Healthy Futures Start with a Plan. Member. Handbook. Advocate

Transcription

1 Healthy Futures Start with a Plan. Member Handbook Advocate

2 WellCare Advocate Managed Long Term Care Plan Member Handbook

3 Healthy Futures Start with a Plan. MEMBER HANDBOOK ADVOCATE TABLE OF CONTENTS Welcome to WellCare Advocate... 1 Getting Help from the Plan...2 Important Things for You to Know as a New Plan Member...3 Eligibility and Enrollment in the WellCare Advocate Plan...4 Services Covered by the WellCare Advocate Managed Long Term Care Plan...6 Services Not Covered by WellCare Advocate How Our Providers Are Paid What Do I Do If...11 Service Authorizations and Plan Actions Other Decisions About Your Care Grievances Disenrollment from the Program Member Rights Member Responsibilities Information About WellCare of New York, Inc Notice of Privacy Practices Advance Directives...28 Health Care Proxy...28 Health Care Proxy Form...37

4 WELCOME TO WELLCARE ADVOCATE Welcome to the WellCare Advocate Managed Long Term Care Plan. This plan has been specially designed for people with Medicaid who need health and supportive long-term care services, like home care and personal care. These services help members stay in their homes and communities for as long as possible. As a plan member, you have more community-based service options than are available in regular Medicaid. These options include but are not limited to: personal care services in the home, nursing services, physical and occupational therapies and adult day health care. The services offer the help you need and make it possible for you to be more active and independent. A Care Manager will help you and your caregivers find your way in the health care system. A Care Manager is a health care professional, usually a nurse or a social worker. He or she will work with your doctor. They will review your health and long-term care needs with you. They will also help you decide on the services that will help you to be as independent and healthy as possible. In addition, your Care Manager will: Approve services that are medically necessary Arrange and monitor the services and care that you need Coordinate your medical and long-term care with all of your providers Provide information to your doctors or to the hospital to help you get the best care As a plan member, you need to be committed to your care. It s important that you be active, use only the services that you need, try to do more for yourself, and do as much as you can yourself to manage and monitor your own chronic conditions. This member handbook will help you understand: How the plan works The benefits that the plan provides to you How to request a service How to contact and work with your Care Manager How to contact Member Services How to file a complaint or grievance How to disenroll from the plan The coverage explained in this handbook is in effect from the date you enroll in the plan. Enrollment in the plan is voluntary. Welcome to WellCare Advocate 1

5 GETTING HELP FROM THE PLAN If you need help from the plan, you can call your Care Manager or Member Services. HELP FROM YOUR CARE MANAGER Your Care Manager is your main connection to the plan. He or she will be in regular contact with you. When you need help or have a question, call your Care Manager. You can call your Care Manager during business hours. Call Monday through Friday, from 8 a.m. to 6 p.m. He or she can help you arrange services, assist with a provider, coordinate care with your doctor, and answer your questions about things like your benefits, medical care, or medicines. If your Care Manager cannot help you, then he or she will make sure that you talk with someone who can. My Care Manager s Name: Phone Number: Sometimes you may need to call your Care Manager after business hours, on holidays, or on weekends. At these times, a nurse will answer the phone. The nurse may be able to answer many of your questions and assist you if you are not feeling well. Also, the nurse will let your Care Manager and doctor (if appropriate) know that you called, why you called, and what he or she told you to do. HELP FROM MEMBER SERVICES You can call Member Services Monday through Friday, from 8 a.m. to 6 p.m. Call with questions about your benefits, claims, replacing a lost ID card, or if you have a complaint or service appeal. You can also call your Care Manager and they will assist you in getting these issues resolved with WellCare Member Services. Member Services Toll-Free Phone Number: If you do not speak English, we can help. We want you to know how to use your health care plan, no matter what language you speak. Just call us and we will find a way to talk to you in your own language. We have translation services available. We also have information in large print, Braille, and audible media. Our TTY phone number is Welcome to WellCare Advocate 2

