South Carolina. Member. Handbook

Transcription

1 South Carolina Member Handbook

2

3 WellCare Caring for You Welcome to WellCare! We re glad you joined our family. As you work with everyone here, you ll see that we put you first. This means you get better care. You are our priority. We work hard to make sure you get the care you need to stay healthy. To do this, we work with many different providers to give you care. These include: Primary care providers (PCPs) Specialists Hospitals and other health care facilities Labs Pharmacies Your member handbook will tell you more about your benefits and how your health plan works. Please read it and keep it in a safe place. We hope it will answer most of your questions. If it doesn t, call us. Our toll-free number is (TTY ). We re here to answer all of your questions. You can also find us on the Web. Go to southcarolina.wellcare.com. Be on the lookout for your WellCare identification (ID) card. You should receive it in the mail within a few days of this handbook. Keep reading for more information about your ID card and how to use it. Again, welcome to WellCare. We wish you good health! Este manual incluye información importante. Para obtenerlo en español u otro idioma, llámenos. El número sin cargo es (TTY ). También podemos proveerlo en sistema Braille o audio. SCCADMHB64394E

4

5 Table of Contents The WellCare Dictionary... 1 Important Phone Numbers... 3 GETTING STARTED WITH US...4 Check Your ID Card and Keep It with You at All Times...5 Get to Know Your PCP...6 Remember to Use Our 24-Hour Nurse Advice Line...8 In an Emergency...8 Contact Us...9 Our Website...10 Know Your Rights and Responsibilities...10 Hold onto this Handbook...10 Care Basics Medically Necessary...11 Making and Getting to Your Medical Appointments...11 YOUR HEALTH PLAN Services Covered by WellCare Cost Sharing...14 The WellCare Extras!...19 Services Not Covered by WellCare Services Covered by Medicaid Fee-for-Service...21 Transportation Services...22

6 How to Get Services Covered by WellCare Prior Authorization (PA)...23 Services Available Without Authorization...24 Utilization Management (UM)...24 Second Medical Opinion...25 After-Hours Care...25 Urgent Care...26 Emergency Care...26 Out-of-Area Emergency Care...27 Post-Stabilization Care...27 Pregnancy and Newborn Care...28 Women, Infants and Children (WIC)...29 Behavioral Health Care...29 What to Do in a Behavioral Health Emergency or if You Are Out of Our Service Region...30 Prescriptions...30 Preferred Drug List...31 Other Drugs You Can Get at the Pharmacy...32 Care Management...32 Disease Management Program...33 Transition of Care...37 Planning Your Care Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services...38 Preventive Health Guidelines...39 Adult Preventive Health Guidelines...39 Pediatric Preventive Health Guidelines (Newborn to Age 21)...44 Advance Directives...47

7 Member Grievance and Appeals Procedures...49 Grievances...49 Appeals...51 Expedited or Fast Appeals Additional Information...53 State Fair Hearings...53 Continuation of Benefits During the Appeals Process...54 IMPORTANT MEMBER INFORMATION Remember to Renew Your Eligibility with the South Carolina Department of Health and Human Services (SCDHHS)...56 Enrollment...57 Open Enrollment...57 Reinstatement...57 Disenrollment...58 Voluntary Disenrollment...58 Involuntary Disenrollment...58 Important Information about WellCare...60 Plan Structure/Operations and How Our Providers Are Paid Evaluation of New Technology Quality Improvement and Member Satisfaction Fraud, Waste and Abuse...61 To Report Fraud, Waste or Abuse with WellCare...61 To Report Fraud, Waste or Abuse with South Carolina Medicaid Member Rights...63 Member Responsibilities...67 WellCare Notice of Privacy Practices...68

8 The WellCare Dictionary As you read this handbook, you ll see some words we use throughout it. Here s what we mean when we use them. Words/Phrases Advance Directive: A legal document, like a living will, that tells your doctor and family how you wish to be cared for if you re unable to make your wishes known yourself Appeal: A request for a review you can make when you don t agree with our decision to deny, reduce and/or end a service Benefits/Services: Health care that s covered by our plan Co-pay: A fee you should pay when you get certain care or fill a prescription Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Visits: Regular health exams for children Emergency: A very serious medical condition that must be treated right away Generic Drugs: A drug that has the same active ingredient as a brand-name drug and usually costs less Grievance: When you let us know that you re not happy with our plan, a provider or a benefit/service Identification (ID) Card: A card we give you that shows you re a member of our plan Immunizations: Shots that can help keep you and your children safe from many serious diseases Inpatient: When you get admitted to a hospital Managed Care Plan: A plan like ours that works with health care providers to give care to keep you and your family healthy southcarolina.wellcare.com 1

