Your Rights and Plan Protections
At ICS, we work very hard to protect your privacy, your records, and your rights. This is the work of our dedicated Compliance Department; it is also the work of each and every staff person here at Independence Care System.
As a participant of ICS Community Care Plus FIDA-MMP you have a number of rights and responsibilities. Here you will find information about how to file a complaint or grievance, how to ask for a coverage determination, drug requirements, step therapy and utilization management.
You will also find links to the major policies and procedures that govern the work of our agency, as well as policies and procedures specific to our Community Care Plus FIDA-MMP. If you have any questions or would like any more information, contact email@example.com.
Filing a grievance (making a complaint) about your prescription coverage
A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive.
Grievances do not involve problems related to approving or paying for Medicare Part D drugs.
Some types of problems that might lead to filing a grievance include:
- Issues with the service you receive from Participant Services.
- If you feel that you are being encouraged to leave (disenroll from) the plan.
- If you disagree with our decision not to give you a “fast” decision or a “fast” appeal.
- We don’t give you a decision within the required time frame.
- We don’t give you required notices.
- You believe our notices and other written materials are hard to understand.
- Waiting too long for prescriptions to be filled.
- Rude behavior by staff or providers
If you have any of these types of problems and want to make a complaint, it is called “filing a grievance.”
Who may file a grievance
You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.
If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, you can ask your Care Manager or download the form here: Appointment of Representative Form 1696.
Filing a grievance with our plan
You can file a grievance any time by phone, mail, fax or email. You can mail a grievance to 257 Park Avenue South, 2nd Floor. New York, NY 10010, call 877-ICS-2525, fax to: 212-584-2555 or email A&G@icsny.org.
If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.
- You may submit a written request for a Fast Grievance to ICS Community Care Plus FIDA-MMP at 257 Park Avenue South, 2nd Floor, NY, NY 10010 or
- You may fax your written request to 212-584-2555.
- You may call us to file an expedited Grievance at: 877-ICS-2525, 8 a.m. – 8 p.m. local time, Monday – Friday. TTY users, call: 800-ICS -4TTY.
Please be sure to include the words “fast”, “expedited” or “24 hour review” on your request.
Whether you call or write, you should contact Participant Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. You will receive written acknowledgement from ICS within 15 days. Most complaints are resolved in 30 calendar days.
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 (44 calendar days total) to answer your complaint.
Learn more about Grievance and Appeals Procedures.
Asking for a coverage determination (coverage decision)
The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.
An initial coverage decision about your Part D drugs is called a “coverage determination”, or simply put, a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
Drug requirements and limitations
For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. Some covered drugs may have additional requirements or limits that help ensure safe, effective drug use. And some drugs may require a coverage determination to verify whether they are covered by our plan. The coverage determination process allows you or your prescriber to request coverage of drugs with additional requirements or ask for exceptions to your benefits.
You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan’s drug list.
Some drugs covered by the Medicare Part D plan have “limited access” at network pharmacies because:
- The FDA says the drug can be given out only by certain facilities or doctors.
- These drugs may require extra handling, provider cooperation or patient education that can’t be done at a network pharmacy.
Requirements and limits apply to retail and mail service. These may include:
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don’t get approval, the plan may not cover the drug.
Download the Prior Authorization Request Form here.
Quantity Limits (QL)
The plan will cover only a certain amount of this drug for one copay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug.
You can find our Step Therapy Policy on our Pharmacy Benefits page.
Medicare Part B or Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare.
NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.
Download the Prior Authorization Request Form here.
In addition to the above, you can ask the plan to make the following exceptions to the plan’s coverage rules:
- Coverage for a drug not on the plan’s drug list (formulary). If an exception is approved, you would get the prescription drug.
How to request a coverage determination (including benefit exceptions)
How will this be done at ICS? Call the ICS Community Care Plus FIDA-MMP Participant Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception, we require a statement from your doctor supporting your request. Please have your prescriber complete this form. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor’s supporting statement (if required).
You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor’s supporting statement.
Download this form to request an exception:
- Request for Medicare Prescription Drug Coverage Determination—(for use by members and providers)
This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form or the Prior Authorization Request Form listed below. The Prior Authorization Department will accept both request forms.
What happens if we deny your request?
If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision.
Learn more about Grievance and Appeals Procedures.
How to appoint a representative to help you with a coverage determination
The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Download the Appointment of Representative Form 1696.
Making an appeal
If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.
To file an appeal:
- Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by downloading and mailing in the Redetermination Request Form (PDF) or by secure email to A&G@icsny.org.
- Review our Grievance and Appeals Procedures for information on where to send your redetermination request form.
- You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline.
