Personal Wellness Plan

Member Handbook

This handbook will tell you how to use your Healthfirst plan. Keep this handbook where you can find it when you need it. Please fill in names and Important phone numbers Contact Information Your Primary Care Provider (PCP):

We make it easy to reach us when you need help. The fastest way to get the answers you need is usually online, but we’re Your Health Home Care Manager: also available to talk to you in person at Healthfirst Community Offices or over the phone. Your Health Home:

ONLINE healthfirst.org (For general information) MyHFNY.org (Log in to your secure Healthfirst account) Healthfirst Websites HFDocFinder.org (Find a doctor, specialist, urgent care center, or hospital) MAIL Personal Wellness Plan General Member Correspondence 100 Church Street, New York, NY 10007 CVS Pharmacy Mail Order Prescription Service (only) P.O. Box 2110, Pittsburgh, PA 15230-2110 PHONE 1-855-659-5971 Healthfirst Member Services 24 hours a day, 7 days a week TTY: 1-888-542-3821 1-800-404-8778 Healthfirst Care Management Monday to Friday, 8:30am–5:30pm TTY: 1-888-542-3821 CVS Pharmacy Mail Order 1-800-378-5697 Prescription Service (only) Monday to Friday, 8am–8:30pm Dental Care Choose a primary dentist (dental home) for your 1-800-508-2047 dental care. These benefits are administered by Monday to Friday, 9am–6pm DentaQuest.

Vision Care 1-800-753-3311 Select an eye doctor for your vision care. Monday to Friday, 8am–11pm; Saturday, 9am–4pm; These benefits are administered by Davis Vision. Sunday, 12pm–4pm

Medical Answering Services (Monday to Friday, 7am–6pm): NYC Residents: 1-844-666-6270 Orange County Residents: 1-855-360-3543 Non-Emergency Transportation Westchester County Residents: 1-866-883-7865 Please call three days in advance to arrange for Sullivan County Residents: 1-866-573-2148 transportation to your doctor’s appointment medanswering.com (online scheduling available 24/7) LogistiCare for Long Island Residents: 1-844-678-1103, Monday to Friday, 7am–6pm Healthfirst Medical Management Department For preauthorization or to notify Healthfirst 1-888-394-4327 Personal Wellness Plan of an admission Fax: 1-646-313-4603 Monday to Friday, 8:30am–5:30pm

Personal Wellness Plan Member Handbook Important Websites

ONLINE

New York State Department of Health http://www.health.ny.gov

New York State Office of Mental Health http://www.omh.ny.gov (NYS OMH)

New York State Office of Addiction http://www.oasas.ny.gov Services and Supports (NYS OASAS)

New York State Department of Health http://www.health.ny.gov/diseases/aids/ (NYSDOH) HIV/AIDS Information

Uninsured Care Programs https://www.health.ny.gov/diseases/aids/general/resources/adap/

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org C Welcome To Health Insurance That's Here for You

Thank you for choosing Healthfirst. We’re here Looking for a doctor in the Healthfirst network? for you with access to a wide range of care and Check our Provider Directory. Visit MyHFNY.org to services to fit your needs and budget, including view it online, call Member Services to have our large network of doctors and specialists a copy mailed to you, or return the enclosed at many top hospitals and medical centers in card in the postage-paid envelope to: New York City and on Long Island. Also, we Healthfirst Provider Directory, P.O. Box 5165, offer in-network urgent care centers to give New York, NY 10275-0308. you extra convenience. Plus, our community Ready to get started? wellness events are designed around members Continue reading to learn more about your health just like you. Need answers to your health plan and benefits. You have two ways to register questions? Healthfirst is here for you from your secure Healthfirst account and get the virtually anywhere—online, in person, and over information you need, including a complete list of the phone. plan benefits and coverage: Did you know your Healthfirst plan is also the ¡ Visit MyHFNY.org from your computer only 5-star-rated (out of five) Medicaid plan in or smartphone NYC and Long Island six years in a row?* More stars means better plan performance, ¡ Call Member Services at 1-855-659-5971 so you can trust Healthfirst to provide you with (TTY 1-888-542-3821), access to quality care and service. 24 hours a day, 7 days a week, for assistance

This Member Handbook gives you important IMPORTANT: information—including your benefits, online You need to renew your Healthfirst Personal tools, and more—to help you get to know your Wellness Plan every year to keep your health new health plan. We also included the following coverage. Please write down your plan’s start date member material in your Welcome Kit: and remember to renew with Healthfirst around the same time next year. ¡ Quick Reference Drug List: A list of the most commonly prescribed medications covered under your plan

*Ratings are based on a five-star scale from indicators chosen by the New York State Department of Health and are published in its 2014 through 2019 publications of A Consumer’s Guide to Medicaid Managed Care in NYC and on Long Island.

I Personal Wellness Plan Member Handbook Let’s Get Started As a new Healthfirst member, you should have already received:

Your Member ID Card with Primary Care Provider (PCP) assignment. It identifies you as a Healthfirst member and shows the PCP assigned to you. Of course, you can choose at any time to switch to another doctor in the Healthfirst network. Your card helps you receive care at doctor offices, specialists, urgent care centers, hospitals, and pharmacies in the Healthfirst network. Please carry it with you at all times. If you haven’t received it yet, call Member Services at 1-855-659-5971.

What you can do in the next 30 days to help you get the most from your Healthfirst health plan:

Schedule your annual checkup with your PCP. Decide whether you want to switch from Make an appointment with your PCP for your your assigned PCP to another doctor in the free annual checkup. Healthfirst network. Visit HFDocFinder.org to search for doctors in our network, and go Choose your dentist* by calling to MyHFNY.org to update your PCP yourself 1-800-508-2047, and make an appointment or call our Member Services to make for your annual free dental checkup the change. and cleanings. Call and join a Health Home for help Choose your eye doctor** by calling coordinating your healthcare services. 1-800-753-3311, and make an appointment See page III for more information. for your annual free vision checkup. Find a Healthfirst Community Office near Visit MyHFNY.org to sign up for your own you so you can get answers to your health secure Healthfirst account. For steps to set insurance questions in person. Are you more up an account, see page V. Or call Member comfortable speaking a language other than Services and we’ll set up your online account English? No problem. Our Member Services for you. reps speak many languages.

Complete your Annual Health Assessment. It’s a simple survey that helps us get to know your health needs better. Your survey will arrive in the mail in two to three weeks, or you can complete it online at MyHFNY.org.

*Dental care benefits are administered by DentaQuest. **Vision care benefits are administered by Davis Vision.

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org II II What Should I Know About My Health Plan? Your Healthfirst Personal Wellness Plan offers you access to health benefits including:

Primary Care Services with your PCP Family Planning that helps you manage (or main doctor) for most of your the timing of pregnancies. healthcare needs, such as checkups and health screenings. See page IV Maternity and Pregnancy Care that for details. includes doctor visits before and after your baby is born, plus hospital stays. Specialist Services with doctors or Your baby will also be automatically nurses who specialize in treating enrolled into Medicaid. certain conditions, such as hypertension, diabetes, asthma, Well-Child Visits that cover and arthritis. immunizations.

Urgent care and ER visits. Pharmacy benefits that cover prescription and non-prescription drugs. Hospital Services with inpatient (requires overnight stay or longer) Lab tests and imaging (including and outpatient (does not require an blood tests and X-rays) to find the overnight stay) care. cause of illness.

Dental Care with comprehensive Transportation to help you get to dental treatment. your doctor appointments.

Vision Care with routine eye exams and glasses.

How Else Does Healthfirst Help Me Stay Healthy?

Health Home Care Management Behavioral Health Home- and We encourage you to join a Health Home to better Community-Based Services (BH-HCBS) coordinate your health services. You’ll be assigned These services provide you with support for living in a Health Home Care Manager who can help make your community. They can also help you with getting appointments, help you get social services, set up a job, returning to school, finding a safe place to stay, a Plan of Care that is designed for you, and more. family support, and other areas of your life. You’ll Someone from your Health Home will be available need to complete a brief assessment with a Health 24 hours a day, 7 days a week. Call 1-855-659-5971 Home Care Manager or Recovery Coordinator to to learn more. see if you can benefit from these services. Call us at 1-855-659-5971 for more information.

III Personal Wellness Plan Member Handbook Access To Many Types of Care

Your Healthfirst Personal Wellness Plan gives Urgent Care you access to different types of care. If you’re With access to a robust network of urgent not sure where to go for healthcare, here’s a care centers, you can get immediate, general guide: non-emergency care whenever your doctor’s ¡ For primary care such as checkups and office is closed. This can help save you time vaccinations, you should see your PCP and money. Urgent care centers are walk-in (main doctor) medical facilities (no advance appointment ¡ For specialty care, like skincare or foot care, needed) equipped to handle minor health issues you should see a specialist like infections, upset stomach, fevers, sprains, minor fractures and broken bones, stitches, ¡ When your PCP is not available and you X-rays, and more. have an immediate but non-life-threatening health problem, you should go to an urgent Visit HFDocFinder.org to find an urgent care care center center near you. Emergency Care Primary Care If you have an emergency, always call 911 Your PCP is the doctor you go to for your or visit the nearest emergency room, healthcare needs. Your PCP can be a general especially if you think waiting will worsen doctor, an OB/GYN, or (in some cases) your condition. Emergencies are things a specialist. like uncontrollable bleeding, chest pain, Specialty Care poisoning, and severe allergic reaction. As a Healthfirst member, you do not need to Did you know? You don’t need preauthorization get referrals from your PCP to see in-network if you need immediate emergency care. specialists. However, it is recommended However, please call Healthfirst within 48 that you talk with your PCP before going to hours to let us know you’ve been treated in an a specialist. Your PCP can help guide you to emergency room. the most appropriate specialty care for your specific health concern and also recommend specialists to you.

Important: Whether you need access to preventive medical services (like a flu shot) or to an urgent care center, you can trust your Healthfirst health insurance plan to be there for you. Please make sure your doctor, specialist(s), urgent care center, hospital, or lab is in-network before making an appointment. This can help you to avoid any surprise costs when you need care. Why? Because your plan’s coverage doesn’t include out-of-network benefits (except for emergency or urgent care situations, or for out-of-network renal dialysis or other services). For a complete list of all your covered medical services, please see pages 11–17. You may also call Member Services at 1-855-659-5971 or visit MyHFNY.org. Once there, just sign up for your secure Healthfirst account to view your plan details. Our website is mobile-friendly, so you can access your online account on your smartphone or any mobile device.

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org IV IV What Kind of Online Tools Are Available? Whether you want to find a doctor, view or print a temporary Member ID card, or learn about all your plan benefits, you can easily do it online 24/7—using your computer, tablet, or even your smartphone. Our website is available in English, Spanish, and Chinese.

Activate your secure Healthfirst account today. Need a new doctor or want to see if your current Here’s how: doctor is in our network? Step 1 Use our easy-to-use online provider directory to ¡ Visit MyHFNY.org get the information you need—including office hours, locations, and hospital affiliation. ¡ Click "New Users -- Sign Up" Visit HFDocFinder.org and select your Healthfirst ¡ Read the License Agreement, health plan to access our directory. Besides finding and click "Agree" Primary Care Providers (PCPs) in our network, Step 2 you can also search for specialists, dentists, ¡ Fill out your personal information, including pharmacies, behavioral health providers, hospitals, your Healthfirst Member ID number. urgent care centers, and more. Click "Next" Step 1 ¡ Create your Username, Password, and enter  ¡ Visit HFDocFinder.org your email address. Click "Next" ¡ Select your language from the Step 3 top-right corner (English and Spanish available) ¡ Select your security questions and fill in the answers. Click "Next" ¡ Select your plan from the list of options: Healthfirst Personal Wellness Plan ¡ Verify your information. Click "Complete" And you’re all set! Step 2 ¡ Use the search box to find a doctor by name, Enjoy 24/7 online access to your specialty, facility, and more, or click on the secure Healthfirst account: shortcuts to search by category ¡ Search for a doctor, pharmacy, urgent care center, or clinic in our network Step 3 Narrow the list of results by: ¡ Print out a temporary Member ID card ¡ Entering your zip code to find the ¡ View recent medical services and authorizations closest doctor ¡ Review your plan benefits ¡ Selecting a specialty ¡ Change your PCP ¡ Selecting doctors who are accepting ¡ Take an online Annual Health new patients Assessment survey ¡ Selecting a preferred gender, or ¡ Access pharmacy benefits ¡ Selecting other search options ¡ See a complete list of prescription drugs covered under your plan Manage your prescriptions conveniently and easily online. If you’re a member under the age of 18, please Register your account at caremark.com to quickly call Member Services for special instructions on order refills, get prescription alerts, check order setting up your secure Healthfirst account. status, get your medicine mailed to you, and more. Having trouble getting online? You can always call our Member Services for assistance. We‘ll set up your online account for you and help you with anything else.

V Personal Wellness Plan Member Handbook V What Information Is on My Member ID Card? Please remember to keep your Healthfirst Member ID card handy so you can get access to care when you need it. And be sure to show it when you receive healthcare services from a doctor or hospital, or when you get a prescription. If you haven’t received your card in the mail yet, please call Member Services.

Your Member ID Number

Personal Wellness Plan This card does not guarantee coverage. I agree by the use of this card to release to Healthfirst and its delegates any medical information needed RxBin 004336 RxPCN ADV RxGrp RX1113 to administer my benefits. Plans are offered by affiliates of Healthfirst, Inc. Jane Doe Member ID: XX00000X For Members Member Services: 1-855-659-5971 (TTY: 1-888-542-3821) Your Primary Website: healthfirst.org Provider Name: Dr. John Doe Care Provider Benefits Copay For Providers Provider Phone: 212-000-0000 Non-Preferred Brand Drugs $0 Medical Pharmacy Dental: 800-508-2047 Generic/Preferred Drugs $0 Dental 800# Elegibility: What you 1-888-801-1660pay for Help Desk: 1-800-364-6331 Non-Prescription Priorsome Authorization: prescriptions1-888-394-4327 Claims: CVS Caremark (over the counter) Drugs $0 Electronic Claims: Payer ID 80141 P.O. Box 52136 Paper Claims: Healthfirst Claims Department Phoenix, AZ 85072-2136 P.O. Box 958438 Lake Mary, FL 32795-8438 Visit MyHFNY.org to find a doctor, view your benefits, and more!

