Explore important plan information below.
Organization Determinations
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 organizational determination whenever we decide what is covered for you and how much we pay
Who can request an organization determination?
You, your doctor, or your authorized representative may request an organization determination. You may appoint an individual to act as your representative by filling out an Appointment of Representative Form. To get the form, you may call Member Services or download the form here:
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 the medical care you have not yet received. You cannot get a fast decision if your request is about payment for the 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.
If you would like a copy of the guideline that was used to make your coverage determination, please call Member Services at 1-800-469-6292 (TTY 711) to request a copy. A copy will be mailed directly to you.
Appeals
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 another prescriber) or your authorized representative may file an appeal. You may appoint an individual to act as your representative by filling out an Appointment of Representative Form. To get the form, you may call Member Services or download the form here:
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 an appeal?
- Call Member Services at 1-800-469-6292 or TTY 711
- Fax to 347-226-5180
- 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 FLEX 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 FLEX Plan, please send your request in writing to Compliance Officer, VillageCareMAX, 112 Charles Street, New York, NY 10014.
Member Grievances
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 800-469-6292 or TTY 711
- Fax 347-226-5180
- 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.
Disenrollment Rights
Ending your membership in VillageCareMAX Medicare Health Advantage FLEX 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 FLEX Plan.
If you receive services from doctors or other medical providers who are not plan providers before your membership with VillageCareMAX Medicare Health Advantage FLEX 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 FLEX 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 FLEX 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.
Quality Assurance
VillageCareMAX Medicare Health Advantage FLEX 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.
How to Appoint a Representative?
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.
Appointment of Representative Form (PDF)
Getting Care During a Disaster
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).
