Affinity Health Plan

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  • Customer Services

    Have a question about how your plan works? Don’t see what you’re looking for? We’re here to help!

    Visit a Customer Service Center

    Call Us: 
    Mon-Sun: 8:00 AM - 8:00 PM

    877.234.4499 | Fax: 718.794.7804

     TTY: 711

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    • Member Rights and Responsibilities More

      As a Member of Affinity Health Plan you will have the right to...

      • Get quality health services with care and respect no matter what your race, color, religion, sex, age, homeland, sexual orientation, physical or emotional state.
      • Get a second opinion about your care and treatment.
      • Get information from your PCP and other doctors that is clear, complete and in your language. It will say what is wrong and what can be done for you.
      • Know what is to be done in any surgery, and have the chance to agree to it before anything is started.
      • Get thoughtful and respectful care in a clean and safe setting free of unwanted restraints.
      • Say no to treatment when the law allows, and be told clearly what will happen if you do so.
      • Say your views to Affinity Health Plan staff, including any complaints you may have, and get a thoughtful, helpful answer.
      • Get a copy of your health record and talk about it with your doctor.
      • Have your treatment and records kept private (except as the law or a contract may call for).
      • Make a written or spoken complaint to Affinity Health Plan at any time.
      • Make a written or spoken complaint to the New York State Department of Health or your Local Department of Social Services.
      • Use the State Fair Hearing process.
      • Name someone you trust to decide about your care, if you are too sick to know what to do.

      As a Member of Affinity Health Plan, you have the responsibility to...

      • Talk over your health care needs with your Affinity doctor and follow the care you both agree on.
      • Use the hospital ER only for real emergencies that might cause death or lasting harm.
      • Call your PCP or Affinity Health Plan if you need care at night or on the weekend.
      • Let Affinity Health Plan staff know if your rights have not been honored.
      • Keep your office visits, or call to cancel if you know you won't make it to an appointment.
      • Follow the rules in your Member Handbook.
      • Treat health care staff with the respect you expect yourself.
      • Learn how your health care system works.
      • Tell Affinity Health Plan if your address and/or phone number changes.
      • Tell Affinity if you become eligible for Medicare or get other insurance coverage.
      • Listen to your PCP’s advice and ask questions when you’re in doubt.
      • Call or go back to your PCP if you do not get better, or ask for a second opinion.
      • Tell us if you have problems with any health care staff. Call Customer Service.
    • Care Management Programs More

      Medical Programs
      These are programs focused on health conditions such as high blood pressure, cholesterol, asthma, and special diets. They are designed to enrich the health and lifestyles of our members: English | Spanish

      Pharmacy Program
      Medication Management is for those on multiple medications or with multiple conditions that are feeling overwhelmed, or just want a better understanding of how to manage your conditons with medications. We are here to help: English

    • Claim Information More

      You must submit your claim to us within one year of the date you received the service, item, or drug. Contact Customer Services at 877.234.4499, Monday to Sunday, 8:00 am to 8:00 pm; TTY: 711 if you have any questions. If you don't know what you should have paid, or you receive bills and you don't know what to do about those bills, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us.

    • Appeals and Grievances More

      Your Medicare Advantage health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.

      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.

      How to make a Level 1 Appeal (How to ask for a review of a medical care coverage decision made by our plan) 

      Step 1: You contact us and make your appeal.If your health requires a quick response, you must ask for a "fast appeal."

      What to do

      • To start an appeal you, your doctor, or your representative, must contact us either by phone or in writing. 
      • If you are asking for a standard appeal, make your standard appeal in writing by submitting a request. Write a letter describing your appeal, and include any paperwork that may help in the research of your case.  Send the appeal request to Affinity Health Plan, CGA Unit- Quality Management Department, 1776 Eastchester Road, Bronx, NY 10461 .  You may also ask for an appeal by calling us at  888.543.9069. Calls to this number are free. We are open 8:30am to 5:00 pm, Monday through Friday. TTY users can call 711.
        • If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. (To get the form, call Customer Service at 877.234.4499. Call to this number are free. We are open from 8:00a.m. to 8:00 p.m. Monday through Sunday.) and ask for the “Appointment of Representative” form. It is also available here. While we can accept an appeal request without the form, we cannot complete our review until we receive it. If we do not receive the form within 44 days after receiving your appeal request (our deadline for making a decision on your appeal), your appeal request will be dismissed.  If this happens, we will send you a written notice explaining your right to ask the Independent Review Organization to review our decision.
         