9 Words/Phrases Medically Necessary Services: Medical services you need to get well and stay healthy Member: You or someone who has joined our health plan Out-of-Network: A term we use when a provider is not contracted with our plan Outpatient: When you get treated at a medical facility, but are not admitted as an inpatient Post-Stabilization Services: Follow-up care after you leave the hospital to make sure you get better Pharmacy Network: A group of drug stores that plan members can use Preferred Drug List (PDL): A list of drugs that has been put together by doctors and pharmacists Prescription: A drug for which your doctor writes an order Prior Authorization (PA): When we need to approve care or prescriptions before you get them Primary Care Provider (PCP): Your personal doctor who helps manage all of your health care needs Provider: Those who work with us to give medical care, like doctors, hospitals, pharmacies and labs Provider Network: All of the providers who have a contract with us to give care to our members Specialist: A doctor who has been to medical school, trained and practices in a specific field of medicine Treatment: The care you get from doctors and facilities TTY: A special number to call if you have trouble hearing or have a speech impairment southcarolina.wellcare.com 2

10 Important Phone Numbers WellCare Member Services TTY Member Services Fax Hour Nurse Advice Line Fraud, Waste and Abuse Hotline State of South Carolina South Carolina Department of Health and Human Services (SCDHHS) South Carolina Healthy Connections Choices southcarolina.wellcare.com 3

11 Getting Started with Us

12 Getting Started with Us Here are a couple of important things to remember as you get started with WellCare. Check Your ID Card and Keep It with You at All Times You ll get your WellCare ID card in the mail. If you don t receive it, call us. Our toll-free number is (TTY ). We ll send you another one. You can also order a new one through our website. Log on to southcarolina.wellcare.com. When you get your WellCare ID card, look it over. You want to make sure the information on it is correct. On it, you ll find your: Primary care provider s (PCP s) name, address and phone Medicaid ID number Effective date (the date you became our member) Your Medicaid ID number The date your WellCare membership started Your name Medicaid #: < > Effective Date: <XX/XX/XXXX> Member: <First MI. Last Name> Primary Care Provider: <Dr. First Last Name> <Group ID Name> <XXXX Main Street> <Suite XXXX> <City, ST XXXXX> Phone: <XXX-XXX-XXXX> Member ID #: < > Plan Name: <Plan Name> Your WellCare ID number Your PCP s contact information Our website How to contact us southcarolina.wellcare.com For emergencies, go to the nearest ER. Contact your primary care provider (PCP) as soon as possible. Member Services TTY Hour Nurse Advice Line TTY WellCare of South Carolina P.O. Box Columbia, SC Medical claims are to be mailed to: WellCare Rx Bin: P.O. Box Rx PCN: Tampa, FL Rx GRP: Call hours a day, 7 days a week. This ID card is not a guarantee of coverage. Go to our website or contact South Carolina Healthy Connections. southcarolina.wellcare.com 5

13 Don t forget to keep your WellCare ID card with you at all times. You ll need to show it every time you get care. It has important information on it about your health plan. By showing your card, you can avoid getting a bill from a provider. Remember, if you get a letter or voice message from a provider asking for your insurance/health plan information, call them right away. Give them your WellCare member information on your ID card. If you get a bill from a provider, give us a call. We ll help to resolve the issue. If your ID card is lost or stolen, call us. Or log on to our website to get a new one. Get to Know Your PCP Your WellCare ID card has important information on it about your health plan. By showing it, you can avoid getting a bill from your provider. Your PCP is your partner in health. He or she will help arrange all of your medical care. This includes: Regular checkups Immunizations Referrals to other providers, like specialists We encourage all of our new members to visit their PCPs within the first 90 days (3 months) of joining our plan. If you re pregnant, you should get prenatal care within 14 days of joining our plan. This way your PCP will be able to get to know your health history. Plus, he or she can create a plan of care for you. Be sure to get your medical records from any doctors you ve seen in the past. This will be very helpful to your PCP. If you need help with this, call us toll-free at (TTY ). We ll be happy to help. The PCPs in our network are trained in different specialties. Specialties like: Family and internal medicine General practice Geriatrics Pediatrics Women can choose a women s health specialist as a PCP for preventive and routine care. southcarolina.wellcare.com 6

14 If you didn t decide on a PCP before joining our plan, we chose one for you. We made this choice based on: Where you may have received care or services before Where you live Your language preference (like English or Spanish) If the PCP is accepting new patients If you re not happy with our PCP choice, you can change your PCP at any time. When choosing your new PCP, remember: Our providers are sensitive to the needs of many cultures We have providers who speak your language and understand your traditions and customs We can tell you about a provider s schooling, residency and qualifications You can pick the same PCP for your entire family or a different one for each family member (depending on each family member s needs) We have a few ways for you to look for PCPs and other providers. Our printed provider directory: We mailed one to you with this handbook In it, we ve listed providers by county and specialty Find a Provider: This is a tool on our website You can search for a provider within a certain distance of your home Because we re always adding new providers to our network, this is the best way to get our most current provider network information Call us: We can help you find a provider right over the phone To change your PCP, call us. Call toll-free (TTY ). You can request the change through our website too. PCP changes made between the 1 st and 10 th If your PCP or other provider decides to leave our network, we ll send you a letter 30 calendar days ahead of time. The letter will give you details about the change and how we re handling it. southcarolina.wellcare.com 7

