NY Manual
SHP Manual

New York Provider Manual
2.3 Healthfirst Commercial Programs | 3.1 Description of the Networks

2.4 Benefits/Covered Services

Members who participate under a government-sponsored program (Medicaid, Child Health Plus, and Medicare) are entitled to receive all services covered by that program. Benefits among the programs vary. For example, Medicaid members are entitled to receive all of the services covered under the Medicaid program, but some services, such as prescription drugs, are covered directly by Medicaid Fee-for-Service. Medicare members are entitled to receive all of the services under the Medicare program. Further, for Medicare members, the Healthfirst Medicare Plan offers a variety of products that not only cover the services available under Original Medicare, but also offer additional benefits such as dental and vision. Commercial health plan members are entitled to receive all services covered by their plan.

To view a detailed summary of the benefits offered by the Medicaid and CHPlus programs please refer to the Health Provider Portal or to our member handbooks located on our website, www.healthfirst.org. For the Medicare programs, please refer to the applicable Summary of Benefits. Any changes to a particular benefit package will be noted in The Source, our provider newsletter, or in other mailings. Copies of these materials are located on our website at www.healthfirst.org/providerservices. 

To view a detailed summary of the benefits offered by the Healthfirst Leaf or HMO A–D plans, please refer to the Summary of Benefits available on our website at www.healthfirst.org/health-insurance/healthfirst-leaf-plans.  

Consent to Receive Noncovered Services

If you believe that a given service is not covered by Healthfirst, you must do the following:

·     Determine if the member is covered by one of the Healthfirst Medicare programs. If they are, refer to Section 15 for instructions
·     For non-Medicare programs, inform the member that you believe that their Healthfirst program does not cover the service.  You should contact Member Services directly in order to determine whether the service is covered.  You should explain to the member that they may also contact Member Services. 
·     If Member Services confirms that the service is not covered, you should advise the member that if they disagree with Healthfirst’s determination, they may file a grievance or an appeal if dissatisfied. Information on the process for filing grievances and appeals may be obtained by calling Member Services
·     If Member Services confirms that the service is not covered, and the member elects for you to provide the noncovered service, you must tell the member how much the non-covered service will cost, explain to the member that they will be billed directly for and be responsible for paying for the noncovered services and that Healthfirst will not be in any way financially responsible.
·    You must also receive the members written consent to indicating that they were advised of the cost and agree to be financially responsible for the noncovered services. A general consent signed by the member indicating the member is financially responsible for any services not paid for by Healthfirst​ is not sufficient. The written consent must be indicate the specific services and costs for the noncovered services that will be provided.
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