2016 Medicaid Member Handbook and Welcome Kit

Transcription

1 FLORIDA 2016 Medicaid Member Handbook and Welcome Kit MAGELLAN COMPLETE CARE

2

3 Table of Contents Introduction and First Steps About Magellan Complete Care SM...2 Welcome to Magellan Complete Care!....2 Please Call Today!...2 Your Care Coordination Team...3 Helpful Tips...3 Contact Information...4 These telephone numbers may also help you..4 Becoming a Member...6 Enrollment...6 Open Enrollment...6 Pregnancy and Newborn Enrollment...6 Enrollment Member ID Card...7 Enrollment & Disenrollment...7 Reinstatement Process...8 How to Get Services...9 Selecting a PCP...9 Changing a PCP...9 Access to Care/Appointment...9 Continuity of Care...10 Referral and Approval for Specialty, Ancillary and Hospital Care...10 Access to Behavioral Health Services Getting Behavioral Health & Substance Abuse Services...12 Emergency Services...13 Emergency Services...13 Behavioral Health Emergencies...13 Please Let Us Know...13 Did you seek care for an emergency?...13 Out of Area Emergency Services...13 Covered Services...14 Covered Service and Limitations...14 Magellan Complete Care Expanded Services..18 Additional Notes for Covered Services...19 Services Not Covered by Magellan Complete Care...21 How to Get Medications...21 Informed Consent for Certain Drugs Improving Your Health...22 Member Rewards Program...22 Prevention Programs...22 Case Management and Disease Management Programs...22 Online Interactive Tools For Health and Wellness...22 Child Health Check-Up/Vaccines...23 Urgent Care...23 Quality Benefit Enhancement Programs...24 Review of New Treatment Options...24 Complaints, Grievances and Appeals Process...25 Complaints...25 Grievances...25 Appeals...25 Expedited Appeal...25 Medicaid Fair Hearing/ Subscriber Assistance Program...26 Protected Health Information...27 Release of Information on Sensitive Conditions...27 Member Rights and Responsibilities...28 Second Medical Opinion...29 Reporting Abuse, Neglect, or Exploitation...29 Reporting Fraud, Waste, and Abuse...29 Living Wills and Advance Directives...31 The Patient s Right to Decide Questions About Health Care Advance Directives...32 More Information on Health Care Advance Directives...34 Helpful Forms...36 Adult Health Assessment...37 Child Health Assessment...41 Grievance Form...45 Appeals Form...47 Living Will...49 Designation of Health Care Surrogate...51 Uniform Donor Form...53 Health Care Advance Directives

4 Introduction and First Steps About Magellan Complete Care SM Magellan Complete Care has a lot of know-how in health care. We help our members with these services: Coordinating medical care with your doctors. Coordinating behavioral health services with medical care. Giving you the okay for specialty and hospital services. Quality management programs. Case management and disease management programs for members with special needs and conditions. Managing your pharmacy benefits. To join Magellan Complete Care you must have Medicaid benefits and a Serious Mental Illness (SMI). Our plan specializes in linking your physical and behavioral health care. We make sure your care is coordinated and you have whole health care. If you would like to learn more about Magellan Complete Care, please visit our website at You will be able to learn about our health plan. Learn about quality programs, healthy living programs, physician incentive programs and health education resources. You can also find performance measures and information about our plan s performance. Magellan Complete Care is a Managed Care Plan with a Florida Medicaid contract. The Florida Agency for Healthcare Administration (AHCA) oversees our plan. They have information on their website at Welcome to Magellan Complete Care! We are happy you are our member. Your member handbook has important information. This handbook will help you better understand your health plan. This is also your certificate of coverage. If you need the Member Handbook in a different language, please call Magellan Complete Care Customer Service. This service is available free of charge. Si necesita el manual de miembro en otro idioma, por favor llame a Magellan Complete Care. We will help you with important steps to stay healthy! Please Call Today! Call Magellan Complete Care Member Services at or TTY only and our member specialists will: Welcome you to Magellan Complete Care and answer your questions. If you have not chosen a primary care doctor (PCP), we will help you choose one over the phone. Help you schedule an appointment with your PCP. Help you visit your PCP within the first 90 days of enrollment to get a health assessment. Tell you about extra benefits. Tell you about special programs. It will only take a few minutes, but it will help us to serve you better. If we don t hear from you, we will try to call you to make it easier for you. We want to do everything we can to help you stay healthy. 2

