FIDA Participant Rights and Responsibilities

The following are your rights and responsibilities as an active member of Elderplan FIDA. You may also read your rights upon disenrollment here.

Our plan must honor your rights as a Participant of Elderplan FIDA Total Care. You have the right:

  • To receive medically necessary items and services as needed to meet your needs, in a manner that is sensitive to your language and culture, and that is provided in an appropriate care setting, including the home and community;
  • To receive timely access to care and services;
  • To request and receive written and oral information about Elderplan FIDA Total Care, its Participating Providers, its benefits and services, and the Participants’ rights and responsibilities in a manner the Participant understands;
  • To receive materials and/or assistance in a foreign language and in alternative formats, if necessary;
  • To be provided qualified interpreters, free of charge, if you need interpreters during appointments with Providers and when talking to Elderplan FIDA Total Care;
  • To be treated with consideration, respect and full recognition of your dignity, privacy and individuality;
  • To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation;
  • Not to be neglected, intimidated, physically or verbally abused, mistreated, or exploited;
  • To not be discriminated against on the basis of and to get care without regard to sex, race, health status, disability, color, age, national origin, sexual orientation, marital status or religion;
  • 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 Providers are not available in the Elderplan FIDA Total Care network;
  • To complain to NYSDOH or the Local Department of Social Services; and, the right to use the New York State Fair Hearing System and/or a New York State External Appeal, where appropriate;
  • To be advised in writing of the availability of the NYSDOH toll-free hotline, the telephone number, the hours of its operation and that the purpose of the hotline is to receive complaints or answer questions about home care agencies;
  • To appoint someone to speak for you about the care you need;
  • To be informed of all rights, and the right to exercise such rights, in writing prior to the Effective Date of Enrollment;
  • To participate in your care planning and participate in any discussions around changes to the Person-Centered Service Plan, if/when they are warranted;
  • To recommend changes in policies and services to agency personnel, NYSDOH or any outside representative of your choice;
  • To have telephone access to a nursing hotline and on-call Participating Providers 24/7 in order to obtain any needed emergency or urgent care or assistance;
  • 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 for Participants with disabilities or other conditions limiting mobility, in accordance with the Americans with Disabilities Act;
  • To receive reasonable accommodations in accessing care, in interacting with Elderplan FIDA Total Care and Providers, and in receiving information about your care and coverage;
  • To see a specialist and request to have a specialist serve as Primary Care Provider;
  • To talk with and receive information from Providers on all conditions and all available treatment options and alternatives, regardless of cost, and to have these presented in a manner the Participant understands. This includes the right to be told about any risks involved in treatment options and about whether any proposed medical care or treatment is part of a research experiment;
  • To choose whether to accept or refuse care and treatment, after being fully informed of the options and the risks involved. This includes the right to say yes or no to the care recommended by Providers, the right to leave a hospital or other medical facility, even if against medical advice, and to stop taking a prescribed medication;
  • To receive a written explanation if Covered Items or Services were denied, without having to request a written explanation;
  • To have privacy in care, conversations with Providers, and Medical Records such that:
  • Medical and other records and discussions with Providers will be kept private and confidential;
  • You get to approve or refuse to allow the release of identifiable medical or personal information, except when the release is required by law;
  • You may request that any communication that contains Protected Health Information from Elderplan FIDA Total Care be sent by alternative means or to an alternative address;
  • You are provided a copy of Elderplan FIDA Total Care’s Privacy Practices, without having to request the same;
  • You may request and receive a copy of your Medical Records and request that they be amended or corrected, as specified in 45 CFR 164.524 and 164.526., if the privacy rule, as set forth in 45 CFR 160 and 164, A and E, applies;
  • You may request information on how your health and other personal information has been released by Elderplan FIDA Total Care;
  • To seek and receive information and assistance from the independent, conflict free Participant Ombudsman;
  • To make decisions about Providers and coverage, which includes the right to choose and change Providers within the Elderplan FIDA Total Care network and to choose and change coverage (including how one receives his/her Medicare and/or Medicaid coverage – whether by changing to another FIDA Plan or making other changes in coverage);
  • To be informed at the time of enrollment and at PCSP update or revision meetings of the explanation of what is an Advance Directive and the right to make an Advance Directive – giving instructions about what is to be done if you are not able to make medical decisions for yourself – and to have Elderplan FIDA Total Care and its Participating Providers honor it; and
  • To access information about Elderplan FIDA Total Care, its network of Providers, and Covered Items and Services including:
    • Information about Elderplan FIDA Total Care’s financial condition, its performance rating, how it compares to other plans, and the number of appeals made by Participants;
    • Information about the qualifications of the Participating Providers and how they are paid; and
    • Information about the rules and restrictions on Covered Items and Services.
  • The right to have all plan options, rules and benefits fully explained, including through use of a qualified interpreter if needed;
  • The right to access an adequate network of primary and specialty Providers who are capable of meeting your needs with respect to physical access and communication and scheduling needs;
  • The right to have a voice in the governance and operation of Elderplan FIDA Total Care, Provider or health plan, as detailed in this Contract; and
  • The right to participate in all aspects of care and to exercise all rights of appeal.
  • You have a responsibility to be fully involved in maintaining your health and making decisions about your health care, including the right to refuse treatment if desired, and must be appropriately informed and supported to this end. Specifically, you must:
  • Receive an in-person Comprehensive Assessment upon enrollment in Elderplan FIDA Total Care to participate in the development and implementation of a Person-Centered Service Plan (PCSP). You, or your designated representative, also have the right to request a Comprehensive Reassessment by Elderplan FIDA Total Care and to be fully involved in any such Comprehensive Reassessment.
  • You must get your services and items from network providers.
    • Usually, Elderplan FIDA Total Care will not cover services or items from a provider who has not joined Elderplan FIDA Total Care’snetwork. Here are some cases when this rule does not apply:
      • The plan covers emergency or urgently needed care from an out-of-network provider.
      • If you need care that our plan covers and our network providers cannot give it to you, you can get the care from an out-of-network provider. In this situation, we will cover the care as if you got it from a network provider and at no cost to you.
      • The plan covers services and items from out-of-network providers and pharmacies when a provider or pharmacy is not available within a reasonable distance from your home.
      • The plan covers kidney dialysis services when you are outside the plan’s service area for a short time. You can get these services at a Medicare-certified dialysis facility.
      • When you first join the plan, you can continue seeing the providers you see now during the “transition period.” In most cases, the transition period will last for 90 days or until your Person-Centered Service Plan is finalized and implemented, whichever is later. However, your out-of-network provider must agree to provide ongoing treatment and accept payment at our rates. After the transition period, we will no longer cover your care if you continue to see out-of-network providers.
      • If you are a resident of a nursing facility, you can continue to live in that nursing facility for the duration of the FIDA Program, even if the nursing facility does not participate in Elderplan FIDA Total Care’s network.
      • If you are receiving services from a behavioral health provider at the time of your enrollment, you may continue to get services from that provider until treatment is complete, but not for more than two years.
    • If you need to go to an out-of-network provider, please work with Elderplan FIDA Total Care or your IDT to get approval to see an out-of-network provider and to find one that meets applicable Medicare or Medicaid requirements. If you go to an out-of-network provider without first getting Plan or IDT approval, you may have to pay the full cost of the services you get.
  • Receive complete and accurate information on your health and Functional Status by the Interdisciplinary Team.
  • Be provided information on all program services and health care options, including available treatment options and alternatives, presented in a culturally appropriate manner, taking into consideration your condition and ability to understand. If you are unable to participate fully in treatment decisions, you have the right to designate a representative. This includes the right to have translation services available to make information appropriately accessible.