      • If you are asking for a fast appeal, make your appeal in writing or call us at 888.543.9069. Calls to this number are free. We are open 8:30am to 5:00 pm, Monday through Sunday. TTY users can call 711.
      • You must make your appeal request within 60 calendar daysfrom the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.
      • You can ask for a copy of the information regarding your medical decision and add more information to support your appeal.
        • You have the right to ask us for a copy of the information regarding your appeal. We are allowed to charge a fee for copying and sending this information to you.
        • If you wish, you and your doctor may give us additional information to support your appeal.
         

      If your health requires it, ask for a “fast appeal” (you can make a request by calling us)
      A “fast appeal” is also called an "expedited reconsideration."

      • If you are appealing a decision we made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal.”
      • To start a fast appeal you, your doctor, or your representative, must contact us either by phone or in writing.  Send the fast appeal request to Affinity Health Plan, CGA Unit- Quality Management Department, 1776 Eastchester Road, Bronx, NY 10461 .  You may also ask for a fast appeal by calling us at 888.543.9069. Calls to this number are free. We are open 8:30am to 5:00 pm, Monday through Sunday. TTY users can call 711.
      • If your doctor tells us that your health requires a “fast appeal,” we will give you a fast appeal.

      Step 2: We consider your appeal and we give you our answer.

      • When we are reviewing your appeal, we take another careful look at all of the information about your request for coverage of medical care. We check to see if we were following all the rules when we said no to your request.
      • We will gather more information if we need it. We may contact you or your doctor to get more information.

      Deadlines for a “fast” appeal

      • When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.
        • However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you in writing.
        • If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization.
         
      • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal. 
      • If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal.

      Deadlines for a “standard” appeal

      • If we are using the standard deadlines, we must give you our answer within 30 calendar daysafter we receive your appeal if your appeal is about coverage for services you have not yet received. We will give you our decision sooner if your health condition requires us to.
        • However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days.
        • If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.
        • If we do not give you an answer by the deadline above (or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization.
         
      • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal.
      • If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal.

      Step 3: If our plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process.

      • To make sure we were following all the rules when we said no to your appeal, we are required to send your appeal to the “Independent Review Organization.”When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2. 

      Filing a Grievance

      The formal name for “making a complaint” is “filing a grievance” 

      Step 1: Contact us promptly – either by phone or in writing.

      • Usually, calling Customer Services is the first step. If there is anything else you need to do, Customer Services will let you know. You can call us at 877.234.4499. Calls to this number are free. We are open 8:00am to 8:00pm, Monday through Sunday. TTY users can call 711.
      • If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.

      For Medical Grievances:

      You can send your written complaint to Affinity Health Plan Customer Service/Medicare, Affinity Health Plan, 1776 Eastchester Road, Bronx, NY 10461 .

      After we receive your written grievance, you will receive an acknowledgement letter from us within 5 days. The letter will summarize your grievance, tell you who is working to resolve your grievance, how to contact this person, and whether we need more information from you. You will receive a letter from us within 24 hours if your grievance involves a decision to not conduct an expedited organization/coverage determination or reconsideration or to take extensions on initial decision or appeals. If you disagree with this decision, you can file an expedited grievance with our plan.  We must notify you by mail of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint.  We may extend the timeframe by up to 14 days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

      • Whether you call or write, you should contact Customer Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.
      • 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.
        • What this section calls a “fast complaint” is also called an “expedited grievance.”
         

      Step 2: We look into your complaint and give you our answer.

      • If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
      • Most complaints are answered 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.
      • If we do not agreewith some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.
         

      You can also submit a complaint directly to Medicare. To submit a complaint to Medicare, go to http://www.medicare.gov/MedicareComplaintForm/home.aspx. If you have any other feedback or concerns, or if you feel the plan is not addressing your issue, please call 800.MEDICARE (800.633.4227). TTY users can call 711.

