caring for you and your family member handbook · 2012-02-27 · mailing address (if different than...

Caring for you andyour family

MemberHandbook

MEMBER INFORMATION UPDATE FORMIt’s important that we have your current information. That way we can keep you up to date on your Staywell benefits and services. Please use this form to give us your address and phone number. If you move, please give us the changes. You can also update it through our website. Go to www.wellcare.com.

Sometimes we need to release your medical history. Please read the Notice of Privacy Practices in this handbook. It explains the details. Then sign the statement below and return it to us. We’ve included a stamped envelope for you.

Questions? Call Customer Service at 1-866-334-7927 (TTY/TDD 1-877-247-6272) Monday–Friday, 7 a.m. to 7 p.m. Eastern.

Member Name:

First Name Middle Name Last Name

Home Address:

Street City Zip Code

Mailing Address (if different than your home address):

Street City Zip Code

Phone Number: County in Which You Live:

I allow Staywell to release my medical facts as needed. I have read the Notice of Privacy Practices. I understand:

• How this information may be used

• When this information may be released

• How I can get this information

Signature (or signature of parent or guardian if member is under 21 years of age) Date

STAYWELL MEMBER HANDBOOK

TABLE OF CONTENTS

WELCOME TO STAYWELL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Getting Started ...............................................................................................................................................................................1

To Contact Us .................................................................................................................................................................................1

MEMBER INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Enrollment in Staywell ................................................................................................................................................................2

The MediKids Program ...............................................................................................................................................................2

Your Identification (ID) Card. ..................................................................................................................................................3

Your Doctor ....................................................................................................................................................................................3

Changing Your Primary Care Physician ..............................................................................................................................3

Informed Consent ........................................................................................................................................................................4

ACCESS TO COVERED SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Out-of-Network Care.................................................................................................................................................................4

HOW TO GET COVERED SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Covered Services...........................................................................................................................................................................5

Non-Covered Services ...............................................................................................................................................................6

How to Get Authorized Services ..........................................................................................................................................6

Services Available Without Authorization ......................................................................................................................7

Second Medical Opinion ...........................................................................................................................................................7

How to Get After-Hours Medical Care ............................................................................................................................7

What to Do in an Emergency .................................................................................................................................................7

Out-of-Area Emergency Care .................................................................................................................................................8

Pregnancy and Newborn Care ..............................................................................................................................................8

Prescriptions ...................................................................................................................................................................................9

Transportation Services .............................................................................................................................................................9

GETTING BEHAVIORAL HEALTH SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 How to Get Behavioral Health Services ............................................................................................................................11

What to Do if You Need Help ...............................................................................................................................................11

What to Do in an Emergency or if You Are Out of the Staywell Service Area ......................................... 12

What is Post-Stabilization ....................................................................................................................................................... 12

Prevention Programs ................................................................................................................................................................. 12

Behavioral Health Limitations and Exclusions ................................................................................................................13

OTHER PROGRAMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Personal Health Advisor (24-Hour Nurse Helpline) .....................................................................................................13

Maternity Education and Prenatal Rewards Program ...............................................................................................13

Case and Disease Management . ......................................................................................................................................... 14

Community-Based Programs ................................................................................................................................................ 14

PREVENTIVE HEALTH CARE GUIDELINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Adult Preventive Health Guidelines . ................................................................................................................................ 15

Pediatric Preventive Health Guidelines—Newborn to 21 Years Old ................................................................ 17

Over-the-Counter Items ......................................................................................................................................................... 19

Post OTC Listing .......................................................................................................................................................................... 19

ADVANCE DIRECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Your Medical Care Is Your Decision ................................................................................................................................ 19

Advance Directives—Making Your Decision Known . ............................................................................................. 19

IMPORTANT INFORMATION ABOUT STAYWELL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Enrollment ...................................................................................................................................................................................... 20

Open Enrollment ........................................................................................................................................................................ 20

Reinstatement ............................................................................................................................................................................... 21

Moving Out of Our Service Area ........................................................................................................................................ 21

Disenrollment ................................................................................................................................................................................ 21

Involuntary Disenrollment ..................................................................................................................................................... 22

Fraud and Abuse ......................................................................................................................................................................... 22

Confidentiality ............................................................................................................................................................................. 23

How Doctors Are Paid ........................................................................................................................................................... 23

Utilization Management Program ..................................................................................................................................... 23

Quality Improvement and Member Satisfaction ....................................................................................................... 23

Evaluation of New Technology .......................................................................................................................................... 23

Public Information About Staywell ................................................................................................................................. 24

MEMBER APPEALS AND GRIEVANCES PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Making an Appeal ....................................................................................................................................................................... 25

Medicaid Fair Hearing ............................................................................................................................................................... 28

Filing a Grievance ....................................................................................................................................................................... 29

Exhaustion of Grievance Procedures ............................................................................................................................... 30

Additional Help with Appeals and Grievances ............................................................................................................ 30

MEMBER RIGHTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31MEMBER RESPONSIBILITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32NOTICE OF PRIVACY PRACTICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33IMPORTANT PHONE NUMBERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

www.wellcare.com | 1

WELCOME TO STAYWELL!This is your member handbook. This book will tell you how your health plan works. Please read it carefully. Keep it in a safe place so you can refer to it when you need it.

GETTING STARTEDIt’s easy! Just follow these steps and you’ll be on your way to getting the health care you need.

1.) You should have gotten your Staywell ID card in the mail. If you have not, please call us toll-free at 1-866-334-7927 (TTY/TDD 1-877-247-6272). Please take time to look at your ID card. Check the primary care physician (PCP) name on the card. The date your membership starts is also listed. You need to give your ID card to the health care provider when you need care. It has details about your plan. Be sure to keep this card and your Medicaid Gold Card with you.

2.) Set up a visit with your PCP. You must do so within 90 days of joining. You must be seen within 30 days of joining the plan if you are pregnant. Your PCP will take care of your basic medical care. He or she will set you up with specialists or hospital care if needed. Call your PCP at the number on your ID card for non-emergencies.

3.) You should also get your medical records. You can get these from the doctors you saw before you joined Staywell. Tell your PCP if you are taking any medicines that another doctor ordered for you. This will help your PCP when planning your care. If you need or want to see your current medical records, ask your PCP. For help with this, call Customer Service.

4.) Get to know your Personal Health Advisor. Not sure what kind of care you need? Staywell has an advisor who can answer health care questions. It’s free! A trained professional is there for you at all times. Call toll free 1-800-919-8807.

