Molina Community Plus Long Term Care (LTC)

Transcription

1 Molina Community Plus Long Term Care (LTC) Member Handbook Florida MolinaHealthcare.com This information is available for free in other languages. Please contact our customer service number at Molina Member Services Monday-Friday 8am 7pm at TTY/TDD users please call Esta información está disponible gratuitamente en otros idiomas. Favor de comunicarse con nuestro Departamento de Servicios para Miembros al o para los usuarios de TTY/TDD al , de lunes a viernes, de las 8:00 a.m. a 7:00 p.m.

2 Non-Discrimination Notification Molina Healthcare of Florida Medicaid Molina Healthcare of Florida (Molina) complies with all Federal civil rights laws that relate to healthcare services. Molina offers healthcare services to all members without regard to race, color, national origin, age, disability, or sex. Molina does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This includes gender identity, pregnancy and sex stereotyping. To help you talk with us, Molina provides services free of charge: Aids and services to people with disabilities o Skilled sign language interpreters o Written material in other formats (large print, audio, accessible electronic formats, Braille) Language services to people who speak another language or have limited English skills o Skilled interpreters o Written material translated in your language o Material that is simply written in plain language If you need these services, contact Molina Member Services at (866) If you think that Molina failed to provide these services or treated you differently based on your race, color, national origin, age, disability, or sex, you can file a complaint. You can file a complaint in person, by mail, fax, or . If you need help writing your complaint, we will help you. Call our Civil Rights Coordinator at (866) , or TTY, 711. Mail your complaint to: Civil Rights Coordinator 200 Oceangate Long Beach, CA You can also your complaint to civil.rights@molinahealthcare.com. Or, fax your complaint to (877) You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Complaint forms are available at You can mail it to: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C You can also send it to a website through the Office for Civil Rights Complaint Portal, available at If you need help, call ; TTY FL0717

3 رقم( Non-Discrimination Tag Line Section 1557 Molina Healthcare of Florida, Inc. English Spanish ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). French Creole ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. (Haitian Creole) Rele (TTY: 711). Vietnamese Portuguese Chinese French Tagalog Russian Arabic Italian German CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711)! ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (TTY : 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان ھاتف الصم والبكم:!). 711 اتصل برقم ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오.$ Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). Gujarati!ચન : % તi ગuજર ત બ લત હ, ત ન:શuCક ભ ષ સહ ય 9વ ઓ તમ ર મ = ઉપલCધ e. ફ ન કર (TTY: 711). Thai เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711).! MHF 1557 tag lines_v2 Created 10/14/16, rev 12/14/16

4 Important Phone Numbers Member Service Available Monday Friday: 8 A.M. 7 P.M local time. TTY English (Hearing Impaired) TTY Spanish (Hearing Impaired) Hour Nurse Advice Line (English) (Spanish) A Medicaid Fair Hearing: Office of Appeals Hearing Fax The Department of Children and Families (DCF) Transportation: Secure Transportation Dental Benefits: Dentaquest To Report Physical Abuse: National Domestic Violence Hotline SAFE(7233) TTY To Report Healthcare Fraud and Abuse: Statewide Abuse Hotline ABUSE(22873) To Enroll, Dis-enroll, or Check Eligibility: Choice Counseling TTY/TTD Fax Florida s Aging and Disability Resource Center: Elder Helpline ELDER(35337) You can also visit the website at: Locate Residential Facilities or Other Long Term Care Providers ELDER(35337) You can also visit or Agency of Health Care Administration Helpline TTD Esta información está disponible gratuitamente en otros idiomas. Favor de comunicarse con nuestro Departamento de Servicios para Miembros al o para los usarios de TTY/TDD al , de lunes a viernes, de las 8:00 a.m. a 7:00 p.m. 3 Welcome to the Molina Family

5 Table of Contents Welcome to Molina... 6 Molina Community Plus...7 Your Case Manager...8 Member Services...9 Molina s Member Service Department...9 Translation Services... 9 After-Hours... 9 Enrollment and Disenrollment Enrollment Open Enrollment Reinstatement (Renewal of Molina Membership) Medicaid Pending Disenrollment Pregnancy and Newborn Care...11 Choosing a Provider...11 Provider Directory Non-Emergency Care Outside the Service Area...11 Authorization Process Second Opinions...12 Emergency Care Services Access to Behavioral Health Services Emergency Behavioral Health Services Your Benefits Grievance and Appeals...16 The Grievance Process...16 Complaints and Grievances Filing a Complaint Filing a Grievance...16 Appeals Filing an Appeal...17 Expedited or Rushed Appeals Filing a Rushed Appeal What Happens if Molina Denies a Rushed Appeal?...18 Medicaid Fair Hearing...18 Subscriber Assistance Program (SAP) Welcome to the Molina Family

