FLORIDA MEMBER HANDBOOK

Transcription

1 FLORIDA MEMBER HANDBOOK CAD_08136E State Approved WellCare 2017 FL_10_17 FL7WMCMHB08136E_1017

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3 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) Behavioral care providers Specialists Hospitals and other health care facilities Labs Pharmacies Again, welcome to Staywell. We wish you good health! 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 (TTY ). We re here to answer all of your questions. You can also find us on the web. Go to Be on the lookout for your Staywell identification (ID) card. You should receive it in the mail within a few days of enrolling in the plan. Keep reading for more information about your ID card and how to use it. i FL7WMCMHB08136E_1017

4 If you speak a different language or need something in Braille or audio, don t worry. We can provide translations and alternate formats at no cost to you. Just give us a call toll-free at (TTY ) Monday Friday, 8 a.m. to 7 p.m. Si usted habla un idioma diferente o necesita algo en Braille o audio, no se preocupe. Nosotros podemos proporcionarle traducciones y formatos alternativos sin costo para usted. Simplemente, llámenos sin cargo al (TTY ) de lunes a viernes de 8 a.m. a 7 p.m.

5 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 Sometimes we may need to release your medical records. Please read the Notice of Privacy Practices you received when you enrolled in the plan. It explains why. Then sign the statement below. You can return it in the included stamped envelope or mail to: ATTN: Staywell Health Plan, PO Box 31370, Tampa, FL Member ID Number: Member Name: First Middle Last 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

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7 Table of Contents The Staywell Dictionary...1 Important Phone Numbers...4 GETTING STARTED WITH US...7 Check Your ID Card and Keep It With You at All Times...8 Get to Know Your PCP...9 Send Us Your Health Risk Assessment (HRA)...11 Remember to Use Our 24-Hour Nurse Advice Line...12 In an Emergency...12 Contact Us...12 Our Website...13 Know Your Rights and Responsibilities...14 Hold on to this Handbook...14 Care Basics...15 Medically Necessary...15 Making and Getting to Your Medical Appointments...15 Cost Sharing...16 YOUR HEALTH PLAN...17 Services Covered by Staywell...18 The Staywell Extras...36 Services Not Covered by Staywell...37 How to Get Covered Services...38 Prior Authorization (PA)...38 Services Available Without Authorization...39 Utilization Management (UM)...39 Disease Management Program v

8 Second Medical Opinion...41 After-Hours Care...41 Urgent Care...41 Emergency Care...42 Out-of-Area Emergency Care...43 Post-Stabilization Care...43 Pregnancy and Newborn Care...44 Doula Services for Pregnant Members Under Age Dental Care for Members Over Age Dental Care for Members Under Age Your Dental ID Card...46 Changing Your Primary Care Dentist...46 Behavioral Health Care Hour Behavioral Health Crisis Line...47 What to Do in a Behavioral Health Emergency or if You Are Out of Our Service Region...47 Prescriptions...48 Specialty Pharmacy...48 Preferred Drug List...48 Other Drugs You Can Get at the Pharmacy...49 Care Management...50 Transition of Care...51 Planning Your Care...52 Child Health Checkup (CHCUP) Services...52 Preventive Health Guidelines...53 Adult Preventive Health Guidelines...53 Pediatric Preventive Health Guidelines (Newborn to Age 21)...56 Advance Directives vi

9 Member Grievance and Appeals Procedures...61 Complaints...61 Grievances...62 Appeals...63 Fast or Expedited Appeals...64 Additional Information...64 Additional Appeals Assistance...65 Subscriber Assistance Program (SAP)...65 Medicaid Fair Hearing...65 Continuation of Benefits During the Appeals Process...67 Continuation of Benefits During Medicaid Fair Hearings...67 IMPORTANT MEMBER INFORMATION...69 Your Staywell Membership...70 Remember to Recertify Your Eligibility With the Department of Children and Families (DCF)...70 Enrollment...71 Open Enrollment...71 Reinstatement...71 Disenrollment...71 Involuntary Disenrollment...72 Important Information About Staywell...74 Plan Structure and Operations and How Our Providers Are Paid...74 Evaluation of New Technology...74 Quality Improvement and Member Satisfaction...75 Fraud, Waste and Abuse...75 To Report Fraud, Waste or Abuse With Staywell...76 To Report Fraud, Waste or Abuse With Florida Medicaid...76 Member Rights...77 Member Responsibilities vii

