Rights & responsibilities

Information in a way that meets your needs

We must tell you about Aetna Better Health FIDA Plan benefits and your rights in a way that you can understand. We must tell you about your rights each year that you are a Participant in Aetna Better Health FIDA Plan. We must also tell you about all of your rights and how to exercise your rights in writing prior to the effective date of coverage.

You have the right to receive timely information about Aetna Better Health FIDA Plan changes.  This includes the right to receive annual updates to the Marketing, Outreach and Participant Communications materials. This also means you have the right to receive notice of any significant change in the way in which services are provided to you at least 30 days prior to the intended effective date of the change.  

You have the right to have all plan options, rules, and benefits fully explained, including through the use of a qualified interpreter if needed. To get information in a way that you can understand, please call Participant Services. Aetna Better Health FIDA Plan has people who can answer questions in different languages. Written materials are available in Spanish, Chinese, Russian, Italian, Haitian-Creole, and Korean. We can also give you information in other formats such as Braille, audio, and large print. This information is free.

If you are having trouble getting information from Aetna Better Health FIDA Plan because of language problems or a disability and you want to file a grievance, call Medicare at 1-800-MEDICARE (1-800-633-4227). You can call 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also file a complaint with the New York State Department of Health at any time. You can call them at 1-800-206-8125.

Respect, fairness and dignity at all times

Aetna Better Health FIDA Plan must obey laws that protect you from discrimination or unfair treatment. We do not discriminate against Participants because of any of the following:

• Race
• Ethnicity
• National origin
• Religion
• Sex
• Sexual orientation
• Age
• Mental ability
• Behavior
• Mental or physical disability
• Health status
• Color
• Marital status
• Receipt of health care
• Use of services
• Claims experience
• Appeals
• Medical history
• Genetic information
• Evidence of insurability
• Geographic location within the service area

Under the rules of Aetna Better Health FIDA Plan, you have the right to be free of any form of physical restraint or seclusion that would be used as a means of coercion, force, discipline, convenience, or retaliation. You have the right to not be neglected, intimidated, physically or verbally abused, mistreated, or exploited. You also have the right to be treated with consideration, respect, and full recognition of your dignity, privacy, and individuality. 

We cannot deny services to you or punish you for exercising your rights. Your exercising of your rights will not negatively affect the way Aetna Better Health FIDA Plan and its providers, New York State, or CMS provide or arrange for the provision of services to you.

For more information, or if you have concerns about discrimination or unfair treatment, call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 (TTY users call 1-800-537-7697). You can also call your local Office for Civil Rights. You can also contact the Civil Rights Bureau of the New York State Attorney General’s Office at (212) 416-8250.

If you have a disability and need help getting care or reaching a provider, call Participant Services. If you have a grievance, such as a problem with wheelchair access, Participant Services can help. You can reach Participant Services at 1-855-494-9945, 24 hours a day, 7 days a week. TTY users call 711.

 

Timely access to covered services, items and drugs

If you cannot get services within a reasonable amount of time, we have to pay for out-of-network care.

As a Participant of Aetna Better Health FIDA Plan these are your rights:

• You have the right to receive medically necessary services, items, and drugs as required to meet your needs, in a way that is sensitive to your language and culture, and that is provided in an appropriate care setting, including the home and community.
• You have the right to choose a Primary Care Provider (PCP) in Aetna Better Health FIDA Plan’s network. A network provider is a provider who works with Aetna Better Health FIDA Plan. You can also ask us to have a specialist serve as your PCP.

»    Call Participant Services or look in the Provider and Pharmacy Directory to learn which providers are accepting new patients.

• You have the right to make decisions about providers and coverage, which includes the right to choose and change providers within our network.
• You have the right to go to a gynecologist or another women’s health specialist without getting a referral or prior authorization.

»    A referral is approval from your Primary Care Provider to see another Provider. Referrals are not required in Aetna Better Health FIDA Plan.

»    Prior authorization means that you must get approval from your Interdisciplinary Team (IDT), Aetna Better Health FIDA Plan, or another specified provider before you can get certain services, items, or drugs or see an out-of-network provider.  

