Call us at 1-833-252-2737 (TTY 711)

8AM-8PM Monday-Friday

Call us at 1-833-252-2737 (TTY 711)

8AM-8PM Monday-Friday
https://static1.squarespace.com/static/570e35b01d07c0cbf8f6a375/t/65158e5697c7286a83ff9c98/1695911510295/CLH-28136_CenterLight-Pace_Logo_Horz_Color-Full_CMYK.png

As a member of CenterLight Healthcare's Program of All-Inclusive Care for the Elderly (PACE), our healthcare team of physicians, nurses, social workers and rehab specialists will help you stay safely in your own home and community for as long as possible, and will make sure you receive high quality, complete care.

In this section, you will find the tools you need to understand and manage your healthcare benefits. Click on the links below to access information available to you as a participant of our program. Materials are listed in alphabetical order.

Consumer Directed Personal Assistance Services (CDPAS)

Drug Coverage Determination Form (English, Spanish coming soon) (PDF 25KB)

Drug Coverage Determination Form (Online)

Grievances and Appeals Process

Formulary
Please note: Diabetic supplies and Continuous Glucose Monitoring (CGM) are limited to Abbott meters, test strips, reader (1 per year) and sensors (2 sensors per 28 days) such as FreeStyle Freedom Lite, FreeStyle Lite, Precision Xtra, FreeStyle Libre, and FreeStyle Libre 2.

2024 Formulary (English) (English, PDF 1.3MB) (last update: March 2024)

2024 Formulary (Spanish) (English, PDF 1.3MB) (last update: March 2024)

How to Appoint a Representative

My Needs Card

Notice of Non-Discrimination

PACE Center Locations

Participant Rights and Responsibilities

Pharmacy Directory/Directoria de Farmacias (English/Spanish, PDF 2.5MB) (Last update March 2024)

Pharmacy Directory (Online)

2024 Prior Authorization Criteria (PDF, 871KB) (Last Update: March 2024)

Provider Directory (Last Updated December 2022)

2024 Step Therapy Criteria (PDF, 114KB) (Last update: March 2024)

Transition Policy

Consumer Directed Personal Assistance Services (CDPAS)

The Consumer Directed Personal Assistance Services (CDPAS) is a self-directed home care model available to qualified Teamcare participants.

Eligibility for CDPAS home care is determined upon evaluation by CenterLight Teamcare. Our staff will conduct an assessment to determine the level of assistance with personal care and/or nursing services you are eligible to receive. We will assist you in deciding if the program is right for you.

What are your responsibilities as a CDPAS participant?

  • You or your designated representative must be able and willing to make informed choices related to personal care and/or nursing services that you receive at home.
  • You or your designated representative must be willing and able to interview, train, supervise and schedule your personal assistant.
  • If you are 21 and older, your parent can be your personal assistant. However, this role cannot be filled by your spouse. Your personal assistant can live in the same household. If you are authorized for 24 hour care each day, you will need more than one assistant in each 24 hour period.
  • The personal assistant you select and train must meet the same requirements for health tests, immunizations and examinations that apply to all home care services agency personnel.
  • You must have alternate workers trained and available in the event that your primary personal assistant is on vacation, holiday or cannot report to work due to illness.
  • This program gives you the flexibility to select the right worker for you. It also means that you (or your designated representative) are responsible for your care if the arrangement with the personal assistant does not work out.
  • You will work with a designated Fiscal Intermediary (FI), which, on your behalf, will administer payroll and tax withholdings required by State and Federal law, Disability, Workers Compensation, Health Insurance, Unemployment Insurance and more.
  • You are responsible for making sure that care is actually delivered – tracking and verifying time worked and signing off on time sheets for payment. These are sent to the FI for validation and payment.
  • You must notify CenterLight and the FI of any change in your medical condition or social circumstances including any hospitalization, vacation, change of address or telephone number.
  • FIs do not manage anything that would be related to your direct care. this remains solely your responsibility. FIs take care of the financial side, allowing you the freedom to direct care without being overburdened by paperwork.

