.
We will cover a temporary supply (or supplies) of your drug during the first 90 days of
the calendar year. The total supply will be for up to a 98-day supply days. If your
prescription is written for fewer days, we will allow multiple fills to provide up to a
maximum of 91 days of medication. (Please note that the long-term care pharmacy may
provide the drug in smaller amounts at a time to prevent waste.)

§ You are new to the plan and live in a long-term care facility.
We will cover a temporary supply (or supplies) of your drug during the first 90 days of
your membership in the plan. The total supply will be for up to a 98-day supply days. If
your prescription is written for fewer days, we will allow multiple fills to provide up to a
maximum of 98 days of medication. (Please note that the long-term care pharmacy may
provide the drug in smaller amounts at a time to prevent waste.)

§ You have been in the plan for more than 90 days and live in a long-term care
facility and need a supply right away.
We will cover one 31-day supply, or less if your prescription is written for fewer days.
This is in addition to the above long-term care transition supply.
§

If you are a current participant in our plan and you experience a change in the level of
care, such as an admission or discharge from the long-term care facility, you will be
allowed an “early” refill of your medications, as needed, to assist with your transition to
your new level of care.

 To ask for a temporary supply of a drug, call Participant Services.
When you get a temporary supply of a drug, you should talk with your provider to
decide what to do when your supply runs out. Here are your choices:

§ You can change to another drug.

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

There may be a different drug covered by the plan that works for you. You can call
Participant Services to ask for a list of covered drugs that treat the same medical
condition. The list can help your provider find a covered drug that might work for you.
OR

 You can ask for an exception.
You and your provider can ask GuildNet Gold Plus FIDA Plan or your IDT to make an
exception. For example, you can ask GuildNet Gold Plus FIDA Plan or your IDT to
approve a drug even though it is not on the Drug List. Or you can ask GuildNet Gold
Plus FIDA Plan or your IDT to approve and cover the drug without limits. If your
provider says you have a good medical reason for an exception, he or she can help
you ask for one.
If a drug you are taking will be taken off the Drug List or limited in some way for next year, we
will allow you to ask for an exception before next year. We will tell you about any change in
the coverage for your drug for next year. You can then ask us or your IDT to make an
exception and cover the drug in the way you would like it to be covered for next year.
GuildNet Gold Plus FIDA Plan or your IDT will answer your request for an exception within 72
hours after we get your request (or your prescriber’s supporting statement).

 To learn more about asking for an exception, see Chapter 9.
 If you need help asking for an exception, you can contact Participant Services or your
Care Manager.

E. Changes in coverage for your drugs
Most changes in drug coverage happen on January 1. However, the plan might make
changes to the Drug List during the year. The plan might:

 Add drugs because new drugs, including generic drugs, became available or the
government approved a new use for an existing drug.

 Remove drugs because they were recalled or because cheaper drugs work just as
well.

 Add or remove a limit on coverage for a drug.
 Replace a brand-name drug with a generic drug.
If any of the changes below affect a drug you are taking, the change will not affect you until
January 1 of the next year:

 We put a new limit on your use of the drug.

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

 We remove your drug from the Drug List, but not because of a recall or because a new
generic drug has replaced it.
Before January 1 of the next year, you usually will not have an increase in your payments or
added limits to your use of the drug. The changes will affect you on January 1 of the next
year.
In the following cases, you will be affected by the coverage change before January 1:

 If a brand name drug you are taking is replaced by a new generic drug, the plan must
give you at least 60 days’ notice about the change.
» The plan may give you a 60-day refill of your brand-name drug at a network
pharmacy.
» You should work with your Care Manager or your provider during those 60 days to
change to the generic drug or to a different drug that the plan covers.
» You and your Care Manager or your provider can ask the plan to continue covering
the brand-name drug for you. To learn how, see Chapter 9.

 If a drug is recalled because it is found to be unsafe or for other reasons, the plan will
remove the drug from the Drug List. We will tell you about this change right away.
» Your Care Manager and your provider will also know about this change. He or she
can work with you to find another drug for your condition.

 If there is a change to coverage for a drug you are taking, the plan will send you a
notice. Normally, the plan will let you know at least 60 days before the change.

F. Drug coverage in special cases
If you are in a long-term care facility
Usually, a long-term care facility, such as a nursing facility, has its own pharmacy or a
pharmacy that supplies drugs for all of its residents. If you are living in a long-term care
facility, you may get your prescription drugs through the facility’s pharmacy if it is part of our
network.
Check your Provider and Pharmacy Directory to find out if your long-term care facility’s
pharmacy is part of our network. If it is not, or if you need more information, please contact
your Care Manager or Participant Services.

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

If you are in a long-term care facility and become a new Participant of the plan
If you need a drug that is not on our Drug List or is restricted in some way, the plan will cover
a temporary supply or multiple temporary supplies up to 98 days days when you ask for a
refill during the first 90 days of your membership.
If you have been a Participant of the plan for more than 90 days and you need a drug that is
not on our Drug List, we will cover one 31-day supply. We will also cover one 31-day supply if
the plan has a limit on the drug’s coverage. If your prescription is written for fewer than 31
days, we will pay for the smaller amount.
When you get a temporary supply of a drug, you should talk with your Care Manager or your
provider to decide what to do when your supply runs out. A different drug covered by the plan
might work just as well for you. Or you and your Care Manager or your provider can ask the
plan to make an exception and cover the drug in the way you would like it to be covered.

 To learn more about asking for exceptions, see Chapter 9.
If you are in a Medicare-certified hospice program
Drugs are never covered by both hospice and our plan at the same time. If you are enrolled
in a Medicare hospice and require a pain medication, anti-nausea, laxative, or antianxiety
drug not covered by your hospice because it is unrelated to your terminal prognosis and
related conditions, our plan must get notification from either the prescriber or your hospice
provider that the drug is unrelated before our plan can cover the drug. To prevent delays in
getting any unrelated drugs that should be covered by our plan, you can ask your hospice
provider or prescriber to make sure we have the notification that the drug is unrelated before
you ask a pharmacy to fill your prescription.
If you leave hospice, our plan should cover all of your drugs. To prevent any delays at a
pharmacy when your Medicare hospice benefit ends, you should bring documentation to the
pharmacy to verify that you have left hospice. See the previous parts of this chapter that tell
about the rules for getting drug coverage under Part D.

 To learn more about the hospice benefit, see Chapter 4.
G. Programs on drug safety and managing drugs
Programs to help Participants use drugs safely
Each time you fill a prescription, we look for possible problems, such as:

 Drug errors
 Drugs that may not be needed because you are taking another drug that does the
same thing

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Chapter 5: Getting your outpatient prescription drugs
and other covered medications through the plan

 Drugs that may not be safe for your age or gender
 Drugs that could harm you if you take them at the same time
 Drugs that are made of things you are allergic to
If we see a possible problem in your use of prescription drugs, we will notify your Care
Manager and have your Interdisciplinary Team (IDT) work with your provider to correct the
problem.

Programs to help Participants manage their drugs
If you take medications for different medical conditions, you may be eligible to get services, at
no cost to you, through a medication therapy management (MTM) program. This program
helps you and your provider make sure that your medications are working to improve your
health. A pharmacist or other health professional will give you a comprehensive review of all
your medications and talk with you about:

 How to get the most benefit from the drugs you take
 Any concerns you have, like medication costs and drug reactions
 How best to take your medications
 Any questions or problems you have about your prescription and over-the-counter
medication
You’ll get a written summary of this discussion. The summary has a medication action plan
that recommends what you can do to make the best use of your medications. You’ll also get
a personal medication list that will include all the medications you’re taking and why you take
them.
It’s a good idea to schedule your medication review before your yearly “Wellness” visit, so
you can talk to your doctor about your action plan and medication list. Bring your action plan
and medication list with you to your visit or anytime you talk with your doctors, pharmacists,
and other health care providers. Also, take your medication list with you if you go to the
hospital or emergency room.
Medication therapy management programs are voluntary and free to Participants that qualify.
If we have a program that fits your needs, your Interdisciplinary Team (IDT) will discuss
whether you should enroll in the program.

 If you have any questions about these programs, please contact Participant Services or
your Care Manager.

CHAPTER 6
Understanding the plan’s drug coverage

129

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Chapter 6: Understanding the plan’s drug coverage

GuildNet Gold Plus FIDA Plan Participant Handbook

Chapter 6: Understanding the plan’s drug coverage

Introduction
This chapter discusses your outpatient drug coverage through GuildNet Gold Plus
FIDA Plan. By “drugs,” we mean:

§ Medicare Part D prescription drugs, and
§ drugs and items covered under Medicaid, and
§ drugs and items covered by the plan as additional

benefits.
Because you are enrolled in the Fully Integrated Duals Advantage (FIDA)
Demonstration, you have no costs for any covered drugs.
To learn more about prescription drugs, you can look in these places:

§ GuildNet Gold Plus FIDA Plan’s List of Covered Drugs. We call this the
“Drug List.” It tells you:

» Which drugs GuildNet Gold Plus FIDA Plan pays for
» Which of the four tiers each drug is in
» Whether there are any limits on the drugs
If you need a copy of the Drug List, call Participant Services. You can also
find the Drug List on our website at www.guildnetny.org. The Drug List on
the website is always the most current.

§ Chapter 5 of this Participant Handbook. Chapter 5 tells how to get your

outpatient prescription drugs through our Plan. It includes rules you need to
follow. It also tells which types of prescription drugs are not covered by GuildNet
Gold Plus FIDA Plan.

§ GuildNet Gold Plus FIDA Plan’s Provider and Pharmacy Directory. In most
cases, you must use a network pharmacy to get your covered drugs. Network
pharmacies are pharmacies that have agreed to work with GuildNet Gold Plus
FIDA Plan. The Provider and Pharmacy Directory has a list of network
pharmacies. You can read more about network pharmacies in Chapter 5.

GuildNet Gold Plus FIDA Plan Participant Handbook

Chapter 6: Understanding the plan’s drug coverage

A. The Explanation of Benefits (EOB)
GuildNet Gold Plus FIDA Plan keeps track of your drugs and your total drug costs,
including the amount Medicare pays for you.
When you get prescription drugs through GuildNet Gold Plus FIDA Plan, we send
you a report called the Explanation of Benefits. We call it the EOB for short. The
EOB includes:

§ Information for the month. The report tells what prescription drugs you got. It

shows the total drug costs, what the plan paid, and what Medicare paid for you.
The EOB is not a bill. It is just for your records.

§ “Year-to-date” information. These are your drugs used during the year and
the total payments made by GuildNet Gold Plus FIDA Plan and Medicare for
you since January 1.

We offer coverage of drugs not covered under Medicare. We also pay for some over-thecounter drugs. To find out which drugs GuildNet Gold Plus FIDA Plan covers, see the Drug
List.

B. Keeping track of your drugs
To keep track of your drugs, we use records we get from you and from your pharmacy.
Here is how you can help us:
1. Use your Participant ID Card.
Show your GuildNet Gold Plus FIDA Plan Participant ID Card every time you get a
prescription filled. This will help us know what prescriptions you fill.
2. Make sure we have the information we need if we need to reimburse you.
You should not have to pay for any covered drugs under GuildNet Gold Plus FIDA Plan. In
the event of a mix-up at the pharmacy or some other reason that you end up paying for a
covered drug, give us copies of receipts. You can ask us to pay you back for the drug.
Here are some times when you should give us copies of your receipts:

§ When you buy a covered drug at a network pharmacy at a special price or using a
discount card that is not part of GuildNet Gold Plus FIDA Plan’s benefit

§ When you pay a copay for drugs that you get under a drug maker’s patient
assistance program

§ When you buy covered drugs at an out-of-network pharmacy

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Chapter 6: Understanding the plan’s drug coverage

§ When you pay the full price for a covered drug

To learn how to ask us to pay you back for the drug, see Chapter 7.
3. Check the reports we send you.
When you get an Explanation of Benefits in the mail, please make sure it is complete and
correct. If you think something is wrong or missing from the report, or if you have any
questions, please call Participant Services. Be sure to keep these reports.

C. A summary of your drug coverage
The plan’s tiers
Tiers are groups of drugs. Every drug on the plan’s Drug List is in one of four tiers. There is
no cost to you for drugs on any of the tiers.

§ Tier 1 drugs are generic drugs covered by Medicare Part D.
§ Tier 2 drugs are brand name drugs covered by Medicare Part D.
§ Tier 3 drugs are Medicaid covered (non-Part D) prescription drugs.
§ Tier 4 drugs are over-the-counter items.
Getting a long-term supply of a drug
For some drugs, you can get a long-term supply (also called an “extended supply”) when
you fill your prescription. A long-term supply is up to a 90-day supply. There is no cost to
you for a long-term supply.

For details on where and how to get a long-term supply of a drug, see Chapter 5 or the
Provider and Pharmacy Directory.

Your coverage for a one-month or long-term supply of a covered prescription
drug from:

GuildNet Gold Plus FIDA Plan Participant Handbook

A network
pharmacy
A one-month
or up to a 90day supply

Tier 1

Chapter 6: Understanding the plan’s drug coverage

The plan’s
mail-order
service
A one-month
or up to a 90day supply

A network
long-term
care
pharmacy
Up to a 98
day supply

An out-ofnetwork
pharmacy
Up to a 30-day
supply. Coverage
is limited to
certain cases.
See Chapter 5
for details.

(generic drugs
covered by
Medicare )
Tier 2
(brand name
drugs covered by
Medicare)
Tier 3
(non-Medicare
prescription drugs)
Tier 4
(over-the-counter
drugs )

For information about which pharmacies can give you long-term supplies, see the plan’s
Provider and Pharmacy Directory.

D. Vaccinations
GuildNet Gold Plus FIDA Plan covers Medicare Part D vaccines. There are no
costs for vaccinations that are covered under GuildNet Gold Plus FIDA Plan.
Before you get a vaccination
We recommend that you talk to your Care Manager whenever you would like to
get a vaccination. Your Interdisciplinary Team (IDT) will discuss appropriate
vaccinations.

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Chapter 6: Understanding the plan’s drug coverage

It is best to use a network provider and pharmacy to get your vaccinations. If you are not
able to use a network provider and pharmacy, you may have to pay the entire cost for both
the vaccine itself and for getting the vaccine. For example, sometimes you may get the
vaccine as a shot given to you by your provider. If you are in this situation, we recommend
that you call your Care Manager first. If you pay the full cost of the vaccine at a provider’s
office, we can tell you how to ask us to pay you back.

To learn how to ask us to pay you back, see Chapter 7.

CHAPTER 7
Asking us to pay a bill you have gotten for covered
services, items, or drugs

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Chapter 7: Asking us to pay a bill you have gotten for
covered services, items, or drugs
Table of Contents
A. When can you ask GuildNet Gold Plus FIDA Plan to pay for your services, items, or
drugs? ........................................................................................................................................... 137
B.How and where to send your request for payment.......................................................................... 139
C.GuildNet Gold Plus FIDA Plan or your IDT will make a coverage decision ..................................... 140
D.You can appeal the coverage decision ........................................................................................... 140

A. When can you ask GuildNet Gold Plus FIDA Plan to pay for your
services, items, or drugs?
You should not get a bill for any in-network services, items, or drugs. Our network providers
must bill GuildNet Gold Plus FIDA Plan for the services, items, and drugs you already got. A
network provider is a provider who works with the FIDA Plan.
If you get a bill for health care or drugs, do not pay the bill. Instead, send the bill to
GuildNet Gold Plus FIDA Plan or your Interdisciplinary Team (IDT). To send GuildNet Gold
Plus FIDA Plan or your IDT a bill, see page 140.

 If the services, items, or drugs are covered, GuildNet Gold Plus FIDA Plan will pay the
provider directly.

 If the services, items, or drugs are covered and you already paid the bill, it is your right
to be paid back.

 If the services, items, or drugs are not covered, GuildNet Gold Plus FIDA Plan or your
IDT will tell you. You may appeal the decision.

 Contact Participant Services or your Care Manager if you have any questions. If you get a
bill and you do not know what to do about it, Participant Services can help. You can also
call if you want to give more information about a request for payment you already sent to
GuildNet Gold Plus FIDA Plan or your IDT.

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Chapter 7: Asking us to pay a bill you have gotten
for covered services, items, or drugs

 The Independent Consumer Advocacy Network (ICAN) can also give you free information
and assistance about your FIDA Plan coverage and rights. To contact ICAN, call 1-844614-8800. (TTY users call 711, then follow the prompts to dial 844-614-8800.)
Here are examples of times when you may get a bill and may need to ask GuildNet Gold Plus
FIDA Plan or your IDT to decide if the plan will pay you back or pay the bill that you got:
1. When you get emergency or urgently needed health care from an out-of-network provider
You should ask the provider to bill GuildNet Gold Plus FIDA Plan.

 If you pay the full amount when you get the care, ask us to pay you back. Send
GuildNet Gold Plus FIDA Plan or your IDT the bill and proof of any payment you made.

 You may get a bill from the provider asking for payment that you think you do not owe.
Send GuildNet Gold Plus FIDA Plan or your IDT the bill and proof of any payment you
made.
» If the provider should be paid, GuildNet Gold Plus FIDA Plan will pay the provider
directly.
» If you have already paid for the service, GuildNet Gold Plus FIDA Plan will pay you
back.
2. When a network provider sends you a bill
Network providers must always bill GuildNet Gold Plus FIDA Plan.

 Whenever you get a bill from a network provider, send us the bill. GuildNet Gold Plus
FIDA Plan will contact the provider directly and take care of the problem.

 If you have already paid a bill from a network provider, send GuildNet Gold Plus FIDA
Plan or your IDT the bill and proof of any payment you made. GuildNet Gold Plus FIDA
Plan will pay you back for your covered services, items, and drugs.
3. When you use an out-of-network pharmacy to get a prescription filled
If you go to an out-of-network pharmacy, you will have to pay the full cost of your
prescription.

 In some cases, GuildNet Gold Plus FIDA Plan or your IDT will approve prescriptions filled
at out-of-network pharmacies. Send GuildNet Gold Plus FIDA Plan or your IDT a copy of
your receipt when you ask GuildNet Gold Plus FIDA Plan to pay you back. Please see
Chapter 5 to learn more about out-of-network pharmacies.
4. When you pay the full cost for a prescription because you do not have your GuildNet Gold
Plus FIDA Plan Participant ID Card with you
If you do not have your Participant ID Card with you, you can ask the pharmacy to call
GuildNet Gold Plus FIDA Plan or to look up your plan enrollment information. If the pharmacy

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Chapter 7: Asking us to pay a bill you have gotten
for covered services, items, or drugs

cannot get the information they need right away, you may have to pay the full cost of the
prescription yourself.

 Send GuildNet Gold Plus FIDA Plan or your IDT a copy of your receipt when you ask
GuildNet Gold Plus FIDA Plan to pay you back.
5. When you pay the full cost for a prescription for a drug that is not covered
You may pay the full cost of the prescription because the drug is not covered.

 The drug may not be on GuildNet Gold Plus FIDA Plan’s List of Covered Drugs (Drug
List), or it could have a requirement or restriction that you did not know about or do not
think should apply to you. If you decide to get the drug, you may need to pay the full
cost for it.
» If you do not pay for the drug but think it should be covered, you can ask for a
coverage decision from GuildNet Gold Plus FIDA Plan or your IDT (see Chapter 9).
» If you and your doctor or other prescriber think you need the drug right away, you
can ask for a fast coverage decision from GuildNet Gold Plus FIDA Plan or your IDT
(see Chapter 9).

 Send GuildNet Gold Plus FIDA Plan or your IDT a copy of your receipt when you ask
for GuildNet Gold Plus FIDA Plan to pay you back. In some situations, GuildNet Gold
Plus FIDA Plan or your IDT may need to get more information from your doctor or other
prescriber in order for GuildNet Gold Plus FIDA Plan to pay you back for the drug.
When you send GuildNet Gold Plus FIDA Plan or your IDT a request for payment, your
request will be reviewed and a decision will be made as to whether the service, item, or
drug should be covered. This is called making a “coverage decision.” If GuildNet Gold
Plus FIDA Plan or your IDT decides it should be covered, GuildNet Gold Plus FIDA Plan
will pay for the service, item, or drug. If GuildNet Gold Plus FIDA Plan or your IDT denies
your request for payment, you can appeal the decision.

 To learn how to make an appeal, see Chapter 9.
B. How and where to send your request for payment
Send GuildNet Gold Plus FIDA Plan or your Interdisciplinary Team (IDT) your bill and proof of
any payment you have made. Proof of payment can be a copy of the check you wrote or a
receipt from the provider. It is a good idea to make a copy of your bill and receipts for your
records. You can ask your Care Manager for help.
Mail your request for payment together with any bills or receipts to us at this address:

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Chapter 7: Asking us to pay a bill you have gotten
for covered services, items, or drugs

GuildNet Gold Plus FIDA
Plan c/o Emblem Health
Claims PO Box 2845
New York, NY 10116-2845
You may also call GuildNet Gold Plus FIDA Plan to ask for payment. Please call our Plan at
1-800-815-0000, Monday through Sunday from 8am to 8pm. TTY/TDD users call 711.
You must submit your claim to us within 60 days of the date you got the service, item, or
drug.

C. GuildNet Gold Plus FIDA Plan or your IDT will make a coverage
decision
When GuildNet Gold Plus FIDA Plan or your Interdisciplinary Team (IDT) gets your request
for payment, it will be reviewed and a coverage decision will be made. This means that
GuildNet Gold Plus FIDA Plan or your IDT will decide whether your health care or drug is
covered by the plan. GuildNet Gold Plus FIDA Plan or your IDT will also decide the amount, if
any, you have to pay for the health care or drug.

 GuildNet Gold Plus FIDA Plan or your IDT will let you know if it needs more information
from you.

