Enrollee Handbook. Broward, Miami-Dade and Monroe Counties. Effective March 1, 2017

Transcription

1 Enrollee Handbook Broward, Miami-Dade and Monroe Counties Effective March 1, 2017 PHC Florida is a Managed Care Plan with a Florida Medicaid contract. AHCA PHC MMA Form 14.5

2 Discrimination Is Against the Law PHC Florida complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PHC Florida does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PHC Florida: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Member Services. If you believe that PHC Florida has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Member Services, P.O. Box 46160, Los Angeles, CA 90046, (888) , TTY 711, Fax (888) , php@positivehealthcare.org. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC , (TDD) Complaint forms are available at

3 ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). 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 (ATS : 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 فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: 711(. 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). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). સ ચન : જ તમ ગ જર ત બ લત હ, ત નન:શ લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: 711). เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711).

4 Table of Contents Chapter 1: Introduction... 1 What to Do Next...1 Important Telephone Numbers...4 Who Can Enroll in PHC Florida?...5 Member Rights and Responsibilities...6 Member Identification (ID) Card...6 If You Lose Your ID Card...7 Changing Your Primary Care Provider...7 Continuity of Care for New Members...7 If You Get a Bill from a Provider...7 Specific Health Benefits...7 Interpreter and Alternative Communication Systems...8 Chapter 2: Getting Medical Services... 9 Provider Network...9 Primary Care Provider (PCP)...9 Referrals Services that Do Not Require a Referral After-Hours Care After-Hours Nurse Advice Line Emergency Care Out-of-Area Emergency Care Post-Stabilization Care Emergency Transportation Hospital Care Outpatient Services Urgent Care Services Second Medical Opinion In Lieu of Services Non-Emergency Transportation Chapter 3: Covered Services Covered Services and Limits Inpatient Hospital Services Preventive Care Family Planning Services Maternity Care Prenatal/Perinatal Program Laboratory, X-Ray and Imaging Services Home Health Care Services i -

5 Behavioral Health Services Dental Services Vision Services Hearing Services Non-Emergency Transportation Meal Service after Hospital Discharge Vaccines Medically Related Lodging and Food Chapter 4: Prescription Drug and Over-the-Counter Pharmacy Benefit Prescription Drugs Pharmacy Network How to Fill Prescriptions When Out of the Plan s Service Area Over-the-Counter Pharmacy Benefit Chapter 5: Disease Management What Is Disease Management? Your Registered Nurse Care Manager Initial Health Assessment Follow-Up Health Check-Ins Working with Your Primary Care Provider Medication Adherence Taking Care of Yourself Member Education Chapter 6: Other Programs Healthy Behaviors Education and Other Wellness Information Report Abuse, Neglect or Exploitation MediKids Program Chapter 7: Access to Medical Services Access Standards Informed Consent Parental Permission for Psychotropic Medications Confidentiality Physician Incentive Payments Medicaid Covered Health Services Cultural Competency Chapter 8: Enrollment and Disenrollment Voluntary Enrollment Mandatory Enrollment Open Enrollment Reinstatement ii -

6 Getting Medicaid Coverage for Your Newborn Moving Out of the Service Area Disenrollment Involuntary Disenrollment Chapter 9: Advance Directive Making Your Medical Decisions Known Five Wishes Advance Directive Chapter 10: Complaints, Grievances and Appeals Filing a Complaint or Grievance Filing an Appeal Filing an Expedited Appeal Continuation of Benefits Asking for a Medicaid Fair Hearing Appealing to the Subscriber Assistance Program (SAP) Exhaustion of the Grievance and Appeal Process Chapter 11: Member Rights and Responsibilities Chapter 12: Information about PHC Florida Quality and Member Satisfaction Information Information about Quality Enhancement Programs Public Information about PHC Florida Chapter 13: Fraud and Abuse Chapter 14: Notice of Privacy Practices Who Will Follow this Notice Our Pledge and Responsibilities Regarding Your Medical Information How We May Use and Disclose Medical Information about You Special Situations Your Rights Regarding Medical Information about You Changes to This Notice Concerns about Our Use of Your Medical Information Other Uses of Medical Information iii -