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11 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 1

12 Words/Phrases 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 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 2

13 Words/Phrases 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 3

14 Important Phone Numbers Staywell Customer Service TTY Hour Nurse Advice Line Hour Behavioral Health Crisis Line Fraud, Waste and Abuse Hotline Florida Medicaid Agency Agency for Health Care Administration Medicaid Helpline Agency for Health Care Administration Facilities Complaints Florida Abuse Hotline To report abuse, neglect or exploitation (including elder) Toll-free: or (TDD: ) Toll-free: (TDD: ) Toll-free: ABUSE ( ) (TTY ) You can also report abuse through the DCF website: Florida Medicaid Complaints Agency for Health Care Administration Medicaid Helpline: If you have a complaint about Medicaid Services, please complete the Florida Medicaid Complaint Form online at If you need help completing this form or prefer to speak to a Medicaid representative about your complaint, please call toll-free or (TDD: ). 4

15 Agency for Health Care Administration Facilities Complaints: If you have a complaint about a health care facility such as a hospital, nursing home, assisted living facility, home health agency or other type of health care facility, please call toll-free (TDD: ). Representatives can help you with complaints or other information Monday Friday, 8 a.m. to 5 p.m., Eastern. You can also file a complaint online by using the Health Care Facility Complaint Form at 5

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17 Getting Started With Us 7

18 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 (TTY ). We ll send you another one. You can also order a new one through our website. Log on to (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 Member ID #: Member: Jane A. Smith Effective Date: 01/01/2016 Primary Care Provider: John Adams 1234 Oak Street, Suite 123 Tampa, FL Medicaid #: Plan Name: Staywell Phone: The date your Staywell membership started Your Medicaid ID number Our website How to contact us 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: /TTY/TDD Hour Nurse Advice Line: Hour Behavioral Health Crisis Line: Staywell Health Plan P.O. Box Tampa, FL Medical claims are to be mailed to: Staywell Health Plan RxBIN: P.O. Box RxPCN: ADV Tampa, FL RxGRP: RX8888 Call hours a day, 7 days a week. Information your PCP and other providers need to correctly bill for your care/services 8

19 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. Remember: if you get a letter or voice message from a provider asking for your insurance or 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. 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 (TTY ). 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 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 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. Women may choose a women s health specialist as a PCP for preventive and routine care 9

20 Where you live Your language preference (like English or Spanish) If the PCP is accepting new patients 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. You can request a printed provider directory be mailed to you: 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 When you ve made a choice, call us to be assigned to that provider. Call toll-free (TTY ). You can also choose a provider by logging on to the secure member portal to make your choice. PCP changes made between the 1 st and 10 th of the month will go into effect right away. Changes made after the 10 th of the month will take effect at the beginning of the next month. Call the provider you ve picked and set up an appointment. Remember to take your ID card with you. We ll send you a new ID card with your new PCP listed on it. Do you have Medicare? If you do, we can help! Medicare and Medicaid are two different health plans that work together. Make sure your doctors know you have both plans. Make sure your pharmacy knows too. Bring your Medicare or Medicare Advantage ID card and your Staywell (Medicaid) ID card to your doctor visits. Bring them both to the pharmacy too. That way, you will get the most from your health plans. 10

21 If you have Medicare, your primary care provider (PCP) must be a Medicare PCP. Your PCP must accept Medicaid. (They must be enrolled in/registered with Medicaid.) If you have a Medicare Advantage plan, your PCP must be in the plan network. Your PCP must accept Medicaid. (They must be enrolled in/registered with Medicaid.) You can choose a PCP in the Staywell network. Make sure they are a Medicare PCP or a PCP with your Medicare Advantage plan. If you have Medicare, your PCP doesn t have to be in our network. If you have a Medicare Advantage plan, you don t need to choose a PCP for your Staywell plan. Send Us Your Health Risk Assessment (HRA) Please note that some providers may not perform some services because of religious or moral reasons. We ask that you fill out the HRA completely. It helps us know about your needs. This helps us give you benefits that really matter. Your answers to the questions can help us to make sure you get the right care. 2 ways to get your HRA form: By Phone: Call toll-free (TTY ) to have a copy mailed to you Online: Log on to the member portal at and click on Wellness Tools 3 ways to fill out your HRA form: By phone: For ADULT HRA forms: Call Our friendly staff will help you with completing the form. For PEDIATRIC HRA forms: Call Our friendly staff will help you with completing the form. Online: Log on to the member portal at and click on Wellness Tools By mail Fill out the form and mail it to: ATTN: STAYWELL HEALTH PLAN PO BOX TAMPA, FL