15 of the month will go into effect right away. Changes made after the 10 th of the month will take effect at the beginning of the next month. We ll send you a new ID card with your new PCP listed on it. Remember to Use Our 24-Hour Nurse Advice Line We have nurses to take your call any day of the week. You can call anytime you re not sure how to handle a health-related problem. One of our nurses will help you decide what kind of care you need. You can get help with problems like: Back pain A cut or burn A cough, cold or the flu Dizziness or feeling sick to your stomach A crying baby When you call, a nurse will ask some questions about your problem. Give as many details as you can; for example, where it hurts or what it looks and feels like. The nurse can then help you decide if you: Can care for yourself at home Need to see a doctor or go to an urgent care center or the hospital Remember, a nurse is always there to help. Consider calling our Nurse Advice Line before calling your doctor or going to the hospital. But if you think it is a real medical emergency, call 911 or go to the nearest emergency room. 24-Hour Nurse Advice Line toll-free number: (TTY ) In an Emergency Call 911 or go to the nearest emergency room. We ll talk more about emergencies later in this handbook. southcarolina.wellcare.com 8

16 Contact Us Call us with any questions you have. We re here to help Monday Friday, 8 a.m. to 6 p.m. Member Services toll-free number: (TTY ) Call us any time you need help with: Updating your contact information, like your mailing address and phone number Getting a replacement ID card Finding and choosing a provider Making an appointment with a provider Filing a grievance or an appeal It s important for us and the South Carolina Department of Health and Human Services (SCDHHS) to know if there is a major change in your life. For example, if you: Move Your family size changes, like you get married or divorced, have a baby or adopt a child or experience the death of your spouse or child Start a new job or your income changes Get health insurance from another company If you speak a different language or need something in Braille, large print or audio, we can help. We have translation and alternative format services (including sign language). We can even arrange to have a translator or sign language interpreter at your appointments. Just give us a call. There is no cost to you for this. If you call us after business hours with a non-urgent request, leave a message. We ll call you back within 1 business day. To write to us, send your request to: WellCare of South Carolina Attn: Member Services P.O Box Tampa, FL southcarolina.wellcare.com 9

17 Our Website You may be able to find answers to your questions on our website. Log on to southcarolina.wellcare.com for information on/about: Our member handbook, provider directory or the Find a Provider search tool How we protect your privacy Your member rights and responsibilities Member newsletters Pediatric and adult preventive health Pregnancy care Childhood obesity, lead poisoning, asthma, diabetes and chronic kidney disease On our website, you can also: Update your address and phone number Request a change to your PCP Place your monthly over-the-counter (OTC) items order Our website: southcarolina.wellcare.com Know Your Rights and Responsibilities As a member of our plan, you have rights and responsibilities. Keep reading to learn more. Hold onto this Handbook You ll find very valuable information in this handbook. Information about: Your covered benefits and services and how to get them Advance directives (learn more about these in the Advance Directives section later in this handbook) How to use our grievance and appeals process for when you re not happy with our health plan or a decision we made How we protect your privacy If you lose it, call us. We ll send you a new one. You can also find it on our website. southcarolina.wellcare.com 10

18 Care Basics You ll get your care from doctors, hospitals and others who are in our provider network. We or a network doctor must approve your care. We ll pay for approved care. If you get a service that we do not approve, you may have to pay for it yourself. Medically Necessary We approve care that is medically needed or necessary. This just means the care: Is for an illness that would put your health in danger Follows accepted medical practices Is provided in a safe, proper and cost-effective place, depending on the diagnosis and how sick you are Is not for convenience only Is needed when there is no better or less costly care, service or place available Making and Getting to Your Medical Appointments We have guidelines to make sure you get to your medical appointments in a timely manner.* (This is also called access to care. ) This table will give you an idea of the furthest distance you should have to drive to get to a medical appointment. Type of Provider Distance to the Provider from Your Home PCPs 30 miles Specialists 50 miles *The doctors in our network must offer you the same office hours as patients with other insurance. When you arrive at your appointment, you should only have to wait up to 45 minutes (for a scheduled appointment). southcarolina.wellcare.com 11

19 How long you should wait for an appointment depends on the kind of care you need. Keep these times in mind as you re setting your appointments. Type of Appointment Medical Behavioral Health Type of Care Emergency Urgent Routine/wellness PCP visits Specialist visit Emergency Urgent Routine visit Appointment Time Right away (both in and out of our service area), 24 hours a day, 7 days a week (prior authorization is not required for emergency services) Within 48 hours of your request 4 weeks of your request 4 to 6 weeks of your request Right away (both in and out of our service area), 24 hours a day, 7 days a week (prior authorization is not required for emergency services) Within 48 hours of your request Less than 10 days of your request southcarolina.wellcare.com 12