6 Table of Contents Cont. Rights & Responsibilities...20 Your Member Rights Your Member Responsibilities...21 The Quality of Care You Receive is Important to Us Disease Management Programs...22 Caregiver Support...22 Other Information...23 Participant Direction Option (PDO)...23 What Do I Have to Pay For?...23 Access to regular Medicaid Benefits Coverage...23 Medicare or Other Coverage Notifying You of Changes Abuse and Neglect Advance Directives...24 Disaster/Emergency Plan...25 Non-Discrimination Fraud, Waste, and Abuse...26

7 Molina Community Plus I have received the Member Handbook, Member Name Provider Directory, along with the New Member Welcome Packet. Should I have any questions, I can call my Case Manager or Member Services at (866) or (800) TTY/TTD. Member/Authorized Representative: Signature Date: 5 Welcome to the Molina Family

8 Welcome to Molina Dear Member, Welcome to Molina Healthcare of Florida, Inc. Thank you for picking Molina as your health plan. Molina contracts with state governments and operates as a Managed Care Plan. Molina provides high quality of service to people who qualify for Medicaid. The purpose of the LTC Program is to provide you with an array of services that meet your needs and allow you to live in the setting of your choice. This includes allowing you to live in the community for as long as you choose. If you want to know about the structure and operations of the plan call us at Your Member Handbook will help you with: Your Benefits How to get care Important Phone numbers Your PCP Please read this handbook carefully. Our goal is to make this handbook a useful tool for you. This is why we review it every year. It lets you know how to get medical care or services. You might need this book in another language. Call the Member Services Department at or for TTY/TDD You can also ask for this book or other materials in: Large Print Braille Audio (sound) These requests are free. You can call the Member Services Department at , Monday to Friday, 8:00 am to 7:00 p.m. local time. You may also go to the website at without having to log in. You can print a copy of the Member Handbook. 6 Welcome to the Molina Family

9 Molina Community Plus Welcome to the Molina Healthcare of Florida Family! Molina is part of the Molina Healthcare family. Molina is a nationally known provider for health care. Molina will serve counties through the LTC program in: Dade Highlands Monroe Polk Hardee Hillsborough Manatee As a new member it s important that you complete this checklist: Review your Member Welcome Kit You will get a Molina ID card and new member kit. It ll include helpful information about your benefits. It ll also have contact information and important forms like your Medical Release Form. Verify your Member ID card You will receive an ID card from Molina Community Plus. Please have this ID card with you at all times. The card will have your name, ID #, effective date. It has important information for you and your providers. Read Your Member Handbook It is important that you read your Member handbook. This handbook has important information about your benefits. It also has information about your rights and responsibilities 7 Welcome to the Molina Family

10 Your Case Manager As a member of Molina Community Plus you will have your own Case Manager. The Case Manager is ready to help you with your care. We will always talk to you and your family. We will also talk to your caregiver and your providers. Your Case Manager will take care of all your needs. A plan of care will be created to help you live in your home and community or in a Nursing Home. The care plan lets you know the services that you need. As your needs change, we can review the care plan with you. If needed, your care plan will be changed. If you have any questions, or need your plan of care updated, please call your Case Manager at (866) , Monday to Friday, 8:00a.m. to 7:00p.m. We are here to help you. Your care plan is based on: Your medical needs Your home setting Support available from family and friends The Case Manager will help you by: Completing your review and initial care plan. This will let us know what services you need. Making an appointment Approving your services Access services that are part of your plan of care Answering any questions Sending meals to your home Assisted living services and/or personal care aides Hospitals and home health care Medical supplies and equipment Talking with you and your family caregiver often about your needs Teaching you and your family/caregiver about your plan of care. (This includes treatments and goals). An assessment or reassment of your Care Plan Talking to your providers of care about your needs. Giving your providers a copy of your care plan. Talking to you about any gaps in service. Checking and keeping a record that you are receiving the services per your care plan Making sure a Service Gap Contingency and Plan is completed for you. We review services such as: Personal Care, including participant directed services Attendant Care Services, including participant directed services Homemaker In-home respite Nursing Talking to you about the Grievance and Appeals policies Talking to you about a disaster/emergency plan if you are in a home setting Making sure you get this Member Handbook and a Provider Directory. Talking to you about how to combine community activities to your personal goal planning. Also making sure you know that you can be part of this process. Talking to you or your caregiver about Advance Directives. Requesting copies of your medical case files and records Telling you about your right to receive home and community-based services in a home-like environment no matter how your living arrangements are. Giving you information about community integration/personal goal planning process and how you can be a part of that process. Call us if any of these changes happen: Your address Your telephone number You have other insurance You are admitted to a hospital or nursing home You should also call your DCF case/worker at (866) We will help you if you are not getting the care you need. Let us know if you have problems like: If the number of hours for a service is less than what was approved. If you are not receiving the services that were ordered 8 Welcome to the Molina Family

