- What are your hours of operation?
- What are your premiums?
- What co-payments, co-insurance and deductibles are required for VNS CHOICE Medicare?
- What happens if a member's provider is not in the network or is terminated from network?
- What is your out of network coverage?
- How does VNS CHOICE Medicare protect my confidential health information?
- What are the members' appeal and grievance rights?
- How can Members obtain and aggregate number of grievances, appeals and exceptions filed with the plan?
- Is there potential for VNS CHOICE Medicare's contract to be terminated?
- What rights and responsibilities do members have upon disenrollment from VNS CHOICE Medicare?
- How many Pharmacies do you have in your network?
- How does VNS CHOICE Medicare meet access requirements?
- What is VNS CHOICE's Medication Therapy Management (MTM) program?
- What are your quality assurance and medical management policies and procedures?
- What happens if a drug a member takes is not covered?
- What happens if a drug a member takes is removed from the formulary?
- Where can I find a link to...
What are your hours of operation?
VNS CHOICE Medicare general information, member and provider service lines are available:
- Monday - Friday 8:00 AM - 8:00 PM
- Weekends and Holidays 8:00 AM - 8:00 PM
Click here for information on VNS CHOICE Medicare hours of operation
What are your premiums?
VNS CHOICE Medicare Coordinated Care Plan (Medical Benefit) has no monthly plan premium for its medical services (Medicare Part A and Part B services).
The VNS CHOICE Medicare Prescription Drug plan has no monthly premium or yearly deductible for fully subsidized members. Members with partial subsidy may be responsible for some portion of the prescription drug premium, depending on the level of extra assistance that you are eligible for.
Click here to view our low-income subsidy premium table or contact us for more information.
For more information on plan premiums, please refer to the Member Handbook (Evidence of Coverage) for Option 1, Option 2, or MLTC Plus, or the Summary of Benefits for Option 1, Option 2, or MLTC Plus, or contact us.
What co-payments, co-insurance and deductibles are required for VNS CHOICE Medicare?
Because VNS CHOICE Medicare members are eligible for benefits from Medicaid, the State is required to cover Medicare cost-sharing amounts that the member would otherwise be required to pay in most cases. These amounts may differ based on what kind of Medicaid benefits the member has. For more information on plan premiums and cost sharing amounts, please refer to the Member Handbook (Evidence of Coverage) for Option 1, Option 2, or MLTC Plus, or the Summary of Benefits for Option 1, Option 2, or MLTC Plus, or contact us.
What happens if a member's provider is not in the network or is terminated from network?
A Member receiving care from a provider who is not in the network may request to continue using the provider until they complete the approved course of treatment.
For more information on how we transition members to new providers, please contact us.
What is your out of network coverage?
Members may use out of network providers under certain circumstances, such as for emergency care or urgent care when traveling outside of the service area. For more information on out of network coverage, please see the Member Handbook (Evidence of Coverage) for Option 1, Option 2, or MLTC Plus, or the Summary of Benefits for Option 1, Option 2, or MLTC Plus, or contact us.
How does VNS CHOICE Medicare protect my confidential health information?
VNS CHOICE is very concerned about the privacy and security of member's confidential information. Our systems and processes are fully compliant with the government's required standards.
Click here to view our privacy policies and HIPAA disclosures or contact us for more information
Click here to link to the VNS CHOICE Medicare "Authorization for Release of Health Information" or contact us for more information
What are the members' appeal and grievance rights?
What is an appeal or grievance?
An "appeal" is the type of complaint you make when you want us to reconsider and change a decision we have made about what services or benefits are covered for you or what we will pay for a service or benefit. For example, if we refuse to cover or pay for services you think we should cover, you can file an appeal. If VNS CHOICE Medicare or one of our plan providers refuses to give you a service you think should be covered, you can file an appeal. If VNS CHOICE Medicare or one of our plan providers reduces or cuts back on services or benefits you have been receiving, you can file an appeal. If you think we are stopping your coverage of a service or benefit too soon, you can file an appeal. There are different time frames and terms that VNS CHOICE Medicare uses when we receive an appeal, depending on whether the appeal concerns your prescription drug coverage or your other Medicare services. Please see below for specific information about how your appeal will be handled.
A "grievance" is the type of complaint you make if you have any other type of problem with VNS CHOICE or one of our plan providers. For example, you would file a grievance if you have a problem with things such as the quality of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor's office. Members of VNS CHOICE Medicare have the right to file a grievance or complaint with us about our plan, our network pharmacies or participating providers.
What is the difference between a standard and a "fast" or "expedited" appeal for Medical Care?