 If GuildNet Gold Plus FIDA Plan or your IDT decides that the service, item, or drug is
covered and you followed all the rules, the plan will pay for it. If you have already paid
for the service, item, or drug, GuildNet Gold Plus FIDA Plan will mail you a check for
what you paid. If you have not paid for the service, item, or drug yet, GuildNet Gold
Plus FIDA Plan will pay the provider directly.

 Chapter 3 explains the rules for getting your services covered. Chapter 5 explains the
rules for getting your Medicare Part D prescription drugs covered.

 If GuildNet Gold Plus FIDA Plan or your IDT decides the plan should not to pay for the
service, item, or drug, the plan will send you a letter explaining why not. The letter will
also explain your rights to make an appeal.

 To learn more about coverage decisions, see Chapter 9.

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Chapter 7: Asking us to pay a bill you have gotten
for covered services, items, or drugs

D. You can appeal the coverage decision
If you think GuildNet Gold Plus FIDA Plan or your Interdisciplinary Team (IDT) made a
mistake in turning down your request for payment, you can ask GuildNet Gold Plus FIDA
Plan to change the decision. This is called making an appeal. You can also make an appeal
if you do not agree with the amount GuildNet Gold Plus FIDA Plan or your IDT decides that
the plan will pay.

 The appeals process is a formal process with detailed procedures and important
deadlines. To learn more about appeals, see Chapter 9.

§ If you want to make an appeal about getting paid back for a service or item, go to page
175.

§ If you want to make an appeal about getting paid back for a drug, go to page 189.
The Independent Consumer Advocacy Network (ICAN) can also give you free information
and assistance with any appeals you may file with GuildNet Gold Plus FIDA Plan. To
contact ICAN, call 1-844-614-8800. (TTY users call 711, then follow the prompts to dial
844-614-8800.)

CHAPTER 8
Your rights and responsibilities

142

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Chapter 8: Your rights and responsibilities
Table of Contents
Introduction ........................................................................................................................................ 145
A.You have a right to get information in a way that meets your needs ............................................... 145
B.We must treat you with respect, fairness, and dignity at all times ................................................... 150
C.We must ensure that you get timely access to covered services, items, and drugs ....................... 151
D.We must protect your personal health information ......................................................................... 153
How we protect your health information ........................................................................................ 153
You have a right to see your medical records ............................................................................... 154
E. We must give you information about GuildNet Gold Plus FIDA Plan, its network providers,
and your covered services ............................................................................................................ 154
F.Network providers cannot bill you directly ...................................................................................... 156
G.You have the right to leave GuildNet Gold Plus FIDA Plan at any time.......................................... 156
H.You have a right to make decisions about your health care ........................................................... 156
You have the right to know your treatment options and make decisions about your
services ....................................................................................................................................... 156
You have the right to say what you want to happen if you are unable to make health care
decisions for yourself ................................................................................................................... 157
What to do if your instructions are not followed............................................................................ 158
I. You have the right to ask for help ................................................................................................ 159
J. You have the right to file a grievance and to ask us to reconsider decisions we have made ........ 159
What to do if you believe you are being treated unfairly or your rights are not being
respected .................................................................................................................................... 159
How to get more information about your rights ............................................................................ 160
How to get help understanding your rights or exercising them ..................................................... 160
K.You have the right to suggest changes ......................................................................................... 160

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Chapter 8: Your rights and responsibilities

L. You also have responsibilities as a Participant of GuildNet Gold Plus FIDA Plan ........................ 161

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 8: Your rights and responsibilities

Introduction
In this chapter, you will find your rights and responsibilities as a Participant of GuildNet Gold
Plus FIDA Plan. GuildNet Gold Plus FIDA Plan must honor your rights.

A. You have a right to get information in a way that meets your needs
We must tell you about GuildNet Gold Plus FIDA Plan benefits and your rights in a way that you
can understand. We must tell you about your rights each year that you are a participant in GuildNet
Gold Plus FIDA Plan. We must also tell you about all of your rights and how to exercise your rights
in writing prior to the effective date of coverage.
You have the right to get timely information about GuildNet Gold Plus FIDA Plan changes. This
includes the right to get annual updates to the Marketing, Outreach and Participant
Communications materials. This also means you have the right to get notice of any significant
change in the way in which services are provided to you at least 30 days prior to the intended
effective date of the change.
You have the right to have all plan options, rules, and benefits fully explained, including through the
use of a qualified interpreter if needed. To get information in a way that you can understand, please
call Participant Services. GuildNet Gold Plus FIDA Plan has people who can answer questions in
different languages.
Our plan can also give you materials in languages other than English and in formats such as large
print, Braille or audio. Written materials are available in Spanish, Italian, Haitian-Creole, Chinese,
Russian and Korean. You can make a request now and in the future, for a language other than
English or for an alternate format by calling 1-800-815-0000 and TTY/TDD 711, during Monday
through Sunday, 8am to 8pm.

If you are having trouble getting information from GuildNet Gold Plus FIDA Plan because
of language problems or a disability and you want to file a grievance, call Medicare at
1-800-MEDICARE (1-800-633-4227). You can call 24 hours a day, 7 days a week. TTY
users should call 1-877-486-2048.

You can also contact Medicaid by calling the New York State Department of Health at
1- 866-712-7197 for more information and help in handling a problem.

Usted tiene el derecho de recibir información en una forma que satisfaga
sus necesidades
Debemos informarle sobre los beneficios de GuildNet Gold Plus FIDA Plan y sobre sus
derechos en una forma que Ud. pueda entender. Debemos informarle sobre sus derechos

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 8: Your rights and responsibilities

cada año mientras Ud. sea un Participante de GuildNet Gold Plus FIDA Plan. Además,
debemos informarle por escrito sobre todos sus derechos y sobre cómo ejercitar esos
derechos, antes de la fecha en que su cobertura entre en vigor.
Ud. tiene el derecho a recibir puntualmente información sobre los cambios de GuildNet Gold
Plus FIDA Plan. Esto incluye el derecho a recibir actualizaciones anuales de los materiales
de comunicación para el participante, de alcance a la comunidad y de mercadeo. Esto
significa que Ud. tiene el derecho a recibir notificaciones de cualquier cambio significativo en
la forma en que se le proporcionan sus servicios, al menos 30 días antes de la fecha en que
se programa del dicho cambio entre en vigor.
Ud. tiene el derecho a que se le expliquen en su totalidad todas las opciones de planes, las
reglas y los beneficios, incluso mediante el uso de un intérprete calificado, si fuese
necesario. Para recibir información en una forma en que Ud. pueda entenderla, sírvase
llamar a la oficina de Servicios para el Participante. GuildNet Gold Plus FIDA Plan cuenta
con personal que puede atender preguntas en diferentes idiomas.
Nuestro plan también le puede dar materiales en otros formatos, tales como letra grande,
Braille o audio. Los materiales escritos están disponibles en español, italiano, haitiano criollo,
chino, ruso y coreano. Por favor llame a su administrador de atención al solicitar un idioma
distinto del Inglés o si necesita materiales en un formato alternativo.

 Si tiene problemas obteniendo información de parte de GuildNet Gold Plus FIDA Plan
debido a problemas de lenguaje o alguna incapacidad y desea presentar una queja,
sírvase llamar a Medicare al 1-800-MEDICARE (1-800-633-4227). Se puede llamar a este
número las 24 horas del día, los 7 días de la semana. Los usuarios del sistema TTY
pueden llamar al 1-877-486-2048.

 Para obtener mayor información y ayuda sobre el manejo de algún problema, también
puede comunicarse con Medicaid, llamando al Departamento de Salud del Estado de
Nueva York al 1-866-712-7197.

Ou gen yon dwa pou jwenn enfòmasyon yo nan yon fason ki satisfè
bezwen ou yo
Nou dwe ba ou enfòmasyon sou avantaj GuildNet Gold Plus FIDA Plan ak ak enfòmasyon
sou dwa ou nan yon fason ou kapab konprann. Nou dwe fè ou konnen dwa ou chak ane ou
se yon Patisipan nan GuildNet Gold Plus FIDA Plan. Nou dwe fè ou konnen tou tout dwa ou
ak fason pou egzèse dwa ou alekri anvan dat pwoteksyon ou kòmanse.
Ou gen dwa pou resevwa enfòmasyon kòmsadwa sou chanjman GuildNet Gold Plus FIDA
Plan. Dwa sa a gen ladan dwa pou resevwa dènye enfòmasyon yo chak ane nan dokiman
Maketing, Asistans ak Kominikasyon avèk Patisipan yo. Sa vle di tou ou gen dwa pou

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Chapter 8: Your rights and responsibilities

resevwa avi sou nenpòt chanjman enpòtan nan fason nou ba ou sèvis yo omwen 30 jou
anvan dat nou gen entansyon mete chanjman an anvigè.
Ou gen dwa pou jwenn eksplikasyon sou tout posiblite, règ ak avantaj plan an, ansanm avèk
itilizasyon yon entèprèt kalifye si li nesesè. Pou jwenn enfòmasyon yo nan yon fason ou
kapab konprann, tanpri rele Sèvis Patisipan yo. GuildNet Gold Plus FIDA Plan gen moun ki
kapab reponn kesyon yo nan anpil lang diferan.
Plan nou yo kapab tou ba ou materyèl nan lòt fòma tankou gwo lèt, Bray oswa odyo.
materyèl Ekri yo disponib nan lang Panyòl, Italyen, ayisyen-kreyòl, Chinwa, Ris ak Korean.
Tanpri rele Manadjè Swen ou pou mande pou yon lòt pase angle oswa si ou bezwen
materyèl nan yon fòma altènatif lang.

 Si ou gen pwoblèm pou jwenn enfòmasyon yo nan GuildNet Gold Plus FIDA Plan akòz
pwoblèm lang oswa akòz yon andikap, epi si ou vle fè yon doleyans pou sa, rele Medicare
nan nimewo 1-800-MEDICARE (1-800-633-4227). Ou kapab rele nimewo sa a 24 èdtan
pa jou, 7 jou pa semèn. Itilizatè TTY yo ta dwe rele 1-877-486-2048.

 Ou kapab kontakte Medicaid depi ou rele Depatman Sante Eta New York (New York State

Department of Health) nan nimewo 1-866-712-7197 pou jwenn plis enfòmasyon ak èd pou
rezoud pou pwoblèm.

Lei ha diritto a ricevere informazioni con modalità confacenti alle sue
esigenze
Siamo tenuti ad informarla sui programmi di benefit GuildNet Gold Plus FIDA Plan e sui suoi
diritti in modo comprensibile. Dobbiamo comunicarle i suoi diritti ogni anno in cui lei ha
sottoscritto il piano GuildNet Gold Plus FIDA Plan. Inoltre dobbiamo comunicarle tutti i suoi
diritti e le modalità per esercitarli per iscritto prima della data di decorrenza del piano
sottoscritto.
Lei ha diritto a ricevere informazioni tempestive sui cambiamenti che riguardano GuildNet
Gold Plus FIDA Plan, ad esempio, il diritto a ricevere aggiornamenti annuali ai materiali di
marketing, programmi di outreach e comunicazione ai partecipanti.
In questo senso lei ha inoltre il diritto a ricevere comunicazione di eventuali cambiamenti
significativi sulle modalità di erogazione dei servizi con almeno 30 giorni di preavviso sulla
data di entrata in vigore del cambiamento.
Lei ha diritto a ricevere spiegazioni esaurienti su tutte le opzioni, i regolamenti ed i benefit dei
piani, con l'intervento, all'occorrenza, di un interprete qualificato. Per ottenere informazioni in
un modo per lei comprensibile contatti telefonicamente i Servizi dedicati ai titolari (Participant
Services). GuildNet Gold Plus FIDA Plan dispone di personale plurilingue.

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK

Chapter 8: Your rights and responsibilities

Il nostro piano può anche fornire materiali in altri formati, come stampa a grandi caratteri,
Braille o audio. materiali scritti sono disponibili in spagnolo, italiano, haitiano-creolo, cinese,
russo e coreano. Si prega di chiamare la vostra cura Manager per richiedere una lingua
diversa dall'inglese o se si ha bisogno di materiali in un formato alternativo.

 In caso di difficoltà ad ottenere le informazioni da GuildNet Gold Plus FIDA Plan a causa
di problemi linguistici o disabilità, e per esprimere lamentele contattare telefonicamente
Medicare al numero 1-800-MEDICARE (1-800-633-4227). Il servizio è disponibile 24 ore
su 24, 7 giorni su 7. Il numero per gli abbonati TTY è 1-877-486-2048.

 Per ulteriori informazioni e per ricevere assistenza in caso di problemi è possibile
contattare Medicaid anche telefonando al Dipartimento della Salute dello Stato di New
York al numero 1-866-712-7197.

여러분은 여러분께 필요한 방법으로 정보를 얻을 권리가 있습니다.
저희는 GuildNet Gold Plus FIDA Plan 의 혜택과 여러분의 권리에 대해 여러분이 이해하실 수
있는 방법으로 말씀드려야 합니다. 저희는 여러분이 GuildNet Gold Plus FIDA Plan 의
가입하는 해마다 여러분의 권리에 대해 말씀드려야 합니다. 저희는 또한 보장내용이 효력을
발생하는 날 이전에 서면으로 여러분의 모든 권리와 여러분의 권리를 행사하는 방법에
대해서도 말씀드려야 합니다.
여러분은 GuildNet Gold Plus FIDA Plan 의 변경사항에 대해 시의적절한 정보를 받으실
권리가 있습니다. 여기에는 마케팅, 아웃리치, 가입자 연락 자료 등에 대한 연례 업데이트를
수령할 권리도 포함됩니다. 또한, 이것은 여러분에게 제공되는 서비스가 상당 부분 변경되는
경우, 여러분은 그러한 변경사항이 효력을 발생하기로 되어 있는 날로부터 최소한 30 일 전에
그 변경내용에 대한 통지를 받을 권리가 있다는 뜻이기도 합니다.
여러분은 모든 플랜 옵션, 규칙, 그리고 보장혜택에 대해 충분히 설명을 들을 권리가 있습니다.
여기에는 필요한 경우 자격을 갖춘 통역을 이용할 권리도 포함됩니다. 여러분이 이해할 수
있는 방법으로 정보를 얻으시려면, 가입자 서비스(Participant Services)로 문의하십시오.
GuildNet Gold Plus FIDA Plan 에는 여러 다른 언어로 질문에 답해드릴 수 있는 직원들이
대기하고 있습니다.
우리의 계획은 또한 당신에게 대형 인쇄, 점자 또는 오디오와 같은 다른 형식으로 자료를 제공
할 수 있습니다. 서면 자료는, 스페인어, 이탈리아어 아이티 크리올 어, 중국어, 러시아어,
한국어 사용할 수 있습니다. 영어 이외의 또는 다른 형식으로 자료를 필요로하는 경우 다른
언어를 요청하기 위해 케어 매니저를 문의하십시오.

 언어 문제나 장애로 인해 GuildNet Gold Plus FIDA Plan 에서 정보를 얻는 데 어려움을
겪고 계시고, 불만사항을 접수하고자 하시는 경우, 1-800-MEDICARE(1-800-633-4227)로
Medicare 에 전화해 주십시오. 연중무휴 하루 24 시간 전화하실 수 있습니다. TTY 사용자는
1-877-486-2048 로 전화하셔야 합니다.

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Chapter 8: Your rights and responsibilities

 또한, 문제를 처리하는데 더 자세한 정보와 도움이 필요하시면, 뉴욕주 보건국
1-866-712-7197 로 전화하셔서 Medicaid 로 연락하실 수 있습니다.

您有权以符合您需要的方式获取信息
我们必须以您可以理解的方式向您介绍 GuildNet Gold Plus FIDA 所提供的福利与您的权利。
我们必须每年向您重申您作为 GuildNet Gold Plus FIDA 会员所享有的权利。我们还必须在保
险生效日期之前以书面形式告知您的所有权利以及如何行使这些权利。
您有权及时收到有关 GuildNet Gold Plus FIDA 变更情况的信息。包括有权收到营销、外展和
会员通讯材料的年度更新。这还意味着，您有权收到有关任何重大服务变更的通知，并且此通
知将在预定的变更生效之前至少 30 天发送给您。
您有权获得有关此计划中所有可选方案、规则和福利的完整说明，包括在必要时获得符合资格
的口译人员的协助。要以您可以理解的方式获取信息，请致电会员服务部。GuildNet Gold
Plus FIDA 备有工作人员可以用各种不同语言解答问题。
我們的計劃也可以給你的材料在其他格式如大字，盲文或音頻。書面材料西班牙語，意大利語，
海地克里奧爾語，中國人，都可以俄文和韓文。請致電您的服務經理，要求除了英語，或者如
果你需要的材料以其他格式以外的其他語言。

 如果您在从 GuildNet Gold Plus FIDA 获取信息时因语言问题或身体残障而遇到了困难，并
且您希望提出申诉，请致电 1-800-MEDICARE (1-800-633-4227) 与联邦医疗保险联系。您
可每周 7 天、每天 24 小时拨打。听障用户请致电 1-877-486-2048。

 您還可以通過撥打 1-866-712-7197 健康的紐約州部門的更多信息，並在處理問題的幫助聯
繫醫療補助。

Вы имеете право получать информацию тем способом, который
отвечает вашим потребностям
Мы должны сообщить вам о ваших льготах и правах в рамках плана GuildNet Gold Plus
FIDA понятным для вас способом. В течение каждого года вашего участия в плане
GuildNet Gold Plus FIDA, мы должны сообщить вам о ваших правах. Более того, до
наступления даты действия страхового покрытия мы обязаны в письменном виде
сообщить вам обо всех ваших правах и способах их осуществления.
Вы имеете право своевременно получить информацию об изменениях в плане GuildNet
Gold Plus FIDA. Сюда также входит право на получение ежегодных обновлений в
маркетинговых, социальных и информационных материалах для участников. Это,
помимо прочего, означает, что вы имеете право получить уведомление обо всех
значительных изменениях в способах предоставленных услуг, в котором

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Chapter 8: Your rights and responsibilities

предоставляются услуги для вас, как минимум, за 30 дней до установленной даты
вступления в силу таких изменений.
Вы имеете право на подробное пояснение всех доступных вариантов, правил и льгот,
действующих в рамках плана, в том числе при помощи услуг квалифицированного
перевода, если потребуется. Чтобы получить информацию удобным для вас способом,
позвоните в Отдел обслуживание участников. В плане GuildNet Gold Plus FIDA
работают специалисты, которые могут ответить на вопросы на различных языках.
Наш план также может дать вам материалы в других форматах, таких как крупным
шрифтом, шрифтом Брайля или аудио. Письменные материалы доступны на
испанском, итальянском, гаитянских-креольском, китайском, русском и корейском
языках. Пожалуйста, обратитесь к менеджеру по уходу, чтобы запросить любого
другого языка, кроме английского, или если вы нужны материалы в альтернативном
формате.

 Если у вас возникли проблемы с получением информации от плана GuildNet Gold
Plus FIDA из-за языковых трудностей или ограниченных способностей, и вы хотите
подать жалобу, позвоните в Медикейр по телефону 1-800-MEDICARE (1-800-6334227). Служба работает без перерывов и выходных. Лицам, использующим TTY,
следует звонить по номеру 1-877-486-2048.

 Вы также можете обратиться в Медикейд, позвонив в Департамент здравоохранения
штата Нью-Йорк по телефону 1-866-712-7197, чтобы получить дополнительную
информацию и помощь в разрешении проблем.

B. We must treat you with respect, fairness, and dignity at all times
GuildNet Gold Plus FIDA Plan must obey laws that protect you from discrimination or unfair
treatment. We do not discriminate against Participants because of any of the following:

 Age

 Genetic information

 Appeals

 Gender identity

 Behavior

 Geographic location within the

 Claims experience

service area

 Color

 Health status

 Ethnicity

 Marital status

 Evidence of insurability

 Medical history
 Mental ability

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 Mental or physical disability

 Religion

 National origin

 Sex

 Race

 Sexual orientation

 Receipt of health care

 Use of services

Under the rules of GuildNet Gold Plus FIDA Plan, you have the right to be free of any form of
physical restraint or seclusion that would be used as a means of coercion, force, discipline,
convenience, or retaliation. You have the right to not be neglected, intimidated, physically or
verbally abused, mistreated, or exploited. You also have the right to be treated with
consideration, respect, and full recognition of your dignity, privacy, and individuality.
We cannot deny services to you or punish you for exercising your rights. Your exercising of
your rights will not negatively affect the way GuildNet Gold Plus FIDA Plan and its providers,
New York State, or CMS provide or arrange for the provision of services to you.

 For more information, or if you have concerns about discrimination or unfair treatment, call

the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019
(TTY users call 1-800-537-7697). You can also visit http://www.hhs.gov/ocr for more
information.

 You can also call your local Office for Civil Rights. For New York City, please call the New
York City Commission on Human Rights at 212-306-7450 or 311. Westchester residents,
please call the Westchester Human Rights Commission at 914-995-7710. Suffolk
residents, please call the Suffolk Human rights Commission at 631-853-5480. Nassau
residents, please call the Nassau Commission on Human Rights at 516-571-3662.

 If you have a disability and need help getting care or reaching a provider, call Participant
Services. If you have a grievance, such as a problem with wheelchair access, Participant
Services can help. You can reach Participant Services at 1-800-815-0000, Monday
through Sunday from 8am to 8pm. TTY users call 711.

C. We must ensure that you get timely access to covered services, items,
and drugs
As a Participant of GuildNet Gold Plus FIDA Plan these are your rights:

 You have the right to get medically necessary services, items, and drugs as required
to meet your needs, in a way that is sensitive to your language and culture, and that is
provided in an appropriate care setting, including the home and community.

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§ You have the right to choose a Primary Care Provider (PCP) in GuildNet Gold Plus

FIDA Plan’s network. A network provider is a provider who works with GuildNet Gold
Plus FIDA Plan. You can also ask us to have a specialist serve as your PCP. You
may also choose an out-of-network Medicare provider as your PCP, as long as your
provider is willing to bill the plan. Providers are encouraged to participate in your
Interdisciplinary Team (IDT), but they do not have to agree to participate in order to
be someone's PCP.
» Call Participant Services or look in the Provider and Pharmacy Directory to learn
which providers are accepting new patients.