6 IMPORTANT THINGS FOR YOU TO KNOW AS A NEW PLAN MEMBER MEMBER ID CARD After you join, we will send a welcome letter that confirms your enrollment and start date. Your member ID card should arrive within 14 days of when your membership becomes effective. Your card identifies you as a plan member and has your member identification number. If you need care before the card comes, your welcome letter is proof that you are a member. Keep your member ID card with your Medicaid benefit card and your Medicare card, if needed. You will need these cards to get services that the plan does not cover. Please carry all of your health care ID cards at all times, including any private health insurance cards, as well as Medicare or Medicaid cards. Each time you go for care, be sure to show them to your provider. HOW TO GET CARE AND SERVICES Care Management Services You and your doctor will work with your Care Manager to decide on the services that you need and to develop a Care Plan. Your Care Plan outlines the services you need. The Care Plan includes the specific types of services that will be provided and the number of visits or personal care hours that will be covered. It also tells you the length of time that services have been authorized. We will update your Care Plan at least every 6 months. We will update it more often if there is a change in your condition and when service authorizations come to an end. Your Care Manager will: Answer your questions about your health or medical care Monitor your care and health status Work with your doctors to help make sure that you are getting the right care at the right time Work with you and your doctor to review and update your Care Plan regularly Review your requests for services Arrange for and monitor services provided by the plan Coordinate care and services with all of your providers Work with your doctor and other providers if you need to go in the hospital Plan for your care needs when you leave the hospital Assist with doctors and appointments and make certain you have transportation to those services Your Care Manager will contact you a few days before your enrollment becomes effective to see how you are doing and to make sure that your Care Plan is still right for you. This contact is called a new member orientation. Your Care Manager will talk to you on the phone often and a reassessment nurse will visit at least every 6 months. He or she will also talk to your caregivers, your doctor, and other providers. He or she will work closely with the home care agency providing services to you, with other community providers, and with your doctors. If you are hospitalized, your Care Manager will work with your doctor and the hospital to plan for a fast and smooth transition back to the community. You may be receiving care that will continue when you join the plan. In this case, your Care Manager will contact your provider and arrange for services to be transitioned to your new plan. Member Services: (TTY/TDD: ) 3

7 Coordinating Benefits and Services Please make sure to let us know if you have other health insurance. This includes Medicare. We will coordinate benefits with the health insurance that you have. If you have Medicare, you will continue to have the same benefits and services as you do today. There are no changes to your coverage and you do not need to have Medicare services approved by WellCare. We will work with your Medicare providers and will pay the co-payments and deductibles for any services covered by the plan. Your Care Manager will help you with services that are covered by Medicare, such as doctor and hospital visits. Medicaid will continue to pay co-payments or deductibles for services covered by Medicaid that are not part of this plan. Your Care Manager will coordinate services that are not part of the services covered by the plan, such as mental health services. Transitional Care When you become a plan member, you may be under the care of a health care provider. You may continue treatment even if the provider is not in our network (for example, if you are receiving dental care and the treatment is not finished). You may continue treatment for up to 60 days from when you join the plan. Your provider must agree to accept payment at the plan rate, follow our policies, and agree to provide us with medical information about your care. Sometimes, a provider may choose to leave the plan network. Your care may be continued for up to 90 days. When you become a member, you may be receiving community-based long-term care services from another program. You will continue to receive the same services you are receiving for at least 90 days after enrollment. However, during the first 30 days, you may receive a person-centered service plan and care management assessment which could lead to a reduction of your services after the first 90 days of enrollment have passed. If there is a reduction, you will be notified prior to the reduction talking effect. ELIGIBILITY AND ENROLLMENT IN THE WELLCARE ADVOCATE PLAN ELIGIBILITY FOR MANAGED LONG TERM CARE You are eligible to enroll in the plan if you: Have Medicaid; or you are eligible for Medicaid Are a Medicaid-eligible New Yorker age 18 or older Are determined eligible for the plan using an assessment tool designated by DOH Live in the plan s service area this includes Bronx, Kings (Brooklyn), Manhattan, Queens, Orange, Rockland, Albany, Ulster, Erie, Nassau, Suffolk, Richmond (Staten Island) and Westchester counties. Are able to stay safely at home at the time you join the plan Are expected to need care management and at least one or more of the following services for more than 120 days from the date that you join the plan: Adult day health care Consumer Directed Personal Assistance Services Home health aide services in the home Nursing services in the home Personal care services in the home Private duty nursing Rehabilitation therapies in the home Welcome to WellCare Advocate 4

