Participant Rights and Responsibilities

Our plan must honor your rights as a Participant of Elderplan FIDA Total Care. You have the right:

  • To receive medically necessary items and services as needed to meet your needs, in a manner that is sensitive to your language and culture, and that is provided in an appropriate care setting, including the home and community;
  • To receive timely access to care and services;
  • To request and receive written and oral information about Elderplan FIDA Total Care, its Participating Providers, its benefits and services, and the Participants’ rights and responsibilities in a manner the Participant understands;
  • To receive materials and/or assistance in a foreign language and in alternative formats, if necessary;
  • To be provided qualified interpreters, free of charge, if you need interpreters during appointments with Providers and when talking to Elderplan FIDA Total Care;
  • To be treated with consideration, respect and full recognition of your dignity, privacy and individuality;
  • To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation;
  • Not to be neglected, intimidated, physically or verbally abused, mistreated, or exploited;
  • To not be discriminated against on the basis of and to get care without regard to sex, race, health status, disability, color, age, national origin, sexual orientation, marital status or religion;
  • 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 Providers are not available in the Elderplan FIDA Total Care network;
  • To complain to NYSDOH or the Local Department of Social Services; and, the right to use the New York State Fair Hearing System and/or a New York State External Appeal, where appropriate;
  • To be advised in writing of the availability of the NYSDOH toll-free hotline, the telephone number, the hours of its operation and that the purpose of the hotline is to receive complaints or answer questions about home care agencies;
  • To appoint someone to speak for you about the care you need;
  • To be informed of all rights, and the right to exercise such rights, in writing prior to the Effective Date of Enrollment;
  • To participate in your care planning and participate in any discussions around changes to the Person-Centered Service Plan, if/when they are warranted;
  • To recommend changes in policies and services to agency personnel, NYSDOH or any outside representative of your choice;
  • To have telephone access to a nursing hotline and on-call Participating Providers 24/7 in order to obtain any needed emergency or urgent care or assistance;
  • 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 for Participants with disabilities or other conditions limiting mobility, in accordance with the Americans with Disabilities Act;
  • To receive reasonable accommodations in accessing care, in interacting with Elderplan FIDA Total Care and Providers, and in receiving information about your care and coverage;
  • To see a specialist and request to have a specialist serve as Primary Care Provider;
  • To talk with and receive information from Providers on all conditions and all available treatment options and alternatives, regardless of cost, and to have these presented in a manner the Participant understands. This includes the right to be told about any risks involved in treatment options and about whether any proposed medical care or treatment is part of a research experiment;
  • To choose whether to accept or refuse care and treatment, after being fully informed of the options and the risks involved. This includes the right to say yes or no to the care recommended by Providers, the right to leave a hospital or other medical facility, even if against medical advice, and to stop taking a prescribed medication;
  • To receive a written explanation if Covered Items or Services were denied, without having to request a written explanation;
  • To have privacy in care, conversations with Providers, and Medical Records such that:
  • Medical and other records and discussions with Providers will be kept private and confidential;
  • You get to approve or refuse to allow the release of identifiable medical or personal information, except when the release is required by law;
  • You may request that any communication that contains Protected Health Information from Elderplan FIDA Total Care be sent by alternative means or to an alternative address;
  • You are provided a copy of Elderplan FIDA Total Care’s Privacy Practices, without having to request the same;
  • You may request and receive a copy of your Medical Records and request that they be amended or corrected, as specified in 45 CFR 164.524 and 164.526., if the privacy rule, as set forth in 45 CFR 160 and 164, A and E, applies;
  • You may request information on how your health and other personal information has been released by Elderplan FIDA Total Care;
  • To seek and receive information and assistance from the independent, conflict free Participant Ombudsman;
  • To make decisions about Providers and coverage, which includes the right to choose and change Providers within the Elderplan FIDA Total Care network and to choose and change coverage (including how one receives his/her Medicare and/or Medicaid coverage – whether by changing to another FIDA Plan or making other changes in coverage);
  • To be informed at the time of enrollment and at PCSP update or revision meetings of the explanation of what is an Advance Directive and the right to make an Advance Directive – giving instructions about what is to be done if you are not able to make medical decisions for yourself – and to have Elderplan FIDA Total Care and its Participating Providers honor it; and
  • To access information about Elderplan FIDA Total Care, its network of Providers, and Covered Items and Services including:
    • Information about Elderplan FIDA Total Care’s financial condition, its performance rating, how it compares to other plans, and the number of appeals made by Participants;
    • Information about the qualifications of the Participating Providers and how they are paid; and
    • Information about the rules and restrictions on Covered Items and Services.
  • The right to have all plan options, rules and benefits fully explained, including through use of a qualified interpreter if needed;
  • The right to access an adequate network of primary and specialty Providers who are capable of meeting your needs with respect to physical access and communication and scheduling needs;
  • The right to have a voice in the governance and operation of Elderplan FIDA Total Care, Provider or health plan, as detailed in this Contract; and
  • The right to participate in all aspects of care and to exercise all rights of appeal.
  • You have a responsibility to be fully involved in maintaining your health and making decisions about your health care, including the right to refuse treatment if desired, and must be appropriately informed and supported to this end. Specifically, you must:
  • Receive an in-person Comprehensive Assessment upon enrollment in Elderplan FIDA Total Care to participate in the development and implementation of a Person-Centered Service Plan (PCSP). You, or your designated representative, also have the right to request a Comprehensive Reassessment by Elderplan FIDA Total Care and to be fully involved in any such Comprehensive Reassessment.
  • You must get your services and items from network providers.
    • Usually, Elderplan FIDA Total Care will not cover services or items from a provider who has not joined Elderplan FIDA Total Care’s network. Here are some cases when this rule does not apply:
      • The plan covers emergency or urgently needed care from an out-of-network provider.
      • 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.
      • 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.
      • 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.
      • 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 Elderplan FIDA Total Care’s network.
      • If you are receiving 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.
    • If you need to go to an out-of-network provider, please work with Elderplan FIDA Total Care 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 without first getting Plan or IDT approval, you may have to pay the full cost of the services you get.
  • Receive complete and accurate information on your health and Functional Status by the Interdisciplinary Team.
  • Be provided information on all program services and health care options, including available treatment options and alternatives, presented in a culturally appropriate manner, taking into consideration your condition and ability to understand. If you are unable to participate fully in treatment decisions, you have the right to designate a representative. This includes the right to have translation services available to make information appropriately accessible.