§ You have the right to make decisions about providers and coverage, which includes
the right to choose and change providers within our network.

§ You have the right to go to a gynecologist or another women’s health specialist
without getting a referral or prior authorization.
» A referral is approval from your Primary Care Provider to see another Provider.
Referrals are not required in GuildNet Gold Plus FIDA Plan.
» Prior authorization means that you must get approval from your Interdisciplinary
Team (IDT), GuildNet Gold Plus FIDA Plan, or another specified provider before you
can get certain services, items, or drugs or see an out-of-network provider for your
Medicaid-covered services.

§ You have the right to access other services that do not require prior authorization,
such as emergency and urgently needed care, out-of-area dialysis services, and
Primary Care Provider visits. Please see Chapter 4 for more information on services
requiring prior authorization and those that do not.

§ You have the right to get covered services from network providers within a reasonable
amount of time.
» This includes the right to get timely services from specialists.

§ You have the right to have telephone access to your providers through on-call
services. You also have the right to access the GuildNet Gold Plus FIDA Plan Nurse
Advice Call Line 24 hours a day, 7 days a week in order to obtain any needed
emergency or urgent care or assistance.

§ You have the right to get your prescriptions filled at any of our network pharmacies
without long delays.

§ You have the right to access care without facing physical barriers. This includes the
right to be able to get in and out of a provider’s office, including barrier-free access if
you have any disabilities or other conditions limiting your mobility, in accordance with
the Americans with Disabilities Act.

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 You have the right to access an adequate network of primary and specialty providers
who are capable of meeting your needs with respect to physical access, as well as
communication and scheduling needs.

 You have the right to get reasonable accommodations in accessing care, in
interacting with GuildNet Gold Plus FIDA Plan and providers, and in getting
information about your care and coverage.

 You have the right to be told where, when, and how to get the services you need,
including how to get covered benefits from out-of-network providers if the providers
you need are not available in GuildNet Gold Plus FIDA Plan’s network. To learn about
out-of-network providers, see Chapter 3.
Chapter 9 explains what you can do if you think you are not getting your services, items, or
drugs within a reasonable amount of time. Chapter 9 also tells you what you can do if we
have denied coverage for your services, items, or drugs and you do not agree with our
decision.

D. We must protect your personal health information
We protect your personal health information as required by federal and state laws.

 You have the right to have privacy during treatment and to expect confidentiality of all
records and communications.

 Your personal health information includes the information you gave us when you
enrolled in GuildNet Gold Plus FIDA Plan. It also includes your conversations with
your providers, your medical records, and other medical and health information.

 You have the right to get information and to control how your health information is
used. We give you a written notice called the “Notice of Privacy Practice” that tells
about these rights. The notice also explains how we protect the privacy of your health
information.

 You have the right to ask that any communication that contains protected health
information from GuildNet Gold Plus FIDA Plan be sent by alternative means or to an
alternative address.
How we protect your health information

 We make sure that unauthorized people do not see or change your records.
 In most situations, we do not give your health information to anyone who is not
providing your care or paying for your care. If we do, we are required to get written

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permission from you first. Written permission can be given by you or by someone who
has the legal power to make decisions for you.

 There are certain cases when we do not have to get your written permission first.
These exceptions are allowed or required by law.
» We are required to release health information to government agencies that are
checking on our quality of care.
» We are required to give Medicare and Medicaid your health and drug information. If
Medicare or Medicaid releases your information for research or other uses, it will be
done according to Federal laws. You have the right to ask for information on how
your health and other information has been released by GuildNet Gold Plus FIDA
Plan.
You have a right to see your medical records

 You have the right to look at your medical records and to get a copy of your records.
 You have the right to ask us to update or correct your medical records. If you ask us
to do this, we will work with your health care provider to decide whether the changes
should be made.

 You have the right to know if and how your health information has been shared with
others.

 If you have questions or concerns about the privacy of your personal health information,
call Participant Services at 1-800-815-0000, Monday through Sunday from 8am to
8pm. TTY users call 711.

E. We must give you information about GuildNet Gold Plus FIDA Plan, its
network providers, and your covered services
As a Participant of GuildNet Gold Plus FIDA Plan, you have the right to get timely information
and updates from us. If you do not speak English, we must give you the information free of
charge in a language that you can understand. We must also provide you with a qualified
interpreter, free of charge, if you need one during appointments with providers. If you have
questions about GuildNet Gold Plus FIDA Plan or you are in need of interpreter services, just
call us at 1-800-815-0000. This is a free service. Written materials are available in Spanish,
Italian, Haitian-Creole, Chinese, Russian and Korean. We can also give you information in
other formats, such as large print, Braille, and audio.
If you want any of the following, call Participant Services:

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 Information about how to choose or change plans
 Information about GuildNet Gold Plus FIDA Plan, including:
» Financial information
» How GuildNet Gold Plus FIDA Plan has been rated by plan Participants
» The number of appeals made by Participants
» How to leave GuildNet Gold Plus FIDA Plan

 Information about our network providers and our network pharmacies,
including:

» How to choose or change Primary Care Providers
» The qualifications of our network providers and pharmacies
» How we pay the providers in our network

 For a list of providers and pharmacies in GuildNet Gold Plus FIDA Plan’s network,
see the Provider and Pharmacy Directory. For more detailed information about our
providers or pharmacies, call Participant Services, or visit our website at
www.guildnetny.org.

 Information about covered services, items, and drugs and about rules you must
follow, including:

» Services, items, and drugs covered by GuildNet Gold Plus FIDA Plan
» Limits to your coverage and drugs
» Rules you must follow to get covered services, items, and drugs

 Information about why a service, item, or drug is not covered and what you can
do about it, including:

» Asking us to put in writing why something is not covered
» Asking us to change a decision we made
» Asking us to pay for a bill you got

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F. Network providers cannot bill you directly
Doctors, hospitals, and other providers in our network cannot make you pay for covered
services, items, or drugs. They also cannot charge you if we pay less than the provider
charged us or if we don’t pay them at all. You have the right to not be charged any copays,
premiums, deductibles, or other cost-sharing. To learn what to do if a network provider tries
to charge you for covered services, items, or drugs, see Chapter 7 or call Participant
Services.

G. You have the right to leave GuildNet Gold Plus FIDA Plan at any time
No one can make you stay in our plan if you do not want to. You can leave the plan at any
time. If you leave GuildNet Gold Plus FIDA Plan, you will still be in the Medicare and
Medicaid programs as long as you remain eligible. You have the right to get most of your
health care services through Original Medicare or a Medicare Advantage plan. You can get
your Medicare Part D prescription drug benefits from a prescription drug plan or from a
Medicare Advantage plan. You also have the right to get your Medicaid services through
other programs including the Program of All-Inclusive Care for the Elderly (PACE), Medicaid
Advantage Plus, Managed Long-Term Care, or Medicaid Fee-For-Service (Original
Medicaid).

H. You have a right to make decisions about your health care
You have the right to know your treatment options and make decisions about your
services
You have the right to get full information from your doctors and other health care providers
when you get services. You also have the right to have access to doctors and other providers
who can meet your needs. This includes providers who can help you meet your health care
needs, communicate with you in a way that you can understand, and provide you with
services in locations that you can physically access. You may also choose to have a family
member or caregiver involved in your services and treatment discussions. You have the right
to appoint someone to speak for you about the care you need.

 Know your choices. You have the right to be told about all the kinds of treatment.
You have the right to talk with and get information from providers on all available

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treatment options and alternatives, regardless of cost, and to have these options
presented in a way you understand.

 Know the risks. You have the right to be told about any risks involved. You must be

told in advance if any service or treatment is part of a research experiment. You have
the right to refuse experimental treatments.

 You can get a second opinion. You have the right to see another provider before
deciding on treatment.

 You can say “no.” You have the right to accept or refuse any treatment. This

includes the right to leave a hospital or other medical facility, even if your provider
advises you not to. You also have the right to stop taking a drug. If you refuse
treatment or stop taking a drug, you will not be dropped from GuildNet Gold Plus
FIDA Plan. However, if you refuse treatment or stop taking a drug, you accept full
responsibility for what happens to you.

 You can ask us to explain why a provider denied care. You have the right to get

an explanation from us if a provider has denied care that you believe you should get.

 You have the right to get a written explanation. If covered services, items, or drugs
were denied, you have the right to get a written explanation without having to ask for
one.

 You can ask us to cover a service, item, or drug that was denied or is usually

not covered. This is called a coverage decision. Chapter 9 tells how to ask GuildNet
Gold Plus FIDA Plan or your Interdisciplinary Team (IDT) for a coverage decision.

 You can participate in your care planning. As a Participant in GuildNet Gold Plus

FIDA Plan, you will get an in-person Comprehensive Assessment within the first 90
days of your enrollment or within six months of your last assessment if you joined
GuildNet Gold Plus FIDA Plan from GuildNet MLTC or GuildNet Gold HMO SNP. You
will also meet with your IDT to develop your Person-Centered Service Plan (PCSP)
and to update it, when necessary. You have the right to ask for a new Comprehensive
Assessment or an update to your PCSP at any time. For more information, see
Chapter 1.

 You have the right to complete and accurate information related to your health
and functional status from your provider, your IDT, and GuildNet Gold Plus
FIDA Plan.

You have the right to say what you want to happen if you are unable to make health
care decisions for yourself
Sometimes people are unable to make health care decisions for themselves. Before that
happens to you, you can:

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§ Fill out a written form to give someone the right to make health care decisions
for you.

§ Give your providers written instructions about how you want them to handle your
health care if you become unable to make decisions for yourself.

The legal document that you can use to give your directions is called an advance directive.
There are different types of advance directives and different names for them. Examples are a
living will and a power of attorney for health care. When you enroll in the plan, we will inform
you about your right to make an advance directive. You will also be told about this right when
your Person-Centered Service Plan is updated.
You do not have to use an advance directive, but you can if you want to. Here is what to do:

 Get the form. You can get a form from your Primary Care Provider, a lawyer, a legal

services agency, or a social worker. Organizations that give people information about
Medicare or Medicaid (including Hospitals, Skilled Nursing Facilities, New York State
Health Insurance Information Counseling and Assistance Program) may also have
advance directive forms. You can get a New York State Health Care Proxy form on
the web at
http://www.health.state.ny.us/professionals/patients/health_care_proxy/intro.htm. You
can also contact Participant Services to ask for the forms.

 Fill it out and sign the form. The form is a legal document. You should consider
having a lawyer help you prepare it.

 Give copies to people who need to know about it. You should give a copy of the
form to your Primary Care Provider. You should also give a copy to the person you
name as the one to make decisions for you. You may also want to give copies to
close friends or family members. Be sure to keep a copy at home.

If you are going to be hospitalized and you have signed an advance directive, take a copy of
it to the hospital.

 The hospital will ask you whether you have signed an advance directive form and
whether you have it with you.

 If you have not signed an advance directive form, the hospital has forms available and
will ask if you want to sign one.
Remember, it is your choice to fill out an advance directive or not.
What to do if your instructions are not followed
GuildNet Gold Plus FIDA Plan and our providers must honor your instructions. If you have
signed an advance directive, and you believe that a provider did not follow the instructions in
it, you may file a complaint with the New York State Department of Health Hospital
Complaint Line at 1-800-804-5447 or the Managed Long Term Care Technical Assistance
Center at 1-866-712-7197.

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Chapter 8: Your rights and responsibilities

I. You have the right to ask for help
Chapter 2 contains contact numbers for many helpful resources. You have the right to ask for
help without interference from our GuildNet Gold Plus FIDA Plan. You can ask for help from
agencies like the Independent Consumer Advocacy Network (ICAN) or the NY State Long
Term Care Ombudsman.

 ICAN can provide information and assistance related to your GuildNet Gold Plus FIDA
Plan coverage. ICAN can be reached at 1-844-614-8800. (TTY users call 711, then
follow the prompts to dial 844-614-8800.)

 The NY State Long Term Care Ombudsman can provide information and assistance
about your rights as a resident of a long-term care facility. Call 1-800-342-9871 for
information about contacting your local long-term care ombudsman.
There are other resources available to you, including those listed in Chapter 2. You have the
right to ask for help from the entities listed in Chapter 2 or from any other entity you identify.

J. You have the right to file a grievance and to ask us to reconsider
decisions we have made
Chapter 9 tells what you can do if you have any problems or concerns about your covered
services or care. For example, you could ask us to make a coverage decision, make an
appeal to us to change a coverage decision, or file a grievance.
You have the right to get information about appeals and grievances that other Participants
have filed against GuildNet Gold Plus FIDA Plan. To get this information, call Participant
Services.
What to do if you believe you are being treated unfairly or your rights are not being
respected
If you believe you have been treated unfairly—and it is not about discrimination for the
reasons listed on page 150—you can get help in these ways:

 You can call Participant Services and file a grievance with GuildNet Gold Plus FIDA
Plan as outlined in Chapter 9.

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 You can call the Health Insurance Information, Counseling and Assistance
Program (HIICAP) at 1-800-701-0501.

 You can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7
days a week. TTY users call 1-877-486-2048.

 You can call Medicaid at 1-800-541-2831. TTY users call 1-877-898-5849.
 You can call the Independent Consumer Advocacy Network (ICAN) at 1-844-6148800. (TTY users call 711, then follow the prompts to dial 844-614-8800.)

Under all circumstances, you have the right to file an internal grievance with GuildNet Gold
Plus FIDA Plan, an external grievance with Medicare or the New York State Department of
Health (NYSDOH), or an appeal of any coverage decision. The processes for filing any of
these are outlined in Chapter 9.
How to get more information about your rights
There are several ways to get more information about your rights:

 You can call Participant Services.
 You can call the Health Insurance Information, Counseling and Assistance
Program (HIICAP) at 1-800-701-0501.

 You can contact Medicare.
» You can visit the Medicare website to read or download “Medicare Rights &
Protections.” (Go to http://www.medicare.gov/Publications/Pubs/pdf/11534.pdf.)
» Or you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days
a week. TTY users call 1-877-486-2048.

How to get help understanding your rights or exercising them
You can call the Independent Consumer Advocacy Network (ICAN) at 1-844-6148800. TTY users call 711, then follow the prompts to dial 844-614-8800. ICAN
provides free information and assistance. It is not affiliated with our plan.

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K. You have the right to suggest changes
You have the right to recommend changes in policies and services to GuildNet Gold Plus
FIDA Plan, Medicare, the New York State Department of Health, or any outside
representative of your choice.

L. You also have responsibilities as a Participant of GuildNet Gold Plus
FIDA Plan
As a Participant of GuildNet Gold Plus FIDA Plan, you have a responsibility to do the
things that are listed below. If you have any questions, call Participant Services.

 Read the Participant Handbook to learn what is covered and what rules you

need to follow to get covered services, items, and drugs. This includes choosing
a Primary Care Provider and using network providers for Medicaid-covered services,
items, and drugs. If you don’t understand something, call Participant Services.

» For details about your covered services and items, see Chapters 3 and 4. Those
chapters tell you what is covered, what is not covered, what rules you need to
follow, and what you pay.
» For details about your covered drugs, see Chapters 5 and 6.

 Tell us about any other health or prescription drug coverage you have. We are
required to make sure you are using all of your coverage options when you get
services. Please call Participant Services if you have other coverage.

 Tell your Primary Care Provider and other providers that you are enrolled in

GuildNet Gold Plus FIDA Plan. Show your GuildNet Gold Plus FIDA Plan Participant
ID Card whenever you get services, items, or drugs.

 Help your Primary Care Provider and other providers give you the best care.
» Call your Primary Care Provider or Care Manager if you are sick or injured for
direction right away. When you need emergency care from out-of-network
providers, notify GuildNet Gold Plus FIDA Plan as soon as possible. In case of
emergency, call 911.
» Give your providers the information they need about you and your health. Learn as
much as you can about your health problems. Follow the treatment plans and
instructions that you and your providers agree on.
» Make sure that your Primary Care Provider and other providers know about all of the
drugs you are taking. This includes prescription drugs, over-the-counter drugs,
vitamins, and supplements.

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» If you have any questions, be sure to ask. Your providers must explain things in a
way you can understand. If you ask a question and you do not understand the
answer, ask again.
» Understand the role of your Primary Care Provider, your Care Manager, and your
Interdisciplinary Team (IDT) in providing your care and arranging other health care
services that you may need.
» Participate in the development of your Person-Centered Service Plan (PCSP) with
your IDT and keep appointments or notify your Care Manager or IDT if an
appointment cannot be met.

 Be considerate. We expect all of our Participants to respect the rights of other

Participants. We also expect you to act with respect in your Primary Care Provider’s
office, hospitals, other providers’ offices, and when dealing with GuildNet Gold Plus
FIDA Plan employees.

 Pay what you owe. As a GuildNet Gold Plus FIDA Plan Participant, you are

responsible for paying the full cost of any services, items, or drugs that are not
covered by the plan.

 If you disagree with your IDT’s decision or GuildNet Gold Plus FIDA Plan’s

decision to not cover a service, item, or drug, you can make an appeal. Please see
Chapter 9 to learn how to make an appeal.

 Tell us if you move. If you are going to move, it is important to tell us right away. Call
Participant Services.

» If you move outside of our service area, you cannot be a GuildNet Gold Plus
FIDA Plan Participant. Chapter 1 tells about our service area. The Enrollment
Broker can help you figure out whether you are moving outside our service area and
can help you identify alternative Medicare and Medicaid coverage. Also, be sure to
let Medicare and Medicaid know your new address when you move. See Chapter 2
for phone numbers for Medicare and Medicaid.
» If you move within our service area, we still need to know. We need to keep
your membership record up to date and know how to contact you.

 Tell us if you have any changes in your personal information, including your

income or assets. You must provide GuildNet Gold Plus FIDA Plan with accurate
and complete information.

» It is important to tell us right away if you have a change in personal information such
as phone number, address, marital status, additions to your family, eligibility, or
other health insurance coverage.

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» If your assets in bank accounts, cash in hand, certificates of deposit, stocks, life
insurance policies, or any other assets change, please notify Participant Services
and New York State.

 Call Participant Services for help if you have any questions or concerns. Let us
know about any problems immediately.

CHAPTER 9
What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

164

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Table of Contents
What’s in this chapter? .......................................................................................................................167
If you are facing a problem with your health or long-term services and supports ................................ 167
Section 1: Introduction .......................................................................................................................168
Section 1.1: What to do if you have a problem .............................................................................. 168
Section 1.2: What do the legal terms mean? ................................................................................ 168
Section 2: Where to call for help ........................................................................................................ 169
Section 2.1: Where to get more information and help .................................................................... 169
Section 3: Problems with your coverage ............................................................................................ 170
Section 3.1: Deciding whether you should file an appeal or a grievance ....................................... 170
Section 4: Coverage decisions and appeals....................................................................................... 171
Section 4.1: Overview of coverage decisions and appeals ............................................................ 171
Section 4.2: Getting help with coverage decisions and appeals..................................................... 171
Section 4.3: Which section of this chapter will help you? ............................................................... 172
Section 5: Problems about services, items, and drugs (but not Medicare Part D drugs) ..................... 172
Section 5.1: When to use this section ............................................................................................ 172
Section 5.2: Asking for a coverage decision .................................................................................. 176
Section 5.3: Level 1 Appeal for services, items, and drugs (but not Medicare Part D drugs).......... 178
Section 5.4: Level 2 Appeal for services, items, and drugs (but not Medicare Part D drugs).......... 182
Section 5.5: Payment problems ..................................................................................................... 184
Section 6: Medicare Part D drugs....................................................................................................... 186
Section 6.1: What to do if you have problems getting a Part D drug or you want us to pay
you back for a Part D drug ............................................................................................................. 186
Section 6.2: What is an exception?................................................................................................ 187
Section 6.3: Important things to know about asking for exceptions ................................................ 188

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(coverage decisions, appeals, grievances)

Section 6.4: How to ask for a coverage decision about a Part D drug or reimbursement for
a Part D drug, including an exception .......................................................................................... 189
Section 6.5: Level 1 Appeal for Part D drugs ............................................................................... 192
Section 6.6: Level 2 Appeal for Part D drugs ............................................................................... 195
Section 7: Asking us to cover a longer hospital stay ......................................................................... 197
Section 7.1: Learning about your Medicare rights ........................................................................ 197
Section 7.2: Quality Improvement Organization (QIO) Level 1 Appeal to change your
hospital discharge date................................................................................................................. 198
Section 7.3: Quality Improvement Organization (QIO) Level 2 Appeal to change your
hospital discharge date................................................................................................................. 200
Section 7.4: What happens if I miss an appeal deadline? ............................................................ 201
Section 8: What to do if you think your home health care, skilled nursing care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon ............ 203
Section 8.1: We will tell you in advance when your coverage will be ending ................................ 203
Section 8.2: Quality Improvement Organization (QIO) Level 1 Appeal to continue your
care ............................................................................................................................................. 203
Section 8.3: Quality Improvement Organization (QIO) Level 2 Appeal to continue your
care ............................................................................................................................................. 206
Section 8.4: What if you miss the deadline for making your Level 1 Appeal? ............................... 207
Section 9: Taking your appeal beyond Level 2 ................................................................................. 209
Section 9.1: Next steps for services, items, and drugs (not Medicare Part D drugs) .................... 209
Section 9.2: Next steps for Medicare Part D drugs ...................................................................... 209
Section 10: How to file a grievance .................................................................................................. 210
Section 10.1: Internal grievances ................................................................................................ 211
Section 10.2: External grievances ............................................................................................... 212

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)
What’s in this chapter?
This chapter has information about coverage decisions and your grievance and appeal rights.
Read this chapter to find out what to do if:
 You have a problem with or complaint about your plan.
 You need a service, item, or drug that your Interdisciplinary Team (IDT) or plan has
said the plan will not pay for.
 You disagree with a decision that your IDT or plan has made about your care.
 You think your covered services and items are ending too soon.
If you have a problem or concern, you only need to read the parts of this chapter that
apply to your situation. This chapter is broken into different sections to help you easily find
information about what to do for your problem or concern.