8 You may also join if you have Medicare. Your Care Manager will coordinate your Medicare benefits and services for you. You are not eligible to join the WellCare Advocate Managed Long Term Care Plan if you are: A resident of a psychiatric, a residential care or an intermediate care facility for the mentally retarded (ICF/MR) or an Assisted Living Program (ALP) An inpatient or resident of a facility operated by the State Office of Mental Health (OMH), the Office of Alcoholism and Substance Abuse Services (OASAS), or the New York State Office for People With Developmental Disabilities (OPWDD); Enrolled in another Medicaid managed care or managed long-term care plan; Receiving services from waiver programs (Traumatic Brian Injury, Nursing Home Transition & Diversion), an OPWDD day treatment program, or a hospice program; Expected to be Medicaid eligible for less than six (6) months or eligible for Emergency Medicaid; Individuals eligible for Medicaid benefits only with respect to tuberculosis-related services; In the family planning expansion program or in the Foster Family Care Demonstration; Under the age of 65 and in the Centers for Disease Control and Prevention breast and/or cervical cancer early detection program and need treatment for breast or cervical cancer, and are not otherwise covered under creditable health coverage; or In receipt of Limited Licensed Home Care Services. HOW TO ENROLL You may learn about the plan in different ways: Your doctor, your provider, or staff from a community organization or agency may refer you. They may think you are eligible for the plan and could benefit from the services available. You or a family member may learn about the plan through our sales staff, at your doctor s office, or in a community setting. You may already be a member of another WellCare health plan or pharmacy plan and be identified by one of our staff as needing the kinds of services available through this program. Staff may include a nurse in our Medical Management Department, a case manager, a disease management nurse, the plan s Medical Director, a plan pharmacist, or a Member Services representative. We follow up on each referral, regardless of the source, in the order in which we receive them. You will be contacted by telephone by an enrollment coordinator. The coordinator will provide you with information about managed longterm care, eligibility, and plan options. The coordinator will also ask you some basic questions to find out if you meet basic eligibility (for example, that you live within our service area, or that you have Medicaid). If you do not have Medicaid but think that you might be eligible, we will help you apply for coverage. The coordinator may need to find out if you meet the minimum eligibility requirements for enrollment. He or she may ask questions like: Do you currently receive home care services? Do you need help with certain tasks like bathing or dressing? How many medications do you take? Do you need help taking them? If you meet basic eligibility for the plan, an enrollment nurse will visit you at your home. The nurse will meet with you and your family, if they help you stay at home. He or she will review your needs and tell you about the WellCare Advocate Plan. The nurse will ask you questions about your health care and evaluate your medical care needs. If you meet the minimum eligibility requirements and would like to join, the nurse will complete a comprehensive assessment. With input from you, your caregivers, and your doctors, he or she will develop a Care Plan. The nurse may need to meet with you several times to do this. Member Services: (TTY/TDD: ) 5

9 To finish, you ll need to sign an enrollment agreement. Enrollment is processed by NY Medicaid Choice (NYMC), your Local Department of Social Services (LDSS) or an entity designated by the state for review and approval. Your Medicaid eligibility will be verified by the NYC Human Resources Administration (HRA) or your LDSS. Medicaid surplus is the difference between your monthly income and the Medicaid income limit. If your income is above the Medicaid income limit, you are required to pay the difference to the health plan to cover a portion of your health care coverage. Your surplus payment is determined by the HRA or your LDSS. The effective date of your enrollment depends on when the process is done. Completed applications that are processed by noon on the 20 th of the month generally take effect on the first day of the next month. If you decide that you do not want to enroll, you may stop your application for enrollment at any time before the effective date. We will refer you to other providers if you need services. REASONS FOR DENYING ENROLLMENT Your enrollment will not be accepted if: You do not meet the clinical, age, service need, or service area eligibility requirements. You cannot live safely in your home. You were a member of the plan in the past and you were involuntarily disenrolled and the reasons for the disenrollment have not changed or been resolved. WellCare can advise you if you are not eligible. You may choose to withdraw your application. If you do not withdraw your application, WellCare will send your application to NY Medicaid Choice (NYMC), your Local Department of Social Services (LDSS) or an entity designated by the state to review your application. They will decide if you are eligible or not. They will let you and WellCare know the decision. SERVICES COVERED BY THE WELLCARE ADVOCATE MANAGED LONG TERM CARE PLAN COVERED SERVICES The plan provides you with services that are medically necessary. Medically necessary means any service required to prevent, diagnose, correct or cure conditions in the enrollee that cause acute suffering, endanger life, result in illness or infirmity, interfere with such enrollee s capacity for normal activity, or threaten some significant handicap. That is, they are needed to prevent or treat your illness or disability. Your Care Manager will help identify covered services and will select providers to work with you. You may have to get prior authorization from your Care Manager or a referral from your doctor to get these services. SERVICE DESCRIPTIONS This is a summary description of your covered benefits. Adult Day Health Care a supervised nursing home-based program. Members receive any of the following medically necessary services: nursing care, physical therapy, occupational therapy, speech therapy, nutritional counseling, therapeutic recreational activities, social work counseling, podiatry, dental services, and personal care, such as bathing and grooming. This service is generally provided as a substitute for in-home personal care and/or when extensive rehabilitation services are required. Community-Based Physical Therapy, Occupational Therapy, and Speech Therapy facility-based services usually provided in an outpatient setting for when a member requires more extensive services that cannot be provided in the home, or that are provided more effectively in an outpatient setting. Medicaid coverage of Welcome to WellCare Advocate 6