7 Chapter 1: Introduction This Enrollee Handbook is for all PHC Florida members. It tells you what you need to know about your health care plan. PHC Florida is a specialty care Managed Care Plan. It is designed to provide medical care for members with HIV. PHC Florida aims to improve the lives of their members. We help you and your doctors and nurses manage your disease and avoid any health crises. PHC Florida stresses the value of education to prevent disease. We promote healthy lifestyle changes and help you improve how you manage your own care. Our goal is to increase member and family satisfaction. This is the Enrollee Handbook. Please read it with care. It will tell you how the Managed Care Plan works. It tells you how to get the most out of what the plan offers. Keep this handbook in a safe place so you can look at it in the future. If you have any questions about any part of this handbook, call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. The plan can translate this and other forms into any language you need, free of charge. Throughout this handbook, we will refer to PHC Florida as either the Managed Care Plan or the plan. What to Do Next There are a few steps you should take as a PHC Florida plan member: 1. Check Your Member Identification (ID) Card. Your PHC Florida member ID card came in your new member welcome packet. If you have not gotten your member ID card, please call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. When you need health care, give your ID card to your doctor s office. Your card has details about your health care coverage. Be sure to keep this card and your Medicaid card with you at all times and in a safe place. Please look at what is written on your ID card. Check the name of the primary care provider (PCP) on the card. You were given a PCP if you did not choose one. Each household member who is eligible to be enrolled in the plan, i.e., they have HIV and Medicaid, may see the same PCP if the PCP accepts patients in their age group. You - 1 -

8 cannot choose more than one PCP. The PCP you pick really matters. You must see the PCP to whom you are assigned. If you want to change your PCP for any reason, call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Or you can complete and return the Primary Care Provider (PCP) Selection Form found in your new member welcome packet. Your member ID card looks like this: Front Back 2. Complete and Return the Forms in Your New Member Welcome Packet The letter in your new member welcome packet tells you which forms you need to complete, sign and return to the plan. These are forms like the Authorization for Use or Disclosure of Health Information, Doctors You Have Been Seeing and Medical Services You Have Been Getting form, and Primary Care Provider (PCP) Selection Form. If you want to choose a PCP other than the one who is shown on your member ID card, you can return this form with your new choice. See the letter in your New Member Welcome Packet for more details. If you have any questions about these forms, call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call Tell Us if You Are Currently Getting Care or Treatment If you are currently under doctor s care, getting treatment or are authorized (approved) to get care, please tell us as soon as possible. Call Member Services to tell us. Call (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Or you can fill out the form in your new member welcome packet called, Doctors You Have Been Seeing and Medical Services You Have Been Getting. If you use the form, send it back to us in the envelope provided. We are asking for this information so we can coordinate any care required by a treatment plan you have but didn t finish. We will call your old health plan and/or - 2 -

9 doctor(s). We will do this to make sure your care isn t interrupted. We will make sure you finish any treatment that was ordered by your doctor before you enrolled in the plan. If you are seeing providers who are not part of PHC Florida s network, we will cover your care for 60 days with your providers. If your treatment lasts longer than 60 days, we will move your care to network providers by the end of the 60 days. 4. Transfer Your Medical Records to Your PHC Florida Primary Care Provider (PCP) Please ask your current PCP to send your medical records to your new PHC Florida PCP. You can also ask your new PCP to ask your old PCP for your records. If your PCP is already in the PHC Florida network, this does not apply. You can check to see if your PCP is in the network online at If you need any help with this, you can call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call Learn about PHC Florida s Disease Management Program PHC Florida uses an approach called Disease Management to help you manage your illness. The program helps you follow your treatment plan. A nurse will work with you to help you manage your health care needs. PHC Florida provides you with a Registered Nurse Care Manager (RNCM) within 30 days from the date you first join the Managed Care Plan. You should expect to meet with your RNCM for a health assessment (health check-in) within 90-days from the day you become a member. Your RNCM will contact you to set up a time to meet. Your RNCM will be a key player on your healthcare team. Your RNCM will call you every once in a while to see how you are. How often they call you will depend on your current health status and needs. To contact your RNCM or if you have any questions about the program, call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. To learn more about the program, see Chapter 6: Disease Management. 6. Visit Your Primary Care Provider (PCP) Your PHC Florida PCP is the doctor who will take care of all your routine health care. He or she has a background in treating people living with HIV/AIDS. Your PCP will arrange for any specialists or hospital care you need. Call your PCP at the number on your ID card for non-emergency health needs. They are ready to see you. We check their education and training. We look at their experience

