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Forms & Documents
Viewing documents for:
Medicare & Managed Long Term Care Plans
* = managed long-term care plan
Plan Documents
Member Resources
65 Plus Plan (HMO)
2022 Star Ratings
Every year, Medicare evaluates plans based on a 5-star rating system.
CompleteCare (HMO D-SNP)*
Evidence of Coverage Errata
2022 Star Ratings
Every year, Medicare evaluates plans based on a 5-star rating system.
Connection Plan (HMO D-SNP)
2022 Star Ratings
Every year, Medicare evaluates plans based on a 5-star rating system.
Coordinated Benefits Plan (HMO)
2022 Star Ratings
Every year, Medicare evaluates plans based on a 5-star rating system.
Increased Benefits Plan (HMO)
2022 Star Ratings
Every year, Medicare evaluates plans based on a 5-star rating system.
Life Improvement Plan (HMO D-SNP)
Evidence of Coverage Errata
2022 Star Ratings
Every year, Medicare evaluates plans based on a 5-star rating system.
Senior Health Partners*
Member Handbook Insert-New York Independent Assessor-Initial Assessment Process
Signature (HMO)
2022 Star Ratings
Every year, Medicare evaluates plans based on a 5-star rating system.
Medicare Part D Resources
Medicare Advantage Plan Enrollment Resources
Privacy, Protected Health Information (PHI), and Non-Discrimination
General Forms, Documents, and Resources
Member Resources
Appointment of Representative Form
Appoint a representative to make requests for you—give a caregiver or another person permission to file a complaint (grievance), ask for coverage, or make an appeal for you. Have the person you appoint sign the completed Appointment of Representative form and send it to us. This person is then your appointed representative for one year from the date that you both sign an Appointment of Representative form.
65 Plus Plan (HMO)
CompleteCare (HMO D-SNP)*
Connection Plan (HMO D-SNP)
Coordinated Benefits Plan (HMO)
Increased Benefits Plan (HMO)
Life Improvement Plan (HMO D-SNP)
Senior Health Partners*
Signature (HMO)
Medicare Part D Resources
Pharmacy Claims Reimbursement Form
Medicare Advantage Plan Enrollment Resources
Privacy, Protected Health Information (PHI), and Non-Discrimination
Medicare Advantage Members:
Premiums, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”). Plans contain exclusions and limitations.
Healthfirst Health Plan, Inc. offers HMO plans that contract with the Federal Government. Healthfirst Medicare Plan has a contract with New York State Medicaid for Healthfirst CompleteCare (HMO SNP) and a Coordination of Benefits Agreement with the New York State Department of Health for the Healthfirst Life Improvement Plan (HMO SNP). Enrollment in Healthfirst Medicare Plan depends on contract renewal.
Healthfirst Medicare Plan, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-305-0408 (TTY 1-888-867-4132).
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-866-305-0408 (TTY 1-888-542-3821).
Last update January 4, 2022 @ 10:15 am
Y0147_MKT22_56 1081-21_2022
Medicaid Plans
Plan Documents
Essential Plan 1
Medicaid Managed Care
Personal Wellness Plan
Child Health Plus
Member Resources
Privacy and Protected Health Information (PHI)
Essential Plan 2
Essential Plan 3
Essential Plan 4
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