• You have the right to access other services that do not require prior authorization, such as emergency and urgently needed care, out-of-area dialysis services, and Primary Care Provider visits. Please seeyour Participant Handbook for more information on services requiring prior authorization and those that do not. 
• You have the right to get covered services from network providers within a reasonable amount of time.

»    This includes the right to get timely services from specialists.

• You have the right to have telephone access to your providers through on-call services. You also have the right to access the Aetna Better Health FIDA Plan Nurse Advice Call Line 24 hours a day, 7 days a week in order to obtain any needed emergency or urgent care or assistance.
• You have the right to get your prescriptions filled at any of our network pharmacies without long delays.
• You have the right to access care without facing physical barriers. This includes the right to be able to get in and out of a provider’s office, including barrier-free access if you have any disabilities or other conditions limiting your mobility, in accordance with the Americans with Disabilities Act.
• You have the right to access an adequate network of primary and specialty providers who are capable of meeting your needs with respect to physical access, as well as communication and scheduling needs.
• You have the right to receive reasonable accommodations in accessing care, in interacting with Aetna Better Health FIDA Plan and providers, and in receiving information about your care and coverage.
• You have the right to be told where, when, and how to get the services you need, including how to get covered benefits from out-of-network providers if the providers you need are not available in Aetna Better Health FIDA Plan’s network. To learn about out-of-network providers, see your Participant Handbook.
• Your Participant Handbook explains what you can do if you think you are not getting your services, items, or drugs within a reasonable amount of time. Your Participant Handbook also tells you what you can do if we have denied coverage for your services, items, or drugs and you do not agree with our decision.

Protecting your personal health information

We protect your personal health information as required by federal and state laws.

• You have the right to have privacy during treatment and to expect confidentiality of all records and communications.
• Your personal health information includes the information you gave us when you enrolled in Aetna Better Health FIDA Plan. It also includes your conversations with your providers, your medical records, and other medical and health information.
• You have the right to get information and to control how your health information is used. We give you a written notice called the “Notice of Privacy Practice” that tells about these rights. The notice also explains how we protect the privacy of your health information.
• You have the right to request that any communication that contains protected health information from Aetna Better Health FIDA Plan be sent by alternative means or to an alternative address.
• We make sure that unauthorized people do not see or change your records.
• In most situations, we do not give your health information to anyone who is not providing your care or paying for your care. If we do, we are required to get written permission from you first. Written permission can be given by you or by someone who has the legal power to make decisions for you.
• There are certain cases when we do not have to get your written permission first. These exceptions are allowed or required by law.

How we protect your health information

»    We are required to release health information to government agencies that are checking on our quality of care.

»    We are required to give Medicare and Medicaid your health and drug information. If Medicare or Medicaid releases your information for research or other uses, it will be done according to Federal laws. You have the right to request information on how your health and other information has been released by Aetna Better Health FIDA Plan.  

You have a right to see your medical records

• You have the right to look at your medical records and to get a copy of your records.
• You have the right to ask us to update or correct your medical records. If you ask us to do this, we will work with your health care provider to decide whether the changes should be made.
• You have the right to know if and how your health information has been shared with others.

– If you have questions or concerns about the privacy of your personal health information, call Participant Services at 1-855-494-9945, 24 hours a day, 7 days a week. TTY users call 711.

Information about the plan, network providers and your covered services

As a Participant of Aetna Better Health FIDA Plan, you have the right to get timely information and updates from us. If you do not speak English, we must give you the information free of charge in a language that you can understand. We must also provide you with a qualified interpreter, free of charge, if you need one during appointments with providers. If you have questions about Aetna Better Health FIDA Plan or you are in need of interpreter services, just call us at 1-855-494-9945 (TTY: 711). This is a free service. Written materials are available in Spanish, Chinese, Russian, Italian, Haitian-Creole, and Korean. We can also give you information in other formats, such as Braille, audio, and large print.