10 See your PCP within 90 days after you become a PHC Florida member. Even if you have seen a PCP in the recent past, you should still see your new PCP. If you are pregnant, see your doctor within 30 days from the date you join the plan. Your start date with PHC Florida is printed on your ID card. It is very helpful to get to know your PCP. Also, your PCP needs to get to know you. Call your doctor s office to schedule a visit for a checkup. 7. Know What to Do in a Medical Emergency For a medical emergency, call 911 or go to the nearest ER. This Enrollee Handbook explains more about your Managed Care Plan and how to get health care. Please read it with care. Pay special attention to the Emergency Care section. There is a list of examples of what a medical emergency is. 8. Know Where to Go if You Need Help or Have Questions about the Plan Call us with questions about the Managed Care Plan and your benefits. We are here to help you. Interpretation services and other communication options are offered, free of charge, for all foreign languages or other special needs. Member Services staff are here to help you Monday through Friday, 8:00 a.m. to 8:00 p.m. Call (888) , TTY 711. Important Telephone Numbers Your Primary Care Provider (PCP) On the front of your ID card PHC Florida Member Services (888) Monday through Friday, 8:00 a.m. to 8:00 p.m. Behavioral Health Services (Beacon Health (855) Options) Pharmacy (Prescription Drug) Benefit Line (866) TTY (888) hours a day, seven days a week. Over-the-Counter Pharmacy Benefit Line (954) Monday through Saturday, 10:00 a.m. to 7:00 p.m. After Hours Nurse Advice Line (866) Non-Emergency Transportation (888) Call at least 48 hours before your scheduled appointment

11 Enrollment Broker Helpline TTY Monday through Thursday, 8:00 a.m. to 8:00 p.m.; Friday 8:00 a.m. to 7:00 p.m. Agency for Health Care Administration Fraud and Abuse Hotline Agency for Health Care Administration Health Care Facility and Consumer Complaints (877) (866) (888) (888) Office of Public Assistance Appeals Hearings (877) Agency for Health Care Administration Medicaid Helpline Aging & Disability Resource Center of Broward County Alliance for Aging (Aging & Disability Resource Center for Miami-Dade and Monroe Counties) (877) or (800) (954) (305) 670-HELP (4357) TTY users should call 711 for the above phone numbers unless otherwise noted. Who Can Enroll in PHC Florida? PHC Florida is a specialty care health maintenance organization (HMO) that serves Broward, Miami-Dade and Monroe Counties Medicaid-eligible children and adults who are HIV-positive. Medicaid is the state and federal partnership that provides health coverage for certain groups of children and adults with low incomes. Three basic groups may receive Medicaid: People receiving Supplemental Security Income (SSI) Children and families in the Temporary Assistance for Needy Families (TANF) program Aged, blind, and disabled people (ABD, also known as SSI-related Medicaid) A person must qualify in order to receive Medicaid. The Social Security Administration sets the rules for SSI eligibility. The Florida Department of Children and Families (DCF) decides on all other Medicaid standards, including programs for children and families; aged; blind and disabled; and institutional care. After you are approved for Medicaid, the state will send you a list of managed care programs in your area, like PHC Florida. You must choose one of the two types of managed care programs within 30 days: - 5 -

12 Health maintenance organization (HMO). HMOs are run by companies that have contracts with Florida Medicaid. PHC Florida is an HMO. Provider Service Network (PSN), a managed care program run by a network of doctors and hospitals that have a contract with Florida Medicaid. If you do not choose a Managed Care Plan, the state will select a plan for you. The option to join PHC Florida is voluntary. If you wish to leave the plan, you must do it during your open enrollment time. You may also join another plan or managed care program during your open enrollment time. You may also disenroll or leave the plan for good cause at any time. (See Voluntary Disenrollment in Chapter 9 for more information.) Call the Enrollment Broker Helpline at (877) , TTY (866) , if you think you have a good cause to leave the plan. Agents are available Monday through Thursday, 8:00 a.m. to 8:00 p.m. and Friday, 8:00 a.m. to 7:00 p.m. Member Rights and Responsibilities Florida law requires that your health care providers recognize your rights. You must respect the rights of your providers too. Please read an outline of your rights and responsibilities included in this Enrollee Handbook. You will also see them posted in your doctor s office. Member Identification (ID) Card Every member of PHC Florida will get a member ID card. Show this card and your Medicaid gold card to doctors when you get health care. Show it to hospitals and pharmacies too. This card shows you are a member of PHC Florida. Keep it with you at all times. Do not let anyone else use your card. If you do, you could lose your benefits. Your member ID card looks like this sample: Front Back - 6 -

13 If You Lose Your ID Card If you lose your PHC Florida ID card, call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Confirm your address and we will mail you a new card. If you lose your Medicaid card, call your caseworker at the Florida Department of Children and Families (DCF). Changing Your Primary Care Provider You can change your PCP at any time. If you want to change your PCP, call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Continuity of Care for New Members If you are new to PHC Florida and are under doctor s care, getting treatment or are authorized (approved) to get care, please tell us as soon as possible. This is important. We want to make sure your care is not interrupted. Call Member Services to tell us. Call (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Or you can fill out the form in your new member welcome packet called, Doctors You Have Been Seeing and Medical Services You Have Been Getting. If you use the form, send it back to us in the envelope provided in your packet. We need to know so we can coordinate any care required by a treatment plan you have but didn t finish. We will call your old health plan and/or doctor(s). We will make sure you finish any treatment that was ordered by your doctor before you joined the plan. If you are seeing providers who are not part of PHC Florida s network, we will cover your care for 60 days with your providers. If your treatment lasts longer than 60 days, we will move your care to network providers by the end of the 60 days. If You Get a Bill from a Provider If you get a bill from a doctor or a billing company for a service while you are a PHC Florida member and you do not think that you owe any money, please call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Specific Health Benefits For information on these benefits, please see Chapter 3: Covered Services