5 Your Care Coordination Team Magellan Complete Care will connect you to a Care Manager who will help you: Find your way through the health care system. Make sure all of your doctors have a copy of your medical records. Help you with making appointments. Help you complete your health and wellness questionnaire. Connect to support services in your community. We will work with you to choose a primary care doctor and primary behavioral health doctor. They will be part of your Care Coordination Team. Your team will also include you, your family or supports and others such as a case manager, as needed. Please let us know if someone on your care coordination team is not a good fit. You can choose a different Health Guide, Integrated Care Case Manager and/or Wellness Specialist within Magellan Complete Care, if one is available. Helpful Tips Before you go to your first primary care doctor (PCP) appointment, you may want to write down important information to share with him/her. Behavioral health provider name (if seeing one). Other specialists names. Your health conditions (for example, bipolar disorder, heart disease, asthma). Medications and how much you take. Questions or concerns you have about your health. Please keep a copy of these documents handy: Member ID card. Member Handbook. Provider Directory. You will need these documents as a member of our health plan. If you need help with anything about your health or health plan, please call Customer Service toll free at If you are hearing impaired, call our TTY number at We are able to talk with you in any language or format at no charge to you. We are here for you 24 hours a day, seven days a week. If you have health questions, our Nurse Line is here for you. If you have an emergency such as chest pain or trouble breathing, call 911 instead of the Nurse Line. If your address changes, please contact us at and the State Medicaid Enrollment Broker to update your address. 3

6 Contact Information We want to hear from you. You are not alone. Just give us a call for help. Magellan Complete Care s telephone numbers are toll free. We can answer your questions in any language. We can help you if you are hearing or vision impaired too. These services are free of charge. Customer Service is available from 8:00 am 7:00 pm at If you are hearing impaired, call our TTY number toll free at Nurses are available 24/7 to help with nonemergency health questions at If you are hearing impaired, call our TTY number toll free at Please visit our website at These telephone numbers may also help you: Florida Department of Children and Families Hours: 8:00 am to 5:00 pm Toll free: State Medicaid Enrollment Broker Toll free: TTY/TDD: Web: Local Medicaid office Bay, Franklin, Gulf, Holmes, Jackson, and Washington Counties Office: Toll free: Local Medicaid office Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia Counties Office: Toll free: Local Medicaid office Pasco and Pinellas Office: Toll free: Local Medicaid office Hardee, Highlands, Hillsborough, Manatee, and Polk Counties Office: Toll free: Local Medicaid office Brevard, Orange, Osceola, and Seminole Counties Office: Toll free: Local Medicaid office Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie Counties Office: Toll free: Local Medicaid office Broward County Office: Toll free: Local Medicaid office Miami-Dade and Monroe Counties Office: Toll free: Aging and Disabilities Resource Centers Hours: 8:00 am 5:00 pm Toll free: (ELDER)-5337 TDD: Web: Local Medicaid office Calhoun, Gadsden, Jefferson, Leon, Liberty, Madison, Taylor, and Wakulla Counties Office: Toll free:

7 Area 2 Agency Area Agency on Aging for North Florida, Inc Mahan Drive Tallahassee, FL, Office: Web: Area 4 Agency ElderSource, The Area Agency on Aging of Northeast Florida Old St Augustine Road Jacksonville, FL Office: Web: Area 5 Agency Area Agency on Aging of Pasco-Pinellas, Inc Kroger Boulevard North, Suite 100 St. Petersburg, FL Office: Web: Area 9 Agency Your Aging Resource Center 4400 N. Congress Avenue West Palm Beach, FL Office: Web: Area 10 Agency Aging & Disability Resource Center of Broward County, Inc Hiatus Road Sunrise, FL Office: Web: Area 11 Agency Alliance for Aging, Inc. 760 NW 107th Avenue, Suite 214, 2nd floor Miami, FL Office: Web: Area 6 Agency West Central Florida Area Agency on Aging, Inc Breckenridge Parkway, Suite F Tampa, FL Office: Web: Area 7 Agency Senior Resource Alliance 988 Woodcock Road, Suite 200 Orlando, FL Office: Web: 5

8 Enrollment Becoming a Member To join Magellan Complete Care, you must have Medicaid benefits and a serious mental illness (SMI). Eligibility is managed by the Florida Department of Children and Families (DCF) at ACCESS ( ). Membership begins on the first day of any calendar month once you are approved by the State. You have the right to choose a health plan. If you don t choose a health plan, the State will choose one for you. Enrollment If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Magellan Complete Care or the State enrolls you in a health plan, you will have 120 days from the date of your first enrollment to try the Managed Care Plan. During the first 120 days, you can change plans for any reason. After the 120 days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next eight months. This is called lock-in. Open Enrollment If you are a mandatory enrollee, 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 can change Managed Care Plans during your 60 day open enrollment period. Some Medicaid recipients are voluntary enrollees and can change health plans whenever they choose, for any reason. For example, people who reside in residential community facilities operated through DJJ or mental health treatment facilities can change plans at any time for any reason. To find out if you may change plans, call the Enrollment Broker: Enrollment Broker / Choice Counseling Hours: Mon Thurs 8:00 am to 8:00 pm Fri 8:00 am to 7:00 pm Sat 9:00 am to 1:00 pm Toll free: TTY/TDD: Web: Pregnancy and Newborn Enrollment Getting medical care during pregnancy is an important step in making sure that you and your baby are healthy. We will ask you if you are pregnant when you join the plan and you can call us at any time to let us know if you become pregnant. Magellan Complete Care would like to help you get the care you need during your pregnancy. You must call the Florida Department of Children and Families (DCF) to enroll your baby in Medicaid. They will provide you with your baby s Medicaid number. You may also call Medicaid Options for assistance in choosing a plan for your baby. Their toll free number is (TTY/TDD ). 6