22 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 any time 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 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. Contact Us 24-Hour Nurse Advice Line toll-free number: 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: (TTY ) 12

23 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 If you make a major change in your life, it s important that you let us know. You must also inform the Department of Children and Families (DCF) and/or Social Security Administration (SSA). A major change is something like: Moving Your family size changes: for example, you get married or divorced, have a baby or adopt a child, or experience the death of your spouse or child Starting a new job or your income changes Getting 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: Staywell Health Plan Attn: Customer Service P.O. Box Tampa, FL Our Website You may be able to find answers to your questions on our website. Go to for information about: Our member handbook and Find a Provider search tool How we protect your privacy 13

24 Your member rights and responsibilities Member newsletters Pediatric and adult preventive health Pregnancy care Childhood obesity, lead poisoning, asthma, diabetes and chronic kidney disease Our website: 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 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. 14

25 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 your condition 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 an appointment. Type of Provider PCPs Hospitals Behavioral Health Providers Drive Time/Distance if You Live in an Urban Area 30 minutes/20 miles to get to your appointment 30 minutes/20 miles to get to your appointment 30 minutes/20 miles to get to your appointment Drive Time/Distance if You Live in a Rural Area 30 minutes/20 miles to get to your appointment 30 minutes/20 miles to get to your appointment 60 minutes/45 miles to get 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. 15

26 Type of Appointment Medical Dental Behavioral Health Type of Care Emergency Urgent Sickness Routine/Wellness Follow-up care after a hospital stay Emergency Urgent Sickness Routine/Wellness Follow-up care after an exam Emergency Urgent Sickness Routine/Wellness Appointment Time Right away (both in and out of our service area), 24 hours a day, 7 days a week (prior authorization is not required for emergency services) Within 24 hours (1 day) Within 1 week Within 4 weeks As needed Right away (both in and out of our service area), 24 hours a day, 7 days a week (prior authorization is not required for emergency services) Within 24 hours (1 day) Within 1 week Within 4 weeks (1 month) Within 4 weeks (1 month) Right away (both in and out of our service area), 24 hours a day, 7 days a week (prior authorization is not required for emergency services) Within 24 hours (1 day) Within 1 week Within 4 weeks (1 month) 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) - children and pregnant women do not pay Chiropractic copays 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. 16

27 Your Health Plan 17

28 Services Covered by Staywell What follows is a list of services we cover. Here are some important things to remember when getting your care: We ll pay for approved care You can get services from any provider in our network 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. Staywell will ensure that the cost to the member is no greater than it would be if the services were provided within the Staywell network. 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. You can reach us toll-free at (TTY ). Staywell must provide all medically necessary services for its members who are under age 21. This is the law. This is true even if Staywell does not cover a service or the service has a limit. As long as your child s services are medically necessary, services have: No dollar limits; and No time limits, like hourly or daily limits. Your provider may need to ask Staywell for approval before giving your child the service. Call if you want to know how to ask for these services. 18

29 Covered Service Covered Service Description Advanced registered nurse practitioner (ARNP) services These are services given by an ARNP who s licensed to practice in the State of Florida The ARNP and a doctor must make decisions about your care as a team You re limited to: 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 Adult Hearing Services One hearing exam every two years for the purpose of determining hearing aid candidacy; one hearing aid; every two years Adult Vision Services In addition to standard eyeglasses, $100 with which members may purchase frames, lenses, and contact lenses per year Prior Authorization 19

30 Covered Service Covered Service Description Ambulatory surgical center (ASC) services These centers provide medically necessary surgical care when you don t need to stay in a hospital ASC services shouldn t be used: When you need emergency care If the service is minor enough to be done by your doctor in his/her office Assistive care services These services are available if you live in an assisted living facility, adult family care home or residential treatment facility. A health assessment must be completed: 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 Components include health support and help with: Health Support includes member s understanding of his/her well-being on a daily basis and reporting changes to a health care provider as appropriate Activities of Daily Living (ADLs) such as bathing, walking, and other daily care Instrumental Activities of Daily Living (IADLs) such as shopping and scheduling appointments Giving yourself medication Art therapy Unlimited visits; limited to SSI and Medicare/Medicaid dual-eligible members; members identified through case management or disease management; subject to prior authorization Prior Authorization PA is required 20