20 Your Health Plan

21 Services Covered by WellCare Cost Sharing You may have to make a small co-payment, or co-pay for short, when you get care. Be sure to read this section for co-pay amounts. There are no co-pays for: Children under age 19 Federally recognized Native Americans Emergency care Pregnant women Institutionalized individuals Members of the Health Opportunity Accounts (HOA) program Here are some important things to remember when getting your care: We ll pay for approved care If you get a service that we do not approve, you may have to pay for it yourself Sometimes we may not have a provider in our network who can give you needed care. If this happens, we ll cover the care out-of-network (at no additional cost to you), but you will need to get approval first from us or your PCP. We will make sure that your cost is no more than it would be if the services were done within our network. WellCare could choose not to cover a benefit due to moral or religious grounds. If that happens, we would notify you to let you know about the change. We would do this at least 90 days before the change takes effect. We will also let you know how you may be able to get this service before the change takes effect. This is not a complete list of covered services. For questions about covered services, give us a call. We can be reached toll-free at (TTY ). If a benefit changes at any time, we ll send you a letter 30 calendar days ahead of time. The letter will give you details about the change and how we re handling it. (Changes can include adding or ending a benefit.) southcarolina.wellcare.com 14

22 Covered Services and Any Limits Co-Pays Abortions and related services Covered only in the case of rape or incest or if the member s life is in danger $0 Allergy testing and treatment $3.30 Ambulance transportation $0 Ambulatory Surgical Center (ASC)/Short Procedure Unit (SPU) services $3.30 Behavioral health inpatient services (at a general hospital) $25 Behavioral health outpatient facility services $3.40 Certified Registered Nurse Practitioner services $3.30 Chiropractic services Limited to manual manipulation of the spine to treat vertebrae misalignment Limited to 1 treatment/visit a day, up to 8 treatments/visits each year $1.15 Communicable disease (HIV/AIDS, STDs, syphilis, TB) services Directly observed therapy for TB Education and counseling Testing Treatment $3.30 southcarolina.wellcare.com 15

23 Covered Services and Any Limits Durable medical equipment (DME) and supplies Items that are not covered include wheelchair accessories and ramps, gloves, car/individual lifts, etc. Repairs not covered under the manufacturer s warranty are covered Replacement is covered if the equipment is still medically necessary at the time of replacement Early and Periodic Screening, Diagnosis and Treatment (EPSDT)/Well-child services Physicals for sports are not covered Co-Pays $3.40 (equipment under a rent-to-purchase plan will have the co-pay split evenly among the 10-month rental payment schedule) $0 Emergency medical services $0 Vision Services One set of glasses per year Contact lenses as medically necessary Replacements as medically necessary One comprehensive eye exam per year for members under age 21 $0 (for members age 18 and under); $3.30 (for members ages 19 and 20) Family planning services Annual visit Contraception and supplies Family planning and HIV counseling Lab tests Pregnancy testing $0 Federally Qualified Health Center (FQHC) services $3.30 Hearing services (for members under age 21) Cochlear implants Ear molds 4 for each ear, every year Hearing aids fittings, related hearing services, testing $0 southcarolina.wellcare.com 16

24 Covered Services and Any Limits Co-Pays Home health services Home health aide visits Skilled nursing visits Therapy visits occupational, physical and speech therapies Up to 50 visits each year Services that are not covered include full-time nursing, drugs, home-delivered meals, homemaker services, routine supplies and home health services provided in a nursing home and/or institution $3.30 Hysterectomy services (when medically necessary) Advance written and verbal notification to the member that she will be permanently unable to have children is required; the notification must be signed and dated by the member Hysterectomies are not covered if done only to prevent pregnancy Inpatient hospital services (physician care and rehabilitation) Institutional long-term care facilities/nursing homes Limited to the first 90 continuous days Maximum limit of covered days is 120 $0 $25 per admission $0 Internal prosthetic devices $3.40 Lab and X-ray services and diagnostic tests $0 Maternity services Birthing centers for obstetrical and newborn care Prenatal, delivery and postpartum services and nursery charges Postpartum services (one home visit within 6 weeks of delivery) $0 southcarolina.wellcare.com 17

25 Covered Services and Any Limits Co-Pays Outpatient hospital (non-emergency) services $3.40 Outpatient pediatric AIDS clinic services $0 Outpatient rehabilitative therapy services $3.40 Physician services $3.30 Physical therapy, occupational therapy, speech therapy and audiology Pharmacy services $0 $0 (for members ages 18 and under) $3.40 (for members ages 19 and above) Podiatry services $1.15 Preventive and Rehabilitative Services for Primary Care Enhancement (PSPCE/RSPCE) Evaluation of health status and needs Identification of risk factors Development of care plan Education and counseling $0 Rural Health Clinic (RHC) services $3.30 Sterilization services (for members age 21 and older who are mentally competent, not in an institution and have consented to the service) Advanced informed consent to the member is required $0 southcarolina.wellcare.com 18

26 Covered Services and Any Limits Co-Pays Transplant services Bone marrow, cornea, heart, kidney, liver, lung, multivisceral, pancreas, small bowel All services provided 72 hours before surgery, posttransplant services following discharge and posttransplant pharmacy services $0 The WellCare Extras! We re excited to offer extra benefits and special programs to our members. Things like: Diaper Rewards Program: New moms and babies can earn rewards by completing postpartum and well-child checkups Circumcisions: Covered for infants up to 6 months of age Healthy Rewards Program: The Healthy Behaviors Program rewards you for taking steps that help you live a healthy life. When you complete a healthy behavior, we ll send you a $20 CVS Select gift card. Complete another healthy behavior and we ll load another $20 onto your gift card. It s that simple. Call Member Services for more details. Or you can refer to the brochure found in your New Member kit. FREE Over-the-Counter Items: Get $120 a year ($10 a month) for over-the-counter drugs and supplies. You can get things like diapers, vitamins and almost 100 other items. We ll ship them right to your home. southcarolina.wellcare.com 19