10 physical therapy, occupational therapy, and speech therapy outside the home is limited to 20 visits each per calendar year, except for children under age 21 and the developmentally disabled. Consumer Directed Personal Assistance Services (CDPAS) the provision of some or total assistance with personal care services, home health aide services and skilled nursing tasks by a consumer-directed personal assistant, who may include any relative, excluding a spouse or parent, under the instruction, supervision and direction of a consumer or the consumer s designated representative. The designated representative may not also be the consumer-directed personal assistant. Dental Care members receive up to 2 routine dental exams per year. These include medically necessary cleaning and restorative dental care, such as fillings and dentures. You do not need prior authorization to see a dentist. However, you must use a dentist that is in our network. If you need a specific dental service that requires prior authorization, your dentist will directly contact Healthplex, our dental network provider. Durable Medical Equipment (DME), Prosthetics, and Orthotics* medically necessary durable medical equipment, prosthetics and orthotics. Your Care Manager will work with your provider to arrange for home delivery and pick up and for equipment maintenance and repair for DME. If you have any medical equipment or devices, please let us know when you join the plan. We will coordinate with your current DME vendor if the equipment is rented. Prosthetics and orthotics are obtained through network providers. DME, prosthetics and orthotics require a prescription. They also must be authorized by your Care Manager. *Prescription footwear and inserts are limited to use in conjunction with a lower limb orthotic brace, as part of a diabetic treatment plan, or if there are foot complications in children under age 21. Environmental Supports medically necessary home modifications or equipment to help members stay safely in their home. Examples include purchasing an air conditioner for a member with respiratory problems, installing a ramp or widening doorways to accommodate a wheelchair, and housekeeping/chore services. Eye Care covered benefits include eye exams and eyeglasses or medically necessary contact lenses. Low vision aids are covered if needed to help you function independently. Generally, you can get new eyeglasses every 2 years. New lenses may be ordered more often (for example, if your vision changes more than onehalf diopter). If you break your glasses, they can be repaired. Lost eyeglasses or broken frames that cannot be repaired will be replaced with the same prescription and style of frame. Hearing Exams, Hearing Aids, and Hearing Aid Batteries benefits include hearing exams and, if medically necessary, hearing aids. You may access services directly through an audiologist in our network without contacting the plan. However, plan authorization may be required for some services. If so, the audiologist will contact us on your behalf. Home-Delivered Meals home delivery of a prepared meal or meals to members who are not able to prepare meals on their own. Home Health Aide (HHA) or Personal Care Services medically necessary help with bathing, eating, dressing, going to the toilet, walking, and health-related tasks provided under the supervision of a registered nurse. Note that the plan benefits do not include HHA or personal care services for the sole purposes of safety supervision, personal companionship, or to provide housekeeping or chore services. Home Health Care includes nursing services and occupational, physical, and speech therapies provided in a member s home by the staff of a licensed home care services agency or a certified home health agency. Medical Social Services initial and periodic evaluation of a member s mental health status, social and family supports, eligibility for entitlements and advance directives. Includes routine supportive counseling of complex member and family needs. Member Services: (TTY/TDD: ) 7

11 Medical/Surgical Supplies** medically necessary items for medical use which are used for a specific medical condition and which are generally disposable, not reusable, and are used for specific medical purposes. **Medicaid covered compression and support stockings are limited to coverage only for pregnancy or treatment for venous stasis ulcers. Nutrition assessment of nutritional needs, nutrition education, and nutritional counseling provided by a nutritionist or registered dietitian Enteral formula limited to nasogastric, jejunostomy, or gastrostomy tube feeding; or treatment of an inborn error of metabolism* Nutritional supplements: Coverage of enteral formula and nutritional supplements is limited to individuals who cannot obtain nutrition through any other means, and to the following three conditions: 1) Individuals who are fed via nasogastric, jejunostomy, or gastrostomy tube; 2) Individuals with rare inborn metabolic disorders; and 3) Children up to age 21 who require liquid oral enteral nutritional formula when there is a documented diagnostic condition where caloric and dietary nutrients from food cannot be absorbed or metabolized Coverage of certain inherited disease of amino acid and organic acid metabolism will include modified solid food products that are low protein or which contain modified protein Nutritional Supplements enteral formulas for tube or oral feeding when a member has a diagnosis or condition that prevents nutrients from being absorbed from food. Nursing Home Care (provided you are eligible for institutional Medicaid) members may require short-term nursing home admissions following a hospital stay to promote recovery. Or they may require a long-term stay when the member, their caregivers, their physician, and WellCare find that it is no longer safe for the member to remain in his or her home. If a member has Medicare, most short-term admissions are covered. If a member does not have Medicare, we will cover medically necessary short-term nursing home admissions. We will cover longterm stays when the member has institutional Medicaid. Personal Emergency Response System (PERS) an electronic device connected to the phone that a member can activate if he or she is alone and there is an emergency. Podiatry the plan covers the services of a licensed podiatrist to provide medically necessary foot care. Medicare is usually the primary payer for these services, so you may access these services directly without contacting the plan. We will pay your co-payments directly to the provider. Private Duty Nursing continuous skilled nursing care provided in a member s home by a licensed registered professional or practical nurse, if medically necessary. Respiratory Therapy Services in-home services provided by a licensed respiratory therapist. Includes teaching how to use equipment, such as nebulizers or oxygen. Social Day Care a supervised community-based program. Members can socialize with others and participate in therapeutic recreational group activities that promote physical activity and social interactions. Members will receive personal care services and a group meal. Non-Emergency Transportation your Care Plan will indicate the transportation we will provide to help you get to and from doctors appointments. We will provide ambulette, taxi, or car service, depending on your need. If you are able to use public transportation, we will reimburse you directly. Welcome to WellCare Advocate 8