9 Member ID Card Here is a picture of a sample Member ID card. Please keep your card with you at all times and take it with you to your doctor visits. English ID Card front: back: Member Name: xxxmembernamexxx Member #: xxmembernbr-xx Group: xxxxx Enrollment Date: xx/xx/xxxx Utilize Medicaid Participating Pharmacies BIN #: PCN #: 622 RxGroup: XXXXXXX 7600 Corporate Drive, Suite 600 Miami FL, MagellanCompleteCareofFL.com Customer Service, Claims/Billing, and Transportation: (Monday Friday 8 a.m. 7 p.m. EST) If you are hearing impaired, call our TTY number at Emergency Services: Seek treatment at the nearest emergency room or urgent care center or call 911. Notify your doctor and the health plan within 48 hours or as soon as possible if you are admitted to the hospital. Authorizations/Eligibility (Participating and Non-Participating Providers): Mail Claims to: Magellan Complete Care PO Box 2097 Maryland Heights, MO Payor ID#: Possession of an ID card does not guarantee eligibility or payment for services provided. If you lose your card, please call Customer Service toll free at If you are hearing impaired, call our TTY number toll free at Magellan Complete Care will send you a new card. Enrollment & Disenrollment 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 If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Magellan Complete Care or the State enrolls you in a plan, you will have 120 days from the date of your first enrollment to try the Managed Care Plan. During the first 120 days you can change Managed Care Plans for any reason. After the 120 days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next eight months. This is called lock-in. If you are a mandatory enrollee, 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. 7

10 If you are a mandatory enrollee and you want to change plans after the initial 120-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: 1. The enrollee moves out of the region, or the enrollee s address is incorrect, and the enrollee does not live in a county where the Health Plan is authorized to provide services. 2. The provider is no longer with the Health Plan. 3. The enrollee is excluded from enrollment. 4. A substantiated marketing or community outreach violation has occurred. 5. The enrollee is prevented from participating in the development of his/her treatment plan. 6. The enrollee has an active relationship with a provider who is not on the Health Plan s panel, but is on the panel of another health plan. 7. The enrollee is in the wrong health plan as determined by the Agency. 8. The Health Plan no longer participates in the region. 9. The state has imposed intermediate sanctions upon the Health Plan, as specified in 42 CFR (a) (3). 10. The enrollee needs related services to be performed concurrently, but not all related services are available within the Health Plan s network, or the enrollee s PCP has determined that receiving the services separately would subject the enrollee to unnecessary risk. 11. The Health Plan does not, because of moral or religious objections, cover the service you seek. 12. The enrollee missed open enrollment due to a temporary loss of eligibility. 13. Other reasons per 42 CFR (d) (2), 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 the enrollee s health care needs; or fraudulent enrollment. 14. To find out if you can change plans, call the State Medicaid Enrollment Broker, toll free: Reinstatement Process Keeping your Medicaid benefits is critical. We do not want you to lose them. Here are a few things to remember: Contact your Enrollment Broker / Choice Counselors, toll free at Get your case status. Respond to all requested paperwork. Keep all scheduled appointments. If you miss an appointment, call and reschedule immediately. We can help you with transportation to your appointment, if needed. If you lose your benefits, you can no longer be part of our plan. However, if you get your benefits back within 180 days, you will automatically be with Magellan Complete Care again. When you return, you will have the same PCP unless: The PCP is no longer available. You live in a different area. You choose another PCP. 8

