As a member of Teamcare™, 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.
Formulary (PDF, 681KB) (Last Updated November 2018)
Please note: Diabetic supplies are limited to Abbott meters and test strips such as FreeStyle Freedom Lite, FreeStyle Lite, and Precision Xtra. Please refer to the Summary of Benefits for copay and coinsurance information or the Evidence of Coverage (EOC) for general benefit and coverage information.
Grievances and Appeals Process
How to Appoint a Representative
PACE Center Locations
Participant Rights and Responsibilities
Pharmacy Directory 2019 (PDF, 696KB) (Last Updated August 2018)
Prior Authorization Criteria 2018 (PDF, 417KB) (Last Updated November 2018)
Prior Authorization Criteria 2019 (PDF, 311KB) (Last Updated December 2018)
Provider Directory (PDF, 4.5MB) (Last Updated November 2017)
PACE Over-The-Counter Enhanced Benefit
Step Therapy Criteria 2018 (PDF, 223KB) (Last Updated November 2018)
Step Therapy Criteria 2019 (PDF, 801KB) (Last Updated October 2018)
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 TeamCare 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 express dissatisfaction with CenterLight TeamCare, and on an annual basis. CenterLight TeamCare will continue to furnish all required services during the grievance process.
- 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 TeamCare Participant Services 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
1733 Eastchester Road
Bronx, New York 10461
Grievance forms are available on request. Just ask any staff member or call us at 1-833-CL-CARES (1-833-252-2737) (TTY users call 711). CenterLight TeamCare staff will explain the grievance process to you and help you complete the form if needed.
- Grievance Review
You 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:
- Acknowledge each grievance; and
- Provide the name, address and telephone number of the person, or department, designated by CenterLight TeamCare to handle your grievance; and
- Notify you if we need additional information in order to decide the grievance.
If an immediate resolution of the grievance can be made, the resolution will be indicated in the grievance form.
When your grievance concerns a clinical matter, the reviewing staff shall include one or more health professionals.
- Grievance Resolution
We will send you the written decision within 15 days of receiving your grievance or let you know if we need more time to decide.
C. Internal Appeal Process
An “appeal” is your action taken with respect to CenterLight TeamCare’s non coverage of, or nonpayment for, a service, including denials, reductions, or termination of services. The appeals process will be reviewed with you upon enrollment, and thereafter on an annual basis, and whenever the Interdisciplinary Team denies a request for services or payment or reduces services.
You must file your appeal no later than 45 days from your receipt of CenterLight TeamCare’s written decision. You can submit your appeal by using the appeal form provided, or by letter, to:CenterLight TeamCare Participant Services
1733 Eastchester Road
Bronx, New York 10461
An oral appeal can also be made by calling CenterLight TeamCare at 1-833-CL-CARES (1-833-252-2737), Monday-Friday, 8AM through 8PM. TTY users should call 711. A CenterLight TeamCare staff member will complete the appeal form for your acknowledgement.
All appeals will be reviewed by an impartial qualified health care professional who was not involved in the original decision, and by the CenterLight TeamCare Appeals Panel.
During the appeals process, CenterLight TeamCare will continue to provide all other required services.
At your request, CenterLight TeamCare will continue to 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.
- 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 without the disputed health service.
CenterLight TeamCare will respond within 72 hours of our receipt of your appeal, or within 14 days thereafter if you request an extension, or if CenterLight TeamCare 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.
- Standard Appeal
All other appeals will be resolved as expeditiously as is required by the condition of your health, but no later than 30 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.
If the appeal is resolved in your favor, CenterLight TeamCare will provide or pay for the disputed service immediately.
If your appeal is denied in whole or in part, a copy of the decision will be forwarded to the federal government and the New York State Department of Health. You will also be notified in writing of your additional appeal rights under Medicare and Medicaid.
CenterLight TeamCare will provide you with a written notice of the appeal decision and the reasons.
