2014 Staywell Member Handbook

Transcription

2014
61087
Member Handbook
FL021705_CAD_MHB_ENG State Approved 07312014
©WellCare 2014 FL_07_14
FLMMAMHB61087E
Member Information Update Form
It’s important that we have your current contact information. That way we can get in touch
with you when needed. Please use this form to update your address and phone number.
You can also update it on our website. Simply go to florida.wellcare.com.
Sometimes we may need to release your medical records. Please read the Notice of Privacy
Practices in this handbook. It explains why. Then sign the statement below. You can return it
in the included stamped envelope.
Member Name:
__________________________________________________________________________
First
Middle
Last
Home Address:
__________________________________________________________________________
Street
City
ZIP
Mailing Address (if different than your home address):
__________________________________________________________________________
Street
City
ZIP
Phone: ___________________________________________________________________
County You Live In: _________________________________________________________
I allow Staywell to release my medical records as needed. I have read the Notice of Privacy
Practices. I understand:
• How this information may be used
• When this information may be released
• How I can get this information
__________________________________________________________________________
Signature (or signature of parent or guardian if member is under age 21)
Date
Staywell … Caring for You
Welcome to Staywell! We’re glad you joined our family.
As you work with everyone here, you’ll see that we put
you first. This means you get better care.
You’re our priority. We work hard to make sure you get
the care you need to stay healthy. To do this, we work
with many different providers to give you care:
• Primary care providers (PCPs)
• Specialists
• Hospitals and other health care facilities
• Labs
• Pharmacies
This member handbook will tell you more about your
benefits and how your health plan works. Please read it
and keep it in a safe place. We hope it will answer most
of your questions. If it doesn’t, call us. Call toll-free at
1-866-334-7927 (TTY 1-877-247-6272). We’re here to
answer all of your questions. You can also find us on the
Web. Go to florida.wellcare.com.
Again, welcome
to Staywell.
We wish you
good health!
Be on the lookout for your Staywell identification (ID)
card. You should receive it in the mail within a few days
of this handbook. Keep reading for more information
about your ID card and how to use it.
Esta información está disponible gratis en otros idiomas. Por favor comuníquese
con nuestro Servicio al Cliente al 1-866-334-7927 (TTY 1-877-247-6272) de lunes a
viernes, de 8 a.m. a 7 p.m.
Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele depatman Sèvis Kliyantèl
nan 1-866-334-7927 (TTY 1-877-247-6272) lendi-vandredi, 8 a.m. jiska 7 p.m.
Table of Contents
The Staywell Dictionary.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Important Phone Numbers.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
GETTING STARTED WITH US
Getting Started with Us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Check Your ID Card and Keep It with You at All Times . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Get to Know Your PCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Send Us Your Health Risk Assessment (HRA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Remember to Use Our 24-Hour Nurse Advice Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
In an Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Contact Us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Our Website . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Know Your Rights and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Hold on to this Handbook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Care Basics.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Medically Necessary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Making and Getting to Your Medical Appointments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Cost Sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
YOUR HEALTH PLAN
Services Covered by Staywell.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
The Staywell “Extras” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Services Not Covered by Staywell.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
How to Get Covered Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Prior Authorization (PA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Services Available Without Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Utilization Management (UM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Second Medical Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
After-Hours Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Out-of-Area Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Post-Stabilization Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Pregnancy and Newborn Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Doula Services for Pregnant Members Under Age 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Dental Care for Members Over Age 21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Dental Care for Members Under Age 21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Your Dental ID Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Changing Your Primary Care Dentist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Mental Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
24-Hour Mental Health Crisis Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
What to Do in a Mental Health Emergency or if You Are Out
of Our Service Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Preferred Drug List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Other Drugs You Can Get at the Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Care Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Transition of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Electronic Visit Verification (EVV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Planning Your Care.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Child Health Checkup (CHCUP) Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Preventive Health Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Adult Preventive Health Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Pediatric Preventive Health Guidelines (Newborn to Age 21) . . . . . . . . . . . . . . . . . . . . . . 49
Advance Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Member Grievance and Appeals Procedures.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Grievances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Fast or “Expedited” Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Additional Appeals Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Beneficiary Assistance Program (BAP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Medicaid Fair Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Continuation of Benefits during the Appeals Process . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
IMPORTANT MEMBER INFORMATION
Your Staywell Membership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Remember to Recertify Your Eligibility with the Florida Department
of Children and Families (DCF).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Enrollment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Open Enrollment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Reinstatement.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Disenrollment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Involuntary Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Important Information about Staywell.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Plan Structure and Operations and How Our Providers Are Paid . . . . . . . . . . . . . . . . . . . . 65
Evaluation of New Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Quality Improvement and Member Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Fraud, Waste and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
To Report Fraud, Waste or Abuse with Staywell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
To Report Fraud, Waste or Abuse with Florida Medicaid . . . . . . . . . . . . . . . . . . . . . . . . 67
Member Rights.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Member Responsibilities.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
WellCare Notice of Privacy Practices.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
The Staywell Dictionary
As you read this handbook, you’ll see some words we use throughout it. Here’s what we
mean when we use them.
Words/Phrases
Advance Directive: A legal document that tells your doctor and family how you wish to be
cared for if you’re unable to make your wishes known yourself
Appeal: A request you can make when you don’t agree with our decision to deny,
reduce and/or end a service
Benefits/Services: Health care that’s covered by our plan
Child Health Checkup (CHCUP) Visits: Regular health exams for children
Emergency: A very serious medical condition that must be treated right away
Grievance: When you let us know that you’re not happy with our plan, a provider or a
benefit/service
Identification (ID) Card: A card we give you that shows you’re a member of our plan
Immunizations: Shots that can help keep you and your children safe from many
serious diseases
Inpatient: When you get treated at a hospital and have to stay overnight or for a longer
period of time
Managed Care Plan: A plan like ours that works with health care providers to provide
care to keep you and your family healthy
Medically Necessary Services: Medical services you need to get well and stay healthy
Member: You or someone who has joined our health plan
Out-of-Network: A term we use when a provider is not contracted with our plan
florida.wellcare.com |
1
Words/Phrases
Outpatient: When you get treated at a medical facility, but don’t have to stay overnight
Post-Stabilization Services: Follow-up care after you leave the hospital to make sure you
get better
Preferred Drug List (PDL): A list of drugs that has been put together by doctors and
pharmacists
Prescription: A drug for which your doctor writes an order
Prior Authorization (PA): When we need to approve care or prescriptions before you get
them
Primary Care Provider (PCP): Your personal doctor who helps manage all of your health
care needs
Provider: Those who work with us to give medical care, like doctors, hospitals,
pharmacies and labs
Provider Network: All of the providers who have a contract with us to give care to our
members
Specialist: A doctor who has been to medical school, trained, and practices in a specific
field of medicine
Treatment: The care you get from doctors and facilities
TTY: A special number to call if you have trouble hearing or have a speech impairment
florida.wellcare.com | 2
Important Phone Numbers
Staywell
Customer Service:
1-866-334-7927
24-Hour Nurse Advice Line:
1-800-919-8807
TTY:
1-877-247-6272
24-Hour Mental Health Crisis Line:
1-855-606-3622
Fraud, Waste and Abuse Hotline: 1-866-678-8355
Medicaid
Area
2A
3A
4
Medicaid Field Office
Phone Numbers
Counties
Bay, Calhoun, Franklin,
Gadsden, Gulf, Holmes,
Jackson, Jefferson, Leon,
Liberty, Madison, Taylor,
Wakulla and Washington
Alachua, Bradford, Citrus,
Columbia, Dixie, Gilchrist,
Hamilton, Hernando,
Lafayette, Lake, Levy,
Marion, Putnam, Sumter,
Suwannee and Union
Baker, Clay, Duval,
Flagler, Nassau, St. Johns
and Volusia
Aging and Disability
Resource Centers
Local: 850-767-3400
Area Agency on Aging for
North Florida
Toll-free: 1-800-226-7690
Local: 850-488-0055
Toll-free: 1-866-467-4624
Local: 386-462-6200
Toll-free: 1-800-803-3245
Elder Options
Local: 352-378-6649
Toll-free: 1-800-963-5337
Local: 904-798-4200
ElderSource, the Area
Agency on Aging of
Northeast Florida
Toll-free: 1-800-273-5880
Local: 904-391-6699
Toll-free: 1-888-242-4464
Medicaid
Area
5
6
7
8
11
Medicaid Area Office
Phone Numbers
Counties
Aging and Disability
Resource Centers
Local: 727-552-1900
Area Agency on Aging of
Pasco–Pinellas
Toll-free: 1-800-299-4844
Local: 727-570-9696
Hardee, Highlands,
Hillsborough, Manatee
and Polk
Local: 813-350-4800
Toll-free: 1-800-963-5337
West Central Florida Area
Agency on Aging
Toll-free: 1-800-226-2316
Local: 813-740-3888
Brevard, Orange,
Osceola and Seminole
Local: 407-420-2500
Charlotte, Collier,
DeSoto, Glades, Hendry,
Lee and Sarasota
Local: 239-335-1300
Toll-free: 1-800-963-5337
Senior Choices of
Southwest Florida
Toll-free: 1-800-226-6735
Local: 239-652-6900
Pasco and Pinellas
Toll-free: 1-877-254-1055
Miami-Dade and Monroe
Local: 305-593-3000
Toll-free: 1-800-953-0555
Toll-free: 1-800-336-2226
Senior Resource Alliance
Local: 407-514−1800
Toll-free: 1-866-413-5337
Alliance for Aging
Local: 305-670-6500
Toll-free: 1-800-963-5337
To report abuse, neglect or exploitation (including elder),
call the Florida Abuse Hotline:
1-800-96-ABUSE (1-800-962-2873)
(TTY 1-800-453-5145)
You can also report abuse through the DCF website:
http://www.dcf.state.fl.us/abuse/report/
Getting
Started with Us
Getting Started with Us
Here are a couple of important things to remember as you get started with Staywell.
Check Your ID Card and Keep It with You at All Times
You’ll get your Staywell ID card in the mail. If you don’t receive it, call us. Our toll-free
number is 1-866-334-7927 (TTY 1-877-247-6272). We’ll send you another one. You can
also order a new one through our website. Log on to florida.wellcare.com. (Keep reading
to learn more.)
When you get your Staywell ID card, look it over. You want to make sure the
information on it is correct. On it, you’ll find your:
• Primary care provider’s (PCP’s) name, address and phone
• Medicaid ID number
• Effective date (the date you became a member of our plan)
Your Staywell
ID number
Your name
Your PCP’s contact
information
Our website
How to
contact us
The date your Staywell
membership started
Member ID #: 987654321
Member: JANE SMITH
Effective Date: 05/01/2014
Primary Care Provider:
JOHN ADAMS
1234 OAK STREET
TAMPA FL 33613
Phone: 813-123-4567
Medicaid #: 012345678
Plan Name: STAYWELL
Your Medicaid
ID number
florida.wellcare.com
For emergencies, call 911 or go to the nearest ER.
Contact your primary care provider (PCP) as soon as possible.
Customer Service:.............................. 1-866-334-7927/TTY/TDD 1-877-247-6272
24-Hour Nurse Advice Line:............................................................... 1-800-919-8807
24-Hour Behavioral Health Crisis Line:.......................................... 1-855-606-3622
Staywell Health Plan
P.O. Box 31370 Tampa, FL 33631-3370
Medical claims are to be mailed to:
P.O. Box 31372
Tampa, FL 33631-3372
Rx Bin: 603286
Rx PCN: 01410000
Rx GRP: 806257
Call 1-866-334-7927 24 hours a day, 7 days a week.
Information your
PCP and other
providers need to
correctly bill for
your care/services
Remember: if you get a letter or voice
message from a provider asking for your
insurance/health plan information, call
them right away. Give them your Staywell
member information on your ID card. If
you get a bill from a provider, give us a call.