14 Interpreter and Alternative Communication Systems Interpreter services for foreign languages and alternate communication systems for the vision and hearing impaired are available through your primary care provider (PCP) or by calling PHC Florida Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Language access services are offered to members at no charge

15 Chapter 2: Getting Medical Services Provider Network PHC Florida contracts with doctors, hospitals, and other providers who provide care to members. These doctors, hospitals and other providers make up PHC Florida s provider network. You can see a list of providers in PHC Florida s Provider and Pharmacy Directory. PHC Florida s provider network will provide medical and behavioral health services to you. The Managed Care Plan has contracts with PCPs and specialists who have training background in treating patients who are HIV positive. The plan s network doctors or the Managed Care Plan itself must approve all your care. If you need care from a specialist or health care facility that is not in PHC Florida s network, the plan will approve and arrange the care you need from out-of-network providers. If you have questions about the plan s provider network, call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Some providers may not be insured against malpractice. If they are not, they must have a notice in their office that says so. If you are not sure that your doctor has malpractice insurance, please ask the doctor. Some doctors may not perform certain types of care based on religious or moral beliefs. For counseling or referral services that PHC Florida doesn t cover because of moral or religious objections, we don t need to give you information on how or where to get them. Primary Care Provider (PCP) It s easy to use your PHC Florida plan benefits. You are assigned a PCP. Your PCP will provide you with your routine, well and acute care needs. Your PCP will arrange for any specialist or hospital care, if needed. For non-emergency health needs, call your PCP at the number on your ID card. Let your PCP know that you are a PHC Florida member. Give your PCP your most recent contact information. Your PCP should be able to contact you at all times. Have your medical records sent to your new doctor. Visit your PCP within three (3) months

16 Your PCP will: Provide well care Help you when you are sick Give vaccine shots Order lab tests and x-rays when needed Coordinate hospital care Help you get emergency care Each household member who is eligible to enroll in the plan, i.e., they have HIV and Medicaid, may see the same PCP. This depends on age. You cannot choose more than one PCP. You must see the PCP to whom you are assigned. It is very helpful get to know your PCP. Don t forget to set up your first visit with your PCP. Your doctor or PHC Florida will arrange for or approve your care. Be sure your doctor approves any specialist you need to see. If you need care by a doctor who is not in the PHC Florida network, call your PCP for help. For the most part, you must get all of your health care from doctors who are part of the PHC Florida network. Referrals Your (PCP) may not be able to provide all the types of care you need. Your PCP will arrange for you to see other doctors if you need special care. He or she may refer you to a hospital or specialist. Your doctor may not be set up to do lab work or x-rays. He or she may refer you to another place or someone else to get the tests done. Ask your PCP if you think they need to refer you. If you are still unsure, call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Services that Do Not Require a Referral You do not need be referred from your (PCP) for certain types of care: Behavioral health services (see page 22 for more information) Chiropractors Dermatologists (no more than 5 visits) Podiatrists Obstetrics/Gynecology (OB/GYN) One OB/GYN visit per year Family planning (any provider who participates with Medicaid) Yearly eye exams and glasses Dental care

17 After-Hours Care If you become sick after your PCP s normal office hours and it is not an emergency health problem, call your PCP. Your PCP s phone number is printed on your ID card. You can also call the After-Hours Nurse Advice Line at (866) , TTY 711. Do not go to the hospital first for non-emergency help. Your PCP can help you even when the office is closed. After-Hours Nurse Advice Line PHC Florida has an After-Hours Nurse Advice Line for non-emergency help. If you get sick and are not sure what kind of medical care you need or what to do, and it is not a medical emergency, call the After-Hours Nurse Advice Line. Call (866) ; TTY 711. During normal business hours, please contact your PCP. A nurse will answer your call after normal business hours, on holidays and weekends. He or she will answer your health care questions or concerns. This is a service that is at no cost to you. When you call the After-Hours Nurse Advice Line, a nurse will ask about your symptoms. He or she will help you decide if you need to go to the hospital, see your doctor, or care for yourself at home. The nurse can help with an illness such as: When you feel sick Fever or sick to your stomach Colds and flu Feel light-headed or dizzy Cuts Back pain A cough that will not stop Burns