Information must be available:

  • Before Enrollment.
  • At Enrollment.
  • At the time your needs necessitate the disclosure and delivery of such information in order to allow you to make an informed choice.
  • Be encouraged to involve caregivers or family participants in treatment discussions and decisions.
  • Be afforded the opportunity to file an Appeal if Items or Services are denied that you think are medically indicated and to be able to ultimately take that Appeal to an independent external system of review.
  • The right to freely exercise your rights and that the exercise of those rights does not adversely affect the way the Elderplan FIDA Total Care and its Providers or the State Agency or CMS provide, or arrange for the provision of, medical services to you.
  • The right to receive timely information about Elderplan FIDA Total Care plan changes. This includes the right to request and obtain the information listed in the Marketing, Outreach and Participant Communications materials at least once per year and the right to receive notice of any significant change in the information provided in the Orientation materials at least 30 days prior to the intended effective date of the change.
  • The right to be protected from liability for payment of any fees that are the obligation of the Elderplan FIDA Total Care.
  • The right not to be charged any cost for Medicare Parts A and B services.

As a Participant of Elderplan FIDA Total Care, you have the following responsibilities:

  1. To try to understand Covered Items and Services and the rules around getting Covered Items and Services;
  2. To tell Providers that you are enrolled in an Elderplan FIDA Total Care and show your Elderplan FIDA Total Care card;
  3. To treat Providers and employees of the Elderplan FIDA Total Care with respect;
  4. To communicate problems immediately to the Elderplan FIDA Total Care;
  5. To keep appointments or notify the Interdisciplinary Team if an appointment cannot be kept;
  6. To supply accurate and complete information to Elderplan FIDA Total Care’s employees;
  7. To actively participate in PCSP development and implementation;
  8. To notify the State and the Elderplan FIDA Total Care of any changes in income and assets. Assets include bank accounts, cash in hand, certificates of deposit, stocks, life insurance policies, and any other assets;
  9. To ask questions and request further information regarding anything not understood;
  10. To use Elderplan FIDA Total Care’s Participating Providers for services included in the Elderplan FIDA Total Care Plan Benefit Package;
  11. To notify Elderplan FIDA Total Care of any change in address or lengthy absence from the area;
  12. To comply with all policies of Elderplan FIDA Total Care as noted in the Participant Handbook;
  13. If sick or injured, to call your doctors or care coordinators for direction right away;
  14. In case of emergency, to call 911; and
  15. If Emergency Services are required out of the service area, to notify Elderplan FIDA Total Care as soon as possible.