Personal Wellness Plan This card does not guarantee coverage. I agree by the use of this card to release to Healthfirst and its delegates any medical information needed RxBin 004336 RxPCN ADV RxGrp RX1113 to administer my benefits. Plans are offered by affiliates of Healthfirst, Inc. Member Services Jane Doe Member ID: XX00000X For Members phone number Member Services: 1-855-659-5971 (TTY: 1-888-542-3821) Website: healthfirst.org Provider Name: Dr. John Doe Benefits Copay For Providers Provider Phone: 212-000-0000 Non-Preferred Brand Drugs $0 Medical Pharmacy Dental: 800-508-2047 Generic/Preferred Drugs $0 Other contact Elegibility: 1-888-801-1660 Help Desk: 1-800-364-6331 Mailing address Non-Prescriptionnumbers Prior Authorization: 1-888-394-4327 Claims: CVS Caremark (over the counter) Drugs $0 Electronic Claims: Payer ID 80141 P.O. Box 52136 for prescription Paper Claims: Healthfirst Claims Department Phoenix, AZ 85072-2136 P.O. Box 958438 drug claims Lake Mary, FL 32795-8438 Visit MyHFNY.org to find a doctor, view your benefits, and more!

What if I lose my Member ID card? Print a temporary ID card Don’t worry. You’re still covered! We’ve made it easy If you need to see a doctor before you get for you to get a replacement Member ID card as your replacement Member ID card, just visit soon as possible: MyHFNY.org to print a temporary card or pull 1. The fastest way is to go online at MyHFNY.org up an image of your Member ID card on your (your secure Healthfirst account) and request a smartphone or tablet. replacement Member ID card (turn to page V for You can also call Member Services and they can more information), or give you the information you need to give to 2. Call Member Services at 1-855-659-5971, your doctor. 24 hours a day, 7 days a week.

IMPORTANT: Please make sure we have your correct mailing address in our system. If not, please call Member Services or contact NY State of Health to update your information.

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org VI VI Frequently Asked Questions (FAQs) About Renewing Your Medicaid Managed Care Plan Your Healthfirst Personal Wellness Plan is a type of Medicaid Managed Care Plan, so you will need to renew it each year. The easiest way to renew your Healthfirst Personal Wellness Plan is to call us at 1-844-201-8346, so please contact us when it’s time to renew your coverage. You can make an appointment by phone, visit us at one of our community offices, or schedule a convenient in-home visit and we’ll come to you. Here are some answers to frequently asked questions about renewing Medicaid coverage:

Do I need to renew my How do I renew my Medicaid Managed Medicaid Managed Care plan? Care plan? Yes. Your Medicaid Managed Care plan generally The easiest way to renew your Medicaid Managed expires one year after you signed up, and you Care plan is to call us at 1-844-201-8346 when need to renew your health plan every year. it’s time to renew your coverage. You can also carefully follow the instructions in your notification Will I be notified before my letter and handle it yourself. coverage expires? If you originally enrolled through the NY State You will receive a notice from either NY State of Health website or marketplace, you can of Health (NYSOH), the Human Resources renew your coverage through their website. Administration (HRA), or your local Department of Social Services (LDSS) before your anniversary If you originally enrolled through a paper date. Make sure you open and read the notice application, you may be asked to renew by to get all the details about renewing your health paper application or through the NY State of insurance plan! The easiest way to renew is Health website. to call us at 1-844-201-8346 or come to one of our community offices. Your coverage What happens if you don't renew? will be cancelled if you don’t renew by the Your Medicaid coverage will expire and you requested date. will be without health insurance. If you get sick or injured, you won’t have health coverage—even in Important: If you move, please contact Healthfirst an emergency—and you will have to pay for any and LDSS/HRA/NYSOH to update your mailing care received. address. If any mail is returned undeliverable, your health coverage will automatically be cancelled.

When should I renew my Medicaid Managed Care plan? It's important to renew your Medicaid coverage once your renewal period starts. You should receive a letter from either NYSOH, HRA, or your local Department of Social Services (LDSS) approximately 60–90 days before your renewal date, or you may receive an email from the NYSOH approximately 45 days before your renewal date. Just follow the instructions in your reminder notice. If you don't receive your reminder notice, call us and we will help you.

VII Personal Wellness Plan Member Handbook VII Here’s Where To Find Information You Want

Welcome to the Healthfirst Personal Wellness Plan

How Health and Recovery Plans Work. . . . .2 Help from Member Services ...... 3

How To Use This Handbook...... 3 Your Member ID Card...... 4

PART I FIRST THINGS YOU SHOULD KNOW

How to Choose Your PCP...... 4 Emergencies...... 10

How To Get Regular Healthcare...... 6 Urgent Care...... 10

How To Get Specialty Care ...... 7 We Want To Keep You Healthy...... 11

Get These Services from Our Plan Without a Referral...... 8

PART II YOUR BENEFITS AND PLAN PROCEDURES Benefits...... 11 Disenrollment and Transfers...... 22 Services Covered by Our Plan...... 11 1. If You Want to Leave the Plan . . . . .22 Benefits You Can Get from Our Plan 2. You Could Become Ineligible or with Your Medicaid Card...... 17 for Medicaid Managed Care...... 23 Benefits Using Your Medicaid Card Only . 18 3. We Can Ask You To Leave the Plan . . 23 Services NOT Covered ...... 18 Plan Appeals...... 24 Service Authorization ...... 19 External Appeals...... 27 Prior Authorization and Timeframes. . . 19 Fair Hearings ...... 28 Other Decisions About Your Care:. . . . 21 Complaint Process ...... 29 How Our Providers Are Paid ...... 21 How To File a Complaint with Our Plan. . . .29 You Can Help with Plan Policies...... 22 What Happens Next ...... 30 Information from Member Services. . . . . 22 Complaint Appeals ...... 30 Keep Us Informed...... 22 Member Rights and Responsibilities. . . . . 31 Advance Directives...... 31 Privacy Notice ...... 33

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 1

YOUR MEMBER HANDBOOK HAS BEEN CHANGED TO INCLUDE NEW SERVICES

Crisis Residence Services for Children and Adults

Starting December 1, 2020, Healthfirst Personal Wellness Plan will pay for Crisis Residence services. These are overnight services that treat children and adults who are having an emotional crisis. These services include:

Residential Crisis Support This is a program for people who are age 18 or older with symptoms of emotional distress. These symptoms cannot be managed at home or in the community without help.

Intensive Crisis Residence This is a treatment program for people who are age 18 or older who are having severe emotional distress.

Children’s Crisis Residence This is a support and treatment program for people under age 21. These services help people cope with an emotional crisis and return to their home and community.

To learn more about these services, call Member Services at 1-855-659-5971 (TTY 1- 888-542-3821), 7 days a week, 24 hours a day.

Coverage is provided by Healthfirst PHSP, Inc. Plans contain exclusions and limitations.

© 2020 HF Management Services, LLC 1293-20 INAHARP20_19

YOUR MEMBER HANDBOOK HAS BEEN CHANGED TO INCLUDE NEW INFORMATION

Specialty Care

Physical Therapy, Occupational Therapy, and Speech Therapy

In anticipation of a January 1, 2021, start date, Healthfirst Personal Wellness Plan will remove service limits on physical therapy (PT), occupational therapy (OT), and speech therapy (ST). Instead, Healthfirst Personal Wellness Plan will cover medically necessary PT, OT, and ST visits ordered by a doctor or other licensed professional. To learn more about these services, call Member Services at 1-855-659-5971 (TTY 1- 888-542-3821), 24 hours a day, 7 days a week.

Coverage is provided by Healthfirst PHSP, Inc.

© 2020 HF Management Services, LLC 1424-20 INAHARP20_22 As a member of the Healthfirst Personal Wellness Welcome to the Plan, you will have all the benefits available in Healthfirst Personal regular Medicaid, plus you can get specialty Wellness Plan services to help you reach your health goals. We offer extended services to help you get and We are glad that you enrolled in the Healthfirst stay healthy, and help with your recovery. Personal Wellness Plan. The Healthfirst Personal Wellness Plan is a Health and Recovery Plan, or The Healthfirst Personal Wellness Plan offers HARP, approved by New York State. HARPs are a new services, called Behavioral Health Home- new kind of plan that provide Medicaid members and Community-Based Services (BH-HCBS), with their healthcare, plus care for behavioral to members who qualify. health. In this handbook, behavioral health BH-HCBS may help you: means mental health, substance use disorder, and rehabilitation. n Find housing

n We are a special healthcare plan with providers Live independently who have a great deal of experience treating n Return to school persons who may need mental health and/ n Find a job or substance use care to stay healthy. We also n Get help from people who have been there provide care management services to help you and your healthcare team to work together to n Manage stress keep you as healthy as possible. n Prevent crises

This handbook will be your guide to the full As a member of the Healthfirst Personal Wellness range of healthcare services available to you. Plan, you will also have a Health Home Care Manager who will work with all your physical We want to be sure you get off to a good start and behavioral health providers to pay special as a new member of the Healthfirst Personal attention to your whole healthcare needs. Wellness Plan. In order to get to know you The Health Home Care Manager will help make better, we will get in touch with you in the next sure you get the medical, behavioral health, two weeks. You can ask us any questions you and social services you may need, such as help have, or get help making appointments. to get housing and food assistance. If you want to speak with us sooner, just call 1-855-659-5971 (TTY 1-888-542-3821), You may be using your Medicaid card to get a 7 days a week, 24 hours a day. You can also behavioral health service that is now available visit our website at healthfirst.org to get more through the Healthfirst Personal Wellness Plan. information about the Healthfirst Personal To find out if a service you already get is now Wellness Plan. provided by the Healthfirst Personal Wellness How Health and Recovery Plan, contact Member Services at 1-855-659-5971 (TTY 1-888-542-3821), Plans Work 7 days a week, 24 hours a day.

The Plan, Our Providers, and You n You and your healthcare team will work You may have seen or heard about the changes together to make sure you enjoy the best in healthcare. Many consumers get their health physical and emotional health possible. benefits through managed care, which provides You can get special services for healthy a central home for your care. If you were getting living, such as nutrition classes and help to behavioral health services using your Medicaid stop smoking. card, now those services may be available through the Healthfirst Personal Wellness Plan.

2 Personal Wellness Plan Member Handbook n The Healthfirst Personal Wellness Plan has a Confidentiality contract with the New York State Department of Health to meet the healthcare needs of We respect your right to privacy. The Healthfirst people with Medicaid. In turn, we choose a Personal Wellness Plan recognizes the trust group of healthcare, mental health, and needed between you, your family, your doctors, substance use providers to help us meet and other care providers. The Healthfirst your needs. These doctors and specialists, Personal Wellness Plan will never give out your hospitals, clinics, labs, case managers, and medical or behavioral health history without other healthcare facilities make up our your written approval. The only persons that provider network. You will find a list of them will have your clinical information will be the in our provider directory. If you do not have a Healthfirst Personal Wellness Plan, your Primary provider directory, call Member Services at Care Provider, your Health Home Care Manager, 1-855-659-5971 (TTY 1-888-542-3821), other providers who give you care, and your 7 days a week, 24 hours a day, to get a copy, authorized representative. The Healthfirst or visit our website at HFDocFinder.org. Personal Wellness Plan staff have been trained in keeping strict member confidentiality. n When you join the Healthfirst Personal Wellness Plan, one of our providers will take How To Use This Handbook care of you. Most of the time that person will n be your Primary Care Provider (PCP). You This handbook will tell you how your new may want to choose a PCP from your mental healthcare plan will work and how you can health or substance use clinic. If you need to get the most from the Healthfirst Personal have a test, to see another specialist, or to go Wellness Plan. This handbook is your guide to into the hospital, your PCP will arrange it. health and wellness services. It tells you the steps to take to make the plan work for you. n Your Primary Care Provider is available to you n every day, day and night. If you need to speak The first several pages will tell you what you to him or her after hours or on weekends, need to know right away. The rest of the leave a message and how you can be handbook can wait until you need it. Use it reached. Your PCP will get back to you as for reference or check it out a bit at a time. soon as possible. Even though your PCP is When you have a question, check this your main source for healthcare, in some handbook or call our Member Services cases you can self-refer to certain doctors Representatives at 1-855-659-5971 for some services. See page 8 for details. (TTY 1-888-542-3821), 7 days a week, 24 hours a day. You can also call the New York n You may be restricted to certain plan Medicaid Choice Helpline at 1-800-505-5678. providers if you are: ➤ Getting care from several doctors for the Help from Member Services same problem If you are in crisis and need to talk to someone ➤ Getting medical care more often right away, there is someone to help you at than needed Member Services 24 hours a day, 7 days a week. ➤ Using prescription medicine in a way that Call 1-855-659-5971 (TTY 1-888-542-3821). may be dangerous to your health n You can call Member Services to get help any ➤ Allowing someone other than yourself to time you have a question. You may call us to use your plan ID card choose or change your Primary Care Provider (PCP for short), to ask about benefits and services, to get help with referrals, to replace a lost ID card, to report your pregnancy or the birth of a new baby, or to ask about any change that might affect your benefits.