If you want any of the following, call Participant Services:

• Information about how to choose or change plans
• Information about Aetna Better Health FIDA Plan, including:

»    Financial information

»    How Aetna Better Health FIDA Plan has been rated by plan Participants

»    The number of appeals made by Participants

»    How to leave Aetna Better Health FIDA Plan

• Information about our network providers and our network pharmacies, including:

»    How to choose or change Primary Care Providers

»    The qualifications of our network providers and pharmacies

»    How we pay the providers in our network

– For a list of providers and pharmacies in Aetna Better Health FIDA Plan’s network, see the Provider and Pharmacy Directory. For more detailed information about our providers or pharmacies, call Participant Services, or visit our website at www.aetnabetterhealth.com.

• Information about covered services, items, and drugs and about rules you must follow, including:

»    Services, items, and drugs covered by Aetna Better Health FIDA Plan

»    Limits to your coverage and drugs

»    Rules you must follow to get covered services, items, and drugs

• Information about why a service, item, or drug is not covered and what you can do about it, including:

»    Asking us to put in writing why something is not covered

»    Asking us to change a decision we made

»    Asking us to pay for a bill you have received

Network providers cannot bill you directly

Doctors, hospitals, and other providers in our network cannot make you pay for covered services, items, or drugs. They also cannot charge you if we pay less than the provider charged us or if we don’t pay them at all. You have the right to not be charged any co-payments, premiums, deductibles, or other cost-sharing. To learn what to do if a network provider tries to charge you for covered services, items, or drugs, see your Participant Handbook or call Participant Services.

Making decisions about your health care

You have the right to know your treatment options and make decisions about your services

You have the right to get full information from your doctors and other health care providers when you get services. You also have the right to have access to doctors and other providers who can meet your needs. This includes providers who can help you meet your health care needs, communicate with you in a way that you can understand, and provide you with services in locations that you can physically access. You may also choose to have a family member or caregiver involved in your services and treatment discussions. You have the right to appoint someone to speak for you about the care you need.

• Know your choices. You have the right to be told about all the kinds of treatment.  You have the right to talk with and receive information from providers on all available treatment options and alternatives, regardless of cost, and to have these options presented in a way you understand.
• Know the risks. You have the right to be told about any risks involved. You must be told in advance if any service or treatment is part of a research experiment. You have the right to refuse experimental treatments.
• You can get a second opinion. You have the right to see another provider before deciding on treatment.
• You can say “no.” You have the right to accept or refuse any treatment. This includes the right to leave a hospital or other medical facility, even if your provider advises you not to. You also have the right to stop taking a drug. If you refuse treatment or stop taking a drug, you will not be dropped from Aetna Better Health FIDA Plan. However, if you refuse treatment or stop taking a drug, you accept full responsibility for what happens to you.
• You can ask us to explain why a provider denied care. You have the right to get an explanation from us if a provider has denied care that you believe you should get.
• You have the right to receive a written explanation. If covered services, items, or drugs were denied, you have the right to get a written explanation without having to request one.
• You can ask us to cover a service, item, or drug that was denied or is usually not covered. Your Participant Handbook tells how to ask Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT) for a coverage decision.
• You can participate in your care planning. As a Participant in Aetna Better Health FIDA Plan, you will receive an in-person Comprehensive Assessment upon enrollment. You will also meet with your IDT to develop your Person-Centered Service Plan (PCSP) and to update it, when necessary. You have the right to request a new Comprehensive Assessment or an update to your PCSP at any time. For more information, see your Participant Handbook.
• You have the right to complete and accurate information related to your health and functional status from your provider, your IDT, and Aetna Better Health FIDA Plan.

You have the right to say what you want to happen if you are unable to make health care decisions for yourself

Sometimes people are unable to make health care decisions for themselves. Before that happens to you, you can:

• Fill out a written form to give someone the right to make health care decisions for you.
• Give your providers written instructions about how you want them to handle your health care if you become unable to make decisions for yourself.

The legal document that you can use to give your directions is called an advance directive. There are different types of advance directives and different names for them. Examples are a living will and a power of attorney for health care. When you enroll in the plan, we will inform you about your right to make an advance directive. You will also be told about this right when your Person-Centered Service Plan is updated.

