Health Plan Member Agreement

You must check the ‘I Accept’ box at the bottom of this page to confirm that you accept the health plan’s rules listed on this page.

I attest that I am the person enrolling in the health plan or the parent/relative or guardian of the minor who is enrolling in the plan.

I confirm that I understand the following information.

That in order to receive Family Health Plus benefits, I must join a managed care health plan In some counties, joining a Medicaid health plan may be required to receive Medicaid.
I have read the information on this online enrollment that informed me if I was required to join a plan. I was also made aware of the plans available to me in Family Health Plus, Medicaid managed care.
If I am found eligible for Family Health Plus, I will be enrolled in the Family Health Plus plan I have chosen. If I am found eligible for Medicaid instead of Family Health I live in a county that requires Medicaid enrollees to be in a managed care health plan, I will be enrolled in the health plan I chose unless that health plan does not participate in Medicaid managed care. This same rule applies to all members of my household.
I am aware of the rights and benefits that I will have as a member of a managed care health plan and the benefit limitations of managed care membership.
That in both Family Health Plus and Medicaid managed care, I must choose a Primary Care Provider (PCP) and will have a choice of at least three (3) PCPs in my health plan. Once I enroll in a health plan, I will have to use my PCP and other providers in my health plan except in a few special circumstances.
If a child is born to me while I am a member of a Medicaid managed care health plan, my child will be enrolled in the same health plan that I am in. If I am a member of a Family Health Plus plan that also participates in Medicaid managed care, my child will be enrolled in the same health plan that I am in.

I consent to the release of any medical information about me and any members of my family for whom I can give consent:

By my PCP, any other health care provider or the New York State Department of Health (SDOH); or the county department of social services/NYC HRA to my health plan and any health care providers involved in caring for me or my family, as reasonably necessary for my health plan or my providers to carry out treatment, payment, or health care operations.

This may include pharmacy and other medical claims information needed to help manage my care.
By my health plan and any health care providers to SDOH and other authorized federal, state, and local agencies for the purposes of administration of the Medicaid, Child Health Plus, and Family Health Plus programs.
And by my health plan to other persons or organizations, as reasonably necessary for my health plan to carry out treatment, payment, or health care operations.
I also agree that the information about me and members of my family released for treatment, payment and health care operations may include information about mental health, HIV, alcohol and substance abuse, and any disability information needed to determine a disability status to the extent permitted by law, until I revoke it.

Maximus NYMC

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