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 3 n If you do not speak English, we can help. member. You should also keep your Medicaid We want you to know how to use your benefit card, as you will need it to get services healthcare plan, no matter what language that the Healthfirst Personal Wellness Plan does you speak. Just call us and we will find a way not cover. to talk to you in your own language. We have translators on staff. We will also help you find Part I — First Things You a PCP (Primary Care Provider) who can speak to you in your language. Should Know n For people with disabilities: If you use a How to Choose Your Primary wheelchair, or are visually impaired, or have Care Provider (PCP) trouble hearing or understanding, call us if you need extra help. We can tell you if a You may have already picked your Primary Care particular provider’s office is wheelchair Provider (PCP). Your PCP will serve as your regular accessible or is equipped with special doctor. This person could be a doctor or a nurse communications devices. Also, we have practitioner. If you have not chosen a PCP, please services like: call Member Services. If you have not chosen a ➤ TTY service: 1-888-542-3821 PCP, you should do so right away. If you do not choose a doctor within 30 days, we will choose ➤ Information in large print one for you. Healthfirst Member Services can ➤ Case Management check to see if you already have a PCP or help you ➤ Help in making or getting to choose a PCP. You may also be able to choose appointments a PCP at your behavioral health clinic. You may call Member Services at 1-855-659-5971 ➤ Names and addresses of providers who (TTY 1-888-542-3821), 7 days a week, 24 hours a day. specialize in your disability n If you are getting care in your home now, n To access our online Provider Directory, visit your nurse or attendant may not know you HFDocFinder.org. To request a hard copy, have joined our plan. Call us right away to call Member Services at 1-855-659-5971. make sure your home care does not The directory lists all the doctors, clinics, stop unexpectedly. hospitals, labs, and other medical providers who work with Healthfirst. It lists the address, Your Member ID Card phone, special training of the doctors, and After you enroll, we will send you a welcome will indicate which doctors are accepting letter. Your Healthfirst Personal Wellness Plan new patients. You can also get a list of ID card should arrive within 14 days after your providers on our website by activating your enrollment date. Your card has your Primary secure Healthfirst account at MyHFNY.org. Care Provider’s (PCP’s) name and phone number n With this handbook, you should have a on it. It will also have your Client Identification provider directory card that describes the Number (CIN). If any information is incorrect many ways you can look up a Healthfirst on your Healthfirst Personal Wellness Plan ID provider that accepts the Healthfirst Personal card, call us right away. Your ID card does not Wellness Plan. You may want to find a doctor: show that you have Medicaid or that Healthfirst ➤ Whom you have seen before, Personal Wellness Plan is a special type of ➤ Who understands your health problems, health plan. ➤ Who is taking new patients, Carry your ID card at all times and show it each ➤ Who can serve you in your language, or time you go for care. If you need care before the card comes, your welcome letter is proof ➤ Who is easy to get to that you are a Healthfirst Personal Wellness Plan

4 Personal Wellness Plan Member Handbook n For women’s health issues, you can access n You can change your PCP in the first 30 days an OB/GYN specialist without a PCP referral. after your first appointment with your PCP. An OB/GYN does routine checkups, follow- After that, you can change without cause or up care, and regular care during pregnancy. more often if you have a good reason. You n Federally Qualified Health Centers (FQHCs) can also change your OB/GYN or a specialist provide primary and specialty care. You have to whom your PCP has referred you. the option to see a PCP at one of the n If any of these conditions applies to you, Healthfirst-contracted FQHCs. For a list of check with your PCP or call Member Services FQHCs in your area, visit HFDocFinder.org or at 1-855-659-5971 (TTY 1-888-542-3821), call Member Services at 1-855-659-5971. 7 days a week, 24 hours a day. n In almost all cases, your doctors will be n If your provider leaves the Healthfirst Healthfirst Personal Wellness Plan providers. network, we will inform you within 15 days There are four instances when you can still from when Healthfirst Personal Wellness Plan see another provider that you had before you is notified. You may continue to see the joined the Healthfirst Personal Wellness Plan. provider if you are more than three months In these cases, your provider must agree to pregnant or receiving ongoing treatment for work with Healthfirst. You can continue to a condition. If you are pregnant, you may see your provider if: continue to see your doctor for up to 60 ➤ You are more than three months days after delivery. If you are seeing a doctor pregnant when you join the Healthfirst regularly for an ongoing condition, you may Personal Wellness Plan and you are continue your present course of treatment getting prenatal care. In that case, you for up to 90 days. Your doctor must agree to can keep your doctor until after your work with the plan during this time. delivery through postpartum care. If any of these conditions apply to you, check ➤ At the time you join the Healthfirst with your PCP or call Member Services at Personal Wellness Plan, you have a 1-855-659-5971. life-threatening disease or condition that gets worse with time. In that case, Health Home Care Management you can ask to keep your provider for The Healthfirst Personal Wellness Plan is up to 60 days. responsible for providing and coordinating your ➤ At the time you join the Healthfirst physical healthcare and your behavioral health Personal Wellness Plan, you are being services. We use Health Homes to coordinate treated for a behavioral health condition. services for our members. It is your choice if you In that case, you can ask to keep your want to join a Health Home, and we encourage provider through treatment for up to you to join one for your Care Management. two years. The Healthfirst Personal Wellness Plan can help n At the time you join the Healthfirst Personal you enroll with a Health Home that will assign Wellness Plan, regular Medicaid paid for your you a personal Health Home Care Manager. home care and you need to keep getting that Your Health Home Care Manager can help you care for at least 120 days. In that case, you make appointments, help you get social services, can keep your same home care agency, and keep track of your progress. nurse, or attendant, and the same amount of home care, for at least 90 days. Your Health Home is responsible for giving you The Healthfirst Personal Wellness Plan must an assessment to see what Behavioral Health tell you about any changes to your home Home- and Community-Based Services you care before the changes take effect. may need. Using the assessment, you and

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 5 your Health Home Care Manager will work How To Get Regular Healthcare together to make a plan of care that is designed especially for you. Regular medical care means exams, routine checkups, shots, or other treatments to keep Your Health Home Care Manager can: you well. It also means providing you with medical advice when you need it and referring n Work with your PCP and other providers to coordinate all of your physical and you to hospitals or specialists when necessary. behavioral healthcare; Your PCP will work with you to get you the care n Work with the people you trust, like family you need. If you have a medical question or members or friends, to help you plan and concern, you need to call your PCP. If you call get your care; after hours or on weekends, leave a message and where or how you can be reached. Your n Support your getting social services, like SNAP (food stamps) and other social PCP will call you back as quickly as possible. service benefits; Remember, your PCP knows you and knows how your health plan works. n Develop a plan of care with you to help identify your needs and goals; n Your healthcare will include regular checkups for all your medical needs. n Help with appointments with your PCP and other providers; New members are strongly encouraged to see their PCP for a first medical visit soon n Help manage ongoing medical issues like after enrolling in the Healthfirst Personal diabetes, asthma, and high blood pressure; Wellness Plan. This will give you a chance to n Help you find services to help with talk with your PCP about your past health weight loss, healthy eating, and exercis,e and issues, the medicines you take, and any to stop smoking; questions that you have. n Support you during treatment; n Day or night, your PCP is only a phone call n Identify resources you need that are located away. Be sure to call your PCP whenever you in your community; have a medical question or concern. If you call after hours or weekends, leave a n Help you with finding or applying for message and where or how you can be stable housing; reached. Your PCP will call you back as n Help you safely return home after a quickly as possible. Remember, your PCP hospital stay; and knows you and knows how your health n Make sure you get follow-up care, plan works. medications, and other needed services. n You can call the Healthfirst Personal Wellness Plan Member Services Your Health Home Care Manager will be in Representative 24 hours a day, 7 days a week touch with you right away to find out what care at 1-855-659-5791 if you have questions you need and to help you with appointments. about getting services or if, for some reason, Your Health Home Care Manager or someone you cannot reach your PCP. from your Health Home provider is available to you 24 hours a day, 7 days a week, n Your care must be medically necessary— at 1-855-659-5971. the services you get must be needed to: ➤ Prevent, or diagnose and correct what If you are in crisis and need to talk to could cause more suffering, or someone right away, call 1-855-659-5971 (TTY 1-888-542-3821), 7 days a week, ➤ Deal with a danger to your life, or 24 hours a day. ➤ Deal with a problem that could cause illness, or

6 Personal Wellness Plan Member Handbook ➤ Deal with something that could limit your Behavioral Health and Home- and normal activities. Community-Based (BH-HCBS) n Your PCP will take care of most of your healthcare needs. You should have an Behavioral Health includes mental health and appointment to see your PCP. If ever you can’t substance use treatment services. You have access keep an appointment, call to let your PCP know. to services that can help you with emotional health. You can also get help with alcohol or other n As soon as you choose a PCP, call to make a substance use issues. first appointment. If you can, prepare for your first appointment. Your PCP will need to know If you need help to support your living in the as much about your medical history as you can community, the Healthfirst Personal Wellness Plan tell him or her. Make a list of your medical provides additional services, called Behavioral background, any problems you have now, any Health Home- and Community-Based (BH-HCBS). medications you are taking, and the questions These services can help you stay out of the you want to ask your PCP. In most cases, your hospital and live in the community. Some services first visit should be within four weeks of your can help you reach life goals for employment, joining the plan. If you have the need for school, or for other areas of your life you might treatment over the coming weeks, make your like to work on. first appointment in the first week of joining the Healthfirst Personal Wellness Plan. Your Health To be eligible for these services, you will need to Home Care Manager can help you make and get an assessment. To find out more, call us at the get ready for your first appointment. Healthfirst Personal Wellness Plan or ask your Care Manager about these services. n If you need care before your first appointment, call your PCP’s office to explain See page 15 of this handbook for more your situation. He or she will give information about these services and how to you an earlier appointment for this concern. get them. (You should still keep your first appointment to discuss your medical history and How To Get Specialty Care ask questions.) You do not need to get referrals from your PCP n Use the following list as a guide for the longest to see in-network specialists. However, it is time you may have to wait after you ask for an recommended that you talk with your PCP before appointment. Your Care Manager can also help going to a specialist for any specialty care. This way, you make or get appointments. your PCP can be aware of your health needs.

➤ Urgent care: within 24 hours n If you need care that your PCP cannot provide, ➤ Non-urgent sick visits: within 3 days he or she can suggest a specialist who can. ➤ Routine, preventive care: within 4 weeks n If you think a specialist does not meet your needs, ask your PCP if he or she can help you ➤ First prenatal visit: within 3 weeks during find a different specialist. 1st trimester (2 weeks during 2nd, 1 week during 3rd) n There are some treatments and services that your PCP must ask Healthfirst to approve ➤ First family planning visit: within 2 weeks before you can get them. Your PCP will be ➤ Follow-up visit after mental health/ able to tell you what they are. substance use ER or inpatient visit: 5 days n If you are having trouble getting a referral you ➤ Non-urgent mental health or substance think you need, contact Member Services at use specialist visit: within 1 week 1-855-659-5971. ➤ Adult baseline and routine physicals: within 4 weeks

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 7 n There are some treatments and services that n If you have a long-term disease or a disabling your PCP must ask Healthfirst to approve illness that gets worse over time, your PCP before you can get them. Your PCP will be may be able to arrange for: able to tell you what they are. ➤ your specialist to act as your PCP; or n If we do not have a specialist in our provider ➤ a referral to a specialty care center that network who can give you the care you need, deals with the treatment of your illness. we will get you the care you need from a You can also call Member Services for help in specialist outside our plan. This is called an getting access to a specialty care center. out-of-network referral. You, your PCP, or plan provider must ask Healthfirst Personal Wellness Get These Services from Plan for approval before you can get an out-of-network referral. If your PCP or plan Our Plan Without a Referral provider refers you to a provider who is not in For some services, you can choose where to get our network, you are not responsible for any of the care. You can get these services by using your the costs except copayments, as described in Healthfirst Member ID card. You can also go to this handbook. providers who will take your Medicaid benefit • Sometimes we may not approve an card. You do not need a referral from your PCP out-of-network referral because we have to get these services. If you have questions, call a provider in the Healthfirst Personal the Healthfirst Personal Wellness Plan Member Wellness Plan network that can treat you. If Services representative at 1-855-659-5971 (TTY you think our plan provider does not have 1-888-542-3821), 7 days a week, 24 hours a day. the right training or experience to treat you, Women’s Healthcare you can ask us to check if your out-of- network referral is medically needed. You You can go to any doctor or clinic that takes will need to ask for a Plan Appeal. See the Medicaid and offers family planning services. Plan Appeal section in this handbook to You can visit any Healthfirst Personal Wellness Plan find out how. family planning providers as well. It’s always good • Sometimes, we may not approve an out-of- to let your PCP know if there are any changes to network referral for a specific treatment your health, and especially if you: because you asked for care that is not very n Are pregnant, or different from what you can get from a Healthfirst Personal Wellness Plan provider. n Need OB/GYN services, or You can ask us to check if your out-of- n Need family planning services, or network referral for the treatment you want n Want to see a midwife, or is medically needed. You will need to ask for a Plan Appeal. See the Plan Appeal section n Need to have a breast or pelvic exam. to find out how. Family Planning n If your doctor does not send this information, n we will still review your action appeal. Your Personal Wellness Plan includes family However, you may not be eligible for planning services such as birth control advice, an external appeal. See page 27 for more birth control prescriptions, male and female information about external appeals. condoms, pregnancy tests, sterilization, and abortion. n If you need to see a specialist for ongoing care, n your PCP may be able to refer you for a Starting October 1, 2019, Healthfirst will cover specified number of visits or length of time some drugs for infertility. This benefit will (a standing referral). If you have a standing be limited to coverage for three cycles of referral, you will not need a new referral for treatment per lifetime. See page 17 for each time you need care. more details.