If you are facing a problem with your health or long-term
services and supports
You should get the health care, drugs, and long-term services and supports that your
Interdisciplinary Team (IDT) determines are necessary for your care, whether included in
your Person-Centered Service Plan (PCSP) or because a need arose outside of your PCSP.
If you are having a problem with your care, you can call the Independent Consumer
Advocacy Network (ICAN) at 1-844-614-8800 for help. This chapter explains the different
options you have for different problems and complaints, but you can always call ICAN to help
guide you through your problem.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 1: Introduction
Section 1.1: What to do if you have a problem
This chapter tells you what to do if you have a problem with your plan or with your services or
payment. Medicare and Medicaid approved these processes. Each process has a set of
rules, procedures, and deadlines that must be followed by us and by you.

Section 1.2: What do the legal terms mean?
There are difficult legal terms for some of the rules and deadlines in this chapter. Many of
these terms can be hard to understand, so we have used simpler words in place of certain
legal terms. We use abbreviations as little as possible.
For example, we will say:
 “Coverage decision” rather than “organization determination” or “coverage
determination”
 “Fast coverage decision” rather than “expedited determination”
Understanding and knowing the meaning of the proper legal terms can help you
communicate more clearly, so we provide those too.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 2: Where to call for help
Section 2.1: Where to get more information and help
Sometimes it can be confusing to start or follow the process for dealing with a problem. This
can be especially true if you do not feel well or have limited energy. Other times, you may not
have the knowledge you need to take the next step.

You can get help from the Independent Consumer Advocacy Network
If you need help, you can always call the Independent Consumer Advocacy Network (ICAN).
The state created ICAN to help you with appeals and other issues. ICAN can answer your
questions and help you understand what to do to handle your problem. ICAN is not
connected with us or with any insurance company or health plan. ICAN can help you
understand your rights and how to share your concerns or disagreement. ICAN can also help
you in communicating your concerns or disagreement with us. The toll-free phone number for
ICAN is 1-844-614-8800. The services are free.

You can get help from the State Health Insurance Assistance Program
You can also call your State Health Insurance Assistance Program (SHIP). The SHIP is a
state program that gets funding from the federal government. In New York State, the SHIP is
called the Health Insurance Information, Counseling, and Assistance Program (HIICAP).
HIICAP counselors can answer your questions and help you understand what to do to handle
your problem. The HIICAP is not connected with us or with any insurance company or health
plan. The HIICAP has trained counselors and services are free. The HIICAP phone number
is 1-800-701-0501.

Getting help from Medicare
You can also call Medicare directly for help with problems. Here are two ways to get help
from Medicare:
 Call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048. The call is free.
 Visit the Medicare website (http://www.medicare.gov).

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 3: Problems with your coverage
Section 3.1: Deciding whether you should file an appeal or a
grievance
If you have a problem or concern, you only need to read the parts of this chapter that
describe the process for your type of concern. The chart below will help you find the right
section of this chapter for appeals and grievances.
Is your problem or concern about your coverage?
(This includes problems about whether particular services, items, or prescription drugs are
covered or not, the way in which they are covered, and problems related to payment for
services, items, or prescription drugs.)

Yes.

No.

My problem is about
coverage.

My problem is not about
coverage.

Go to Section 4: “Coverage
decisions and appeals” on page 171.

Skip ahead to Section 10: “How to file
a grievance” on page 210.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 4: Coverage decisions and appeals
Section 4.1: Overview of coverage decisions and appeals
The process for asking for coverage decisions and making appeals deals with problems
related to your benefits and coverage. It also includes problems with payment.

What is a coverage decision?
A coverage decision is an initial decision your Interdisciplinary Team (IDT), the plan, or an
authorized specialist makes about your benefits and coverage or about the amount the plan
will pay for your medical services, items, or drugs. The IDT, plan, or authorized specialist is
making a coverage decision whenever it decides what is covered for you and how much the
plan will pay. Authorized specialists include dentists, optometrists, ophthalmologists, and
audiologists.
If you or your provider is not sure if a service, item, or drug is covered by the plan, either of
you can ask for a coverage decision before the provider gives the service, item, or drug.

What is an appeal?
An appeal is a formal way of asking us to review a decision made by your IDT, the plan, or an
authorized specialist and change it if you think a mistake was made. For example, the IDT,
plan, or authorized specialist might decide that a service, item, or drug that you want is not
covered. If you or your provider disagree with that decision, you can appeal.



NOTE: You are a member of your IDT. You can appeal even if you participated in the
discussions that led to the coverage decision that you wish to appeal.

Section 4.2: Getting help with coverage decisions and appeals
Who can I call for help asking for coverage decisions or making an appeal?
You can ask any of these people for help:
 Call Participant Services at 1-800-815-0000. TTY users call 711.
 Call your Care Manager at 1-800-815-0000. TTY users call 711.
 Call the Independent Consumer Advocacy Network (ICAN) for free help. ICAN is an
independent organization. It is not connected with this plan. The phone number is 1844-614-8800.
 Call the Health Insurance Information, Counseling, and Assistance Program
(HIICAP) for free help. The HIICAP is an independent organization. It is not connected
with this plan. The phone number is 1-800-701-0501.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

 Talk to your provider. Your provider can ask for a coverage decision or appeal on
your behalf.
 Talk to a friend or family member and ask him or her to act for you. You can name
another person to act for you as your “representative” to ask for a coverage decision or
make an appeal.
» Anyone can help you request a coverage determination or an appeal.
» Only someone you designate in writing can represent you during your appeal. If you
want a friend, relative, or other person to be your representative during your appeal,
you can either complete an “Appointment of Representative” form or you can write
and sign a letter indicating who you want to be your representative.
o

To get an “Appointment of Representative” form, call Participant Services and
ask for the form. You can also get the form on the Medicare website at
https://www.cms.gov/Medicare/CMS-Forms/CMSForms/downloads/cms1696.pdf or on our website at www.guildnetny.org. The
form gives the person permission to act for you. You must give us a copy of
the signed form; OR

You can write a letter and either send it to us or have the person listed in the
letter as your representative send it to us.

 You also have the right to ask a lawyer to act for you. You may call your own lawyer,
or get the name of a lawyer from the local bar association or other referral service.
Some legal groups will give you free legal services if you qualify. If you want a lawyer
to represent you, you will need to fill out the Appointment of Representative form.
However, you do not need to have a lawyer to ask for any kind of coverage decision
or to make an appeal.

Section 4.3: Which section of this chapter will help you?
There are four different types of situations that involve coverage decisions and appeals.
Each situation has different rules and deadlines. We separate this chapter into different
sections to help you find the rules you need to follow. You only need to read the section
that applies to your problem:


Section 5 on page 175 gives you information on what to do if you have problems
about services, items, and drugs (but not Medicare Part D drugs). For example, use
this section if:
o

You are not getting medical care you want, and you believe the plan covers
this care.

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The Interdisciplinary Team (IDT), plan, or authorized specialist did not approve
services, items, or drugs that your provider wants to give you, and you believe
this care should be covered.
§



NOTE: Only use Section 5 if these are drugs not covered by Part D.
Drugs in the List of Covered Drugs in tiers 3 or 4 <(*) > are not covered
by Part D. See Section 6 on page 186 for instructions about the Part D
drug appeals process.

You got services or items you think should be covered, but the IDT, plan, or
authorized specialist decided that the plan will not pay for this care.

You got and paid for services or items that you thought were covered, and you
want the plan to pay you back.

You are being told that coverage for care you have been getting will be
reduced or stopped, and you disagree with the decision.
§



Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

NOTE: If the coverage that will be stopped is for hospital care, home
health care, skilled nursing facility care, or Comprehensive Outpatient
Rehabilitation Facility (CORF) services, you need to read a separate
section of this chapter because special rules apply to these types of
care. See Sections 7 and 8 on pages 197 and 203.

Section 6 on page 186 gives you information about Part D drugs. For example, use
this section if:
o

You want to ask the plan or your IDT to make an exception to cover a Part D
drug that is not on the plan’s List of Covered Drugs (Drug List).

You want to ask the plan or your IDT to waive limits on the amount of the drug
you can get.

You want to ask the plan or your IDT to cover a drug that requires prior
approval.

The plan or your IDT did not approve your request or exception, and you or
your provider think we should have.

You want to ask the plan to pay for a prescription drug you already bought.
(This is asking the plan or your IDT for a coverage decision about payment.)

Section 7 on page 197 gives you information on how to ask us to cover a longer
inpatient hospital stay if you think the provider is discharging you too soon. Use this
section if:

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o


Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

You are in the hospital and think the provider asked you to leave the hospital
too soon.

Section 8 on page 203 gives you information if you think your home health care,
skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility
(CORF) services are ending too soon.

If you’re not sure which section you should use, please call Participant Services at 1800-815-0000. TTY users call 711.
If you need other help or information, please call the Independent Consumer Advocacy
Network (ICAN) at 1-844-614-8800.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 5: Problems about services, items, and drugs (but not
Medicare Part D drugs)
Section 5.1: When to use this section
This section is about what to do if you have problems with your coverage for your medical,
behavioral health, and long term care services. You can also use this section for problems
with drugs that are not covered by Part D. Drugs in the List of Covered Drugs in tiers 3 and 4
(*) are not covered by Part D. Use Section 6 of this chapter for information about Part D drug
appeals.
This section tells what you can do if you are in any of the five following situations:

1. You think the plan covers a medical, behavioral health, or long-term care
service that you need but are not getting.
What you can do: You can ask your Interdisciplinary Team (IDT), the plan, or
an authorized specialist to make a coverage decision. Go to Section 5.2 on
page 176 for information on asking for a coverage decision. If you disagree
with that coverage decision, you can file an appeal.

2. The IDT, plan, or authorized specialist did not approve care your provider
wants to give you, and you think it should have.
What you can do: You can appeal the decision to not approve your services.
Go to Section 5.3 on page 178 for information on making an appeal.

3. You got services or items that you think the plan covers, but the IDT,
plan, or authorized specialist decided that the plan will not pay.
What you can do: You can appeal the decision that the plan will not pay.
Go to Section 5.3 on page 178 for information on making an appeal.

4. You got and paid for services or items you thought were covered, and
you want the plan to reimburse you for the services or items.
What you can do: You can ask the IDT, plan, or authorized specialist
to authorize the plan to pay you back. Go to Section 5.5 on page 184 for
information on asking for payment.

5. The IDT, plan, or authorized specialist changed or stopped your
coverage for a certain service, and you disagree with the decision.
What you can do: You can appeal the decision to change or stop the
service. Go to Section 5.3 on page 178 for information on making an appeal.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

NOTE: If the coverage that will be stopped is for hospital care, home health
care, skilled nursing facility care, or Comprehensive Outpatient
Rehabilitation Facility (CORF) services, special rules apply. Read Sections
7 or 8 on pages 197 and 203 to find out more.

Section 5.2: Asking for a coverage decision
How to ask for a coverage decision to get a medical, behavioral health, or long-term
care service
If there is a service, item, or drug that you feel you need, ask your Interdisciplinary Team
(IDT), the plan, or an authorized specialist to approve that service, item, or drug for you. You
can do this by contacting your Care Manager and telling him/her that you want a coverage
decision. Or you can call, write, or fax us, or ask your representative or provider to contact us
and ask for a coverage decision.
o

You can call us at: 1-800-815-0000 TTY users call: 711.

You can fax us at: 212-769-1621

You can write to us at:
Attn: Utilization Management Department
15 West 65th Street
New York, NY 10023

Once you’ve asked, the IDT, plan, or authorized specialist will make a coverage decision.
How long does it take to get a coverage decision?
It usually takes up to 3 business days after you asked. If you do not receive a decision within
3 business days, you can appeal.



Sometimes the IDT, plan, or authorized specialist needs more time to make a decision. In
this case, you will get a letter telling you that it could to take up to 3 more calendar days.
The letter will explain why more time is needed.

There are three exceptions to the decision deadline described above:

 For coverage decisions about continuing or adding to your current health care
services, you will get a decision within 1 business day.

 For coverage decisions about home health care services after an inpatient hospital
stay, you will get a decision within 1 business day. However, if the day after your
request is a weekend or holiday, you will get a decision within 72 hours.

 For coverage decisions on a service, item, or drug that you already got, you will get a
decision within 14 calendar days.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Can I get a coverage decision faster?
Yes. If you need a response faster because of your health, ask for a “fast coverage decision.”
If the IDT, plan, or authorized specialist approves the request, you will get a decision within
24 hours.
However, sometimes the IDT, plan, or authorized specialist needs more time. In this case,
you will get a letter telling you that it could to take up to 3 more calendar days. The letter will
explain why more time is needed.

The legal term for “fast coverage decision” is “expedited determination.”

If you want to ask for a fast coverage decision, you can do one of three things:


Call your Care Manager;



Call Participant Services at 1-800-815-0000 (TTY users call 711) or fax us at 1-212769-1621; or



Have your provider or your representative call Participant Services.

Here are the rules for asking for a fast coverage decision:
You must meet the following two requirements to get a fast coverage decision:
1. You can get a fast coverage decision only if you are asking for coverage for a service,
item, or drug you have not yet received. (You cannot get a fast coverage decision if
your request is about payment for a service, item, or drug you already got.)
2. You can get a fast coverage decision only if the standard 3 business day deadline
could seriously jeopardize your life, health, or ability to attain, maintain or regain
maximum function.



If your provider says that you need a fast coverage decision, you will
automatically get one.



If you ask for a fast coverage decision without your provider’s support, the
IDT, plan, or authorized specialist will decide if you get a fast coverage
decision.


If the IDT, plan, or authorized specialist decides that your health does
not meet the requirements for a fast coverage decision, you will get a
letter. The IDT, plan, or authorized specialist will also use the standard
3 business day deadline instead.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

This letter will tell you that if your provider asks for the fast coverage
decision, you will automatically get a fast coverage decision.

The letter will also tell how you can file a “fast grievance” about the
decision to give you a standard coverage decision instead of a fast
coverage decision. For more information about the process for filing
grievances, including fast grievances, see Section 10 on page 210.

If the coverage decision is Yes, when will I get the service, item, or drug?
If the coverage decision is Yes, that means you are approved to get the service, item, or
drug. If possible, you will receive or start to receive the approved service, item, or drug within
3 business days from the date of our decision. If the service, item, or drug cannot reasonably
be provided within 3 business days, your IDT will work with the provider to make sure you get
the approved service, item, or drug as quickly as possible.

If the coverage decision is No, how will I find out?
If the answer is No, you will receive a letter explaining why. The plan or your IDT will also
notify you by phone.


If the IDT, plan, or authorized specialist says No, you have the right to ask us to
change the decision. You can do this by making (or “filing”) an appeal. Making an
appeal means asking our plan to review the decision to deny coverage.



If you decide to make an appeal, it means you are going on to Level 1 of the
appeals process (read the next section for more information).

Section 5.3: Level 1 Appeal for services, items, and drugs (but not
Medicare Part D drugs)
What is an appeal?
An appeal is a formal way of asking us to review the coverage decision and change it if you
think there was a mistake. If you or your provider disagree with the decision, you can appeal.
In all cases, you must start your appeal at Level 1.
If you need help during the appeals process, you can call the Independent Consumer
Advocacy Network (ICAN) at 1-844-614-8800. ICAN is not connected with us or with any
insurance company or health plan.

What is a Level 1 Appeal?
A Level 1 Appeal is the first appeal to GuildNet Gold Plus FIDA Plan. Our plan will review
your coverage decision to see if it is correct. The reviewer will be someone at our plan who is
not part of your Interdisciplinary Team (IDT) and was not involved in the original coverage

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

decision. When we complete the review, we will give you our decision in writing. If you need a
fast decision because of your health, we will also try to notify you by phone.
If we do not decide the Level 1 Appeal in your favor, we will automatically forward your
appeal to the Integrated Administrative Hearing Office for a Level 2 Appeal.

How do I make a Level 1 Appeal?
o

To start your appeal, you, your provider,
or your representative must contact us.
You can call us at 1-800-815-0000 or
you may appeal in writing. For additional
details on how to reach us for appeals,
see Chapter 2.
You can ask us for a “standard appeal”
or a “fast appeal.”

decision you are appealing. If you miss
the deadline for a good reason, you
may still appeal.

If you are asking for a fast appeal, you
should call us at 1-800-815-0000. TTY
users should call 711.

If you are asking for a standard appeal,
make your appeal in writing or call us.
You can submit a request to the
following address:
GuildNet Gold Plus FIDA Plan
Appeals
15 West 65th Street
New York, NY 10023


You, your doctor, or your representative
may put your request in writing and mail
or fax it to us. You may also ask for an
appeal by calling us.

 Ask within 60 calendar days of the



At a glance: How to make a Level 1
Appeal

 If you appeal because you were told
that a service you currently get will be
changed or stopped, you have fewer
days to appeal if you want to keep
getting that service while your appeal
is processing.

 Keep reading this section to learn
about what deadline applies to your
appeal.

You may also ask for an appeal by
calling us at 1-800-815-0000. TTY
users should call 711.

The legal term for “fast appeal” is “expedited appeal.”

Can someone else make the appeal for me?
Yes. Anyone can make the appeal for you, but only someone you designate in writing can
represent you during your appeal. To make someone your representative, you must complete

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

an “Appointment of Representative” form or write and sign a letter indicating who you want to
be your representative. The form or letter gives the other person permission to act for you.

 To complete an “Appointment of Representative” form, call Participant Services and
ask for the form. You can also get the form on the Medicare website at
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf or
on our website at www.guildnetny.org. The form gives the person permission to act
for you. You must give us a copy of the signed form; OR

 You can write a letter and either send it to us or have the person listed in the letter as
your representative send it to us.



NOTE: Sometimes, a provider may appeal a plan decision about payment for your care.
This is different from an appeal made on your behalf. You do not need to be involved in
the provider’s appeal.

How much time do I have to make an appeal?
You must ask for an appeal within 60 calendar days from the date on the letter that you
received informing you of the coverage decision.
If you miss this deadline and have a good reason for missing it, we may give you more time
to make your appeal. Examples of a good reason are: you had a serious illness, or we gave
you the wrong information about the deadline for requesting an appeal.

 NOTE: If you appeal because you were told that a service you currently get will be

changed or stopped, you have fewer days to appeal if you want to keep getting that
service while your appeal is processing. Read “Will my benefits continue during Level
1 Appeals” on page 182 for more information.

Can I get a copy of my case file?
Yes. Call Participant Services at 1-800-815-0000 (TTY users call 711) and ask for a copy of
your case file. We will provide a copy of your case file at no cost to you.

Can my provider give you more information about my appeal?
Yes, you and your provider may give us more information to support your appeal.

How will we make the appeal decision?
We take a careful look at all of the information about your request for coverage of
services or items. Then, we check to see if all the rules were followed when the IDT, plan, or
authorized specialist said No to your request. The reviewer will be someone who is not on
your IDT and was not involved in making the original decision.
If we need more information, we may ask you or your provider for it.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

When will I hear about a “standard” appeal decision?
If your appeal is about Medicaid prescription drugs, we must give you our answer within 7
calendar days from the date we received the appeal. For all other appeals, we must give you
our answer within 30 calendar days from the date we received the appeal. We will give you
our decision sooner if your health condition requires us to do so.
§ However, if you ask for more time or if we need to gather more information, we can
take up to 14 more calendar days. If we decide to take additional time to make the
decision, we will send you a letter that explains why we need more time.
§ If you believe we should not take extra time, you can file a “fast grievance” about our
decision to take extra time. When you file a fast grievance, we will respond to your
grievance within 24 hours. For more information about the process for filing grievances,
including fast grievances, see Section 10 on page 210.
§ If we do not give you an answer to your “standard” appeal within 7 calendar days (for
Medicaid prescription drug appeals) or 30 calendar days (for all other appeals), or by
the end of the extra time (if it was taken), we will automatically send your case to Level
2 of the appeals process. You will be notified when this happens. For more information
about the Level 2 Appeal process, go to Section 5.4 on page 182.



If our answer is Yes to part or all of what you asked for, we must approve the coverage
within 7 calendar days after we get your Medicaid prescription drug appeal or 30 calendar
days after we get your other type of appeal.



If our answer is No to part or all of what you asked for, we will send you a letter. The
letter will tell you that we sent your case to the Integrated Administrative Hearing Office
for a Level 2 Appeal. For more information about the Level 2 Appeal process, go to
Section 5.4 on page 182.

When will I hear about a “fast” appeal decision?
If you ask for a fast appeal, we will give you an answer within 72 hours after we get your
appeal. We will give you our answer sooner if your health requires us to do so.
§ However, if you ask for more time or if we need to gather more information, we can
take up to 14 more calendar days. If we decide to take extra time to make the decision,
we will send you a letter that explains why we need more time.
§ If you believe we should not take extra time, you can file a “fast grievance” about our
decision to take extra time. When you file a fast grievance, we will respond to your
grievance within 24 hours. For more information about the process for filing grievances,
including fast grievances, see Section 10 on page 210.
§ If we do not give you an answer to your appeal within 72 hours or by the end of the
extra time (if it was taken), we will automatically send your case to Level 2 of the

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appeals process. You will be notified when this happens. For more information
about the Level 2 Appeal process, go to Section 5.4 on page 182.



If our answer is Yes to part or all of what you asked for, we must authorize or provide
the coverage within 72 hours after we get your appeal.