27 Services NOT Covered by WellCare We do not cover the following services. This is not a complete list of non-covered services. For questions about non-covered services, give us a call. We can be reached toll-free at (TTY ). Non-Covered Services Cosmetic procedures Experimental and investigational procedures Hypnotherapy Services provided outside of the U.S. southcarolina.wellcare.com 20

28 Services Covered by Medicaid Fee-for-Service These services are covered by Medicaid fee-for-service (or the SCDHHS Medicaid Plan). To get them, you ll need to show your South Carolina Healthy Connections Medicaid ID card. Call us with any questions you have about these services. You can also contact SCDHHC toll-free at Services Covered by SCDHHS Certain behavioral health services: Targeted case management services Intensive family treatment services Therapeutic day services for children Out-of-home therapeutic placement services for children Inpatient psychiatric hospital and residential treatment facility services Dental services: Preventive, restorative and surgical services are covered for members under age 21 Emergency dental services are covered for members over age 21 SCDHHS is partnered with DentaQuest to provide dental care; call DentaQuest toll-free at (TTY ) to: Get more information about covered services Find a provider in your area Set up an appointment Developmental Evaluation Services (DECs): These are medically necessary services for members under age 21 who may have developmental delays, learning disabilities or other disabling conditions Family planning services through the Medicaid Adolescent Pregnancy Prevention Services (MAPPS) program: These services are for at-risk youths and include Counseling Education Services are provided in schools, office settings and homes southcarolina.wellcare.com 21

29 Services Covered by SCDHHS Home- and community-based waiver services Non-emergency transportation: Keep reading for more details Nursing home care after 90 continuous days (WellCare covers the first 90 continuous days) Pregnancy prevention for targeted populations Substance abuse treatment services Transportation Services For non-emergency transportation, please call a transportation broker listed in the following table. In most cases, we ask that you call 3 days before you need the service. Each broker has a toll-free telephone number to schedule transportation services and is available Monday Friday from 8 a.m. to 6 p.m. In an emergency, call 911 for a ride to the hospital. LogistiCare Region 1 If you live in one of these counties, call: Region 2 If you live in one of these counties, call: Region 3 If you live in one of these counties, call: Counties Served Abbeville, Anderson, Cherokee, Edgefield, Greenville, Greenwood, Laurens, McCormick, Oconee, Pickens, Saluda and Spartanburg Aiken, Allendale, Bamberg, Barnwell, Calhoun, Chester, Clarendon, Fairfield, Kershaw, Lancaster, Lee, Lexington, Newberry, Orangeburg, Richland, Sumter, Union and York Beaufort, Berkeley, Charleston, Chesterfield, Colleton, Darlington, Dillon, Dorchester, Florence, Georgetown, Hampton, Horry, Jasper, Marion, Marlboro and Williamsburg If you need help arranging non-emergency transportation, give us a call. Our toll-free number is (TTY ). We ll be happy to help. southcarolina.wellcare.com 22

30 How to Get Services Covered by WellCare Call your PCP when you need regular care. He or she will send you to see a specialist for tests, specialty care and other covered services that he or she does not provide. Be sure your PCP approves you to see a specialist. We will cover this care. If your PCP does not provide an approved service, ask him or her how you can get it. Prior Authorization (PA) Prior authorization (or PA for short) means we must approve a service before you can get it. Your PCP/specialist should contact us to ask for this approval. If we do not approve the request, we ll let you know. Plus, we ll give you details about how to file an appeal. (Keep reading for more on appeals.) Prior Authorization How To Type of Request Decision Time Frame Who Can Request One How to Request Standard* (for nonemergency care) Expedited/Fast** (for urgent care) 14 calendar days Your provider 72 hours Your provider Call: Fax: Call: Fax: In a case when we do not approve a request, we don t give anyone a reward to deny coverage or care. We don t pay anyone or promote decisions that end up in care being denied. *Sometimes we may need more time to make a standard decision. This may be because we need more information and it s in your best interest. If so, we ll take up to 14 more calendar days. **Sometimes we may need more time to make a fast decision. If so, we ll take up to 48 more hours. southcarolina.wellcare.com 23