Background Checks and Ongoing Supervision

Please note that prior to CDPAS taking effect, we will conduct a Criminal History Background Check on the personal assistant you select. This is in accordance with PACE regulations.

We will be providing your personal assistant with an orientation regarding the PACE program as well as ongoing supervision to help ensure that they will be able to offer high quality assistance according to your plan of care.

Where can I get more information?

If you have any questions, you may contact CDPAANYS at 1-518-813-9537.

You may also find answers to Frequently Asked Questions regarding the program by visiting www.cdpaanys.org.

Back to top of page

Participant Grievance and Appeal Process

All of us at CenterLight TeamCare want you to be satisfied with the care that you receive. We want to know your concerns, so we can make improvements and resolve any problems you may have as quickly as possible.

We encourage you to discuss your concerns first with your nurse or social worker, however, you may file a grievance or an appeal with any staff member at any time through the grievance and appeal process.

You have the right to designate a family member or representative to file grievances and appeals on your behalf. If you do not speak English or need other assistance, we will make every reasonable effort to assist you with the process.

A. CenterLight TeamCare’s Grievance and Appeal Policy

CenterLight Healthcare assures you that we will not retaliate or take any discriminatory action against you because you filed a grievance or appealed a decision that we made. Grievances and appeals will be kept confidential.

B. Grievance Process

The grievance process will be reviewed with you upon enrollment, when you or your designated representative express dissatisfaction with CenterLight Healthcare, and on an annual basis. CenterLight Healthcare will continue to furnish all required services during the grievance process.

  1. Filing a Grievance

    A “grievance” is a complaint, either written or oral, expressing dissatisfaction with service delivery or the quality of care furnished. An oral grievance may be filed at any time with any staff member or by calling CenterLight Healthcare Service Coordination Team at 1-833-CL-CARES (1-833-252-2737), Monday-Friday, 8AM through 8PM. TTY users should call 711.

    A written grievance may be filed at any time by either sending a letter or grievance form to:

    CenterLight TeamCare Participant Services
    Appeals and Grievances Department
    555 Albany Avenue
    Amityville, NY 11701
    Fax: 315-825-4813

    CenterLight Healthcare staff can explain the grievance process to you and help you to file a complaint if needed.


  2. Grievance Review

    You or your designated representative will receive a written notice and an outline of the grievance process from us acknowledging receipt of either the oral or written grievance. The notice will notify you if we need additional information in order to decide the grievance.

    If an immediate resolution of the grievance (same day grievance) can be made, the resolution will be communicated verbally.

    When your grievance concerns a clinical matter, the reviewing staff shall include one or more health professionals.


  3. Grievance Resolution

    If your grievance is regarding a home care complaint, we will send you a written decision within 15 days of receiving your grievance or let you know if we need more time to decide. All other grievances will be resolved within 30 days.

C. Internal Appeal Process

An "appeal" is a request made by the participant or designee for a review of an initial non-coverage or non-payment decision taken by the Interdisciplinary Team (IDT), related to a service including denials, reductions, or termination of services.

You or your designated representative can submit your appeal in writing to:

CenterLight Teamcare Participant Services
555 Albany Avenue
Amityville, NY 11710
Fax: 315-825-4813

An oral appeal can also be made by calling CenterLight Healthcare at 1-833-CL-CARES (1-833-252- 2737), Monday-Friday, 8AM through 8PM. TTY users should call 711. Appeal requests are accepted either orally or in writing within 60 calendar days of the of the written denial of services, notification of non-payment, termination, or reduction in services. If you believe that you have information that will help us to decide in your favor, you may present it in person as well as in writing.

The appeal review and decision is made by an appropriate third-party reviewer or committee. An appropriate third-party reviewer or member of a review committee must be an individual who meets all of the following:

a. Appropriately credentialed in the field(s) or discipline(s) related to the appeal.
b. Was not involved in the original action related to the SDR or request for payment.
c. Does not have a stake in the outcome of the appeal.

During the appeals process, you can request that CenterLight Healthcare continue to the provide the disputed service(s) while the appeal is pending, with the understanding that you may be liable for the cost of those services if the appeal is not resolved in your favor.