11 How to Get Services Selecting a PCP Your primary care doctor (PCP) is your main doctor who will manage all of your health care. You have the right to choose any PCP that is part of Magellan Complete Care. We have many PCPs to choose from. Please refer to your provider directory, our website or call us at If you are hearing impaired, call our TTY number toll free at We can mail you a new provider directory if you need one. If you do not choose a PCP, Magellan Complete Care will choose one for you. You may choose to have your whole family with the same PCP. You can choose a different PCP based on each family member s needs. A female member may choose an obstetrician/ gynecologist (OB/GYN) as her PCP if the OB/GYN agrees to serve as the PCP. Please call us at or TTY only, if you would like to choose an OB/GYN as your PCP. We will work with you to choose a PCP for your baby before the baby is born. The name and telephone number of your PCP can be found on: Your Welcome Letter. Provider Directory. Magellan Complete Care s website at If you would like additional information about a doctor, like their professional qualifications, please call Customer Service. Professional qualifications include medical school attended, where your doctor did their residency after medical school, and board certification. Changing a PCP If you want to change your PCP, please call Customer Service toll free at If you are hearing impaired, call our TTY number toll free at You can complete and submit the Change Primary Care Doctor form on our member website at under Members > My Plan > Change Primary Care Doctor (PCP). Access to Care/Appointment You deserve the right to care. Providers in our network must make an appointment: Right away, if an emergency. In one day, if Urgent Care. In one week, if routine Sick Patient Care. In one month, if Well Care Visit. If Magellan Complete Care cannot give you a needed and covered service by a provider in our network, we will cover these services by an out-of network provider well and timely. The services will be covered as long as Magellan Complete Care does not have a provider in network to give you the services. Don t forget to bring your Member ID card to each visit. Some new members will need help making the change from their old health plan to their new one. We will ask you about appointments and treatment you were receiving before you joined Magellan Complete Care. We will help you make the change. Once you have a Magellan Complete Care doctor, your doctor should see you within one hour of your appointment time. 9

12 Your primary care doctor (PCP) is ready to help you 24 hours a day and seven days a week. If you call at night or on the weekend, you will be told how to reach your doctor. Continuity of Care Magellan Complete Care will make sure that you keep getting the care your doctors give you today. For your first 60 calendar days with our plan, your doctor does not have to get an okay from us. Please call us if you have any questions or need any help with your appointments. After the 60 days pass, if you wish to see a doctor that is not in the directory your PCP can contact us for an okay. We can also help you schedule a visit, tell your previous provider, and move your health records to your new provider. We can also help you with transportation to your appointment. Referral and Approval for Specialty, Ancillary and Hospital Care If you need to see a specialty doctor, you need an okay from your primary care doctor (PCP). Most other services need an okay from your primary care doctor (PCP) and Magellan Complete Care. We have a team of nurses and behavioral health clinicians to review your doctor s ask for an okay. They use notes from your doctor and a set of guides to decide if the service is medically necessary for you. Many health plans use the same guides. Call us at or TTY only, if you need more information. We can help you with getting a referral or if you want details on how we decide to okay your service. If we do not give your doctor an okay, we will send you and your doctor a letter and tell you how you can appeal. Decisions for approved services are based on making sure the service is what you need and that it is a covered benefit. We do not reward or encourage staff to make decisions that result in less care than you need. We also do not reward doctors or others for issuing denials for services. These services do not require prior approval: Emergency services and crisis stabilization. Post stabilization services or other post stabilization care. Some chiropractic services at a participating provider. Optometrist annual exam at a participating provider. 10

13 Some podiatric services at a participating provider. Dermatology services up to 5-times per year with no referral at a participating provider. Family planning services; these may be obtained from any participating Medicaid provider. Gynecology services including annual well woman exam and follow-up care as a result of the exam at a participating provider. Diagnosis and treatment of sexually transmitted disease when provided at the County Health Department. Routine outpatient behavioral health services such as evaluations, medication management, individual and/or family therapy. Your provider directory lists doctors and hospitals that are part of our network. If you wish to see a doctor not in the directory, not in our network, your primary care doctor (PCP) can contact us for an okay and to let us know about your needs. We will only give the okay to see a doctor that is out of network when the type of doctor you need is not available in the Magellan Complete Care network. Normally, we do not pay for out-of-network care except emergency care and family planning services. You may be able to see a specialty doctor without getting an okay each time. This is a standing referral for when you have a long-term illness. Your PCP will contact us to arrange this. Access to Behavioral Health Services Taking care of your behavioral health condition is very important. To maintain good health and wellbeing Magellan Complete Care wants to make sure that you have the right care when you need it. We are here to support you in your recovery process. If you feel like you are having the following feelings or problems or they are getting worse, you may need to see your behavioral health provider right away: Constantly feeling sad Feeling hopeless or helpless Feelings of guilt Feeling of worthlessness Difficulty sleeping Poor appetite Weight loss Loss of interest Difficulty concentrating Irritability Constant pain such as headaches, stomach and back aches We are here to help you make sure that you get the behavioral health care you need to feel better. Your Health Guide and our Nurses available through the Nurse Line, can help you make appointments to make sure you see your provider quickly. If you need help with an urgent or emergency appointment please call us at or if you are hearing impaired please dial our TTY number