11 Member Services You can also call the Member Services Department at (866) , Monday to Friday, 8:00a.m. to 7:00p.m. Molina's Member Services Department Our Member Services Department can answer all your questions. You may call us at (866) or (800) for TTY/TDD, Monday to Friday, 8:00am to 7:00pm, but not on state approved holidays. We can help you in English, Spanish or Creole. If you need to talk to us in another language, we can help you. This will not cost you anything. When you call us, please have your ID card so we can help you with: Your benefits Info on providers How to get services Your concerns If you call when we are closed, please leave a message. We will call you back the next working day. If you have an urgent question, you may call our Nurse Advice Line at (888) , or (866) in Spanish. Our nurses are able to help you 24 hours a day and 7 days a week. You can have someone talk to us for you about joining the plan or your plan of care. That person can also talk to us about services you need. If you need this, call the Member Services Department at (866) and we will let you know if that can happen. Follow up about a prior approval With sign language This is a free service. If you need a translator, call the Member Services Department or your Case Manager at (866) If you are hearing or sight impaired, Molina can help you. You may ask for the member materials in braille. You call our TTY/TDD line at (800) (English) or (877) (Spanish). After-Hours You might need to call your provider when the office is closed. Molina Healthcare has a 24-Hour Nurse Advice Line to help you understand and get the medical care you need. You can call the Nurse Advice Line, 24 hours a day, 7 days a week at (888) or (866) for Spanish. For TTY/TDD, please call (866) or (866) for Spanish. They can help you: Access to care Call 911 or find an emergency department near you Make an appointment Answer questions you may have Translation Services If you need to talk to us in your own language, we can help. A translator is always available when you call to speak with us. They can also help you talk to your provider. A translator can help you: Make an appointment Talk with your provider Get emergency care File a complaint, grievance, or appeal 9 Welcome to the Molina Family

12 Enrollment If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Molina Healthcare Communit Plus 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 may 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 may change Managed Care Plans during your 60 day open enrollment period, without cause. 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 does not live in a region where the Managed Care Plan is authorized to provide services, as indicated in FMMIS. 2. The provider is no longer with the Managed Care Plan. 3. The enrollee is excluded from enrollment. 4. A substantiated marketing violation has occurred. 5. The enrollee is prevented from participating in the development of his/her treatment plan/plan of care. 6. The enrollee has an active relationship with a provider who is not on the Managed Care Plan's panel, but is on the panel of another managed care plan. "Active relationship" is defined as having received services from the provider within the six months preceding the disenrollment request. 7. The enrollee is in the wrong Managed Care Plan as determined by the Agency. 8. The Managed Care Plan no longer participates in the region. 9. The state has imposed intermediate sanctions upon the Managed Care Plan, as specified in 42 CFR (a)(4). 10. The enrollee needs related services to be performed concurrently, but not all related services are available within the Managed Care Plan network, or the enrollee's PCP has determined that receiving the services separately would subject the enrollee to unnecessary risk. 11. The Managed Care Plan does not, because of moral or religious objections, cover the service the enrollee seeks. 12. The enrollee missed open enrollment due to a temporary loss of eligibility. 13. Other reasons per 42 CFR (d)(2) and s (2), F.S., including, but not limited to: poor quality of care; lack of access to services covered under the Contract; inordinate or inappropriate changes of PCPs; service access impairments due to significant changes in the geographic location of services; an unreasonable delay or denial of service; lack of access to providers experienced in dealing with the enrollee s health care needs; or fraudulent 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 at (877) Reinstatement (Renewal of Molina Membership) If you lose your Medicaid eligibility temporarily and regain it within sixty (60) days, Molina will stay as your health plan. Your Case Manager can help you with the eligibility process. 10 Welcome to the Molina Family