  1. Expedited Appeal

    Your appeal will be handled on an expedited basis if you indicated on your appeal that you believe your life, health or ability to regain or maintain maximum function could be seriously jeopardized.

    CenterLight Healthcare will respond within 72 hours of our receipt of your expedited appeal, or within 14 days thereafter if you request an extension, or if CenterLight Healthcare can justify to the State the need for additional information and how the delay is in your best interest. You will have the opportunity to present evidence on your case, in person, as well as in writing.


  2. Standard Appeal

    All other appeals will be resolved as expeditiously as is required by the condition of your health, but no later than 30 calendar days from our receipt of your appeal. You will have the opportunity to present additional evidence on your case, in person, as well as in writing.

    CenterLight Healthcare will provide you with a written notice of the appeal decision and the reasons. If the appeal is resolved in your favor, CenterLight Healthcare will provide or pay for the disputed service immediately. If your appeal is denied, you will be notified in writing of your additional appeal rights under Medicare or Medicaid.

D. External Appeal Process

If you are not satisfied with the decision made on your internal appeal, you can pursue your external appeal rights under either Medicaid or Medicare. The next level of appeal is an external process and involves a new and impartial review of your case through either the Medicare or Medicaid program. Your request to file an external appeal can be made either verbally or in writing. If you are enrolled in both Medicare and Medicaid, we can help you choose which appeal process to follow, as you may not use both processes.

  1. Medicaid Appeal Process

    The Medicaid program conducts appeals through the New York State Fair Hearing process. Fair hearings are conducted by the New York State Office of Hearings and Appeals. If you are enrolled in Medicaid only, or in both Medicare and Medicaid and choose to appeal under Medicaid, we will inform you of your New York Fair Hearing rights.


  2. Medicare Appeal Process

    If you are enrolled in Medicare only or in both Medicare and Medicaid, you may choose to appeal using Medicare’s external appeal process. A written request for reconsideration must be filed with the independent review entity within 60 calendar days from the date of the decision by the third party reviewer. Contact 1–800–MEDICARE for information and assistance, including to make a complaint related to the quality of care or the delivery of a service.


  3. Private Pay

    If you are paying privately for CenterLight Healthcare services, you may make a complaint to the New York State Department of Health by calling 212-417-5888.

    Note: For appeals under both Medicare and Medicaid, the appeal determination is binding and supersedes any other decisions regarding the matter under appeal.


    Back to top of page

How to Appoint a Representative

As a CenterLight Participant, you can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to make your coverage decisions for you or to make an appeal.

There may be someone who is already legally authorized to act as your representative under State law.

If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services at 1-833-CL-CARES (1-833-252-2737) (TTY 711), Monday-Friday, 8:00 a.m. to 8:00 p.m., and ask for the “Appointment of Representative” form, or download by clicking on the links provided below. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.

Appointment of Representative Form

Appointment of Representative Form (Spanish)


Back to top of page

PARTICIPANT RIGHTS AND RESPONSIBILITIES

At CenterLight Healthcare, we are dedicated to providing you with quality health care services so that you may remain as independent as possible. This includes providing all Medicare-covered items and services and Medicaid services, and other services determined to be necessary by the interdisciplinary team across all care settings, 24 hours a day, 7 days a week. Our staff and contractors seek to affirm the dignity and worth of each participant by assuring the following rights:

You have a right to be treated with respect.

You have the right to be treated with dignity and respect at all times, to have all of your care kept private and confidential, and to get compassionate, considerate care. You have the right:

  • To get all of your health care in a safe, clean environment and in an accessible manner.
  • To be free from harm. This includes excessive medication, physical or mental abuse, neglect, physical punishment, being placed by yourself against your will, and any physical or chemical restraint that is used on you for discipline or convenience of staff and that you do not need to treat your medical symptoms.
  • To be encouraged and helped to use your rights in the PACE program.
  • To get help, if you need it, to use the Medicare and Medicaid complaint and appeal processes, and your civil and other legal rights.
  • To be encouraged and helped in talking to PACE staff about changes in policy and services you think should be made.
  • To use a telephone while at the PACE Center.
  • To not have to do work or services for the PACE program.
You have a right to protection against discrimination.