8 Personal Wellness Plan Member Handbook n In addition to breast and pelvic exams negative, we can help you learn to stay that way. that test for cancer, you can also get tested for sexually transmitted infections during HIV Prevention Services these visits. Many HIV prevention services are available n You can use your Medicaid card if you want to you. We will talk with you about any to go to a doctor or clinic outside our plan. activities that might put you or others at risk of Ask your PCP or call Healthfist Member transmitting HIV or getting sexually transmitted Services at 1-855-659-5971 for a list of diseases. We can help you learn how to protect places to go to get these services. You can yourself. We can also help you get free male and also call the New York State Growing Up female condoms and clean syringes. Healthy Hotline at 1-800-522-5006 for the If you are HIV positive, we can help you talk names of family planning providers near you. to your partners. We can help you talk to your HIV and STI Screening and Counseling family and friends and help them understand HIV and AIDS and how to get treatment. If you need Everyone should know their HIV status. HIV and help talking about your HIV status with future sexually transmitted infection (STI) screenings partners, Healthfirst Personal Wellness Plan staff are part of your regular healthcare. will assist you. We can even help you talk to your n You can get an HIV or STI test any time you children about HIV. have an office or clinic visit. You do not need Eye Care a referral from your PCP (Primary Care Provider). Just make an appointment with The covered service includes the needed any family planning provider. For help in services of an ophthalmologist, optometrist, finding either a plan provider or a Medicaid and an ophthalmic dispenser and includes an provider for family planning services, call eye exam and pair of eyeglasses, if needed. Member Services at 1-855-659-5971 Generally, you can get these once every two (TTY 1-888-542-3821), 7 days a week, years, or more often if medically needed. 24 hours a day. Enrollees diagnosed with diabetes may self-refer for a dilated eye (retinal) examination once in Everyone should talk to their doctor about any 12-month period. You just choose one of having an HIV test. To get free HIV testing or our participating providers. testing where your name isn’t given, call 1-800-541-AIDS (English) New eyeglasses, with Medicaid-approved or 1-800-233-SIDA (Spanish). frames, are usually provided once every two years. New lenses may be ordered more often Or, if you’d rather not see one of our Healthfirst if, for example, your vision changes more than Personal Wellness Plan providers, you can use one-half diopter. If you break your glasses, your Medicaid card to see a family planning they can be repaired. Lost eyeglasses or broken provider outside of the Healthfirst Personal eyeglasses that can’t be fixed will be replaced Wellness Plan network. For help in finding either with the same prescription and style of frames. a plan provider or a Medicaid provider for family If you need to see an eye specialist for care of planning services, call Member Services at an eye disease or defect, your PCP will refer you. 1-855-659-5971 (TTY 1-888-542-3821), 7 days a week, 24 hours a day. Behavioral Health (Mental Health and Substance Use) Some tests are “rapid tests,” and the results are prepared while you wait. The provider who gives We want to help you get the mental health and you the test will explain the results and arrange substance use services that you may need. for follow-up care if needed. You will also learn If at any time you think you need help with how to protect your partner. If your test is mental health or substance use, you can see

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 9 behavioral health providers in our network to Non-emergencies may also be family issues, see what services you may need. This includes a break up, or wanting to use alcohol or other services like clinic and detox services. You do drugs. These may feel like an emergency, not need a referral from your PCP. but they are not a reason to go to the emergency room. Smoking Cessation If you have an emergency, here’s what to do: You can get medication, supplies, and counseling if you want help to quit smoking. n If you believe you have an emergency, You do not need a referral from your PCP to call 911 or go to the emergency room. get these services. You do not need the Healthfirst Personal Wellness Plan or your PCP’s approval before Maternal Depression Screening getting emergency care, and you are not If you are pregnant and think you need help required to use our hospitals or doctors. with depression, you can get a screening to see n If you’re not sure, call your PCP or a what services you may need. You do not need a Healthfirst Personal Wellness Plan Member referral from your PCP. You can get a screening Services representative. during pregnancy and for up to a year after your delivery. Tell the person you speak with what is happening. Your PCP or the Healthfirst Emergencies Personal Wellness Plan representative will: You are always covered for emergencies. ➤ Tell you what to do at home, or In New York State, an emergency means a medical or behavioral condition: ➤ Tell you to come to the PCP’s office, ➤ Tell you about community services you can n That comes on all of a sudden, and get, like 12 step meetings or a shelter, or n Has pain or other symptoms. ➤ Tell you to go to the nearest An emergency would make a person with an emergency room. average knowledge of health be afraid that n You can also contact the Healthfirst someone will suffer serious harm to body parts Personal Wellness Plan Member Services or functions or serious disfigurement without representatives at 1-855-659-5971 care right away. Examples of an emergency are: (TTY 1-888-542-3821), 24 hours a day, 7 days a week, if you are in crisis or need help n A heart attack or severe chest pain with a mental health or drug use situation. n Bleeding that won’t stop or a bad burn n If you are out of the area when you have n Broken bones an emergency: n Trouble breathing, convulsions, or loss of consciousness ➤ Go to the nearest emergency room or call 911. n When you feel you might hurt yourself or others ➤ Call Healthfirst Personal Wellness Plan as soon as you can (within 48 hours if n If you are pregnant and have signs like pain, you can). bleeding, fever, or vomiting n Drug overdose Urgent Care Examples of non-emergencies are: colds, sore throat, upset stomach, minor cuts and bruises, You may have an injury or an illness that is not an or sprained muscles. emergency but still needs prompt care. n This could be the flu or if you need stitches. 10 Personal Wellness Plan Member Handbook n It could be a sprained ankle, or a bad splinter n Diabetes counseling and you can’t remove. self-management training

n You can get an appointment for an urgent care Asthma counseling and visit for the same or next day. If you are at home self-management training or away, call your PCP any time, day or night. n Sexually Transmitted Infection (STI) If you cannot reach your PCP, call us at testing and protecting yourself from STIs 1-855-659-5971 (TTY 1-888-542-3821), n Domestic violence services 7 days a week, 24 hours a day. Tell the person Call Member Services at 1-855-659-5971 who answers what is happening. They will tell (TTY 1-888-542-3821), 7 days a week, 24 hours you what to do. a day, or visit our website at healthfirst.org to find out more and get a list of upcoming classes. Remember You do not need prior approval for PART II — Your Benefits emergency services. and Plan Procedures Use the emergency room only if you have a TRUE EMERGENCY. The rest of this handbook is for your information when you need it. It lists the covered and the It should NOT be used for problems like flu, non-covered services. If you have a complaint, sore throats, or ear infections. the handbook tells you what to do. If you have questions, call your PCP or The handbook has other information you may our plan at 1-855-659-5971 find useful. Keep this handbook handy for when (TTY 1-888-542-3821), you need it. 7 days a week, 24 hours a day. Benefits Care Outside of the United States Health and Recovery Plans provide a number of services you get in addition to those you get If you travel outside of the United States, you with regular Medicaid. We will provide or arrange can get urgent and emergency care only in the for most services that you will need. You can get District of Columbia, Puerto Rico, the Virgin a few services, however, without going through Islands, Guam, the Northern Mariana Islands, and your PCP. These include emergency care; family American Samoa. If you need medical care while planning; HIV testing; mobile crisis services; and in any other country (including Canada and specific self-referral services, including those Mexico), you will have to pay for it. you can get from within the Healthfirst Personal We Want To Keep You Healthy Wellness Plan and some that you can choose to go to any Medicaid provider of the service for. Besides the regular checkups and the shots you need, here are some other services we provide Services Covered by Our Plan and ways to keep you in good health: You must get these services from the providers n Stop-smoking classes who are in our plan. All services must be medically or clinically necessary and provided n Prenatal care and nutrition or referred by your PCP (primary care provider). n Grief/Loss support Please call Member Services at 1-855-659-5971 n Breastfeeding and baby care if you have any questions or need help with any n Stress management of the services below. n Weight control Regular Medical Care n Cholesterol control n Office visits with your PCP

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 11 n Referrals to specialists by you. To speak with a Healthfirst Personal n Eye/hearing exams Wellness Plan Member Services representative call 1-855-659-5971 (TTY 1-888-542-3821), n Help staying on schedule with medicines 7 days a week, 24 hours a day. n Coordination of care and benefits Personal Emergency Response System (PERS) Preventive Care This is a piece of equipment you wear to get help if you have an emergency. In order to qualify n Regular checkups and receive this service, you must be receiving n Access to free needles and syringes personal care/home attendant or CDPAS. n Smoking cessation counseling Adult Day Healthcare n HIV education and risk reduction n Must be recommended by your Primary Care n Referral to Community-Based Organizations Provider (PCP). (CBOs) for supportive care n Smoking cessation care Provides some or all of the following: health education; nutrition; interdisciplinary care Maternity Care planning; nursing and social services; assistance and supervision with the activities of daily living; n Pregnancy care restorative, rehabilitative, and maintenance n Doctors/midwife and hospital services therapy; planned therapeutic or recreational n Screening for depression during pregnancy activities; pharmaceutical services; referrals and up to a year after birth for necessary dental services and other specialty care. Home Healthcare Therapy for Tuberculosis (TB) n Must be medically needed and arranged by the Healthfirst Personal Wellness Plan n This is help with taking your medication for TB and follow-up care. n One medically necessary postpartum home health visit; additional visits as medically Hospice Care necessary for high-risk women n Must be medically needed and arranged by the n Other home healthcare visits as needed and Healthfirst Personal Wellness Plan. ordered by your PCP/specialist n Provides support services and some medical Personal Care/Home Attendant/Consumer services to patients who are ill and expect to Directed Personal Assistance Services live for one year or less. (CDPAS) n Hospice helps patients and their families with n Must be medically needed and arranged by the their special needs that come during the final Healthfirst Personal Wellness Plan stages of illness and after death. n Personal Care/Home Attendant — Provide n You can get these services in your home or in some or total assistance with personal a hospital or nursing home. hygiene, dressing and feeding, and assist in preparing meals and housekeeping If you have any questions about these services, you can call Member Services at n CDPAS — Provide some or total assistance with 1-855-659-5971 (TTY 1-888-542-3821), personal hygiene, dressing and feeding, 7 days a week, 24 hours a day. assistance in preparing meals and housekeeping, as well as home health aide and nursing tasks. This is provided by an aide chosen and directed

12 Personal Wellness Plan Member Handbook Dental Care n Glasses, with new pair of Medicaid-approved frames every two years, or more often if The Healthfirst Personal Wellness Plan believes medically needed. that providing you with good dental care is important to your overall healthcare. We offer n Low vision exam and vision aids ordered by dental care through contracts with individual your doctor. dentists and with DentaQuest, an expert in The Healthfirst Personal Wellness Plan has providing high-quality dental services. arranged for Davis Vision to provide you with Covered services include regular and routine vision services. Call 1-800- 753-3311, Monday to dental services such as preventive dental Friday, from 8am to 11pm; Saturday, from 9am to checkups, cleaning, X-rays, fillings, and 4pm; Sunday, from 12pm to 4pm, to find a vision other services to check for any changes or care provider. abnormalities that may require treatment and/ Pharmacy or follow-up care for you. You do not need a referral from your PCP to see a dentist. n Prescription drugs

How to Access Dental Services n Over-the-counter (OTC) medicines n Insulin and diabetic supplies If you need to find a dentist or to change your dentist, please call 1-800-508-2047 or n Smoking cessation agents, including a Healthfirst Personal Wellness Plan Member OTC products Services representative at 1-855-859-5971 to n Hearing aid batteries help you. Our reps speak many languages and can also connect you with a translator from a n Emergency contraception language line service contracted with Healthfirst. (six per calendar year) You can use your Healthfirst Member ID card to n Medical and surgical supplies receive dental care. A pharmacy copayment may be required You do not need a referral from your PCP to see for some people, for some medications and a dentist, or to a dental clinic that is run by an pharmacy items. There are no copayments for academic dental center. the following members or services: Call Member Services for a list of academic n Consumers who are pregnant: during dental clinics within a 30-mile radius. pregnancy and for the two months after the month in which the pregnancy ends. You can also go to a dental clinic that is run by an academic dental center. n Family Planning drugs and supplies like birth control pills, male or female condoms, Vision Care syringes, and needles. n Services of an ophthalmologist, ophthalmic n Consumers in a Comprehensive Medicaid dispenser, and optometrist. Care Management (CMCM) or Service n Coverage for contact lenses, polycarbonate Coordination Program. lenses, artificial eyes, and/or replacement of n Consumers in an OMH or OPWDD Home lost or destroyed glasses, including repairs, and Community Based Services (HCBS) when medically necessary. Artificial eyes are Waiver Program. covered as ordered by a plan provider. n Consumers in a DOH HCBS Waiver Program n Eye exams, generally every two years, unless for persons with Traumatic Brain Injury (TBI). medically needed more often n Generic copays, if applicable

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 13 n Drugs to treat mental illness (psychotropic) n First quarter: January 1–March 31 and tuberculosis n Second quarter: April 1–June 30 n Third quarter: July 1–September 30 PRESCRIPTION COPAYMENT COPAYMENT n Fourth quarter: October 1–December 31 ITEM AMOUNT DETAILS If you are unable to pay the requested copay, Brand name $3.00/$1.00 1 copay prescription charge for you should tell the provider. The provider drugs each new cannot refuse to give you services or goods prescription because you are unable to pay the copay. and each refill (Unpaid copays are a debt you owe Generic $1.00 the provider.) prescription To learn more about these services, call drugs Member Services at 1-855-659-5971 (TTY Over-the- $0.50 1-888-542-3821). counter drugs, such as for Hospital Care smoking cessation and n Inpatient care diabetes n Outpatient care

n If you have a copay, there is a copayment n Lab, X-ray, other tests for each new prescription and each refill. Emergency Care n If you transferred to a new plan during the n calendar year, keep your receipts as proof Emergency care services are procedures, of your copayments or you may request treatments, or services needed to evaluate proof of paid copayments from your or stabilize an emergency. pharmacy. You will need to give a copy to n After you have received emergency care, your new plan. you may need other care to make sure you n Certain drugs may require that your doctor remain in stable condition. Depending on get prior authorization before writing your your need, you may be treated in the prescription. Your doctor can work with the emergency room, in an inpatient hospital Healthfirst Personal Wellness Plan to make room, or in another setting. This is called sure you get the medications that you need. Post Stabilization Services. Learn more about prior authorization later n For more about emergency services, in this handbook. see page 10.

n You have a choice in where you fill your Specialty Care prescriptions. You can go to any pharmacy that participates with our plan or you can fill Includes the services of other practitioners, your prescriptions by using a mail-order including pharmacy. For more information on your n Physical Therapy is limited to 40 visits per options, please contact Member Services. calendar year Starting April 1, 2020, your maximum n Occupational and speech therapists –­ pharmacy copayment (copay) will be $50 Limited to 20 visits each per calendar year per quarter year. The copay maximum resets n Audiologists each quarter, regardless of the amount you paid last quarter. The quarters are: n Midwives n Cardiac rehabilitation n Podiatry as medically needed

14 Personal Wellness Plan Member Handbook Residential Healthcare Facility Care Substance Use Disorder Services (Nursing Home) n Inpatient and outpatient substance use n Includes short-term, or rehab, stays; disorder (alcohol and drug) treatment n Must be ordered by a physician and authorized n Inpatient detoxification services by the Healthfirst Personal Wellness Plan; n Opioid, including Methadone n Covered nursing home services include Maintenance treatment medical supervision, 24-hour nursing n Residential Substance Use care, assistance with daily living, Disorder Treatment physical therapy, occupational therapy, n Outpatient alcohol and drug and speech-language pathology. treatment services Long-term (permanent) nursing home stays n Detox services are not a covered benefit in Healthfirst Personal Wellness Plan. If you qualify for permanent long- Harm-Reduction Services term placement, you will need to disenroll from If you’re in need of help related to substance use Healthfirst Personal Wellness Plan. This benefit will disorder, harm-reduction services can offer a be covered by Medicaid fee-for-service until you complete, patient-oriented approach to your health are enrolled in a Medicaid managed care plan. and well-being. Healthfirst covers services that may help reduce substance use and other related harms. Call 1-855-659-5971 for help finding a nursing These services include: home in the Healthfirst network. n A plan of care developed by a person experienced Behavioral Healthcare in working with substance users Behavioral Healthcare includes mental health n Individual supportive counseling that assists in and substance use (alcohol and drugs) treatment achieving your goals and rehabilitation services. All our members have n Group supportive counseling in the form of a safe access to services to help with emotional health, space to talk with others about issues that affect or to help with alcohol or other substance use your health and well-being issues. These services include: n Counseling to help you with taking your Mental Healthcare prescribed medication and continuing treatment

n Intensive psychiatric rehab treatment (IPRT) n Support groups to help you better understand substance use and identify coping techniques n Clinic and skills that will work for you n Inpatient mental health treatment To learn more about these services, n Partial hospital care call Member Services at 1-855-659-5971.