IN AN EMERGENCYIn a real medical emergency, call 911. Or go to the nearest emergency room. This handbook has a section called What to Do in an Emergency (page 7). Please read it. It has a list of examples of real medical emergencies.

TO CONTACT US Call Staywell Customer Service. We can help you weekdays, 7 a.m. to 7 p.m. Eastern. Call 1-866-334-7927 (TTY/TDD 1-877-247-6272). Or visit our website at www.wellcare.com. Then click on the Staywell page.

Do you speak a language other than English? If so, we offer interpreters for free. You can get material in different formats too. This includes large print, Braille and audio tapes. If you are hearing-impaired we can give you special help.

You can also call Customer Service or visit our website to:

• Ask for ID cards

• Change your PCP

• Get a list of doctors in the health plan

• Get a list of pharmacies in the health plan


Members have rights and responsibilities. The law says your health care providers must recognize your rights. It also says you must respect their rights. This handbook lists your rights and responsibilities (page 31, 32). You’ll also see them posted in your doctor’s office.

Want to know how to use your health benefits? This handbook can tell you.

You are now ready to begin using all of the health benefits you get with Staywell. We look forward to serving you.

MEMBER INFORMATIONENROLLMENT IN STAYWELLStaywell serves people who qualify for the Medicaid program in Florida. This is a state and federal program. It gives health coverage to people with low incomes. Three basic groups can get Medicaid:

• People in the Supplemental Security Income (SSI) program

• Children and families

• Aged, blinded or disabled people, including people needing institutional care (also known as “SSI-related” Medicaid)

A person must qualify to get Medicaid. The Social Security Administration sets rules for who can be in the SSI program. The Florida Department of Children and Families (DCF) decides who can be in the other programs. Need to know if you qualify? Call 1-888-367-6554 (TTY/TDD 1-800-653-9803). Ask to speak with a Medicaid Options representative. (This is a helpline that is sponsored by the state. It helps you join the plan of your choice.)

THE MEDIKIDS PROGRAMMediKids is a state insurance program. It is for children under age 5. Is your child in this program? If so, he or she is eligible for all of the Staywell services mentioned in this handbook. The same rules apply to them.

• Request ID cards

• Change your PCP

• Get a list of doctors in the health plan

• Get a list of pharmacies in the health plan

HOW DOES MEDIKIDS DIFFER FROM MEDICAID?• small monthly premium

• child must not be a dependent of a state employee

• child must not be over age 5

• may not have a Medicaid Fair Hearing

• children must join during an open enrollment period

• program is subject to available funds

• no co-payment for services we provide for a child in MediKids

Interested in this program? Call MediKids at 1-877-506-0578.


YOUR IDENTIFICATION (ID) CARDEvery member gets a Staywell ID card. Show this ID card and your Medicaid Gold Card to doctors when you want to get care. Show it to hospitals and pharmacies too. This card proves you are a member of our plan. Keep it with you at all times. Do not let anyone else use your card. If you do, you may lose your benefits.

WHAT DO I DO IF I LOSE MY ID CARD?Call Staywell toll-free at 1-866-334-7927 (TTY/TDD 1-877-247-6272). A new card will be mailed to you right away. Need a new Medicaid card? Call your caseworker at DCF.

YOUR DOCTORYour primary care physician (PCP) is the doctor who will care for you. Your PCP’s name, address and phone number are on your ID card. When you need care, call your PCP. Your PCP’s office will make an appointment for you.

Remember—you must see your PCP within 90 days of becoming a Staywell member. If you are a new member and pregnant, you must see your PCP within 30 days. You can find your membership start date on your ID card.

Your PCP can take care of most of your health care needs. There may be times you’ll need care from other kinds of doctors. There may also be times when you’ll need hospital care. Staywell offers services from many different kinds of doctors who provide other types of care. These doctors are called specialists. They are trained in special areas of medicine. Specialists include:

• Allergists (focus on treating allergies)

• Cardiologists (focus on treating heart problems)

• Dermatologists (focus on treating skin conditions)

• Podiatrists (focus on treating foot problems)

Your PCP may refer you to a specialist in the network. He or she may also refer you for hospital care. He or she will do this if they can’t give you the care you need. In most cases, you need a referral from your PCP to see another doctor. Staywell makes sure our providers are qualified to see you. You can learn more about your providers by calling us. We can tell you about a provider’s schooling or residency. We can tell you about their qualifications, or whether they accept new patients. You can also find these facts in your provider directory. Some of our providers may not have malpractice insurance. They must have a notice in their office saying so. Ask your doctor if you are not sure.

Some doctors may not perform certain services based on their own religious or moral beliefs.

CHANGING YOUR PRIMARY CARE PHYSICIAN (PCP)You can change your PCP at any time. To do so, check your provider directory. You should have received one with your welcome kit. You can also visit our website to use our online provider directory. It has the latest list of providers. Visit us at www.wellcare.com.

When you have made your choice, call us. Our toll-free number is 1-866-334-7927 (TTY/TDD 1-877-247-6272). You can also change your PCP on our website. Visit www.wellcare.com and click on the Staywell page.

Women can choose a doctor trained in obstetrics/gynecology (OB/GYN) as their PCP.

If you have family members enrolled with Staywell, they can each choose a different PCP. Or they can all use the same one. It depends on their needs.


INFORMED CONSENTWe need your O.K. for all care except when your life is in danger. Sometimes your written O.K. is needed. You have a right to understand any procedure. You have a right to know the reasons why it is needed. If you do not want to have a procedure done, talk to your PCP. Your PCP will tell you about your choices. You make the final decision.

ACCESS TO COVERED SERVICES Staywell has providers that can get our members quick service. For most services, average response/travel time can and should be:

Location Time

PCPs Within 30 minutes

Hospitals Within 30 minutes

Specialists Within 1 hour

Emergency Care Right away (in and out of plan)

Urgent Care Within 24 hours

Routine Sick Care Within a week of request

Physical Exams Within a month of request

Follow-up Care As needed

OUT-OF-NETWORK CARE We want to make sure you get the care that you need. Sometimes we don’t have a network provider who can give you covered services. In that case we’ll cover the services out-of-network. A doctor in the network must approve that care. We’ll make sure your cost is no more than it would be if the services were in-network.

