Molinalogo

We want to give you good care!

Molina Healthcare works with our member providers to give you good health care. We look at your member benefits and make choices about care based on what you need. We want you to know:

• We do not reward providers to deny care.
• We do not reward staff or other people to deny care or give you less care.
• We do not pay extra money to providers or our staff members to deny tests or treatments that you need to get better or stay healthy.

Members who have a concern about their health care can call Member Services at (800) 223-7242 or TTY: 711.

• Our staff is here to take calls Monday to Thursday between 8 a.m. - 5p.m. and Friday, 9 a.m. – 5 p.m. (except holidays) If members call after 7 p.m. or over the weekend, they can leave a message and their phone number. Our staff will return the call in a timely manner, no more than one business day.
• Staff is also available to accept collect calls.
• There are nurses you can talk to about your health care choices and getting the needed care available through our Nurse Advice Line.
• A bilingual staff member or interpreter is available for members.

Primary Care

A PCP is a doctor who helps you when you are sick and can also help you stay healthy. You may think you do not need a doctor until you are sick. This is not the best time for you to meet your doctor for the first time. Call your doctor to make your first appointment. This first visit will help your doctor get to know you and help you stay well. Please call Member Services if you need help getting an appointment.

Go to your Molina Healthcare PCP for:

• Check-ups
• Shots
• Illnesses
• Specialist visits
• Hospital visits

 
Seeing a doctor for check-ups helps find problems early. If you need special care, your PCP will help you. Your doctor works with you to keep you and your family healthy.

Specialty Care

Your PCP will take care of most of your needs. There will be times when you will need to see other type of doctors. These doctors are called specialists.

Examples of specialists are:

• Cardiologists
• ENT physicians (Ear, Nose & Throat)
• Neurologists
• Allergists

There are some providers that do need referrals. For example:

• Gynecologists
• Dermatologists
• Psychologists

It is a good idea to check with Member Services if the doctor is part of Molina Healthcare. You might need a provider that is not part of Molina. If this happens, call your PCP to get prior approval from Molina.

Out of Network Services

If a Molina Healthcare provider is unable to provide a member with necessary and covered services, Molina Healthcare must cover the needed services through an out-of-network provider. The cost to members should be no greater than it would be if the provider were in Molina Healthcare’s network. This must be done in a timely manner for as long as Molina Healthcare is unable to provide the service.

After Hours Care

You might need to reach your provider after or before their office is open. If you do, you may call the number you usually reach them at. All providers have coverage for their patients 24 hours a day, 7 days a week. Your doctor may have an answering service where someone can help you with your medical issue or call the doctor. Sometimes your provider may have another provider cover for them either after hours or if your doctor is away. They could give you advice over the phone and sometimes prescribe a medication. You might be asked to visit the provider or be sent to an urgent care center.

Molina Healthcare also has Nurse Advice Line with highly trained nurses. They can help you decide if you or your child should see a provider right away. The nurses can also help you make an appointment if you need to see a provider quickly. Sometimes, you have questions but you do not think you need to see your provider. You can call the Nurse Advice Line and talk to a nurse. They will help you 24 hours a day, 7 days a week.

(800) 223-7242
For the hearing impaired, please call TTY 711

If you feel this is an emergency, call 911 or go to the nearest emergency room.

Emergency Care

It’s a medical problem that needs to be treated immediately. We cover emergencies wherever you are. You do not have to call Molina Healthcare for approval in an emergency. Call 911 or go to the nearest emergency room. This includes a facility that is not part of Molina Healthcare. You can get emergency care 24 hours a day, 7 days a week.

Some examples of emergency are:

• Miscarriage or pregnancy problems
• Seizures or convulsions
• Unusual or excessive bleeding
• Unconsciousness
• Overdose/Poison
• Severe pain
• Severe burns
• Trouble breathing
• Chest pains 

Please carry your Member ID Card with you. If you are told you need to stay in the hospital, make sure the hospital calls Molina Healthcare. If you are asked to stay in a hospital that is not part of Molina, we will transfer you to a hospital that is part of Molina as soon as you are well enough to be moved. If the emergency room doctor decides that you do not have to stay but you decide to stay, you may have to pay. Once you leave the ER and are told you need further medical care, call your doctor. Do not go to the ER for follow-up care. Make an appointment with your doctor.

If you are not sure if you need emergency care, call your PCP or call our 24-Hour Nurse Advice Line toll-free (800) 223-7242. The Nurse Advice Line is staffed by registered nurses (RNs). You can call the Nurse Advice Line 24 hours a day, 7 days a week.

Hospital emergency rooms are only for real emergencies. These are not good places to get non-emergency care. They are often very busy and must care first for those whose lives are in danger. Please do not go to a hospital emergency room if your condition is not an emergency.