Will my benefits continue during Level 1 Appeals?
If the IDT, plan, or authorized specialist decided to change or stop coverage for a service,
item, or drug that you currently get, we will send you a notice before taking the proposed
action.
If you disagree with the action, you can file a Level 1 Appeal. We will continue covering the
service, item, or drug if you ask for a Level 1 Appeal within 10 calendar days of the
postmark date on our notice or by the intended effective date of the action, whichever
is later.
If you meet this deadline, you can keep getting the service, item, or drug with no changes
while your appeal is pending. All other services, items, or drugs (that are not the subject of
your appeal) will also continue with no changes.

Section 5.4: Level 2 Appeal for services, items, and drugs (but not
Medicare Part D drugs)
If the plan says No at Level 1, what happens next?
If we say No to part or all of your Level 1 Appeal, we will automatically send your case to
Level 2 of the appeals process for review by the Integrated Administrative Hearing Office.

What is a Level 2 Appeal?
A Level 2 Appeal is the second appeal, which is done by the Integrated Administrative
Hearing Office (IAHO). The IAHO is an independent organization that is not connected to
GuildNet Gold Plus FIDA Plan. The IAHO is part of the FIDA Administrative Hearing Unit at
the State Office of Temporary and Disability Assistance (OTDA).

What will happen at the Level 2 Appeal?
We will automatically send any Level 1 denials (in whole or in part) to the IAHO for a Level 2
Appeal. We will notify you that your case was sent to Level 2 and that the IAHO will be in
touch. The notice will also provide the contact information for the IAHO in the event that you
do not hear from them to schedule your Level 2 Appeal hearing. You should receive a Notice

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

of Administrative Hearing from the IAHO at least 10 calendar days before your hearing date.
Your hearing will be conducted by a Hearing Officer in-person or on the phone. You may
ask us for a copy of your case file by calling Participant Services at 1-800-815-0000.
Your Level 2 Appeal will either be a “standard” appeal or it will be a “fast” appeal. If you had
a fast appeal at Level 1, you will automatically have a fast appeal at Level 2. Additionally, if
the IAHO determines that you need a fast appeal, they will give you one. Otherwise, you will
have a standard appeal.

Standard Level 2 Appeal: If your standard appeal is about Medicaid prescription drugs,
the IAHO must give you an answer within 7 calendar days of when it gets your appeal.
For all other standard appeals, the IAHO must give you an answer within 62 calendar
days from the date you asked for an appeal with our plan. The IAHO will give you a
decision sooner if your health condition requires it.



Fast Level 2 Appeal: The IAHO must give you an answer within 72 hours of when it gets
your appeal.

Will my benefits continue during Level 2 Appeals?
If you qualified for continuation of benefits when you filed your Level 1 Appeal, your benefits
for the service, item, or drug under appeal will also continue during Level 2. Go to page 182
for information about continuing your benefits during Level 1 Appeals.
All other services, items, and drugs (that are not the subject of your appeal) will also
continue without any changes.

How will I find out about the decision?
When the IAHO makes a decision, it will send you a letter that explains its decision and
provides information about your further appeal rights. If you qualified for a fast appeal, the
IAHO will also tell you the decision by phone.

If the IAHO says Yes to part or all of what you asked for, we must authorize the items or
services immediately (within no more than 1 business day from the date of the decision).



If the IAHO says No to part or all of what you asked for, it means that they agree with the
Level 1 decision. This is called “upholding the decision.” It is also called “turning down
your appeal.” You can further appeal the IAHO’s decision.

If the IAHO’s decision is No for all or part of what I asked for, can I make
another appeal?
If you disagree with the IAHO’s decision, you may appeal that decision further to the
Medicare Appeals Council (MAC) for a Level 3 Appeal. The IAHO’s decision is not
automatically forwarded to the MAC. Instead, you will have to request that appeal.

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Instructions on how to file an appeal with the MAC will be included in the IAHO’s decision
notice.
See Section 9 on page 209 for more information on additional levels of appeal.

Section 5.5: Payment problems
GuildNet Gold Plus FIDA Plan has rules for getting services, items, and drugs. One of the
rules is that the services, items, and drugs that you get must be covered by our plan. Another
rule is that you must get your services, items, and drugs from providers that our plan works
with. Chapter 3 explains the rules, including special rules for when you first join the plan. If
you follow all of the rules, then we will pay for your services, items, and drugs.
If you are not sure if we will pay for a service, item, or drug, ask your Care Manager. Your
Care Manager will be able to tell you if we will likely pay for the service, item, or drug, or if
you need to ask us for a coverage decision.
If you choose to get a service, item, or drug that is not covered by our plan, or if you get a
service, item, or drug from a provider that our plan does not work with, then we will not
automatically pay for the service, item, or drug. In that case, you may have to pay for the
service, item, or drug yourself. If you want to ask us for payment, start by reading Chapter 7:
Asking us to pay a bill you have gotten for covered services, items, or drugs. Chapter 7
describes the situations in which you may need to ask us for reimbursement or to pay a bill
you got from a provider. It also tells how to send us the paperwork that asks us for payment.

What if I followed the rules for getting services, items, and drugs, but I got a bill
from a provider?
We do not allow providers to bill you for covered services, items, and drugs. This is true even
if we pay the provider less than the provider charges for a covered service, item, or drug. If a
provider bills you for any charges that we did not pay, that is called “balance billing.” You are
never required to pay the balance of any bill.
If you get a bill for covered services, items, or drugs, send the bill to us. You should not pay
the bill yourself. We will contact the provider directly and take care of the problem.

Can I ask to be paid back for a service, item, or drug I paid for?
Remember, if you get a bill for a covered service, item, or drug, you should not pay the bill
yourself. But if you do pay the bill, you can get a refund if you followed the rules for getting
services, items, and drugs.
If you are asking to be paid back, you are asking the plan or your Interdisciplinary Team (IDT)
for a coverage decision. The plan or your IDT will decide if the service, item, or drug you paid
for is covered, and will check to see if you followed all the rules for using your coverage.

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 If the service, item, or drug you paid for is covered and you followed all the rules, we
will reimburse you for the cost of the service, item, or drug within 60 calendar days after
we get your request.
Or, if you haven’t paid for the service, item, or drug yet, we will send the payment
directly to your provider. When we send the payment, it’s the same as saying Yes to
your request for a coverage decision.
 If the service, item, or drug is not covered, or you did not follow all the rules, we will
send you a letter telling you that we will not pay for the service, item, or drug, and
explaining why.

What if the plan or your IDT says the plan will not pay?
If you do not agree with the plan or your IDT’s decision, you can make an appeal.
Follow the appeals process described in Section 5.3 on page 178. When you follow these
instructions, please note:
 If you make an appeal for reimbursement, we must give you our answer within
60 calendar days after we get your appeal.
 If you are asking us to pay you back for a service, item, or drug you already got and
paid for yourself, you cannot ask for a fast appeal.



If we answer No to your appeal, we will automatically send your case to the Integrated
Administrative Hearing Office (IAHO). We will notify you by letter if this happens.
o If the IAHO reverses the decision and says we should pay you, we must send the
payment to you or to the provider within 30 calendar days. If the answer to your
appeal is Yes at any stage of the appeals process after Level 2, we must send the
payment you asked for to you or to the provider within 60 calendar days.
o If the IAHO says No to your appeal, it means they agree with the decision not to
approve your request. (This is called “upholding the decision.” It is also called
“turning down your appeal.”) You may appeal this decision to the Medicare
Appeals Council, as described in Section 9 on page 209.

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Chapter 9: What to do if you have a problem or complaint
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Section 6: Medicare Part D drugs
Section 6.1: What to do if you have problems getting a Part D drug
or you want us to pay you back for a Part D drug
Your coverage as a Participant of our plan includes many prescription drugs. Most of these
drugs are “Part D drugs.” There are a few drugs that Medicare Part D does not cover but that
Medicaid may cover. This section only applies to Part D drug appeals.
o

The List of Covered Drugs (Drug List), includes some drugs in tiers 3 and 4. These
drugs are not Part D drugs. Appeals or coverage decisions about drugs in tier 3 and 4
follow the process in Section 5 on page 175.

Can I ask for a coverage decision or make an appeal about Part D prescription
drugs?
Yes. Here are examples of coverage decisions you can ask GuildNet Gold Plus FIDA Plan or
your Interdisciplinary Team (IDT) to make about your Part D drugs:
 You ask the plan or your IDT to make an exception such as:
» Asking the plan or your IDT to cover a Part D drug that is not on our List of Covered
Drugs (Drug List).
» Asking the plan or your IDT to waive a restriction on our coverage for a drug (such
as limits on the amount of the drug you can get).
 You ask the plan or your IDT if a drug is covered for you (for example, when your drug
is on our Drug List but we require you to get approval before we will cover it for you).
» NOTE: If your pharmacy tells you that your prescription cannot be filled, you will get
a notice explaining who to contact for a coverage decision.
 You ask the plan or your IDT to decide that the plan must pay for a prescription drug
you already bought. This is asking for a coverage decision about payment.

The legal term for a coverage decision about your Part D drugs is “coverage
determination.”

If you disagree with a coverage decision made by the plan or your IDT, you can appeal. This
section tells you how to ask for coverage decisions and how to request an appeal.

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Use the chart below to help you decide which section has information for your situation:

Which of these situations are you in?

Do you need a
drug that isn’t on
our Drug List or
need us to waive a
rule or restriction
on a drug we
cover?

Do you want us to
cover a drug on
our Drug List and
you believe you
meet any plan
rules or restrictions
(such as getting
approval in
advance) for the
drug you need?

Do you want to
ask us to pay you
back for a drug
you already got
and paid for?

Have we already
told you that we
will not cover or
pay for a drug in
the way that you
want it to be
covered or paid
for?

You can ask the
plan or your IDT
make an
exception. (This is
a type of coverage
decision.)

You can ask the
plan or your IDT for
a coverage
decision.

You can ask the
plan or your IDT to
have the plan pay
you back. (This is a
type of coverage
decision.)

You can make
an appeal. (This
means you
are asking the plan
to reconsider.)

Start with Section
6.2 on page 187.
Also see Sections
6.3 and 6.4 on
pages 188 and
189.

Skip ahead to
Section 6.4 on page
189.

Skip ahead to
Section 6.4 on
page 189.

Skip ahead to
Section 6.5 on
page 192.

Section 6.2: What is an exception?
An exception is permission to get coverage for a drug that is not normally on our List of
Covered Drugs or to use the drug without certain rules and limitations. If a drug is not on our
List of Covered Drugs or is not covered in the way you would like, you can ask the plan or
your Interdisciplinary Team (IDT) to make an “exception.”
When you ask for an exception, your prescriber will need to explain the medical reasons why
you need the exception.
Here are examples of exceptions that you or your prescriber can ask the plan or your IDT to
make:
1. Covering a Part D drug that is not on our List of Covered Drugs (Drug List).

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Chapter 9: What to do if you have a problem or complaint
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2. Removing a restriction on our coverage. There are extra rules or restrictions that apply to certain
drugs on our Drug List (for more information, go to Chapter 5).
 The extra rules and restrictions on coverage for certain drugs include:
» Being required to use the generic version of a drug instead of the brand name drug.
» Getting approval before the plan will cover the drug for you. (This is sometimes
called “prior authorization.”)
» Being required to try a different drug first before the plan will cover the drug you are
asking for. (This is sometimes called “step therapy.”)
» Quantity limits. For some drugs, the plan limits the amount of the drug you can have.

The legal term for asking for removal of a restriction on coverage for a drug is
sometimes called asking for a “formulary exception.”

Section 6.3: Important things to know about asking for exceptions
Your prescriber must tell us the medical reasons
Your prescriber must give the plan or your Interdisciplinary Team (IDT) a statement
explaining the medical reasons for requesting an exception. The decision about the
exception will be faster if you include this information from your prescriber when you ask for
the exception.
Typically, our Drug List includes more than one drug for treating a particular condition. These
are called “alternative” drugs. If an alternative drug would be just as effective as the drug you
are asking for and would not cause more side effects or other health problems, the plan or
your IDT will generally not approve your request for an exception.
GuildNet Gold Plus FIDA Plan or your IDT will say Yes or No to your request for an
exception
§ If the plan or your IDT says Yes to your request for an exception, the exception usually
lasts until the end of the calendar year. This is true as long as your provider continues
to prescribe the drug for you and that drug continues to be safe and effective for
treating your condition.
§ If the plan or your IDT says No to your request for an exception, you can ask for a
review of the decision by making an appeal. Section 6.5 on page 192 tells how to
make an appeal.
The next section tells you how to ask for a coverage decision, including an exception.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 6.4: How to ask for a coverage decision about a Part D drug
or reimbursement for a Part D drug, including an exception
What to do
§ Ask for the type of coverage decision
you want. Call, write, or fax your Care
Manager or Participant Services to
make your request. You, your
representative, or prescriber can do
this. You can call Participant Services
at 1-800-815-0000 (TTY users call
711). You can call your Care Manager
at 1-800-815-0000 (TTY users call
711).
§ You or your prescriber or someone
else who is acting on your behalf can
ask for a coverage decision. You can
also have a lawyer act on your behalf.
Read Section 4 on page 171 to find out
how to give permission to someone
else to act as your representative.

You do not need to give your

At a glance: How to ask for a coverage
decision about a drug or payment
Call, write, or fax your Care Manager or
Participant Services. Or ask your
representative or prescriber to ask for a
coverage decision for you. You will get an
answer on a standard coverage decision
within 72 hours. You will get an answer
on reimbursing you for a Part D drug you
already paid for within 14 calendar days.

 If you are asking for an exception,
include the supporting statement from
your prescriber.

 You or your prescriber may ask for a
fast decision. (Fast decisions usually
come within 24 hours.)

 Read this section to make sure you
qualify for a fast decision! Read it also
to find information about decision
deadlines.

prescriber written permission to
ask for a coverage decision on
your behalf.

 If you want to ask the plan to pay you
back for a drug, read Chapter 7 of this handbook. Chapter 7 describes times when you
may need to ask for reimbursement. It also tells how to send us the paperwork that
asks us to pay you back for the cost of a drug you have paid for.
 If you are asking for an exception, provide the “supporting statement.” Your provider
must give the plan or your Interdisciplinary Team (IDT) the medical reasons for the
drug exception. We call this the “supporting statement.”
Your prescriber can fax or mail the statement to us. Or your prescriber can speak with
us on the phone, and then fax or mail a statement.

If your health requires it, ask for a “fast coverage decision”
The “standard deadlines” will apply unless the plan or your IDT have agreed to use the “fast
deadlines.”

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

§ A standard coverage decision means the plan or your IDT will give you an answer
within 72 hours after your prescriber’s statement is received.
§ A fast coverage decision means the plan or your IDT will give you an answer within
24 hours after your prescriber’s statement is received.
» You can get a fast coverage decision only if you are asking for a drug you have not
yet received. (You cannot get a fast coverage decision if you are asking us to pay
you back for a drug you already bought.)
» You can get a fast coverage decision only if using the standard deadlines could
cause serious harm to your health or hurt your ability to function.
» If your prescriber says that your health requires a “fast coverage decision,” the plan
or your IDT will automatically agree to give you a fast coverage decision, and the
letter will tell you that.
If you ask for a fast coverage decision on your own (without your prescriber’s
support), the plan or your IDT will decide whether you get a fast coverage decision.
If the plan or your IDT decides that your medical condition does not meet the
requirements for a fast coverage decision, the standard deadline will be used
instead. You will get a letter telling you that. The letter will tell you how to file a
grievance about the decision to give you a standard decision. You can file a “fast
grievance” and get a response to your grievance within 24 hours. For more
information about the process for filing grievances, including fast grievances, see
Section 10 on page 210.

The legal term for “fast coverage decision” is “expedited coverage determination.”

Deadlines for a “fast coverage decision”
 If the plan or your IDT is using the fast deadlines, you will get an answer within 24
hours. This means within 24 hours after the plan or your IDT gets your request. Or, if
you are asking for an exception, 24 hours after the plan or your IDT gets your
prescriber’s statement supporting your request. You will get an answer sooner if your
health requires it.
 If the plan or your IDT does not meet this deadline, we will send your request to Level 2
of the appeals process. At Level 2, an Independent Review Entity will review your
request.



If the answer is Yes to part or all of what you asked for, we must give you the coverage
within 24 hours after your request is received or your prescriber’s supporting statement is
received.

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Chapter 9: What to do if you have a problem or complaint
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If the answer is No to part or all of what you asked for, you will receive a letter explaining
why. The letter will also explain how you can appeal our decision.

Deadlines for a “standard coverage decision” about a drug you have not
yet received
 If the plan or your IDT is using the standard deadlines, you will get an answer within 72
hours after your request is received. Or, if you are asking for an exception, after your
prescriber’s supporting statement is received. You will get an answer sooner if your
health requires it.
 If the plan or your IDT does not meet this deadline, we will send your request on to
Level 2 of the appeals process. At Level 2, an Independent Review Entity will review
your request.



If the answer is Yes to part or all of what you asked for, we must approve or give the
coverage within 72 hours of your request or, if you are asking for an exception, your
prescriber’s supporting statement.



If the answer is No to part or all of what you asked for, you will receive a letter explaining
why. The letter will also explain how you can appeal the decision.

Deadlines for a “standard coverage decision” about payment for a drug you
have already bought
 The plan or your IDT must give you an answer within 14 calendar days after your
request is received.
 If the plan or your IDT does not meet this deadline, we will send your request to Level 2
of the appeals process. At level 2, an Independent Review Entity will review your
request.



If the answer is Yes to part or all of what you asked for, we will make payment to you
within 14 calendar days after your request is received.



If the answer is No to part or all of what you asked for, you will receive a letter explaining
why. The letter will also explain how you can appeal the decision.

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Chapter 9: What to do if you have a problem or complaint
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Section 6.5: Level 1 Appeal for Part D drugs
 To start your appeal, you, your
prescriber, or your representative
must contact us.
 If you are asking for a standard
appeal, you can make your appeal
by sending a request in writing.
You may also ask for an appeal by
calling us at 1-888-447-6855 (TTY
users call 711).
 If you want a fast appeal, you may
make your appeal in writing or you
may call us.

At a glance: How to make a Level 1
Appeal
You, your prescriber, or your
representative may put your request in
writing and mail or fax it to us. You may
also ask for an appeal by calling us.

 Ask within 60 calendar days of the

decision you are appealing. If you miss
the deadline for a good reason, you
may still appeal.

 You, your prescriber, or your
 Make your appeal request within
representative can call us to ask for a
60 calendar days from the date
fast appeal.
on the notice that tells you the
decision. If you miss this deadline
 Read this section to make sure you
qualify for a fast decision! Read it also
and have a good reason for
to find information about decision
missing it, we may give you more
deadlines.
time to make you appeal. For
example, good reasons for missing
the deadline would be if you have
a serious illness that kept you from
contacting us or if we gave you incorrect or incomplete information about the deadline
for requesting an appeal.

The legal term for an appeal to the plan about a Part D drug coverage decision
is plan “redetermination.”

 You have the right to ask us for a copy of the information about your appeal. To ask for
a copy, call Participant Services at 1-800-815-0000 (TTY 711).
» If you wish, you and your prescriber may give us additional information to support
your appeal.

If your health requires it, ask for a “fast appeal”
 If you are appealing a decision the plan or your IDT made about a drug you have not
yet received, you and your prescriber will need to decide if you need a “fast appeal.”

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Chapter 9: What to do if you have a problem or complaint
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 The requirements for getting a “fast appeal” are the same as those for getting a “fast
coverage decision” in Section 6.4 on page 189.
The legal term for “fast appeal” is “expedited redetermination.”

Our plan will review your appeal and give you our decision
 We take another careful look at all of the information about your coverage request. We
check to see if all the rules were followed when the plan or your IDT said No to your
request. We may contact you or your prescriber to get more information. The reviewer
will be someone who did not make the original coverage decision.

Deadlines for a “fast appeal”
 If we are using the fast deadlines, we will give you our answer within 72 hours after we
get your appeal, or sooner if your health requires it.
 If we do not give you an answer within 72 hours, we will send your request to Level 2 of
the appeals process. At Level 2, an Independent Review Entity will review your appeal.



If our answer is Yes to part or all of what you asked for, we must give the coverage
within 72 hours after we get your appeal.



If our answer is No to part or all of what you asked for, we will send you a letter that
explains why we said No and tells how to appeal our decision.

Deadlines for a “standard appeal”
 If we are using the standard deadlines, we must give you our answer within 7 calendar
days after we get your appeal, or sooner if your health requires it. If you think your
health requires it, you should ask for a “fast appeal.”
 If we do not give you a decision within 7 calendar days, we will send your request to
Level 2 of the appeals process. At Level 2, an Independent Review Entity will review
your appeal.



If our answer is Yes to part or all of what you asked for:
» If we approve a request for coverage, we must give you the coverage as quickly as
your health requires, but no later than 7 calendar days after we get your appeal.
» If we approve a request to pay you back for a drug you already bought, we will send
payment to you within 30 calendar days after we get your appeal request.

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Chapter 9: What to do if you have a problem or complaint
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If our answer is No to part or all of what you asked for, we will send you a letter that
explains why we said No and tells how to appeal our decision.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 6.6: Level 2 Appeal for Part D drugs
If we say No to part or all of your appeal,
you can choose whether to accept this
decision or make another appeal. If you
decide to go on to a Level 2 Appeal, the
Independent Review Entity (IRE) will
review our decision.
 If you want the IRE to review your
case, your appeal request must be in
writing. The letter we send about our
decision in the Level 1 Appeal will
explain how to request the Level 2
Appeal.
 When you make an appeal to the
IRE, we will send them your case file.
You have the right to ask us for a
copy of your case file by calling
Participant Services at 1-800-8150000 (TTY users call 711). We are
allowed to charge you a fee for
copying and sending this information
to you.

At a glance: How to make a Level 2
Appeal
If you want the Independent Review
Entity to review your case, your appeal
request must be in writing.

 Ask within 60 calendar days of the

decision you are appealing. If you miss
the deadline for a good reason, you
may still appeal.

 You, your prescriber, or your
representative can request the Level 2
Appeal.