14 Getting Behavioral Health & Substance Abuse Services You can get help in finding a behavioral health provider by calling If you are hearing impaired, call our TTY number toll free at You can also look in our provider directory or you can look on our website at Someone is available to help you 24 hours a day and seven days a week. If you want to change to a different provider or request help in finding a second opinion, we are available to assist you. Call Magellan Complete Care at If you are hearing impaired, call our TTY number toll free at If you call, you will be given the names of a number of providers in your local area. You can choose to call one for an appointment. You do not need to call your primary care doctor (PCP) for a referral for behavioral health appointments. Some services do require an okay from us. Your provider will ask for an okay when it is needed. Behavioral health and substance abuse services you can get include inpatient and outpatient hospital services and psychiatric doctor services. You can also get a wide range of behavioral health services. Sometimes you can get these services in the community, in your home, or in schools. Some of the behavioral health services you may seek for you or a family member include: Individual, family, and group therapy. Day treatment for adults and children. Individual and family assessments. Evaluations. Treatment planning. Psychosocial rehabilitation. Targeted case management. Therapeutic behavioral on-site services for children and adolescents. 12

15 Emergency Services Emergency Services An emergency is when you have severe pain, illness, behavioral health crisis or injury that could result in danger to you or your unborn child. Call 911 right away. In an emergency, you have the right to choose any hospital or other medical setting. You do not need to get approval from your PCP or Magellan Complete Care for emergency care. Behavioral Health Emergencies First, decide if you are having a behavioral health emergency. Do you think that you are a danger to yourself or others? If so, call 911 or go the nearest emergency room for help if you think you are in danger. Follow these steps even if the emergency room is not in our service area. If you need help right away or have a behavioral health emergency outside the plan s service area, call 911. Please Let Us Know Once you are in a safe place, please let us know or ask someone to let us know by calling the number on your ID card. You should also call your care manager. We will call your PCP or regular behavioral health provider. For out-of-area emergency care, when you are stable, we will help with plans to move you to in-network care when possible. Did you seek care for an emergency? If you go to the hospital for an emergency, you need to make sure you get care after the emergency event, called Post Stabilization services. This may help to keep you from having another behavioral health emergency. Post- Stabilization services are covered services you get after emergency room care within or outside the Provider Network. These are services delivered to keep your condition stable after an emergency. Post-stabilization care services are provided and covered without asking for an okay. Once you leave the hospital: It is important to follow-up with your doctor within twenty-four (24) to forty-eight (48) hours. You should schedule a visit to see a behavioral health provider for follow-up care. We can help you make this appointment and schedule transportation, if needed. We recommend you get an appointment before you leave the hospital. Please call us or TTY only, if you need help making an appointment. Out of Area Emergency Services If you are out of the service area, please get help from the nearest urgent care center or hospital. Please call us or TTY when you are out of the service area and have required urgent or emergency services. We would like to make sure that we are able to help you get the care you need. 13

16 Covered Services Covered Service and Limitations Magellan Complete Care covers Medicaid-covered services as specified in the contract with the State of Florida Agency for Health Care Administration. You are limited to how often you use some of these services and there are differences for adults and children. Please call us at or for hearing impaired TTY, if you have questions about benefit limits. Your care manager can also assist you. Magellan Complete Care has no co-pays for covered services. You do not have to pay money for any covered service if you visit a network provider. The following is a summary of the services that are covered by Magellan Complete Care. Service Adult Basic Dental Services Child Health Check Up (CHCUP)/EPSDT Diabetes Supplies and Education Emergency Services Description Full dental services for all enrollees age 20 and below. Medically necessary oral and maxillofacial surgery for all eligible Medicaid recipients regardless of age. Emergency dental services to enrollees age 21 and older, and denture and denture-related services. Medicallynecessary, emergency dental procedures to alleviate pain or infection to enrollees age 21 and older. Emergency dental care for enrollees 21 years of age and older is limited to a problem focused oral evaluation, necessary radiographs in order to make a diagnosis, extractions, and incision and drainage of an abscess. Full and removable partial dentures and denture-related services are also covered services for enrollees 21 years of age and older. For children, CHCUP includes comprehensive health and developmental history, unclothed physical examination, developmental assessment, nutritional assessment, appropriate immunizations, laboratory testing, health education, dental screening, vision screening, hearing screening, diagnosis and treatment and referral and follow-up as appropriate. Coverage for medically appropriate and necessary equipment, supplies, and services used to treat diabetes. This includes outpatient self-management training and educational services. Includes emergency medical care 24 hours a day, 7 days a week. You do not need approval from Magellan Complete Care, nor your PCP to go to the emergency room if you are having a medical situation. 14