The plan pays for just the care it approves. You may have to pay for care the plan doesn’t approve. The plan approves care that is medically needed. Services that are medically needed include those that:

• Are for an illness that would place your health in danger

• Follow accepted medical practices

• Are given in a safe, proper and cost-effective place, depending on the diagnosis and how sick you are

• Are not for convenience only

• Are not custodial

• Are needed when there is no better or less costly care, service or place available

Extra benefits/Special Programs

• Over-the-Counter Items - $300 a year for over-the-counter drugs and supplies–that’s $25 dollars a month for items like diapers, sunscreen, aspirin, vitamins and more–more than 100 items to choose from, mailed right to your home


• Free baby stroller–To qualify expectant mothers must attend at least six (6) prenatal doctor visits before the birth of their baby

• Free maternity education booklet–tips to help you stay well while you are pregnant

• Free 24-hour, 7-day-a-week health advice when you call your Personal Health Advisor

• Personal help: setting doctor appointments, getting rides to your doctor visits, social services and more

• Free referrals and guides to free community programs—programs that help with domestic violence, stopping smoking and drug/alcohol abuse

• All materials are available in English, Spanish and other languages upon request

• Free flu shots

• Online facts and education are available at www.wellcare.com

• Also please visit our Health and Wellness site located on www.wellcare.com–health facts from many sources in one convenient place

HOW TO GET COVERED SERVICESStaywell contracts with providers. These providers give care to our members. A plan doctor or Staywell must approve all of your care.

There is no co-payment for any service given by Staywell. Staywell will pay for the cost of approved care. You may have to pay for care that is not approved by the plan.

COVERED SERVICESStaywell offers the same covered services as Medicaid. But with Staywell, there are no co-payments.

Some Medicaid care may not be covered by Staywell. There may be cost sharing with these Medicaid services too. Call Customer Service for help with this. You can reach us at 1-866-334-7927. TTY/TDD 1-877-247-6272.

Here is a list of some of the covered services. For details, visit our website. Go to www.wellcare.com.

COVERED SERVICES

Advanced nurse practitioner services Home health services

Ambulatory surgical centers Hospice services

Assistive care services Hospital services—inpatient and outpatient

Birth center services Independent lab services

Child health checkups (well-child checkups) Licensed midwife services

Chiropractic services Nursing facility services

Community behavioral health services Physician services

County health department clinic services Podiatry services

Durable medical equipment and medical supplies Rural health clinic services

Early intervention services Therapy services—occupational, physical, respiratory and speech

Federally qualified health center services Transplant services—organ and bone marrow

Freestanding dialysis center services Vision services (medically necessary)

Hearing services


NON-COVERED SERVICES

The following services are not covered by the Health Plan:

NON-COVERED SERVICES

Specialized therapeutic foster care

Therapeutic group care services

Behavioral health overlay services

Community substance abuse services, except as required by this Contract

Residential care

Statewide Inpatient Psychiatric Program (SIPP) services

Clubhouse services

Comprehensive behavioral assessment

HOW TO GET AUTHORIZED SERVICESCall your PCP when you need routine care. He or she will set up tests if you need them. Your PCP may also refer you to a specialist. We will pay for this care. This is care that is “medically necessary.” Medically necessary means health care services that are:

• Reasonable and needed to stop sickness or medical conditions, or provide early screening and/or treatments for conditions that cause suffering or pain, cause a deformity or could limit a function, threaten to cause a handicap or make one worse, or cause sickness or put a member’s life in danger

• Given at proper places and at the proper levels of care for the treatment of a member’s health problems

Following health care practice guidelines and standards that are approved by professionally known health care organizations or governmental agencies:

• In line with the diagnoses of the conditions

• Not interfering any more than needed to give a proper balance of safety, while being effective and efficient

• Not part of an experiment or investigation

• Not mainly for the ease of the member or provider

You’ll have to pay for care that is not approved. Call your PCP when you need care from a doctor not in the plan. For some services, we must give consent before you can get them. Your PCP will work with you to do that.

In some cases, you or your doctor may ask for a faster decision before you get services. This is called an “expedited” decision. Ask for this when waiting for a standard decision could place your life, health or daily functions in danger. You or your PCP can ask for a faster decision. Call Customer Service at 1-866-334-7927. TTY/TDD 1-877-247-6272. We can help Monday–Friday, 7 a.m. to 7 p.m. Eastern (except for holidays). Or fax us at 1-813-262-2907. Be sure to ask for a fast or expedited review.

Remember—be sure your PCP gives you the O.K. to see a specialist.


SERVICES AVAILABLE WITHOUT AUTHORIZATIONYou do not need approval from your PCP or Staywell to get these services from plan providers:

• Chiropractic

• Dermatology

• Family planning (any participating Medicaid provider)

• Medically necessary vision

• Podiatry

Traditional outpatient behavioral health and psychiatric (with the exception of psychological testing, electroconvulsive therapy, psycho-social rehabilitation, therapeutic behavioral on-site services (TBOS))

Also, female members can visit a plan OB/GYN once a year without approval. You don’t need consent from the plan. But you do need to choose one of these specialists from our provider directory. You should have gotten one with this handbook. If not, call us to ask for one. Call to make an appointment. Tell them you are a Staywell member. Show your ID card.

SECOND MEDICAL OPINIONWhat if you want a second medical opinion about your health care? Call your PCP and ask for one. You may choose a plan doctor for the second opinion. We will pay for the second opinion when you choose a plan doctor. Please note—tests for a second opinion must be done by a plan doctor.

Your PCP will review your second opinion. He or she will decide on a treatment plan that is best for you.

HOW TO GET AFTER-HOURS MEDICAL CARE In some cases, you may get sick or hurt when your PCP’s office is closed. If it is not an emergency call your PCP. The number is on your ID card. Your PCP’s office will have a doctor on call. That doctor will call you back and tell you what to do. If you can’t reach your doctor, go to an urgent care center.

You can also call the Personal Health Advisor at 1-800-919-8807. (See the Personal Health Advisor section on page 13)

WHAT TO DO IN AN EMERGENCYA medical emergency is when you think that your health is in serious danger. An emergency is when the condition could cause:

• Bodily injury

• Damage to a body part

• Harm to yourself or others due to alcohol or drug abuse

• Harm to your health (this includes a mom-to-be and her unborn baby)

• Injury to yourself or others

• Organ damage


For moms-to-be, it may be an emergency:

• If you think there is no 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

• If you think that you are in labor

Some examples of emergencies are:

• Broken bones

• Cuts requiring stitches

• Heavy blood loss

• Heart attack

• Loss of breath or consciousness

• Poisoning

• Severe chest pains

In the case of an emergency, call 911. If you do not have 911 services in your area, call an ambulance. Or go to a nearby hospital emergency room (ER) right away. The choice is yours. If you’re not sure it is an emergency, call your doctor. Or call the Personal Health Advisor line at 1-800-919-8807. You do not need prior consent for emergency services.