We’ll help to resolve the issue.
Your Staywell ID card has important
information on it about your health
plan. By showing it, you can avoid
getting a bill from your provider.
If your ID card is lost or stolen, call us. Or log on to our website to get a new one.
Get to Know Your PCP
Your PCP is your partner in health. He or she will help arrange all of your medical care.
This includes:
• Regular checkups
• Immunizations
• Referrals to other
providers, like specialists
We encourage all of our new members to visit their PCPs within the first 90 days (three
months) of joining our plan. If you’re pregnant, you should get prenatal care within 14
days of joining our plan. This way your PCP will be able to get to know your health
history. Plus, he or she can create a plan of care for you.
Be sure to get your medical records from any doctors you’ve seen in the past.
This will be very helpful to your PCP. If you need help with this, call us toll-free
at 1-866-334-7927 (TTY 1-877-247-6272). We’ll be happy to help.
The PCPs in our network are trained in different specialties. Specialties like:
• Family and internal medicine
• General practice
• Geriatrics
Women can choose a women’s
health specialist as a PCP for
preventive and routine care.
• Pediatrics
If you didn’t decide on a PCP before joining our plan, we chose one for you. We made
this choice based on:
• Where you may have received
care or services before
• Where you live
• Your language preference
(like English or Spanish)
• If the PCP is accepting new patients
Don’t forget to keep your Staywell ID card with you at all times. You’ll need to show it
every time you get care. It has important information on it about your health plan. By
showing your card, you can avoid getting a bill from a provider.
If you’re not happy with our PCP choice, you can change your PCP at any time. When
choosing your new PCP, remember:
• Our providers are sensitive to the needs of many cultures
• We have providers who speak your language and understand your traditions and
customs
• We can tell you about a provider’s schooling, residency and qualifications
• You can pick the same PCP for your entire family or a different one for each family
member (depending on each family member’s needs)
We have a few ways for you to look for PCPs and other providers.
1. Our printed provider directory:
• We mailed one to you with this handbook
• In it, we’ve listed providers by county and specialty
2. Find a Provider:
• This is a tool on our website
• You can search for a provider within a certain distance of your home
• Because we’re always adding new providers to our network, this is the best way to
get our most current provider network information
3.Call us:
• We can help you find a provider right over the phone
To change your PCP, call us. Call toll-free 1-866-334-7927 (TTY 1-877-247-6272). (You can
request the change through our website too.) PCP changes made between the 1st and 10th
of the month will go into effect right away. Changes made after the 10th of the month will
take effect at the beginning of the next month.
We’ll send you a new ID card with your new PCP listed on it.
You should have received an HRA with this member handbook. (If you didn’t, call us and
we’ll send you another one.) We ask that you fill it out completely. Then send it back
to us in the provided stamped envelope. Your answers to the questions can help us to
make sure you get the right care.
So you know:
• We’ll keep this information private
• We will not disenroll you from our plan because of your answers
Remember to Use Our 24-Hour Nurse Advice Line
We have nurses to take your call any day of the week. You can call anytime you’re not
sure how to handle a health-related problem. One of our nurses will help you decide
what kind of care you need.
You can get help with things like:
• Back pain
• A cut or burn
• A cough, cold or the flu
• Dizziness or feeling sick to your stomach
• A crying baby
24-Hour Nurse Advice Line
toll-free number:
1-800-919-8807
When you call, a nurse will ask some questions
about your problem. Give as many details as
you can. For example, where it hurts. Or what it looks and feels like. The nurse can then
help you decide if you:
• Can care for yourself at home
• Need to see a doctor or go to the hospital
Remember, a nurse is always there to help. Consider calling our Nurse Advice Line
before calling your doctor or going to the hospital. But if you think it is a real medical
emergency, call 911 first or go to the nearest emergency room.
In an Emergency…
Call 911 or go to the nearest emergency room. We’ll talk more about emergencies later
in this handbook.
Send Us Your Health Risk Assessment (HRA)
Contact Us
Call us with any questions you have. We’re here to help Monday–Friday, 8 a.m. to 7 p.m.
Customer Service toll-free number:
1-866-334-7927
(TTY 1-877-247-6272)
Call us any time you need help with:
• Updating your contact information, like your mailing address and phone number
• Getting a replacement ID card
• Finding and choosing a provider
• Making an appointment with a provider
• Filing a complaint, grievance or appeal
It’s important for us and the Department of Children and Families (DCF) and/or Social Security
Administration (SSA) to know if there is a major change in your life. For example, if you:
• Move
• Your family size changes, like you get married or divorced, have a baby or adopt a
child, or experience the death of your spouse or child
• Start a new job or your income changes
• Get health insurance from another company
If you speak a different language or need something in Braille, large print or audio, don’t
worry. We have translation and alternative format services (including sign language). We
can even arrange to have a translator or sign language interpreter at your appointments.
Just give us a call. There’s no cost to you for this.
If you call us after business hours with a non-urgent request, leave a message. We’ll call
you back the next business day.
To write to us, send your request to:
Attn: Customer Service
P.O. Box 31370
Tampa, FL 33631-3370
You may be able to find answers to your questions on our website. Go to
florida.wellcare.com for information on/about:
• Our member handbook, provider directory or Find a Provider search tool
• How we protect your privacy
• Your member rights and responsibilities
• Member newsletters
• Pediatric and adult preventive health
• Pregnancy care
• Childhood obesity, lead poisoning, asthma,
Our website:
diabetes and chronic kidney disease
On our website, you can also:
• Update your address and phone number
• Request a change to your primary care provider (PCP)
• Place your monthly over-the-counter (OTC) items order
Know Your Rights and Responsibilities
As a member in our plan, you have rights and responsibilities. Keep reading to learn more.
Hold on to this Handbook
You’ll find very valuable information in this handbook. Information about:
• Your covered benefits and services and how to get them
• Advance directives (learn more about these in the Advance Directives section later
in this handbook)
• How to use our grievance and appeals process for when you’re not happy with a
decision we made
• How we protect your privacy
If you lose it, call us. We’ll send you a new one. You can also find it on our website.
Our Website
Care Basics
You’ll get your care from doctors, hospitals and others who are in our provider
network. We or a network doctor must approve your care.
We’ll pay for approved care. If you get a service that we do not approve, you may have
to pay for it yourself.
Medically Necessary
We approve care that is “medically needed” or “necessary.” This just means the care:
• Is for an illness that would put your health in danger
• Follows accepted medical practices
• Is provided in a safe, proper and cost-effective place, depending on the diagnosis
and how sick you are
• Is not for convenience only
• Is needed when there is no better or less costly care, service or place available
Making and Getting to Your Medical Appointments
We have guidelines to make sure you get to your medical appointments in a timely
manner. (This is also called “access to care.”)
This table will give you an idea of how long it should take to get to a medical
appointment.
Type of Provider
PCPs
Hospitals
Mental Health
Providers
Drive Time/Distance if You Live
in an Urban Area
Drive Time/Distance if You
Live in an Rural Area
30 minutes/20 miles to get
to your appointment
to your appointment
to your appointment
to your appointment
to your appointment
to your appointment
How long you should wait for an appointment depends on the kind of care you need.
Keep these times in mind as you’re setting your appointments.
Type of Care
Emergency
Medical
Urgent
Sickness
Routine/Wellness
Follow-up care after
a hospital stay
Emergency
Dental
Urgent
Sickness
Routine/Wellness
Follow-up care after
an exam
Emergency
Mental Health
and Substance Urgent
Abuse
Sickness
Routine/Wellness
Appointment Time
Right away (both in and out of our service
area), 24 hours a day, seven days a week
(prior authorization is not required for
emergency services)
Within 24 hours (one day)
Within one week
Within four weeks (one month)
As needed
Type of
Appointment
emergency services)
Within one week
emergency services)
Within one week
The doctors in our network must offer you the same office hours as patients with other
insurance.
Cost Sharing
There are no co-pays with Staywell, except for these services:
• Chiropractic ($1 each visit)
• Non-emergency services received in an emergency room (ER) setting (5% coinsurance, but
no more than $15 out of your pocket)
Please read through the next section for more details. If you are charged by a provider for
any other service, let us know. We’ll help to resolve the issue.
Your
Health Plan
Services Covered by Staywell
What follows is a list of services we cover.
Here are a couple of important things to remember when getting your care:
• We’ll pay for approved care
• If you get a service that we do not approve, you may have to pay for it yourself
• Sometimes we may not have a provider in our network who can give you needed
care; if this happens, we’ll cover the care out-of-network (at no additional cost to
you), but you will need to get approval first from us or your PCP
• We may not cover certain services provided by Medicaid (there may be cost
sharing with these Medicaid-provided services)
For questions about these services, give us a call. We can be reached toll-free at
1-866-334-7927 (TTY 1-877-247-6272).