17 Service Family Planning Services Freestanding Dialysis Facility Services Hearing Services Durable Medical Equipment Home Health Care Services and Durable Medical Equipment Description Family Planning Services includes information, referral education, counseling, diagnostic procedures and contraceptive drugs and supplies. Services are voluntary and you are permitted full freedom of choice of methods for Family Planning to help you plan a family size or help you space the time between having children. You can go to any provider that participates with Medicaid for these services without a referral from your PCP. Includes routine laboratory tests, dialysis-related supplies, ancillary and other items. Services include all services and procedures rendered by a participating provider when needed for preventive, diagnostic, therapeutic, or to treat a particular injury, illness or disease. Hearing Services include examinations and evaluations necessary for the furnishing of one standard hearing aid every three years. Medical items (limited to approved types of supplies and equipment, suitable for use in the home). Benefit includes prosthetics and orthotics and respiratory equipment and supplies. Includes intermittent or part-time nursing services (R.N.or L.P.N.), personal care services by a home health aide, and medical items (limited to approved types of supplies and equipment, suitable for use in the home). All services and equipment must be ordered by a participating provider. Your PCP must notify Magellan Complete Care for services or equipment that requires home health care. Home health care does not include homemaker services, Meals on Wheels, companion, sitter or social services. Home Health Care Services and Private Duty Nursing Care Magellan Complete Care covers home health services that are medically necessary. Home health services include home health visits (nurse and home health aide), private duty nursing and personal care services for children, therapy services medical supplies and durable medical equipment. Home healthcare does not include homemaker services, Meals on Wheels, companion, sitter or social services. Magellan Complete Care follows the state Medicaid Home Health Services Coverage and Limitations Handbook. 15

18 Service Hospital Ancillary Services Immunizations Independent Laboratory and Portable X-Ray Services Inpatient Hospital Services Interpreter Services Maternity Services Mental Health and Substance Abuse Services Outpatient Services Description When your provider authorizes these to be provided by the hospital: radiology, pathology, neurology, neonatology, and anesthesiology. According to childhood immunization schedule as approved by the appropriate Recommended Childhood Immunization Schedule for the United States. Includes laboratory and X-ray services when ordered by a participating provider. Includes all items and services needed to give appropriate care during a stay at a participating hospital, including room and board, nursing care, medical supplies, and all diagnostic and therapeutic services. Magellan Complete Care covers a maximum of 45 inpatient days for the period from July 1 through June 30 (includes only non-emergency care at hospitals where prior notification was obtained by your PCP from Magellan Complete Care). If you are in need of interpreter services or are vision and/or hearing impaired, please call the Customer Service phone number on the back of your ID card. These services are free of charge for all foreign languages as well as the visually and/or hearing impaired. Maternity services include the following: nursing assessment and counseling, Florida s Health Start Prenatal Risk Screening, nutrition assessment, delivery and follow-up care, Florida s Health Start Infant (Postnatal) Screening, and follow-up care. Mental Health counseling and referral services or substance abuse services; Please call our Customer Service Team or your assigned Health Guide so that we can provide further information about all of these benefits. You can contact us at Outpatient services provided in an outpatient hospital setting. Your PCP can obtain prior notification for health care services that may require notification. 16

19 Service Physician Services Prescribed Drugs Therapy Services: Physical, Respiratory, Occupational and Speech therapies Transportation Description Includes all services and procedures rendered by a participating provider when needed for preventive, diagnostic, therapeutic, or to treat a particular injury, illness or disease. Excludes experimental procedures and cosmetic surgery. These physicians include: advanced registered nurse practitioner, physician assistant, podiatry, ambulatory surgical centers, community health departments, rural health clinic services, federally qualified health centers, birthing centers, certified nurse midwives, chiropractic, psychiatrist and nursing care. Includes prescribed drugs currently covered by the Medicaid Program, when ordered by a participating provider and supplied by a licensed participating pharmacy. Are covered for recipients under 21 years of age as medically necessary. Urgent care transportation to and from your covered medical and dental appointments. Medicaid eligible non-emergency transportation services are given through LogistiCare, Call them to make your appointment. Make your appointment 48 hours before you need to be picked up. If the transportation service is late to pick up, call to find out why it is late. Call if you need to cancel your transportation. If you have an emergency and need to be taken to the hospital, you must call 911. You can also call our customer service for assistance at Vision Services Vision services include eye exams and up to two pairs of standard eyeglasses per year. Contact lenses for cosmetic purposes are not covered. 17