n Continuing day treatment Behavioral Health Home and Community Based Services n Personalized Recovery Oriented Services (PROS) Behavioral Health Home and Community Based Services (BHHCBS) can help you achieve life n Assertive Community Treatment Services (ACT) goals such as employment, education, or other areas of your life you want to work on. n Individual and group counseling An assessment is conducted by your Health Home n Crisis intervention services Care Manager or Recovery Coordinator and used to determine your whole health needs, life goals,

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 15 and the BHHCBS you’re eligible for. A Health n Empowerment Services-Peer Supports – Home Care Manager or Recovery Coordinator people who have been there help you reach will help you to identify which BHHCBS you may your recovery goals. benefit from and connect you to those services. n Non-Medical Transportation – transportation BHHCBS includes: to non-medical activities related to a goal in your plan of care. n Psychosocial Rehabilitation (PSR) – helps you improve your skills to reach your goals. Other Covered Services n Community Psychiatric Support and n Durable medical equipment (DME)/hearing Treatment (CPST) – is a way to get treatment aids/prosthetics/orthotics services n Court-ordered services you need for a short time at a location of n your choosing, such as your own home. Case management CPST helps connect you with a licensed n Help getting social support services treatment program. n Federally Qualified Health Center (FQHC) n Habilitation Services – helps you learn n Family planning new skills in order to live independently in the community. National Diabetes Prevention Program (NDPP) Services n Family Support and Training – teaches skills to the people in your life so they can help If you are at risk of developing type 2 diabetes, support you in your recovery. Healthfirst Personal Wellness Plan covers services n Short-Term Respite – gives you a safe that may help. place to go when you need to leave a Starting February 1, 2020, Healthfirst Personal stressful situation. Wellness Plan will cover diabetes prevention n Intensive Respite – helps you stay out of the services through the National Diabetes hospital when you are having a crisis by Prevention Program (NDPP). This benefit will providing a safe place to stay that can offer cover 22 NDPP group training sessions over you treatment. the course of 12 months. n Education Support Services – helps you find The National Diabetes Prevention Program is ways to return to school to get education and an educational and support program designed training that will help you get a job. to assist at-risk people from developing type 2 n Pre-Vocational Services – helps you with diabetes. The program consists of group training skills needed to prepare for employment. sessions that focus on the long-term, positive n Transitional Employment Services – gives you effects of healthy eating and exercise. The goals support for a short time while trying out for these lifestyle changes include modest different jobs. This includes on-the-job weight loss and increased physical activity. training to strengthen work skills to help keep NDPP sessions are taught using a trained a job at or above minimum wage. lifestyle coach. n Intensive Supported Employment Services Eligibility – helps you find a job at or above minimum wage and keep it. You may be eligible for diabetes prevention services if you have a recommendation by a n Ongoing Supported Employment Services physician or other licensed practitioner and – helps you keep your job and be successful at it. n are at least 18 years old, n are not pregnant, n are overweight, and 16 Personal Wellness Plan Member Handbook n have not been previously diagnosed with other related conditions are also included in type 1 or type 2 diabetes. family planning visits.

And you meet one of the following criteria: Infertility Services

n You have had a blood test result in the If you are unable to get pregnant, your Personal prediabetes range within the past year, or Wellness Plan covers services that may help. n You have been previously diagnosed with gestational diabetes, or As of October 1, 2019, Healthfirst Personal Wellness Plans covers some drugs for infertility. n You score 5 or higher on the Centers for This benefit is limited to coverage for three cycles Disease Control and Prevention (CDC)/ of treatment per lifetime. American Diabetes Association (ADA) Prediabetes Risk Test. Your plan will also cover services related to Talk to your doctor to see if you qualify to take prescribing and monitoring the use of infertility part in the NDPP. drugs, including:

n To learn more about these services, Office visits call Member Services at 1-855-659-5971 n X-rays of the uterus and fallopian tubes (TTY 1-888-542-3821), 7 days a week, n Pelvic ultrasounds 24 hours a day. n Blood testing

Benefits You Can Get from Our Eligibility for Infertility Services

Plan or with Your Medicaid Card You may be eligible for infertility services if: For some services, you can choose where to get n you are 21–34 years old and are unable your care. You can get these services by using to get pregnant after 12 months of regular, your Healthfirst Personal Wellness Plan ID card. unprotected sex; or You can also go to providers who will take your Medicaid Benefit card. Call a Healthfirst Member n you are 35–44 years old and are unable Services representative if you have questions at to get pregnant after six months of regular, 1-855-659-5971. unprotected sex. To learn more about these services, please call Family Planning Member Services at 1-855-659-5971. You can go to any doctor or clinic that takes HIV and STI Screening Medicaid and offers family planning services. You can get this service any time from your PCP or Or, visit one of our family planning providers. Healthfirst Personal Wellness Plan doctors. When Either way, you do not need a referral from you get this service as part of a family planning your PCP. visit, you can go to any doctor or clinic that takes You can get birth control drugs and devices Medicaid and offers family planning services. (IUDs and diaphragms) that are available with a Everyone should talk to their doctor about having prescription, as well as emergency contraception, an HIV test. To access free HIV testing or testing sterilization, pregnancy testing, prenatal care, and where your name isn’t given, abortion services. call 1-800-541-AIDS (English) You can also see a family planning provider for or 1-800-233-SIDA (Spanish). HIV and sexually transmitted infection (STI) TB Diagnosis and Treatment testing, treatment, and counseling related to your test results. Screenings for cancer and You can go to your PCP or to the county public

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 17 health agency for diagnosis and/or treatment n Westchester: 1-866-883-7865 of TB. You do not need a referral to go to the n Sullivan: 1-866-573-2148 county public health agency. If you require an attendant to go with you to your Benefits Using Your Medicaid doctor’s appointment or if your child is the member Card Only of the plan, transportation is also covered for the attendant or parent or guardian. There are some services the Healthfirst Personal If you have questions about transportation, please Wellness Plan does not provide. You can get call Medical Answering Services if you live in NYC, these services from any provider who takes or in Orange, Sullivan, or Westchester County, Medicaid by using your Medicaid Benefit card. or call LogistiCare if you live in Long Island. Developmental Disabilities If you have an emergency and need an ambulance, n Long-term therapies you must call 911. n Day treatment Services NOT Covered n Housing services These services are not available from Healthfirst n Medicaid Service Coordination (MSC) program Personal Wellness Plan or Medicaid. If you get n Services received under the Home and any of these services, you may have to pay Community-Based Services Waiver the bill. n Medical Model (Care-at-Home) n Cosmetic surgery if not medically needed Waiver Services n Personal and comfort items Transportation n Services from a provider that is not part of Emergency: If you need emergency the Healthfirst Personal Wellness Plan, unless transportation, call 911. it is a provider you are allowed to see as described elsewhere in this handbook, or the Non-Emergency: Non-emergency medical Healthfirst Personal Wellness Plan or your transportation will be covered by regular Medicaid. PCP sends you to that provider. To get non-emergency transportation, you or your provider must call either LogistiCare Solutions for You may have to pay for any out-of-network Long Island residents (Nassau County and Suffolk service that your PCP does not approve. Or, County) at 1-844-678-1103 or contact Medical if you agree to be a “private pay” or “self-pay” Answering Service (MAS) at the web address or patient before you get a service, you will have to number listed below for the county you live in. pay for the service. If possible, you or your provider should call for This includes: non-emergency transportation at least three days before your medical appointment and provide n Non-covered services (listed above), your Medicaid identification number (example: n Unauthorized services, AB12345C). Non-emergency medical transportation includes bus, taxi, ambulette, and n Services provided by providers not part of the public transportation. Healthfirst Personal Wellness Plan

Visit medanswering.com to schedule online 24/7, or call an office near you, Monday to Friday, If You Get a Bill 7am–6pm. If you get a bill for a treatment or service you do not think you should pay for, do not ignore it. n New York City: 1-844-666-6270 Call Healthfirst Personal Wellness Plan at n Orange: 1-855-360-3543 1-855-659-5971 right away. Healthfirst Personal

18 Personal Wellness Plan Member Handbook Wellness Plan Member Services representatives can n Dental (please remember that for you to help you understand why you may have gotten a receive this service, your provider will have to bill. If you are not responsible for a payment, the contact DentaQuest at 1-800-508-2047) Healthfirst Personal Wellness Plan will contact the n Vision/Glasses (please remember that for you to provider and help fix the problem for you. receive this service, your provider will have to You have the right to ask for fair a hearing if you contact Davis Vision at 1-800-753-3311) think you are being asked to pay for something Asking for approval of a treatment or service is Medicaid or Healthfirst Personal Wellness Plan called a service authorization request. To get should cover. See the Fair Hearing section later in approval for these treatments or services you this handbook. need to:

If you have any questions, call Healthfirst For preauthorization or to notify Healthfirst Member Services at 1-855-659-5971 Personal Wellness Plan of an admission, please (TTY 1-888-542-3821), 7 days a week, contact the: 24 hours a day. Healthfirst Medical Management Department Service Authorization Phone: 1-888-394-4327; Fax: 1-646-313-4603 Prior Authorization: Monday to Friday, There are some treatments and services that you 8:30am–5:30pm need to get approval for before you receive them or in order to be able to continue receiving them. This You will also need to get prior authorization is called prior authorization. You or someone you if you are getting one of these services now trust can ask for this. The following treatments and but need to continue or get more of the care. services must be approved before you get them: This is called concurrent review.

n All Out-of-Network Services What happens after we get your service (Non-emergent services) authorization request:

n Acute Rehabilitation Admissions The health plan has a review team to be sure you n All Cosmetic Surgery (Medically Necessary) get the services we promise. We check that the n All Elective Admissions to a Hospital service you are asking for is covered under your health plan. Doctors and nurses are on the review n Air Ambulance team. Their job is to be sure the treatment or n DME (diabetic and dressing supplies do not service you asked for is medically needed and right require authorization) for you. They do this by checking your treatment n EMG/Nerve Conduction Studies plan against medically acceptable standards. n Home Health Services We may decide to deny a service authorization n Home Care InteliHealth Monitoring request or to approve it for an amount that is n Pain Management Services less than requested. These decisions will be n Physical Therapy/Occupational Therapy/ made by a qualified healthcare professional. If we Speech Therapy decide that the requested service is not medically necessary, the decision will be made by a clinical n Procedures and Equipment for Erectile peer reviewer, who may be a doctor or may be a Dysfunction healthcare professional who typically provides the n Skilled Nursing Facility Admissions care you requested. You can request the specific n Transplant medical standards, called clinical review criteria, n Injectable (through our Specialty we use to make decisions about Pharmacy network) medical necessity.

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 19 After we get your request we will review it received your request. We will tell you by the under a standard or fast-track process. You 14th day if we need more information. or your doctor can ask for a fast-track review n Fast-track review: We will make a decision if it is believed that a delay will cause serious within one (1) workday of when we have all harm to your health. If your request for a fast- the information we need. You will hear from track review is denied, we will tell you and your us no later than 72 hours after we received case will be handled under the standard review your request. We will tell you within one (1) process. work day if we need more information.

We will fast-track your review if: Special timeframes for other requests:

n A delay will seriously risk your health, life, n If you are in the hospital or have just left the or ability to function; hospital and you are asking for home health n Your provider says the review must be faster: care, we will make a decision within 72 hours of your request. n You are asking for more of a service you are n If you are getting inpatient substance use getting right now disorder treatment and you ask for more In all cases, we will review your request as fast services at least 24 hours before you are to as your medical condition requires us to, but no be discharged, we will make a decision within later than mentioned below. 24 hours of your request. n If you are asking for mental health or We will tell you and your provider both by phone substance use disorder services that may be and in writing if your request is approved or related to a court appearance, we will make a denied. We will also tell you the reason for the decision within 72 hours of your request. decision. We will explain what options for appeals or fair n If you are asking for an outpatient hearings you will have if you don’t agree with prescription drug, we will make a decision our decision. (See also the Plan Appeals and Fair within 24 hours of your request. Hearing sections later in this handbook.) n A step therapy protocol means we require you to try another drug before we will Timeframes for prior authorization requests: approve the drug you are requesting. If you n Standard review: We will make a decision are asking for approval to override a step about your request within three (3) workdays therapy protocol, we will make a decision of when we have all the information we need, with 24 hours for outpatient prescription but you will hear from us no later than 14 days drugs. For other drugs, we will make a after we receive your request. We will tell you decision within 14 days of your request. by the 14th day if we need more information. If we need more information to make either a standard or fast-track decision about your n Fast-track review: We will make a decision service request we will: and you will hear from us within 72 hours. We will tell you within 72 hours if we need n Write and tell you what information is more information. needed. If your request is in a fast-track review, we will call you right away and send Timeframes for concurrent review requests: a written notice later. n Standard review: We will make a decision n Tell you why the delay is in your best interest. within one (1) work day of when we have all n Make a decision no later than 14 days from the information we need, but you will hear the day we asked for more information. from us no later than 14 days after we You, your provider, or someone you trust may