Participant Rights Upon Disenrollment

A. When can you end your participation in our FIDA Plan?

You can end your participation in Elderplan FIDA Total Care 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 Elderplan FIDA Total Care, see the table in Section E below.

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 a.m. to 8:00 p.m. and Saturday from 10:00 a.m. to 6:00 p.m. 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 FIDA Participant Ombudsman can also give you free information and assistance with any issues you may have with your FIDA Plan. To contact the FIDA Participant Ombudsman, call 1-844-614-8800.

B. How do you end your participation in our FIDA Plan?

If you decide to end your participation in Elderplan FIDA Total Care, call the Enrollment Broker or Medicare and tell them you want to leave Elderplan FIDA Total Care:

  • Call the Enrollment Broker (New York Medicaid Choice) at 1-855-600-FIDA, Monday through Friday from 8:30 a.m. to 8:00 p.m. and Saturday from 10:00 a.m. to 6:00 p.m. 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 Elderplan FIDA Total Care is in the chart in Section E1.

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 a.m. to 8:00 p.m. and Saturday from 10:00 a.m. to 6:00 p.m. TTY users should call 1-888-329-1541. Tell the Enrollment Broker you want to leave Elderplan FIDA Total Care 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 1-855-600-FIDA if you need them to mail you one. TTY users should call 1-888-329-1541.

Your coverage with Elderplan FIDA Total Care will 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 Elderplan FIDA Total Care 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:

Call the Enrollment Broker (New York Medicaid Choice) at 1-855-600-FIDA, Monday through Friday from 8:30 a.m. to 8:00 p.m. and Saturday from 10:00 a.m. to 6:00 p.m. TTY users should call 1-888-329-1541. Tell the Enrollment Broker you want to leave Elderplan FIDA Total Care 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 Elderplan FIDA Total Care, you will go back to getting your Medicare and Medicaid services separately as described below.

E1. 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 Elderplan FIDA Total Care.

1. You can change to:
A Medicare health plan, such as a Medicare Advantage plan

Here is what to do:

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 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 Elderplan FIDA Total Care when your new plan’s coverage begins.

2. You can change to:
Original Medicare with a separate Medicare prescription drug plan

Here is what to do:

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.

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 Elderplan FIDA Total Care when your Original Medicare coverage begins.

3. You can change to:
Original Medicare without a separate Medicare prescription drug plan

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.

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.

Here is what to do:

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.

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 Elderplan FIDA Total Care when your Original Medicare coverage begins.

E2. How you will get Medicaid services

If you leave the FIDA Plan, you will still be able to receive 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 receive your Medicaid physical and behavioral health services through Medicaid Fee-for-Service. You can choose to completely stop receiving long-term services and supports. However, it may take extra time to complete a safe discharge process.

  • If you choose to completely stop receiving 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 Elderplan FIDA Total Care. Your change request on your Medicare coverage will not be delayed and will take effect on the first day of the month after you request the change.

If you were receiving services through the Nursing Home Transition & Diversion 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 receive any existing Nursing Home Transition & Diversion services from Elderplan FIDA Total Care or enroll in a Medicaid Managed Long-Term Care plan to receive 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 Elderplan FIDA Total Care, it may take time before your participation ends and your new Medicare and Medicaid coverage begins. During this time, you will keep getting your services, items and drugs through Elderplan FIDA Total Care.

  • 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:

  • If there is a break in your 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 Elderplan FIDA Total Care’s service area.
  • If you go to jail, prison or a correctional facility.
  • If you lie about or withhold information about other insurance you have for health care or prescription drugs.

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 request that the FIDA Program remove you from Elderplan FIDA Total Care for the following reasons:

  • If you intentionally give us incorrect information when you are enrolling in Elderplan FIDA Total Care 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 Elderplan FIDA Total Care 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 Elderplan FIDA Total Care 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 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 request FIDA Program approval to have you disenrolled from Elderplan FIDA Total Care. 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 approves our request, you will receive 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 requesting that you be disenrolled from Elderplan FIDA Total Care 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 request a fair hearing if the FIDA Program ends your participation in our FIDA Plan

If the FIDA Program ends your participation in Elderplan FIDA Total Care, the FIDA Program must tell you its reasons in writing. It must also explain how you can request a fair hearing about the decision to end your participation.

J. You have the right to file a grievance with Elderplan FIDA Total Care 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.

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 1-855-462-3167, 8 a.m. to 8 p.m., 7 days a week. TTY users call 711.

The FIDA Participant Ombudsman can also give you free information and assistance with any issues you may have with your FIDA Plan. To contact the FIDA Participant Ombudsman, call 1-844-614-8800.