31 There are some instances when a PA is not needed from us: If you move to our plan from another managed care plan or Medicaid fee-forservice and have an existing PA for a medical service, your service will continue until your provider releases you or you complete the treatment If you re taking a prescription for major depression, schizophrenia or bipolar disorder that was prior authorized by your previous managed care plan or Medicaid fee-forservice, we will continue to cover it up to 60 days (from when you become our member) Services Available Without Authorization You don t need approval from us or your PCP for the following services: Dialysis DME purchases under $250 and orthotics and prosthetics under $500 Emergency or urgent care services Emergency transportation services Observation services Routine lab tests and X-ray services Select outpatient procedures (please call us for a complete list of these procedures) Even though you don t need approval for these services, you will need to pick a network provider. Look through your provider directory to find one. Remember to use our online provider search tool Find a Provider. It s on our website. Log on to southcarolina.wellcare.com. When you ve made your choice, call to set up an appointment. Remember to take your ID card with you. Utilization Management (UM) Utilization management (UM) is a common process used by health plans. It s how we make sure members get the right care at the right place. It also helps us control costs and deliver good care at the same time. Our UM program has four parts. They are: 1. Prior authorization getting our approval before getting a service 2. Prospective reviews making sure the care is right for you before you get it 3. Concurrent reviews reviewing your care as you get it to see if something else might be better for you 4. Retrospective reviews finding out if the care you got was appropriate southcarolina.wellcare.com 24

32 At times, we may deny coverage for services or care. (All medically necessary denial decisions are made by a doctor.) Here are some things you should know about this decision process: Decisions are based on the best use of care and services The people who make decisions don t get paid to deny care (no one does) We do not promote denial of care in any way Call us if you have questions about our UM program. Call toll-free (TTY ). Second Medical Opinion Call your PCP when you want a second opinion about your care. He or she will ask you to pick another doctor in our network. If you can t find one, don t worry. You ll be able to choose a doctor outside of our network. (You won t have to pay for this.) The second-opinion doctor may order some tests for you. If so, these tests must be done by a provider in our network. Your PCP will review the second opinion. He or she will then decide the best way to treat you. You may have to pay for services you get when you go to a doctor who is not in our network without approval. A second medical opinion can be requested by anyone who is allowed to act on your behalf. This includes a: Parent Guardian Social worker After-Hours Care What if you get sick or hurt when your PCP s office is closed? If it s not an emergency, call our 24-hour Nurse Advice Line. Or you can call your PCP. His or her number is on your ID card. Your PCP s office will have a doctor on call. This on-call doctor is available 24 hours a day, 7 days a week. He or she will call you back and tell you what to do. You may go to an urgent care center if you can t reach your PCP s office. You don t need a PA to go to an urgent care center. If you do go to an urgent care center, be sure to call your PCP s office the next day for follow-up care. southcarolina.wellcare.com 25

33 Urgent Care You may need urgent care for a health problem that isn t an emergency, but needs treatment within 48 hours. This could be something like: An injury Illness Severe pain If you have one of these problems, try calling our 24-hour Nurse Advice Line. One of our nurses will try and help you over the phone. Or you can call your PCP. He or she can tell you how to treat it. Our advice line or your PCP may tell you to go to an urgent care center for help. Urgent care center services do not require a PA. When you get to the center, show your WellCare ID card. Also, ask the staff to call us. Be sure to let your PCP know if you receive care at an urgent care center so you can get follow-up care. You can also go to an urgent care center when you travel outside of South Carolina. Emergency Care A medical emergency is when your health is in grave danger. An emergency is when the condition could cause: Bodily injury Damage to an organ or other body part Injury to yourself or others Harm to yourself or others due to alcohol or drug abuse Harm to your health For moms-to-be, it may be an emergency if you think: There is no time to go to your doctor s regular hospital Going to another hospital may cause harm to you and your baby You re in labor Here are some examples of an emergency: Broken bones or cuts requiring stitches Heart attack or severe chest pains Shortness of breath Poisoning Heavy blood loss Loss of consciousness Call your PCP or our Nurse Advice Line if you re not sure if it s an emergency. southcarolina.wellcare.com 26

34 In an emergency, you can: Call 911 Call an ambulance if you don t have 911 in your area Go to the nearest hospital emergency room (ER) right away The choice is yours. You don t need a PA for emergency care that is provided at an urgent care center or ER. When you get to the ER, show your WellCare ID card. Also, ask the staff to call us. The ER doctor will decide if your visit is an emergency. If your condition is not an emergency and your health is not in danger, you can choose to stay. But you may have to pay for the care if you do. Out-of-Area Emergency Care It s important to get care when you are sick or hurt. That goes for when you are traveling too. If you have a medical emergency while traveling, go to the nearest hospital. It doesn t matter if you are not in our service area. When you get to the hospital, remember to: Show your WellCare ID card Ask the staff to call us for instructions on how to file your claim Let your PCP know what has happened If you have to pay for this visit, let us know. We ll tell you how you can ask to be reimbursed for the visit. But it is very important that you keep copies of your medical reports, bills and proof of payment. We will need these to reimburse you. Post-Stabilization Care After an ER visit, call your PCP within 24 to 48 hours. You may need to get follow-up care until your health gets better. This is called post-stabilization care. You don t need a PA for post-stabilization care, which we cover. But you must need this care to maintain, improve or resolve your medical condition. southcarolina.wellcare.com 27