- The Appeals and Grievance Department will look into your case and respond with a letter within 7 calendar days of receiving your request. You’ll receive a letter with detailed information about the coverage denial.
- The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.
- To inquire about the status of an appeal, email A&G@icsny.org or call 1-888-ICS-2525.
Who may file your appeal of the coverage determination?
If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.
How soon must you file your appeal?
You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.
How soon will we decide on your appeal?
For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:
- We will give you our decision within 7 calendar days of receiving the appeal request.
For a fast decision about a Medicare Part D drug that you have not yet received.
- We will give you our decision within 72 hours after receiving the appeal request.
To obtain an aggregate number of the plan’s grievances, appeals and exceptions please email A&G@icsny.org or call 1-888-ICS-2525.
The following information about your Medicare Part D Drug Benefit is available upon request:
- Information on the procedures used to control utilization of services and expenditures.
- Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
- A summary of the compensation method used for physicians and other health care providers.
- A description of our financial condition, including a summary of the most recently audited statement.
Quality assurance policies and procedures
At ICS we want to make sure that we follow all state and federal rules to keep our plan participants safe and healthy; this is the job of our Compliance Department—and of every department at ICS. We also want to go beyond following the rules to ensure that our participants have the best experience possible; this is the job of our Quality Assurance Department. The Quality Assurance Department makes sure that we are holding ourselves to ICS and other regulatory standards to provide participants with the care and service they need to live fully in the community.
To learn more about the work of our Quality Assurance Department, or if you have any questions or concerns about our policies and procedures, email firstname.lastname@example.org.
Contacting Medicare Directly or the Participant Ombudsman
For complaints or concerns, you can also call Medicare at 1-800-MEDICARE, go to www.medicare.gov/MedicareComplaintForm/home.aspx, or reach your Participant Ombudsman, an independent entity under contract to New York State to help you and your caregiver to access services through the FIDA Plans, at www.icannys.org.
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 ICS Community Care Plus FIDA-MMP. ICAN may be reached toll-free at 1-844-614-8800 or online at www.icannys.org.
Information is available in other formats
You can get this information for free in other formats, such as Braille or large print. Call 1.877.ICS.2525. The call is free.
Information is available in other languages
You can get this information for free in other languages. Call: 1-877-ICS-2525 and TTY: 1.855.ICS.4TTY Monday through Friday 8 am to 8 pm. The call is free.
Puede obtener toda esta información en otros idiomas de manera gratuita. Llame a ICS al 1.877.ICS.2525 y a la línea TTY 1.855.ICS.4TTY, entre las 8 a. m. y las 8 p. m., de lunes a viernes. La llamada es gratuita.
Вы можете бесплатно получить всю эту информацию на других языках. Звоните в ICS по телефону 1.877.ICS.2525 и телетайпу 1.855.ICS.4TTY с понедельника по пятницу с 8:00 до 20:00. Звонок бесплатный.
您可免费获得所有这些信息的其他语言版本。请在周一至周五上午 8 点至晚上 8 点致电 ICS，电话号码为 1.877.ICS.2525，听障专线 (TTY) 为 1.855.ICS.4TTY。此为免费电话。
Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan 1.877.ICS.2525 ak TTY 1.855.ICS.4TTY, ant 8 a.m. ak 8 p.m., lendi jiska vandredi. Apèl la gratis.
이 모든 정보는 타 언어로 무료로 제공됩니다. 월요일~금요일, 오전 8시~오후 8시 사이에 1.877.ICS.2525 및 TTY(청각 장애인용 전화) 1.855.ICS.4TTY로 ICS에 전화해 주십시오. 이 전화는 무료입니다.
Le informazioni in questione sono disponibili gratuitamente anche in altre lingue. Chiamare ICS ai numeri 1.877.ICS.2525 e TTY 1.855.ICS.4TTY tra le 8:00 e le 20.00 dal lunedì al venerdì. La chiamata è gratuita.
Community Care Plus FIDA-MMP Policies and Procedures
General Agency Policies and Procedures
It is the right of every ICS Community Care Plus FIDA-MMP participant to request a reasonable accommodation, which would allow them to enjoy the same opportunities available to other participants at ICS.
A reasonable accommodation is a modification or activity without which it would be more difficult or impossible for you participate in an activity or receive your healthcare. For example, let’s say you are on our Participant Advisory Council. You need to attend the meetings in person, but to do that you need an ambulette to drive you to ICS and then back to your home. You can request that ICS make a reasonable accommodation and provide that transportation to you.
To make a reasonable accommodation request you need to ask your Care Manager, who will provide you with an answer over the telephone and in writing. If you disagree with the Care Manager’s answer, you can appeal that decision; you can also reach out to the New York Participant Ombudsman at [insert phone and email] for help filing an appeal.