18 Emergency Care If you think you have an emergency medical condition, call 911 or go to your nearest hospital emergency room (ER). You can get emergency care 24 hours, 7 days a week. You can go to a hospital out of network for emergencies and PHC Florida will cover your care. An emergency is a problem that you believe will cause any of the outcomes listed below, if you do not receive treatment at once: Serious harm to your health Serious injury to the body Serious damage of a body part Serious damage of an organ Some examples of emergencies may include: Heavy blood loss Heart attack Stroke Sudden blindness Severe allergic reaction Severe cuts that need stitches Pass out Poisoning Severe chest pains Loss of breath Broken bones Behavioral health/mental health crisis For pregnant women, these problems may be an emergency: Serious harm to your health (this includes a pregnant woman or her unborn baby) If you think there is not enough time to go to your doctor s regular hospital If you think that going to another hospital may cause harm to you and your baby Vaginal bleeding No movement from the baby You will need to show your PHC Florida and Medicaid ID cards at the ER. Ask the staff in the ER to call PHC Florida Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. Let your PCP know as soon as you can when you are in the hospital. Let him or her know if you received care in an ER

19 The ER doctor will decide if your visit is an emergency. If it is not, you will be given the choice to stay or leave the hospital. If you choose to stay, PHC Florida may not cover your stay. Out-of-Area Emergency Care If you think you have an emergency medical issue, call 911 or go to the nearest hospital ER. PHC Florida will cover your care. If you become ill while traveling and you do not think you are having a medical emergency, call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. The staff can assist you with details about how to access care while away. You can also call the After-Hours Nurse Advice Line at (866) , TTY 711, for nonemergency help after normal business hours and on holidays and weekends. See After- Hours Nurse Advice Line on page 9 in this section. Post-Stabilization Care The treatment needed after an emergency is called post-stabilization care. PHC Florida will cover follow-up care to emergency treatment that your doctor says is medically necessary. Prior approval is not needed to receive this care. It does not matter if you are within or outside the PHC Florida network, your doctor does not need to pre-approve this type of care. Emergency Transportation Call 911 if you need emergency transportation to the hospital. Do not call 911 if you can get to the hospital on your own. Show your PHC Florida ID card for emergency transportation. Hospital Care Your doctor will help you choose a hospital. Talk to your doctor about your choices. You may have a hospital that you prefer. All non-emergency hospital care must be received from a network hospital. If you need care while away from the area, call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call

20 Outpatient Services Outpatient services are tests and treatments given to you at the hospital without a hospital stay. Your PCP can help you get outpatient care. All non-emergency care needs to be approved. All outpatient care must be medically needed to be covered by the plan. Outpatient services may include: X-rays Lab tests Therapy (physical or respiratory) Urgent Care Services Urgent care is care needed right away, but is not an emergency. Urgent care is needed for things that could lead to serious injury. Call your PCP for your choices for care. One choice may include a trip to an urgent care center. Second Medical Opinion You can call your PCP and request a second opinion about your health care. If you do not wish to ask your PCP for a second opinion, you may call Member Services for help at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. You may choose a PHC Florida doctor listed in the Provider Directory or a doctor who is in your service area but who is not a PHC Florida doctor. All tests must be done by a PHC Florida in-network doctor. There will not be a fee to have a second opinion when you see a PHC Florida doctor. If a PHC Florida network provider is not available, we will cover a second opinion visit and any needed tests from an out-of-network provider. You may choose a second opinion if: You do not agree with the doctor about whether you need a procedure or surgery You have an injury or illness that could threaten your life Your PCP will review the results of your second opinion. Your PCP will decide on a treatment plan that is best for you. If you do not agree with this plan, you have the right to appeal this decision. The grievance process listed in this handbook will tell you how. Treatment not approved by PHC Florida will be at your expense

21 You or your doctor may ask PHC Florida for a faster, expedited, pre-service decision. If you think your life, health or daily function would be in danger if you have to wait for the approval, ask for an expedited pre-service decision. To request an expedited preservice decision, call Member Services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. You can also bring a written request to: PHC Florida 700 SE 3rd Ave., 4th Floor Ft. Lauderdale, FL You can also fax your request to (888) Be sure to ask for an expedited review. In Lieu of Services When medically appropriate, PHC Florida may provide the following services in lieu described below: Services in a skilled nursing facility in lieu of services may be provided in an inpatient hospital. These services in a skilled nursing facility don t count toward inpatient hospital days. Services in a crisis stabilization unit (CSU) up to 15 days during a month may be provided in lieu of inpatient psychiatric hospital care. Detox or addiction facilities licensed under s. 397, F.S. may be provided for up to 15 days a month in lieu of inpatient detox hospital care. Partial hospitalization services in a hospital may be provided in lieu of inpatient psychiatric hospital care for up to 90 days annually for adults 21 and older. Mobile crises assessment and intervention in the community may be provided in lieu of emergency behavioral health care for up to minute units per year, to a maximum of eight units per day. Ambulatory detox services may be provided in lieu on inpatient detox hospital care for up to three hours per day, up to 30 days. Members have a choice of whether to get covered services when necessary, as described in Chapter 3, or an in lieu of service described above. Non-Emergency Transportation PHC Florida covers transportation to medical, dental, and mental health visits. To schedule non-emergency transportation, call Member Services at least 48 hours before your appointment. Member Services can be reached at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call