13 Other Information Cont. Pregnancy and Newborn Care If you are pregnant, please call the Department of Children and Families (DCF) caseworker to let them know. You must also call DCF, when your baby is born DCF will review the baby's Medicaid benefits. They will give your baby a Medicaid ID number. You can call DCF at (866) Although Molina does not cover your medical benefits we want to make sure that you see an OBGYN and have a healthy baby. Please contact your medical plan. Choosing a Provider You must pick a provider that is on the Molina Community Plus plan. You have the right to choose any provider that is part of Molina. If you do not use one of our providers, we will not pay for your care. Call us or go to our website at to find a provider. Providers sign a contract with Molina. Molina does not reward providers for choices they make on your care. We do not give any bonuses to our providers to give you less care. If you want to know more about how we pay our providers call the Member Services Department. If you want to know about your provider, you can call us. You may want to know about: If they are certified or licensed What languages they speak Hours of operations Molina tries to make sure that our providers are easy to get to if you are disabled. We also try to be sure our provider locations are easy to get to. We can help you find a provider whose facility has these services. Call the Member Services Department if you need help. If you need to see a provider that is not in the plan, it must be approved. Your provider will need to call for the approval. You can call the Member Services Department or your Case Manager at (866) for help. Provider Directory The Provider Directory is a list of providers that are with Molina Community Plus. It is updated every six months. You can find: Provider names by type of provider Office hours Addresses Telephone Languages they speak Age limits If the provider is taking new patients The online provider directory has the latest provider listing. It is updated every week. It is on our website at You can look up provider by: Name Type of provider Close to where you live Zip Code Languages they speak If the provider is taking new patients If you need a copy of the provider directory, you can call the Member Services Department at (866) You can also get a copy at our website at Molina's providers must meet our values. We want you to have the best care. We review if a provider should be added to our group. Every three years all providers are checked to make sure they meet our rules. If you like to know this process, you may call the Member Services Department at (866) Non-Emergency Care Outside the Service Area You must get all services in our service area. The provider must be part of our plan. The counties we service are: Hardee Manatee Pasco Highlands Miami Dade Pinellas Hillsborough Monroe Polk 11 Welcome to the Molina Family

14 If you are not in the above areas, you must call your Case Manager or the Member Services Department. You must call us before you get care. Home and community based services are not covered outside the service area. Authorization Process All covered services need to be approved. This is called a "prior -authorization''. There are two types of covered services: Home and Community Services which are services provider in your home or community like Adult Day Care, Personal Care, Home Delivered Meals and supplies. Nursing Home which are nursing services you receive while in a health care facility, We can give you a copy of this process. This lets you know how we make decisions. You may call the Member Services Department to ask for a copy. You can also call your Case Manager. If you would like to talk to the medical staff, we can help. The following services do not need approval: Over the Counter Medication Vision Services Second Opinions You or your provider has the right to ask for a second opinion. You can ask for a second opinion for any plan of care services. You can do so by calling the Member Services Department. You can also call your Case Manager at (866) This will need to be approved. Emergency Care Services While Molina does not cover your medical services, we want to make sure you get care right away when you have an emergency. You do not need approval for an emergency. Call 911 or go to an emergency room near you. This includes any hospital setting or other emergency facility. You can get Emergency care (24) hours a day, (7) days a week. Some examples of emergency are: Pregnancy problems Seizures or convulsions Unusual or a lot of bleeding Unconsciousness Overdose/Poison Very bad Pain Severe burns Trouble breathing Chest Pains Call your Case Manager as soon as you can to let them know that you had an emergency. Your Case Manager may need to help coordinate services Access to Behavioral Health Services Molina can help you get behavioral health services for you and your family. You need to see a provider, if you are having any of the following feelings or concerns: Sadness that does not go away Feeling hopeless and/or helpless Guilt Worthlessness Anxious Thinking of hurting yourself of others If it is approved, we will help arrange the service. You will not have to pay for the services. If we cannot find a provider that is part of Molina, we will find a provider for you. If it is not approved, we will send you a letter with the appeal rights. 12 Welcome to the Molina Family

15 Other Information Cont. Emergency Behavioral Health Services A behavioral health emergency is a mental health condition that may cause great harm to the body. It may even cause death. Some examples of these emergencies are: Attempted suicide Danger to self or others So much harm that the person is not able to carry out actions of daily life Harm that will likely cause death. If you have an emergency, go to an emergency room near you. You can always call 911. While Molina does not cover inpatient or outpatient behavioral health care services, we can help you coordinate services with your provider. Call your Case Manager for help at (866) Aging and Disability Resource Center (ADRC) The ADRC is able to provide you with help no matter where you live. Aging and Disability Resource Centers (ADRCs) can help: Provide information and referral services Ensure that eligibility determinations are done properly and efficiently. Triage clients who require assistance. Manage the availability of financial resources for certain key long-term care programs targeted for elders to ensure financial stability Elder Helpline toll-free at ELDER ( ). 13 Welcome to the Molina Family