31 Covered Service Covered Service Description Behavioral health services Services include: Day treatment for adults and children Evaluations Individual and family assessments Individual, family, marital and group therapy Psychosocial rehabilitation Targeted and intensive care management Therapeutic behavioral on-site services for children and adolescents Treatment planning Behavioral health-related inpatient hospital care is limited to: If you re over age 21 and not pregnant up to 45 days each year for nonemergency 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 You don t need to get a PA or referral from your PCP to see a behavioral health provider, but certain services do require a Prior Authorization You may also choose an alternative behavioral health care manager or direct service provider who s in our network Parental or guardian informed consent is required for psychotropic medications for children under age 13 (examples of psychotropic medications include tranquilizers, sedatives and antidepressants) See the Emergency Care section later in this handbook for more details about behavioral health emergencies Prior Authorization Prior Authorization is required for psychological testing, electroconvulsive therapy, psychosocial rehabilitation, therapeutic behavioral on-site services (TBOS), Targeted Care Management after the initial 200 HCPC services have been utilized and all IOP, Partial and Inpatient/SIPP and Residential Services 21

32 Covered Service Covered Service Description Birthing center and licensed midwife services These are facilities where you can go for obstetrical, gynecological and family planning services. You re limited to: 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 Child health checkup (CHCUP) services (members under age 21) See the Planning Your Care section later in this handbook for more details about child health checkups Chiropractic services These are services given by a chiropractor who s licensed to practice in the State of Florida. Services include: One visit to a chiropractor if you re a new patient with him/her Manual manipulation of the spine Spinal X-rays You re limited to: One visit each day 24 visits each year Services that are not covered: Massages or heat treatments Experimental or investigational chiropractic services There is a $1 co-pay for these services - children and pregnant women do not pay Chiropractic copays Prior Authorization 22

33 Covered Service Covered Service Description Clinic services These clinics provide primary care services. Clinics include: Rural health clinics (RHCs) Federally qualified health centers (FQHCs) Services you can get at these clinics include: Adult health screenings Child health checkups (CHCUPs) Chiropractic Family planning Behavioral health Podiatry Vision Dental services for adults (over age 21) Services include at no cost to you: One (1) oral exam every six (6) months One (1) cleaning every six (6) months; One (1) X-ray per year; Care to lessen pain or infection due to dental emergency; Full dentures and removable partial dentures; Denture-related procedures; and Sealants Prior Authorization 23

34 Covered Service Covered Service Description Dental services for children (under age 21) Services include at no cost to you: One (1) oral exam every six (6) months; Two (2) cleanings per year; Crowns; One (1) X-ray per year; Endodontic care (soft tissue and nerves within the teeth); Fillings; Fluoride treatments; Full and partial dentures; Oral surgery; Orthodontic treatment with prior authorization; Periodontal care; and Preventive care Restorations Services that are not covered: Bridge work Sealants Emergency services (including behavioral health emergencies) See the Emergency Care section later in this handbook for more details about emergencies There is a 5% coinsurance for non-emergency services received in an emergency room (ER) setting: Up to the first $300 for the cost of the care Your out-of-pocket cost won t be more than $15 Prior Authorization PA is required for orthodontic care 24

35 Covered Service Covered Service Description Equine therapy Ten visits per year; limited to members identified through care management or disease management; limited to members eligible through SSI, child welfare and Medicare/Medicaid dual eligible members; members age 1 and older; subject to prior authorization Family planning services and supplies Services include: One visit each year Lab testing Family planning and HIV counseling Contraceptive supplies Pregnancy testing You don t need to get a PA for these services and you can get them from any participating Medicaid provider Healthy Start services These services are provided to help you have a healthy pregnancy and give birth to a healthy baby. Services include: 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 Prior Authorization PA is required 25

36 Covered Service Covered Service Description Hearing Services Services include: Cochlear implants Hearing aids, including fitting, repairs and testing Testing You re limited to: One hearing test every two years One hearing aid for each ear every two years One cochlear implant in either ear, not both Services that are not covered: 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 Home health services and nursing care These services are provided in your home to help improve your health or lessen the effects of a disability. Services include: 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 for members under age 20 include: Private-duty nursing Personal care Therapies in the home occupational, physical and speech You re limited to: Four visits per day; subject to prior authorization Prior Authorization PA is required for cochlear implants PA is required 26