Information must be available:

  • Before Enrollment.
  • At Enrollment.
  • At the time your needs necessitate the disclosure and delivery of such information in order to allow you to make an informed choice.
  • Be encouraged to involve caregivers or family participants in treatment discussions and decisions.
  • Be afforded the opportunity to file an Appeal if Items or Services are denied that you think are medically indicated and to be able to ultimately take that Appeal to an independent external system of review.
  • The right to freely exercise your rights and that the exercise of those rights does not adversely affect the way the Elderplan FIDA Total Care and its Providers or the State Agency or CMS provide, or arrange for the provision of, medical services to you.
  • The right to receive timely information about Elderplan FIDA Total Care plan changes. This includes the right to request and obtain the information listed in the Marketing, Outreach and Participant Communications materials at least once per year and the right to receive notice of any significant change in the information provided in the Orientation materials at least 30 days prior to the intended effective date of the change.
  • The right to be protected from liability for payment of any fees that are the obligation of the Elderplan FIDA Total Care.
  • The right not to be charged any cost for Medicare Parts A and B services.

As a Participant of Elderplan FIDA Total Care, you have the following responsibilities:

  1. To try to understand Covered Items and Services and the rules around getting Covered Items and Services;
  2. To tell Providers that you are enrolled in an Elderplan FIDA Total Care and show your Elderplan FIDA Total Care card;
  3. To treat Providers and employees of the Elderplan FIDA Total Care with respect;
  4. To communicate problems immediately to the Elderplan FIDA Total Care;
  5. To keep appointments or notify the Interdisciplinary Team if an appointment cannot be kept;
  6. To supply accurate and complete information to Elderplan FIDA Total Care’s employees;
  7. To actively participate in PCSP development and implementation;
  8. To notify the State and the Elderplan FIDA Total Care of any changes in income and assets. Assets include bank accounts, cash in hand, certificates of deposit, stocks, life insurance policies, and any other assets;
  9. To ask questions and request further information regarding anything not understood;
  10. To use Elderplan FIDA Total Care’s Participating Providers for services included in the Elderplan FIDA Total Care Plan Benefit Package;
  11. To notify Elderplan FIDA Total Care of any change in address or lengthy absence from the area;
  12. To comply with all policies of Elderplan FIDA Total Care as noted in the Participant Handbook;
  13. If sick or injured, to call your doctors or care coordinators for direction right away;
  14. In case of emergency, to call 911; and
  15. If Emergency Services are required out of the service area, to notify Elderplan FIDA Total Care as soon as possible.

Looking for information?

Questions? Call Elderplan today.

1-855-462-3167

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Hours of Operation:
8 a.m. - 8 p.m., 7 days a week

Elderplan FIDA Total Care
is available in the Bronx, Kings, New York, Queens, Richmond and Nassau Counties.

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