Discrimination is against the law. Every company or agency that works with Medicare and Medicaid must obey the law. They cannot discriminate against you because of your:

  • Race
  • Ethnicity
  • National Origin
  • Religion
  • Age
  • Sex
  • Mental or physical disability
  • Sexual orientation
  • Source of payment for your health care (For example, Medicare or Medicaid)

If you think you have been discriminated against for any of these reasons, contact a staff member at the PACE program to help you resolve your problem.

If you have any questions, you can call the Office of Civil Rights at 1-800-368-1019. TTY users should call 1-800-537-7697.

You have a right to information and assistance.

You have the right to get accurate, easy-to-understand information and to have someone help you make informed health care decisions. You have the right:

  • To have someone help you if you have a language or communication barrier so you can understand all information given to you.
  • To have the PACE program interpret the information into your preferred language in a culturally competent manner, if your first language is not English and you can’t speak English well enough to understand the information being given to you.
  • To get marketing materials and PACE participant rights in English and in any other frequently used language in your community. You can also get these materials in Braille, if necessary.
  • To have the enrollment agreement fully explained to you in a manner understood by you.
  • To get a written copy of your rights from the PACE program. The PACE program must also post these rights in a public place in the PACE center where it is easy to see them.
  • To be fully informed, in writing, of the services offered by the PACE program. This includes telling you which services are provided by contractors instead of the PACE staff. You must be given this information before you join, at the time you join, and when you need to make a choice about what services to receive.
  • To be provided with a copy of individuals who provide care-related services not provided directly by CenterLight Healthcare upon request.
  • To look at, or get help to look at, the results of the most recent review of your PACE program. Federal and State agencies review all PACE programs. You also have a right to review how the PACE program plans to correct any problems that are found at inspection.
You have the right to a choice of providers.

You have the right to choose a health care provider, including your primary care provider and specialists, from within the PACE program’s network and to get quality health care. Women have the right to get services from a qualified women’s health care specialist for routine or preventive women’s health care services.

You have the right to have reasonable and timely access to specialists as indicated by your health condition.

You also have the right to receive care across all care settings, up to and including placement in a long-term care facility when the PACE organization can no longer maintain you safely in the community.

You have a right to access emergency services.

You have the right to get emergency services when and where you need them without the PACE program’s approval. A medical emergency is when you think your health is in serious danger— when every second counts. You may have a bad injury, sudden illness or an illness quickly getting much worse. You can get emergency care anywhere in the United States and you do not need to get permission from CenterLight Healthcare prior to seeking emergency services.

You have a right to participate in treatment decisions.

You have the right to fully participate in all decisions related to your health care. If you cannot fully participate in your treatment decisions or you want to have someone you trust help you, you have the right to choose that person to act on your behalf. You have the right:

  • To have all treatment options explained to you in a language you understand, to be fully informed of your health status and how well you are doing, and to make health care decisions. This includes the right not to get treatment or take medications. If you choose not to get treatment, you must be told how this will affect your health.
  • To have the PACE program help you create an advance directive, if you choose. An advance directive is a written document that says how you want medical decisions to be made in case you cannot speak for yourself. You should give it to the person who will carry out your instructions and make health care decisions for you.
  • To participate in making and carrying out your plan of care. You can ask for your plan of care to be reviewed at any time.
  • To be given advance notice, in writing, of any plan to move you to another treatment setting and thereason you are being moved.
You have a right to have your health information kept private.
  • You have the right to talk with health care providers in private and to have your personal health care information kept private and confidential, including health data that is collected and kept electronically, as protected under State and Federal laws.
  • You have the right to look at and receive copies of your medical records and request amendments.
  • You have the right to be assured that your written consent will be obtained for the release of information to persons not otherwise authorized under law to receive it.
  • You have the right to provide written consent that limits the degree of information and the persons to whom information may be given.

There is a patient privacy rule that gives you more access to your own medical records and more control over how your personal health information is used. If you have any questions about this privacy rule, call the Office for Civil Rights at 1-800-368-1019. TTY users should call 1-800- 537-7697.You have the right:

You have a right to file a complaint, request additional services or make an appeal.