37 Covered Service Covered Service Description Hospice Services 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) 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 are provided by a hospice agency and care is coordinated by a hospice nurse If you are under 21, you can still get all your other care while you are in hospice Hospital services, including: Inpatient Outpatient These services must be provided under the supervision of a doctor or dentist. Inpatient hospital services include: Room and board Medical supplies Diagnosis and therapies Drugs Nursing care You re limited to: 45 days each year if you re over age 21 (if you re under age 21 or pregnant, there are no limits) Outpatient hospital services include: Drugs Medical supplies Nursing care Therapies Prior Authorization PA is required for inpatient hospital services 27

38 Covered Service Covered Service Description Lab and X-ray services These services include medically needed: Lab tests Portable X-rays Diagnostic imaging MRI (magnetic resonance imaging) CT (computed tomography) PET (positron emission tomography) Medically related lodging and food $ per diem for food and lodging for long-distance travel for medically necessary appointments; subject to prior authorization Medical supplies and durable medical equipment (DME) Medical supplies include: Items that are usable and disposable in your home Durable medical equipment (DME) is medically necessary items that you can use over and over for medical reasons, like: Cane, crutches or a walker Blood glucose meters and strips Diabetic supplies Hospital bed Orthotics and prosthetics Wheelchair You can buy, rent or rent-to-own DME Prior Authorization PA is required PA is required for custom and power wheelchairs, hospital beds and scooters 28

39 Covered Service Covered Service Description Newborn circumcision For members under the age of 3 months; subject to prior authorization Nursing Facility Services For members under the age of 18 years Provides 24-hour medical and nursing care in a residential setting, institution, or a distinct part of an institution Services include the following, as they apply to members: On-site physician services Person-centered care planning Room and board All general nursing services, including restorative nursing Personal hygiene care Personal hygiene items, including incontinence supplies Laundry services Dressing and skin care items Medical supplies and equipment Non-prescription (over-the-counter) drugs, biologicals, and emergency drugs Dietary services, including therapeutic diets and special dietary supplements used for oral or tube feeding Rehabilitative services, including physical, speech, and occupational therapies Social services Activity services Prior Authorization PA is required PA is required 29

40 Covered Service Covered Service Description Nutritional counseling Unlimited visits; limited to members with a chronic disability or a complex medical need who receive home health services; subject to prior authorization Outpatient services Up to an additional $1,350 for outpatient services per state fiscal year for members ages 21 and older Over-the- Counter (OTC) medication/ supplies $25 per household per month, mailed directly to the member s home Pet therapy Unlimited visits; limited to members eligible through SSI or Medicare/Medicaid dual eligible members; members identified through care management or disease management; subject to prior authorization Physician and physician s assistant services These are services provided by a doctor or physician s assistant 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 Physician home visits Unlimited visits by a physician or ARNP; limited to in-home care for members who are frail, homebound, and unable to travel to a physician s office; evaluation and coordination of home health, therapy, and other services as needed; subject to prior authorization Prior Authorization PA is required PA is required PA is required 30

41 Covered Service Covered Service Description Podiatry services These are services provided by a podiatrist who s licensed to practice in the state of Florida Services include: Routine foot care Post-discharge meals Ten meals within two weeks of a member being discharged from an inpatient facility; limited to SSI and Medicare/Medicaid dual eligible members; subject to prior authorization Prenatal/perinatal visits Unlimited prenatal visits; unlimited perinatal visits for the first four weeks postpartum See our Preferred Drug List (PDL) for the drugs we cover The PDL also lists drugs that may have limits. Limits may include things such as: Requiring a PA Quantity limits Prescription drugs Step therapy Age or gender limits Drugs not on our PDL may be covered with a PA You can access our PDL on our website at Prior Authorization PA is required PA is required for certain drugs (please refer to our PDL) 31

42 Covered Service Covered Service Description Primary care visits (non-pregnant adults) Unlimited visits Quality enhancement (QE) services/ programs These services/programs are meant to help you improve your health and/or your children s health These services/programs include: Children s programs (wellness and prevention) Domestic violence (prevention and intervention) Pregnancy prevention Prenatal/postpartum (after birth) Behavioral health Renal dialysis services These services include: Dialysis (hemodialysis and peritoneal) Dialysis-related supplies Lab tests Rural health clinic services These clinics provide primary care services if you live in a rural area. Services you can get at these clinics include: Adult health screenings Child health checkups (CHCUPs) Chiropractic Family planning Behavioral health Podiatry Vision Prior Authorization 32