35 Pregnancy and Newborn Care When you find out you are pregnant, taking care of yourself can help you and your unborn baby stay healthy. Here are some very important things to do when you get the news. Think of this as your baby checklist. Baby To Do List Let these people know I m having a baby: Family WellCare at SCDHHS (South Carolina Department of Health and Human Services) My PCP Schedule my first prenatal visit and talk with the doctor about future prenatal visits and those after baby gets here Start thinking about which doctor to pick for baby I need to have this done before baby gets here Once baby is here, call SCDHHS to get his/her Medicaid # and then call WellCare with it If SCDHHS doesn t put baby on WellCare, call to fix WellCare can help me make my baby appointments! (TTY ) Names??? Clothes??? You should see your PCP within 14 days of joining our plan. Make sure to go to all your prenatal and postpartum (after birth) visits. Just as important as keeping your appointments is letting us know when you become pregnant. We can provide you with helpful information about having and caring for your baby. southcarolina.wellcare.com 28

36 A few reminders: If you have a baby while you re a WellCare member, he or she will automatically be added to WellCare, and we ll cover him or her from birth (unless you tell SCDHHS that you want him or her added to a different health plan before giving birth) You must let SCDHHS know (call ) that you are pregnant; once you have your baby, you need to call SCDHHS again to get his or her Medicaid number Give us your baby s Medicaid number after you get it from SCDHHS If your baby is not automatically added to WellCare, call to have him or her changed over to our plan Choose a PCP for your baby before he or she is born; if you don t, we ll choose one for you Women, Infants and Children (WIC) WIC is a special nutrition program. It s for women (pregnant and those who have recently delivered), infants and children. The program provides: Nutrition education Nutritious food Referrals to other health, welfare and social services Support for breastfeeding mothers If you are pregnant, ask your PCP about WIC. To see if you re eligible and to apply for this program, call your local WIC agency. You will need to schedule an appointment to talk with them. You ll also need to provide proof of South Carolina residency and your income. For more details about WIC, go to the South Carolina WIC website at Behavioral Health Care Your mental or behavioral health is an important part of staying healthy. If you experience any of the symptoms below, call us at (TTY ). We ll give you the names and phone numbers of providers who can help. You can search for a provider on our website too. Log on to southcarolina.wellcare.com. Always feeling sad Feeling hopeless and/or helpless Feelings of guilt or worthlessness southcarolina.wellcare.com 29

37 Problems sleeping No appetite Weight loss or gain Loss of interest in the things you like Problems paying attention Being upset Your head, stomach or back hurts, and your doctor hasn t found a cause Drug or alcohol problems As a reminder, you must get a PA to see a provider who is not in our network. You ll have to pay for the care if you don t. What to Do in a Behavioral Health Emergency or if You Are Out of Our Service Region Do you feel you re a danger to yourself or others? Do you think you re having a behavioral health emergency? Call your PCP or our Nurse Advice Line if you re not sure if it s an emergency. In a behavioral health emergency, you can: Call 911 Call an ambulance if you don t have 911 in your area Go to the nearest hospital emergency room (ER) right away The choice is yours. You don t need a PA for a behavioral health emergency. The doctor who treats you for your behavioral health emergency may feel you need post-stabilization care. You don t need a PA for post-stabilization care. But it must be needed to maintain, improve or resolve your medical condition. Remember to follow up with your PCP within 24 to 48 hours after you leave the hospital. The hospital where you get your emergency care may be out of our service area. If so, you ll be taken to a network facility when you re well enough to travel. Refer back to the Emergency Care section of this handbook for more information about what to do in an emergency. Prescriptions Prescriptions must be written by one of our network providers. (Your PCP must approve a prescription from an out-of-network provider.) Once you have your prescription, go southcarolina.wellcare.com 30

38 to any network pharmacy to get it filled. Our provider directory lists all of the pharmacies who take our plan. You can search for one on our website too. Or call us and we ll help find one near you. At the pharmacy, you ll need to show your WellCare ID card when you pick up your prescription. There is a $3.40 co-pay for drugs. Remember, there are no co-pays for: Children under age 19 years old Federally-recognized Native Americans Pregnant women Members age 21 and older can receive up to 7 prescriptions per month, of which only 4 may be brand. You can get more prescriptions per month, if medically necessary, through the PA process. These limits do not apply to children age 20 and younger. Keep your co-pays low with generic drugs. They can cost less and work the same as brand-name drugs. Ask your provider or pharmacist for a generic drug option, if available. Preferred Drug List We have a Preferred Drug List, or PDL for short. This is a list of drugs that has been put together by doctors and pharmacists. Our network providers use this list when they prescribe a drug for you. To see our PDL, go to our website at southcarolina.wellcare.com. The PDL will include drugs that may have limits, like: Age or gender limits Quantity limits Prior authorization (PA) Step therapy For those drugs that require a PA (and are not on our PDL), your provider will need to send us a Coverage Determination Request (CDR). There are some medications we will not cover. They include: Those used for eating problems or weight gain Those used to help you get pregnant Those used for erectile dysfunction Those that are for cosmetic purposes or to help you grow hair DESI (Drug Efficacy Study Implementation) drugs and drugs that are identical, related or similar to such drugs Investigational or experimental drugs Those used for any purpose that is not medically accepted southcarolina.wellcare.com 31