You’ll need to show your Staywell and Medicaid ID cards at the ER. Ask the staff to call us. Also let your PCP know as soon as you can when you are in the hospital. Let him or her know if you got care in the ER.

The ER doctor will decide if your visit is an emergency. If it is not, you’ll be given the choice to stay or leave the hospital. If you choose to stay, you’ll have to pay for your care.

The plan will cover follow-up care that your doctor says you need. You do not need to get prior consent for care when you are recovering. This is true whether you get this care in- or out-of-network.

OUT-OF-AREA EMERGENCY CAREIt is important to get care when you are sick or hurt. If you get sick while traveling, call Customer Service. If you have an emergency while traveling, go to a hospital. It doesn’t matter if you are not in the plan’s service area. Show your ID card. Call your PCP as soon as you can. Ask the hospital staff to call Staywell.

If you have to pay for these services when you get them, write to our Claims Department. They will need copies of your medical reports. Send copies of bills. Be sure to include proof of payment.

PREGNANCY AND NEWBORN CAREIf you have a baby while a plan member, the baby is also covered from birth. You must call the Department of Children and Families (DCF) to get your baby’s Medicaid ID number.

When you find out you are pregnant, taking care of yourself can help you and your unborn baby stay healthy. See your PCP right away. Be sure to go to all your prenatal visits. And go to all your postpartum visits after the birth. If you need help with this, call us.

You’ll also need to choose a doctor for your baby. That way your baby can get needed checkups and shots. You must do this by the time your baby is born. If you do not, we will choose a doctor for you.


Call your caseworker from the Department of Children and Families (DCF). They will give your baby a Medicaid number. Please call us with this number.

When your baby is born, tell Staywell and DCF. If DCF does not place your new baby on our plan, call Medicaid Options. The toll-free number is 1-888-367-6554 (TTY/TDD 1-800-653-9803).

PRESCRIPTIONSStaywell covers all medically necessary Medicaid-covered medications. We use a preferred drug list (PDL). These are the drugs that we prefer that your provider prescribe. We may also require that your provider gives us a prior authorization (PA) request. This will explain why a certain drug and/or a certain amount are needed. We must approve the request before you can get the medication. Reasons why we may prior authorize a drug include:

• There is a generic or pharmacy alternative drug available

• The drug can be misused/abused

• There are other drugs that must be tried first

Some drugs may also have amount limits. Some drugs are never covered. Drugs for weight loss are one example. If we don’t approve a PA request, we will let you know. We will send you facts on how you can appeal the decision. We will also tell you about your right to a state hearing.

There is no cost to you for prescriptions. Your PCP must approve a prescription from a non-plan doctor. You must pick it up at a plan pharmacy. Always show your Staywell ID card and your Medicaid Gold Card. There is no cost to you.

Questions about our PDL? Questions about drugs that need a PA? Please call us at 1-866-334-7927 (TTY/TDD 1-877-247-6272). You can also find those facts at www.wellcare.com. Please note that our PDL and drugs that need a PA can change. Please check the status before you fill/refill a prescription.

TRANSPORTATION SERVICESNon-emergency transportation services are covered by Medicaid. These services will take you to and from your medical visits. They should be used when you have no other transportation (for example, family and friends).

To set up a ride, call the provider listed for the county in which you live.

Remember: These services are not for emergencies.

Transportation Service Directory

County Vendor Phone

BrevardBroward

TMS of Brevard, Inc. 1-866-867-0729

CalhounCalhoun County Senior Citizens Association

1-850-674-4496 or 1-850-674-2947

Charlotte Charlotte County Transit Department 1-941-575-4000

Citrus Citrus County Transit 1-352-527-7630

Duval MV Contract Transportation, Inc. 1-904-265-8935


County Vendor Phone

Gadsden Jefferson Madison

Big Bend Transit, Inc.

1-850-627-9958

1-850-997-1323

1-850-973-4418

Hernando MidFlorida Community Services, Inc. 1-352-799-5177

Highlands (Avon Park Area)

Highlands (Lake Placid Area)

Highlands (Sebring Area)

Veolia

1-863-452-0139

1-863-699-0995

1-863-382-0139

Hillsborough MMG Transportation, Inc. 1-813-253-3618 or 1-888-413-1116

Indian River Senior Resource Association, Inc. 1-772-569-0903

LakeLake County Program Analysis and Contract Management

1-352-326-2278, ext. 3

Leon Star Metro 1-850-891-5199

Liberty Liberty County Transit 1-850-643-2524

Manatee TMS of Brevard, Inc. 1-866-867-0729

Marion Marion Transit Services 1-352-620-3071

Martin Medical Transportation Management (MTM) 1-866-836-7034

Miami-Dade LogistiCare Solutions LLC 1-866-726-1457 or 1-866-726-1458

Orange, Osceola, Seminole

LYNX/Central Florida Regional Transportation Authority

1-407-423-8747

Palm Beach MV Contract Transportation, Inc.1-866-207-7214 1-561-840-1499, ext. 1012 (Español)

Pasco (Central)

Pasco (East)

Pasco (West)

Pasco County Public Transportation

1-813-235-6059

1-352-521-4300

1-727-834-3456

Pinellas Pinellas County MPO 1-727-545-2100

Polk Polk County Transit Services 1-863-534-5500

Putnam Ride Solution 1-386-325-9999

Sarasota Sarasota County Transportation Authority 1-941-861-1234

Volusia LogistiCare Solutions, LLC 1-866-726-1459 or 1-866-726-1471

Wakulla Wakulla County Senior Citizens’ Council 1-850-926-7145

Call 911 in an emergency. An ambulance will take you to the hospital. You’ll have to pay for the ambulance ride if it is not an emergency.

Questions about transportation? Customer Service can help. Call 1-866-334-7927 (TTY/TDD 1-877-247-6272).


GETTING BEHAVIORAL HEALTH SERVICESHOW TO GET BEHAVIORAL HEALTH SERVICESNeed help finding a behavioral health provider in your area? Call 1-877-712-5340 (TTY/TDD 1-877-247-6272). You can also search our provider directory. Or you can visit www.magellan.com on the Web.

You’ll find the names of several providers. This includes hospital and psychiatric care providers. Pick those that you will need. Then call and set up a time to visit. You may also choose an alternative behavioral health case manager or direct service provider within the health plan, if one is available.