16 Your Benefits Adult Companion Care Adult Day Health Care Assistive Care Services Assisted Living These services help you with: Non-Medical Care Supervision Socialization This service does not include hands-on nursing care. Adult Day Health Centers are centers that provide social and health activities in a day program. You have the right to choose which Assisted Living or Adult Family Care Home you live in, but the place you live must meet the Home Community Based Setting requirements or you may be disenrolled. These are 24-hour service if you are in an adult family care home. You have the right to choose which Assisted Living or Adult Family Care Home you live in, but the place you live must meet the Home Community Based Setting requirements or you may be disenrolled. These services include: Personal Care Homemaker Companion Care Therapeutic social and recreational programs in a home-like environment in an Assisted Living Facility. You have the right to choose which Assisted Living or Adult Family Care Home you live in, but the place you live must meet the Home Community Based Setting requirements or you may be disenrolled. Note: The Florida Department of Children and Families will let you know if you have to pay for room and board. This is called Patient Responsibility. Care Caregiver Training Service Home Accessibility Adaptation Home- Delivered Meals Home & Community Services Homemaker Services Hospice Intermittent and Skilled Nursing These are services that are hands-on both for helpful and health-related type, specific to the needs of a medically These services may be provided by a nurse. These are services that teach and help those that take care of you. This person can be your friend, your neighbor, or your family. These are changes to your home to help you stay healthy and safe in your home. They can also help you to be active on your own. Without these changes, you could not be at home. This does not cover those changes to the home that are of general use. These are meals sent to you at your home if you have a hard time shopping or making food without help. They are also covered if you have a medical need. You have the right to receive services in a home like setting. The setting should allow you to participate in the community regardless of where you live. These are services that help you with household activities. Help such as preparing meals and routine chores. These are services that are forms of palliative healthcare and supportive to meet the physical, social, emotional and spiritual needs of terminally sick members and their families These are skilled nursing care services for members who do not need continuous nursing supervision. Services must be listed in your care plan. 14 Welcome to the Molina Family

17 Other Information Cont. Medical Equipment and Supplies Medication Administration These are services that cover medical devices, equipment, supplies, or appliances that help you increase the ability to perform activities of daily living. These are services to help you take your medicine if you are in a home or in a facility 15 Welcome to the Molina Family

18 Your Benefits Cont. Medication Management These are services that review the medication you are taking. A nurse reviews to make sure: You are taking the right medicine It s for your condition You are taking the right amount Physical Therapy These services are treatments to restore, improve or maintain impaired functions by using: Chemical with heat, light, electricity or sound Massage Active, resistive or passive exercises Nursing Facility Services Occupational Therapy Personal Care Personal Emergency Response System (PERS) These are 24-Hour a day nursing services you receive while in a health care facility, licensed as a Nursing Facility. The Florida Department of Children and Families will let you know if you have to pay. This is called Patient Responsibility. These services are treatments to restore, improve, or maintain impaired functions that you need to do daily tasks. This is to improve your ability to live safely in your home. These are in-home services to help you with: Bathing Dressing Eating Personal Hygiene These are services that cover an electronic device which helps you if you need help at home in an emergency. This is if you live alone or you are alone for a long time and need to be taken care of. Respiratory Therapy Respite Care Services Speech Therapy Transportation Services may also be provided to improve the ability to live safely in the home setting. These services are treatments of conditions that interfere with respiratory functions or other deficiencies of the cardiopulmonary system. These services are provided, for a short term, when you are unable to care for yourself because the person that normally takes care of you is absent or needs time off. These are services to treat problems related to an oral motor dysfunction when treatment will help you live safely in a home setting. These services cover nonemergent transportation services. This includes trips to and from covered services 16 Welcome to the Molina Family