      Pharmacy Grievances and Appeals
      Click here for information concerning your rights in regards to Pharmacy  Grievances and Appeals

    • Important Members Phone Numbers More

      Medicare (how to get help and information directly from the Federal Medicare program)
      http://www.medicare.gov
      . This is the official government website for Medicare. It gives you up-to-date information about Medicare and current Medicare issues. It also has information about hospitals, nursing homes, physicians, home health agencies, and dialysis facilities. It includes booklets you can print directly from your computer. You can also find Medicare contacts in your state. Call 800-MEDICARE, or 800-633-4227. Calls to this number are free 24 hours a day, 7 days a week. TTY 877-486-2048

      Healthways SilverSneakers® Fitness Program
      SilverSneakers® is a fitness benefit that gives eligible members free access to 13,000+ fitness locations nationwide. You can use the exercise equipment, attend social events and group classes led by certified instructors. Get active, have fun and make new friends with SilverSneakers. For more information or to find a location, visit silversneakers.com or call 888.423.4632 (TTY 711), Monday through Sunday, 8:00 am to 8:00 pm.

      Note: SilverSneakers is available to Affinity Medicare Essentials and Essentials NYC members only.

      Superior Vision
      Superior Vision is a national vision benefits manager that provides routine vision care for our members. Visit our website to find a vision provider near you, or call 800.879.6901.

      Dental Services
      DentaQuest provides dental services to our members through their network of contracted dental providers. To find a dental provider near you call 866.731.8004.

      Chiropractic and Acupuncture Services
      EviCore provides managed chiropractic and acupuncture services to our Medicare members through its local provider network. To find a provider near you or for more information call 800.638.4557.

    • Best Available Evidence Policy More

      Call us at 877.234.4499 if you have proof that your medication co-pay should be lower. We are open Monday to Friday, 8:00 am to 8:00 pm (TTY 711; available 24 hours a day, 7 days a week). To view Affinity's Best Available Evidence Policy click here. For more information visit the Best Available Evidence page on the Centers for Medicare and Medicaid Services website.

    • Leaving Our Plan More

      While we value your membership with Affinity, there are certain circumstances when your Affinity Medicare coverage could be terminated or you might be disenrolled. Moving out of the service area, losing your Medicaid eligibility, and wanting to change your plan are just a few of the reasons. Learn how your benefits would be affected below.

      Potential for Coverage Termination
      Your Affinity Medicare coverage could end under certain circumstances. These include but are not limited to:

      • Permanently moving out of the service area.
      • Fraud or material misrepresentation in enrollment or in the use of services or facilities.
      • Losing your Medicaid eligibility.

      Potential for Affinity Medicare Programs Contract Termination
      Affinity Health Plan has a contract with the Centers for Medicare & Medicaid
      Services (CMS), the government agency that runs Medicare. This contract may be renewed each year. However, our plan or CMS can decide to end the contract at any time. You will generally be notified in writing 90 days in advance if this situation occurs. However, your advance notice may be as little as 30 days, or even fewer days if CMS must end our contract in the middle of the year.

      If Affinity Health Plan’s Medicare contract with CMS ends:

      • The benefits and rules described in your Evidence of Coverage will continue until your membership ends.
      • You will qualify for a special enrollment period so you can enroll in another Medicare plan to continue your coverage.

      Please see your Evidence of Coverage for a complete list of termination of coverage and disenrollment provisions.

      Rights and Responsibilities Upon Disenrollment
      "Disenrollment" from Affinity means ending your membership with us. Disenrollment can be voluntary (your choice) or, in limited circumstances, involuntary (not your choice):

      • You might leave one of our plans because you decide that you want to leave.
      • Some situations require you to leave. For example, if you move out of our service area for more than six consecutive months.

      Please refer to your Evidence of Coverage for more information, to learn about choices you have after you leave, and to review the rules that may apply.

      To disenroll, you must send Affinity a written notice stating that you would like to disenroll from our plan. Or you can call 800-MEDICARE (TTY 877-486-2048), 24 hours a day, 7 days a week.

      Your coverage under Original Medicare resumes on the effective date of your disenrollment from Affinity.

  • H5991_AffinityMedicarePlanWebsite2018 Pending Last updated 09/28/2017