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 Carolynn
called the NYC MCCAP because she thought she needed help with disenrolling
from her Medicaid managed care health plan to get certain rehabilitative
services to learn how to live with her new prosthetic leg.
Two years ago, Carolynn lost her right leg in a horrible car accident.
The injury required three major surgeries. Carolynn was devastated
about losing her leg, and was convinced that she would never lead
a normal life again.
After her final surgery, Carolynn was advised that she would be
fitted with a prosthetic (or artificial) leg. In order for her to
return to a normal lifestyle, Carolyn would have to work with a
rehabilitation specialist, like a physical therapist, to learn how
to use her prosthetic leg.
Carolynn’s doctors recommended that she go to a particular
rehabilitative facility, but Carolynn believed the facility would
not provide the level of services she needed. As a result, Carolynn
tried to find a facility that had the services she wanted to have.
She found a facility in Queens that seemed perfect – it offered
all of the intensive therapies Carolynn wanted in one location,
including ramps, stairs and parallel bars that would be used to
strengthen her leg. Carolynn was thrilled to find a safe space where
she could practice using her new leg.
Unfortunately, the Queens facility did not accept her Medicaid
health plan. Carolynn decided that she needed to leave her health
plan, and she phoned various agencies to see how she could get out
of her managed care plan. She was directed to call NY Medicaid CHOICE,
the agency that handles enrollments into and transfers out of Medicaid
managed care plans. Carolynn was certain that she had a good reason
to be disenrolled from her health plan. When she learned that she
did not have “good cause” to disenroll, Carolynn hung
up the phone in frustration. She contacted the NYC MCCAP Helpline
for assistance.
Carolynn explained her situation to the NYC MCCAP representative,
and hoped that she would receive help with disenrolling from her
health plan. Carolynn insisted that the Queens facility was the
only place where she could get the type of therapy she needed to
get better. The NYC MCCAP representative asked several questions
and explained that there might be ways for Carolynn to get the therapy
she wanted without leaving her managed care plan. The representative
did some research on the internet and called Carolynn’s health
plan to see if there were any specialized rehabilitation facilities
for amputees that would be covered by the health plan. The representative
got a list of facilities and called each one to find out what type
of services they offered.
The NYC MCCAP representative then called Carolynn to tell her about
the various facilities and explained what each offered. Carolynn
was delighted to find out that there was another facility in Queens
that not only offered similar services to the one she had found
but was also closer to Carolynn’s home, and would be covered
by her health plan. Carolynn would not need to disenroll from her
health plan, and she would be able to get the care she wanted to
speed up her recovery. Carolynn was grateful for the help she received
from the NYC MCCAP.
- Get familiar with the services and benefits covered by your
health plan. If you are unsure about whether or not a service
will be covered, call your health plan’s Member Services
Department to find out. The Member Services 800 number is located
on the back of your health plan card.
- When calling your health plan, make a list of questions that
you want to ask about how to get certain services. Be sure to
write down the answers to the questions you ask. The information
you gather may help you to find the right doctor/specialist
for your condition within the plan.
- If your health plan does not cover a particular service, there
may be ways for you to get that benefit outside of your health
plan’s network. When your health plan gives you permission
to get care from a provider or facility that is not in the health
plan’s network, this is called an out-of-network referral.
- If you have a medical condition that requires you to see several
different doctors, you may want to consider requesting a Case
Manager through your health plan. Call your health plan’s
Member Services Department for information on how to do this.
- If you are admitted to a hospital for an operation, you should
receive a discharge plan that explains the type of follow-up
care you need after you leave the hospital, and where you can
get the care.
- If you need help with any of these steps, call your local
NYC MCCAP agency.
Read more NYC MCCAP Cases of the
Month |
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