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 will help you choose which appeal process to follow, as you may not use both processes. Just ask us if you are not sure which program you are enrolled in.
- 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 and forward your appeal accordingly.
- 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. CenterLight Healthcare will send your appeal to CMS’ Independent Review Entity.
For appeals under both Medicare and Medicaid, the appeal determination is binding and supersedes any other decisions regarding the matter under appeal.
- Private Pay
If you are paying privately for CenterLight TeamCare services, you may make a complaint to the New York State Department of Health by calling 1-866-712-7197.
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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.
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PARTICIPANT RIGHTS AND RESPONSIBILITIES
As a participant of CenterLight Teamcare, you are entitled to 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 your care kept private, and to get compassionate, considerate care from all CenterLight Teamcare staff and contractors at all times.
You have the right:
- To get your health care in a safe, clean environment.
- To be free from harm. This includes physical or mental abuse, neglect, physical punishment, being placed by yourself against your will, excessive medication, 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 to use your rights in CenterLight Teamcare.
- 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 CenterLight Teamcare 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 CenterLight Teamcare.
- You have a right to protection against discrimination.
We may not discriminate against you because of your:
- National Origin
- Sexual orientation
- Mental or physical ability
- 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 CenterLight Teamcare to help you resolve your problem.
If you have any questions, you can call the Office of Civil Rights at 1-800-368-1019 (TYY 1-800-537-7697).
You have a right to information and assistance.
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 get accurate, easy to understand information and to have someone help you make informed health care decisions.
- To have CenterLight Teamcare interpret the information into your preferred language in a culturally competent manner, if needed.
- To get marketing materials and this statement of your rights and responsibilities in English and in your principal language.
- To get a written copy of your rights from CenterLight Teamcare. CenterLight Teamcare must also post these rights in a visible, public place in the PACE center.
- To be fully informed, in writing, of the services offered by CenterLight Teamcare. This includes telling you which services are provided by contractors instead of the CenterLight Teamcare staff. You must be given this information before you join, at the time you join, and when there is a change in services.
- To look at, or get help to look at the results of the most recent review of CenterLight Teamcare. Federal and State agencies review PACE programs. You also have a right to review how CenterLight Teamcare 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 within CenterLight Teamcare’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 a right to access emergency services.
You have the right to get emergency services when and where you need them without CenterLight Teamcare’s approval. A medical emergency is when you think your health is in serious danger.
You have a right to participate in treatment decisions.
You have the right to fully participate in 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 treatment options explained to you, 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 CenterLight Teamcare help you create an advance directive, a written document that says how you want medical decisions to be made if you lose the ability to make decisions for yourself.
- 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 request a reassessment by your Interdisciplinary Team.
- To be given advance notice, in writing, of any plan to move you to another treatment setting and the reason 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 as protected under State and federal laws. You also have the right to look at and receive copies of your medical records, and to request amendments to those records. If you have any questions about privacy rules, call the Office for Civil Rights at 1-800-368-1019 (TYY 1-800-537-7697). You have the right:
- To be assured of confidential treatment of all information contained in your medical records, including information contained in an automated data bank.
- 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.
- To provide written consent that limits the degree of information and the persons to whom information may be given.
You have a right to file a complaint.
You have the 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 CenterLight TeamCare. You have the right to a fair and timely process for resolving concerns. You have the right:
- To a full explanation of the complaint process.
- To be encouraged and helped to freely explain your complaints to CenterLight TeamCare 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 appeal any treatment decision by CenterLight Teamcare, staff, or contractors.
You have a right to leave the program.
If for any reason, you do not feel that CenterLight Teamcare is what you want, you have the right to leave the program and may initiate disenrollment at any time. If you leave, you will still be in the Medicare and/or Medicaid programs if eligible and get Medicare and/or Medicaid-covered services. But, you will not get your Medicare and Medicaid services through CenterLight Teamcare.
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.
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.