22 For emergency transportation, call 911 if you cannot get to a hospital yourself. PHC Florida covers emergency transportation

23 Chapter 3: Covered Services This section tells you about the covered services and benefits you have while enrolled in PHC Florida. Call member services at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m., if you have questions about the services and benefits of the plan. TTY users call 711. Covered Services and Limits A summary of the benefits and limits PHC Florida provides is below. PHC Florida must provide all medically necessary services for its members who are under age 21. This is the law. This is true even if PHC Florida does not cover a service or the service has a limit. As long as your child's services are medically necessary, services have: No dollar limits; or No time limits, like hourly or daily limits. Your provider may need to ask PHC Florida for approval before giving your child the service. Call Member Services if you want to know how to ask for these services. Call (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Medicaid Services Provided Advanced Registered Nurse Practitioner/Physician Assistant Services Ambulance Services Ambulatory Surgery at an Ambulatory Surgery Center Behavioral Health Inpatient Hospital Services (See page 27 for more information about Behavioral Health Services.) Behavioral Health Outpatient Services (See page 27 for more information about Behavioral Health Services.) Child Health Check-Up Services (CHCUP) Limitations Covered when medically necessary; limited to one (1) visit per day; no co-pay; requires prior authorization For emergencies; covered when medically necessary; no limits; no co-pay Covered when medically necessary; no limits; no co-pay; requires prior authorization Covered; up to 45 days per year; no copay; requires prior authorization unless emergency. Covered; no limits; no co-pay; certain services require prior authorization Covered; no limits; no co-pay

24 Medicaid Services Provided Chiropractic Services Clinical Services from Federally Qualified Health Care Centers Clinical Services from County Health Department Clinical Services from Rural Health Clinics Dental Services for Adults (See page 28 for more information about Dental Services.) Dental Services for Children (members under the age of 21) (See page 28 for more information about Dental Services.) Dermatology Services Dialysis Services (hospital-based and free standing) Durable Medical Equipment and Medical Supplies Emergency Room Services Limitations Members may self-refer to a network chiropractor; covered when medically necessary; limited to one (1) visit per day; limited to 24 visits per year; no co-pay; procedures require prior authorization Covered; limit of one (1) visit per day; no co-pay; certain services require prior authorization Covered; limit of one (1) visit per day; no co-pay; certain services require prior authorization Covered; limited to one (1) visit per day; no co-pay; certain services require prior authorization Emergency dental procedures covered when medically necessary. Full and partial denture services covered. Limitations apply; see a network dentist for details. No co-pay. See Expanded Benefits table for Dental Services for Adults. The plan has enhanced adult dental services to provide routine and restorative dental care. Comprehensive preventive, restorative and emergency treatments and orthodontics covered when medically necessary. See a network dentist for details. No co-pay. Members may self-refer to a network dermatologist; covered when medically necessary; no co-pay; procedures require prior authorization Covered when medically necessary; no limits; no co-pay; requires prior authorization Covered when medically necessary; no copay; certain items and services require prior authorization. Covered when medically necessary; no limits; no co-pay

25 Medicaid Services Provided Family Planning Services and Supplies including: Education and Counseling Initial Examination Diagnostic Procedures and Lab Studies Contraceptive Drugs/Supplies (See page 25 for more information about Family Planning Services.) Limitations Covered; no co-pay; certain services require prior authorization. Hearing Services (See page 28 for more information about Hearing Services.) Diagnostic testing, cochlear implants and hearing aids covered when medically necessary. Diagnostic testing may be limited to once every three (3) years. Hearing aids limited to once every three (3) years. Newborn hearing screening covered. No co-pay; certain services require prior authorization. See Expanded Benefits table for Hearing Services. Plan has enhanced this service to provide members with an enhanced hearing exam and hearing aid benefit. Healthy Start/Maternity Services including: Prenatal Care and Screening Obstetrical Delivery and Hospital Care Birthing Center Services Postnatal Risk Screening Physician Care for Mother and Newborn Nutrition Assessment and Counseling (For pregnant enrollees, newborns and infants. See page 25 for more information about Maternity Care.) Members may self-refer to a network OB/Gyn provider; covered when medically necessary; no co-pay; certain services require prior authorization. See Expanded Benefits table for Prenatal/Perinatal Services. The plan has enhanced prenatal/perinatal services to remove doctor visitation limits

