If you have Medicare and get assistance from Medicaid, the information below applies to all of your Medicare and Medicaid benefits. You do not have to use one process for your Medicare benefits and a different process for your Medicaid benefits. This is sometimes called an “integrated process” because it integrates Medicare and Medicaid processes.
A Coverage Determination is when the plan, or delegated vendor has made an organization determination when it makes a decision about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are called “coverage decisions.” You, your representative, or any provider that furnishes, or intends to furnish, services to you, may request an organization determination by filing a request with VNSNY CHOICE.
If a drug is not covered in the way you would like it to be covered, you can ask VNSNY CHOICE to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:
If we say no to your coverage decision, you have the right to ask for an appeal. Asking for an appeal means asking us to reconsider — and possibly change — the decision we made. You may also ask for an appeal if you disagree with our decision to stop services that you are receiving. For example, you could file an appeal if:
You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a 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. Please include your reason in your appeal request.
Our timeframes to respond to your appeal are as follows:
A complaint is a process our members can use for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. If your problem is related to benefits, coverage decisions, or payment, please refer to the coverage decision and appeal sections above. Some examples of problems that would follow the complaint process are:
For more information, see Common Questions about Filing an Appeal or Complaint, below.
Whether you call or write, you should contact us right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about. We recommend that you file your complaint as soon as you are able to and provide as much information as you can to help us understand your problem and help resolve it sooner.
Our timeframes to respond to complaints are:
Below are frequently asked questions about filing an appeal or complaint.
You can ask for a fast coverage decision only if you or any doctor believes that waiting for a standard coverage decision could cause serious harm to your health or hurt your ability to function. Fast decisions apply only to requests for medical care. You cannot get a fast decision on requests for payment for care you have already received.
If VNSNY CHOICE denies your request to file an expedited coverage decision, we will process the request under the standard timeframe and make a decision within 14 calendar days. The Plan will notify you orally and in writing within 3 calendar days that your expedited request will be handled under the standard timeframe, the member’s right to file an expedited complaint; including the process and timeframe, the right to resubmit a request for an expedited determination and that if the member obtains any physician support indicating that applying the standard timeframe for making a determination could cause serious harm to you or hurt your ability to function, the request will be expedited.
You have the right, by law, to ask for a review (an appeal) of a discharge date from the Hospital, Skilled Nursing Facility, Home Health Aide services, or Comprehensive Outpatient Rehabilitation Facility. You must contact the Quality Improvement Organization (QIO) for review. If you believe that you are being discharged too soon and appeal, you will receive a Detailed Notice of Discharge. The Detailed Notice of Discharge explains the specific reasons for the discharge. You can see a sample notice online at www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html.
If you do not ask the QIO for a “fast appeal” by the deadline (no later than noon on the day after the date your Medicare coverage ends), you may ask VNSNY CHOICE EasyCare or EasyCare Plus for a “fast appeal” of the discharge. For more information on member appeal and complaint rights, please refer to the EasyCare Member Handbook (Evidence of Coverage), EasyCare Plus Member Handbook (Evidence of Coverage, or contact us.
To file a complaint or request an appeal, please either: Call us at 1-866-783-1444 (TTY: 711). 8 am – 8 pm, 7 days a week; or,
Members may also submit their appeals or complaints in writing and mail or fax to:
Medicare Grievance & Appeals
PO Box 445
Elmsford, NY 10523
Fax: 1-866-791-2213
If you are not satisfied with the outcome of your appeal, details regarding your right to further appeal and your next steps will be included in your decision letter. Please refer to the EasyCare Member Handbook (Evidence of Coverage), EasyCare Plus Member Handbook (Evidence of Coverage), the EasyCare Summary of Benefits, EasyCare Plus Summary of Benefits), or for more information, please contact us. To appoint a representative to act on your behalf, please use the Appointment of Representative form (CMS-1696) in English, en español or 中文.
You or your authorized representative may also file an external complaint with the Centers for Medicare and Medicaid Services (CMS) by:
Phone: 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Submit complaints: www.medicare.gov/MedicareComplaintForm/home.aspx.
To obtain the total number of complaints, appeals, and exceptions filed with the plan, please call us at 1-866-783-1444 (TTY; 711), 8 am – 8 pm, 7 days a week.
Or reach us by mail at:
VNSNY CHOICE
Medicare Appeals and Grievances
P.O. Box 445 Elmsford, NY 10523
For more information, please refer to the EasyCare Member Handbook (Evidence of Coverage) or the EasyCare Plus Member Handbook (Evidence of Coverage).
Call your VNSNY CHOICE Care Team at 1-866-783-1444 (TTY: 711), 7 days a week, from 8 am – 8 pm.
All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If your plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
If you have Medicare and get assistance from Medicaid, the information below applies to all of your Medicare and Medicaid benefits. You do not have to use one process for your Medicare benefits and a different process for your Medicaid benefits. This is sometimes called an “integrated process” because it integrates Medicare and Medicaid processes.