Assistive care
services
Ambulatory
surgical center
(ASC) services
Advanced
registered nurse
practitioner
(ARNP) services
Covered
Service
• Activities of daily living (ADLs)
• Instrumental activities of daily living
(IADLs)
• Giving yourself medication
Components include health support and
help with:
YOUR HEALTH PLAN
• By a licensed practitioner
•To confirm medical necessity for at least
two of the four service components
and the need for at least one specific
service each day
A health assessment must be completed:
These services are available if you live in
an assisted living facility, adult family care
home or residential treatment facility
• When you need emergency care
• If the service is minor enough to be done by your doctor in his/her office
ASC services shouldn’t be used:
These centers provide medically necessary surgical care when you don’t need to stay in
a hospital
• One long-term care facility visit by an ARNP each month, except for emergencies
• Ten prenatal visits and two postpartum visits, if you’re pregnant (each pregnancy)
• Two routine care visits each month, if you’re not pregnant
• One visit to an ARNP if you’re a new patient for him/her
You’re limited to:
The ARNP and a doctor must make decisions about your care as a team
These are services given by an ARNP who’s licensed to practice in the State of Florida
Covered Service Description
Prior
Authorization
(PA) Required
Mental health
services
Covered
Service
• Targeted and intensive case
management
• Therapeutic mental on-site services for
children and adolescents
•Treatment planning
See the Emergency Care section later in this handbook for more details about mental
health emergencies
Parental or guardian informed consent is required for psychotropic medications for
children under age 13 (examples of psychotropic medications include tranquilizers,
sedatives and antidepressants)
You may also choose an alternative mental health case manager or direct service provider
who’s in our network
You don’t need to get a PA or referral from your PCP to see a mental health provider, but
certain services do require a PA
• If you’re over age 21 and not pregnant – up to 45 days each year for non-emergency
and up to 365 days for emergencies
• Children and adolescents up to age 21 – up to 365 days
• If you’re pregnant – up to 365 days
Mental health-related inpatient hospital care is limited to:
• Day treatment for adults and children
• Evaluations
• Individual and family assessments
• Individual, family, marital and group
therapy
• Psychosocial rehabilitation
Services include:
PA is required
for psychological
testing,
electroconvulsive
therapy,
psychosocial
rehabilitation,
therapeutic
mental on-site
services (TBOS)
and all inpatient
mental health
services
Prior
Authorization
(PA) Required
Chiropractic
services
Child health
checkup
(CHCUP)
services (for
members
under age 21)
Birthing center
and licensed
midwife
services
Covered
Service
• Massages or heat treatments
• Experimental or investigational
chiropractic services
There is a $1 co-pay for these services
• One visit each day
• 24 visits each year
Services that are not covered:
YOUR HEALTH PLAN
• One visit to a chiropractor if you’re a
new patient with him/her
• Manual manipulation of the spine
• Spinal X-rays
Services include:
These are services given by a chiropractor
who’s licensed to practice in the State of
Florida
See the Planning Your Care section later in this handbook for more details about child
health checkups
• One family planning visit each year at a birthing center
• One ultrasound during each pregnancy
• Ten prenatal visits and two postpartum visits during each pregnancy
• One newborn checkup at the facility
These are facilities where you can go for obstetrical, gynecological and family planning
services
Prior
Authorization
(PA) Required
Dental
services for
children
(under age 21)
Dental
services for
adults (over
age 21)
Clinic services
Covered
Service
• Adult health screenings
• Child health checkups (CHCUPs)
• Chiropractic
• Family planning
• Mental health
• Podiatry
• Vision
Services you can get at these clinics include:
• Checkups
• Crowns
• Endodontic care (soft tissue and
nerves within the teeth)
• Full and partial dentures
• Oral surgery
Services include:
• Bridge work
• Sealants on baby teeth
• Orthodontic treatment
• Periodontal care
• Preventive care
•Restorations
• Care to lessen pain or infection because of a dental emergency (for example, draining
an abscess)
• Full and removable partial dentures
• Denture-related procedures
Services include:
• Rural health clinics (RHCs)
• Federally qualified health centers
(FQHCs)
Clinics include:
These clinics provide primary care
services
PA is required for
orthodontic care
Prior
Authorization
(PA) Required
Healthy Start
services
Family
planning
services and
supplies
Emergency
services
(including
mental health
emergencies)
Covered
Service
YOUR HEALTH PLAN
• Coordination of care with the Healthy Start Program
• Referrals to the Women, Infants and Children (WIC) and Children’s Medical
Services (for children with special health care needs) Programs
Services include:
These services are provided to help you have a healthy pregnancy and give birth to
a healthy baby
You don’t need to get a PA for these services and you can get them from any
participating Medicaid provider
• One visit each year
• Lab testing
• Family planning and HIV counseling
• Contraceptive supplies
•Pregnancy testing
Services include:
• Up to the first $300 for the cost of the care
• Your out-of-pocket cost won’t be more than $15
There is a 5% coinsurance for non-emergency services received in an emergency
room (ER) setting:
See the Emergency Care section later in this handbook for more details about
emergencies
Prior
Authorization
(PA) Required
Home health
services and
nursing care
Hearing services
Covered
Service
• Home visits by a registered nurse
(RN), licensed practical nurse (LPN) or
qualified home health aide (HHA)
• Medical supplies and durable medical
equipment (DME)
Services include:
These services are provided in your
home to help improve your health or
lessen the effects of a disability
• One hearing test every two years
• One hearing aid for each ear every
two years
• Cochlear implants
• Hearing aids, including fitting, repairs
and testing
• Newborn hearing test
• Testing
Services include:
• Three home health visits each day
• Private-duty nursing
• Personal care
• Therapies in the home –
occupational, physical and speech
Services for members under age 20
include:
• Hearing aid repairs while it’s covered
under the manufacturer’s warranty
(when the warranty runs out, repairs will
be covered)
• Regular maintenance, batteries, cord or
wire replacement or cleaning of
hearing aids
• One cochlear implant in either ear,
not both
PA is required for
cochlear implants
Prior
Authorization
(PA) Required
•Inpatient
•Outpatient
Hospital
services,
including:
Hospice
services
Covered
Service
• Drugs
• Medical supplies
• Nursing care
• Therapies
YOUR HEALTH PLAN
Outpatient hospital services include:
•45 days each year if you’re over age 21 (if you’re under age 21 or pregnant,
there are no limits)
• Room and board
• Medical supplies
• Diagnosis and therapies
• Drugs
• Nursing care
Inpatient hospital services include:
These services must be provided under the supervision of a doctor or dentist
These services are provided by a hospice agency and care is coordinated by a
hospice nurse
A person is considered to be terminally ill if he or she has a medical diagnosis with a
life expectancy of six months or less if the disease runs its normal course
These services provide palliative care to you and your family (palliative care is care
that’s given to provide relief from symptoms, like pain and stress, caused by a
terminal illness; it’s not meant to cure the illness)
PA is required for
inpatient hospital
services
Prior
Authorization
(PA) Required
Medical
supplies
and durable
medical
equipment
(DME)
Lab and X-ray
services
Covered
Service
You can buy, rent or rent-to-own DME
• Cane, crutches or a walker
• Blood glucose meters and strips
• Diabetic supplies
• Hospital bed
• Orthotics and prosthetics
•Wheelchair
Durable medical equipment (DME) is medically necessary items that you can use
over and over for medical reasons, like:
•Items that are usable and disposable in your home
Medical supplies include:
• Lab tests
• Portable X-rays
• Diagnostic imaging
−− MRI (magnetic resonance imaging)
−− CT (computed tomography)
−− PET (positron emission tomography)
These services include medically needed:
PA is required
for custom
and power
wheelchairs,
hospital beds and
scooters
Prior
Authorization
(PA) Required
Prescription
drugs
Podiatry
services
Physician and
physician’s
assistant
services
Covered
Service
YOUR HEALTH PLAN
You can access our PDL on our website at florida.wellcare.com
Drugs not on our PDL may be covered with a PA
• Require a PA
• Quantity limits
• Step therapy
•Age or gender limits
The PDL also lists drugs that may have limits, such as:
See our Preferred Drug List (PDL) for the drugs we cover
• Routine foot care if you have a metabolic disease (like diabetes), bad circulation,
wounds or infections
Services include:
These are services provided by a podiatrist who’s licensed to practice in the State
of Florida
These are services provided in your home, a doctor’s office, hospital or nursing
home to treat an injury, illness or disease
These are services provided by a doctor or physician’s assistant who’s licensed to
practice in the State of Florida
PA is required
for certain drugs
(please refer to
our PDL)
Prior
Authorization
(PA) Required
Rural health
clinic services
Renal dialysis
services
Quality
enhancement
(QE) services/
programs
Covered
Service
• Adult health screenings
• Child health checkups (CHCUPs)
• Chiropractic
• Family planning
• Mental health
• Podiatry
• Vision
Services you can get at these clinics include:
These clinics provide primary care services if you live in a rural area
• Dialysis (hemodialysis and peritoneal)
• Dialysis-related supplies
• Lab tests
These services include:
• Children’s programs (wellness and prevention)
• Domestic violence (prevention and intervention)
• Pregnancy prevention
• Prenatal/postpartum (after birth)
• Mental health
These services/programs include:
These services/programs are meant to help you improve your health and/or your
children’s health
Prior
Authorization
(PA) Required
Therapy
services –
respiratory
Therapy
services –
physical
Therapy
services –
occupational
Covered
Service
YOUR HEALTH PLAN
• Include evaluation and treatment of problems related to your lungs
• Are available in your home or in an outpatient facility, regardless of your age
Respiratory therapy services:
These are services provided by a respiratory therapist who’s licensed to practice in
the State of Florida
• Include evaluation and treatment related to range-of-motion, muscle strength,
functional abilities and use of therapeutic equipment
• Are available in your home if you’re under age 21 and in an outpatient facility if
you’re over age 21
Physical therapy services:
These are services provided by a physical therapist who’s licensed to practice in the
State of Florida
• Include evaluation and treatment to prevent or correct physical and emotional
deficits or to lessen the effect of these deficits
Occupational therapy services:
These are services provided by an occupational therapist who’s licensed to practice
in the State of Florida
PA is required for
physical therapy
PA is required
for occupational
therapy
Prior
Authorization
(PA) Required
Transportation
services –
non-emergency
Transportation
services –
emergency
Therapy
services –
speech
Covered
Service
• Call 1-866-591-4066 (TTY 1-800-855-2880)
• You must call at least 24 hours ahead of your appointment
• If you call less than 24 hours before your appointment, we’ll review your request
to decide if it’s urgent
When setting up your transportation:
• Have no way to get a ride (in your own car or from a family member or friend)
• Live in an area where there’s no public transportation
• Cannot get to public transportation because of your medical condition
Pre-arranged transportation in an ambulance because of life-support needs is not
emergency transportation
These services are available when you need transportation to medically needed
appointments and you:
See the Emergency Care section later in this handbook for more details about
emergencies
These services provide medically needed ground or air ambulance transportation in
emergency situations
• Include evaluation and treatment of speech-language conditions
Speech therapy services:
These are services provided by a speech-language pathologist who’s licensed to
practice in the State of Florida
PA is required for
speech therapy
Prior
Authorization
(PA) Required
Vision services
Covered
Service
YOUR HEALTH PLAN
• Two pairs of eyeglasses (two frames and four lenses) each year (if you’re under
age 21)
• One pair of eyeglasses every two years (if you’re over age 21)
• Eyeglasses
• Eyeglass repairs
• Eye exams
• Medically needed contact lenses
• Prosthetic eyes
Services include:
These are services given by an ophthalmologist, optometrist or optician who’s
licensed to practice in the State of Florida
PA is required
for a second pair
of eyeglasses
within a two-year
period (if you’re
over age 21)
Prior
Authorization
(PA) Required
The Staywell “Extras”
We’re excited to offer:
• Extra benefits
• Special programs
Things like:
• Alternative therapies (art, equine and pet)
• Mail-order pharmacy
• Meals program
You should have received a booklet with this handbook. In the booklet we talk about
these benefits and programs in more detail. Make sure to read it. Plus, you may want to
keep it with your handbook. That way you can refer back to it whenever you need to.
Services Not Covered by Staywell
We do not cover these services:
YOUR HEALTH PLAN
• Cosmetic surgery
• Experimental or investigational procedures
How to Get Covered Services
Call your PCP when you need regular care. He or she will send you to see a specialist for
tests, specialty care and other covered services that he or she doesn’t provide. Be sure
your PCP approves you to see a specialist. We will cover this care.
If your PCP does not provide an approved service, ask him or her how you can get it.
Prior Authorization (PA)
Prior authorization (or PA for short) means we must approve a service or prescription
drug before you can get it. You or your PCP/specialist should contact us to ask for this
approval. If we do not approve your request, we’ll let you know. Plus, we’ll give you
details about how to file an appeal. (Keep reading for more on appeals.)
We listed the services we cover on earlier pages. In that same chart, we also told you
which services require a PA.
Prior Authorization “How To”
Type of Request
Decision Time
Frame
Who Can
Request One
How to Request
Normal* (for nonemergency care)
Seven
calendar days
You, your
provider
Call: 1-866-334-7927
Fax: 1-877-297-3112
Expedited/Fast**
(for urgent care)
48 hours
You, your
provider
Call: 1-866-334-7927
Fax: 1-877-297-3112
Say: ‘I’d like an expedited/
fast decision”
*Sometimes we may need more time to make a standard decision. This may be because
we need more information and it’s in your best interest. If so, we’ll take up to seven
more calendar days.
**Sometimes we may need more time to make a fast decision. If so, we’ll take up to two
more business days.
Services Available Without Authorization
You don’t need approval from us or your PCP for the following services:
Even though you don’t need approval for these services, you will need to pick a
network provider. Look through your provider directory to find one. (Don’t forget
about our online provider search tool – Find a Provider. It’s on our website. Log on to
florida.wellcare.com.) When you’ve made your choice, call to set up an appointment.
Remember to take your ID card with you.
Utilization Management (UM)
Utilization management (UM) is a common process used by health plans. It’s how we
make sure members get the right care at the right place. It also helps us control costs
and deliver good care at the same time.
Our UM program has four parts. They are:
1. Prior authorization – getting our approval before getting a service
2. Prospective reviews – making sure the care is right for you before you get it
3. Concurrent reviews – reviewing your care as you get it to see if something else
might be better for you
4. Retrospective reviews – finding out if the care you got was appropriate
At times, we may deny coverage for services or care. These denial decisions are made
by our clinical staff. (They’re doctors and nurses.) Here are some things you should know
about this decision process:
• Decisions are based on the best use of care and services
• The people who make decisions don’t get paid to deny care (no one does)
• We do not promote denial of care in any way
Call us if you have questions about our UM program. Call toll-free 1-866-334-7927
(TTY 1-877-247-6272).
