2020 Plan Information
Benefits & Services
VillageCareMAX Medicare Health Advantage Plan (HMO D-SNP) members get all covered Medicare and many non-Medicare benefits. Your Care Manager will work with you and your providers to meet your needs. You receive Medicare-covered benefits and extra benefits such as:
- $130 per month ($1,560 per year) on your Over-the-Counter (OTC) card to purchase approved health-related items
- Preventive dental services including oral exams, X-rays, cleanings & fluoride treatments (one every six months)
- $2,000 per year for comprehensive dental services such as dentures, crowns and oral surgery
- 1 eye exam every year
- $300 per year for eyewear (eye glasses and contact lenses)
- 10 one-way trips by taxi or van every 6 months
- 1 routine hearing exam
- $1,500 per year for 2 hearing aids limited to $750 per ear
- 48 acupuncture visits per year
- Fitness Membership at participating locations or home fitness kits
- Physician Call Line with 24 hour access to speak to a doctor about your non-emergency health related concerns
- Doctor visits
- $0 preventive services including bone mass measurement, diabetes screenings, cancer screenings, flu shots, and glaucoma tests
- Diagnostic testing (including X-ray, EKG, MRI, CT Scans)
- Inpatient hospital and skilled nursing facility services
- $50,000 per year for Worldwide Emergency/Urgent Coverage when you travel outside of the United States and its territories
- Durable Medical Equipment (DME) and supplies
- Medicare Part D prescription drug coverage
You can learn more about the services that are available to VillageCareMAX Medicare Health Advantage members, by downloading and reviewing the following booklets, or contacting us at 1-800-469-6292 (TTY users call 711). We are available 7 days a week, from 8:00 a.m. to 8:00 p.m. to answer your questions.
This information is not a complete description of benefits. Premium, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. Contact the plan for more information.
You can enroll in VillageCareMAX Medicare Health Advantage Plan if you:
- Live in Bronx, Brooklyn, Manhattan or Queens
- Have Medicare Parts A and B
- Have Medicaid
There are three ways to enroll:
- Call VillageCareMAX to schedule an appointment with a licensed sales agent. Call us at 1-800-469-6292 (TTY 711), 7 days a week 8 am to 8 pm.
- Download and complete an Enrollment Request Application. Download it in English, Spanish or Chinese [中文], complete the form and send it to us by mail to VillageCareMAX, 112 Charles Street, New York, NY 10014
- Medicare beneficiaries may also enroll in VillageCareMAX Medicare Health Advantage (HMO D-SNP) through the CMS Medicare Online Enrollment Center located at https://www.medicare.gov. Call 1-800-Medicare 1-800-633-4227 (TTY: 1-877-486-2048).
Prescription Drug Coverage
VillageCareMAX Medicare Health Advantage (HMO D-SNP) members who receive full extra help pay $0 or low co-pays for their prescription drugs. Please see Low Income Subsidy Chart in Resources Section of our website.
Premium, copays, coinsurance and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
VillageCareMAX Medicare Health Advantage Plan has a list of covered drugs called the formulary. The formulary lists which Part D prescription drugs are covered by the plan. The formulary also tells you if there are any restrictions in coverage for certain drugs.
Use our online search tool to find out if your prescription drug is on the Formulary
Changes in the Formulary
The Formulary is updated throughout the year. If you are taking a prescription that is affected by a change in the Formulary, you will receive information about this in your monthly Explanation of Benefits (EOB) that we will send you. Below is a list of changes made to the Formulary this year.
The VillageCareMAX Medicare Health Advantage Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, the plan may not cover the drug.
Certain drugs have limits on the amount of the drug that VillageCareMAX Medicare Health Advantage Plan will cover. For example, the Plan provides 90 tablets per prescription for Lorazepam 1 mg.
In some instances, VillageCareMAX Medicare Health Advantage Plan may require you to try certain drugs to treat your medical condition before we will cover another drug for that same condition. This is called Step Therapy. For example, if Drug A and Drug B both treat your medical condition, VillageCareMAX Medicare Health Advantage Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.
If your drug is not listed in the Formulary, you should call VillageCareMAX Member Services to confirm that the drug is not covered. If it’s not covered, you have two options:
- Ask Member Services for a list of similar drugs that are covered. Show the list to your doctor and ask him/her to prescribe a similar drug that is covered by VillageCareMAX Medicare Health Advantage Plan
- Ask the Plan to make a coverage determination and cover your drug.