19 Expanded Benefits This covers a $15 maximum per month for OTC drugs. 24-Hour Nurse Advice Helpline Services Access to registered nursing to help you with medical questions you may have if your provider's office is closed. You must use Navarro Pharmacy. You can call (888) You can also go to the website at: a_web/molina_login.asp. Assisted Living Facility/Adult Family Care Home Bed Hold If you need to leave your Assisted Living Facility or Adult Family Care Home and plan on going back, your bed will be held for 14 days. The facility must let Molina know and get an approval. Over the Counter (OTC) Pharmacy Services Call Member Services to find out what drugs are covered. You can also go to for a list of drugs that you can choose from. If you have a concern or a complaint, please call Molina's Member Services Department at (866) or for TTY/TDD (800) Dental Services These services cover a year preventive exam for adults 21 and over. It also covers X-rays every 3 years. You will need to see a dentist that is part of DentaQuest. You can call DentaQuest at (888) If you have a concern or a complaint, please call Molina's Member Services Department at (866) or for TTY/TDD (800) Support to Move Out of a Nursing Facility Vision Services There is a $1,500 per member per lifetime to help you move from a Nursing Facility to your home. These services include one pair of eyeglasses per year. You must see a doctor that is part of icare Health Solutions. You can find a provider at molinahealthcare.com. If you have a concern or a complaint, please call Molina's Member ServicesDepartment at (866) or for TTY/TDD (800) You can access a copy of the Florida Medicaid Statewide Medicaid Managed Care Long-Term Care Coverage Policy by visiting For information about in-lieu services please call Molina Member Services. 17 Welcome to the Molina Family

20 Grievance and Appeals The Grievance Process Molina has a grievance process for your questions or problems. You may also use this process when you do not like a choice we made. The Grievance and Appeals Department and the Member Services Department can help you with this process. They are free by calling (866) , Monday through Friday, from 8:00a.m. to 7:00 p.m. or for TTY/TDD at (800) If you wish to talk in your own language, we can help. A translator is available to talk with you and help you file the request. This service is free to all members. If you agree in writing, we can take your complaint, grievance, or appeal from: Yourself A friend A family member A provider that is part of Molina A provider that is not part of Molina A lawyer In order to be fair, cases will not be looked at by the same person that made the first decision. All cases about medical services are looked at by our medical staff. We keep files of all your cases. You may ask for copies at any time. Your file will include: All of your medical records Documents related to your case The information from before and during the appeal process Benefits, rules and criteria used to make the decision We will not take any bad action if your provider files a grievance or appeal for you. Complaints and Grievances Complaints are solved by the end of the next day. If they are not solved, they are moved to a grievance within (24) hours. Types of complaints and grievances may include: You have a problem with the quality of your care Wait times are too long Your provider behaves badly You can't reach someone by phone You can't get information Your enrollment ends You can't find a provider in your area We will try to solve all complaint or grievance over the phone. This is true if the problem is because: Someone has the wrong information Someone did not understand Someone needs more information Filing a Complaint If you have a complaint, you can call or write to the Member Services Department at: Molina Healthcare of Florida Attention: Member Services Department 8300 SW 33rd Street, Suite 400 Doral, Florida 33122, (866) , or by fax (877) Filing a Grievance To file your grievance you can: Call the Member Services Department Write a letter Fill out the Grievance/Appeal Form A complaint or a grievance is when you are not happy with issues that are not related to a denial. A complaint is the first part of the grievance process. 18 Welcome to the Molina Family

21 Grievance and Appeals Cont. Mail the letter or fax the form to: Molina Healthcare of Florida Attention: Member Services Department rd Street, Suite 400 Doral, Florida 33122, (866) , or by fax (877) If you need a copy of the Grievance/Appeal Form, you can call the Member Services Department. The form is also on our website at We can help you write your grievance. Your request needs: Your first and last name Your Signature Date Your Molina ID number. It is on the front of your member ID card. Your address and telephone number. Explain the problem Your grievance is looked at by a Grievance and Appeals Coordinator. A letter is mailed to you in (5) days. This letter lets you know that we have your grievance. The Coordinator will note and take care of your grievance. The coordinator will work with the right departments to solve your grievance. We will mail our decision in (90) days from the day we received it. At any time you may ask for your file, medical records or any other material used in the review. There is no cost to look or get copies of your case. You may call us if you need more time to send new information. We will give you fourteen (14) days. If we need more time, we will ask for your approval and a letter will be mailed to you in five (5) days. Appeals If you receive a denial letter and do not like the choice we made, you can file an appeal. An appeal is a request to review a denial. The appeal must be about the following: The care you want is denied The amount of care is decreased Your approved care was ended When payment for services is denied Filing an Appeal All appeals must be filed in (60) days from the day of the denial. If you call, you will be asked to send more information in writing. You will need to send the letter in (10) days from your verbal appeal. To file your appeal you can: Call the Member Services Department Write a letter Fill out the Grievance/Appeal Form. Mail the letter or fax the form to: Molina Healthcare of Florida Attention: Member Services Department rd Street, Suite 400 Doral, Florida 33122, (866) , or by fax (877) If you need a copy of the Grievance/Appeal Form you can call Member Services Department. The form is also on our website at We can help you write your appeal Your request needs: Your first and last name Your Signature Date Your Molina ID number. It is on the front of your member ID card. Your address and telephone number. Explain the problem. We try to solve your appeal right away. Your appeal is looked at by a Grievance and Appeals Coordinator. A letter is mailed to you, in (5) days. This letter lets you know we have your appeal. 19 Welcome to the Molina Family