12 To schedule a ride, call your Care Manager or call Member Services directly. Please call 2 business days before your appointment. If you call less than 2 business days before your appointment, we may not be able to meet your need. Or you may have to wait longer than expected for pick up or return. Member Services Toll-Free Phone Number: Your Care Manager: Tell your Care Manager or Member Services that you are in the WellCare Advocate Plan. He or she will contact our transportation vendor. Please be ready to answer these questions: Type of transportation you need (for example, car service, ambulette) Address where you need to be picked up Time you need to be picked up Address of where you are going Time that you will need to be picked up for the return trip Any special needs (for example, help getting in and out of the car, wheelchair, escort, etc.) Traffic and other conditions are out of the control of WellCare and our transportation providers. We allow a 30-minute grace period before a pick up is considered late. All covered services must be provided by WellCare network providers. WellCare Advocate members may choose from among the WellCare network of providers which is made up of highly qualified providers who are located throughout our service area for convenience. Members and/or their providers must obtain prior approval from the plan for most services. Care Managers work with members and their providers to review member needs, develop Care Plans, and approve medically necessary services and care. Your Care Manager will work with you and your family to arrange for all of your services as part of your Care Plan. They are also able to help you identify a network provider or make an appointment for any services that you require. * If you have Medicare, these services may be paid for in whole or in part. Your provider will bill Medicare directly. WellCare Advocate will pay co-payments or deductibles. If Medicare is the primary payer, you may choose any provider that accepts it. When Medicare stops paying for these services, you may need to change to a provider in our network. Please note that if you have Medicare or any other insurance, WellCare Advocate is billed last. You must use a provider in the plan network and obtain prior authorization from the plan where needed, as explained below. You have a choice of providers. If you are not satisfied with your provider, you may choose another one from our network. Your Care Manager can help you. Note that it may take up to 2 weeks for you to be able to schedule an appointment with a new provider. There may be times when you need a service that is covered by the plan, but you need help finding a provider. We can help you find a provider in our network with the training, experience, or the scope of services that your care requires. Ask your Care Manager to help find a provider and for prior authorization to use a provider outside of the network. You need prior authorization to use a provider outside of the network, except in the case of an emergency. Member Services: (TTY/TDD: ) 9

13 SERVICES NOT COVERED BY WELLCARE ADVOCATE WellCare Advocate does not cover the following services that are covered by Medicare and/or Medicaid: Alcohol and substance abuse services Chronic renal dialysis Emergency services Emergency transportation Family planning services Inpatient hospital services Laboratory services Mental health services Outpatient hospital services Physician services, including services provided in an office setting, a clinic, a facility, or in the home Prescription and non-prescription drugs Radiology and radioisotope services Rural health clinic services Services provided by the New York State Office for People With Developmental Disabilities (OPWDD) You can get these services from any provider who takes Medicaid and/or Medicare. If you are a member of a Medicare Advantage plan, you must follow your plan s rules and get services from a network provider. You may choose to keep your other insurance coverage for your Medicare Part D Prescription Drug coverage. If you have any questions about whether a benefit is covered, call your Care Manager. You can also call Member Services. HOW OUR PROVIDERS ARE PAID You have the right to ask us if we have any special financial arrangement with our providers that might affect your use of services. Call Member Services if you have specific concerns. We want you to know that for certain covered services, such as vision and dental, providers are paid a set fee each month for each member. This fee is called capitation. It stays the same whether a member uses the services or not. For most covered services and for non-covered services, most of our providers are paid on a fee-forservice basis either by us, by Medicaid, or sometimes by Medicare. This means that they get a fee that they have agreed to for each service they provide. We pay all providers directly for the services you receive. A provider should not bill you for any covered services. If a provider sends you a bill by mistake, do not pay the bill. Tell the provider that you are a member of WellCare Advocate and that they should bill WellCare directly. If you have any questions, please call Member Services. Welcome to WellCare Advocate 10