43 Covered Service Covered Service Description Therapy services occupational These are services provided by an occupational therapist who s licensed to practice in the state of Florida Occupational therapy services: Include evaluation and treatment to prevent or correct physical and emotional deficits or to lessen the effect of these deficits Are available in your home or in an outpatient facility, regardless of your age Therapy services physical These are services provided by a physical therapist who s licensed to practice in the state of Florida Physical therapy services: 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 Therapy services respiratory These are services provided by a respiratory therapist who s licensed to practice in the state of Florida Respiratory therapy services: Include evaluation and treatment of problems related to your lungs Are available in your home or in an outpatient facility, regardless of your age Therapy services speech These are services provided by a speech-language pathologist who s licensed to practice in the state of Florida Speech therapy services: Include evaluation and treatment of speech-language conditions Are available in your home or in an outpatient facility, regardless of your age Prior Authorization PA is required for occupational therapy PA is required for physical therapy PA is required PA is required for speech therapy 33

44 Covered Service Covered Service Description Transportation services emergency These services provide medically needed ground or air ambulance transportation in emergency situations See the Emergency Care section later in this handbook for more details about emergencies Transportation services non-emergency These services are available when you need transportation to medically needed appointments and you: 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 When setting up your transportation: Call (TTY ) You must call at least 48 hours ahead of your appointment If you call less than 48 hours before your appointment, we ll review your request to decide if it s urgent Prior Authorization 34

45 Covered Service Covered Service Description Vision services These are services given by an ophthalmologist, optometrist or optician who s licensed to practice in the state of Florida Services include: Eyeglasses Eyeglass repairs Eye exams Medically needed contact lenses Prosthetic eyes You re limited to: 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) Waived co-payments Members shall not be subject to co-payment charges, except: emergency room visits that were not emergencies and chiropractic services Please note: Children and pregnant women do not pay copays Prior Authorization PA is required for a second pair of eyeglasses within a twoyear period (if you re over age 21) 35

46 The Staywell Extras We re excited to offer: Extra benefits Healthy rewards Special programs like: Alternative therapies (art, equine and pet) Member Discount card Free Baby Stroller or Portable Playpen 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. 36

47 Services Not Covered by Staywell Services we don t cover may be available through another Medicaid program. We will refer you to the program that may be able to help you get the services you need. We do not cover these services: Cosmetic surgery Experimental or investigational procedures 37

48 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. A provider may offer alternatives to in lieu of covered services. These are services not normally covered by Staywell Health Plan but are medically appropriate and cost-effective substitutes for covered services. You are not required to use the alternative services offered. Prior Authorization (PA) Prior authorization (or PA for short) means we must approve a service before you can get it. You or your PCP/specialist should call 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. Please note: Prior authorization may be required for all non-emergency inpatient hospital admissions. 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: Fax: Expedited/Fast** (for urgent care) 48 hours You, your provider Call: Fax: Say: I d like an expedited/fast decision 38

49 * 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. You will be notified of this decision to extend the review timeline. ** Sometimes we may need more time to make a fast decision. If so, we ll take up to two more business days. You will be notified of this decision to extend the review timeline. Services Available Without Authorization You don t need approval from us or your PCP for the following services: 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 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. (You may also check our online provider search tool Find a Provider. It s on our website. Go to 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. 39

50 Call us if you have questions about our UM program. Call toll-free (TTY ). Disease Management Program What is the Disease Management Program? Staywell has a program to help members with long-term health issues. It s called the Disease Management Program. It gives you the tools and information you need to take charge of your health. Members in the program work with someone who is trained to coach them. The program also supports the members doctors. We do this by giving them information about the members health and about care they may need. What are some of the issues the program helps with? The Disease Management Program helps members with the following conditions: Asthma Coronary artery disease (CAD)/High blood pressure Congestive heart failure (CHF) Chronic obstructive pulmonary disease (COPD) Diabetes How does it work? There are five phases in the disease management process: Phase 1. We identify members who can benefit from the program. Phase 2. Then we tell members about the program and ask them to take part in it. Phase 3. We work with the member to develop a plan of care. Phase 4. We help the member reach health goals. Phase 5. Finally, we review how the program is working. The program is flexible. Members may opt in or opt out of the program. It s custom made to meet the needs of each member. The level of help a member gets depends on how much he or she needs. Members and providers can find out more about the program. Just visit our website at