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2017 Plan Information

Benefits & Services

Members get all covered Medicare and Medicaid benefits directly from VillageCareMAX Medicare Total Advantage (HMO-SNP) Plan, including long-term services and supports (LTSS) and prescription drugs. In addition, you get extra benefits that are not covered by Medicare or Medicaid. Your Care Manager will work with you, your family and a team of providers to help determine what services will best meet your needs.

You pay no co-pays, deductibles or monthly premium for covered services.

You will pay nothing for benefits such as:

  • Doctor visits
  • Preventive services including bone mass measurement, diabetes screenings, cancer screenings, flu shots, and glaucoma tests
  • Up to $100 per month ($1,200 per year) for Over-the-Counter (OTC) non-prescription health related items
  • Routine eye exam, and up to $175 per year for eyewear
  • Up to 15 acupuncture visits per year
  • Unlimited non-emergency transportation to plan approved locations
  • Long term services and supports including Personal Care, Private Duty Nursing, Social Day Care, and Home Delivered Meals
  • Personal Emergency Response System (PERS)
  • Physical therapy, occupational therapy and speech & language therapy visits
  • Diagnostic testing (including X-ray, EKG, MRI, CT Scans)
  • Inpatient and outpatient hospital services
  • Skilled Nursing Facility
  • Mental health services
  • Medicare Part D prescription drug coverage

You can learn more about the services that are available to VillageCareMAX Medicare Total Advantage members, by downloading and reviewing the following booklets or contacting us at 1-800-469-6292 (TTY users call 711). We are available from 8:00 a.m. to 8:00 p.m. to answer your questions.

2017 Summary of Benefits English  Español  中文

2017 Evidence of Coverage English Español 中文 

This information is available for free in other languages. Please call our member services number at 1-800-469-6292 (TTY 711) during the hours of 8:00 am to 8:00 pm, 7 days a week.  You can get this information for free in other formats, such as large print, braille, or audio. You must continue to pay your Medicare Part B premium. 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 join VillageCareMAX Medicare Total Advantage Plan if you:

  • Are 18 years of age or older
  • Have full Medicaid, Medicare Part A and Part B
  • Live in Brooklyn, Bronx, Manhattan or Queens
  • Require community-based long term care services for more than 120 days.

Call VillageCareMAX to schedule an appointment with an assessment nurse and licensed marketing representative.  Call us at 1-800-469-6292 (TTY 711), 7 days a week 8 am to 8 pm for more information.

VillageCareMAX Medicare Total Advantage Plan is a managed care plan that contracts with both Medicare and New York State Department of Health (Medicaid). Enrollment in VillageCareMAX Medicare Total Advantage Plan depends on contract renewal.

Prescription Drug Coverage

VillageCareMAX Medicare Total Advantage Plan members pay no co-pays for their prescription drugs:

  • $0 annual deductible
  • $0 premium
  • $0 copays

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. Limitations and restrictions may apply. Benefits, list of covered drugs, and pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year. For more information, call VillageCareMAX Medicare Total Advantage Plan at 1-800-469-6292 (TTY 711), 8 am to 8 pm, 7 days a week, or read your Evidence of Coverage. You can ask for this information for free in other formats, such as Braille or large print.

VillageCareMAX Medicare Total 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.

2017 VillageCareMAX Medicare Total Advantage Plan Formulary
English Español 中文

Use our online search tool to find out if your prescription drug is on the formulary (coming soon)

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.

2017 Formulary Changes

The VillageCareMAX Medicare Total 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.

2017 List of drugs that require prior authorization

Certain drugs have limits on the amount of the drug that VillageCareMAX Medicare Total Advantage Plan will cover. For example, VillageCareMAX Medicare Total Advantage Plan provides 90 tablets per prescription for Lorazepam 1 mg.

In some instances, VillageCareMAX Medicare Total 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 Total 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.