YOUR HEALTH PLAN
• Chiropractic
• Dermatology
• Emergency/urgent care
• Family planning from any participating Medicaid provider
• One women’s health visit to an OB/GYN provider each year
• Podiatry
• Post-stabilization care
Second Medical Opinion
Call your PCP when you want a second opinion about your
care. He or she will ask you to pick another doctor in our
network. If you can’t find one, don’t worry. You’ll be able to
choose a doctor outside of our network. (You won’t have to
pay for this.)
The second-opinion doctor may order some tests for you. If
so, these tests must be done by a provider in our network.
Your PCP will review the second opinion. He or she will then
decide the best way to treat you.
Remember – you may have to pay for services you get when
you go to a doctor who is not in our network without approval.
A second medical
opinion can be
requested by
anyone who is
allowed to act on
your behalf. This
includes a:
•Parent
•Guardian
•Social worker
After-Hours Care
What if you get sick or hurt when your PCP’s office is closed?
If it’s not an emergency, call our 24-Hour Nurse Advice Line. Or you can call your PCP.
His or her number is on your ID card.
Your PCP’s office will have a doctor “on call.” This on-call doctor is available 24 hours a
day, seven days a week. He or she will call you back and tell you what to do. You may
go to an urgent care center if you can’t reach your PCP’s office. (You don’t need a PA
to go to an urgent care center.)
If you do go to an urgent care center, be sure to call your PCP’s office the next day for
follow-up care.
Urgent Care
You may need urgent care for a health problem that isn’t an emergency, but needs
treatment within 24 hours. Problems like:
• An injury
• Illness
• Severe pain
If you have one of these problems, try calling our 24-Hour Nurse Advice Line. One of
our nurses will try to help you over the phone. Or you can call your PCP. He or she can
tell you how to treat it. Our advice line or your PCP may tell you to go to an urgent
care center for help. Urgent care center services do not require a PA.
When you get to the center, show your Staywell ID card. Also, ask the staff to call us.
Be sure to let your PCP know if you receive care at an urgent care center so you can
get follow-up care.
Remember… you can also go to an urgent care center when you travel outside of
Florida.
Emergency Care
• Bodily injury
• Damage to an organ or other body part
• Injury to yourself or others
• Harm to yourself or others due to alcohol or drug abuse
• Harm to your health
For moms-to-be, it may be an emergency if you think:
• There is no time to go to your doctor’s regular hospital
• Going to another hospital may cause harm to you and your baby
• You’re in labor
Here are some examples of an emergency:
• Broken bones or cuts requiring stitches
• Heart attack or severe chest pains
• Shortness of breath
• Poisoning
• Heavy blood loss
• Loss of consciousness
Call your PCP or our nurse advice line if you’re not sure if it’s an emergency. In an
emergency, you can:
• Call 911
• Call an ambulance if you don’t have 911 in your area
• Go to the nearest hospital emergency room (ER) right away
The choice is yours. You don’t need a PA for emergency care that is provided at an
urgent care center or ER.
YOUR HEALTH PLAN
A medical emergency is when your health is in grave danger. An emergency is when the
condition could cause:
When you get to the ER, show your Staywell ID card. Also, ask the staff to call us.
The ER doctor will decide if your visit is an emergency. If your condition is not an
emergency and your health is not in danger, you can choose to stay. But, you may have
to pay for the care.
Out-of-Area Emergency Care
It’s important to get care when you’re sick or hurt. That goes for when you’re traveling
too. If you have a medical emergency while traveling, go to the nearest hospital. It
doesn’t matter if you’re not in our service area.
When you get to the hospital, don’t forget to:
1. Show your Staywell ID card
2. Ask the staff to call us for instructions on how to file your claim
3. Let your PCP know what has happened
If you have to pay for this visit, let us know. We’ll tell you how you can ask to be
reimbursed for the visit. But it’s very important that you keep copies of your medical
reports, bills and proof of payment. (We’ll need these to reimburse you.)
Post-Stabilization Care
After an ER visit, call your PCP within 24 to 48 hours. You may need to get follow-up
care until your health gets better. This is called “post-stabilization” care. You don’t need
a PA for post-stabilization care, which we cover. But, it must be needed to maintain,
improve or resolve your medical condition.
Pregnancy and Newborn Care
When you find out you’re pregnant, taking care of yourself can help you and your
unborn baby stay healthy.
Here are some very important things to do when you get the news. Think of this as
your baby checklist.
Baby “To Do” List
−−Family
−−Staywell at 1-866-334-7927
−−DCF (Department of Children and Families)
−−My PCP
❑ Schedule my first prenatal visit and talk with the doctor about future prenatal
visits and those after Baby gets here (postpartum)
❑ Start thinking about which doctor to pick for Baby
−−I need to have this done before Baby gets here
❑ Once Baby is here, call DCF to get his/her
Medicaid # and then call Staywell with it
❑ If DCF doesn’t put Baby on Staywell
with me, call 1-866-762-2237 to fix
Staywell can h
elp me make
my baby appo
intments!
1-866-334-7927
(TTY 1-877-247
-6272)
❑ Names??? Clothes???
You should see your PCP within 14 days of joining our plan. Make sure to go to all your
prenatal and postpartum (after birth) visits.
Just as important as keeping your appointments, is letting us know when you become
pregnant. We can provide you with helpful information about having and caring for
your baby.
YOUR HEALTH PLAN
❑ Let these people know I’m having a baby:
A few reminders:
• If you have a baby while you’re a Staywell member, we’ll cover him or her from birth
• You must let DCF know (call 1-866-762-2237 (TTY 1-800-955-8771)) that you’re
pregnant; once you have your baby, you need to call DCF again to get his or her
Medicaid number
• Give us your baby’s Medicaid number after you get it from DCF
• If your baby is not automatically put on Staywell, call 1-866-762-2237 (TTY 1-800955-8771) to have him or her changed over to our plan
• Choose a PCP for your baby before he or she is born; if you don’t we’ll choose one
for you
Doula Services for Pregnant Members Under Age 20
If you’re pregnant and under age 20, we offer doula services.
What’s a doula? A doula is like a labor coach. She’ll work with you before, during and
after you give birth.
Your doula will be there to:
• Give you emotional support
• Help you through the birthing process
• Encourage you to go to all of your prenatal visits and
well-baby checkups for your baby, as well as get all of
your baby’s immunizations
A doula is like a
labor coach.
Doula services are given through our Care Management Program. (Keep reading for
more details about this free program.) To learn more about doula services, call our Care
Management team. They can be reached toll-free at 1-888-421-7690.
Dental Care for Members Over Age 21
Emergency dental care is covered if you’re over 21. Please refer to the Services Covered
by Staywell section for more details.
Dental Care for Members Under Age 21
Dental care is just as important as medical care. You/Your child should see a dentist at
least once every six months. (Or at a minimum, once per year.)
Your Dental ID Card
You’ll receive a dental ID card in the mail. (It’ll be
sent separate from your Staywell ID card.) Keep
it with you at all times. You’ll need to show it
every time you get dental care. It has important
information on it about your health plan. By
showing your dental ID card, you can avoid getting
a bill from a provider.
Liberty Dental Plan will
provide your dental
care for us.
Call them to:
If your dental ID card is lost or stolen, call Liberty.
They’ll send you a new one.
Changing Your Primary Care Dentist
•Get answers to your
dental questions
•Change dentists
1-888-352-0217
(TTY 1-800-735-2929)
Monday–Friday,
8 a.m. to 7 p.m.
On your dental ID card, you’ll see your primary
care dentist’s name and phone number.
This dentist was chosen for you. If you’re not happy with this choice, you can change
your dentist at any time. To ask for a change, call Liberty toll-free at 1-888-352-0217
(TTY 1-800-735-2929). Changes made before the 20th of the month will go into effect at
the beginning of the next month.
You’ll get a new ID card with your new dentist listed on it.
Mental Health Care
Your mental health is an important part of staying healthy. If you experience any of the
below, call us. We’ll give you the names and phone numbers of providers who can help.
(You can search for a provider on our website too. Log on to florida.wellcare.com.)
• Always feeling sad
• Feeling hopeless and/or helpless
• Feelings of guilt or worthlessness
• Problems sleeping
YOUR HEALTH PLAN
Liberty Dental Plan will provide your dental care
on our behalf. Like your PCP, you’ll have a primary
care dentist. You’ll go to him or her for all of your
covered dental care. (Go to the Services Covered
by Staywell section in this handbook. There you
can find what’s covered.)
• No appetite
• Weight loss or gain
• Loss of interest in the things you like
• Problems paying attention
• Being upset
• Your head, stomach or back hurts, and your doctor hasn’t found a cause
• Drug or alcohol problems
As a reminder, you must get a PA to see a provider who is not in our network.
You’ll have to pay for the care if you don’t.
24-Hour Mental Health Crisis Line
We have a 24-hour crisis line. If you think you
or a family member is having a mental health
crisis, call this number. A trained person will
listen to your problem. He or she will help
you determine the best way to handle
the crisis.
24-Hour
Mental Health Crisis Line
toll-free number:
What to Do in a Mental Health
Emergency or if You Are Out of
Our Service Region
1-855-606-3622
Do you feel you’re a danger to yourself or others? Do you think you’re having a mental
health emergency? Call your PCP or our crisis line if you’re not sure if it’s an emergency.
In a mental health emergency, you can:
• Call 911
• Call an ambulance if you don’t have 911 in your area
• Go to the nearest hospital emergency room (ER) right away
The choice is yours. You don’t need a PA for this kind of emergency.
The doctor who treats you for your mental health emergency may feel you need
post-stabilization care. You don’t need a PA for post-stabilization care, which we
cover. But, it must be needed to maintain, improve or resolve your medical condition.
Remember to follow up with your PCP within 24 to 48 hours after you leave
the hospital.
The hospital where you get your emergency care may be out of our service area. If so,
you’ll be taken to a network facility when you’re well enough to travel.
Refer back to the Emergency Care section of this handbook for more information
about what to do in an emergency.
Prescriptions
Prescriptions must be written by one of our network providers or an out-of-network
provider as outlined in Florida Statute 409.913. Once you have your prescription, go to
any network pharmacy to get it filled. Our provider directory lists all of the pharmacies
who take our plan. You can search for one on our website too. Or call us and we’ll help
find one near you.
We have a Preferred Drug List – or PDL for short. This is a list of drugs that has been
put together by doctors and pharmacists. Our network providers use this list when they
prescribe a drug for you. To see our PDL, go to our website at florida.wellcare.com.
The PDL will include drugs that may have limits, like:
• Prior authorization (PA)
• Quantity limits
• Step therapy
• Age or gender limits
For those drugs that require a PA (and those not on our PDL), your provider will need to
send us a Coverage Determination Request (CDR).
There are some medications we will not cover. They include:
• Those used for eating problems or weight gain
• Those used to help you get pregnant
• Those used for erectile dysfunction
• Those that are for cosmetic purposes or to help you grow hair
• DESI (Drug Efficacy Study Implementation) drugs and drugs that are identical, related
or similar to such drugs
• Investigational or experimental drugs
• Those used for any purpose that is not medically accepted
YOUR HEALTH PLAN
Preferred Drug List
Other Drugs You Can Get at the Pharmacy
There are some over-the-counter (OTC) drugs you can get at the pharmacy with a
prescription. (These are different from the $25 OTC extra benefit we offer.) Some of
these drugs we cover include:
• Diphenhydramine (for allergy relief)
• Meclizine (to help with motion sickness)
• H2 receptor antagonists (to treat acid reflux and ulcers)
• Ibuprofen (pain reliever for headaches, toothaches and back pain)
• Multivitamins/multivitamins with iron
• Insulin
• Insulin syringes
• Non-sedating antihistamines (allergy relief that
To get these items, simply
won’t make you sleepy)
take your prescription
• Iron
to a network pharmacy.