14 WHAT DO I DO IF... I Am Planning to Be Out of the Area If you are planning to leave our service area, you must tell your Care Manager ahead of time. If you are receiving services in your home, talk to your Care Manager at least 5 business days before you leave. We need to tell your provider of your plans. If you think that you will need services, such as personal care, when you are out of the area, talk to your Care Manager at least 2 weeks before you leave. It is very important that you give us notice before you leave and return. If we do not have enough notice, we will not be able to make any arrangements for your care and services. We need to know where you are going, where you are staying, how long you plan to be away, and how we can reach you. While you are away, your Care Manager will call you to see how you are doing and to plan for your return. If you have a problem or if your condition changes, please call your Care Manager at We need 5 business days notice to make arrangements for your return. If you are not able to provide enough notice, we will make every effort to arrange for services once you return. However, we may not be able to do so. If you are out of the area for 30 consecutive days or longer, you will be disenrolled from the plan. Please call your Care Manager if you have any questions. I Go to the Emergency Room or I Am Admitted to the Hospital If you go to the emergency room, call your Care Manager as soon as possible. The sooner we know, the sooner we can follow up with you and your doctor. We can see if there is anything that you need or that can be done so you don t need to go there again. If you are admitted to the hospital, please call your Care Manager as soon as you can. If you are not able to call, please ask a family member or friend to call for you. Tell the hospital that you are a member of WellCare Health Plans. Show them your card. Ask them to contact us so that we can work with them to arrange for after care. I Need Emergency Care An emergency is a medical or behavioral condition that comes on suddenly. You are afraid serious harm could happen if you do not get care right away. Examples of an emergency are: A heart attack or severe chest pain Trouble breathing, convulsions, or loss of Bleeding that won t stop or a bad burn consciousness Broken bones When you feel you might hurt yourself or others Some examples of things that are not emergencies: colds, sore throats, stomach aches, minor cuts and bruises, and sprained muscles. What to Do If You Have an Emergency Call 911 or go to the emergency room. You do not need prior authorization from WellCare before getting emergency care. You may use any provider. Call your doctor or your Care Manager if you are not sure if it is an emergency. Explain what is happening. You will be told what to do at home, or told to go to your doctor s office or the nearest emergency room. If you are out of the area when you have an emergency, go to the nearest emergency room. If you return home during business hours, please call your Care Manager. Tell him or her what happened and how you are doing. If you call after hours, please leave a message. Your Care Manager will follow up with your doctor promptly. Member Services: (TTY/TDD: ) 11

15 SERVICE AUTHORIZATIONS AND PLAN ACTIONS PRIOR AUTHORIZATION Most covered services must be approved by your Care Manager before you receive them or continue receiving them. This is called prior authorization. You or someone you trust can ask for prior authorization from the plan. When you ask for prior authorization of a treatment or service, it is called a service authorization request. Your Care Plan includes those services that have been identified as medically necessary and that have been authorized. You or your health care provider may make a service authorization request by: Contacting your Care Manager directly Faxing a request to your Care Manager at Sending a request in writing to WellCare Advocate Service Authorization Request 110 Fifth Ave., 3rd Floor New York, NY Services will be approved in a certain amount and for a specific period of time. This is called an authorization period. CONCURRENT AUTHORIZATION During an authorization period, you or your health care provider may ask us to consider approving more of a specific service that has already been approved and is part of your Care Plan. In this case, we will re-evaluate your care to see if you still need the level of care being provided. This is called a concurrent authorization. What Happens After We Get Your Service Authorization Request The health plan has a review team to be sure you get the services we authorized. Doctors and nurses are on the review team. Their job is to be sure the treatment or service you asked for is medically needed and right for you. They do this by checking your treatment plan against acceptable medical standards. An action is any decision to deny a service authorization request, to approve it for an amount or time period that is less than requested, or to reduce, suspend, or end a service that we have already approved and that you are now getting within an authorization period. These decisions will be made by a qualified health care professional. If we decide that the service is not medically needed, the decision will be made by a clinical peer reviewer. This reviewer may be a doctor, a nurse, or a health care professional who typically provides the care you requested. You can ask for the specific medical standards used to make the decision for actions related to medical necessity. These standards are called clinical review criteria. After we receive your request, we will review it under a standard or fast track process. You or your health care provider can ask for a fast track review if it is believed that a delay will cause serious harm to your health. If the request for a fast track review is denied, we will tell you. Your request will be handled under the standard review process. In all cases, we will review your request as fast as your medical condition requires us to do so, but no later than the time frames identified below. We will tell you and your provider both by phone and in writing if your request is approved or denied. We will also tell you the reason for the decision. We will explain what options for appeals or fair hearings you will have if you do not agree with our decision. Welcome to WellCare Advocate 12