Out of Area Care

If you are away from Molina Healthcare’s service areas and need emergency care, go to the nearest emergency room for care. Please contact Molina Healthcare within 24 hours or as soon as you can. Call toll-free (800) 223-7242. If you are deaf or hard of hearing, call our dedicated TTY/TDD line toll-free 711. When you are away from Molina Healthcare’s service area, only emergency care is covered. *Out of area urgent care services require prior authorization. No services are covered outside the United States.

Urgent Care

Urgent care services are for conditions that need attention right away. You should call your PCP for urgent care services. Your PCP may send you to an after-hours clinic or an urgent care center, when the doctor’s office is closed.

Some examples of urgent services are:

• Minor injuries
• Minor illnesses
• High fever for children or elderly
• Simple fractures
• Flu
• Eye injuries
• Insect bites 

An urgent care center is not an emergency room. If you are not sure if you need to go to the ER, call your PCP or Molina Healthcare’s 24-hour Nurse Advice Line. Your PCP or our nurses can help you decide what to do. The Nurse Advice Line telephone number is (800) 223-7242 (TTY/TDD 711).

Second Opinions

You or your doctors have the right to ask for a second opinion. You or your doctor can call Member Services to request the second opinion.

If the request is urgent and serious:

• Molina will respond within one (1) day.
• The second opinion will be given within (72) hours.

Reasons why second opinions are needed:

• You are not sure you need the treatment doctor suggests.
• You are not sure of the doctor’s diagnosis.
• You have a complex problem.
• Your doctor is not sure of a correct diagnosis.
• You have complex symptoms.
• You have followed the doctor’s care plan but have not improved.
• You have talked with your doctor about your concerns but still are not satisfied.

 
If a second opinion is approved, you will not have to pay for the services. The doctor that you see for a second opinion will send a written report to you and your PCP.
Molina may decide a second opinion is not needed. If so, we will send you a denial with the appeal rights.

Language Assistance

If you prefer to speak in your own language, Member Services can help. An interpreter will be available to speak with you. They can also help you speak to the doctor. An interpreter can help you:

• Make an appointment.
• Talk with your doctor or nurse.
• Get emergency care.
• File a complaint, grievance, or appeal.
• Get help from a pharmacist about taking medicine.

The Quality Improvement Program:

• Checks providers to be sure you have access to a qualified health care team.
• Reviews and takes action when there is an issue with the quality of care that has been provided.
• Promotes safety in health care through education for our members and our providers.
• Provides a Grow and Stay Healthy Guide to help members know what services are needed and when.
• Provides a Guide to Accessing Quality Health Care to help members access our programs and services.
• Evaluates the quality of health care through HEDIS^® (Healthcare Effectiveness Data and Information Set).
  • These scores tell us when you have received the type of care you need. The scores look at how often members receive services such as flu shots, immunizations, eye tests, cholesterol tests and prenatal care for members who are pregnant.
• Surveys members’ satisfaction with care. One type of survey is called CAHPS^® (Consumer Assessment of Healthcare Providers and Systems).
  • This tells us if you are happy with your care and your provider. It also tells us what we can make better for our members. Some things are getting the right type of appointment at the right time and having enough providers to take care of your needs.

^*You may request printed copies of all content posted on our website.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Healthcare Effectiveness Data and Information Set (HEDIS^®)

Molina Healthcare of New York uses the Healthcare Effectiveness Data and Information Set (HEDIS®) tool each year as a way to measure quality. This is done by looking at the type of care and services provided. HEDIS® is maintained by the National Committee for Quality Assurance (NCQA). This allows the review of certain aspects of care. This includes clinical and non-clinical care. It also shows where plans can improve care and service. Molina’s goal is to be better than 75% of other Medicaid health plans in the nation.

Detailed results can be found by clicking the link below:
HEDIS^® Annual Trends

If you have any questions or would like additional information about HEDIS®, please contact Molina Healthcare of New York Quality Department at (800) 223-7242.

*You may request printed copies of all content posted on our website by calling the Member Services phone number on your member ID card.

HEDIS® is a Registered Trademark of the National Committee for Quality Assurance.

Consumer Assessment of Healthcare Providers and Systems (CAHPS^®)

The CAHPS® (Consumer Assessment of Healthcare Providers and Systems) is a program managed by the U.S. Agency for Healthcare Research and Quality (AHRQ) and administered by the NY State Department of Health. CAHPS surveys are used by the National Committee for Quality Assurance (NCQA), a non-profit group that wants to improve health care quality. Molina Members are surveyed each year by an independent organization using the CAHPS Adult and Child Medicaid Health Plan surveys. These surveys measure how happy members are with their health plan and the care received from doctors. Molina Healthcare’s goal is to be better than 75 percent of Medicaid health plans in the nation who report their results to NCQA.