A decision about whether we will cover medical care can be a "standard decision" that is made within the standard time frame (typically within 14 days; see below), or it can be a "fast decision" that is made more quickly (typically within 72 hours; see below). A fast decision is sometimes called a 72-hour decision or an "expedited organization determination."
You can ask for a fast decision only if you or any doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. (Fast decisions apply only to requests for medical care. You cannot get a fast decision on requests for payment for care you have already received.)
Members may also request an appeal for any coverage determination made by VNS CHOICE Medicare. (click here to view our coverage determination form) When VNS CHOICE Medicare makes a coverage determination, we are deciding whether to provide or pay for covered medical services or prescription drugs and what your share of the cost will be. Members have the right to file an appeal if they would like VNS CHOICE Medicare to reconsider and change a decision made concerning medical services, prescription drug benefits, or the share of the costs that the member is responsible for paying.
What is the difference between a standard and a "fast" or "expedited" coverage determination for Part D Prescription Drug Coverage?
A decision about whether we will cover a Part D prescription drug can be a "standard" coverage determination that is made within the standard timeframe (typically within 72 hours), or it can be a "fast" coverage determination that is made more quickly (typically within 24 hours). A fast decision is sometimes called a 24-hour review or an "expedited coverage determination."
You can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. (Fast decisions apply only to requests for Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Part D drug that you already received.)
An exception request is a type of coverage determination that applies to your Medicare prescription drug coverage. There are several types of exceptions you can request:
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
- You can ask us to provide a higher level of coverage for your drug. For example, if your drug is usually considered a Brand drug, you can ask us to cover it as a Generic drug instead. This would lower the co-insurance amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.
Generally, we will only approve your request for an exception if the alternative drugs included on the plan's formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
Click here to view our exception request form
What if a member wants to appeal a discharge from Facility Based Care?
A Member has the right, by law, to ask for a review of a discharge date from the Hospital, SNF, HHA, or CORF. Members must contact the Quality Improvement Organization (QIO) for review. If a Member believes he is being discharged too soon he or she must fill out a Notice of Discharge & Medicare Appeal Right provided by VNS CHOICE Medicare.
This notice will tell you:
- Why you are being discharged.
- The date that we will stop covering your hospital stay (stop paying our share of your hospital costs).
- What you can do if you think you are being discharged too soon.
- Who to contact for help.
If a Member does not ask the QIO for a "fast appeal" by the deadline (no later than noon of the day before the date the Members' Medicare coverage ends) the Member may ask VNS CHOICE Medicare for a "fast appeal" of their discharge.
For more information on member appeal and grievance rights, please refer to the Member Handbook (Evidence of Coverage) for Option 1, Option 2, or MLTC Plus, or the Summary of Benefits for Option 1, Option 2, or MLTC Plus, or contact us.
How Do I File a Grievance or Appeal?
To file a grievance or request an appeal, please
- Call member services at 1-866-783-1444, or
- Send a fax to: 1-866-791-2213, or
- For TTY, please call 1-888-844-5530
- Representatives are available Monday through Friday 8:00 AM - 8:00 PM and Weekends and Holidays from 8:00 AM - 8:00 PM
Members may also mail appeals to:
VNS CHOICE Medicare
Attn: Appeals and Grievances Coordinator
1250 Broadway, 11th Floor
New York, New York 10001
If you are not satisfied with the outcome of your appeal, you will then have the right to an external appeal from an organization or judge not affiliated with VNS CHOICE Medicare. Please refer to the Member Handbook (Evidence of Coverage) for Option 1, Option 2, or MLTC Plus, or the Summary of Benefits for Option 1, Option 2, or MLTC Plus, for more information about how to file an external appeal, or contact us.
If you would like to appoint another individual to act as your representative and file an appeal on your behalf, you will need to send us your request in writing. You must also complete an "Authorization for the Release of Health Information" form, in order for VNS CHOICE Medicare to share confidential information about you and your health records.
To appoint a representative to act on your behalf, please use the "Appointment of Representative" form (CMS-1696)
How can Members obtain and aggregate number of grievances, appeals and exceptions filed with the plan?
To obtain an aggregate number of grievances, appeals and exceptions filed with the plan please contact us by calling 1-866-783-1444 or by mailing:
VNS CHOICE Medicare
Attn: Appeals and Grievances Coordinator
1250 Broadway, 11th Floor
New York, New York 10001
For more information on appeals and grievances, please see the section above.
Is there potential for VNS CHOICE Medicare's contract to be terminated?