• Topical antifungals
You’ll also need to show
• Urine test strips
them your ID card.
• Coated aspirin
• Antacids
• Proton pump inhibitors (also help with acid reflux and ulcers)
For questions about prescriptions, call us. We can be reached at 1-866-334-7927
(TTY 1-877-247-6272).
Care Management
We understand you may have special care needs. To help with these, we have a Care
Management Program. The goal of this program is to help you understand how to take
care of yourself and maintain good health.
You may qualify for care management services if you:
• Need help with getting care and/or using medical services
• Have a serious or long-term health condition, like asthma, diabetes, HIV/AIDS or
high-risk pregnancy
While in the program, you’ll work with a care manager. He or she will partner with you
to help coordinate your care needs. To do this, he or she:
• May ask you questions to get more information about your condition
• Will work with your PCP to arrange services you need and help you understand
your illness
• Will provide information to help you understand how to care for yourself and how
to access services, including local resources
We may contact you to talk about care management if:
• You ask about this program
• Your PCP thinks the program would help you
• We feel you may qualify for these services
To learn more about this no-cost program, talk with your PCP. You can also give our Care
Management team a call. Call toll-free at 1-888-421-7690.
Transition of Care
We want to be sure you keep seeing your doctors and getting your medications. If you
move from another health plan to ours, we will not require PAs for medical care and
prescriptions for a period of time. For medical care and prescriptions, that period is 60
days after your start date with us. This will help you to move to our plan smoothly with
no interruption in your care.
Please call or have your provider call us if any of the following apply to you. We can be
reached at 1-866-334-7927.
• Take regular medication(s) that need(s) authorization
• See a specialist
• Get therapy (for example, occupational or physical therapy)
• Use durable medical equipment, like oxygen or a wheelchair
• Receive in-home services (for example, wound care or in-home infusion)
Effective 09/01/14 any new member to the plan in any region will have a 60 day
Transition of Care period.
We will cover some services beyond the 60 days. You can keep getting these services
from your provider, even if he or she is not in our network:
• Prenatal and postpartum care during your entire pregnancy, including postpartum care
six weeks after your baby is born
• Transplant services, including care up to one year after a transplant
• Oncology – Radiation and/or Chemotherapy services for the current round of
treatment
• Full course of therapy Hepatitis C treatment drugs
YOUR HEALTH PLAN
Getting the care you need is very important to us. That’s why we’ll work with you to make
sure you get your care when:
• You’re leaving another health plan and just starting with us
• One of your providers leaves our network
• You leave our health plan to go to another one
Electronic Visit Verification (EVV)
We use Electronic Visit Verification (EVV). This technology helps to confirm that you’re getting
the care and services you should be. It’s used when you get home health from a caregiver.
Here’s how it works:
1.You’ll receive an EVV card that has a special code on it. (This card is different than
the ID card you use for your other care.)
2.When your caregiver gets to your house, he or she will ask to see this card. Show it
to him or her.
3.The caregiver will scan the card. He or she will then provide your care.
4.After your caregiver is done, he or she will ask to see the card again to scan it one
more time.
With this EVV card, we’ll be able to verify that you received the care you were
scheduled to get. This assists us in a few other ways too. It helps:
• Make sure your plan of care is being followed.
• With the coordination of follow-up care.
• To prove the identity of the provider and that he or she performed the service.
• To reduce the chance of health care fraud.
Here’s what your EVV card will look like.
The special code your
caregiver will scan before
and after your care
Your name
The phone number to call
if you lose your EVV card
Here are some things to remember with this card:
• It’s only good for EVV – you cannot use it as a form of identification (ID).
• Keep this card with you at all times.
• If you have any questions about your EVV card, call the number on the back of it.
• If you lose your EVV card, call 1-866-334-7927 to get a new one.
Planning Your Care
Here we want to give you information about prevention and planning for your
care needs.
Child Health Checkup (CHCUP) Services
• A comprehensive history and physical exam
• Behavioral and mental health assessment
• Growth and development chart
• Vision, hearing and language screening
• Nutritional health and education
• Lead risk assessment and testing, as appropriate
• Age-appropriate immunizations
• Dental screening and referral to a dentist
• Referral to specialists and treatment, as appropriate
• Any needed services as part of a treatment plan that is approved as medically
necessary by us
• Regular preventive dental and treatment services, including screening examinations
• Preventive dental treatment (scaling and polishing), following the American Academy
of Pediatrics guidelines
A big part of the CHCUP program is the well-child checkup. This is a checkup your
child’s PCP will do to make sure that your child is growing up healthy. During one of
these checkups, your child’s PCP will:
• Do a comprehensive head-to-toe physical and mental health exam
• Give any needed immunizations (shots)
• Do any needed blood and urine tests
• Look into your child’s mouth and check his or her teeth
• Test your child for tuberculosis (TB) and lead (when age-appropriate)
YOUR HEALTH PLAN
We have a Child Health Checkup (CHCUP) program. This program provides needed care
for children up to age 21. CHCUP care may include services like:
• Give you health tips and education based on your child’s age
• Talk to you about your child’s growth, development and eating habits
• Measure your child’s height, weight, blood pressure, vision and hearing
These well-child checkups are done at certain ages. (We’ll talk about these a little later
in this section.) It’s very important that you get your child in to see his or her PCP for
these checkups. They can help to find health concerns before they become bigger
problems. Also, your child can get his or her needed immunizations.
Best of all, these checkups are done at no cost to you. So make sure to schedule your
child’s checkup today. If you need help setting up an appointment, call us. And don’t
forget, if you need to cancel the appointment, reschedule it as soon as you can.
Preventive Health Guidelines
The following are guidelines for preventive care. We’ve provided these to help you
remember to see your PCP. Your PCP will tell you when you and your family are due for
your checkups. He or she will also remind you when you and your family need certain
screenings and immunizations.
To help you stay on top of getting your recommended exams, we may call you. Or we
might send you a letter. We do this as a reminder for you. So if you get a call or letter
about your yearly flu shot or your child missing a well-child checkup, don’t ignore it.
These reminders are meant to help you and your family stay healthy.
Please remember – these are suggested guidelines. They do not replace your PCP’s
judgment. You should always talk with your PCP about the care that’s right for you and
your family.
Adult Preventive Health Guidelines
If you’re new to Staywell, you should get a baseline physical exam within the first 90
days of joining our plan. If you’re pregnant, you should get this done within 14 days.
Recommendations for periodic health exam visits for asymptomatic adults are:
• Age 19 to 39 – every one to three years (women should get an annual Pap smear – if
three normal smears in a row, then one every three years)
• Age 40 to 64 – every one to two years based on risk factors
• Age 65 and older – every year
Screening
Timing
Age 18 and older
Blood pressure, height,
body mass index (BMI),
alcohol use
Each year from age 18
to 21; then, every one
to two years or at PCP’s
recommendation
Men age 35 to 65
Cholesterol (non-fasting
TC/HDL)
Every five years (more
often if elevated)
Women age 45 to 65
TC/HDL)
often if elevated)
High-risk men and
women age 20 and older
TC/HDL)
often if elevated)
Women age 18 to 25
who are sexually active
(consider at age 12 if
sexually active)
Chlamydia
Each year and at PCP’s
recommendation
Women age 18 to 65
(or 3 years after onset
of sexual activity,
whichever comes first)
Pap smear
Every one to three years
Women 40 and older
Baseline (first)
mammography
Every one to two years
Age 50 and older
Colorectal (colonoscopy)
Periodically, depending
upon test
Women age 65 and
older (60 and older if
at risk)
Osteoporosis
Bone density test every
two years
Age 65 and older
Vision, hearing
Periodically
YOUR HEALTH PLAN
Age
Immunizations
Timing
Td: every 10 years, age 19 and older
Tetanus-Diphtheria and acellular
pertussis (Td/Tdap)
Tdap: substitute one dose of Tdap for
Td (one-time administration)
Varicella (VZV)
Susceptible adults only, age 18 and
older: two doses
Measles, Mumps, Rubella (MMR)
Adults age 19 to 49 who do not show
evidence of immunity: 1–2 doses
Pneumococcal
Age 65 and older: one dose
Flu shot
Every year
Hepatitis B vaccine (HepB)
Adults at risk, age 18 and older: three
doses
Meningococcal conjugate vaccine
College freshmen living in dormitories
and others at risk, age 18 and older:
one dose
Human papillomavirus vaccine (HPV)***
All previously unvaccinated women
through age 26: three doses
Prevention
Talk about aspirin to prevent
cardiovascular events
Men: age 40 and older periodically
Women: age 50 and older periodically
Talk about breast cancer (for women at high risk)
Talk about prostate-specific antigen (PSA) test and rectal exam (for men after age
40, at PCP’s discretion)
Counseling
Calcium: 1,000mg a day for women age 18 to 50; 1,200mg to 1,500mg a day for
women age 50 and older
Folic acid: 0.4mg a day for women of childbearing age; 4mg a day for women who
have had children with neural tube defects (NTDs)
Breastfeeding: women after giving birth
Pediatric Preventive Health Guidelines
(Newborn to Age 21)
These guidelines are recommendations only. Other services may be needed.
Age
Screening/Immunizations and Timing
Newborn
Well-baby* checkup at birth
Hearing test
Newborn screening blood tests
Immunizations: HepB shot
2 to 4 days
Well-baby checkup if discharged less than 48 hours after delivery
Newborn screening blood tests
Immunizations: HepB (if not done at birth)
1 month
Well-baby checkup
Newborn screening blood test if not already completed
Immunizations: second HepB
2 months
Well-baby checkup
Newborn screening blood test if not already completed
Immunizations: RV, DTaP, Hib, PCV, IPV
YOUR HEALTH PLAN
Quitting tobacco; drug and alcohol use; STDs and HIV; nutrition; physical activity;
sun exposure; oral health; injury prevention; polypharmacy
Age
4 months
Well-baby checkup
Immunizations: RV, DTaP, Hib, PCV, IPV
6 months
Well-baby checkup
Immunizations: RV, DTaP, Hib, PCV, IPV, HepB, flu shot
9 months
Well-baby checkup
Lab testing: blood lead
12 months
(1 year)
Well-baby checkup
Lab testing: blood lead, hemoglobin or hematocrit
Immunizations: Hib, MMR, HepA, flu shot
Dental visit** as needed
15 months
Well-baby checkup
Lab testing: urine and blood lead if not done at age 9 months or
12 months
18 months
Well-baby checkup
Immunizations: second HepA (six months after the first dose)
Dental visit
24 months
(2 years)
30 months
3 years
Well-baby checkup
Lab testing: blood lead
Immunizations: flu shot
Well-baby checkup
Well-child* checkup
Eye screening
Immunizations: flu shot
Dental visit once a year
Well-child checkup each year
Eye screening
4 and 5 years Lab testing: urine test at age 5
Immunizations: MMR, DTaP, IPV, Varicella, flu shot each year
Dental visit twice a year
Age
Well-child checkup every year
6 to 10 years Immunizations: flu shot every year
11 and 12
years
Well-child checkup each year
Immunizations: MCV, Tdap, HPV series, flu shot each year
*Well-baby, -child and -adolescent checkups/physical exam with infant totally
undressed or older child undressed and suitably covered, health history, developmental
and behavioral assessment, health education (sleep position counseling from age 0–9
months, injury/violence prevention and nutrition counseling), height, weight, test for
obesity (BMI), vision and hearing screening, head circumference at age 0–24 months and
blood pressure at least every year beginning at age 3
**Dental visits may be recommended beginning at age 6 months
***Subject to individual state coverage
The following services are provided as needed:
• Hemoglobin or hematocrit at ages 4, 18, 24 months and 3 years through 21 years
• Lead risk assessments and/or testing from age 6 months to age 6 years
• Tuberculosis risk assessments and/or testing from age 12 months through age 21
years
• Cardiovascular disease risk assessments and cholesterol screening from age 2 years
through age 21 years
• Sexually transmitted infections testing from age 11 years through age 21 years
• “Catch up” on any shots that have been missed at an earlier age
YOUR HEALTH PLAN
Well-adolescent* checkup every year
Females should have a pelvic exam and Pap smear between
13 to 21 years ages 18 and 21 years
Lab testing: urine by age 16
Immunizations: HPV series*** if not already completed, flu shot
Legal Disclaimer: Preventive health guidelines are based on guidelines from third parties
available before printing; these guidelines are not a replacement for your doctor’s
medical advice; he/she may have more current details; you should always talk with your
doctor(s) about what care and treatment is right for you; the fact that a service or item
is in these guidelines is not a guarantee of coverage or payment; members should look
at their own plan coverage papers to see what is or is not a covered benefit; Staywell
does not offer medical advice or provide medical care, and does not guarantee any
results or outcomes; Staywell does not warrant or guarantee, and shall not be liable for:
• Information in these guidelines
• Information not in these guidelines
• Any recommendations made by independent third parties from whom any of the
information was obtained
Version: 05/2011 (revised)
Advance Directives
Many people today worry about the medical care they would get if they became too
sick to make their wishes known. Some people may not want to spend months or years
on life support. Others may want every step taken to lengthen their lives.