There are several types of coverage determinations that you can ask us to make, including:
- Cover your drug even if it’s not on our Formulary. This is also called an exception.
- Waive coverage restrictions or limits on your drug.
When you are requesting an exception you should submit a statement from your physician supporting your request. We must make a decision within 72 hours of getting your physician’s supporting statement.
You can request an expedited exception if you or your doctor believes your health could be seriously harmed by waiting up to 72 hours. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your physician’s supporting statement.
How to request a coverage determination for a prescription drug?
- Call Member Services at 1-888 807-6806 (TTY 711), 7 days a week, 8 am to 8 pm.
- Mail your request to: MedImpact Healthcare Systems, Inc., Attention: PA Department, 10181 Scripps Gateway Ct, San Diego, CA 92131.
- Fax your request to: 1-858-790-7100
- Submit your request online (Coverage Determination Request)
New to Plan and do not live in a long-term care facility
As a new member in VillageCareMAX Medicare Health Advantage Plan, you may be taking drugs that are not on our Formulary or that are subject to certain restrictions such as prior authorization or step therapy. You should talk to you doctor right away to decide if s/he can switch you to another drug that is covered or request a Formulary exception. While you talk to your doctor, we will cover your drug during the first 90-days of membership in our plan.
Changes in drug coverage – current member
If you are a current member affected by a Formulary change from one year to the next, VillageCareMAX Medicare Health Advantage Plan may provide up to 30 days temporary supply of the non-formulary drug unless the drug was recalled for unsafe reasons. If you need a refill for the drug during the first 90 days of the new plan year, we will provide you with the opportunity to request a Formulary exception in advance for the following year.
We will send you a letter in the mail whenever you receive a transitional fill on your prescription. It will provide you with more information and will explain the steps you can take to request an exception, if you and your doctor believe this is needed for you.
(See the section Coverage Determinations above)
New to Plan and living in a long-term care facility
If you are a resident of a long-term care facility, we will allow you to refill your prescription for up to 98-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs during the first 90-days of your membership in our plan.
More than 90 days in plan and living in a long-term care facility
If you need a drug that is not on our Formulary or if your ability to get your drugs is limited, but you are past the first 90-days of membership in our plan – we will cover one 31-day supply, or less if your prescription is written for fewer days.
When your transition period ends
For each of your drugs that is not on our Formulary or if your ability to get your drugs is limited – VillageCareMAX Medicare Health Advantage Plan will temporarily cover up to 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your 90-day transition period ends, we generally will not pay for these drugs. We will provide you with written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to switch to an appropriate drug that we cover. You will receive an approval letter if we approve the request from you and your doctor.
Change in your level of care (after the first 90-days of membership)
There are times when you may experience a change in your level of care, such as a discharge from a hospital to a home setting. In these cases, we will cover a one-time temporary supply for up to 30-days (or 31- days if you are a long-term care resident) when you go to a network pharmacy. During this period, you should use the plan’s exception process if you wish to have continued coverage of the drug after the temporary supply is finished.
Our Medication Therapy Management (MTM) program focuses on improving therapeutic outcomes at no additional cost to participants who have multiple medical conditions, who are taking many prescription drugs and have high drug costs. Headed by licensed pharmacists, our team helps you manage the medications you are taking to stay healthy, and protects you from potentially harmful drug combinations.
You will be automatically enrolled if you:
- Take eight or more Medicare Part D covered drugs for maintenance of chronic conditions
- Have three or more chronic conditions such as diabetes, asthma, high cholesterol, high blood pressure, congestive heart failure or chronic obstructive pulmonary disease
- Your drugs cost more than $4,255 a year
If you qualify you will receive an invitation to have a phone call with one of our pharmacists. The pharmacist will review all the drugs, vitamins and over-the-counter products you are taking and discuss them with you. Any concerns will be identified and shared with you and your doctor. The pharmacist will be able to answer any questions and address any of the concerns that you have about your medications and will send you the reviews and other useful information by mail.
If you do not wish to participate, please call Member Services. This program is not a benefit.