2017 List of drugs that require step therapy

If your drug is not listed in the formulary, you should call VillageCareMAX Member Services or check our formulary look up (external link) and confirm that the drug is not covered. If it’s not covered, you have two options:

  1. 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 Total Advantage Plan
  2. 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?

Learn more about Coverage Determinations and Exceptions

Part D Coverage Determination Form

New to Plan and do not live in a long-term care facility

As a new member in VillageCareMAX Medicare Total 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 Total Advantage Plan may provide up to 30-day 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 Total 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 members 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 seven or more Medicare Part D covered drugs for maintenance of chronic conditions
  • Have two 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 $3,919 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

Provider and Pharmacy Network

VillageCareMAX Medicare Total Advantage has a large network of doctors, hospitals, long-term services providers, pharmacies, and other providers. We work closely with you and your providers to help ensure that your healthcare needs are met.

You must use network providers and pharmacies to get your medical care, services and prescription drugs, with limited exceptions.

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 Total Advantage Plan to deliver covered services to members.

As a member, you must choose one of our network providers to be your Primary Care Provider (PCP). Your PCP will coordinate services with specialists and other network providers if needed. There is no prior authorization required to get care from network specialists. If you need a service that requires prior authorization from the plan, your provider will contact us to get necessary prior authorization.

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 directory.

Use our simple online provider search tool

Provider and Pharmacy Directory (PDF)   Bronx Brooklyn Manhattan Queens

Find a Pharmacy

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 Total 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.

Member Reimbursement

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
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.

Provider and Pharmacy Directory (PDF)   Bronx Brooklyn Manhattan Queens

Important Plan Information

An organization 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 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 to 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 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 Member Services or go to 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. 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.

How do I request an appeal?

  • Call Member 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 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 Total 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 VillageCareMAX website).

If you would like to obtain an aggregate number of grievances, appeals and exceptions filed with VillageCareMAX Medicare Total Advantage, 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 Medicare Total Advantage 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 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 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 Evidence of Coverage.

Ending your membership in VillageCareMAX Medicare Total 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:

  • Submitting a signed written request to VillageCareMAX, 112 Charles Street, New York NY 10014
  • 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 1-888-401-6582. 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.

You can enroll in another Medicare plan, Original Medicare or a Prescription Drug Plan. If you wish to continue to receive Medicaid Long Term Services and Supports, you must join a plan that offers long term care services.

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 member and must continue to get your care as usual through VillageCareMAX Medicare Total Advantage Plan.

If you receive services from doctors or other medical providers who are not plan providers before your membership with VillageCareMAX Medicare Total 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 Total 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 or other special eligibility requirements.
  • If you become no longer eligible for nursing home level of care 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 ninety (90) days 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 member expires
  • VillageCareMAX Medicare Total 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 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 member 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 Total 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: 1-888-807-6806 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 belowand mail it to us or fax it to 212-337-5711.

Appointment of Representative Form (EnglishSpanish)

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

Plan Materials and Resources

2017 Evidence of Coverage English Español 中文 
2017 Summary of Benefits English Español  中文 
2017 Provider and Pharmacy Directory Bronx Brooklyn Manhattan Queens
2017 Formulary 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)
2017 Extra Help Premium Summary Table English
Prescription Drug Mail Order Form English
Privacy Notice English
Notice of Non-Discrimination English Español 中文 Creole Русский Italiano 한국
Part D Coverage Re-Determination Form English (coming soon)

*By clicking these links, you will be leaving VillageCareMAX website.

New York Medicaid Choice – Enrollment Broker

CMS Best Available Evidence Policy

Submit a complaint to MedicareMedicaid Ombudsman Office

The State of New York has created an ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide members with free, confidential assistance on any services offered by VillageCareMAX Medicare Total Advantage Plan. ICAN may be reached toll-free at 1-844-614-8800 or online at icannys.org

Medicare Ombudsman Office

H2168_MKT17_23 CMS Approved
This page was last modified on September 18, 2017
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