If you want to change to a different provider:

• Check your provider directory

• Visit the Web at www.magellanhelp.com

• Call 1-877-712-5340 (TTY/TDD 1-877-247-6272)

You can also get case management services if you need them. You can get these services in the community. Or in your home and in schools. Other types of care you may get include:

• Day treatment for adults and children

• Evaluations

• Individual and family assessments

• Individual, family, marital and group therapy

• Psychosocial rehabilitation

• Targeted and intensive case management

• Therapeutic behavioral on-site services for children and adolescents

• Treatment planning

To learn more, call 1-877-712-5340 (TTY/TDD 1-877-247-6272)

WHAT TO DO IF YOU NEED HELPAre you having any of the feelings or problems listed below? If so, call 1-877-712-5340 (TTY/TDD 1-877-247-6272). Someone is available to help you 24 hours a day, 7 days a week.

• Always feeling sad

• Constant pain like headaches, stomach or backaches

• Feeling hopeless and/or helpless

• Feelings of guilt or worthlessness

• Problems paying attention

• Problems sleeping

• Being upset

• Loss of interest

• Poor appetite

• Weight loss


You do not need an approval from your PCP to see an outpatient behavioral health provider. The following services do require prior consent:

• Psychological testing

• Electroconvulsive therapy

• Psycho-social rehabilitation

• Therapeutic behavioral on-site services (TBOS)

• All inpatient behavioral health services

You must also get consent to see a provider who is not with the plan. You’ll have to pay for the care if you do not get consent.

WHAT TO DO IN AN EMERGENCY OR IF YOU ARE OUT OF THE STAYWELL SERVICE AREAIs it a real behavioral health emergency? Do you feel you are a danger to yourself or others? If so, call 911. Or go to the nearest emergency room (ER). Even if you are out of our service area. You can also call us 24 hours a day, 7 days a week. Call your doctor too, if you can. Follow up with your PCP within 24 to 48 hours.

What if you are getting care when you are out of the area? We’ll help you get to a doctor in the network when you are able.

WHAT IS POST-STABILIZATION?Did you go to the hospital for a mental health emergency? If so, you need to make sure you get care after you leave. This may help you avoid another mental health emergency.

Post-stabilization services are covered services you get after emergency room care. They can be inside or outside the network. These are services to keep you stable after an emergency. They are services covered without prior approval 24 hours a day, seven days a week.

If you need this kind of care:

• Tell us if you called 911 or went to the emergency room.

• You must notify the plan as soon as possible so we can help you get the care you need. A friend can call for you.

• You should plan a visit to see a behavioral health provider for follow-up. Do this before you leave the hospital. Call us if you need help making an appointment.

PREVENTION PROGRAMSThere are programs available to members that may help prevent mental illness. They work to find early signs of mental illness. If signs are found, we can help you get services to treat the illness. Getting care early may lessen the severity of the illness.

You can learn more about these programs. Call 1-877-712-5340 (TTY/TDD 1-877-247-6272)


BEHAVIORAL HEALTH LIMITATIONS AND EXCLUSIONSWith Medicaid, adults can get:

• Up to 45 inpatient days a year

• Substance abuse treatment not covered with Medicaid

Note—There may be limits on some outpatient behavioral health services. Questions? Please call the plan.

OTHER PROGRAMSPERSONAL HEALTH ADVISOR (24-HOUR NURSE HELPLINE)

Personal Health Advisor is your 24-hour nurse advice line. You can call seven days a week, every day of the year. There is no charge for this service. Call the Personal Health Advisor at 1-800-919-8807 when you need health advice.

When you call, a nurse will ask you some questions about your problem. Give as many details as you can. Tell the nurse where it hurts, what it looks like and what it feels like.

The nurse can help you decide if you need to:

• Go to the doctor

• Care for yourself at home

• Go to the hospital

Remember—a nurse is always there to help. Call before you visit a doctor or go to the hospital. But if you think it is a real emergency, call 911 or your local emergency services first.

MATERNITY EDUCATION AND PRENATAL REWARD PROGRAMStaywell has a Maternity Education and Prenatal Reward Program for pregnant women.

We want to help you and your baby stay healthy. It is important that you see your doctor as soon as you know you are pregnant. As a member you’ll get an educational booklet. It is called Mommy & Baby Matters, Taking care of yourself and your baby. It will tell you how to care for yourself and your baby, before and after birth. One way you can do this is by going to all doctor visits before and after the birth.

Another part of the program is the Prenatal Reward Program. We invite you to join. Then attend at least six prenatal visits. If you do, you can get a new stroller. It is a reward for taking care of yourself and your baby.

To get your stroller, be sure that:

• your doctor completes the Prenatal Reward form and signs it at each visit

• your doctor faxes the completed form to us within 30 days

• the form is complete

• you are still a member when you deliver

• you are still a member at the time the stroller is shipped

We also have a High Risk Pregnancy program. It is for women with high risk factors.


CASE AND DISEASE MANAGEMENTStaywell has case and disease management programs. These programs are for members with long-term, complex or chronic health problems such as:

• Asthma

• Congestive heart failure

• Diabetes

• HIV/AIDS

• Hypertension (high blood pressure)

Members can choose to take part in these programs. If they do, they will work with a case or disease manager. Our case and disease managers are registered nurses (RNs). These nurses:

• work with members to help them understand their illness

• help members to get the health care services they need by working with the member, their family and providers

• work with members to help manage their illness through medical, social and community resources

These programs are free to our members. To learn more, call 1-866-635-7045.

COMMUNITY-BASED PROGRAMSThere are other services you can get besides the ones listed in this handbook. You can get many of these in your community. The services include:

• Children’s programs

• Domestic violence programs

• Drug and alcohol abuse programs

• Pregnancy prevention programs

• Prenatal/Postpartum programs

• Stop-smoking programs

Ask your PCP to find out more about these services. Or call Customer Service.

PREVENTIVE HEALTH CARE GUIDELINES Preventive health care guidelines are in this book for your use. You can use them to help you remember to see your PCP. They tell you when you and your family are due for checkups. They also remind you when you or members of your family are due for tests or shots.

These rules are only a general guide. They do not replace your PCP’s judgment. Always talk with your PCP to be sure you’re getting the right care.

Call your PCP if you or a family member misses an appointment.

Remember to see your PCP within 90 days of joining the plan.