16 TIME FRAMES FOR SERVICE AUTHORIZATION REQUESTS Prior Authorization Standard Review we will make a decision within 3 business days of when we have all the information we need. You will hear from us no later than 14 days after we receive your request. We will tell you by the 14 th day if we need more information. Fast Track Review we will make a decision and you will hear from us within 3 business days. We will tell you by the 3rd business day if we need more information. Concurrent Authorization Standard Review we will make a decision within 1 business day of when we have all the information we need. You will hear from us no later than 14 days after we receive your request. Fast Track Review we will make a decision within 1 business day of when we have all the information we need. You will hear from us no later than 3 business days after we receive your request. In the case of a request for Medicaid covered home health care services following an inpatient admission, one (1) business day after receipt of necessary information; except when the day subsequent to the request for services falls on a weekend or holiday, seventy-two (72) hours after receipt of necessary information; but in any event, no more than three (3) business days after receipt of the request for services. We may need more information to make either a standard or fast track decision about your service authorization or concurrent review request. In this case, the time frames above can be extended up to 14 days. We will: - Write and tell you what information is needed. If your request is in a fast track review, we will call you right away and send a written notice later. - Tell you why the delay is in your best interest. - Make a decision as quickly as we can when we receive the necessary information. You will hear from us no later than 14 days from the original time frame. You, your provider, or someone you trust may also ask us to take more time to make a decision. This may be because you have more information to give the plan to help decide your case. You can write to us or call You or someone you trust can file a grievance with the plan if you do not agree with our decision to take more time to review your request. We will contact you by the date our time for review has expired. If you are not satisfied with this answer, you have the right to file an action appeal with us. See the Action Appeals section of this handbook. OTHER DECISIONS ABOUT YOUR CARE Sometimes we will do a review of the care you are already receiving. This is an internal review conducted by WellCare to re-evaluate care and services. We do this to see if you still need the care or to evaluate the amount of care you are receiving. If it is found that you do not need the services you are currently receiving, this can result in a termination, reduction, or suspension of benefits. In most cases, we must tell you at least 10 days before we change the service. Member Services: (TTY/TDD: ) 13

17 GRIEVANCES WellCare will try its best to deal with your concerns or issues as quickly as possible and to your satisfaction. You may use either our grievance process or our appeal process, depending on what kind of problem you have. There will be no change in your services or the way you are treated by WellCare staff or a health care provider because you file a grievance or an appeal. We will maintain your privacy. We will give you any help you may need to file a grievance or appeal. This includes providing you with interpreter services or help if you have vision and/or hearing problems. You may choose someone (like a relative or friend or a provider) to act for you. To file a grievance or to appeal a plan action, please our Member Services Department. Call Monday through Friday between 8 a.m. and 6 p.m. at If you call us after hours, leave a message. We will call you back the next business day. We will tell you if we need more information to make a decision. Or write to: WellCare Health Plans P.O. Box Tampa, FL When you contact us, you will need to give us your name, address, telephone number and the details of the problem. What is a Grievance? A grievance is any communication by you to us of dissatisfaction about the care and treatment you receive from our staff or providers of covered services. For example, if someone was rude to you or you do not like the quality of care or services you have received from us, you can file a grievance with us. The Grievance Process You may file a grievance orally or in writing with us. The person who receives your grievance will record it, and appropriate plan staff will oversee the review of the grievance. We will send you a letter telling you that we received your grievance and a description of our review process. We will review your grievance and give you a written answer within one of two time frames. 1. If a delay would significantly increase the risk to your health, we will decide within 48 hours after receipt of necessary information. 2. For all other types of grievances, we will notify you of our decision within 45 days of receipt of necessary information, but the process must be completed within 60 days of the receipt of the grievance. The review period can be increased up to 14 days if you request it, or if we need more information and the delay is in your interest. Our answer will describe what we found when we reviewed your grievance and our decision about your grievance. How do I Appeal a Grievance Decision? If you are not satisfied with the decision we make concerning your grievance, you may request a second review of your issue by filing a grievance appeal. You must file a grievance appeal in writing. It must be filed within 60 business days of receipt of our initial decision about your grievance. Once we receive your appeal, we will send you a written acknowledgement telling you the name, address and telephone number of the individual we have designated to respond to your appeal. All grievance appeals will be conducted by appropriate professionals, including health care professionals for grievances involving clinical matters, who were not involved in the initial decision. For standard appeals, we will make the appeal decision within 30 business days after we receive all necessary information to make our decision. If a delay in making our decision would significantly increase the risk to your health, we will use the expedited grievance appeal process. For expedited grievance appeals, we will make our appeal decision within 2 business days of receipt of necessary information. For both standard and expedited grievance appeals, we will provide you with written notice of our decision. The notice will include the detailed reasons for our decision and, in cases involving clinical matters, the clinical rationale for our decision. Welcome to WellCare Advocate 14

