Member Notices

Potential for Contract Termination

We are required by law to inform you that we can choose to not renew our contract with CMS and CMS may also refuse to renew their contract with us, resulting in a termination or non-renewal. This may result in termination of your enrollment in the plan. In addition, we may reduce our service area and no longer offer services in the area where you reside.

Ending your membership (Disenrollment)

Ending your membership in your QHPNY plan may be voluntary (your own choice) orinvoluntary (not your own choice):

  • You might leave our plan because you have decided that you want to leave.
    • There are only certain times during the year, or certain situations, when you may voluntarily end your membership in a plan. Chapter 10, Section 2 of your Evidence of Coverage document describes these situations.
    • The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. Chapter 10 , Section 3 of your Evidence of Coverage document tells you how to end your membership in each situation.
  • There are also limited situations where you do not choose to leave, but we are required to end your membership. Chapter 10, Section 5 of your Evidence of Coverage document describes the situations when we must end your membership.

If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends.

Referral Rules

When your PCP thinks that you need specialized treatment, he/she must give you a referral (approval in advance) to see a plan specialist or certain other providers. If you don’t have a referral before you get services from a specialist, you may have to pay for these services yourself.

For some types of referrals, your PCP may need to get approval in advance from our plan; this is called getting “prior authorization”. Services needing “prior authorization” are marked with bold letters in the Medical Benefits Chart in Chapter 4 of your plans Evidence of Coverage document.

Privacy Notice

At QHPNY, we take confidentiality seriously. We are required by law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal obligations, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect.

Lock-in and Out-of-Network Services

You generally must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered.

Here are three exceptions:

  • The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Chapter 3 of your Evidence of Coverage document.
  • If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You must, however, get authorization from the plan. In this situation, you will pay the same as you would pay if you got the care from a network provider.
  • Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

Best Available Evidence

Best Available Evidence (BAE) is used to determine the Medicaid eligibility  and/or Extra Help status for members when it is not readily available in other applications. Medicare has outlined what is considered BAE and acceptable by Part D plan sponsors. Please use the below link to view the CMS issued information.

Contact Medicare

To submit feedback about your Medicare health plan or prescription drug plan directly to Medicare, please visit the Medicare Complaint Form page or download the below form.

Reporting Fraud, Waste or Abuse

We are committed to ethical and efficient service delivery.  Below are links to information on how to identify and report  Fraud, Waste and Abuse.