MTM Program Description (pdf)
Provider and Pharmacy Network
VillageCareMAX Medicare Health Advantage has a large network of doctors, hospitals, pharmacies, and other providers. We work closely with you and your providers to help ensure that your healthcare needs are met.
You must receive your care from an in-network provider except when:
- The plan covers emergency care or urgently needed services that you get from an out-of-network provider.
- If you need medical care that Medicare or Medicaid requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider.
- The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.
For more information and prior authorization requirements, see your Evidence of Coverage.
As a member, you must choose an in-network to be your Primary Care Provider (PCP). Your PCP will coordinate services with specialists and other providers if needed. You do not need a referral from your PCP to see a specialist for routine care. If you need a service that requires prior authorization (approval in advance) from the plan, your provider will need to contact VillageCareMAX to get prior authorization. Please refer to your Evidence of Coverage for a complete listing of services that require prior authorization.
Provider & Pharmacy Directory
The directory lists our network providers and pharmacies. Network providers are doctors, other health care professionals, medical groups, hospitals and other health care facilities that have an agreement with VillageCareMAX Medicare Health Advantage Plan to deliver covered services to members.
The providers in the network may change throughout the year. Please check the links below for the most updated information about the providers in the network. You may also call Member Services at 800-469-6292 (TTY: 711) for help in finding a provider near your home or to request a hard copy of the directory.
If you need specialized medical care that we cover (see your Evidence of Coverage) and the providers in our network cannot provide this care, you can get care from an out-of-network provider.
You must get prior authorization from our plan before you can see out-of-network providers. If you don’t get approval before you receive services from an out-of-network provider, VillageCareMAX Medicare Health Advantage Plan may not cover these services. If you need to see that provider for more care, check with us first to be sure that the approval covers more than one visit.
Emergency medical care is available anywhere in the United States or its territories.
Generally, we pay for drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy.
We will pay for prescriptions filled at an out-of-network pharmacy in the following cases:
- A member cannot obtain a covered drug in a timely manner within the plan’s service area because there is no network pharmacy available within a reasonable driving distance.
- A drug that has been dispensed by an out-of-network institution-based pharmacy while a member is in the emergency room.
- A member, while out of the service area, becomes ill or runs out of his/her medications and cannot access a network pharmacy.
- Filling a prescription for a covered drug and that drug is not regularly stocked at an accessible network pharmacy.
- In these cases, please check first with Member Services to see if there is a network pharmacy nearby.
If you pay “out-of-pocket” for a prescription drug from an out-of-network provider and you think that we should cover the expense – save your receipt and contact Member Services or send us a request to review your claim for reimbursement.
Prescription Drug Claim Form (pdf)
Medical Member Reimbursement Claim Form (coming soon)
Once your request for payment is received, we will let you know if we need additional information. Otherwise, we will consider your request and make a coverage determination. If we decide that the plan should pay for the drugs or services, we will mail the reimbursement to you. If we decide that the drugs or services are not covered, or you did not follow all the plan’s rules – we will not provide any payment. Instead, we will send you a letter explaining the reasons why we are not sending the payment and your rights to appeal that decision. Learn more about appeals.
Important Plan Information
Explore important plan information below.
An organization determination is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. We are making an organization determination whenever we decide what is covered for you and how much we pay.
Who can request an organization determination?
You, your doctor or authorized representative may request an organization determination. You may appoint an individual to act as your representative by filling out a personal representative authorization form. To get the form, call Member Services or go Resources.
How do I request an organization determination?
- Call Member Services at 1-800-469-6292 (TTY 711)
- Fax: 212-337-5711
- Write to VillageCareMAX
112 Charles Street
New York, NY 10014
How long will it take to get a decision?
When we give you our decision, we will use the standard deadlines unless we have agreed to use the fast deadlines. A standard coverage decision means we will give you an answer within 14 days after we receive your request.
A fast coverage decision means we will answer within 72 hours.
To get a fast coverage decision you must:
- Be asking for coverage for a medical care you have not yet received. You cannot get a fast decision if your request is about payment for medical care you have already received.
- Be asking for a fast decision because using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If your doctor tells us that your health requires a fast decision, we will agree to give you a fast coverage decision. If you ask for a fast decision without your doctor’s support, we will decide whether your health requires a fast decision. If we say no, you have the right to ask us to reconsider by making an appeal.