You do not have to use an advance directive, but you can if you want to. Here is what to do:

• Get the form. You can get a form from your Primary Care Provider, a lawyer, a legal services agency, or a social worker. Organizations that give people information about Medicare or Medicaid (such as the New York Department for the Aging, New York State Bar Association, and AARP) may also have advance directive forms. You can also contact Participant Services to ask for the forms.
• Fill it out and sign the form. The form is a legal document. You should consider having a lawyer help you prepare it.
• Give copies to people who need to know about it. You should give a copy of the form to your Primary Care Provider. You should also give a copy to the person you name as the one to make decisions for you. You may also want to give copies to close friends or family members. Be sure to keep a copy at home.

If you are going to be hospitalized and you have signed an advance directive, take a copy of it to the hospital.

• The hospital will ask you whether you have signed an advance directive form and whether you have it with you.
• If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.

Remember, it is your choice to fill out an advance directive or not.

What to do if your instructions are not followed

Aetna Better Health FIDA Plan and our providers must honor your instructions. If you have signed an advance directive, and you believe that a provider did not follow the instructions in it, you may file a complaint with the New York State Department of Health Hospital Complaint Line at 1-800-804-5447 or the Managed Long Term Care Technical Assistance Center at 1-866-712-7197.

Asking for help

Your Participant Handbook contains contact numbers for many helpful resources. You have the right to ask for help without interference from Aetna Better Health FIDA Plan.  You can ask for help from agencies like the FIDA Participant Ombudsman or the NY State Long Term Care Ombudsman.

• The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by Aetna Better Health FIDA Plan. ICAN may be reached toll-free at 1-844-614-8800 or online.
• The NY State Long Term Care Ombudsman can provide information and assistance regarding your rights as a resident of a long-term care facility. Call 1-800-342-9871 for information about contacting your local long-term care ombudsman.

There are other resources available to you, including those listed in chapter 2 of your Participant Handbook. You have the right to ask for help from the entities listed in chapter 2 or from any other entity you identify.

Filing a grievance to ask us to reconsider decisions

Your Participant Handbook tells what you can do if you have any problems or concerns about your covered services or care. For example, you could ask us to make a coverage decision, make an appeal to us to change a coverage decision, or file a grievance.

You have the right to get information about appeals and grievances that other Participants have filed against Aetna Better Health FIDA Plan. To get this information, call Participant Services.

What to do if you believe you are being treated unfairly or your rights are not being respected

If you believe you have been treated unfairly—and it is not about discrimination for the reasons listed above you can get help in these ways:

• You can call Participant Services and file a grievance with Aetna Better Health FIDA Plan as outlined in your Participant Handbook.
• You can call the Health Insurance Information, Counseling and Assistance Program (HIICAP) at 1-800-701-0501.
• You can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.
• You can call Medicaid at 1-800-541-2831. TTY users call 1-877-898-5849.
• You can call the FIDA Participant Ombudsman at 1-844-614-8800. TTY users call 711. 

Under all circumstances, you have the right to file an internal grievance with Aetna Better Health FIDA Plan, an external grievance with Medicare or the New York State Department of Health (NYSDOH), or an appeal of any coverage decision. The processes for filing any of these are outlined in your Participant Handbook.

How to get more information about your rights

There are several ways to get more information about your rights:

• You can call Participant Services.
• You can call the Health Insurance Information, Counseling and Assistance Program (HIICAP) at 1-800-701-0501.
• You can contact Medicare.

»    You can visit the Medicare website to read or download “Medicare Rights & Protections.” (Go to http://www.medicare.gov/Publications/Pubs/pdf/11534.pdf.)

»    Or you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days 
a week. TTY users call 1-877-486-2048.

• You can call Medicaid at 1-800-541-2831. TTY users call 1-877-898-5849.
• You can call the FIDA Participant Ombudsman at 1-844-614-8800. TTY users call 711. 

How to get help understanding your rights or exercising them

You can call the FIDA Participant Ombudsman at 1-844-614-8800. TTY users call 711. The Participant Ombudsman provides free information and assistance. It is not affiliated with our plan.