ADULT PREVENTIVE HEALTH GUIDELINESFrequency of Physical Examination

All new members should get a baseline physical exam in the first 90 days as a member. Pregnant members should be seen in the first 30 days. The Cleveland Clinic’s recommendations for periodic health exam visits for asymptomatic adults are:

• Age 19 to 39—every 1 to 3 years (Women should get an annual Pap smear—if 3 normal smears in a row, then 1 every 3 years)

• Age 40 to 64—every 1 to 2 years based on risk factors

• Age 65 and older—every year

Age Screening Frequency

18 years of age and olderBlood pressure, height, body mass index (BMI), alcohol use

Each year from age 18 to 21. Then, every 1 to 2 years or at PCP recommendation

Men 35 to 65 years of age Cholesterol (non-fasting TC/HDL) Every 5 years (more often if elevated)

Women 45 to 65 years of age Cholesterol (non-fasting TC/HDL) Every 5 years (more often if elevated)

High-risk men and women 20 years of age and older

Cholesterol (non-fasting TC/HDL) Every 5 years (more often if elevated)

Women 18 to 25 years of age who are sexually active (consider at age 12 if sexually active)

ChlamydiaEach year and at PCP’s recommendation

Women 18 to 65 years of age (or 3 years after onset of sexual activity, whichever comes first)

Pap smear Every 1 to 3 years

Women 40 years of age and older

Mammography Every 1 to 2 years

50 years of age and older Colorectal Periodically depending upon test

Women 65 years of age and older (60 and older if at risk)

Osteoporosis Routinely

65 years of age and older Vision, hearing Periodically


Tetanus-Diphtheria and acellular pertussis (Td/Tdap)

Td—every 10 years, 19 years and older Tdap—substitute 1 dose of Tdap for Td (one-time administration)

Varicella (VZV) Susceptible adults only, 18 years of age and older—2 doses

Measles, Mumps, Rubella (MMR)

Adults 19–49 years of age who do not show evidence of immunity—1–2 doses

Pneumococcal 65 years of age and older—1 dose

Influenza 6 months of age and older—every year

Hepatitis B vaccine Adults at risk, 18 years of age and older—3 doses

Meningococcal conjugate vaccine

College freshmen living in dormitories and others at risk, 18 years of age and older—1 dose

Human-papillomavirus (HPV) *All previously unvaccinated women through 26 years of age—3 doses

* Subject to individual state coverage

Tetanus-Diphtheria and acellular pertussis (Td/Tdap)Men—40 years of age and older periodically Women—50 years of age and older periodically

Talk about breast cancer (for women at high risk)

Talk about prostate-specific antigen (PSA) test and rectal exam (for men after 40 years of age per PCP’s discretion)

Calcium—1,000mg a day for women 18 to 50 years of age; 1,200 to 1,500mg a day for women 50 years of age and older

Folic acid—0.4mg a day for women of childbearing age; 4mg a day for women who have had children with Neural Tube Defects (NTDs)

Breastfeeding—women after giving birth

Quitting tobacco; drug and alcohol use; STDs and HIV; nutrition; physical activity; sun exposure; oral health; injury prevention; polypharmacy

References: Guide to Clinical Preventive Services, 2007: Recommendations of the U.S. Preventive Services Task Force, 2007. Press Release CDC’s Advisory Committee Recommends Human Papillomavirus Virus Vaccination June 29, 2006.Recommended Adult Immunization Schedule—United States, 2009. Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) May 2001. Bone Health and Osteoporosis: A Report of the Surgeon General (2004).Cleveland Clinic www.cchs.net/health/health-info Periodic Health Exams and Cancer Screening. ACG Recommendations on Colorectal Cancer Screening for Average and Higher Risk Patients in Clinical Practice, April 2008.


PEDIATRIC PREVENTIVE HEALTH GUIDELINES—NEWBORN UP TO 21 YEARS OLD These guidelines for pediatric preventive health are recommendations only. Other services may be needed for the individual.

Age Well-Baby Checkups and Shot Guide

NewbornWell-baby checkup1 at birth Hearing testNewborn screening blood tests and HepB shot

2–4 daysWell-baby checkup if discharged less than 48 hours after deliveryNewborn screening blood testsImmunizations: HepB if not done at birth

1 monthWell-baby checkup Newborn screening blood test if not already completed Immunizations: second HepB

2 monthsWell-baby checkup Newborn screening blood test if not already completed Immunizations: RV, DTaP, Hib, PCV, IPV

4 monthsWell-baby checkup Immunizations: RV, DTaP, Hib, PCV, IPV

6 monthsWell-baby checkupImmunizations: RV, DTaP, Hib, PCV, IPV, HepB, Influenza

9 monthsWell-baby checkup Lab testing: blood lead

12 monthsWell-baby checkupLab testing: blood lead, hemoglobin or hematocrit Immunizations: Hib, MMR, HepA, Varicella, PCV, Influenza

15 months Well-baby checkup Lab testing: urine and blood lead if not done at 9 months or 12 months

18 months Well-baby checkup Immunizations: second HepA (6 months after the first dose)Dental visit

24 monthsWell-baby checkup Lab testing: blood leadImmunizations: Influenza

30 months Well-baby checkup


Age Well-Baby Checkups and Shot Guide

3 yearsWell-child checkup Eye screeningImmunizations: Influenza

4 and 5 years

Well-child checkup each year Eye screeningLab testing: urine test at age 5 yearsImmunizations: MMR, DTaP, IPV, Varicella, Influenza each yearDental visit twice a year

6 to 10 yearsWell-child checkup every year Immunizations: Influenza every yearDental visit twice a year

11 and 12 yearsWell-child checkup each year Immunizations: MCV, Tdap, HPV series, Influenza each yearDental visit twice a year

13 to 21 years

Well-adolescent checkup every yearFemales should have a pelvic exam and Pap smear between ages 18 and 21 yearsLab testing: urine by age 16Immunizations: HPV series if not already completed, Influenza

NOTES:1 Well-baby, -child and -adolescent checkups/physical exam with infant totally undressed or older child undressed and suitably covered, health history, developmental and behavioral assessment, health education (sleep position counseling from 0-9 months, injury/violence prevention and nutrition counseling), height, weight, test for obesity (BMI), vision and hearing screening, head circumference at 0–24 months and blood pressure at least every year beginning at age 3.

2 Dental visits may be recommended beginning at age 6 months.The following services are provided as needed:

• Hemoglobin or hematocrit at ages 4, 18, 24 months and 3 years through 21 years.• Lead risk assessments and/or testing from age 3 to age 6 years.• Tuberculosis risk assessments and/or testing from age 12 months through age 21 years.• Cardiovascular disease risk assessments and cholesterol screening from age 2 years through age 21 years.• Sexually transmitted infections testing from age 11 years through age 21 years.• “Catch up” on any shots that have been missed at an earlier age.