You have the right to choose your own medical care. If you don’t want a certain type
of care, you have the right to tell your doctor you don’t want it. To do this, you should
complete an advance directive. This is a legal document. It tells others what kind of care
you would want if you were unable to communicate it yourself.
There are three types of advance directives:
• A living will
• A health care surrogate for health care decisions
• An anatomical donation
A living will:
Remember…
it’s your choice.
• States the kinds of care you want if you are
unconscious and will not come to
• It can be used for conditions that may lead to death
• It tells your doctor when to continue or stop care to keep you alive
A health care surrogate for health care decisions:
• Is when you name a person you want to make physical and/or mental health decisions
for you
An anatomical donation:
• Tells someone you wish to donate all or part of your body at death
• This can be an organ donation to someone in need of a transplant
• Or it can be a donation of your body to science
• It’s your choice to fill one out
• It is your right, under state law, to make decisions regarding medical care, including
the right to accept or refuse medical or surgical treatment
• Filling one out does not mean you want to commit suicide, physician-assisted
suicide, homicide or euthanasia (mercy killing)
• Filling one out will not affect anything that is based on your life or death (for
example, other insurance)
• You must be of sound mind to complete one
• You must be at least age 18 or an emancipated (legally free) minor
• You must sign it; you’ll need at least one other person to sign it too
• After you fill one out, keep it in a safe place; you should give a copy of it to
someone in your family and your doctor
• You can make changes to it at any time
• A caregiver may not follow your wishes if they go against his or her conscience (if a
caregiver cannot follow your wishes, he or she will help you find someone else who
can); otherwise, your wishes should be followed
−− If they are not being followed, a complaint can be filed by calling the Agency for
Health Care Administration’s (AHCA) Consumer Complaint Hotline toll free at
1-888-419-3456
To get an advance directive, talk with your PCP. You can also talk with an attorney.
If you need help with this, please call us.
YOUR HEALTH PLAN
We know that making these kinds of decisions can be hard. And you need to be ready
to answer some tough questions. Here are some things to think about as you write your
advance directives:
Member Grievance
and Appeals Procedures
We want you to let us know right away if you have any questions, complaints or
problems with your covered services or the care you receive. In this section we’ll
explain how you can tell us about these concerns/complaints.
There are three kinds of complaints you can make. They’re called:
• Complaints
• Grievances
• Appeals
State law allows you to make a complaint if you have any problems with us. The State
has also helped to set the rules for making a complaint. As well as what we must do
when we get a complaint. If you file a grievance or an appeal, we must be fair. We
cannot disenroll you from our plan or treat you differently.
Complaints
A complaint is when you’re unhappy with something with our plan. (It’s less formal than
a grievance.) When you have a complaint, contact us by calling or writing. Call Customer
Service at 1-866-334-7927 (TTY 1-877-247-6272) Monday–Friday, 8 a.m. to 7 p.m.
Or write to:
Attn: Grievance Department
P.O. Box 31384
Tampa, FL 33631-3384
We’ll resolve your complaint by the close of business the next business day or change it
to a formal grievance.
Grievances
A grievance is when you make a complaint about us. It can also be about a provider
and/or a service. These complaints may be about:
• Quality-of-care issues
• Wait times during provider visits
• The way your providers or others act or treat you
• Unclean provider offices
• Not getting the information you need
Attn: Grievance Department
P.O. Box 31384
Tampa, FL 33631-3384
You can fax it too. Our toll-free fax number is 1-866-388-1769.
You can file your grievance yourself. Or you can have someone file it for you. (This
includes your PCP or another provider.) If at any time you need help filing one, call us.
If you wish to have someone act for you, you must send us a signed statement. (It
should be signed by you.) The statement must say you are allowing this person to
represent you. To help with this, we have an Appointment of Representative (AOR) form
on our website. Go to florida.wellcare.com. You can use this form to allow someone to
act for you.
You must file your grievance within one year of the event that caused your
unhappiness.
Within five business days of getting your grievance, we’ll mail you a letter. It’ll tell you
we received your grievance. We’ll send you another letter with our decision within 60
calendar days or sooner.
YOUR HEALTH PLAN
You can file a grievance by calling or writing to us. To do so by phone, call Customer
Service at 1-866-334-7927 (TTY 1-877-247-6272) Monday–Friday, 8 a.m. to 7 p.m. To write
us, mail to:
You may not agree with our decision. If you don’t, you have the right to ask for a
Medicaid Fair Hearing. You must request this within 90 calendar days from receipt of our
decision. Send your request to:
Office of Appeals Hearings
1317 Winewood Boulevard
Building 5, Room 255
Tallahassee, FL 32399-0700
By phone, call 1-850-488-1429. By fax, send to 1-850-487-0662. By email, send to
Appeal_Hearings@dcf.state.fl.us. Or visit www.myflfamilies.com/about-us/officeinspector-general/investigation-reports/appeal-hearings.
Appeals
An appeal is a request you can make when you don’t agree with a decision we made
about your care. Or it can be for if we take too long to make a care decision. You can
ask for an appeal if we:
• Deny or limit a service you or your doctor asks us to approve
• Reduce, suspend or stop services you’ve been getting that we already approved
• Do not pay for the health care services you get
• Fail to give services in the required time frame
• Fail to give you a decision on an appeal you already filed in the required time frame
• Don’t agree to let you see a doctor who is not in our network and you live in a rural
area or in an area with limited doctors
You’ll get a letter from us when any of these actions occur. It’s called a “Notice of
Action” or “NOA.” You can file an appeal if you do not agree with our decision.
You may file an oral appeal or in writing within 30 days from the date on the Notice of
Action (NOA).You can file your appeal by calling or writing to us. To do so by phone,
call 1-866-334-7927 (TTY 1-877-247-6272) Monday–Friday, 8 a.m. to 7 p.m. If you call in
your appeal, you must follow up with a written, signed one. (Make sure to do this within
ten calendar days of calling in your appeal.)
Send Your Written Appeals Here
For appeal requests for
medical services:
For appeal requests for pharmacy
medications:
Attn: Appeals Department
P.O. Box 31368
Attn: Pharmacy Medication
Appeals Department
Tampa, FL 33631-3368
P.O. Box 31398
Tampa, FL 33631-3398
Fax to: 1-888-865-6531
You can file your appeal yourself. Or you can have someone file it for you. (This
includes your PCP or another provider.) We must have your written permission before
someone can file an appeal for you. We can help you with your appeal too.
We’ll send you a letter within five business days of getting your appeal. It’ll let you know
we received your appeal. We’ll then review it and send you a decision letter within 30
calendar days. You or your authorized representative can review the information we
used to make our decision.
Fast or “Expedited” Appeals
There may be times when you or your provider will want us to make a faster appeal
decision. This could be because you or your provider feels that waiting 30 calendar days
could seriously harm your health. If so, you can ask for a fast or “expedited” appeal.
You or your provider must call or fax us to ask for a fast appeal. Our fax number is
1-866-201-0657 (for a medical appeal) or 1-888-865-6531 (for a pharmacy appeal). If your
appeal request is filed verbally, written notice is not needed.
If we decide you need a fast appeal, we’ll call you with our decision. We will do this
within 72 hours after receiving and accepting your fast appeal. We’ll also send you a
letter with our decision.
If you ask for a fast appeal and we decide that one is not needed, we will:
• Change the appeal to the time frame for a standard decision (30 calendar days)
YOUR HEALTH PLAN
Fax to: 1-866-201-0657
• Call you the same day we decide a fast appeal is not needed to tell you about our
denial of your fast appeal request
• Follow up with a written letter within two calendar days
• Tell you over the phone and in writing that you may file a grievance about the denial
of your fast appeal request
Additional Information
You or someone appealing for you can give us more information if you feel it’ll help
your appeal. You can do this at any time during the appeal process.
For a standard appeal, you can ask us for up to 14 more calendar days to provide more
information. If needed, we may ask for 14 more calendar days, too, to make a decision
on a standard appeal. If we need more time, we’ll send you a letter within five business
days telling you why. We’ll do this if we feel more information is needed, and it’s in your
best interest.
Additional Appeals Assistance
If you’re not happy with our appeal decision, you have a couple of options available to
you. You can file a request with the Beneficiary Assistance Program. Or you can ask for
a Medicaid Fair Hearing.
Beneficiary Assistance Program (BAP)
If you’re not happy with our appeal decision, you can file a request with the BAP.
But, you:
• Can only file a request after you’ve gone through all of our appeals steps and
received our appeal decision letter
• Must make your request within one year of receiving our final appeal decision letter
The BAP will only hear your case if it’s when we:
• Deny or limit a service you or your doctor asked us to approve
• Reduce, suspend or stop services you’ve been getting that we already approved
• Don’t pay for the health care services you already received
To file a request with the BAP, write to:
Agency for Health Care Administration
Beneficiary Assistance Program
Building 3, MS#26
2727 Mahan Drive
Tallahassee, FL 32308
By phone, call 1-850-412-4502 or toll-free 1-888-419-3456.
Please be aware:
Medicaid Fair Hearing
Instead of filing a request with the Beneficiary Assistance Program (BAP), you can
ask for a Medicaid Fair Hearing. Unlike a BAP request, you can ask for a Medicaid Fair
Hearing at any time during your grievance or appeal. But you must ask for it within 90
calendar days from receipt of our Notice of Action (NOA) letter.
To request a Medicaid Fair Hearing, write to:
Office of Appeals Hearings
1317 Winewood Boulevard
Building 5, Room 255
Tallahassee, FL 32399-0700
By phone, call 1-850-488-1429. By fax, send to 1-850-487-0662. By email, send to
Appeal_Hearings@dcf.state.fl.us. Or visit www.myflfamilies.com/about-us/officeinspector-general/investigation-reports/appeal-hearings.