 Read this section to make sure you
qualify for a fast decision! Read it also
to find information about decision
deadlines.

 You have a right to give the IRE other information to support your appeal.
 The IRE is an independent organization that is hired by Medicare. It is not connected
with the plan and it is not a government agency.
 Reviewers at the IRE will take a careful look at all of the information related to your

The legal term for an appeal to the IRE about a Part D drug is “reconsideration.”

appeal. The organization will send you a letter explaining its decision.

Deadlines for “fast appeal” at Level 2
 If your health requires it, ask the Independent Review Entity (IRE) for a “fast appeal.”
 If the IRE agrees to give you a “fast appeal,” it must give you an answer to your Level 2
Appeal within 72 hours after getting your appeal request.

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Chapter 9: What to do if you have a problem or complaint
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 If the IRE says Yes to part or all of what you asked for, we must authorize or give you
the drug coverage within 24 hours after we get the decision.

Deadlines for “standard appeal” at Level 2
 If you have a standard appeal at Level 2, the Independent Review Entity (IRE) must
give you an answer to your Level 2 Appeal within 7 calendar days after it gets your
appeal.
» If the IRE says Yes to part or all of what you asked for, we must authorize or give
you the drug coverage within 72 hours after we get the decision.
» If the IRE approves a request to pay you back for a drug you already bought, we will
send payment to you within 30 calendar days after we get the decision.

What if the Independent Review Entity says No to your Level 2 Appeal?
No means the Independent Review Entity (IRE) agrees with our decision not to approve your
request. This is called “upholding the decision.” It is also called “turning down your appeal.”
If you want to go to Level 3 of the appeals process, the drugs you are requesting must meet
a minimum dollar value. If the dollar value is less than the minimum, you cannot appeal any
further. If the dollar value is high enough, you can ask for a Level 3 appeal. The letter you get
from the IRE will tell you the dollar value needed to continue with the appeal process.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 7: Asking us to cover a longer hospital stay
When you are admitted to a hospital, you have the right to get all hospital services that we
cover that are necessary to diagnose and treat your illness or injury.
During your covered hospital stay, your doctor, Interdisciplinary Team (IDT), and the hospital
staff will work with you to prepare for the day when you leave the hospital. They will also help
arrange for any care you may need after you leave.
 The day you leave the hospital is called your “discharge date.”
 Your doctor, IDT, or the hospital staff will tell you what your discharge date is.
If you think you are being asked to leave the hospital too soon, you can ask for a longer
hospital stay. There is a special, faster process for appealing hospital discharge decisions. It
is handled by the Medicare-designated Quality Improvement Organization (QIO). It is highly
recommended that you use the faster process instead of the regular appeal process
described in Section 5 on page 175. However, both options are available to you. This section
tells you how to ask for a QIO appeal, and also reminds you about your appeal option with
the plan.

Section 7.1: Learning about your Medicare rights
Within two days after you are admitted to the hospital, a caseworker or nurse will give you a
notice called An Important Message from Medicare about Your Rights. If you do not get this
notice, ask any hospital employee for it. If you need help, please call Participant Services at
1-800-815-0000 (TTY users call 711). You can also call 1-800-MEDICARE (1-800-633-4227),
24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
Read this notice carefully and ask questions if you don’t understand. The Important Message
tells you about your rights as a hospital patient, including your rights to:
 Get Medicare-covered services during and after your hospital stay. You have the right
to know what these services are, who will pay for them, and where you can get them.
 Be a part of any decisions about the length of your hospital stay.
 Know where to report any concerns you have about the quality of your hospital care.
 Appeal if you think you are being discharged from the hospital too soon.
You should sign the Medicare notice to show that you got it and understand your rights.
Signing the notice does not mean you agree to the discharge date that may have been told
to you by your doctor or hospital staff.
Keep your copy of the signed notice so you will have the information in it if you need it.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

 To look at a copy of this notice in advance, you can call Participant Services at
1-800-815-0000. You can also call 1-800 MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week. TTY users call 1-877-486-2048. The call is free.
You can also see the notice online at https://www.cms.gov/Medicare/MedicareGeneral-Information/BNI/HospitalDischargeAppealNotices.html.



If you need help, please call Participant Services or Medicare at the numbers listed
above.

Section 7.2: Quality Improvement Organization (QIO) Level 1 Appeal
to change your hospital discharge date
If you want us to cover your inpatient hospital services for a longer time, you must request an
appeal. This section tells you how to ask for a Level 1 Appeal with the Quality Improvement
Organization. The Quality Improvement Organization will do a Level 1 Appeal review to see if
your planned discharge date is medically appropriate for you.
In New York, the Quality Improvement Organization is called Livanta. To make a Level 1
Appeal to change your discharge date, call Livanta at 1-866-815-5440.

Call right away!
Call the Quality Improvement Organization before you leave the hospital and no later than
your planned discharge date. An Important Message from Medicare about Your Rights
contains information on how to reach the Quality Improvement Organization.



 If you call before you leave, you are
allowed to stay in the hospital after your
planned discharge date without paying
for it while you wait to get the decision
on your appeal from the Quality
Improvement Organization.

At a glance: How to make
a Level 1 Appeal to change your
discharge date

 If you do not call to appeal, and you
decide to stay in the hospital after your
planned discharge date, you may have
to pay all of the costs for hospital care
you get after your planned discharge
date.

Call before you leave the hospital and
before your planned discharge date.

Call the Quality Improvement
Organization for your state at 1-866815-5440 and ask for a “fast review”.

If you miss the deadline for contacting the Quality Improvement Organization about
your appeal, you can make your appeal directly to our plan instead. For details,
see Section 7.4 on page 201.

We want to make sure you understand what you need to do and what the deadlines are.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

 Ask for help if you need it. If you have questions or need help at any time, please call
Participant Services at 1-800-815-0000. You can also call the Health Insurance
Information, Counseling and Assistance Program (HIICAP) at 1-800-701-0501. You may
also call the Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800.

What is a Quality Improvement Organization?
It is a group of doctors and other health care professionals who are paid by the federal
government. These experts are not part of our plan. They are paid by Medicare to check on
and help improve the quality of care for people with Medicare.

Ask for a “fast review”
You must ask the Quality Improvement Organization for a “fast review” of your discharge.
Asking for a “fast review” means you are asking the organization to use the fast deadlines for
an appeal instead of using the standard deadlines.

The legal term for “fast review” is “immediate review.”

What happens during the fast review?
 The reviewers at the Quality Improvement Organization will ask you or your
representative why you think coverage should continue after the planned discharge
date. You don’t have to prepare anything in writing, but you may do so if you wish.
 The reviewers will look at your medical record, talk with your provider, and review all of
the information related to your hospital stay.
 By noon of the day after the reviewers tell us about your appeal, you will get a letter
that gives your planned discharge date. The letter explains the reasons why your
provider, the hospital, and we think it is right for you to be discharged on that date.

The legal term for this written explanation is called the “Detailed Notice of
Discharge.” You can get a sample by calling Participant Services at 1-800-815-0000.
You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week. (TTY users call 1-877-486-2048.) Or you can see a sample notice online at
https://www.cms.gov/Medicare/Medicare-GeneralInformation/BNI/HospitalDischargeAppealNotices.html

What if the answer is Yes?
 If the Quality Improvement Organization says Yes to your appeal, we must keep
covering your hospital services for as long as they are medically necessary.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

What if the answer is No?
 If the Quality Improvement Organization says No to your appeal, they are saying that
your planned discharge date is medically appropriate. If this happens, our coverage for
your inpatient hospital services will end at noon on the day after the Quality
Improvement Organization gives you its answer.
 If the Quality Improvement Organization says No and you decide to stay in the hospital,
then you may have to pay for your continued stay at the hospital. The cost of the
hospital care that you may have to pay begins at noon on the day after the Quality
Improvement Organization gives you its answer.
 If the Quality Improvement Organization turns down your appeal and you stay in the
hospital after your planned discharge date, then you can make a Level 2 Appeal.

Section 7.3: Quality Improvement Organization (QIO) Level 2 Appeal
to change your hospital discharge date
If the Quality Improvement Organization has turned down your appeal and you stay in the
hospital after your planned discharge date, then you can make a Level 2 Appeal. You will
need to contact the Quality Improvement Organization again and ask for another review.
Ask for the Level 2 review within 60 calendar days after the day when the Quality
Improvement Organization said No to your Level 1 Appeal. You can ask for this review only if
you stayed in the hospital after the date that your coverage for the care ended.
In New York, the Quality Improvement Organization is called Livanta. You can reach Livanta
at 1-866-815-5440.
 Reviewers at the Quality Improvement
Organization will take another careful
look at all of the information related to
your appeal.

At a glance: How to make
a Level 2 Appeal to change your
discharge date

 Within 14 calendar days of receipt of
your request for a second review, the
Quality Improvement Organization
reviewers will make a decision.

Call the Quality Improvement
Organization for your state at 1-866815-5440 and ask for another review.

What happens if the answer is Yes?
 We must pay you back for our share
of the costs of hospital care you got since noon on the day after the date of your first
appeal decision. We must continue providing coverage for your inpatient hospital care
for as long as it is medically necessary.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

 You must continue to pay your share of the costs and coverage limitations may apply.

What happens if the answer is No?
It means the Quality Improvement Organization agrees with the Level 1 decision and will not
change it. The letter you get will tell you what you can do if you wish to continue with the
appeal process.
If the Quality Improvement Organization turns down your Level 2 Appeal, you may have to
pay the full cost for your stay after your planned discharge date.

Section 7.4: What happens if I miss an appeal deadline?
If you miss the Level 1 appeal deadline with the Quality Improvement Organization, you can
still file an appeal directly with our plan. Follow the same process described in Section 5 on
page 175, which is also summarized below.

Level 1 Alternate Appeal to change your hospital discharge date
If you miss the deadline for contacting the Quality Improvement Organization, you can file an
appeal with our plan. Ask us for a “fast review.” A fast review is an appeal that uses the fast
deadlines instead of the standard deadlines.
 During this review, we take a look at all of
the information about your hospital stay.
We check to see if the decision about
when you should leave the hospital was
fair and followed all the rules.
 We will use the fast deadlines rather than
the standard deadlines for giving you the
answer to this review. This means we will
give you our decision as fast as your
condition requires but no later than 72
hours after you ask for a “fast review.”

At a glance: How to make a
Level 1 Alternate Appeal
Call our Participant Services
number and ask for a “fast review”
of your hospital discharge date.
We will give you our decision
within 72 hours.

 If we say Yes to your fast review, it means we agree that you still need to be in the
hospital after the discharge date. We will keep covering hospital services for as long as
it is medically necessary.
It also means that we agree to pay you back for our share of the costs of care you got
since the date when we said your coverage would end.
 If we say No to your fast review, we are saying that your planned discharge date was
medically appropriate. Our coverage for your inpatient hospital services ends on the
day we said coverage would end.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

» If you stayed in the hospital after your planned discharge date, then you may have
to pay the full cost of hospital care you got after the planned discharge date.



To make sure we were following all the rules when we said No to your fast appeal, we will
send your appeal to the Integrated Administrative Hearing Office. When we do this, it
means that your case is automatically going to Level 2 of the appeals process.

The legal term for “fast review” or “fast appeal” is “expedited appeal.”

Level 2 Alternate Appeal to change your hospital discharge date
If we do not agree with you that your hospital discharge date should be changed, we will
send the information for your Level 2 Appeal to the Integrated Administrative Hearing Office
(IAHO) within 2 business days of the Level 1 decision being reached. If you think we are
not meeting this deadline or other deadlines, you can file a grievance. Section 10 on page
210 tells how to file a grievance.
During the Level 2 Appeal, the IAHO reviews
the decision we made when we said No to
your “fast review.” This organization decides
whether the decision we made should be
changed.

At a glance: How to make a Level
2 Alternate Appeal
You do not have to do anything.
The plan will automatically send
your appeal to the Integrated
Administrative Hearing Office
(IAHO).

 The IAHO does a “fast review” of your
appeal. The reviewers give you an
answer within 72 hours.
 The IAHO is not connected with our
plan.

 A Hearing Officer from the IAHO will take a careful look at all of the information related
to your appeal of your hospital discharge.
 If the IAHO says Yes to your appeal, then we must pay you back for our share of the
costs of hospital care you have received since the date of your planned discharge. We
must also continue our coverage of your hospital services for as long as it is medically
necessary.
 If the IAHO says No to your appeal, it means they agree with us that your planned
hospital discharge date was medically appropriate.
The letter you get from the IAHO will tell you what you can do if you wish to continue
with the review process. It will give you the details about how to go on to a Level 3
Appeal, which is handled the Medicare Appeals Council (MAC). Section 9 of this
chapter has more information about additional appeal levels.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 8: What to do if you think your home health care,
skilled nursing care, or Comprehensive Outpatient
Rehabilitation Facility (CORF) services are ending too soon
This section is about the following types of care only:
 Home health care services.
 Skilled nursing care in a skilled nursing facility.
 Rehabilitation care you are getting as an outpatient at a Medicare-approved
Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are
getting treatment for an illness or accident, or you are recovering from a major
operation.



With any of these three types of care, you have the right to keep getting covered services
for as long as your provider or Interdisciplinary Team (IDT) says you need it.

When we decide to stop covering any of these, we must tell you before your services
end. When your coverage for that care ends, we will stop paying for your services.

If you think we are ending the coverage of your care too soon, you can appeal our
decision. There is a special, faster process for appealing these types of coverage decisions.
It is handled by the Medicare-designated Quality Improvement Organization (QIO). It is
highly recommended that you use the faster process instead of the regular appeal process
described in Section 5 on page 175. However, both options are available to you. This section
tells you how to ask for a QIO appeal, and also reminds you about your appeal option with
the plan.

Section 8.1: We will tell you in advance when your coverage will be
ending
You will get a notice at least two days before we stop paying for your services. This is called
the Notice of Medicare Non-Coverage.
 The written notice tells you the date when we will stop covering your services.
 The written notice also tells you how to appeal this decision.
You or your representative should sign the written notice to show that you got it. Signing it
does not mean you agree with the plan that it is time to stop getting services.
When your coverage ends, we will stop paying for your services.

Section 8.2: Quality Improvement Organization (QIO) Level 1 Appeal
to continue your care
If you think we are ending coverage of your services too soon, you can file an appeal. This
section tells you how to ask for a Level 1 Appeal with the Quality Improvement Organization.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Before you start your appeal, understand what you need to do and what the deadlines are.


Meet the deadlines. The deadlines are important. Be sure that you understand and
follow the deadlines that apply to things you must do. There are also deadlines our plan
must follow. (If you think we are not meeting our deadlines, you can file a grievance.
Section 10 on page 210 tells you how to file a grievance.)



Ask for help if you need it. If you have questions or need help at any time, please call
Participant Services at 1-800-815-0000. Or call the Health Insurance Information,
Counseling and Assistance Program (HIICAP) at 1-800-701-0501.

During a Level 1 Appeal, the Quality
Improvement Organization will review your
appeal and decide whether to change the
decision we made. In New York, the Quality
Improvement Organization is called Livanta.
You can reach Livanta at 1-866-815-5440.
Information about appealing to the Quality
Improvement Organization is also in the
Notice of Medicare Non-Coverage. This is the
notice you got when you were told we would
stop covering your care.

At a glance: How to make a Level 1
Appeal to ask the plan to continue
your care
Call the Quality Improvement
Organization for your state at 1-866815-5440 and ask for a “fast-track
appeal.”
Call before you leave the agency or
facility that is providing your care and
before your planned discharge date.

What is a Quality Improvement
Organization?

It is a group of doctors and other health care
professionals who are paid by the federal government. These experts are not part of our
plan. They are paid by Medicare to check on and help improve the quality of care for people
with Medicare.

What should you ask for?
Ask them for a “fast-track appeal.” This is an independent review of whether it is medically
appropriate for us to end coverage for your services.

What is your deadline for contacting this organization?
§ You must contact the Quality Improvement Organization no later than noon of the day
after you got the written notice telling you when we will stop covering your care.
§ If you miss the deadline for contacting the Quality Improvement Organization about
your appeal, you can make your appeal directly to us instead. For details about this
other way to make your appeal, see Section 8.4 on page 207.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

The legal term for the written notice is “Notice of Medicare Non-Coverage.”
To get a sample copy, call Participant Services at 1-800-815-0000 or
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users
call 1-877-486-2048. Or see a copy online at https://www.CMS.gov/MedicareGeneral-Information/BNI/MAEDNotices

What happens during the Quality Improvement Organization’s review?
 The reviewers at the Quality Improvement Organization will ask you or your
representative why you think coverage for the services should continue. You don’t have
to prepare anything in writing, but you may do so if you wish.
 When you ask for an appeal, the plan must write a letter to you and the Quality
Improvement Organization explaining why your services should end.
 The reviewers will also look at your medical records, talk with your provider, and review
information that the plan has given to them.
 Within one full day after reviewers have all the information they need, they will
tell you their decision. You will get a letter explaining the decision.

The legal term for the letter explaining why your services should end is “Detailed
Explanation of Non-Coverage.”

What happens if the reviewers say Yes?
 If the reviewers say Yes to your appeal, then we must keep providing your covered
services for as long as they are medically necessary.

What happens if the reviewers say No?
 If the reviewers say No to your appeal, then your coverage will end on the date we told
you. We will stop paying our share of the costs of this care.
 If you decide to keep getting the home health care, skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date your
coverage ends, then you will have to pay the full cost of this care yourself.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 8.3: Quality Improvement Organization (QIO) Level 2 Appeal
to continue your care
If the Quality Improvement Organization said No to the Level 1 Appeal and you choose to
continue getting care after your coverage for the care has ended, you can make a Level 2
Appeal.
During the Level 2 Appeal, the Quality Improvement Organization will take another look at
the decision they made at Level 1. If they say they agree with the Level 1 decision, you may
have to pay the full cost for your home health care, skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we
said your coverage would end.
In New York, the Quality Improvement
Organization is called Livanta. You can
reach Livanta at 1-866-815-5440. Ask for
the Level 2 review within 60 calendar days
after the day when the Quality Improvement
Organization said No to your Level 1
Appeal. You can ask for this review only if
you continued getting care after the date
that your coverage for the care ended.
 Reviewers at the Quality Improvement
Organization will take another careful
look at all of the information related to
your appeal.

At a glance: How to make a Level 2
Appeal to require that the plan
cover your care for longer
Call the Quality Improvement
Organization for your state at 1-866815-5440 and ask for another review.
Call before you leave the agency or
facility that is providing your care and
before your planned discharge date.

 The Quality Improvement
Organization will make its decision within 14 calendar days of receipt of your appeal
request.

What happens if the review organization says Yes?
 We must pay you back for our share of the costs of care you got since the date when
we said your coverage would end. We must continue providing coverage for the care
for as long as it is medically necessary.

What happens if the review organization says No?
 It means they agree with the decision they made on the Level 1 Appeal and will not
change it.
 The letter you get will tell you what to do if you wish to continue with the review
process. It will give you the details about how to go on to the next level of appeal,
which is handled by a judge.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 8.4: What if you miss the deadline for making your Level 1
Appeal?
If you miss the Level 1 appeal deadline with the Quality Improvement Organization, you can
still file an appeal directly with our plan. Follow the same process described in Section 5 on
page 175, which is also summarized below.

Level 1 Alternate Appeal to continue your care for longer
If you miss the deadline for contacting the
Quality Improvement Organization, you can
file an appeal with our plan. Ask us for a
“fast review.” A fast review is an appeal that
uses the fast deadlines instead of the
standard deadlines.

At a glance: How to make a Level 1
Alternate Appeal
Call our Participant Services number
and ask for a “fast review.”

We will give you our decision within
 During this review, we take a look at
72 hours.
all of the information about your home
health care, skilled nursing facility
care, or care you are getting at a
Comprehensive Outpatient
Rehabilitation Facility (CORF). We check to see if the decision about when your
services should end was fair and followed all the rules.
 We will use the fast deadlines rather than the standard deadlines for giving you the
answer to this review. We will give you our decision as quickly as your condition
requires but not later than 72 hours after you ask for a “fast review.”
 If we say Yes to your fast review, it means we agree that we will keep covering your
services for as long as it is medically necessary.
It also means that we agree to pay you back for our share of the costs of care you got
since the date when we said your coverage would end.
 If we say No to your fast review, we are saying that stopping your services
was medically appropriate. Our coverage ends as of the day we said coverage
would end.
» If you continue getting services after the day we said they would stop, you may
have to pay the full cost of the services.



The legal term for “fast review” or “fast appeal” is “expedited appeal.”

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Level 2 Alternate Appeal to continue your care for longer
If we do not agree with you that your services should continue, we will send the information
for your Level 2 Appeal to the Integrated Administrative Hearing Office (IAHO) within 2
business days of the Level 1 decision being reached. If you think we are not meeting this
deadline or other deadlines, you can file a grievance. Section 10 on page 210 tells how to
file a grievance.
During the Level 2 Appeal, the IAHO reviews the decision we made when we said No to your
“fast review.” This organization decides whether the decision we made should be changed.
 The IAHO does a “fast review” of your
appeal. The reviewers give you an
answer within 72 hours.
 The IAHO is not connected with our
plan.
 A Hearing Officer from the IAHO will
take a careful look at all of the
information related to your appeal.

At a glance: How to make a Level 2
Alternate Appeal to require that the
plan continue your care
You do not have to do anything. The
plan will automatically send your
appeal to the Integrated
Administrative Hearing Office (IAHO).