20 Magellan Complete Care Expanded Services Service Benefit OK from Doctor and Magellan Needed Dental expanded for adults Maximum $1500 benefit Preventive services one cleaning and oral exam every 6 months One x-ray per year Treatment for periodontal disease Yes for treatment of periodontal disease Home Health Visits enhanced for non- pregnant adults Intensive Outpatient Therapy for Substance Abuse Can exceed 3 visits per day Yes No limits when medically necessary Yes Nutritional Counseling Up to 15 visits per year Yes OB Visits visits for routine pregnancy care No limit for high risk pregnancy care 1 postpartum home visit Outpatient Hospital Services Not limited to $1500 based on medical necessity and in lieu of hospital admission No Yes Over the Counter Medication/Supplies Certain over the counter medications and supplies See drug and supply list on web site Requires prescription Post discharge meals Post discharge from inpatient admission; Up to 48 hours for member and up to 3 family members; requires 48 hours notice by member Yes Primary Care Visits enhanced for non-pregnant adults One per day Not limited to 2 per month No Vaccines adult Pneumonia, flu, shingles No 18

21 Magellan Complete Care Expanded Services continued Service Benefit OK from Doctor and Magellan Needed Vision Services Routine eye exam and glasses once every 12 months Additional exams and glasses with OK from doctor For Specialty Fits (new wearers, historic, RGP, multi-focal, etc.), the enrollee must pay for any charges over $50, less a 20 percent discount Yes for services beyond the annual benefit Co-pays Waived Yes Additional Notes for Covered Services Service Dental adult Benefit All dental treatment or surgery is considered necessary when the dental condition is likely to result in a medical condition if left untreated. OK from Doctor and Magellan Needed Yes Diabetes Care We cover all needed equipment, supplies, and services to treat diabetes, including selfmanagement training and educational services if ordered by your doctor. No Family Planning Services Inpatient Hospital Services May get services from any participating Medicaid provider Members over the age of 21 are limited to 45 days per Medicaid fiscal year There is no limit for members under the age of 21 or for emergency care and pregnant adults. No Yes Outpatient Services There is no limit for members under the age of 21. Yes 19

22 Additional Notes for Covered Services continued Service Physician Services Therapeutic Group Care Women s Health Benefit May be given by individuals who are not licensed physicians, including nurse practitioners and physician assistants, when under the direction of your PCP Limited to one visit per day unless for an emergency, one new patient evaluation, one long term care facility visit per month Therapeutic group care services or specialized therapeutic group care are community-based, psychiatric residential treatment services designed for recipients under the age of 21 years with moderate to severe emotional disturbances. They are provided in a licensed residential group home setting serving no more than 12 recipients. Providers must comply with the regulations and requirements listed in the Specialized Therapeutic Services Coverage and Limitations Handbook. A copy of the authorization form for this service can be found in our website under the provider section: Authorizations. A female member, without an OK from her PCP, may visit a contracted obstetrician/gynecologist (OB/GYN) for one annual visit and for medically necessary follow up care as a result of that visit. OK from Doctor and Magellan Needed No Yes No The benefit information provided is a brief summary, not a complete description of benefits; limitations and restrictions may apply and benefits may change. We provide coverage for all services identified by the State of Florida. No services are excluded due to religious or moral objections of Magellan Complete Care. 20

23 Services Not Covered by Magellan Complete Care Routine, out of service area care is not covered by Magellan Complete Care. Only emergency services are covered. If you feel you need care while you are out of the service area call Magellan Complete Care at If you are hearing impaired, call our TTY number toll free at There are additional services that are covered directly through the Medicaid State Plan. Please call us at or our TTY only, for more information or contact the local Medicaid Office. Magellan Complete Care does not offer long-term care institutional services, institutional services for persons with developmental disabilities or state hospital services. Under this plan, routine services that are provided by providers that are not part of the Magellan Complete Care Network are not covered unless there are special situations. For more information, contact Magellan Complete Care at If you are hearing impaired, call our TTY number toll free at How to Get Medications Magellan Complete Care covers prescription drugs and certain over-the-counter drugs. Please call us at or TTY only, for more information or visit the website for the Preferred Drug List. Go to a pharmacy that is signed up with Magellan Complete Care. See your Provider Directory or check the Provider Search online for a list of pharmacies near you. You can also call us at or TTY only, to help you find a pharmacy. At the pharmacy, show them your Magellan Complete Care ID card. Give them your prescription from your doctor. Some medications require an okay from us before the prescription can be filled. Your doctor will call us to get the okay. Informed Consent for Certain Drugs We require our doctors to get written permission informed consent from a parent or legal guardian before prescribing certain drugs to children under the age of 13. These drugs are psychotropic (psychotherapeutic) drugs and include antipsychotics, antidepressants, antianxiety medications, and mood stabilizers. Anticonvulsants and attention-deficit/ hyperactivity disorder (ADHD) medications (stimulants and non-stimulants) are not included at this time. Approval from us may also be required for prescriptions for these drugs. If you have questions, please call us at If you are hearing impaired, call our TTY number toll free at