VNS CHOICE contracts with the Center for Medicare and Medicaid Services (CMS) on an annual basis. Availability of coverage beyond the current contract year is not guaranteed. If the contract between VNS CHOICE and CMS is to be terminated, members will be provided advance notice so that they have sufficient time to select a new health plan for their medical services and/or prescription drug coverage.
What rights and responsibilities do members have upon disenrollment from VNS CHOICE Medicare?
"Disenrollment" from VNS CHOICE Medicare means ending your membership in VNS CHOICE Medicare. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice):
- You might leave VNS CHOICE Medicare because you have decided that you want to leave. You can do this at any time for any reason.
- There are also a few situations where you would be required to leave. For example, you would have to leave VNS CHOICE Medicare if you move permanently out of our geographic service area or if VNS CHOICE Medicare leaves the Medicare program. We are not allowed to ask you to leave the plan because of your health.
- To disenroll, please either:
- Call member services at 1-866-783-1444. Representatives are available Monday through Friday 8:00 AM - 8:00 PM and Weekends and Holidays from 8:00 AM - 8:00 PM, or
- Call 1-800-Medicare, or mail your written disenrollment request to:
VNS CHOICE Medicare
PO Box 4497
Scranton, PA 18505
For more information on plan premiums, please refer to the Member Handbook (Evidence of Coverage) for Option 1, Option 2, or MLTC Plus, or the Summary of Benefits for Option 1, Option 2, or MLTC Plus, or contact us.
How many Pharmacies do you have in your network?
VNS CHOICE Medicare has a comprehensive network of Pharmacies covering every neighborhood in New York City. With over 60,000 pharmacies in our network nationally, you'll never have to go far to fill a prescription.
Click here to search our Pharmacy Directory
How does VNS CHOICE Medicare meet access requirements?
VNS CHOICE Medicare has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in New York City.
What is VNS CHOICE's Medication Therapy Management (MTM) program?
The purpose of the VNS CHOICE Medicare Medication Therapy Management (MTM) program is to develop a customized care plan for the Part D prescription drugs that the member is currently using. This care plan is developed after a MTM pharmacist communicates with the member regarding their medication history, medical history and current therapies.
How do members enroll in MTM?
In order to qualify for MTM, members must meet the following three criteria:
- Members must have at least two chronic diseases
- Members must take, at least, six Medicare covered prescription drugs
- Members are likely to incur annual costs of at least $4,000 or at least $333.33 a month on Medicare prescription drugs.
VNS CHOICE Medicare members will be identified as prospective MTM enrollees through a process that reviews the Medicare prescription drugs that you have filled. Target enrollees will also be identified through participation in VNS CHOICE care management programs and physician referral.
Enrollment is voluntary, although we encourage you to participate in this service if you are eligible. You will receive a letter from us if you are eligible for this service.
Is there a fee to participate in the MTM?
- There is no fee to participate in the Medication Therapy Management Program.
- MTM is not a separate benefit of VNS CHOICE Medicare, but rather is part of our value added services available to all members. It is available to all members of VNS CHOICE Medicare based upon his or her individual prescription drug needs.
- For more information on plan premiums, please refer to the Member Handbook (Evidence of Coverage) for Option 1, Option 2, or MLTC Plus, or contact us.
What are your quality assurance and medical management policies and procedures?
- VNS CHOICE Medicare works hard to ensure our members receive the best possible care.
- For more information on VNS CHOICE Medicare's quality assurance and medical management policies and procedures, please click here or contact us.
What happens if a drug a member takes is not covered?
A member may join the plan while taking a non-covered prescription drug. When this occurs, members taking the non-covered drug will have a 60-day "grace period" authorization to continue taking the prescription while they work with their provider to find an appropriate covered replacement (90 days for members in long term care facilities).
If you think you need more time, or if you or your physician thinks that changing medications would not be in your best interests, you or your physician can file an exception request.
For more information on filing an exception request, please see the appeals and grievance section.
Click here for a link to the Exception Request form.
What happens if a drug a member takes is removed from the formulary?
From time to time, VNS CHOICE Medicare may remove drugs from the formulary. If the member is on one a drug when it is removed from the formulary, he/she can stay on the drug for the remainder of the calendar year, unless the drug is removed due to safety reasons.
If you think you need more time, or if you or your physician thinks that changing medications would not be in your best interests, you or your physician can file an exception request.
For more information on filing an exception request, please see the appeals and grievance section.
Click here for a link to the Exception Request form
Where can I find a link to
The Medicare Prescription Drug Determination Request form (for enrollees)
The Medicare Part D Coverage Determination Request Form (for providers)