 If the IAHO says Yes to your appeal,
then we must pay you back for our
share of the costs of care. We must
also continue our coverage of your services for as long as it is medically necessary.
 If the IAHO says No to your appeal, it means they agree with us that stopping coverage
of services was medically appropriate.
The letter you get from the IAHO will tell you what you can do if you wish to continue with the
review process. It will give you details about how to go on to a Level 3 Appeal with the
Medicare Appeals Council. Section 9 on page 209 has more information about additional
appeal levels.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 9: Taking your appeal beyond Level 2
Section 9.1: Next steps for services, items, and drugs (not Medicare
Part D drugs)
If you made a Level 1 Appeal and a Level 2 Appeal as described in Sections 5, 7, or 8, and
both your appeals have been turned down, you may have the right to additional levels of
appeal. The letter you get from the Integrated Administrative Hearing Office (IAHO) will tell
you what to do if you wish to continue the appeals process.
Level 3 of the appeals process is a review by the Medicare Appeals Council. After that, you
may have the right to ask a federal court to look at your appeal.
If you need assistance at any stage of the appeals process, you can contact the Independent
Consumer Advocacy Network (ICAN). The phone number is 1-844-614-8800.

Section 9.2: Next steps for Medicare Part D drugs
If you made a Level 1 Appeal and a Level 2 Appeal for Medicare Part D drugs as described
in Section 6, and both your appeals have been turned down, you may have the right to
additional levels of appeal. The letter you get from the Independent Review Entity will tell you
what to do if you wish to continue the appeals process.
Level 3 of the appeals process is an Administrative Law Judge (ALJ) hearing. If you want an
ALJ to review your case, the drugs you are requesting must meet a minimum dollar amount.
If the dollar value is less than the minimum level, you cannot appeal any further. If the dollar
value is high enough, you can ask an ALJ to hear your appeal.
If you do not agree with the ALJ’s decision, you can go to the Medicare Appeals Council.
After that, you may have the right to ask a federal court to look at your appeal.
If you need assistance at any stage of the appeals process, you can contact the Independent
Consumer Advocacy Network (ICAN). The phone number is 1-844-614-8800.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Section 10: How to file a grievance
What kinds of problems should be grievances?
“Filing a grievance” is another way of saying “making a complaint.” The grievance process is
used for certain types of problems only, such as problems related to quality of care, waiting
times, and customer service. Here are examples of the kinds of problems handled by the
grievance process.
Grievances about quality
 You are unhappy with the quality of
care, such as the care you got in the
hospital.
Grievances about privacy
 You think that someone did not
respect your right to privacy, or
shared information about you that is
confidential.
Grievances about poor customer service
 A health care provider or staff was
rude or disrespectful to you.

At a glance: How to file a grievance
You can file an internal grievance with
our plan and/or an external grievance
with an organization that is not
connected to our plan.
To file an internal grievance, call
Participant Services or send us a
letter.
There are different organizations that
handle external grievances. For more
information, read Section 10.2 on
page 212.

 GuildNet Gold Plus FIDA Plan staff
treated you poorly.
 You think you are being pushed out of the plan.
Grievances about accessibility
 You cannot physically access the health care services and facilities in a provider’s
office.
 Your provider does not give you a reasonable accommodation you need such as an
American Sign Language interpreter.
Grievances about waiting times
 You are having trouble getting an appointment, or waiting too long to get it.
 You have been kept waiting too long by providers, pharmacists, or other health
professionals or by Participant Services or other plan staff.
Grievances about cleanliness
 You think the clinic, hospital or provider’s office is not clean.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

Grievances about language access
 Your provider does not provide you with an interpreter during your appointment.
Grievances about communications from us
 You think we failed to give you a notice or letter that you should have received.
 You think the written information we sent you is too difficult to understand.
Grievances about the timeliness of our actions related to coverage decisions or
appeals
 You believe that we are not meeting our deadlines for making a coverage decision
or answering your appeal.
 You believe that, after getting a coverage or appeal decision in your favor, we are not
meeting the deadlines for approving or giving you the service or paying you back for
certain services.
 You believe we did not forward your case to the Integrated Administrative Hearing
Office or Independent Review Entity on time.

Are there different types of grievances?
Yes. You may file an internal grievance and/or an external grievance. An internal grievance
is filed with and reviewed by our plan. An external grievance is filed with and reviewed by an
organization that is not affiliated with our plan. If you need help filing an internal and/or
external grievance, you can call the Independent Consumer Advocacy Network (ICAN) at
1-844-614-8800.

Section 10.1: Internal grievances
To file an internal grievance, call Participant Services at 1-800-815-0000 (TTY users call
711), Monday through Sunday, 8am to 8pm. The grievance must be made within 60
calendar days after you had the problem you want to complain about.

 If there is anything else you need to do, Participant Services will tell you.
 You can also write your grievance and send it to us. If you put your grievance in writing,
we will respond to your grievance in writing.

The legal term for “fast grievance” is “expedited grievance.”

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

We answer most grievances within 30 calendar days. If possible, we will answer you right
away. If you call us with a grievance, we may be able to give you an answer on the same
phone call. If your health condition requires us to answer quickly, we will do that.
 If you need a response faster because of your health, we will give you an answer within
48 hours after we get all necessary information (but no more than 7 calendar days from
the receipt of your grievance).
 If you are filing a grievance because we denied your request for a “fast coverage
decision” or a “fast appeal,” we will automatically give you a “fast grievance” and
respond to your grievance within 24 hours.
 If you are filing a grievance because we took extra time to make a coverage decision,
we will automatically give you a “fast grievance” and respond to your grievance within
24 hours.
If we need more information and the delay is in your best interest, or if you ask for more time,
we can take up to 14 more calendar days to answer your grievance. We will tell you in writing
why we need more time.
If we do not agree with some or all of your grievance, we will tell you and give you our
reasons. We will respond whether we agree with the grievance or not. If you disagree with
our decision, you can file an external grievance.

Section 10.2: External grievances
You can tell Medicare about your grievance
You can send your grievance (complaint) to Medicare. The Medicare Complaint Form is
available at: https://www.medicare.gov/MedicareComplaintForm/home.aspx
Medicare takes your complaints seriously and will use this information to help improve
the quality of the Medicare program.
If you have any other feedback or concerns, or if you feel the plan is not addressing
your problem, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call
1-877-486-2048. The call is free.
Your grievance will be sent to the Medicare and Medicaid team overseeing our plan and the
FIDA Program.

You can tell the New York State Department of Health about your grievance
To file a grievance with the New York State Department of Health (NYSDOH), call the
NYSDOH Helpline at 1-866-712-7197. Your grievance will be sent to the Medicare and
Medicaid team overseeing our plan and the FIDA Program.

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Chapter 9: What to do if you have a problem or complaint
(coverage decisions, appeals, grievances)

You can file a grievance with the Office for Civil Rights
You can file a grievance with the Department of Health and Human Services’ Office for Civil
Rights if you think you have not been treated fairly. For example, you can file a grievance
about disability access or language assistance. The phone number for the Office for Civil
Rights is 1-800-368-1019. TTY users should call 1-800-537-7697. You can also visit
http://www.hhs.gov/ocr for more information.
You may also contact the local Office for Civil Rights office at:
Office for Civil Rights
U.S. Department of Health and Human Services
Jacob Javits Federal Building
26 Federal Plaza - Suite 3312
New York, NY 10278
Voice Phone (800) 368-1019
FAX (212) 264-3039
TTY (800) 537-7697
You may also have rights under the Americans with Disability Act and under New York State
ADA Title II: State and Local Government Activities. You can contact the Independent
Consumer Advocacy Network (ICAN) for assistance. The phone number is 1-844-614-8800.

You can file a grievance with the Quality Improvement Organization
When your grievance is about quality of care, you also have two choices:
 If you prefer, you can make your grievance about the quality of care directly to the
Quality Improvement Organization (without making the grievance to us).
 Or you can make your grievance to us and to the Quality Improvement Organization. If
you make a grievance to this organization, we will work with them to resolve your
grievance.
The Quality Improvement Organization is a group of practicing doctors and other health care
experts paid by the federal government to check and improve the care given to Medicare
patients.
In New York, the Quality Improvement Organization is called Livanta. The phone number for
Livanta is 1-866-815-5440.

CHAPTER 10
Ending your participation in our FIDA Plan

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Chapter 10: Ending your participation in our FIDA Plan
Table of Contents
A.When can you end your participation in our FIDA Plan? ................................................................. 216
B.How do you end your participation in our FIDA Plan? ..................................................................... 216
C.How do you join a different FIDA Plan? .......................................................................................... 217
D. If you leave our FIDA Plan and you do not want a different FIDA Plan, how do you get
your Medicare and Medicaid services from a single plan? ............................................................. 217
E. If you leave our FIDA Plan and you do not want a different FIDA, PACE, or MAP Plan,
how do you get your Medicare and Medicaid services? ................................................................. 218
How you will get Medicare services ............................................................................................... 218
How you will get Medicaid services ............................................................................................... 219
F. Until your participation ends, you will keep getting your medical services and drugs
through our FIDA Plan ................................................................................................................... 220
G.Your participation will end in certain situations (even if you haven’t asked for it to end) ................. 220
H. We cannot ask that you be disenrolled from our FIDA Plan for any reason related to your
health ............................................................................................................................................ 222
I. You may have the right to request a fair hearing if the FIDA Program ends your
participation in our FIDA Plan ........................................................................................................ 222
J. You have the right to file a grievance with GuildNet Gold Plus FIDA Plan if we ask the
FIDA Program to end your participation in our FIDA Plan .............................................................. 222
K.Where can you get more information about ending your participation in our FIDA Plan? ................ 222

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000, Monday
through Sunday between 8am and 8pm. TTY/TDD, please call 711. The call is free. For more
information, visit www.guildnetny.org.
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Chapter 10: Ending your participation in our FIDA Plan

Introduction
This chapter tells about ways you can end your participation in our FIDA Plan and access
your Medicare and Medicaid coverage options after you leave GuildNet Gold Plus FIDA Plan.
You will still qualify for both Medicare and Medicaid benefits if you leave GuildNet Gold Plus
FIDA Plan.

A. When can you end your participation in our FIDA Plan?
You can end your participation in GuildNet Gold Plus FIDA Plan at any time. Your
participation will end on the last day of the month that we get your request to change your
plan. For example, if we get your request on January 25, your coverage with our plan will end
on January 31. Your new coverage will begin the first day of the next month.



For information on Medicare options when you leave GuildNet Gold Plus FIDA Plan, see
the table on page 218.



For information about your Medicaid services when you leave GuildNet Gold Plus FIDA
Plan, see page 219.

These are ways you can get more information about when you can end your participation:

 Call the Enrollment Broker (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.

 Call the Health Insurance Information, Counseling and Assistance Program (HIICAP).
The phone number for HIICAP is 1-800-701-0501.

 Call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a
week. TTY users should call 1-877-486-2048.
The Independent Consumer Advocacy Network (ICAN) can also give you free information
and assistance with any issues you may have with your FIDA Plan. To contact ICAN, call
1-844-614-8800. (TTY users call 711, then follow the prompts to dial 844-614-8800.)

B. How do you end your participation in our FIDA Plan?
If you decide to end your participation in GuildNet Gold Plus FIDA Plan, call the Enrollment
Broker or Medicare and tell them you want to leave GuildNet Gold Plus FIDA Plan:

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Chapter 10: Ending your participation in our FIDA Plan

§ Call the Enrollment Broker (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; OR

§ Call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a
week. TTY users should call 1-877-486-2048. When you call 1-800-MEDICARE, you
can also enroll in another Medicare health or drug plan. More information on getting
your Medicare services when you leave GuildNet Gold Plus FIDA Plan is in the chart
on page 218.

C. How do you join a different FIDA Plan?
If you want to keep getting your Medicare and Medicaid benefits together from a single plan,
you can join a different FIDA Plan.
To enroll in a different FIDA Plan:

 Call the Enrollment Broker (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. Tell the Enrollment Broker you want to leave
GuildNet Gold Plus FIDA Plan and join a different FIDA Plan. If you are not sure
which plan you want to join, the Enrollment Broker can tell you about other plans in
your area; OR

 If you know the name of the FIDA Plan you want to join, send the Enrollment Broker
an Enrollment Change Form. You can get the form at
http://www.nymedicaidchoice.com or by calling the Enrollment Broker at 1-855-600FIDA if you need them to mail you one. TTY users should call 1-888-329-1541.
Your coverage with GuildNet Gold Plus FIDA Plan end on the last day of the month that we
get your request. Your coverage with the new FIDA Plan you selected will begin on the first
day of the next month.

D. If you leave our FIDA Plan and you do not want a different FIDA Plan,
how do you get your Medicare and Medicaid services from a single
plan?
If you leave GuildNet Gold Plus FIDA Plan and want to keep getting 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.
To enroll in PACE or MAP:

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Chapter 10: Ending your participation in our FIDA Plan

 Call the Enrollment Broker (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. Tell the Enrollment Broker you want to leave
GuildNet Gold Plus FIDA Plan and enroll in PACE or MAP. If you are not sure which
PACE or MAP Plan you want to join, the Enrollment Broker can tell you about other
plans in your area.

E. If you leave our FIDA Plan and you do not want a different FIDA, PACE,
or MAP Plan, how do you get your Medicare and Medicaid services?
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 as described below.

How you will get Medicare services
You will have a choice about how you get your Medicare benefits.
You have three options for getting your Medicare services. By enrolling in one of these
options, you will automatically end your participation in GuildNet Gold Plus 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 (1-800633-4227), 24 hours a day, seven days a
week. TTY users should call 1-877-486-2048
to enroll in the new Medicare-only health plan.
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.

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Chapter 10: Ending your participation in our FIDA Plan

2. You can change to:

Here is what to do:

Original Medicare with a separate
Medicare prescription drug plan

Call Medicare at 1-800-MEDICARE (1-800633-4227), 24 hours a day, seven days a
week. TTY users should call 1-877-486-2048.
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
Original Medicare coverage begins.

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 (1-800633-4227), 24 hours a day, seven days a
week. TTY users should call 1-877-486-2048.

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:


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 1-800-701-0501.

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.

How you will get Medicaid services
If you leave the FIDA Plan, you will still be able to get your 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 get your Medicaid physical and
behavioral health services through Medicaid Fee-for-Service. You can choose to
completely stop getting long-term services and supports. However, it may take extra
time to complete a safe discharge process.

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If you choose to completely stop getting long-term services and supports, we must
ensure that you will be safe without the receipt of these services. To do this, we
will complete a safe discharge process. This might take a few weeks from the
date you tell us you want to leave long-term services and supports. During this
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 ask for the change.

 If you were getting services through the Nursing Home Transition & Diversion 1915(c)
waiver prior to enrolling in a FIDA Plan, you will have the opportunity to re-apply for
the Nursing Home Transition & Diversion 1915(c) waiver. You will continue to get any
existing Nursing Home Transition & Diversion services from GuildNet Gold Plus FIDA
Plan or enroll in a Medicaid Managed Long-Term Care plan to get your Medicaid
services until your application for the Nursing Home Transition & Diversion 1915(c)
waiver is approved. The Enrollment Broker (New York Medicaid Choice) can help you
with your application.

 You will get a new Medicaid Participant ID Card, a new Participant Handbook, and a
new Provider and Pharmacy Directory.

F. Until your participation ends, you will keep getting your medical
services and drugs through our FIDA Plan
If you leave GuildNet Gold Plus FIDA Plan, it may take time before your participation ends
and your new Medicare and Medicaid coverage begins. See page 216 for more
information. During this time, you will keep getting your services, items, and drugs through
GuildNet Gold Plus FIDA Plan.

 You should use our network pharmacies to get your prescriptions filled.

Usually, your prescription drugs are covered only if they are filled at a network
pharmacy including through our mail-order pharmacy services.

 If you are hospitalized on the day that your participation ends, your hospital
stay will usually be covered by our plan until you are discharged. This will
happen even if your new coverage begins before you are discharged.

G. Your participation will end in certain situations (even if you haven’t
asked for it to end)
These are the cases when the FIDA Program rules require that your participation must end:

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Chapter 10: Ending your participation in our FIDA Plan

 If there is a break in your in Medicare Part A and Part B coverage.
 If you no longer qualify for Medicaid.
 If you permanently move out of our service area.
 If you are away from our service area for more than six consecutive months.
»

If you move or take a long trip, you need to call Participant Services to find out if
the place you are moving or traveling to is in GuildNet Gold Plus FIDA Plan’s
service area.

 If you go to jail, prison, or a correctional facility for a criminal offense.
 If you lie about or withhold information about other insurance you have for health care
or prescription drugs.

 If you are not a United States citizen or are not lawfully present in the United States.
You must be a United States citizen or lawfully present in the United States to be a
Participant in our plan. The Centers for Medicare & Medicaid Services will notify us if you
aren’t eligible to remain a Participant on this basis. We must disenroll you if you don’t meet
this requirement.
In any of the above situations, the Enrollment Broker (New York Medicaid Choice) will send
you a disenrollment notice and will be available to explain your other coverage options.
In addition, we can ask that the FIDA Program remove you from GuildNet Gold Plus FIDA
Plan for the following reasons:

 If you intentionally give us incorrect information when you are enrolling in GuildNet
Gold Plus FIDA Plan and that information affects your eligibility for our plan.

 If you continuously behave in a way that is disruptive and makes it difficult for us to
provide medical care for you and other Participants of GuildNet Gold Plus FIDA Plan
even after we make and document our efforts to resolve any problems you may have.

 If you knowingly fail to complete and submit any necessary consent or release form
allowing GuildNet Gold Plus FIDA Plan and providers to access health care and
service information that is necessary for us to deliver care to you.

 If you let someone else use your Participant ID Card to get medical care.
»

If we end your participation because of this reason, Medicare may have your case
investigated by the Inspector General.

In any of the above situations, we will notify you of our concern before we ask for FIDA
Program approval to have you disenrolled from GuildNet Gold Plus FIDA Plan. We will do
this so that you have the opportunity to resolve the problems first. If the problems aren’t
resolved, we will notify you again once we have submitted the request. If the FIDA Program

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Chapter 10: Ending your participation in our FIDA Plan

approves our request, you will get a disenrollment notice. The Enrollment Broker will be
available to explain your other coverage options.

H. We cannot ask that you be disenrolled from our FIDA Plan for any
reason related to your health
If you feel that we are asking that you be disenrolled from GuildNet Gold Plus FIDA Plan for a
health-related reason, you should call Medicare at 1-800-MEDICARE (1-800-633-4227), 24
hours a day, seven days a week. TTY users should call 1-877-486-2048. You should also
call Medicaid at 1-800-541-2831.

I. You may have the right to ask for a fair hearing if the FIDA Program
ends your participation in our FIDA Plan
If the FIDA Program ends your participation in GuildNet Gold Plus FIDA Plan, the FIDA
Program must tell you its reasons in writing. It must also explain how you can ask for a fair
hearing about the decision to end your participation.

J. You have the right to file a grievance with GuildNet Gold Plus FIDA
Plan if we ask the FIDA Program to end your participation in our FIDA
Plan
If we ask the FIDA Program to end your participation in our plan, we must tell you our
reasons in writing. We must also explain how you can file a grievance about our request to
end your participation. You can see Chapter 9 for information about how to file a grievance.



Note: You can use the grievance process to express your dissatisfaction with our request
to end your participation. However, if you want to ask that the decision be changed, you
must file a fair hearing as described in Section I just above.

K. Where can you get more information about ending your participation
in our FIDA Plan?
If you have questions or would like more information on when we can end your participation,
you can call Participant Services at 1-800-815-0000, Monday through Sunday, 8am to 8pm.
TTY users call 711.

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Chapter 10: Ending your participation in our FIDA Plan

The Independent Consumer Advocacy Network (ICAN) can also give you free information
and assistance with any issues you may have with your FIDA Plan. ICAN may be reached
toll-free at 1-844-614-8800 or online at icannys.org. (TTY users call 711, then follow the
prompts to dial 844-614-8800.)

CHAPTER 11
Legal notices

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Chapter 11: Legal notices

Chapter 11: Legal notices
Table of Contents
A.Notice about laws ...........................................................................................................................225
B.Notice about nondiscrimination.......................................................................................................225
C.Notice about GuildNet Gold Plus FIDA Plan as a second payer .....................................................226
GuildNet Gold Plus FIDA Plan’s Right of Subrogation ................................................................... 226
GuildNet Gold Plus FIDA Plan’s Right of Reimbursement ............................................................. 226
Your Responsibilities ..................................................................................................................... 226
D.Participant confidentiality and notice about privacy practices..........................................................227
E.Notice of action................................................................................................................................227

A. Notice about laws
Many laws apply to this Participant Handbook. These laws may affect your rights and
responsibilities even if the laws are not included or explained in this handbook. The main
laws that apply to this handbook are federal laws about the Medicare and Medicaid
programs. Other federal and state laws may apply too.

B. Notice about nondiscrimination
Every company or agency that works with Medicare must obey the law. You cannot be
treated differently because of your age, claims experience, color, creed, ethnicity, evidence
of insurability, gender, genetic information, geographic location, health status, medical
history, mental or physical disability, national origin, race, religion, or sex. If you think that
you have not been treated fairly for any of these reasons, call the Department of Health and
Human Services, Office for Civil Rights at 1-800-368-1019. TTY users (people who are
deaf, hard of hearing, or speech disabled) should call 1-800-537-7697. You can also visit
http://www.hhs.gov/ocr for more information.

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and

TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711. For
more information, visit www.guildnetny.org.
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Chapter 11: Legal notices

C. Notice about GuildNet Gold Plus FIDA Plan as a second payer
Sometimes someone else has to pay first for the services, items, and drugs that we provide.
For example, if you are in a car accident or if you are injured at work, insurance or Workers
Compensation has to pay first.
GuildNet Gold Plus FIDA Plan has the right and responsibility to collect payment for covered
services, items, and drugs when someone else has to pay first.