39 Other Drugs You Can Get at the Pharmacy There are some over-the-counter (OTC) drugs you can get at the pharmacy with a prescription. (These are different than the $10 OTC extra benefit we offer.) Some of these drugs we cover include: Diphenhydramine (for allergy relief) Meclizine (to help with motion sickness) H2 receptor antagonists (to treat acid reflux and ulcers, such as ranitidine) Ibuprofen (pain reliever for headaches, toothaches and back pain) Multivitamins/multivitamins with iron Insulin Insulin syringes Non-sedating antihistamines (allergy relief that won t make you sleepy) Iron Topical antifungals such as clotrimazole Urine test strips Coated aspirin Antacids such as aluminum hydroxide Proton pump inhibitors (also help with acid reflux and ulcers, such as omeprazole) For questions about prescriptions, call us. We can be reached at (TTY ). To get these items, simply take your prescription to a network pharmacy. You ll also need to show them your WellCare ID card. Care Management We understand you may have special care needs. To help with these, we have a care management program. The goal of this program is to help you understand how to take care of yourself and maintain good health. You may qualify for care management services if you: Have a child with special health care needs Have a chronic illness that requires coordination of many services Have a serious or long-term health condition, like asthma, diabetes, hypertension, coronary artery disease (CAD), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), HIV/AIDS or a high-risk pregnancy southcarolina.wellcare.com 32

40 Have cancer Have had a transplant Need help with getting care and/or using your medical services Suffer from depression While in the program, you ll work with a care manager. He or she will work with you to help coordinate your care needs. To do this, he or she: May ask you questions to get more information about your condition Will work with your PCP to arrange services you need and help you understand your illness Will provide information to help you understand how to care for yourself and how to access services, including local resources We may contact you to talk about care management if: You ask about the program Your PCP thinks the program would help you We think you may qualify for these services To learn more about or to sign up for this no-cost program, give us a call. Call toll-free at (TTY ). Disease Management Program WellCare s Disease Management/Chronic Care Improvement Program (DM/CCIP) helps members and their caregivers with long-term health issues. If you take part in the program, you ll get information and health coaching so you can make good choices and manage your conditions. This allows you to improve your health and quality of life. The program is offered to members who have any of the conditions listed below. Members in the program get services from a team of registered nurses and health professionals who have experience helping people with those conditions. The choice to take part in the program is completely yours. Members receive welcome letters and instructions on how to get more help and services, or how to opt out of the program. If you decide to take part in the program, you ll work with a Disease Manager to create a care plan. The care plan maps steps to help you reach your health care goals. It includes input from your PCP, specialists and, if the member is a minor, the member s caregiver. southcarolina.wellcare.com 33

41 Topics that the program addresses include: Asthma Understanding asthma Avoiding triggers Ways to self-monitor asthma Using a peak flow meter Using an inhaler Following an asthma action plan Taking medications as prescribed Using controller medications Physical activity Maintaining overall health Regular follow-up with providers Resources and tools for asthma Using durable medical equipment when needed Diabetes Understanding diabetes, including the need for: Testing to measure your average blood sugar level Cholesterol testing Need for annual eye exam Managing blood pressure Monitoring kidney disease Symptoms and treatment of high and low blood sugar Nutrition guidance Setting healthy eating goals Importance of meal planning Physical activity Taking medications as prescribed Maintaining overall health Sick day plan Preventive diabetic screenings Resources and tools for diabetes Using durable medical equipment when needed Blood glucose monitoring glucometers Scales Blood pressure cuffs southcarolina.wellcare.com 34

42 Topics that the program addresses include: Coronary Artery Disease (CAD) Understanding CAD, including the need for cholesterol screening Symptoms and treatment of CAD Nutrition guidance Setting healthy eating goals Following a low-salt diet Taking medications as prescribed Physical activity Tips for staying active Maintaining overall health Regular follow-up with providers Managing risk factors Smoking Cholesterol Blood pressure Stress Resources and tools for CAD Using durable medical equipment when needed Blood pressure cuffs Scales Congestive Heart Failure (CHF) Understanding CHF Symptoms and treatment of CHF Nutrition guidance Setting healthy eating goals Following a low-salt diet Taking medications as prescribed Using ACE inhibitors and ARBs Physical activity Tips for staying active Maintaining overall health Regular follow-up with providers Resources and tools for CHF Using durable medical equipment when needed Scales Blood pressure cuffs southcarolina.wellcare.com 35

43 Topics that the program addresses include: Chronic Obstructive Pulmonary Disease (COPD) Understanding COPD Avoiding triggers Self-monitoring Using an inhaler Taking medications as prescribed Using controller medications Maintaining overall health Regular follow-up with providers Smoking cessation Resources and tools for COPD Using durable medical equipment when needed Oxygen High Blood Pressure (Hypertension) Understanding high blood pressure Treating high blood pressure Nutrition guidance Setting healthy eating goals Taking medications as prescribed Physical activity Tips for staying active Maintaining overall health Regular follow-up with providers Managing risk factors Smoking Stress Tools for managing high blood pressure Using durable medical equipment when needed Blood pressure cuffs Scales southcarolina.wellcare.com 36