What is an appeal?
If we make an organization or coverage determination that you disagree with, you can appeal this decision. An appeal is a formal request asking us to review and change a decision we have made about covering or paying for your benefits, services or prescription drugs.
Who can file an appeal?
You, your doctor (or other prescriber) or authorized representative may file an appeal. You may appoint an individual to act as your representative by filling out an Authorization of Representative form. To get the form, call Member Services or go Resources.
When can an appeal be filed?
For medical benefits, the request must be made within 60 calendar days of notice of coverage or organization determination.
How do I request a medical services decision appeal?
- Call Member Services at 1-800-469-6292 or TTY 711
- Fax to 718-517-2709
- Write to VillageCareMAX, 112 Charles Street, New York, NY 10014
How do I request a prescription drug decision appeal?
- Call Member Services at 1-888 807-6806 (TTY 711), 7 days a week, 8 am to 8 pm.
- Mail your request to: MedImpact Healthcare Systems, Inc., Attention: Appeals/Grievances, 10181 Scripps Gateway Ct, San Diego, CA 92131
- Fax your request to 1-858-790-6060.
How long will it take to get an appeal decision?
We will make a standard decision about your prescription drug appeal within 7 calendar days and all other appeals within 30 calendar days. We will make an expedited “fast” decision within 72 hours after we receive your appeal if your health requires it or your doctor or other prescriber asks us to make a fast decision. You, your provider or VillageCareMAX Medicare Health Advantage Plan can also request an extension of up to 14 calendar days.
If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal.
If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your prescription drug appeal to the Independent Review Organization.
- For more information about other levels of appeals please call Member Services at 1-800-469-6292 (TTY 711) or see your Evidence of Coverage. You can also find more information about appeals on the Medicare website (you will leave the VillageCareMAX website).
If you would like to obtain an aggregate number of grievances, appeals and exceptions filed with VillageCareMAX Medicare Health Advantage Plan, please send your request in writing to Compliance Officer, VillageCareMAX, 112 Charles Street, New York, NY 10014.
A grievance is a type of complaint you make about dissatisfaction about the care and treatment you receive from our staff or providers of covered services.
Following are some examples of why you may file a complaint:
- You have a problem with the quality of your care during a hospital stay or from the plan
- You feel you are being encouraged to leave your plan
- You feel waiting times on the phone, at a network pharmacy in the waiting room, or in the exam room are too long
- You feel you are waiting too long for prescriptions to be filled
- You are dissatisfied with the way your doctors, network pharmacists or others behave
- You are unable to reach someone by phone or obtain the information you need.
Who can file a complaint?
You may file a complaint or someone else may file the complaint on your behalf. You may appoint an individual to act as your representative to file a complaint for you by filling out a personal representative authorization form. Call Member Services to obtain the form, or click here to download the form from Medicare’s website.
How do I file a complaint?
- Call VillageCareMAX Member Services at 1-800-469-6292 (TTY 711)
- Fax 212-337-5711
- Write to VillageCareMAX
112 Charles Street
New York, NY 10014
You can also submit your complaint to Medicare by filling this form on Medicare website (this will take you from VillageCareMAX website) or calling 1-800-MEDICARE (1-800-633-4227). TTY/TTD users can call 1-877-486-2048 .
When can I file a complaint?
A complaint must be submitted within 60 calendar days of the event or incident. You have the right to request a fast review or expedited complaint in some cases. A fast complaint means that we will notify you in writing of our decision within 24 hours.
How long will it take to get a decision?
If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that. In these cases where a standard decision would significantly increase risk to your health – we will make an expedited decision within 48 hours, and no more than 7 calendar days.
Otherwise, we will make a decision about your complaint within 30 calendar days for standard requests. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days to answer your complaint.
For more information about the complaints process, refer to your Evidence of Coverage.
Ending your membership in VillageCareMAX Medicare Health Advantage Plan may be voluntary or involuntary:
- You might leave the plan because you have decided you want to leave.
- There are also limited situations where you do not choose to leave, but we are required to end your membership.
Ending your membership voluntarily
We would like you to stay a member of our plan but you can end your membership at any time. Your membership will usually end on the first day of the month after you submit your request to leave. The enrollment in your new plan also begins on this day.