22 Grievance and Appeals Cont. The Coordinator will work with the right departments to solve your appeal. We will mail our decision in (30) days from the day we received it. In order to be fair, cases will not be looked at by the same person that made the first decision. All appeals about medical services are reviewed by our medical staff. At any time you may look at your file, medical records or any other material used in the review. There is no cost to look or get copies of your case. You may call us if you need more time to send new information. We will give you fourteen (14) days. If we need more time, we will ask for your approval and a letter will be mailed to you in five (5) days. Continuing Benefits during appeal process: If you would like to go on with your benefits while you are appealing you must: Let us know in (10) days from the date on the denial letter. Let us know in (10) days after the effective date of the action, whichever is later. The appeal must be about a service that was: Stopped, Paused, or Reduction of a treatment that was approved before The service must have been asked for by an approved provider. The approval cannot have ended. If you request an extension of benefits. If you asked to go on with your benefits and the decision is not in your favor you may have to pay for the services that were given to you. Mail the letter or fax the form to: Molina Healthcare of Florida Attention: Member Services Department rd Street, Suite 400 Doral, Florida 33122, (866) , or by fax (877) Expedited or Rushed Appeals An expedited or a rushed appeal is when waiting for a regular appeal may risk your life or health. All rushed appeals will be solved in 72 hours. Filing a Rushed Appeal You, your provider or someone else, with your approval in writing, may call or write to ask for an appeal to be rushed. We can help you with this. Molina will decide if your appeal meets a rushed review. If the appeal meets a rush review, we will let you know in 24 hours. The decision is made in (72) hours from the time we received your appeal. We will let you know our answer in writing. A letter will be mailed to you in two (2) days from the time the decision was made. What Happens if Molina Denies a Rushed Appeal? If the appeal is not rushed, we will let you know by calling you in 24 hours. We will let you know the appeal will be looked at as a regular appeal. A letter will be sent to you with a new due date. Medicaid Fair Hearing You have the right to ask for a Medicaid Fair Hearing. You can do this at any time by calling the Department of Children and Families Services at: Agency for Health Care Administration Medicaid Hearing Unit P.O. Box Ft. Myers, FL (877) (toll-free) (239) (fax) MedicaidHearingUnit@ahca.myflorida.com 20 Welcome to the Molina Family

23 Grievance and Appeals Cont. You, your provider, or someone else, with your written approval, may call or write to ask for a hearing. You must request this hearing in (120) days or less from the first decision. You can do this after you completed the Molina's grievance and appeals process. If you ask for a Medicaid Fair Hearing, you give up the right to the review by the Subscriber Assistance Program. You will receive a letter from the hearing officer. The letter will tell you know the date and time of the hearing. The letter tells you how to get ready for the hearing. You may have the meeting by phone or in person. You have the chance to explain why you asked for the service. The hearing office will review the case and make a decision. The Office of Appeals will give you a final decision. This happens in (90) days or less from the date you asked for the hearing. Subscriber Assistance Program (SAP) You can ask for a review from the SAP if you are not happy with an appeal decision. You have the panel review your case. You can do this after you completed the Molina's grievance and appeals process. You have one (1) year from the final appeal decision to submit to SAP for review. The SAP will not consider a Grievance or Appeal taken to a Medicaid Fair Hearing. The SAP only hears certain kinds of cases. These are: If you are not able to get health care services. The benefits that are covered. An action or denial we made. A benefit action/ denial made by us. Payment of a claim. The way we handle a claim. Paying you back for benefits. You can choose to have a Medicaid Fair Hearing. You may not have a SAP review if you do. If you wish to request a SAP please contact: Agency for Health Care Administration Subscriber Assistance Program Building 3, MS # Mahan Drive, Tallahassee, Florida (850) (888) (toll-free) 21 Welcome to the Molina Family