Detailed results can be found by clicking below:

CAHPS^® Annual Trends

If you have any questions or would like additional information about CAHPS® please contact Member Services at (800) 223-7242; TTY/TTD 711.

*You may ask for copies of all content on our website by calling the Member Services phone number on your member ID card.

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Molina Healthcare (Molina) wants you and your family to be safe and healthy. We have a Patient Safety program to help us meet this goal. This program gives you the safety facts, so you can make better health care choices. Here are a few of the things we do to improve safety:

• Keep track of our members’ complaints about safety problems in their provider’s office or hospital.
• Look at reports from groups that check hospital safety. Reports tell us about things such as if there was enough staff in the intensive care unit (ICU), use of computer drug orders and so forth.
• Help members coordinate care when moving from one setting to another (e.g., hospital to home).
• Educating members about what to ask when you see a doctor.

Groups that check safety:

• Leap Frog Quality Index Ratings
• The Joint Commission National Patient Safety Goal Ratings

Molina Healthcare members can look at these websites:

• To see what hospitals are doing to be safer.
• To know what to look for when they pick a provider or a hospital.
• Get information about programs and services for members with problems like diabetes and asthma.

^*You may request printed copies of all content posted on our website.

Molina Healthcare uses a medical review process to rate:

• A new drug
• Medical device
• Medical rule or procedure
• Surgical rule or procedure
• Behavioral health rule or procedure
• Therapy

 
We want to make sure that it is safe. We also want to know if it is good for a medical symptom or condition. It is compared to cures. The goals of this process are:

• To review and update coverage choices as new scientific proofs are found.
• To review cases in order to decide if it is or not a certain service we should cover.

Molina Healthcare may deny a drug, device, protocol, procedure or other therapy that is new. We might say it is not medically necessary. If this happens, you can ask us why. You or your doctor can ask for this information. You can have copies of all the rules and procedures we used to make the decision. For information on this process, call Member Services.

• Be cared for with respect, without regard for health status, sex, race, color, religion, national origin, age, marital status or sexual orientation.
• Be told where, when and how to get the services you need from Molina Healthcare.
• Be told by your PCP what is wrong, what can be done for you, and what will likely be the result in language you understand.
• Get a second opinion about your care.
• Give your OK to any treatment or plan for your care after that plan has been fully explained to you.
• Refuse care and be told what you may risk if you do.
• Get a copy of your medical record, and talk about it with your PCP, and to ask, if needed, that your medical record be amended or corrected.
• Be sure that your medical record is private and will not be shared with anyone except as required by law, contract, or with your approval.
• Use the Molina Healthcare complaint system to settle any complaints, or you can complain to the New York State Department of Health or the local Department of Social Services any time you feel you were not fairly treated.
• Use the State Fair Hearing system
• Appoint someone (relative, friend, lawyer, etc.) to speak for you if you are unable to speak for yourself about your care and treatment.
• Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints

• Work with your PCP to guard and improve your health.
• Find out how your health care system works.
• Listen to your PCP’s advice and ask questions when you are in doubt.
• Call or go back to your PCP if you do not get better, or ask for a second opinion.
• Treat health care staff with the respect you expect yourself.
• Tell us if you have problems with any health care staff. Call Member Services.
• Keep your appointments. If you must cancel, call as soon as you can.
• Use the emergency room only for real emergencies.
• Call your PCP when you need medical care, even if it is after-hours.

• You have a problem with the quality of your care.
• Wait times are too long.
• Your doctors or the doctor’s staff behaves badly.
• You can’t reach someone by phone.
• You can’t get info.
• A doctor’s office is not clean.
• Your enrollment ends and you didn’t want it to.
• You can’t find a provider in your area.
• You can’t get your drug. 

• Stop, suspend, reduce or deny a service.
• Deny payment for services provided. 

We want you to have access to the complaint, grievance or appeal process. The Member Services Department can help you with this process. They are free by calling (800) 223-7242, Monday to Thursday, from 8 a.m. - 5 p.m. and Friday, 9 a.m. – 5 p.m. TTY/TDD: 711.

If you wish to talk in your own language, we can help. A translator is available to talk with you and help you file the request. This service is free to all members. We can help you through each step.

HOW TO:

• How to file a complaint or grievance
• How to file an appeal
• Request a Medicaid Fair Hearing

• Do not give your Molina Healthcare ID card, Medical ID Card, or ID number to anyone other than a health care provider, a clinic, or hospital, and only when receiving care.
• Never let anyone borrow your Molina Healthcare ID Card.
• Never sign a blank insurance form.
• Be careful about giving out your social security number.