26 Medicaid Services Provided Home Health Care Services (See page 26 for more information about Home Health Care Services.) Hospice Services Immunizations Limitations Covered when medically necessary; limited to four (4) intermittent visits per day; limited to 60 visits in a lifetime; no co-pay; requires prior authorization Covered; enrollee must be certified by a physician as terminally ill with life expectancy of six (6) months or less; no co-pay. Covered; no limits; no co-pay Inpatient Hospital Services (See page 24 for more information about Inpatient Hospital Services.) Covered; up to 45 days per year; no copay; requires prior authorization unless emergency Inpatient Hospital Substance Abuse Treatment Program Laboratory/X-Ray/Imaging Services (See page 26 for more information about Laboratory/X-Ray/Imaging Services.) Covered for pregnant substance abusers; up to 28 days per year; no co-pay; requires prior authorization. Covered when medically necessary; no limits; no co-pay; certain services require prior authorization Medical/Drug Therapies Covered when medically necessary; no limits; no co-pay; requires prior authorization Outpatient Hospital Services Outpatient Surgery (Hospital) Covered when medically necessary; no limits; no co-pay; requires prior authorization Covered when medically necessary; no limits; no co-pay; requires prior authorization

27 Medicaid Services Provided Optometric and Vision Services (See 28 for more information about Vision Services.) Limitations Exams, eyeglass frames, eyeglass lenses, repairs to eyeglasses covered. Contact lenses covered if medically necessary. Eyeglass frames limited to one (1) pair every two (2) years. Eyeglass lenses limited to replacement once every year. For members under the age of 21, eyeglass frames and lenses limited to replacement two (2) times a year. No copay; additional services require prior authorization. See Expanded Benefits table for Vision Services. Plan has enhanced this service to provide members with an enhanced eyeglass frame benefit. Physician Primary Care Services (See page 24 for more information about Preventive Care.) See Expanded Benefits table for Physician Primary Care Services. Plan has enhanced this service to remove doctor visitation limits. Physician Specialty Care Services Covered when medically necessary; limited to one (1) visit per day per specialist; no co-pay; referral and/or prior authorization required. Podiatry Services Members may self-refer to network podiatrist; covered when medically necessary; limit of 24 visits per year; no copay; procedures require prior authorization Prescription Drugs (See page 30 for more information about Prescription Drugs.) Covered when medically necessary; no limits; no co-pay; prior authorization required on certain drugs

28 Medicaid Services Provided Therapy Services (Hospital- and Community-Based) including: Occupational Therapy Physical Therapy Respiratory Therapy Speech Therapy Transplant Services Transportation (Non-Emergency) (See page 29 for more information about Non-Emergency Transportation.) Tuberculosis Diagnosis and Treatment Services Limitations Covered when medically necessary; no limits; no co-pay; requires prior authorization. No occupational or speech therapy coverage for adults. Covered when medically necessary; no limits; no co-pay; requires prior authorization. Intestinal/multivisceral transplant covered under Medicaid fee-forservice. Covered; no limits; no co-pay. Plan must arrange transportation to and from planapproved locations. Covered; no limits; no co-pay. Expanded Benefits Dental Services for Adults (See page 28 for more information about Dental Services.) Hearing Services (See page 28 for more information about Hearing Services.) Home- and Community-Based Services Limitations Limit of $1,000 per year to cover exams, cleanings, certain fillings, and X-rays. See a network dentist for details. No co-pay. Note that emergency dental procedures are covered under the plan s medical benefit with no limits. For members 21 and older, one (1) hearing exam annually and one (1) hearing aid every two (2) years; no co-pay; prior authorization required. Twelve (12) hours per year; limited to chore, homemaker and personal care services; no co-pay; requires prior authorization

29 Expanded Benefits Home Health Care (Non-Pregnant Adults) (See page 26 for more information about Home Health Care.) Meal Service after Hospital Discharge (See page 29 for more information about Meal Service after Hospital Discharge.) Medically-Related Lodging and Food (See page 29 for more information about Medically Related Lodging and Food. Limitations Up to three (3), two (2)-hour visits per week; any combination of nurse, home health aide, and/or private duty nurse; requires prior authorization. Limited to two (2) meals per day for up to 14 days per year delivered to member after hospital discharge; no co-pay Lodging and maximum of two (2) meals up to $100 per day for the family member of a member who has been approved for a specialized hospital stay more than 150 miles from the member s home. Benefit is limited to 21 days annually. No co-pay; prior authorization required. Newborn Circumcision Covered for a newborn male in the first 30 days of life. No co-pay. Nutritional Counseling Over-the-Counter (OTC) Pharmacy Items (See page 31 for more information about the OTC Pharmacy Benefit.) Up to three (3) visits per year with a registered dietician, nutritionist or other qualified provider covered. No co-pay. Limit of $25 per member per month; no co-pay Outpatient Services For members 21 and older, an additional $300 per year will be allowed for the following outpatient hospital services: outpatient surgery, radiologic imaging services, physical therapy, speech, therapy, occupational therapy, and respiratory therapy; no co-pay; referral and/or prior authorization required