GuildNet Gold Plus FIDA Plan’s Right of Subrogation
Subrogation is the process by which GuildNet Gold Plus FIDA Plan gets back some or all of
the costs of your health care from another insurer. Examples of other insurers include:


Your motor vehicle or homeowner’s insurance



The motor vehicle or homeowner’s insurance of an individual who caused your illness
or injury



Workers’ Compensation

If an insurer other than GuildNet Gold Plus FIDA Plan should pay for services, items, or
drugs related to an illness or injury, GuildNet Gold Plus FIDA Plan has the right to ask that
insurer to repay us. Unless otherwise required by law, coverage under this policy by GuildNet
Gold Plus FIDA Plan will be secondary when another plan, including another insurance plan,
provides you with coverage for FIDA-covered services, items, or drugs.

GuildNet Gold Plus FIDA Plan’s Right of Reimbursement
If you get money from a lawsuit or settlement for an illness or injury, GuildNet Gold Plus FIDA
Plan has a right to ask you to repay the cost of covered services that we paid for. We cannot
make you repay us more than the amount of money you got from the lawsuit or settlement.

Your Responsibilities
As a Participant of GuildNet Gold Plus FIDA Plan, you agree to:


Let us know of any events that may affect GuildNet Gold Plus FIDA Plan’s rights of
Subrogation or Reimbursement.



Cooperate with GuildNet Gold Plus FIDA Plan when we ask for information and
assistance with Coordination of Benefits, Subrogation, or Reimbursement.



Sign documents to help GuildNet Gold Plus FIDA Plan with its rights to Subrogation
and Reimbursement.

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and

TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711. For
more information, visit www.guildnetny.org.
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

Chapter 11: Legal notices

Authorize GuildNet Gold Plus FIDA Plan to investigate, request and release
information which is necessary to carry out Coordination of Benefits, Subrogation, and
Reimbursement to the extent allowed by law.

If you are not willing to help us, you may have to pay us back for our costs, including
reasonable attorneys’ fees, in enforcing our rights under this plan.

D. Participant confidentiality and notice about privacy practices
We will ensure that all information, records, data, and data elements related to you, used by
our organization, employees, subcontractors, and business associates, shall be protected
from unauthorized disclosure pursuant to 42 CFR Part 431, Subpart F; 45 CFR Part 160; and
45 CFR Part 164, Subparts A and E.
We are required by law to provide you with a Notice that describes how health information
about you may be used and disclosed, and how you can get this information. Please review
this Notice of Privacy Practices carefully. If you have any questions, call Participant Services
at 1-800-815-0000. TTY users call 711.

E. Notice of action
We must use a coverage determination notice to notify you of a denial, termination, and
delay or modification in benefits. If you disagree with our decision, you can file an appeal with
our plan. You will not have to pay for any of these proceedings. For more information about
appeals, see Chapter 9.

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and

TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711. For
more information, visit www.guildnetny.org.
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CHAPTER 12
Definitions of important words

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Chapter 12: Definitions of important words
Activities of daily living: The things people do on a normal day, such as eating, using the
toilet, getting dressed, bathing, walking, or brushing the teeth.
Aid paid pending: You can continue getting your services or items that are the subject of
your appeal while you are waiting for a decision on a Level 1, 2, or 3 Appeal. This continued
coverage is called “aid paid pending” or “continuing benefits.” All other services and items
automatically continue at approved levels during your appeal.
Appeal: A way for you to challenge a coverage decision if you think it is wrong. You can ask
us to change a coverage decision by filing an appeal. Chapter 9 explains appeals, including
how to make an appeal.
Balance billing: A situation when a provider (such as a doctor or hospital) bills a person
when only GuildNet Gold Plus FIDA Plan should be billed. We do not allow providers to
“balance bill” you. Because GuildNet Gold Plus FIDA Plan pays the entire cost for your
services, you should not get any bills from providers. Call Participant Services if you get any
bills that you do not understand.
Brand name drug: A prescription drug that is made and sold by the company that originally
made the drug. Brand name drugs have the same active ingredients as the generic versions
of the drugs. Generic drugs are made and sold by other drug companies.
Care Manager: One main person who works with you, with the FIDA Plan, with your care
providers, and with your Interdisciplinary Team (IDT) to make sure you get the care you
need.
Centers for Medicare & Medicaid Services (CMS): The federal agency in charge of
Medicare and Medicaid. Chapter 2 explains how to contact CMS.
Comprehensive assessment: A review of your medical history, your needs and
preferences, and your current conditions. It is used by you and your Interdisciplinary Team
(IDT) to develop your Person-Centered Service Plan (PCSP). The term refers both to the
initial comprehensive assessment you will have when you first join GuildNet Gold Plus FIDA
Plan (or within six months of your last assessment if you joined GuildNet Gold Plus FIDA
Plan from GuildNet MLTC or GuildNet Gold HMO SNP) and the subsequent comprehensive
re-assessments you will have at least every six months but more frequently if necessary due
to changes in your needs. The comprehensive assessment and reassessments will be
completed by a Registered Nurse in your home, which may include the hospital, nursing
facility, or any other place you live at the time the assessment occurs.
Comprehensive outpatient rehabilitation facility (CORF): A facility that mainly provides
rehabilitation services after an illness, accident, or major operation. It provides a variety of

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and

TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711.
For more information, visit www.guildnetny.org.
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services, including physical therapy, social or psychological services, respiratory therapy,
occupational therapy, speech therapy, and home environment evaluation services.
Continuing benefits: See “aid paid pending.”
Coverage decision: A decision made by your IDT, GuildNet Gold Plus FIDA Plan, or
another authorized provider about whether GuildNet Gold Plus FIDA Plan will cover a service
for you. This includes decisions about covered services, items, and drugs. Chapter 9 explains
how to ask us for a coverage decision.
Covered drugs: The term we use to mean all of the prescription and other drugs covered by
GuildNet Gold Plus FIDA Plan.
Covered services and items: The general term we use to mean all of the health care, longterm services and supports, supplies, prescription and over-the-counter drugs, equipment,
and other services covered by GuildNet Gold Plus FIDA Plan. Covered services and items
are individually listed in Chapter 4.
Disenrollment: The process of ending your participation in GuildNet Gold Plus FIDA Plan.
Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).
Drug tier: A group of drugs of generally the same type (for example, brand name, generic,
or over-the-counter drugs). Every drug on the List of Covered Drugs is in one of four tiers.
Emergency: A medical emergency is when you, or any other person with average
knowledge of health and medicine, believe that you have medical symptoms that need
immediate medical attention to prevent death, loss of a body part, or loss of function of a
body part. The medical symptoms may be a serious injury or severe pain.
Emergency care: Covered services that are given by a provider trained to give emergency
services and needed to treat a medical emergency. The plan covers emergency care from
out-of-network providers.
Enrollment Broker: The independent entity (New York Medicaid Choice) that handles FIDA
Plan enrollments and disenrollments for the State of New York.
Exception: Permission to get coverage for a drug that is not normally covered or to use the
drug without certain rules and limitations.
Explanation of Benefits (EOB): A summary of the drugs you got during a certain month. It
also shows the total payments made by GuildNet Gold Plus FIDA Plan and Medicare for you
since January 1.
Extra Help: A Medicare program that helps people with limited incomes and resources pay
for Medicare Part D prescription drugs. Extra Help is also called the “Low-Income Subsidy,”
or “LIS.”

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and

TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711.
For more information, visit www.guildnetny.org.
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Fair hearing: A chance for you to tell your problem in New York State court and show that a
decision we made about your Medicaid or FIDA Program eligibility is wrong.
Fully Integrated Duals Advantage (FIDA) Plan: A managed care organization under
contract with Medicare and Medicaid to provide eligible individuals with all services available
through both programs as well as new services. The plan is made up of doctors, hospitals,
pharmacies, providers of long-term services, and other providers. It also has Care Managers
to help you manage all your providers and services. They all work together to provide the
care you need.
Fully Integrated Duals Advantage (FIDA) Program: A demonstration program jointly run
by New York State and the federal government to provide better health care for people who
have both Medicare and Medicaid. Under this demonstration, the State and federal
government are testing new ways to improve how you get your Medicare and Medicaid
health care services.
Generic drug: A prescription drug that is approved by the federal government to use in
place of a brand name drug. A generic drug has the same active ingredients as a brand
name drug. It is usually cheaper and works just as well as the brand name drug.
Grievance: A written or spoken statement saying that you have a problem or concern about
your covered services or care. This includes any concerns about the quality of your care, our
network providers, or our network pharmacies.
Health Insurance Information, Counseling and Assistance Program (HIICAP): HIICAP
is the State Health Insurance Assistance Program for New York. HIICAP gives free health
insurance counseling to people with Medicare. HIICAP is not connected with any insurance
company, managed care plan, or FIDA Plan.
Hospice: A program of care and support to help people who have a terminal prognosis live
comfortably. A terminal prognosis means that a person has a terminal illness and is expected
to have six months or less to live. An enrollee who has a terminal prognosis has the right to
elect hospice. A specially trained team of professionals and caregivers provide care for the
whole person, including physical, emotional, social, and spiritual needs. GuildNet Gold Plus
FIDA Plan must give you a list of hospice providers in your geographic area.
Independent Consumer Advocacy Network (ICAN): An office that helps you if you are
having problems with GuildNet Gold Plus FIDA Plan. ICAN’s services are free. See Chapter
2 for information about how to contact ICAN.
Inpatient: A term used when you have been formally admitted to the hospital for skilled
medical services. If you were not formally admitted, you might still be considered an
outpatient instead of an inpatient even if you stay overnight.

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and

TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711.
For more information, visit www.guildnetny.org.
231

GuildNet Gold Plus FIDA Plan PARTICIPANT HANDBOOK
words

Chapter 12: Definitions of important

Integrated Administrative Hearing: A meeting before the Integrated Administrative
Hearing Office during which you can explain why you think GuildNet Gold Plus FIDA Plan or
your Interdisciplinary Team (IDT) made the wrong decision.
Integrated Administrative Hearing Office (IAHO): A unit within the New York State Office
of Temporary and Disability Assistance that conducts many of the Level 2 Appeals as
described in Chapter 9.
Interdisciplinary Team (IDT): Your IDT will include your Care Manager and your choice of
other health professional (including your Primary Care Provider [PCP]) who are there to help
you get the care you need. Your IDT will also help you make a Person-Centered Service Plan
(PCSP) and coverage decisions.
List of Covered Drugs (Drug List): A list of prescription drugs covered by GuildNet Gold
Plus FIDA Plan. GuildNet Gold Plus FIDA Plan chooses the drugs on this list with the help of
doctors and pharmacists. The Drug List tells you if there are any rules you need to follow to
get your drugs. The Drug List is sometimes called a “formulary.”
Long-term services and supports (LTSS): Long-term services and supports are services
that help improve a long-term medical condition. Most of these services help you stay in your home
so you don't have to go to a nursing facility or hospital. LTSS are sometimes also
referred to as long-term care, long-term supports and services, or home and communitybased services.
Managed Long-Term Care Program (MLTCP): The Managed Long-Term Care Program is
the Medicaid program through which eligible individuals can get community or facility-based
long-term services and supports (LTSS) through a managed care plan under contract to
provide these and other Medicaid services.
Medicaid (or Medical Assistance): A program run by the federal government and the State
that helps people with limited incomes and resources pay for health care, long-term services
and supports, and medical costs. It covers extra services and drugs not covered by
Medicare. Medicaid programs vary from state to state, but most health care costs are
covered if you qualify for both Medicare and Medicaid. See Chapter 2 for information about
how to contact Medicaid in your state.
Medicaid Advantage Plus (MAP) Program: A Medicare and Medicaid managed care plan
program that is available to eligible individuals as an alternative to the FIDA Program. Please
see Chapter 10 for more information about selecting the MAP.
Medically necessary: Those services and items necessary to prevent, diagnose, correct, or
cure conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere
with your capacity for normal activity, or threaten some significant handicap. GuildNet Gold
Plus FIDA Plan will provide coverage in accordance with the more favorable of the current

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and

TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711.
For more information, visit www.guildnetny.org.
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Medicare and New York State Department of Health (NYSDOH) coverage rules, as outlined
in NYSDOH and federal rules and coverage guidelines.
Medicare: The federal health insurance program for people 65 years of age or older, some people
under age 65 with certain disabilities, and people with end-stage renal disease
(generally those with permanent kidney failure who need dialysis or a kidney transplant).
People with Medicare can get their Medicare health coverage through Original Medicare or a
managed care plan.
Medicare Appeals Council: The entity that conducts Level 3 Appeals, as described in
Chapter 9.
Medicare-covered services and items: Services and items covered by Medicare Part A
and Part B. All Medicare health plans, including GuildNet Gold Plus FIDA Plan, must cover all
of the services and items that are covered by Medicare Part A and Part B.
Medicare Part A: The Medicare program that covers most medically necessary hospital,
skilled nursing facility, home health and hospice care.
Medicare Part B: The Medicare program that covers services (like lab tests, surgeries, and doctor
visits) and supplies (like wheelchairs and walkers) that are medically necessary to
treat a disease or condition. Medicare Part B also covers many preventive and screening
services.
Medicare Part C: The Medicare program that lets private health insurance companies
provide Medicare benefits through a Medicare Advantage Plan.
Medicare Part D: The Medicare prescription drug benefit program. (We call this program
“Part D” for short.) Part D covers outpatient prescription drugs, vaccines, and some supplies
not covered by Medicare Part A or Part B or Medicaid. GuildNet Gold Plus FIDA Plan
includes Medicare Part D.
Medicare Part D drugs: Drugs that can be covered under Medicare Part D. Congress
specifically excluded certain categories of drugs from coverage as Part D drugs. Medicaid
may cover some of these drugs.
Network pharmacy: A pharmacy (drug store) that has agreed to fill prescriptions for
GuildNet Gold Plus FIDA Plan Participants. We call them “network pharmacies” because they have
agreed to work with GuildNet Gold Plus FIDA Plan. In most cases, your prescriptions
are covered only if they are filled at one of our network pharmacies.
Network provider: “Provider” is the general term we use for doctors, nurses, and other
people who give you services and care. The term also includes hospitals, home health
agencies, clinics, and other places that give you health care services, medical equipment,
and long-term services and supports. They are licensed or certified by Medicare and by the
State to provide health care services. We call them “network providers” when they agree to

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and

TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711.
For more information, visit www.guildnetny.org.
233

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work with the health plan and accept our payment and not charge our Participants an extra
amount. While you are a Participant of GuildNet Gold Plus FIDA Plan, you must use network
providers to get covered services and items, unless under certain conditions such as in cases
of an emergency or urgently needed care. Network providers are also called “plan providers.”
Nursing home or facility: A place that provides care for people who cannot get their care at home
but who do not need to be in the hospital.
Organization determination: GuildNet Gold Plus FIDA Plan has made an organization
determination when it, or one of its providers, makes a decision about whether services and
items are covered or how much you have to pay for covered services and items.
Organization determinations are called “coverage decisions” in this handbook. Chapter 9
explains how to ask us for a coverage decision.
Original Medicare (traditional Medicare or fee-for-service Medicare): Original Medicare
is offered by the federal government. Under Original Medicare, Medicare services are
covered by paying doctors, hospitals, and other health care providers in amounts that are set
by Congress. You can see any doctor, hospital, or other health care provider that accepts Medicare.
Original Medicare has two parts: Part A (hospital insurance) and Part B (medical insurance).
Original Medicare is available everywhere in the United States. If you do not want
to be in GuildNet Gold Plus FIDA Plan, you can choose Original Medicare.
Out-of-network pharmacy: A pharmacy that has not agreed to work with GuildNet Gold
Plus FIDA Plan to coordinate or provide covered drugs to Participants of GuildNet Gold Plus
FIDA Plan. Most drugs you get from out-of-network pharmacies are not covered by GuildNet
Gold Plus FIDA Plan unless certain conditions apply.
Out-of-network provider or Out-of-network facility: A provider or facility that is not employed,
owned, or operated by GuildNet Gold Plus FIDA Plan and is not under contract to provide covered
services and items to Participants of GuildNet Gold Plus FIDA Plan. Chapter 3 explains out-ofnetwork providers or facilities. You may see providers who are not in our network to access
services that you used to get through your Original Medicare coverage. You do not need the Plan’s
permission to access Medicare services from providers outside of our network. Please note: If you
go to an out-of-network provider, the provider must be eligible to participate in Medicare. We cannot
pay a provider who is not eligible to participate in Medicare. If you go to a provider who is not
eligible to participate in Medicare, you must pay the full cost of the services you get. Providers must
tell you if they are not eligible to participate in Medicare.
Part A: See “Medicare Part A.”
Part B: See “Medicare Part B.”
Part C: See “Medicare Part C.”
Part D: See “Medicare Part D.”

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and

TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711.
For more information, visit www.guildnetny.org.
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Part D drugs: See “Medicare Part D drugs.”
Partial/MLTC Plan: A Medicaid managed care plan program that is available to eligible individuals
as an alternative to the FIDA Program for Medicaid long-term services and
supports (LTSS).
Participant (Participant of our plan, or plan Participants): A person with Medicare and
Medicaid who qualifies to get covered services and items through the FIDA Program, who
has enrolled in GuildNet Gold Plus FIDA Plan, and whose enrollment has been confirmed by
the Centers for Medicare & Medicaid Services (CMS) and the State.
Participant Handbook and Disclosure Information: This document, along with your
enrollment form and any other attachments, riders, or other optional coverage selected documents,
which explains your coverage, what we must do, your rights, and what you must
do as a Participant of GuildNet Gold Plus FIDA Plan.
Participant Services: A department within GuildNet Gold Plus FIDA Plan responsible for
answering your questions about your participation, benefits, grievances, and appeals. See
Chapter 2 for information about how to contact Participant Services.
Person-Centered Service Plan (PCSP): A plan for what services and items you will get,
how you will get them, and your goals of care. Your PCSP is developed by your
Interdisciplinary Team (IDT) with your input.
Point-Of-Service (POS) Plan – In some plans, you may be able to go out-of-network for
certain services, usually for a higher cost. This is called an HMO with a point-of-service
(POS) option.
Primary Care Provider (PCP): Your main doctor or other provider who is responsible for
providing many of your preventive and primary care services and items. Your PCP will be a
part of your Interdisciplinary Team (IDT), if you so choose. If on your IDT, your PCP will
participate in developing your Person-Centered Service Plan (PCSP), making coverage
determinations about services and items requested by or for you, and approving
authorizations for services and items that will be part of your PCSP. Your PCP may be a
primary care physician, a nurse practitioner, or a physician assistant. For more information,
see Chapter 3.
Prior authorization: Approval needed before you can get certain covered services, items,
or drugs. Some services, items, and drugs are covered only if GuildNet Gold Plus FIDA Plan,
your IDT, or another specific provider authorizes them for you. Covered services and items
that need prior authorization are marked in the Covered Items and Services Chart in Chapter

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and

TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711.
For more information, visit www.guildnetny.org.
235

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4. Some drugs are covered only if you get prior authorization from GuildNet Gold Plus FIDA
Plan or the IDT. Covered drugs that need prior authorization are marked in the List of
Covered Drugs.
Program of All-Inclusive Care for the Elderly (PACE): A Medicare and Medicaid
managed care plan program that is available to eligible individuals as an alternative to the
FIDA Program. Please see Chapter 10 for more information about selecting PACE.
Quality improvement organization (QIO): A group of doctors and other health care experts
who help improve the quality of care for people with Medicare. They are paid by the federal
government to check and improve the care given to Participants. See Chapter 2 for
information about how to contact the QIO for your state.
Quantity limits: A limit on the amount of a drug you can have. Limits may be on the amount
of the drug that we cover per prescription.
Self-directed care: A program that gives you the flexibility to choose and manage your caregivers.
You (or your designee) are responsible for recruiting, hiring, training, supervising,
and terminating caregivers. For more information, see Chapters 3 and 4.
Service area: A geographic area where a health plan accepts Participants. For plans that
limit which doctors and hospitals you may use, it is also generally the area where you can get
routine (non-emergency) services. GuildNet Gold Plus FIDA Plan may request FIDA
Program permission to drop you from the FIDA Plan if you move out of the FIDA Plan’s
service area. For more information about the FIDA Plan’s service area, see Chapter 1.
Skilled nursing facility (SNF): A nursing facility with the staff and equipment to give skilled
nursing care and, in most cases, skilled rehabilitative services and other related health
services.
Skilled nursing facility (SNF) care: Skilled nursing care and rehabilitation services
provided on a continuous, daily basis, in a skilled nursing facility. Examples of skilled nursing
facility care include physical therapy or intravenous (IV) injections that a registered nurse or a
doctor can give.
Specialist: A doctor who provides health care for a specific disease or part of the body.
State Medicaid agency: The New York State Medicaid Agency is the New York State Department
of Health (NYSDOH), Office of Health Insurance Programs (OHIP).
Step therapy: A coverage rule that requires you to first try another drug before we will cover
the drug you are asking for.
Urgently needed care: Care you get for a sudden illness, injury, or condition that is not an
emergency but needs care right away. You can get urgently needed care from out-of-network
providers when network providers are unavailable or you cannot get to them.

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and

TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711.
For more information, visit www.guildnetny.org.
236

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Chapter 12: Definitions of important words

GuildNet Gold Plus FIDA Plan Participant Services
CALL

1-800-815-0000 This call is free.
Hours are Monday through Sunday, 8am to 8pm.
We have free interpreter services for people who do
not speak English.

TTY

711 This call is free.
This number is for people who have hearing or speaking
problems. You must have special telephone equipment to
call it.
Hours are Monday through Sunday, 8am to 8pm.

FAX

1-212-769-1621

WRITE

GuildNet Gold Plus FIDA Plan
15 West 65th Street
New York, NY 10023
guildnetinfo@lighthouseguild.org

WEB SITE

www.guildnetny.org

If you have questions, please call GuildNet Gold Plus FIDA Plan at 1-800-815-0000 and

TTY/TDD 711, Monday through Sunday, 8am to 8pm. The call is free. TTY users call, 711.
For more information, visit www.guildnetny.org.
237

15 West 65th Street
New York, NY 10023-6601
Monday – Sunday 8 am – 8 pm
800-815-0000
TTY: 711
www.guildnetny.org

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