You may end your membership only by:
- Enrolling in another Medicare health or Part D plan, including a PACE organization.
- Calling 1-800-MEDICARE. Available 24 hours a day, 7 days a week TTY users should call 1-877-486-2048.
- Submitting a signed written request to VillageCareMAX, 112 Charles Street, New York, NY 10014
You can enroll in another Medicare plan, Original Medicare or a Prescription Drug Plan.
If you leave our plan, it may take some time for your membership to end and your new way of getting Medicare to take effect. While you are waiting for your membership to end, you are still a member and must continue to get your care as usual through VillageCareMAX Medicare Health Advantage Plan.
If you receive services from doctors or other medical providers who are not plan providers before your membership with VillageCareMAX Medicare Health Advantage Plan ends, neither we nor the Medicare program will pay for these services, with just a few exceptions, like urgently needed care, care for a medical emergency, and care that has been approved by us. If you happen to be hospitalized on the day your membership ends your hospital stay will usually be covered by our plan until you are discharged. If you have any questions about leaving our plan, please call us at 1-800-469-6292 (TTY: 711).
Ending your membership involuntarily
Required Involuntary Disenrollments – your membership in VillageCareMAX Medicare Health Advantage Plan must end your membership in the plan if any of the following happen:
- If you do not stay continuously enrolled in Medicare Part A and Part B.
- If you are no longer eligible for Medicaid. We will send you a letter if you lose your Medicaid.
- If you move out of our service area or are away from our service area for six months or more.
- If you become incarcerated (go to prison).
- The member expires.
- VillageCareMAX Medicare Health Advantage Plan’s contract with CMS is terminated, or no longer provides services in your area.
Discretionary Involuntary Disenrollment – we cannot make you leave our plan for the below reasons unless we get permission from Medicare first:
- If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan.
- If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan.
- If you let someone else use your membership card to get medical care. If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General.
If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can make a complaint about our decision to end your membership.
VillageCareMAX Medicare Health Advantage Plan has a comprehensive quality management program to ensure that we review and improve the quality of care provided to members on an ongoing basis.
In addition to member satisfaction, we have a Quality Assurance Committee that meets regularly to discuss issues, complaints, grievances, and patterns regarding hospitalizations or nursing home admissions.
We provide quality care to members in many ways, including:
- Conducting Quality improvement studies and surveys to ensure we meet your needs.
- Programs such as Medication Therapy Management (MTM), which is a program that helps members manage their drugs and reduce potential problems. Click here to learn more about the MTM program.
You can name a relative, friend, advocate, attorney, doctor, or someone else to be your representative. Others may already be authorized under State law to be your representative. You can call us at 1-800-469-6292 (TTY 711)to learn how to appoint a representative. You can also complete the Appointment of Representative Form below and mail it to us or fax it to 212-337-5711.
If the Governor of New York state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from VillageCareMAX. This includes access to emergency care, urgent care and getting needed prescription drugs.
If you cannot use a network provider during a disaster, VillageCareMAX will allow you to obtain care from out-of-network providers at in-network cost-sharing. If you cannot use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of-network pharmacy.
To get assistance during this time, please contact VillageCareMAX for more information at 1-800-469-6292 (TTY: 711).
Plan Materials and Resources
|2020 Annual Notice of Changes (ANOC)||English Español 中文|
|2020 Summary of Benefits||English Español 中文|
|2020 Evidence of Coverage||English Español 中文|
|2020 Provider and Pharmacy Directory||Bronx Brooklyn Manhattan Queens|
|2020 Formulary||English Español 中文|
|2020 Extra Help Premium Summary Table||English Español 中文|
|Multi-language Insert||English Español 中文 Creole Русский Italiano 한국|
|Enrollment Form||English Español 中文|
|Prescription Drug Claim Form||English|
|Appointment of Representative Form||English Español|
|Health Care Proxy Form & Information*||English Español 中文 Creole Русский Italiano 한국|
|Part D Coverage Determination Form||English|
|Member Reimbursement Form||English (coming soon)|
|Part D Coverage Redetermination Form||English Español 中文|
|Prescription Drug Mail Order Form||English|
|Notice of Non-Discrimination||English Español 中文 Creole Русский Italiano 한국|
|2020 Medicare Star Ratings||English Español 中文 Русский|
This page was last modified on October 7, 2020