YOUR HEALTH PLAN
• The BAP will not hear your appeal case if you have already had a Medicaid Fair
Hearing for the same issue
• Asking for a Medicaid Fair Hearing may make you ineligible for a BAP review
Remember:
BAP
Medicaid Fair Hearing
You must request within one year of
the event that caused your appeal
You must request within 90 calendar
days of receipt of our decision
OR
You can only request after finishing
our appeals process and receiving our
appeal decision
You can request at any time during
your appeal but you must ask for it
within 90 calender days from the date
on the Notice of Action (NOA)
Important:
The BAP will not hear your appeal case if you have
already had a Medicaid Fair Hearing for the same issue
Asking for a Medicaid Fair Hearing may make you ineligible for a BAP review
Continuation of Benefits during the Appeals Process
You can ask that we continue to cover your medical services during the appeals
process. (This includes through a BAP or Medicaid Fair Hearing.) To do this:
• You must file your appeal with us within 10 calendar days of our mailing the Notice
of Action (NOA) to you or the date the service will be reduced, suspended or
stopped, whichever is later
• Your appeal involves an action we’re taking to reduce, suspend or stop a service we
had already approved
• The service must have been ordered by an authorized provider
• The original time period covered by the approval we gave has not yet ended
• You need to ask for a continuation of benefits
If the BAP or Medicaid Fair Hearing is decided in your favor, we’ll approve and pay
for the care that is needed as quickly as possible. (This is if you didn’t receive the care
during the review of your case.)
If our original appeal decision (to deny your appeal) remains the same, you may have to
pay for the service(s) you received while waiting for the decision.
Important Member
Information
Your Staywell Membership
In this section, we’ll touch on our enrollment and disenrollment processes. If you have
any questions, call us. The number is 1-866-334-7927 (TTY 1-877-247-6272).
Remember to Recertify Your Eligibility with the Department of
Children and Families (DCF)
Don’t forget to recertify your eligibility with DCF. If you don’t, you may lose your
Staywell benefits.
You’ll receive a letter from DCF. It’ll be sent when it’s time
to recertify your eligibility. This letter will tell you what
you need to do and by when you need to do it. Be sure to
provide all of the paperwork that’s required.
Here are some of the items you may need:
• Your Social Security number
• Information like your pay, any child support you may
get, bank account details and other insurance you have
(through your job)
• Your monthly expenses (for example, your electric and
phone bills)
It’s important that
you tell us and DCF
when you move.
That way your
renewal letter is sent
to the right address.
Make sure you
respond to this
letter. And do
it quickly. If you
don’t, your Staywell
benefits could end.
You can renew a couple of ways:
• Log on to the DCF ACCESS website at www.myflorida.
com/accessflorida/ and follow the instructions
• Call the DCF ACCESS Customer Call Center toll-free at
1-866-762-2237
• Visit a DCF partner in your area (you can find this information on the website above)
If you have any questions, give us a call. Or you can call DCF at the number above.
Enrollment
If you are a mandatory member required to enroll in a plan, once you are enrolled in
Staywell or the State enrolls you in a plan, you will have 90 days from the date of your
first enrollment to try the managed care plan. During the first 90 days you can change
managed care plans for any reason. After the 90 days, if you are still eligible for Medicaid,
you will be enrolled in the plan for the next nine months. This is called “lock-in.”
Open Enrollment
If you are a mandatory member, the State will send you a letter 60 days before the end
of your enrollment year telling you that you can change plans if you want to. This is
called “Open Enrollment.” You do not have to change managed care plans. If you choose
to change plans during Open Enrollment, you will begin in the new plan at the end of
your current enrollment year. Whether you pick a new plan or stay in the same plan, you
will be locked into that plan for the next 12 months. Every year you may change managed
care plans during your 60-day Open Enrollment period.
Reinstatement
If you lose your Medicaid eligibility, you’ll be removed from our plan. But if you get it
back within 180 days, you’ll return to us. (This is called reinstatement.)
We’ll send you a letter within five days of your reinstatement. It’ll tell you that you’re
back in our plan. We will not automatically send you a new ID card, member handbook
and provider directory. If you need us to send these items to you again, give us a call.
Disenrollment
• You do not live in a region where the managed care plan is authorized to provide
services
• Your provider is no longer with the managed care plan
• You are excluded from enrollment
• A substantiated marketing or community outreach violation has occurred
• You are prevented from participating in the development of your treatment plan/plan
of care
• You have an active relationship with a provider who is not on the managed care plan’s
panel, but is on the panel of another managed care plan (“active relationship” is
defined as having received services from the provider within the six months preceding
the disenrollment request)
• You are in the wrong managed care plan as determined by the Agency
• The managed care plan no longer participates in the region
• The State has imposed intermediate sanctions upon the managed care plan, as
specified in 42 CFR 438.702(a)(3)
If you are a mandatory member and you want to change plans after the initial 90-day
period ends or after your Open Enrollment period ends, you must have a state-approved
good cause reason to change plans. The following are state-approved cause reasons to
change managed care plans:
• You need related services to be performed concurrently, but not all related services
are available within the managed care plan network, or your PCP has determined
that receiving the services separately would subject you to unnecessary risk
• The managed care plan does not, because of moral or religious objections, cover the
service you seek
• You missed Open Enrollment due to a temporary loss of eligibility
• Other reasons per 42 CFR 438.56(d)(2) and s. 409.969(2), F.S., including, but not limited
to poor quality of care, lack of access to services covered under the Contract,
inordinate or inappropriate changes of PCPs, service access impairments due to
significant changes in the geographic location of services, an unreasonable delay or
denial of service, lack of access to providers experienced in dealing with your health
care needs, or fraudulent enrollment
Some Medicaid recipients may change managed care plans whenever they choose, for
any reason. To find out if you may change plans, call the Enrollment Broker at
1-877-711-3662 (TTY 1-866-467-4970).
Involuntary Disenrollment
There are certain reasons you can be disenrolled from our plan. They can include if you:
• Commit fraud or abuse your health care services
• Act in a disruptive way, and this behavior is not caused by a known illness
• Lose your Medicaid eligibility or can no longer be an member
• Go to jail
You CANNOT be removed from our plan for these reasons:
• Medical problems you had before becoming our member
• A change in your health
• Reduced mental capacity
• Disruptive behavior because of your special needs
• The amount of services you use
• Missed medical appointments
• Not following your PCP’s plan for your care
• For filing a grievance or appeal with us
• If a provider asks us to move you to another provider who is not in our network
Important Information
about Staywell
Here we’ll talk about some of the things we do “behind the scenes.” Call us with your
questions. We can be reached at 1-866-334-7927 (TTY 1-877-247-6272). We’re available
Monday–Friday, 8 a.m. to 7 p.m.
Plan Structure and Operations and How Our Providers Are Paid
You may have other questions about how our plan works. Questions like:
• What’s the make-up of our company?
• How do we run our business?
• How do we pay the providers who are in our network?
• Does how we pay our providers affect the way they authorize a service for you?
• Do we offer rewards to the providers in our network?
If you do, call us and we’ll answer them for you.
Evaluation of New Technology
• Make sure we’re aware of changes in the industry
• See how new improvements can be used with the services we provide to
our members
• Make sure that our members have fair access to safe and effective care
We do this review in the following areas:
• Mental health procedures
• Medical devices
• Medical procedures
• Pharmaceuticals
We study new technology every year. Plus, we look at the ways we use the technology
we already have. We do this for a couple of reasons. They are to:
Quality Improvement and Member Satisfaction
We’re always looking at ways to improve care and service for our members. Each year
we select certain things to review for quality. We check to see how we’re doing in
those areas. We may also check to see how our providers are doing in those same
areas. We want to know if our members are happy with the care and services they get.
Want to know about our quality ratings? Give us a call. You can ask about how satisfied
members are with our plan too. You can also provide comments or suggestions about:
• How we’re doing
• How we can improve on our services
Fraud, Waste and Abuse
Billions of dollars are lost to health care fraud every year. What is health care fraud,
waste and abuse? It’s when false information is given on purpose. This can be done by
a member or provider. This false information can lead to someone getting a service or
benefit that is not allowed.
Here are some other examples of provider and member fraud, waste and abuse:
• Billing for a more expensive service than what was actually given
• Billing more than once for the same service
• Billing for services not actually performed
• Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that
aren’t medically necessary
• Filing claims for services or medications not received
• Forging or altering bills or receipts
• Misrepresenting procedures performed to get payment for services that are not
covered
• Over-billing us or a member
• Waiving patient co-pays or deductibles
• Using someone else’s Staywell ID card
• Sharing your own Staywell ID card with another person
To Report Fraud, Waste or Abuse with Staywell
If you know of any fraud that has occurred, call our 24-hour fraud hotline. The toll-free
number is 1-866-678-8355. It’s also private. You can leave a message without leaving
your name. If you do leave a number, we’ll call you back. We’ll call to make sure the
information we have is complete and accurate.
You can also report fraud on our website. Go to florida.wellcare.com. Giving a report
through the Web is kept private too.
To Report Fraud, Waste or Abuse with Florida Medicaid
To report suspected fraud and/or abuse in Florida Medicaid:
• Call the Consumer Complaint Hotline toll-free at 1-888-419-3456, or
• Complete a Medicaid Fraud and Abuse Complaint Form, which is available online at:
https://apps.ahca.myflorida.com/InspectorGeneral/fraud_complaintform.aspx
• If you report suspected fraud and your report results in a fine, penalty or forfeiture of
property from a doctor or other health care provider, you may be eligible for a reward
through the Attorney General’s Fraud Rewards Program (toll-free 1-866-966-7226 or
1-850-414-3990)
• The reward may be up to twenty-five percent (25%) of the amount recovered, or a
maximum of $500,000 per case (Section 409.9203, Florida Statutes)
• You can talk to the Attorney General’s Office about keeping your identity confidential
and protected
Member Rights
As a member of our plan, you have the right to:
• Get details about what we cover and how to use
our services and network providers
As a member of our plan,
you have rights. Plus,
• Have your privacy protected
certain responsibilities.
• Know the names and titles of doctors and others
who treat you
• Talk openly about care needed for your health, no
matter the cost or benefit coverage
• Freely talk about your care options and any risks involved
• Have this information shared in a way you understand
• Know what to do for your health after you leave the hospital or doctor’s office
• Refuse to take part in research
• Create an advance directive
• Suggest ways we can improve our health plan
• File complaints or appeals about our health plan or the care we provide
• Have a say in our member rights
• Have all these rights apply to the person who can legally make health care decisions
for you
• Have all of our staff members observe your rights
• Use these rights no matter your sex, age, race, ethnic, economic, educational or
religious background
• Receive information about our organization, services, practitioners and providers,
and member rights and responsibilities
• Participate with practitioners in making decisions about your health care
• A candid discussion of appropriate or medically necessary treatment options for
your conditions, regardless of cost or benefit coverage
• Make recommendations regarding our member rights and responsibilities
• Be treated with respect and with due consideration for your dignity and privacy
• Receive information on available treatment options and alternatives, presented in a
manner appropriate to the your condition and ability to understand
• Participate in decisions regarding your health care, including the right to refuse
treatment
• Be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience or retaliation
• Ask for and receive a copy of your medical records, and ask that they be amended
or corrected
−− Requests must be received in writing from you or the person chosen to represent
you
−− The records will be provided at no cost to you
−− The records will be sent within 14 days of receipt of the request
• Be furnished health care services in accordance with federal and state regulations;
the State must make sure you are:
−− Free to exercise your rights, and
−− The exercising of these rights does not adversely affect the way Staywell and our
providers or the State treats you
Member Responsibilities
As a member of our plan, you have the responsibility to:
• Know how Staywell works by reading this handbook
• Carry your ID card and Medicaid Gold Card with you at all times and to show them
when you get health care services
• Get non-emergency care from your PCP
• Get referrals for specialty care
• Work with those giving you care
• Be on time for your medical appointments
• Cancel or set up a new time for an appointment ahead of time
• Report unexpected changes in your health to your provider
• Respect your doctors, their staff and other patients
• Help set treatment goals that you and your doctor agree to
• Follow the treatment plan you and your provider agree on
• Understand medical advice and ask questions if you do not
• Know about the medicine you take, what it’s for, and how to take it
• Provide information needed to treat you
• Make sure your doctor has your previous medical records
• Tell us within 48 hours, or as soon as you can, if you are in a hospital or go to the ER
• Give information (to the extent possible) that we and our network providers need in
order to give care
• Understand your health problems and participate in developing mutually agreed-upon
treatment goals to the degree possible
WellCare Notice of Privacy Practices
WellCare Notice of Privacy Practices
This notice describes how medical information about you may be
used and disclosed and how you can get access to this information.