References: 2008 Bright Futures /American Academy of Pediatrics (www.aap.org). Committee on Practice and Ambulatory Medicine Recommendations for Preventive Pediatric Health Care, PEDIATRICS, Vol. 105 (3), March 2000, pages 645-646, Copyright © 2000 by the AAP. Recommended Immunization Schedules for Persons Aged 0-18 Years – United States, 2009 approved by the Advisory Committee on Immunization Practices (ACIP) www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable, the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Catch-up Immunization Schedule for Persons Aged 4 Months Through 18 Years Who Start Late or Who Are More Than 1 Month Behind, United States-2009, approved by the Advisory Committee on Immunization Practices (www.cdc.gov/nip/acip/), 2008 Bright Futures/American Academy of Pediatrics (www.aap.org) and the American Academy of Family Physicians (www.aafp.org). American Dental Association (www.ada.org/).


Legal Disclaimer: Preventive health guidelines are based on guidelines from third parties available before printing. These guidelines are not a replacement for your doctor’s medical advice. He/She may have more current details. You should always talk with your doctor(s) about what care and treatment is right for you. The fact that a service or item is in these guidelines is not a guarantee of coverage or payment. Members should look at their own plan coverage papers to see what is or is not a covered benefit. WellCare does not offer medical advice or provide medical care, and does not guarantee any results or outcomes. WellCare does not warrant or guarantee, and shall not be liable for:

• information in these guidelines• information not in these guidelines• any recommendations made by independent third parties from whom any of the information was obtained

Version: 01/2009 (revised)

OVER-THE-COUNTER ITEMSYour family can get up to $25 in over-the-counter items each month. This includes vitamins, medicines and health supplies. You can choose items found in the list below. You can check our website for the most current list. To order:

• Make your choice

• Call toll-free 1-866-334-7927 (TTY 1-877-247-6272 ) to place your order

• Receive the items when they arrive at your home

POST OTC LISTING • Amount is for each head of household, not each family member

• If you do not use your $25 each month, it does not carry over to the next month

• Items, quantities and prices may change based on availability

• Brand items may be supplied in place of generic item

ADVANCE DIRECTIVESYOUR MEDICAL CARE IS YOUR DECISIONThe law says you can refuse care. This includes care that keeps you alive.

Congress passed the Patient Self Determination Act. It states that we must tell you about your right to advance directives.

ADVANCE DIRECTIVES—MAKING YOUR DECISION KNOWNAn advance directive is a legal paper. It tells others what your wishes are. It says what type of care you want to get–or not–if you are unable to tell a doctor yourself.

You can have an advance directive for your physical health. You can have a separate one for your mental health.

Make sure you tell your doctor and family that you have an advance directive. You can change or cancel your advance directive at any time. If you do, make sure to tell your doctor and family about the change.

Do my caregivers have to follow my advance directives?

Yes. As long as your advance directives follow state law. A caregiver may not wish to follow your wishes. They may go against his or her conscience. If so, he or she will help you find someone else who will follow your wishes.

Other than for conscience reasons, your wishes should be followed. If they are not, complaints can be made to the Consumer Complaint Hotline. Call 1-888-419-3456.


There are three types of advance directives:• A living will

• A health care surrogate for health care decisions

• An anatomical donation

What is a living will?

It states the type of care you want if you are unconscious and will not come to. It can be used for conditions that will lead to death. It tells your doctor when to continue or stop care to keep you alive.

What is a health care surrogate for health care decisions?

This is when you name the person you want to make physical and/or mental health decisions for you. It will be used if you are not able to make choices for yourself. It will also be used if you can’t tell your doctor about the care you want. You can also name an alternate surrogate.

What is an anatomical donation?

This states that you wish to donate all or part of your body at death. This can be an organ donation to persons in need. Or it can be a donation of your body to help train health care workers. You can show your choice to be an organ donor:

• on your driver’s license

• on a state ID card

• in a living will

• by signing a uniform donor form

How can I get an advance directive?

You can call any of the below to get help with advance directives:

• An attorney

• The Florida Medical Association

• Your local Legal Aid office

• Your PCP

Remember, your health care is your choice.

IMPORTANT INFORMATION ABOUT STAYWELLENROLLMENTAre you a mandatory enrollee required to enroll in a plan? Once you are enrolled in Staywell or the state enrolls you in another plan, you have 90 days to try the plan. During the first 90 days, you can change plans for any reason. After the 90 days you may still be eligible for Medicaid. Then you’ll be enrolled in the plan for the next 9 months. This is called “lock-in.”

OPEN ENROLLMENTAre you are a mandatory enrollee? The state will send you a letter 60 days before the end of your enrollment year. This will tell you that you can change plans if you want to. This is called “open enrollment.” You do not have to change plans. If you choose to change plans then, you will start with the new plan at the end of your


current enrollment year. Whether you pick a new plan or not, you’ll be locked into that plan for the next 12 months. Every year you can change health plans during your 60-day open enrollment period.

REINSTATEMENTIf you lose your Medicaid eligibility and get it back within 60 days, the state will put you back into Staywell. We’ll send you a letter within 10 days after you become a member again. You’ll be assigned to your original PCP. Or you can pick a different one.

MOVING OUT OF OUR SERVICE AREAStaywell is available in many Florida counties. Call us if you move. You’ll want to choose a doctor near your new home. You must call the Medicaid Options Helpline if you move out of the service area. The number is 1-888-367-6554. TTY/TDD users can call 1-800-653-9803.

You’ll keep seeing our doctors until you leave the plan.

DISENROLLMENTAre you a mandatory enrollee? Do you want to change plans after the initial 90-day period ends? Or do you want to change after your open enrollment period ends? Then you must have a state-approved good cause reason. The following are state-approved cause reasons to change health plans:

• The enrollee moves out of the county, or the enrollee’s address is incorrect, and the enrollee does not live in the county where the plan is authorized to provide services

• The provider is no longer with the health plan

• The enrollee is excluded from enrollment

• A substantiated marketing or community outreach violation has occurred

• The enrollee is prevented from participating in the development of his/her treatment plan

• The enrollee has an active relationship with a provider who is not on the health plan’s panel, but is on the panel of another health plan

• The enrollee is in the wrong health plan as determined by the Agency

• The health plan no longer participates in the county

• The state has imposed intermediate sanctions upon the health plan, as specified in 42 CFR 438.702(a)(3.