You have the right to suggest changes

You have the right to recommend changes in policies and services to Aetna Better Health FIDA Plan, Medicare, the New York State Department of Health, or any outside representative of your choice.

Understanding your rights & responsibilities

As a Participant of Aetna Better Health FIDA Plan, you have a responsibility to do the things that are listed below. If you have any questions, call Participant Services.

• Read the Participant Handbook to learn what is covered and what rules you need to follow to get covered services, items, and drugs. This includes choosing a Primary Care Provider and using network providers for covered services, items, and drugs. If you don’t understand something, call Participant Services.

»    For details about your covered services and items, see your Participant Handbook. It tells you what is covered, what is not covered, what rules you need to follow, and what you pay.

»    For details about your covered drugs, see your Participant Handbook.

• Tell us about any other health or prescription drug coverage you have. Please call Participant Services to let us know.

»    We are required to make sure that you are using all of your coverage options when you receive services. This is called coordination of benefits.

»    For more information about coordination of benefits, see your Participant Handbook.

• Tell your Primary Care Provider and other providers that you are enrolled in Aetna Better Health FIDA Plan. Show your Aetna Better Health FIDA Plan ID card whenever you get services, items, or drugs.
• Help your Primary Care Provider and other providers give you the best care.

»    Call your Primary Care Provider or Care Manager if you are sick or injured for direction right away. When you need emergency care from out-of-network providers, notify Aetna Better Health FIDA Plan as soon as possible. In case of emergency, call 911.

»    Give your providers the information they need about you and your health. Learn as much as you can about your health problems. Follow the treatment plans and instructions that you and your providers agree on.

»    Make sure that your Primary Care Provider and other providers know about all of the drugs you are taking. This includes prescription drugs, over-the-counter drugs, vitamins, and supplements.

»    If you have any questions, be sure to ask. Your providers must explain things in a way you can understand. If you ask a question and you do not understand the answer, ask again.

»    Understand the role of your Primary Care Provider, your Care Manager, and your Interdisciplinary Team (IDT) in providing your care and arranging other health care services that you may need.

»    Participate in the development of your Person-Centered Service Plan (PCSP) with your IDT and keep appointments or notify your Care Manager or IDT if an appointment cannot be met.

• Be considerate. We expect all of our Participants to respect the rights of other Participants. We also expect you to act with respect in your Primary Care Provider’s office, hospitals, other providers’ offices, and when dealing with Aetna Better Health FIDA Plan employees.
• Pay what you owe. As an Aetna Better Health FIDA Plan Participant, you are responsible for paying the full cost of any services, items, or drugs that are not covered by the plan.

– If you disagree with your IDT’s decision or Aetna Better Health FIDA Plan’s decision to not cover a service, item, or drug, you can make an appeal. Please see your Participant Handbook to learn how to make an appeal.

• Tell us if you move. If you are going to move, it is important to tell us right away. Call Participant Services.

»    If you move outside of our service area, you cannot be a Aetna Better Health FIDA Plan Participant. Your Participant Handbook tells about our service area. The Enrollment Broker can help you figure out whether you are moving outside our service area and can help you identify alternative Medicare and Medicaid coverage. Also, be sure to let Medicare and Medicaid know your new address when you move. See your Participant Handbook for phone numbers for Medicare and Medicaid.

»    If you move within our service area, we still need to know. We need to keep your membership record up to date and know how to contact you.

• Tell us if you have any changes in your personal information, including your income or assets.You must provide Aetna Better Health FIDA Plan with accurate and complete information.

»    It is important to tell us right away if you have a change in personal information such as phone number, address, marital status, additions to your family, eligibility, or other health insurance coverage.

»    If your assets in bank accounts, cash in hand, certificates of deposit, stocks, life insurance policies, or any other assets change, please notify Participant Services and New York State.

Call Participant Services for help if you have any questions or concerns. Let us know about any problems immediately.

Disenrollment rights

No one can make you stay in our plan if you do not want to. You can leave the plan at any time. If you leave Aetna Better Health FIDA Plan, you will still be in the Medicare and Medicaid programs. You have the right to get most of your health care services through Original Medicare or a Medicare Advantage plan. You can get your Medicare Part D prescription drug benefits from a prescription drug plan or from a Medicare Advantage plan. You also have the right to get your Medicaid services through other programs including the Program of All-Inclusive Care for the Elderly (PACE), Medicaid Advantage Plus, Managed Long-Term Care, or Medicaid Fee-For-Service (Original Medicaid).