20 Personal Wellness Plan Member Handbook also ask us to take more time to make a decision. and supports, such as home health care, This may be because you have more information personal care, CDPAS, adult day health care, to give the plan to help decide your case. This and nursing home care. can be done by calling the Healthfirst Medical n If we are checking care that has been given in Management department at 1-888-394-4327 the past, we will make a decision about or by writing to: paying for it within 30 days of receiving all Healthfirst information we need for the retrospective P.O. Box 5166 review. If we deny payment for a service, we New York, NY 10274-5166 will send a notice to you and your provider Attention: Medical Management Department the day the payment is denied. These notices are not bills. You will not have to pay for any You or your representative can file a complaint care you received that was covered by the with the plan if you don’t agree with our decision plan or by Medicaid even if we later deny to take more time to review your request. You payment to the provider. or someone you trust can also file a complaint You can also call the Independent Consumer about the review time with the New York State Advocacy Network (ICAN) to get free, Department of Health by calling 1-800-206-8125. independent advice about your coverage, We will notify you by the date our time for complaints, and appeals’ options. review has expired. But if for some reason They can help you manage the appeal process. you do not hear from us by that date, it is the same as if we denied your service authorization Contact ICAN to learn more about their services: request. If we do not respond to a request to Phone: 1-844-614-8800 override a step therapy protocol on time, your (TTY Relay Service: 711) request will be approved. Web: icannys.org | Email: [email protected] If you think our decision to deny your service authorization request is wrong, you have the How Our Providers Are Paid right to file a Plan Appeal with us. See the Plan Appeal section later in this handbook. You have the right to ask us whether we have any special financial arrangement with Other Decisions About Your Care: our physicians that might affect your use of Sometimes we will do a concurrent review on Healthcare services. You can call Member the care you are receiving to see if you still need Services at 1-855-659-5971 if you have specific the care. We may also review other treatments concerns. We also want you to know that most and services you have already received. This is of our providers are paid in one or more of the called retrospective review. We will tell you if following ways. we make these decisions. n If our PCPs work in a clinic or health center, Timeframes for other decisions they probably get a salary. The number of about your care: patients they see does not affect this. n Our PCPs who work from their own offices n In most cases, if we make a decision to may get a set fee each month for each reduce, suspend, or stop a service we have patient for whom they are the patient’s PCP. already approved and you are now getting, The fee stays the same whether the patient we must tell you at least 10 days before we needs one visit or many — or even none at change the service. all. This is called capitation. n We must tell you at least 10 days before we n Sometimes providers get a set fee for each make any decision about long-term services person on their patient list, but some money

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 21 (maybe 10%) can be held back for an incentive n If you ask us in writing, we will tell you the fund. At the end of the year, this fund is used qualifications needed and how healthcare to reward PCPs who have met the standards providers can apply to be part of the for extra pay that were set by the Plan. Healthfirst Personal Wellness Plan. n Providers may also be paid by n If you ask, we will tell you 1) if our contracts fee-for-service. This means they get a or subcontracts include physician incentive Plan-agreed-upon fee for each service arrangements that affect the use of referral they provide. services; and, if so, 2) the types of arrangements we use; and 3) if stop-loss You Can Help with Plan Policies protection is provided for physicians and physician groups. We value your ideas. You can help us develop policies that best serve our members. If you have n Information about how our company is ideas, tell us about them. Maybe you’d like to organized and how it works. work with one of our member advisory boards or Keep Us Informed committees. Call a Healthfirst Member Services representative at 1-855-659-5971 to find out If you enrolled through the NY State of Health how you can help. (NYSOH), call them at 1-855-355-5777 whenever these changes happen in your life: Information from Member Services n You change your name, address, or telephone number Here is information you can get by calling n You have a change in Medicaid eligibility Member Services at 1-855-659-5971. n You are pregnant n A list of names, addresses, and titles of the n You give birth Healthfirst Personal Wellness Plan’s Board of n There is a change in insurance for you Directors, Officers, Controlling Parties, n When you enroll in a new case management Owners, and Partners. program or receive case management services n A copy of the most recent financial in another community-based organization statements/balance sheets, summaries of After you have contacted NYSOH, call Member income, and expenses. Services at 1-855-659-5971 to make sure we n A copy of the most recent individual direct are aware of the changes. If you no longer pay subscriber contract. qualify for Medicaid, call Member Services to n Information from the Department of Financial see if you are eligible for another program, Services about consumer complaints about or you can check with your local Department the Healthfirst Personal Wellness Plan. of Social Services. n How we keep your medical records and Disenrollment and Transfers member information private. 1. If You Want to Leave the Plan n In writing, we will tell you how our plan checks on the quality of care to our members You can try us out for 90 days. You may leave the Healthfirst Personal Wellness Plan and join n We will tell you which hospitals our health another health plan at any time during that time. providers work with. If you do not leave in the first 90 days, n If you ask us in writing, we will tell you the however, you must stay in the Healthfirst guidelines we use to review conditions or Personal Wellness Plan for nine more months, diseases that are covered by Healthfirst unless you have a good reason (good cause). Personal Wellness Plan. Some examples of good cause include:

22 Personal Wellness Plan Member Handbook n Our health plan does not meet New York 2. You Could Become Ineligible for State requirements and members are Medicaid Managed Care and for Health harmed because of it. and Recovery Plans n You move out of our service area. n You may have to leave the Healthfirst n You, the plan, and the LDSS all agree that Personal Wellness Plan if you: disenrollment is best for you. ➤ Move out of the county or n You are or become exempt or excluded service area, from managed care. ➤ Change to another managed n We do not offer a Medicaid managed care care plan, service that you can get from another ➤ Join an HMO or other insurance health plan in your area. plan through work, n You need a service that is related to a ➤ Go to prison, or benefit we have chosen not to cover and ➤ Otherwise lose eligibility. getting the service separately would put n If you have to leave the Healthfirst your health at risk. Personal Wellness Plan or become n We have not been able to provide services ineligible for Medicaid, all of your to you as we are required to under our services may stop unexpectedly, contract with the State. including any care you receive at home. Call New York Medicaid Choice at Option to Leave the Plan 1-800-505-5678 right away if Call the Managed Care staff at your local this happens. Department of Social Services. 3. We Can Ask You To Leave the Healthfirst If you live in NYC, in Nassau County, or in Personal Wellness Plan Suffolk County, please, call New York You can also lose your Healthfirst Personal Medicaid Choice at 1-800-505-5678. Wellness Plan membership, if you often: The New York Medicaid Choice counselors can help you change health plans. n Refuse to work with your PCP in regard to your care, You may be able to disenroll or transfer to n another plan over the phone. If you have to Don’t keep appointments, be in managed care, you will have to choose n Go to the emergency room for non- another health plan. emergency care, n Don’t follow the Healthfirst Personal It may take between two and six weeks to Wellness Plan’s rules, process, depending on when your request n is received. You will get a notice that the Do not fill out forms honestly or do not give true information (commit fraud), change will take place by a certain date. The Healthfirst Personal Wellness Plan will n Act in ways that make it hard for us to do provide the care you need until then. our best for you and other members even after we have tried to fix the problems. You can ask for faster action if you believe You can also lose your Healthfirst Personal the timing of the regular process will cause Wellness Plan membership, if you cause added damage to your health. You can also abuse or harm to plan members, providers, ask for faster action if you have complained or staff. because you did not agree to the enrollment. Just call your local Department of Social 4. No matter the reason you disenroll, we will Services or New York Medicaid Choice. prepare a discharge plan for you to help you get services you need.

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 23 Plan Appeals Plan Appeal.

There are some treatments and services that you Aid to continue while appealing a decision need to get approval for before you receive them or about your care: in order to be able to continue receiving them. This If we decided to reduce, suspend, or stop is called prior authorization. Asking for approval of a services you are getting now, you may be treatment or service is called a service authorization able to continue the services while you wait for request. This process is described earlier in this your Plan Appeal to be decided. You must ask handbook. The notice of our decision to deny a for your Plan Appeal: service authorization request or to approve it for an n amount that is less than requested is called an Initial Within 10 days from being told that Adverse Determination. your care is changing; or n By the date the change in services is If you are not satisfied with our decision about scheduled to occur, whichever is later. your care, there are steps you can take. If your Plan Appeal results in another denial, Your provider can ask for reconsideration: you may have to pay for the cost of any continued benefits that you received. If we made a decision that your service authorization request was not medically You can call or write to ask for a Plan Appeal. necessary or was experimental or investigational When you ask for a Plan Appeal, or soon after, you and we did not talk to your doctor about it, your will need to give us: doctor may ask to speak with the plan’s Medical n Director. The Medical Director will talk to your Your name and address doctor within one work day. n Enrollee number

n You can file a Plan Appeal: Service you asked for and reason(s) for appealing If you think our decision about your service n Any information that you want us to review, authorization request is wrong, you can ask such as medical records, doctors’ letters or us to look at your case again. This is called a other information that explains why you need Plan Appeal. the service. n You have 60 calendar days from the date of n Any specific information we said we needed in the Initial Adverse Determination notice to ask the Initial Adverse Determination notice. for a Plan Appeal. n To help you prepare for your Plan Appeal, you n You can call Member Services at can ask to see the guidelines, medical records, 1-855-659-5971 if you need help asking and other documents we used to make the for a Plan Appeal or following the steps Initial Adverse Determination. If your Plan of the appeal process. We can help if you Appeal is fast tracked, there may be a short have any special needs like a hearing or time to give us information you want us to vision impairment, or if you need review. You can ask to see these documents or translation services. ask for a free copy by calling n You can ask for a Plan Appeal, or you can 1-855-659-5971. have someone else, like a family member, Give us your information and materials by friend, doctor or lawyer, ask for you. You and phone or mail: that person will need to sign and date a Phone: statement saying you want that person to represent you. 1-855-659-5971 TTY: 1-888-542-3821 n We will not treat you any differently or act 24 hours a day, 7 days a week badly toward you because you ask for a

24 Personal Wellness Plan Member Handbook Mail: to an out-of-network provider. You will need Healthfirst to ask your doctor to send this information P.O. Box 5166 with your appeal: New York, NY 10274-5166 1) a statement in writing that says our Attention: Appeals and Grievances participating provider does not have Department the correct training and experience to meet your needs, and If you ask for a Plan Appeal by phone, unless it is fast tracked, you must also send your Plan 2) that recommends an out-of-network Appeal to us in writing. After your call, we will provider with the correct training and send you a form which is a summary of your experience who is able to provide phoned Plan Appeal. If you agree with our the service. summary, you should sign and return the form Your doctor must be a board-certified or board- to us. You can make any needed changes before eligible specialist who treats people who need sending the form back to us. the service you are asking for. If your doctor does not send this information, we will still If you are asking for an out-of-network service review your Plan Appeal. However, you may or provider: not be eligible for an External Appeal. See the External Appeal section later in this handbook. n If we said that the service you asked for is not very different from a service available from a What Happens After We Get Your Plan Appeal: participating provider, you can ask us to check if this service is medically necessary for n Within 15 days, we will send you a letter to let you. You will need to ask your doctor to send you know we are working on your Plan Appeal. this information with your Plan Appeal: n We will send you a free copy of the medical 1) a statement in writing from your doctor records and any other information we will that the out-of-network service is very use to make the appeal decision. If your Plan different from the service the plan can Appeal is fast tracked, there may be a short provide from a participating provider. time to review this information. Your doctor must be a board-certified n You can also provide information to be or board-eligible specialist who treats used in making the decision, in person or in people who need the service you are writing. Call Healthfirst Member Services at asking for. 1-855-659-5971 if you are not sure what 2) two medical or scientific documents information to give us. that prove the service you are asking n Plan Appeals of clinical matters will be for is more helpful to you and will not decided by qualified healthcare professionals cause you more harm than the service who did not make the first decision, at least the plan can provide from a one of whom will be a clinical peer reviewer. participating provider. n Non-clinical decisions will be handled by If your doctor does not send this information, persons who work at a higher level than the we will still review your Plan Appeal. However, people who worked on your first decision. you may not be eligible for an External Appeal. See the External Appeal section later in this n You will be given the reasons for our decision handbook. and our clinical rationale, if it applies. The notice of the Plan Appeal decision to deny n If you think our participating provider does your request or to approve it for an amount not have the correct training or experience to that is less than requested is called a Final provide a service, you can ask us to check if it Adverse Determination. is medically necessary for you to be referred

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 25 n If you think our Final Adverse Determination n Your request was denied when you asked for is wrong: home health care after you were in the ➤ You can ask for a Fair Hearing. See the hospital; or Fair Hearing section of this handbook. n Your request was denied when you asked for more inpatient substance use disorder ➤ For some decisions, you may be able to treatment at least 24 hours before you were ask for an External Appeal. See the External to leave the hospital. Appeal section of this handbook. If we need more information to make either a ➤ You may file a complaint with the standard or fast-track decision about your Plan New York State Department of Health Appeal, we will: at 1-800-206-8125. n Write you and tell you what information is Timeframes for Plan Appeals: needed. If your request is in a fast-track n Standard Plan Appeals: If we have all the review, we will call you right away and send a information we need, we will tell you our written notice later. decision within 30 calendar days from when n Tell you why the delay is in your best interest. you asked for your Plan Appeal. n Make a decision no later than 14 days from n Fast-Track Plan Appeals: If we have all the the day we asked for more information information we need, fast-track Plan Appeal decisions will be made in two working days You or your representative may also ask us to from your Plan Appeal but not more than take more time to make a decision. This may be 72 hours from when you asked for your because you have more information to give the Plan Appeal. plan to help decide your case. This can be done by calling or writing. ➤ We will tell you within in 72 hours if we need more information. 1-855-659-5971 24 hours a day, 7 days a week ➤ If your request was denied when you TTY: 1-888-542-3821 asked for more inpatient substance use disorder treatment at least 24 hours Healthfirst before you were to leave the hospital, P.O. Box 5166 we will make a decision about your New York, NY 10274-5166 appeal within 24 hours. Attention: Appeals and Grievances Department ➤ We will tell you our decision by phone and send a written notice later. You or your representative can file a complaint Your Plan Appeal will be reviewed under the with the plan if you don’t agree with our decision fast-track process if: to take more time to review your Plan Appeal. You or someone you trust can also file n You or your doctor asks to have your Plan Appeal reviewed under the fast-track a complaint about the review time with the process. Your doctor would have to explain New York State Department of Health by how a delay will cause harm to your health. calling 1-800-206-8125. If your request for fast track is denied, we will If you do not receive a response to your Plan tell you and your Plan Appeal will be Appeal or we do not decide in time, including reviewed under the standard process; or extensions, you can ask for a Fair Hearing. See n Your request was denied when you asked to the Fair Hearing section of this handbook. continue receiving care that you are now getting or need to extend a service that has If we do not decide your Plan Appeal on time, been provided; or and we said the service you are asking for is:

26 Personal Wellness Plan Member Handbook n Not medically necessary; You have four (4) months after you receive the n Experimental or investigational; plan’s Final Adverse Determination to ask for an External Appeal. If you and the plan agreed n Not different from care you can get in the to skip the plan’s appeals process, then you plan’s network; or must ask for the External Appeal within four (4) n Available from a participating provider who months of when you made that agreement. has correct training and experience to meet To ask for an External Appeal, fill out an your needs, the original denial will be reversed. application and send it to the New York State This means your service authorization request Department of Financial Services: 99 Washington will be approved. Avenue, Box 177, Albany, NY 12210. You can call Member Services at 1-855-659-5971 if you need External Appeals help filing an appeal. You and your doctors will have to give information about your medical You have other appeal rights if we said the problem. The External Appeal application says service you are asking for was: what information will be needed.

n Not medically necessary; Here are some ways to get an application at: n Experimental or investigational; n Call the Department of Financial Services, n Not different from care you can get in the 1-800-400-8882. plan’s network; or n Go to the Department of Financial Services’ n Available from a participating provider who website at dfs.ny.gov. has correct training and experience to meet n Contact a Healthfirst Member Services your needs. Representative at 1-855-659-5971. For these types of decisions, you can ask New Your External Appeal will be decided in 30 days. York State for an independent External Appeal. More time (up to five work days) may be needed This is called an External Appeal because it is if the External Appeal reviewer asks for more decided by reviewers who do not work for the information. You and the plan will be told the health plan or the state. These reviewers are final decision within two days after the decision qualified people approved by New York State. is made. The service must be in the plan’s benefit package or be an experimental treatment, clinical trial, or You can get a faster decision if: treatment for a rare disease. You do not have to pay for an External Appeal. n Your doctor says that a delay will cause serious harm to your health: Before you ask for an External Appeal: n You are in the hospital after an emergency n You must file a Plan Appeal and get the plan’s room visit and the hospital care is denied by Final Adverse Determination; or the plan. n If you have not gotten the service, and you This is called an expedited External Appeal. ask for a fast-track Plan Appeal, you may ask The External Appeal reviewer will decide an for an expedited External Appeal at the same expedited appeal in 72 hours or less. time. Your doctor will have to say an If you asked for inpatient substance use disorder expedited External Appeal is necessary; or treatment at least 24 hours before you were to n You and the plan may agree to skip the plan’s leave the hospital, we will continue to pay for appeals process and go directly to External your stay if: Appeal; or n you ask for a fast-track Plan Appeal within n You can prove the plan did not follow the 24 hours, AND rules correctly when processing your Plan Appeal. n you ask for a fast-track External Appeal at the same time.

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 27 We will continue to pay for your stay until there may ask for a Plan Appeal. If you receive a is a decision made on your appeals. We will Final Adverse Determination, you will have make a decision about your fast-track Plan 120 calendar days from the date of the Final Appeal in 24 hours. The fast-track External Adverse Determination to ask for a state Appeal will be decided in 72 hours. Fair Hearing The External Appeal reviewer will tell you and n You are not happy with a decision that we the plan the decision right away by phone or fax. made about your care. You feel the decision Later, a letter will be sent that tells you limits your Medicaid benefits. You are not the decision. happy we decided to:

If you ask for a Plan Appeal and you receive ➤ reduce, suspend or stop care you a Final Adverse Determination that denies, were getting; or reduces, suspends, or stops your service, you ➤ deny care you wanted; can ask for a Fair Hearing. You may ask for a Fair ➤ deny payment for care you received; or Hearing or ask for an External Appeal, or both. If you ask for both a Fair Hearing and an External ➤ did not let you dispute a copay amount, Appeal, the decision of the fair hearing officer other amount you owe, or payment you will be the one that counts. made for your healthcare. You must first ask for a Plan Appeal and receive Fair Hearings a Final Adverse Determination. You will have 120 calendar days from the date of the Final Adverse You may ask for a Fair Hearing from New York Determination to ask for a Fair Hearing. State if: If you asked for a Plan Appeal and received n You are not happy with a decision your local a Final Adverse Determination that reduces, Department of Social Services or the State suspends, or stops care you are getting now, Department of Health made about your you can continue to get the services your staying or leaving the Healthfirst Personal doctor ordered while you wait for your Fair Wellness Plan. Hearing to be decided. You must ask for a fair n You are not happy with a decision we made hearing within 10 days from the date of the to restrict your services. You feel the decision Final Adverse Determination or by the time the limits your Medicaid benefits. You have 60 action takes effect, whichever is later. calendar days from the date of the Notice of However, if you choose to ask for services to Intent to Restrict to ask for a Fair Hearing. If be continued and you lose your Fair Hearing, you ask for a Fair Hearing within 10 days of you may have to pay the cost for the services the Notice of Intent to Restrict, or by the you received while waiting for a decision. effective date of the restriction, whichever is n later, you can continue to get your services You asked for a Plan Appeal, and the time for until the Fair Hearing decision. However, if us to decide your Plan Appeal has expired, you lose your Fair Hearing, you may have to including any extensions. If you do not receive pay the cost for the services you received a response to your Plan Appeal or we do not while waiting for the decision. decide in time, you can ask for a Fair Hearing. The decision you receive from the fair hearing n You are not happy with a decision that your doctor would not order services you officer will be final. wanted. You feel the doctor’s decision stops You can use one of the following ways to or limits your Medicaid benefits. You must request a Fair Hearing: file a complaint with the Healthfirst Personal Wellness Plan. If the Healthfirst Personal n By phone – call toll-free 1-800-342-3334 Wellness Plan agrees with your doctor, you n By fax – 1-518-473-6735

28 Personal Wellness Plan Member Handbook n By internet – if you need help filing a complaint or following otda.state.ny.us/oah/forms.asp the steps of the complaint process. We can help if you have any special needs like a hearing or vision n By mail – NYS Office of Temporary and impairment, or if you need translation services. Disability Assistance Office of Administrative Hearings We will not make things hard for you or take any Managed Care Hearing Unit action against you for filing a complaint. P.O. Box 22023 Albany, New York 12201-2023 You also have the right to contact the New York State Department of Health about your When you ask for a Fair Hearing about a decision complaint at 1-800-206-8125 or write to: the Healthfirst Personal Wellness Plan made, we must send you a copy of the evidence Complaint Unit, Bureau of Consumer Services packet. This is information we used to make our OHIP DHPCO 1CP-1609 decision about your care. The plan will give this New York State Department of Health information to the hearing officer to explain our Albany, New York 12237 action. If there is not time enough to mail it to You may also contact your local Department of you, we will bring a copy of the evidence packet Social Services with your complaint at any time. to the hearing for you. If you do not get your You may call the New York State Department evidence packet by the week before your hearing, of Financial Services at 1-800-342-3736 if your you can call 1-855-659-5971 to ask for it. complaint involves a billing problem.

Remember, you may complain anytime to the How To File a Complaint with Our Plan: New York State Department of Health by calling 1-800-206-8125. You can file a complaint, or you can have someone else, like a family member, friend, doctor or lawyer, You can also call the Independent Consumer file the complaint for you. You and that person will Advocacy Network (ICAN) to get free, need to sign and date a statement saying you want independent advice about your coverage, that person to represent you. complaints, and appeals’ options. They can help you manage the appeal process. Contact ICAN To file by phone, call Member Services at to learn more about their services: 1-855-659-5971. If you call us after hours, leave a message. We will call you back the next Phone: 1-844-614-8800 work day. If we need more information to make (TTY Relay Service: 711) a decision, we will tell you. Web: icannys.org | Email: [email protected] You can write us with your complaint or call Complaint Process the Member Services number and request a complaint form. It should be mailed to: Complaints: Healthfirst We hope our health plan serves you well. If you P.O. Box 5166 have a problem, talk with your PCP, or call or New York, NY 10274-5166 write Member Services. Most problems can be Attention: Appeals and Grievances solved right away. If you have a problem or dispute Department with your care or services, you can file a complaint You may also FAX the complaint to: with the plan. Problems that are not solved right 1-646-313-4618 away over the phone and any complaint that comes in the mail will be handled according to our What Happens Next: complaint procedure described below. If we don’t solve the problem right away over the You can call Member Services at 1-855-659-5971 phone or after we get your written complaint, we will send you a letter within 15 work days.

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 29 The letter will tell you: How To Make a Complaint Appeal:

n Who is working on your complaint n If you are not satisfied with what we decide, n How to contact this person you have at least 60 work days after hearing from us to file a complaint appeal; n If we need more information n You can do this yourself or ask someone you You can also provide information to be used trust to file the complaint appeal for you; reviewing your complaint in person or in writing. n Call the Healthfirst Personal Wellness Plan The complaint appeal must be made in writing. If you make a complaint appeal by phone, it at 1-855-659-5971 if you are not sure what must be followed up in writing. After your call, information to give us. we will send you a form which is a summary of Your complaint will be reviewed by one or more your phone appeal. If you agree with our qualified people. If your complaint involves clinical summary, you must sign and return the form to matters, your case will be reviewed by one or us. You can make any needed changes before more qualified healthcare professionals. sending the form back to us.

After We Review Your Complaint: What Happens After We Get Your Complaint Appeal: n We will let you know our decision in 45 days of when we have all the information we need to After we get your complaint appeal, we will send you answer your complaint, but you will hear from a letter within 15 work days. The letter will tell you: us in no more than 60 days from the day we n Who is working on your complaint appeal get your complaint. We will write and tell you n the reasons for our decision. How to contact this person n n When a delay would risk your health, we will let If we need more information you know our decision in 48 hours of when we Your complaint appeal will be reviewed by one or have all the information we need to answer more qualified people at a higher level than those your complaint, but you will hear from us in no who made the first decision about your complaint. more than seven (7) days from the day we get If your complaint appeal involves clinical matters, your complaint. We will call you with our your case will be reviewed by one or more qualified decision or try to reach you to tell you. You will healthcare professionals, with at least one clinical get a letter to follow up our communication in peer reviewer, that were not involved in making the three (3) work days. first decision about your complaint.

n You will be told how to appeal our decision if If we have all the information we need, you will you are not satisfied and we will include any know our decision in 30 work days. If a delay forms you may need. would risk your health, you will get our decision in n If we are unable to make a decision about two work days of when we have all the information your complaint because we don’t have we need to decide the appeal. You will be given the enough information, we will send a letter and reasons for our decision and our clinical rationale, let you know. if it applies. If you are still not satisfied, you or someone on your behalf can file a complaint at any Complaint Appeals: time with the New York State Department of Health at 1-800-206-8125. If you disagree with a decision we made about your complaint, you can file a complaint appeal You can also call the Independent Consumer with the plan. Advocacy Network (ICAN) to get free, independent advice about your coverage, complaints, and appeals’ options. They can help you manage the appeal process. Contact ICAN to learn more about their services:

30 Personal Wellness Plan Member Handbook Phone: 1-844-614-8800 n Appoint someone (relative, friend, lawyer, (TTY Relay Service: 711) etc.) to speak for you if you are unable to Web: icannys.org | Email: [email protected] speak for yourself about your care and treatment. Member Rights and n Receive considerate and respectful care in Responsibilities a clean and safe environment free of unnecessary restraints. Your Rights Your Responsibilities As a member of the Healthfirst Personal Wellness As a member of the Healthfirst Personal Wellness Plan, you have a right to: Plan, you agree to: n Be cared for with respect, without regard for n health status, sex, race, color, religion, Work with your care team to protect and national origin, age, marital status, or sexual improve your health. orientation. n Find out how your healthcare system works. n Be told where, when, and how to get the n Listen to your PCP’s advice and ask questions services you need from the Healthfirst when you are in doubt. Personal Wellness Plan. n Call or go back to your PCP if you do not get n Be told by your PCP what is wrong, what can better, or ask for a second opinion. be done for you, and what will likely be the n Treat healthcare staff with the respect you result in language you understand. expect yourself. n Get a second opinion about your care. n Tell us if you have problems with any n Give your OK to any treatment or plan for healthcare staff. Call Member Services. your care after that plan has been fully n Keep your appointments. If you must cancel, explained to you. call as soon as you can. n Refuse care and be told what you may risk if n Use the emergency room only for you do. real emergencies. n Refuse enrollment into a Health Home and n Call your PCP when you need medical care, be told how to receive your physical and even if it is after hours. behavioral healthcare needs without having an assigned Health Home Care Manager. Advance Directives

n Get a copy of your medical record, and talk There may come a time when you can’t decide about it with your PCP, and to ask, if needed, about your own healthcare. By planning in that your medical record be amended advance, you can arrange now for your wishes or corrected. to be carried out. First, let family, friends, and n Be sure that your medical record is private your doctor know what kinds of treatment you and will not be shared with anyone except do or don’t want. Second, you can appoint as required by law, contract, or with an adult you trust to make decisions for you. your approval. Be sure to talk with your PCP, your family, or n Use the Healthfirst Personal Wellness Plan others close to you so they will know what you complaint system to settle any complaints,or want. Third, it is best if you put your thoughts you can complain to the New York State in writing. The documents listed below can Department of Health or the local help. You do not have to use a lawyer, but you Department of Social Services any time you may wish to speak with one about this. You can feel you were not fairly treated. change your mind and change these documents at any time. We can help you understand or get n Use the State Fair Hearing system. these documents. They do not change your right

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 31 to quality healthcare benefits. The only purpose is to let others know what you want if you can’t speak for yourself.

Healthcare Proxy

With this document, you name another adult that you trust (usually a friend or family member) to decide about medical care for you if you are not able to do so. If you do this, you should talk with the person so they know what you want.

CPR and DNR

You have the right to decide if you want any special or emergency treatment to restart your heart or lungs if your breathing or circulation stops. If you do not want special treatment, including cardiopulmonary resuscitation (CPR), you should make your wishes known in writing. Your PCP will provide a DNR (Do Not Resuscitate) order for your medical records. You can also get a DNR form to carry with you and/ or a bracelet to wear that will let any emergency medical provider know about your wishes.

Organ Donor Card

This wallet-sized card says that you are willing to donate parts of your body to help others when you die. Also, check the back of your driver’s license to let others know if and how you want to donate your organs.

32 Personal Wellness Plan Member Handbook Notice of Privacy Practices (“Privacy Notice”) Your Information. Your Rights. Our Responsibilities. THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE EFFECTIVE DATE OF THIS NOTICE IS JULY 1, 2019.