18 What is an Action? When WellCare denies or limits services requested by you or your provider; denies a request for a referral; decides that a requested service is not a covered benefit; reduces, suspends or terminates services that we already authorized; denies payment for services; doesn t provide timely services; or doesn t make grievance or appeal determinations within the required time frames, those are considered plan actions. An action is subject to appeal. (See How do I File an Appeal of an Action? below for more information.) Timing of Notice of Action If we decide to deny or limit services you requested or decide not to pay for all or part of a covered service, we will send you a notice when we make our decision. If we are proposing to reduce, suspend or terminate a service that is authorized, our letter will be sent at least 10 days before we intend to change the service. Contents of the Notice of Action Any notice we send to you about an action will: Explain the action we have taken or intend to take; Cite the reasons for the action, including the clinical rationale, if any; Describe your right to file an appeal with us (including whether you may also have a right to the state s external appeal process); Describe how to file an internal appeal and the circumstances under which you can request that we speed up (expedite) our review of your internal appeal; Describe the availability of the clinical review criteria relied upon in making the decision, if the action involved issues of medical necessity or whether the treatment or service in question was experimental or investigational; Describe the information, if any, that must be provided by you and/or your provider in order for us to render a decision on appeal. If we are reducing, suspending or terminating an authorized service, the notice will also tell you about your right to have services continue while we decide on your appeal; how to request that services be continued; and the circumstances under which you might have to pay for services if they are continued while we were reviewing your appeal. How do I File an Appeal of an Action? If you do not agree with an action that we have taken, you may appeal. When you file an appeal, it means that we must look again at the reason for our action to decide if we were correct. You can file an appeal of an action with the plan orally or in writing. When the plan sends you a letter about an action it is taking (like denying or limiting services, or not paying for services), you must file your appeal request within 45 calendar days of the date on our letter notifying you of the action. If you call us to file your request for an appeal, you must send a written request unless you ask for an expedited review. How do I Contact my Plan to File an Appeal? We can be reached by calling Member Services Department. Call Monday through Friday between 8 a.m. and 6 p.m. at If you call us after hours, leave a message. We will call you back the next business day. Or write to: WellCare Health Plans P.O. Box Tampa, FL The person who receives your appeal will record it, and appropriate staff will oversee the review of the appeal. We will send a letter telling you that we received your appeal and how we will handle it. Your appeal will be reviewed by knowledgeable clinical staff who were not involved in the plan s initial decision or action that you are appealing. Member Services: (TTY/TDD: ) 15

19 For Some Actions, You May Request to Continue Service During the Appeal Process If you are appealing a reduction, suspension or termination of services you are currently authorized to receive, you may request to continue to receive these services while we are deciding your appeal. We must continue your service if you make your request to us no later than 10 days from our mailing of the notice to you about our intent to reduce, suspend or terminate your services, or by the intended effective date of our action, and the original period covered by the service authorization has not expired. Your services will continue until you withdraw the appeal, the original authorization period for your services has been met or until 10 days after we mail your notice about our appeal decision, if our decision is not in your favor, unless you have requested a New York State Medicaid Fair Hearing with continuation of services. (See Fair Hearing Section below.) Although you may request a continuation of services while your appeal is under review, if your appeal is not decided in your favor, we may require you to pay for these services if they were provided only because you asked to continue to receive them while your appeal was being reviewed. How Long Will it Take the Plan to Decide My Appeal of an Action? Unless you ask for an expedited review, we will review your appeal of the action taken by us as a standard appeal and send you a written decision as quickly as your health condition requires, but no later than 30 days from the day we receive an appeal. (The review period can be increased up to 14 days if you request an extension or we need more information and the delay is in your interest.) During our review, you will have a chance to present your case in person and in writing. You will also have the chance to look at any of your records that are part of the appeal review. We will send you a notice about the decision we made about your appeal that will identify the decision we made and the date we reached that decision. If we reverse our decision to deny or limit requested services, or reduce, suspend or terminate services, and services were not furnished while your appeal was pending, we will provide you with the disputed services as quickly as your health condition requires. In some cases you may request an expedited appeal. (See Expedited Appeal Process Section below.) Expedited Appeal Process If you or your provider feels that taking the time for a standard appeal could result in a serious problem to your health or life, you may ask for an expedited review of your appeal of the action. We will respond to you with our decision within 2 business days after we receive all necessary information. In no event will the time for issuing our decision be more than 3 business days after we receive your appeal. (The review period can be increased up to 14 days if you request an extension or we need more information and the delay is in your interest.) If we do not agree with your request to expedite your appeal, we will make our best efforts to contact you in person to let you know that we have denied your request for an expedited appeal and will handle it as a standard appeal. Also, we will send you a written notice of our decision to deny your request for an expedited appeal within 2 days of receiving your request. If the Plan Denies My Appeal, What Can I Do? If our decision about your appeal is not totally in your favor, the notice you receive will explain your right to request a Medicaid Fair Hearing from New York State and how to obtain a Fair Hearing, who can appear at the Fair Hearing on your behalf, and for some appeals, your right to request to receive services while the hearing is pending and how to make the request. If we deny your appeal because of issues of medical necessity or because the service in question was experimental or investigational, the notice will also explain how to ask New York State for an external appeal of our decision. Welcome to WellCare Advocate 16