Until your participation ends, you will keep getting your medical services and drugs through our FIDA Plan

If you leave Aetna Better Health FIDA Plan, it may take time before your participation ends and your new Medicare and Medicaid coverage begins. See page 187 for more information. During this time, you will keep getting your services, items, and drugs through Aetna Better Health FIDA Plan.

• You should use our network pharmacies to get your prescriptions filled. Usually, your prescription drugs are covered only if they are filled at a network pharmacy including through our mail-order pharmacy services.

• If you are hospitalized on the day that your participation ends, your hospital stay will usually be covered by our plan until you are discharged. This will happen even if your new coverage begins before you are discharged.

Your participation will end in certain situations (even if you haven’t asked for it to end)

These are the cases when the FIDA Program rules require that your participation must end:

• If there is a break in your in Medicare Part A and Part B coverage.

• If you no longer qualify for Medicaid.

• If you permanently move out of our service area.

• If you are away from our service area for more than six consecutive months.

— If you move or take a long trip, you need to call Participant Services to find out if the place you are moving or traveling to is in Aetna Better Health FIDA Plan’s service area.

• If you go to jail, prison, or a correctional facility.

• If you lie about or withhold information about other insurance you have for health care or prescription drugs.

In any of the above situations, the Enrollment Broker (New York Medicaid Choice) will send you a disenrollment notice and will be available to explain your other coverage options.

In addition, we can request that the FIDA Program remove you from Aetna Better Health FIDA Plan for the following reasons:

• If you intentionally give us incorrect information when you are enrolling in Aetna Better Health FIDA 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 Participants of Aetna Better Health FIDA Plan even after we make and document our efforts to resolve any problems you may have.

• If you knowingly fail to complete and submit any necessary consent or release form allowing Aetna Better Health FIDA Plan and providers to access health care and service information that is necessary for us to deliver care to you.

• If you let someone else use your ID card to get medical care.

— If we end your participation because of this reason, Medicare may have your case investigated by the Inspector General.

In any of the above situations, we will notify you of our concern before we request FIDA Program approval to have you disenrolled from Aetna Better Health FIDA Plan. We will do this so that you have the opportunity to resolve the problems first. If the problems aren’t resolved, we will notify you again once we have submitted the request. If the FIDA Program approves our request, you will receive a disenrollment notice. The Enrollment Broker will be available to explain your other coverage options.

We cannot ask that you be disenrolled from our FIDA Plan for any reason related to your health

If you feel that we are requesting that you be disenrolled from Aetna Better Health FIDA Plan for a health-related reason, you should call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You should also call Medicaid at 1-800-541-2831.

You may have the right to request a fair hearing if the FIDA Program ends your participation in our FIDA Plan

If the FIDA Program ends your participation in Aetna Better Health FIDA Plan, the FIDA Program must tell you its reasons in writing. It must also explain how you can request a fair hearing about the decision to end your participation.

You have the right to file a grievance with Aetna Better Health FIDA Plan if we ask the FIDA Program to end your participation in our FIDA Plan

If we ask the FIDA Program to end your participation in our plan, we must tell you our reasons in writing. We must also explain how you can file a grievance about our request to end your participation. You can see Chapter 9, Section 10, page 182 for information about how to file a grievance.

— Note: You can use the grievance process to express your dissatisfaction with our request to end your participation. However, if you want to ask that the decision be changed, you must file a fair hearing as described in Section I just above.

Where can you get more information about ending your participation in our FIDA Plan?

If you have questions or would like more information on when we can end your participation, you can call Participant Services at 1‑855‑494‑9945, 24 hours a day, 7 days a week. TTY users call 711.

The Independent Consumer Advocacy Network (ICAN) can also give you free information and assistance with any issues you may have with your FIDA Plan. To contact ICAN, call 1-844-614-8800.