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Effective Date of this Privacy Notice: March 29, 2012
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Revised as of August, 2013
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We may change our privacy practices from time to time. If we make any material revisions to this
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the date on which such revised Privacy Notice becomes effective. The revised Privacy Notice will
apply to all of your health information from and after the date of the Privacy Notice.
©WellCare 2013 NA_08_13_V1
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©WellCare 2013 NA_08_13_V1
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How We May Use and Disclose Your Health Information
without Written Authorization
WellCare requires its employees to follow its privacy and security policies and procedures to
protect your health information in oral (for example, when discussing your health information
with authorized individuals over the telephone or in person), written or electronic form. The
following are situations where we do not need your written authorization to use your health
information or to share it with others.
1. Treatment, Payment, and Business Operations. We may use your health information
or share it with others to help treat your condition, coordinate payment for that treatment,
and run our business operations. For example:
Treatment. We may disclose your health information to a health care provider that
provides treatment to you. We may use your information to notify a physician who treats
you of the prescription drugs you are taking.
Payment. We will use your health information to obtain premium payments, specialty pharmacy
payments, or to fulfill our responsibility for coverage and the provision of benefits under a
health plan, such as processing a physician claim for reimbursement for services provided to you.
Health Care Operations. We may also disclose your health information in connection
with our health care operations. These include fraud, waste and abuse detection and
compliance programs, customer service and resolution of internal grievances.
Treatment Alternatives and Health-Related Benefits and Services. We may use
and disclose your health information to tell you about treatment options or alternatives,
appointment reminders, and health-related benefits or services that may be of interest to you.
Underwriting. We may use or disclose your health information for certain underwriting
purposes. However, we will not use or disclose your genetic information for underwriting
purposes.
Family Members, Relatives or Close Friends Involved in Your Care. Unless you
object, we may disclose your health information to your family members, relatives or close
personal friends identified by you as being involved in your treatment or payment for your
medical care. If you are not present to agree or object, we may exercise our professional
judgment to determine whether the disclosure is in your best interest. If we decide to
disclose your health information to your family member, relative or other individual
identified by you, we will only disclose the health information that is relevant to your
treatment or payment.
Business Associates. We may disclose your health information to a “business associate” that
needs the information in order to perform a function or service for our business operations. We
will do so only if the business associate signs an agreement to protect the privacy of your health
information. Third party administrators, auditors, lawyers, and consultants are some examples of
business associates.
2. Public Need. We may use your health information, and share it with others, in order to
comply with the law or to meet important public needs that are described below:
• if we are required by law to do so;
• to authorized public health officials (or a foreign government agency collaborating with
such officials) so they may carry out their public health activities;
• to government agencies authorized to conduct audits, investigations, and inspections,
as well as civil, administrative or criminal investigations, proceedings, or actions, including
those agencies that monitor programs such as Medicare and Medicaid;
• to a public health authority if we reasonably believe you are a possible victim of abuse,
neglect or domestic violence;
• to a person or company that is regulated by the Food and Drug Administration for: (i) reporting
or tracking product defects or problems, (ii) repairing, replacing, or recalling defective or dangerous
products, or (iii) monitoring the performance of a product after it has been approved for
use by the general public;
• if ordered by a court or administrative tribunal to do so, or pursuant to a subpoena, discovery
or other lawful request by someone else involved in the dispute, but only if efforts have been
made to tell you about the request or to obtain a court order protecting the information
from further disclosure;
• to law enforcement officials to comply with court orders or laws, and to assist law enforcement
officers with identifying or locating a suspect, fugitive, witness, or missing person;
• to prevent a serious and imminent threat to your health or safety, or the health or safety
of another person or the public, which we will only share with someone able to help
prevent the threat;
• for research purposes;
• to the extent necessary to comply with workers’ compensation or other programs established
by law that provide benefits for work-related injuries or illness without regard to fraud;
• to appropriate military command authorities for activities they deem necessary to carry
out their military mission;
• to authorized federal officials who are conducting national security and intelligence
activities or providing protective services to the President or other important officials;
• to the prison officers or law enforcement officers if necessary to provide you with health
care, or to maintain safety, security and good order at the place where you are confined;
• in the unfortunate event of your death, to a coroner or medical examiner, for example, to
determine the cause of death;
• to funeral directors as necessary to carry out their duties; and
• in the unfortunate event of your death, to organizations that procure or store organs,
eyes or other tissues so that these organizations may investigate whether donation or
transplantation is possible under law.
3. Completely De-Identified and Partially De-Identified Information. We may use
and disclose “completely de-identified” health information about you if we have removed
any information that has the potential to identify you. We may also use and disclose
“partially de-identified” health information about you for public health and research
purposes, or for business operations, if the person who will receive the information signs an
agreement to protect the privacy of the information as required by federal and state law.
Partially de-identified health information will not contain any information that would directly
identify you (such as your name, street address, Social Security number, phone number, fax
number, electronic mail address, Web site address, or license number).
Requirement for Written Authorization
We may use your health information for treatment, payment, health care operations or other
purposes described in this Privacy Notice. You may also give us written authorization to use your
health information or to disclose it to anyone for any purpose. We cannot use or disclose your
health information for any reason, except those described in this Privacy Notice, unless you give
us a written authorization to do so. For example, we require your written authorization for most
uses and disclosures of psychotherapy notes (where appropriate), uses and disclosures of health
information for marketing purposes, and disclosures that constitute a sale of your health
information. Marketing is a communication about a product or service that encourages recipients
of the communication to purchase or use the product or service.
You may revoke your authorization in writing at any time. Your revocation will not affect any use or
disclosures permitted by your authorization while it was in effect.
Your Rights to Access and Control Your Health Information
We want you to know that you have the following rights to access
and control your health information.
1. Right to Access Your Health Information. You have the right to inspect and obtain a
copy of your health information except for health information: (i) contained in psychotherapy
notes; (ii) compiled in anticipation of, or for use in, a civil, criminal, or administrative proceeding;
and (iii) with some exceptions, information subject to the Clinical Laboratory Improvements
Amendments of 1988 (CLIA). If we use or maintain an electronic health record (EHR) for you, you
have the right to obtain a copy of your EHR in electronic format. You also have the right to direct
us to send a copy of your EHR to a third party that you clearly designate.
If you would like to access your health information, please send your written request to the address
listed on the last page of this Privacy Notice. We will ordinarily respond to your request within 30
days if the information is located in our facility, and within 60 days if it is located off-site at another
facility. If we need additional time to respond, we will let you know as soon as possible. We may
charge you a reasonable, cost-based fee to cover copy costs and postage. If you request a copy of
your EHR, we will not charge you any more than our labor costs in producing the EHR to you.
We may not give you access to your health information if it:
(i) is reasonably likely to endanger the life and physical safety of you or someone else as
determined by a licensed health care professional;
(ii) refers to another person and a licensed health care professional determines that your access
is likely to cause harm to that person; or
(iii) a licensed health care professional determines that your access as the representative of
another person is likely to cause harm to that person or any other person.
If you are denied access for one of these reasons, you are entitled to a review by a health care
professional, designated by us, who was not involved in the decision to deny access. If access is
ultimately denied, you will be entitled to a written explanation of the reasons for the denial.
2. Right to Amend Your Health Information. If you believe we have health information
about you that is incorrect or incomplete, you may request in writing an amendment to your
health information. If we do not have your health information, we will give you the contact
information of someone who does. You will receive a response within 60 days after we receive
your request. If we did not create your health information or your health information is
already accurate and complete, we can deny your request and notify you of our decision in
writing. You can also submit a statement that you disagree with our decision, which we can
rebut. You have the right to request that your original request, our denial, your statement of
disagreement, and our rebuttal be included in future disclosures of your health information.
3. Right to Receive an Accounting of Disclosures. You have the right to receive an
accounting of disclosures of your health information made by us and our business associates.
You may request such information for the six-year period prior to the date of your request.
Accounting of disclosures will not include disclosures:
(i) for payment, treatment or health care operations;
(ii) made to you or your personal representative;
(iii) that you authorized in writing;
(iv) made to family and friends involved in your care or payment for your care;
(v) for research, public health or our business operations;
(vi) made to federal officials for national security and intelligence activities;
(vii) made to correctional institutions or law enforcement; and
(viii) of an incident related to a use or disclosure otherwise permitted or required by law.
If you would like to receive an accounting of disclosures, please write to the address listed
on the last page of this Privacy Notice. If we do not have your health information, we will
give you the contact information of someone who does. You will receive a response within
60 days after your request is received. You will receive one request annually free of charge,
but we may charge you a reasonable, cost-based fee for additional requests within the same
twelve-month period.
4. Right to Request Additional Privacy Protections. You have the right to request that
we place additional restrictions on our use or disclosure of your health information. If we
agree to do so, we will put these restrictions in place except in an emergency situation. We
do not need to agree to the restriction unless (i) the disclosure is for the purpose of carrying
out payment or health care operations and is not otherwise required by law, and (ii) the
health information relates only to a health care item or service that you or someone on your
behalf has paid for out of pocket and in full. You have the right to revoke the restriction at
any time.
5. Right to Request Confidential Communications. You have the right to request
that we communicate with you about your health information by alternative means or via
alternative locations. If you wish to receive confidential communications via alternative
means or locations, please submit your written request to the address listed on the last
page of this Privacy Notice. You must clearly state in your request that the disclosure of
your health information could endanger you and list how or where you wish to receive
communications.
6. Right to Notice of Breach of Unencrypted Health Information. We are required by
law to maintain the privacy of your health information, and to provide you with this Privacy
Notice containing our legal duties and privacy practices with respect to your protected
health information. Our policy is to encrypt our electronic files containing your health
information so as to protect the information from those who should not have access to it. If,
however, for some reason we experience a breach of your unencrypted health information,
we will notify you of the breach. If we have more than ten people that we cannot reach
because of outdated contact information, we will post a notification either on our Web site
(www.wellcare.com) or in a major media outlet in your area.
7. Right to Obtain a Paper Copy of this Notice. You have the right at any time to obtain a
paper copy of this Privacy Notice, even if you receive this Privacy Notice electronically.
Please send your written request to the address listed on this page of this Privacy Notice or
visit our Web site at www.wellcare.com.
Miscellaneous
1. Contact Information. If you have any questions about this Privacy Notice, you may contact
the Privacy Officer at 1-888-240-4946 (TTY/TDD 1-877-247-6272), call the toll-free number
listed on the back of your membership card, visit www.wellcare.com, or write to us at:
WellCare Health Plans, Inc.
Attention: Privacy Officer
P.O. Box 31386
Tampa, FL 33631-3386
2. Complaints. If you are concerned that we may have violated your privacy rights, you may
complain to us using the contact information above. You also may submit a written
complaint to the U.S. Department of Health and Human Services. If you choose to file a
complaint, we will not retaliate or take action against you for your complaint.
3. Additional Rights. This Privacy Notice explains the rights you have with respect to your
health information, including access and amendment rights, under federal law. Some state laws
provide even greater rights, including more favorable access and amendment rights, as well as
more protection for particularly sensitive information, such as information involving HIV/AIDS,
mental health, alcohol and drug abuse, sexually transmitted diseases, and reproductive health.
To the extent the law in the state where you reside affords you greater rights than described in
this Privacy Notice, we will comply with these laws.
1-866-334-7927
(TTY 1-877-247-6272)

2014 Staywell Member Handbook

Transcription

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