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Important Plan Information

Explore important plan information below.

A coverage determination or action is a decision we make about your benefits and coverage or about the amount we will pay for your medical services and long term services and supports. We are making a coverage determination whenever we decide what is covered for you and how much we pay.

Who can request a coverage determination?

You, your doctor or authorized representative may request a coverage determination. You may appoint an individual to act as your representative by filling out a personal representative authorization form. To get the form, call Participant Services or go Participant Forms and Resources.

How do I request a coverage determination?

  • Call Participant 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 if 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 Participant Services or go Participant Forms and Resources.

When can an appeal be filed?

For medical benefits, the request must be made within 60 days of postmark date of notice of action. If you request that we continue your benefits while the appeal decision is pending, you must request an appeal within 10 calendar days of the notice’s postmark date or by the intended effective date of the action, whichever is later. Appeals for coverage determinations must be filed within 60 calendar days.

How do I request an appeal?

  • Call Participant Services at 1-800-469-6292 or TTY 711
  • Fax to 212-337-5711
  • Write to VillageCareMAX
    112 Charles Street
    New York, NY 10014

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 Full Advantage FIDA 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

  • Medicare Part D prescription drug appeal to the Independent Review Organization
  • Medicaid prescription drug and all other appeals to the Integrated Administrative Hearing Officer at the FIDA Administrative Hearing Unit at the State Office of Temporary and Disability Assistance (OTDA) for another review.

For more information about other levels of appeals please call Participant Services at 1-800-469-6292 (TTY 711) or see your Participant Handbook. You can also find more information about appeals on the Medicare website (you will leave VillageCareMAX website). You can contact FIDA Participant Ombudsman to assist you with appeals as well at 1-844-614-8800 or

If you would like to obtain an aggregate number of grievances, appeals and exceptions filed with VillageCareMAX Full Advantage FIDA 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 a problem that does not involve payment or services provided by VillageCareMAX Full Advantage FIDA Plan or its providers.

Following are some examples of why you may file a complaint:

  • You have a problem with things such as the quality of your care during a hospital stay.
  • 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 Participant Services to obtain the form, or click here to download the form from Medicare’s website.

How do I file a complaint?

  • Call VillageCareMAX Participant Services at 800-469-6292 or 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 . You, or someone you trust, can also file a complaint with the New York State Department of Health by calling 1-888-712-7197.

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 Participant Handbook.

Ending your membership in VillageCareMAX Full 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 participant 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.
  • Calling the Enrollment Broker (New York Medicaid Choice) at 1-855-600-FIDA. Available Monday through Friday from 8:30 am to 8:00 pm, and Saturday from 10:00 am to 6:00 pm. TTY users should call 1-888-329-1541.
  • Submitting a signed written request to New York Medicaid Choice:
    New York Medicaid Choice
    P.O. Box 5081
    New York, NY 10274

You can enroll in another FIDA plan, a Medicare plan, Original Medicare or a MLTC plan. VillageCareMAX offers a MLTC plan that you can choose to enroll in when you call New York Medicaid Choice.

If you wish to continue to receive Medicaid Long Term Support Services, you must join another FIDA plan or a Managed Long Term Care (MLTC) plan that is offered by VillageCareMAX.

If you leave our plan, it may take some time for your membership to end and your new way of getting Medicare and Medicaid to take effect. While you are waiting for your membership to end, you are still a participant and must continue to get your care as usual through VillageCareMAX Full Advantage FIDA Plan.

If you receive services from doctors or other medical providers who are not plan providers before your membership with VillageCareMAX Full Advantage FIDA 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 Full Advantage FIDA 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 or other special eligibility requirements.
  • If you become no longer eligible for nursing home placement or Nursing Home Transition & Diversion (NHTD) or require community-based long term care services and supports.
  • 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).
  • If you do not pay your spend-down/surplus or Net Available Monthly Income (NAMI).
  • The participant dies.
  • VillageCareMAX Full Advantage FIDA 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 and Medicaid 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 participants 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.
  • You knowingly fail to complete and submit any necessary consent or release to allow VillageCareMAX Full Advantage Plan and/or Providers to access necessary health care and service information.

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 Full Advantage FIDA Plan has a comprehensive quality management program to ensure that we review and improve the quality of care provided to participants 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 participants in many ways, including:

  • Providing every participant with a dedicated care team, including a Registered Nurse and social worker.
  • Home assessments and regular home visits to ensure care plans are working.
  • Programs such as Medication Therapy Management (MTM), which is a program that helps participants 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 to learn how to appoint a representative. If you have a hearing or speech impairment, please call us at TTY: 711. You can also complete the Appointment of Representative Form below and mail it to us or fax it to 212-337-5711.

Appointment of Representative Form (English, Spanish)

The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by VillageCareMAX Full Advantage FIDA Plan. ICAN may be reached toll-free at 1-844-614-8800 or online at

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 for medical care. 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).

H9345_MKT18_02 CMS Approved
This page was last modified on December 4, 2017
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