At Healthfirst (made up of Healthfirst, Inc., and after the effective date of the new notice. Healthfirst PHSP, Inc., Healthfirst Health Every three years, we will notify our members Plan, Inc., and Healthfirst Insurance about the availability of the Privacy Notice and Company, Inc. (HFIC), we respect the how to obtain it. confidentiality of your health information and will protect your information in a Healthfirst participates in an Organized Health responsible and professional manner. Care Arrangement (OHCA) under the Health We are required by law to maintain the privacy Insurance Portability and Accountability Act. of your health information, provide you with An OHCA is an arrangement that allows this notice, and abide by the terms of this Healthfirst and its hospital partners covered notice. This notice explains how we use by this notice to share protected health information about you and when we can share information (PHI) about their patients or plan that information with others. It also informs members to promote the joint operations of you of your rights as our valued member the participating entities. The organizations and how you can exercise those rights. participating in this OHCA may use and Healthfirst is making this notice available to disclose your health information with each you because our records show that we provide other as necessary for treatment, to obtain health and/or dental benefits to you under payment for treatment, for administrative an individual or group policy. purposes, to evaluate the quality of care that you receive, and for any other joint healthcare This notice applies to Healthfirst, Inc., operations of the OHCA. Healthfirst PHSP, Inc., Healthfirst Health Plan, Inc., and Healthfirst Insurance Company, Inc. The covered entities participating in the OHCA (HFIC). We are required to follow the terms of agree to abide by the terms of this notice this notice until we replace it, and we reserve with respect to PHI created or received by the the right to change the terms of this notice at covered entity as part of its participation in the any time. If we make material changes to our OHCA. The covered entities are Mount Sinai privacy practices, we will revise this notice Health System (Mount Sinai Hospital, Mount and within 60 days of the change will provide Sinai Beth Israel, Mount Sinai St. Luke’s, Mount a new Privacy Notice to all persons to whom Sinai West Roosevelt), St. Barnabas Hospital, we are required to give the new notice. We will Medisys Health Network, Maimonides Medical also post any material revision of this notice Center, BronxCare Health System, NYC Health on our Healthfirst, Inc. website. We reserve the + Hospitals, The Brooklyn Hospital Center, right to make the new changes apply to your Northwell Health, NYU Langone Health, health information maintained by us before Montefiore Medical Center, Stony Brook

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 33 University Medical Center, Interfaith Medical Get a list of those with whom we’ve Center, St. John’s Episcopal Hospital, SUNY- shared information Downstate Medical Center/University Hospital – You can ask for a list (accounting) of of Brooklyn, and NuHealth. the times we’ve shared your health The covered entities, which comprise the information for six years prior to the date OHCA, are in numerous locations throughout you ask, whom we shared it with, and why. the Greater New York area. This notice applies – We will include all the disclosures except to all these sites. for those about treatment, payment, and healthcare operations, and certain other Your Rights disclosures (such as any you asked us to make). When it comes to your health information, you have certain rights. This section explains – We’ll provide one accounting a year for your rights and some of our responsibilities to free but will charge a reasonable, cost- help you. based fee if you ask for another one within 12 months. Get a copy of health and claims records – You can ask to see or get a copy of your Get a copy of this privacy notice health and claims records and other You can ask for a paper copy of this notice at health information we have about you. any time, even if you have agreed to receive Ask us how to do this. the notice electronically. We will provide you with a paper copy promptly. – We will provide a copy or a summary of your health and claims records, usually Choose someone to act for you within 30 days of your request. We may – If you have given someone health charge a reasonable, cost-based fee. care proxy or if someone is your legal guardian, that person can exercise your Ask us to correct health and claims records rights and make choices about your – You can ask us to correct your health health information. and claims records if you think they are incorrect or incomplete. Ask us how to – If you have given someone power do this. of attorney, that person can exercise your rights and make choices about – We may say “no” to your request, but we’ll your premium billing and claims out tell you why in writing within 60 days. of pocket expenses. Request confidential communications – We will make sure the person has this – You can ask us to contact you in a authority and can act for you before we specific way (for example, home or office take any action. phone) or to send mail to a different address. File a complaint if you feel your rights are violated – We will consider all reasonable requests, If you believe that we have violated your and must say “yes” if you tell us you privacy rights, you have the right to file a would be in danger if we do not. complaint with us or to the Secretary of Ask us to limit what we use or share the U.S. Department of Health and Human Services. You may file a complaint with us by – You can ask us not to use or share calling or writing the Privacy Office (below). certain health information for treatment, We will not take action against you for filing a payment, or our operations. complaint with us or with the U.S. Department – We are not required to agree to your of Health and Human Services: request, and we may say “no” if it would affect your care. However, if you tell us you would be in danger if we did not say yes, then we must agree to your request.

34 Personal Wellness Plan Member Handbook Healthfirst Privacy Office – We are not allowed to use genetic P.O. Box 5183 information to decide whether we will New York, NY 10274-5183 give you coverage and the price of that Phone: 1-212-801-6299 coverage. This does not apply to long- Email: [email protected] term care plans. Office for Civil Rights Example: We use health information about you U.S. Department of Health to develop better services for you. and Human Services Jacob Javits Federal Building, Suite 3312 Pay for your health services New York, NY 10278 We can use and disclose your health information as we pay for your health services. O.C.R. Hotlines-Voice: 1-800-368-1019 TDD: 1-800-537-7697 Example: We share information about you with Email: [email protected] your dental plan to coordinate payment for Website: www.hhs.gov/ocr/ your dental work. Administer your plan How do we typically use or share We may disclose your health information your health information? to your health plan sponsor for plan We typically use or share your health administration. information in the following ways: Example: Your company contracts with us to Help manage the healthcare treatment provide a health plan, and we provide your you receive company with certain statistics to explain the premiums we charge. We can use your health information and share it with professionals who are treating you. How else can we use or share your health information? Example: A doctor sends us information about your diagnosis and treatment plan so we can We are allowed or required to share your arrange additional services. information in other ways—usually in ways that contribute to the public good, such as public We may use or share your information health and research. We have to meet many electronically via our Health Information conditions in the law before we can share Exchange to the hospitals and providers that your information for these purposes. For more participate in our OHCA. This information information, see www.hhs.gov/ocr/privacy/ may include visit and clinical information hipaa/understanding/consumers/index.html. including admissions, discharge and transfer notifications, blood pressure readings, body Help with public health and safety issues mass indexes, visit summaries, and lab We can share health information about you for results. We may share information including certain situations such as filled pharmacy claims, medical encounters, – preventing disease. and quality care gaps. We will not share information to any physician’s offices, – helping with product recalls. hospitals, clinics, labs, or other sites that are not part of the OHCA. – reporting adverse reactions to medications. Run our organization – reporting suspected abuse, neglect, or – We can use and disclose your information domestic violence. to run our organization and contact you when necessary. – preventing or reducing a serious threat to anyone’s health or safety.

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 35 Do research For certain health information, you We can use your information in certain can tell us your choices about what research activities. We will be sure to get your we share. permission where required. If you have a clear preference for how we Comply with the law share your information in the situations State and federal laws may require us to described below, talk to us. Tell us what release your health information to others. you want us to do, and we will follow your We may be required to report information instructions. to state and federal agencies that regulate us, such as the U.S. Department of Health and In these cases, you have both the right and Human Services, Centers for Medicare and choice to tell us to Medicaid Services, New York State and – share information with your family, close City Departments of Health, Local Districts friends, or others involved in payment for of Social Service, and New York State your care. Attorney General. – share information in a disaster Respond to organ and tissue donation relief situation. requests and work with a medical examiner or funeral director If you are not able to tell us your preference— – We can share health information for example, if you are unconscious—we may about you with organ procurement go ahead and share your information if we organizations believe it is in your best interest. We may also share your information when needed – We can share health information with to lessen a serious and imminent threat to a coroner, medical examiner, or funeral health or safety. director when an individual dies – We will never share your information for Address workers’ compensation, marketing purposes without your written law enforcement, and other permission. government requests – We will never sell your information. We can use or share health information about you Our Responsibilities – for workers’ compensation claims. – We are required by law to maintain the – for law enforcement purposes or with privacy and security of your protected a law enforcement official. health information. – with health oversight agencies for – We will let you know promptly if a breach activities authorized by law. occurs that may have compromised the privacy or security of your information. – for special government functions such as military, national security, and presidential – We will never share any of your Substance protective services. Use Disorder (SUD) information without your permission. Respond to lawsuits and legal actions We can share health information about you in – We must follow the duties and privacy response to a court or administrative order, or practices described in this notice and in response to a subpoena. give you a copy of it.

36 Personal Wellness Plan Member Handbook – We must comply with additional in policy and advise you of your right to New York State laws that have a instruct us not to make such disclosure higher level of protection for personal (also referred to as “opting out”). At any information, particularly information time, you can tell us not to share any of relating to HIV/AIDS status or treatment; your personal information with affiliated mental health; substance use disorder; companies that provide offers other than and family planning. our products or services.

Collecting, Sharing, We restrict access to your PII to those Healthfirst employees who need to and Safeguarding Your know that information in order to Financial Information provide services to you. We maintain physical, electronic, and procedural In addition to health information, Healthfirst safeguards that comply with federal may collect other information about you and and state regulations to guard your PII. your dependents (referred to as personally Employees who violate our confidentiality identifiable information, or PII) in the normal or security policies are subject to course of business in order to provide disciplinary action, up to and including healthcare service to you, such as termination of employment. – information we receive directly or Changes to the Terms of this Notice indirectly from you or city/state governmental agencies through We can change the terms of this notice, eligibility and enrollment applications and the changes will apply to all information and other forms, such as: name, address, we have about you. The new notice will be date of birth, Social Security number, available upon request, on our website, and marital status, dependent information, we will mail a copy to you. assets, and income tax returns. – information about your transactions with us, our affiliated healthcare providers, or others, including, but not limited to, appeals and grievance information, claims for benefits, premium payment history, and coordination of benefits information. This also includes information regarding your health benefits, and health risk assessments. – How Your PII is Used or Disclosed with Third Parties We do not disclose your PII to anyone without your written authorization, except as permitted by law (i.e., authorizing requests for healthcare services, payment of claims for services, ensuring quality improvement and assurance practices, resolving appeals or grievance inquiries, and any disclosure required to applicable governmental agencies). If we were to do so in the future, we will notify you of such change

REV 07/2019

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 37 Notice of Non-Discrimination

Healthfirst complies with Federal civil rights laws. Healthfirst does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Healthfirst provides the following: Free aids and services to people with disabilities to help you communicate with us, such as: – Qualified sign language interpreters – Written information in other formats (large print, audio, accessible electronic formats, other formats) Free language services to people whose first language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, call Healthfirst at 1-866-305-0408. For TTY services, call 1-888-542-3821. If you believe that Healthfirst has not given you these services or treated you differently because of race, color, national origin, age, disability, or sex, you can file a grievance with Healthfirst by: Mail: Healthfirst Member Services, P.O. Box 5165, New York, NY, 10274-5165 Phone: 1-866-305-0408 (for TTY services, call 1-888-542-3821) Fax: 1-212-801-3250 In person: 100 Church Street, New York, NY 10007 Email: http://healthfirst.org/members/contact/ You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by: Web: Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Mail: U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building Washington, DC 20201 Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html Phone: 1-800-368-1019 (TTY 800-537-7697)

38 Personal Wellness Plan Member Handbook © 2018 HF Management Services, LLC 1523-18

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 39 Community Offices Near You

BRONX QUEENS LONG ISLAND (continued) East Tremont Elmhurst SUFFOLK COUNTY Bay Shore 774 E. Tremont Avenue 40-08 81st Street (between Prospect (between Roosevelt Westfield South Shore Mall and Marmion Avenues) and 41st Avenues) 1701 Sunrise Highway (in the JCPenney Wing) Fordham Flushing Lake Grove 412 E. Fordham Road 41-60 Main Street (entrance on Webster Avenue) Rooms 201 & 311 Smith Haven Mall (between Sanford 313 Smith Haven Mall BROOKLYN and Maple Avenues (in the Sears Wing) Bensonhurst Main Plaza Mall Patchogue 2236 86th Street 37-02 Main Street 99 West Main Street (between Bay 31st (between 37th and 38th Avenues) (between West and Bay 32nd Streets) Jackson Heights and Havens Avenues) Flatbush 93-14 Roosevelt Avenue Shirley (between Whitney Avenue 2166 Nostrand Avenue La Placita (between Avenue H and 94th Street) 58 D Surrey Circle and Hillel Place) Jamaica (between William Floyd Parkway and Floyd Road) Sunset Park Jamaica Colosseum Mall 89-02 165th Street, Main Level 5324 7th Avenue WESTCHESTER COUNTY (between 53rd and 54th Streets) (between 89th and Jamaica Avenues) Yonkers MANHATTAN Richmond Hill 13 Main Street (between Warburton Avenue Chinatown 122-01 Liberty Avenue and N Broadway) (between 122nd 128 Mott Street, Room 407 and 123rd Streets) (between Grand and Hester Streets) ORANGE COUNTY 28 E. Broadway LONG ISLAND Middletown (between Catherine Galleria at Crystal Run and Market Streets) NASSAU COUNTY Hempstead 1 Galleria Drive, Lower Level Harlem (in the Macy’s Wing) 242 Fulton Avenue 34 E. 125th Street (between N. Franklin (corner of 125th Street and Main Streets) and Madison Avenue) Valley Stream Washington Heights Green Acres Mall 1467 St. Nicholas Avenue 2034 Green Acres Mall (between W. 183rd Sunrise Highway, Level 1 and W. 184th Streets) (in the Kohl’s Wing)

Community office locations subject to change. For the most up-to-date locations, please visit healthfirst.org/locations.

40 Personal Wellness Plan Member Handbook Notes

1-855-659-5971 | TTY: 1-888-542-3821 | MyHFNY.org 41 Connect with us on social media at HealthfirstNY for events and activities.

For questions about Personal Wellness Plan benefits, call Member Services at 1-855-659-5971 (TTY 1-888-542-3821), 24 hours a day, 7 days a week. To access your secure Healthfirst account, visit us at MyHFNY.org. We’re mobile-optimized, so you can use your smartphone or any mobile device!

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”). Plans contain exclusions and limitations. This handbook is available in English, Spanish, and Chinese. Este manual está disponible en inglés, español y chino. 本手冊可用英文、西班牙文與中文提供。

© 2020 HF Management Services, LLC 0422-20_EN INAHARP20_16