You have a right to complain about the services you receive or that you need and don’t receive, the quality of your care, or any other concerns or problems you have with your PACE program. You have the right to a fair and timely process for resolving concerns with your PACE program. You have the right:

  • To a full explanation of the complaint process.
  • To be encouraged and helped to freely explain your complaints to PACE staff and outside representatives of your choice. You must not be harmed in any way for telling someone your concerns. This includes being punished, threatened, or discriminated against.
  • To contact 1-800-Medicare for information and assistance, including to make a complaint related to the quality of care or the delivery of a service.

You have the right to request services from the PACE organization that you believe are necessary. You have the right to a comprehensive and timely process for determining whether those services should be provided.

You also have the right to appeal any denial of a service or treatment decision by the PACE program, staff, or contractors.

You have a right to leave the program.

If, for any reason, you do not feel that the PACE program is what you want, you have the right to leave the program at any time and have such disenrollment be effective the first day of the month following the date CenterLight Healthcare receives the participant’s notice of voluntary disenrollment.

Additional Help:

If you have complaints about your PACE program, think your rights have been violated, or want to talk with someone outside your PACE program about your concerns, call 1-800-MEDICARE or 1-800-633-4227 to get the name and phone number of someone in your State Administering Agency.

As a member of CenterLight Teamcare, you are responsible for:

  • Being seen by your doctor if a change in your health status occurs.
  • Sharing complete and accurate health information with your health care providers.
  • Informing staff of any change in your health and making it known if you do not understand or are unable to follow instructions.
  • Following the treatment plan recommended by CenterLight Teamcare.
  • Cooperating with and being respectful to staff, and not discriminating against staff because of race, color, national origin, religion, age, sex, or mental or physical ability.
  • Notifying CenterLight Teamcare in advance whenever you will not be home to receive services or care that have been arranged for you.
  • Informing CenterLight Teamcare before permanently moving out of the service area or any lengthy absence from the service area.
  • Being responsible for your actions if you refuse treatment or do not follow CenterLight Teamcare’s instructions.
  • Being responsible for paying your financial obligations.
Back to top of page

Transition Policy

New participants in our plan may be taking drugs that aren't on our Formulary, or that are subject to certain restrictions, such as prior authorization or step therapy. Current participants may also be affected by changes in our Formulary from one year to the next. Participants should talk to their doctors to decide if they should switch to a different drug that we cover or request a Formulary exception in order for the drug to be covered. Please contact Participant Services if your drug is not on our Formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our Formulary next year, and you need help switching to a different drug that we cover or requesting a Formulary exception.

During the period of time participants are discussing with their doctors to determine the right course of action, we may provide a temporary supply of the non-Formulary drug if those Medicare participants need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current participant affected by a Formulary change from one year to the next, we provide you with the opportunity to request a Formulary exception in advance for the following year.

When a participant goes to a network pharmacy and we provide a temporary supply of a drug that isn't on our Formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover. If a new participant is a resident of a long-term care facility (such as a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the 90 days a new participant is enrolled in our Plan. If the participant has been enrolled in our Plan for more than 90 days and needs a drug that isn't on our Formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new participant pursues a Formulary exception.

Please note that our transition policy applies only to those drugs that are "Part D drugs" and dispensed at a network pharmacy. The transition policy doesn’t apply to a non-Part D drug or a drug at an out-of-network pharmacy.

Click here for the Spanish version of our Transition Policy.

Back to top of page

Members may be liable for the cost of services not authorized by your CenterLight Healthcare program.

If you have questions or concerns about your plan of care, your care providers or any other aspects of your care, please contact a care team member. Alternatively, you can give us a call at 1-833-CL-CARES (1-833-252-2737) (TTY: 711) from 8:00 a.m. to 8:00 p.m. EST, Monday-Friday.


If you have questions, please call us at 1-833-252-2737, Monday-Friday, 8:00 a.m. - 8:00 p.m. TTY users should call 711. You may also request a callback from one of our representatives by completing the form below:

Can't Open a PDF?

You will need to leave this site to download the software.