24 Rights & Responsibilities Your Member Rights As a member of Molina Healthcare, you have the following rights: To be treated with respect and with due consideration for their dignity and privacy. To receive information on available treatment options and alternatives, presented in a manner appropriate to his or her condition and ability to understand. To a prompt and reasonable response to questions and requests. To participate in decisions regarding their health care, including the right to refuse treatment. To be free from any form of restraint or seclusion used as means of coercion, discipline, convenience, or retaliation. To request and receive a copy of their medical records, and request that they be amended or corrected as specified in 45 CFR and To be furnished health care services in accordance with federal and state regulations. To be free to exercise their rights and that the exercise of those rights does not adversely affect the way the managed care plan and its providers treat the member. To know who is providing medical services and who is responsible for his or her care. To know what patient support services are available, including whether an interpreter is available if he or she does not speak English. To know what rules and regulations apply to his or her conduct. To be given by health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis. To be able to take part in decisions about your health care. To have an open discussion about your medically necessary treatment options for your conditions, regardless of cost or benefit. To refuse any treatment, except as otherwise provided by law. To be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care. If you are eligible for Medicare, to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate. To receive, upon request, prior to treatment, a reasonable estimate of charges for medical care. To receive a copy of reasonably clear and understandable, itemized bill and, upon request, to have the charges explained. To impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap, or source of payment. To treatment for any emergency medical condition that will deteriorate from failure to provide treatment. To know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research. To receive information about Molina Healthcare, its services, its practitioners and providers and members' right and responsibilities. To make recommendations about Molina Healthcare's member rights and responsibilities policies. To voice complaints or appeals about the organization or the care it provides. To express grievance regarding any violation of his or her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency listed below. Office of Civil Rights United States Department of Health and Human Services Sam Nunn Atlanta Federal Center, Suite 16T70 Atlanta, GA Voice Phone (800) FAX (404) TDD (800) Welcome to the Molina Family

25 Rights & Responsibilities Cont. Bureau of Civil Rights Florida Agency of Health Care Administration 2727 Mahan Drive Tallahassee, FL (888) Your Membership Responsibilities You have the responsibility: For providing to the health care provider, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters relating to his or her health. For reporting unexpected changes in your condition to the health care provider. For reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her. To follow the care plan that you have agreed on with your provider. For keeping appointments and, when he or she is unable to do so for any reason, to notify the health care provider or health care facility. For his or her actions if he or she refuses treatment or does not follow the health care provider's instructions. For assuring that the financial obligations of his or her health care are fulfilled as promptly as possible. For following health care facility rules and regulations affecting patient care and conduct. To understand your health problems and participate in developing mutually agreedupon treatment goals to the degree possible. 23 Welcome to the Molina Family

26 The Quality of Care You Receive is Important to Us Molina wants you and your family to get the best care possible. We work hard to be sure you get the care you ask for. To give you the best quality care, we have a Quality Improvement (QI) Program. This program makes sure you are getting the care that is recommended. It also makes sure your concerns are heard and dealt with. Each year Molina tries to improve all services provided. We do this by setting goals. These goals are part of the QI Program. Our goal is to help you and your families take better care of yourself. As part of the QI Program, Molina helps you take care of your health and get the best service possible. One way that we measure quality is by looking at a survey. A survey is sent to many of you each year. This survey tells us if you are happy with your care. This survey asks you about the care you receive from Molina. We may send you a few questions about how we are doing. We want to know what is important to you. Based on what you tell us, we will continue to work to improve our services. To learn more about this program or if there are any ways we can serve you even better, please call the Member Services Department at (866) Want to learn more about what we are doing to improve. See ways we can improve Want to ask about our Quality Performance Measures in certain areas of service. Want to get information about our Quality Enhancements Disease Management Programs Molina Healthcare wants you to stay healthy. We have programs that can help you control your condition. These include programs, such as: The "Breathe with Eases" asthma program is adults who are with Molina. You and will learn how to control asthma and work with your provider. The "Healthy Living with Diabetes" program is for members 18 years and over with diabetes. You will learn about diabetes self-care. The "Chronic Obstructive Pulmonary Disease" (COPD) program is for members who have emphysema and chronic bronchitis. The "Heart-Healthy Cardiovascular" program is for members 18 years and older who have one or more of these conditions: coronary artery disease, congestive heart failure or high blood pressure Dementia and Alzheimer's program follows the Guideline for Alzheimer's Disease Management. It helps you manager the disease. Cancer - This program follows the disease management and treatment plan described by the National Comprehensive Cancer Network (NCCN.) A Care Manager/Nurse will teach you about your disease. He/she will manage your care with your provider. He/she will also give you other resources. You may be enrolled in these programs based on your care plan. For more info about our programs, please call the Member Services Department or your case manager at (866) You can also go to Caregiver Support We can help you to manage certain symptoms that can help you improve your health and quality of life. We can help you obtain health goals such as smoking cessation, constipation prevention, pain management, and weight loss. For more info about our programs, please call your Case Manager at (866) Welcome to the Molina Family