24 Improving Your Health Member Rewards Program Magellan Complete Care wants to encourage you to make healthy choices and take part in activities that will help keep you from getting sick. As a Magellan Complete Care member, you can get Member Rewards if you take part in specific activities. Magellan will offer programs to members who want to stop smoking, lose weight, or address any drug abuse problems. We will reward members who join and meet certain goals. These programs will be ready February 1, You will receive information on how to earn Member Rewards from your Care Coordination Team. If you leave Magellan Complete Care, rewards can not be transferred to another health plan. You will lose access to earned rewards if you voluntarily disenroll from Magellan Complete Care or lose Medicaid eligibility for more than one-hundred eighty (180) calendar days. For more information, you can call Magellan Complete Care at If you are hearing impaired, call our TTY number toll free at Prevention Programs There are programs available to members that may help prevent or reduce the symptoms of mental illness and medical conditions and stay healthy. They work to find early signs of illness and help members work with their providers to manage their conditions. If signs are found early, the health plan can help members get the services they need to treat the illness. Getting care early may help slow down how fast or how bad your illness gets. You can learn more about these programs. Please call Magellan Complete Care at If you are hearing impaired, call our TTY number toll free at Case Management and Disease Management Programs Magellan Complete Care has programs that will help you manage your chronic diseases. Some of the programs we offer are: Complex Case Management Asthma Hypertension Diabetes High Risk Maternity Cancer and Cancer Prevention For more information, please call Customer Service toll free at If you are hearing impaired, call our TTY number toll free at They can help you learn more about these programs. Your PCP can also help. Online Interactive Tools For Health and Wellness We have online tools for you that you can use to keep track of your health. These tools can help you stay healthy. You can get information on how to reduce your health risks. The interactive tools have information about healthy weight, stop smoking, and physical activity. You can also get information on healthy eating, dealing with stress and depression, and at-risk drinking. You can see the tools on our website. Please go to and click on the Members tab, then select Interactive Tools. See our website today! 22

25 Child Health Check-Up/ Vaccines Magellan Complete Care promotes wellness visits for children. Child Health Check-ups are an important part of our wellness program. These visits include many preventative screening services and other services to keep your child healthy. Magellan expects the following check-ups: Birth 2 4 days for newborns discharged in less than 48 hours after delivery 1 month 2 months 4 months 6 months 9 months 12 months 15 months 18 months 24 months 30 months Once every year for ages 3 20 Urgent Care Urgent care clinics are there for you and your family when you need to see a doctor and your doctor is not able to see you or the office is closed. Most urgent cares are open 24/7 and have short wait times. Health problems that can be treated in urgent cares include: Common colds and flu symptoms Ear pain Minor cuts and scrapes Sprains or strains Sore throat Minor burns Allergic reaction without shortness of breath Rash Pink or irritated eyes Wheezing/regular cough Thick runny nose/stuffy nose/pain in face Painful/frequent urination It s good to know which urgent care clinic is near you. You can find a list of urgent care clinics in our online Provider Search or you can speak with a nurse toll free at If you have trouble hearing, call our TTY number toll free at Please remember, you should call 911 or go to the emergency room if you have serious health issues like: Chest pain, shortness of breath, and other symptoms of heart attack or stroke Major broken bones Uncontrollable bleeding Deep wounds Serious burns Coughing or throwing up blood Unconsciousness High Fever (105 degrees F) Major head injury Thoughts of hurting yourself or others Fainting It is always best to be safe. If you are having a medical emergency you should call 911. Do not try to drive yourself if you are having bad chest pain, bleeding that doesn t stop, or if you feel like you might faint or if you cannot see well. 23

26 Quality Benefit Enhancement Programs Quality Benefit programs help our members to improve their total health. Magellan partners with local community agencies and offers programs such as: Domestic Violence Prevention Children s Programs Pregnancy Programs Pregnancy Prevention Programs Behavioral Health Programs Stop Smoking Substance Abuse Support Review of New Treatment Options Magellan Complete Care works closely with the Agency for Health Care Administration (AHCA) to determine what new treatment options can be covered as part of your benefits. Magellan reviews new treatment and technology options as part of the quality improvement commitment. Experimental treatments are not part of your benefits. For more information, call Magellan Complete Care at If you are hearing impaired, call our TTY number toll free at For more information visit our website at or call Magellan Complete Care at If you are hearing impaired, call our TTY number toll free at They can help you learn more about these programs. Your PCP can also help. 24