30 Expanded Benefits Physician Home Visits Physician Primary Care Services (See page 24 for more information about Preventive Care.) Prenatal/Perinatal Care (See page 26 for more information about the Prenatal Program.) Vaccines (Adult): Influenza Pneumonia Shingles (See page 29 for more information about Vaccines.) Vision Services (See page 28 for more information about Optometric and Vision Services.) Limitations Up to two (2) visits per month; requires prior authorization. Covered; no limits to primary care doctor visits; no co-pay Covered; no limits to prenatal/perinatal care doctor visits; no co-pay Influenza vaccine covered once every year. Pneumonia vaccine covered once every five (5) years. Shingles vaccine covered once per lifetime; must be ordered by a HIV primary care provider. No co-pay for these vaccines. One (1) pair of eyeglass frames every two (2) years; one (1) pair of eyeglass lenses per year; contact lenses may be substituted for eyeglasses if medically necessary. Inpatient Hospital Services Inpatient services are the care you receive when you have a hospital stay. Your doctor may decide that you need hospital care. Hospital care is covered by your plan. Inpatient services include: Room and board Nursing care Medical supplies All tests and treatments Preventive Care Get your health checks at the right times. Know what health checks are needed at your age. Get checked every five years if you are 21 years old or older. Get checked every

31 two years if you are 40 years old or older. Children should get their routine child health check-ups. Routine health checks will help your doctor provide the best care. Preventive medicine for adults age 21 and over includes: First and follow-up history and physical exam Chronic disease follow-up Child health check-up for members less than 21 years of age include: Periodic medical screening for members Vaccines (shots) Referrals for more tests and treatment Your child should get a child health check-up at these times: Babies Check-ups at ages newborn, 1 month, 2 months, 4 months, 6 months, 9 months and 1 year Toddlers Check-ups at ages 15 months, 18 months and 2 years Young Children Check-ups at ages 3 years, 4 years, 5 years, 6 years Older Children and Teenagers Check-Up Every year Family Planning Services Family planning helps you decide when or if you should have children. You may use family planning services whenever you wish. They do not need to be approved by PHC Florida. You may go to any Florida Medicaid provider to receive these services. You can also get services, education and counseling specific to HIV prevention and transmission. You can also learn more about how to prevent the spread of HIV through family planning services. Types of family planning include: Information and referral for one-on-one classes Tests to check for disease Birth control drugs and supplies Medically needed sterilization and follow-up care Maternity Care Maternity care is covered by your plan. Call your PCP if you think you are pregnant. Your PCP will help you find an obstetrician/gynecologist (OB/GYN) doctor or you can self-refer to a network OB/GYN doctor. Call PHC Florida when you know you are pregnant. Ask to be enrolled into the Prenatal Program

32 If you are pregnant when your membership becomes effective with PHC Florida and have already started treatment with an OB/GYN doctor, you may still go to that doctor. You may still go to that doctor even if he is not a PHC Florida network doctor, but you must call the plan (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m., to let the plan know you are pregnant. TTY users call 711. See your doctor on a routine basis. You doctor will tell you how often to visit. Prenatal/Perinatal Program The PHC Florida Prenatal Program is a program for pregnant members. The Managed Care Plan wants to help you and your baby stay healthy. It is vital that you see an OB/GYN as soon as you find out you are pregnant. Call PHC Florida when you know you are pregnant so we can enroll you in this program. We will send you fact sheets and education about how to best care for yourself and your baby before and after the birth. You can reach us at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Laboratory, X-Ray and Imaging Services Laboratory, X-ray and imaging services are covered by PHC Florida. These help find problems with your health. Ask your doctor to refer you a site in the plan network for this type of care. Home Health Care Services Home health care is covered by PHC Florida. Home health care products are also covered. Your doctor must refer you for home health care. It must be pre-approved by the Managed Care Plan. You must use a network home health provider. Home health care includes short-term or part-time skilled nursing services and medical items. The plan limits items to approved supplies, appliances and durable medical gear for use in the home. The home health care benefit is limited to four (4) visits per day. The lifetime limit is 60 total visits. The plan also has a home health care expanded benefit. This allows for more and longer visits by a nurse, home health aide and/or private duty nurse to your home. The expanded benefit does not have a lifetime limit. This expanded benefit requires prior authorization