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The Advocate's Guide to Managed Health Care

The Advocate's Guide to Managed Health Care was prepared by the Community Service Society of New York (CSS), and is intended for use as an educational resource by human services providers and lay advocates; it is not intended as legal or medical advice, and should not be relied on in that respect.

Table of Contents

Chapter 1: Introduction and User Guide

 

Chapter 2: Acknowledgements

 

Chapter 3: What is Managed Care?

 

Chapter 4: How to Make Managed Care Work

Section 4A: Identity, Residency, and Immigration Status requirements
Section 4B: Income and Resources
Section 4C: What is managed care?
Section 4D: The Six Main Points of Managed Care
Section 4E: How to Enroll in a Managed Care Plan
Section 4F: How to Recertify in Managed Care
Section 4G: How to Change A Managed Care plan

 

Chapter 5: Medicaid Managed Care

Section 5A: Medicaid Managed Care

Section 5B: HIV/AIDS
Section 5C: HIV/AIDS Special Needs Plans (SNPs)
Section 5D: Mental Health
Section 5E: Substance Abuse
Section 5F: Family Planning
Section 5G: Developmental Disabilities
Section 5H: Medicaid Managed Care for People with Physical Disabilities
Section 5I: Solving Problems in Medicaid Managed Care

Section 5I.1: First Steps in "What to do When Things Go Wrong"
Section 5I.2: The Fair Hearing Process
Section 5I.3: Grievance Procedures
Section 5I.4: Utilization Review Process
Section 5I.5: External Review Appeals
Section 5I.6: Who You Can Call For Help

Section 5J: Solving Problems in Medicaid Managed Care

 

Chapter 6: Medicare Managed Care

Section 6A: Medicare Managed Care

Section 6A.1: What is Medicare?
Section 6A.2: What are Medicare HMOs and PPOs?
Section 6A.3: Choosing Which Medicare HMO or PPO to Join
Section 6A.4: What Happens After You Join a Medicare HMO or PPO?

Section 6B: Medicare and Special Services
Section 6C: Government Programs for Low-Income People on Medicare
Section 6D: Medicare and Your Rights
Section 6E: What to do When You Have a Complaint About Your Medicare HMO

Section 6F: The New Medicare Prescription Drug Benefit

Section 6F.1: The New Medicare Prescription Drug Benefit

Section 6F.2: Help Paying for Medicare Drug Costs for People with Low Incomes

Section 6F.3: Using the New Medicare Prescription Drug Benefit

 

Chapter 7: Child Health Insurance/Child Health Plus

 

Chapter 8: Veteran's Health Benefits

 

Chapter 9: Commercial Insurance

Section 9A: Commercial or Private Health Insurance

Section 9A.1: What is Commercial Insurance?
Section 9A.2: How to Choose a Managed Care Plan
Section 9A.3: How to Use an HMO or Managed Care Plan
Section 9A.4: Managed Care for People Who Have Physical Disabilities
Section 9A.5: Commercial Health Coverage Individuals Can Buy for Self and Family

Section 9B: Solving Problems with Commercial Insurance

Section 9B.1: What to do When Things Go Wrong
Section 9B.2: Grievance Procedures
Section 9B.3: Utilization Review Process
Section 9B.4: External Review Appeals
Section 9B.5: Who You Can Call For Help

 

Chapter 10: Programs for the Uninsured

Section 10A: What is the Difference Between Under-insured and Uninsured?
Section 10B: Your Right to Care in a Medical Emergency
Section 10C: Your Right to Inpatient Care When You Have No Health Coverage
Section 10D: Free or Discounted Inpatient Service From Private Hospitals
Section 10E: Your Right to Outpatient Care When You Have No Health Coverage
Section 10F: Department of Health and Mental Health Clinics
Section 10G: Specialized Services
Section 10H: Assistance with the Cost of Prescription Drugs
Section 10I: Government Programs for Which You May be Eligible
Section 10J: Limited Kinds of Insurance for Specific Needs

 

Chapter 11: Family Health Plus

Section 11A: What is Family Health Plus?
Section 11B: What services are provided in a Family Health Plus managed care plan?
Section 11C: Does it cost money to use Family Health Plus?
Section 11D: Who is eligible for Family Health Plus?
Section 11E: How does Family Health Plus work for people who are not citizens of the U.S. or people who are undocumented?
Section 11F: How does a person apply for Family Health Plus?
Section 11G: What does the client need to bring with him/her when applying for Family Health Plus?
Section 11H: What can a client do if there is a problem enrolling in Family Health Plus?
Section 11I: What questions should the client consider when he/she is choosing a Family Health Plus plan?
Section 11J: What type of information does the managed care plan have to give the client to help him/her make a choice?
Section 11K: How does a client renew for Family Health Plus?
Section 11L: How to use a Family Health Plus Managed Care Plan
Section 11M: How to use a Family Health Plus plan's 800 Number
Section 11N: Solving Problems in a Family Health Plus Managed Care plan

 

Chapter 12: Immigrant Concerns

Section 12A: Immigrant Eligibility for New York State Health Insurance Programs
Section 12B: Medicare and Immigrants
Section 12C: Immigrant Concerns: Public Charge, Sponsorship, and Verification of Status and Reporting Issues

 

Appendix A: Glossary

 

Appendix B: New York State Managed Care Bill of Rights Policy and Statement on Working With Maximus

 

Appendix C: Resources

 

Appendix D: Technical Details on Health Insurance and Managed Care Plans


Appendix E: Documentation Guide Immigrant Eligibility for Health Coverage in New York State (PDF)

Appendix G: State Dept. of Health Office of Medicaid Managemetn GIS04 MA/016: Key to I-94 Arrival/Departure Record (PDF)

Appendix H: USCIS (formerly INS) Quick Guide to "Public Charge" (PDF)

Appendix I: State Dept. of Health Office of Medicaid Management GIS 04 MA/002: Clarification of Nonimmigrant Visa Status State Dept. of Health Office of Medicaid Management GIS 04 MA/014: Reporting
Immigrant Status and Disclosure of Medicaid Benefits Information (PDF).

*Note:

Disclaimer

The laws, regulations, rules and policies on which the information in this Guide is based are subject to frequent change. CSS makes no representations or warranties, express or implied, as to the accuracy, completeness or timeliness of the information contained in this Guide. The application of the information contained in this Guide to individual consumers may vary depending upon the individual's circumstances. This Guide should not be used in place of consultations with qualified legal and/or medical professionals. In no event will CSS be liable for any decision made or action taken by anyone in reliance upon the information contained in this Guide.

This Guide may not be copied or distributed without the permission of the New York City Department of Health, Division of Health Care Access, and the respective licensors of the materials herein:

This Guide was revised and updated April 2007.

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