• The enrollee needs related services to be performed concurrently, but not all related services are available within the health plan network–or the enrollee’s PCP has determined that receiving the services separately would subject the enrollee to unnecessary risk

• The health plan does not, because of moral or religious objections, cover the service the enrollee seeks

• The enrollee missed open enrollment due to a temporary loss of eligibility–this is 60 days or less for non-Reform populations and 180 days or less for Reform populations

Other reasons per 42 CFR 438.56(d)(2), including, but not limited to: • poor quality of care

• lack of access to services covered under the contract

• inordinate or inappropriate changes of PCPs

• service access impairments due to significant changes in the geographic location of services

• lack of access to providers experienced in dealing with the enrollee’s health care needs

• or fraudulent enrollment


Some Medicaid members can change plans whenever they choose, for any reason. For example, people who are eligible for both Medicaid and Medicare benefits can change plans. Children who get SSI benefits can also change plans. To find out if you can change plans, call the Medicaid Options Helpline at 1-888-367-6554.

INVOLUNTARY DISENROLLMENTYou may lose your membership if you:

• Allow someone else to use your ID card

• Lose your Medicaid eligibility

The plan cannot disenroll you for the following reasons:

• Pre-existing medical conditions

• Changes in your health status

• Periodically missed appointments

FRAUD AND ABUSEWhat is health care fraud and abuse? It is when false data is given on purpose. This can be done by a member or provider. This false data can lead to someone getting a service or benefit that is not allowed.

Billions of dollars are lost to health care fraud every year. That means money is paid for services that may never have been given. It could also mean that the service that was billed was not the one that was given.

Here are some other examples of fraud and abuse:• Billing for a more expensive service than what was actually given

• Billing more than once for the same service

• Billing for services not actually performed

• Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that are not medically necessary

• Filing claims for services or medications not received

• Forging or altering bills or receipts

• Misrepresenting procedures performed to obtain payment for services that are not covered

• Over-billing the plan or member

• Using someone else’s ID and/or Medicaid card

• Waiving patient co-pays or deductibles

If you know of any fraud, call our 24-hour fraud hotline. The toll-free number is 1-866-678-8355. It is private. You may leave a message without leaving your name. If you do leave a number, we’ll call you back. We’ll do this to be sure our data is complete and accurate. You can also report fraud on our website. Go to www.wellcare.com. Giving a report through the Web is private too.

To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll-free at 1-888-419-3456. Or complete a Medicaid Fraud and Abuse Complaint Form, which is available online at http://apps.ahca.myflorida.com/inspectorgeneral/fraud_complaintform.aspx.


CONFIDENTIALITYWe respect your right to privacy. You must allow us to give out any of your medical facts. It is given only to those involved in your care. We make an exception if we are required to do so by law.

HOW DOCTORS ARE PAIDWe work hard to give you the health care you need. This means we work with many doctors. You may ask how they are paid. You may ask if that will affect your doctor’s use of referrals. You may also ask if it will affect other services you need. Call Customer Service for more details.

UTILIZATION MANAGEMENT PROGRAMStaywell has a utilization management (UM) program. This program looks at the care and services you need. We also look at services that need consent before they can be given. Then we check to see if this is the right care for you before it starts. We complete checks called:

• Prospective reviews—before you get care we check to see if you need it

• Concurrent reviews—we look at care while you are getting it to see if you need to keep getting it, and/or if other care would better meet your needs

• Retrospective reviews—we check to see if you needed the care you got, after you received it

We do these reviews to measure the health care and services that our members receive. We measure this based on your health plan coverage. We check to see if the care and services are right. Then we decide how much coverage we can provide. And we decide on how to pay those who provide the care.

There may be times when we say we can’t cover services. Or we can’t cover care your provider asks for. These decisions may be made by our staff. Or they may be made by a doctor or other reviewer. When this happens, we do not reward anyone who makes these decisions.

Questions? Call us at 1-866-334-7927 (TTY/TDD 1-877-247-6272).

QUALITY IMPROVEMENT AND MEMBER SATISFACTION We are always looking at ways to improve care and service for our members. Each year we select certain things to review for quality. We check to see how we are doing in those areas. We may also check to see how our providers are doing. We want to know if our members are happy with the care and service they get.

Want to know about our quality ratings? Just call Customer Service. You can ask about how satisfied members are with the plan.

You can also provide comments or suggestions about:

• How we are doing

• How we can improve on our services

EVALUATION OF NEW TECHNOLOGYWe look at new technology every year. We also look at the ways we use the technology we have. The findings are reviewed to:

• Determine how new advancements can be included in the benefits that members receive

• Make sure that members have fair access to safe and effective care

• Make sure we are aware of changes in the industry

The review of new technology is done in the following areas:


• Behavioral health procedures

• Medical devices

• Medical procedures

• Pharmaceuticals

Questions? Call Customer Service.

PUBLIC INFORMATION ABOUT STAYWELLThe Florida Agency for Health Care Administration has data about us. This includes:

• Counties in which our plan is offered

• Our accreditation(s)

• Our financial information

• Quality of care indicators

You can find this at: www.floridahealthfinder.gov.

MEMBER APPEALS AND GRIEVANCES PROCEDURESLet us know right away about problems with your health care services. Or with any questions you may have. Call us at 1-866-334-7927 (TTY/TDD 1-877-247-6272). You can reach us Monday–Friday, 7 a.m. to 7 p.m. Eastern, except on holidays.

Let us know if you need an interpreter.

This section gives the rules for making complaints. State law says you can make complaints about any part of your medical care. The state has helped set the rules about what you need to do to make a complaint. The state also has rules about what we must do when we get a complaint. We must be fair in handling complaints. You cannot be dropped from the plan for making a complaint. We will not penalize you for making a complaint.

What are appeals and grievances?

You have the right to make a complaint about your coverage or care. There are two types of complaints. They are called “appeals” and “grievances.”

What is an Appeal?

An appeal is a complaint you make when you want us to change a decision we made about your care. You can file one when we:

• Deny or limit a service request

• Reduce or stop services you have been getting

• Refuse to pay for services that you think should be covered

• Fail to give services in the required timeframe


What is a Grievance?

A grievance is a different type of complaint. It is about something other than a coverage decision. File a grievance for issues such as:

• Not being able to get information

• The condition of your doctor’s office

• The quality of your care

• The way your doctors or others behave

• Waiting times

MAKING AN APPEAL Do you have a problem getting care? Or payment for care? There are steps you can take. Your request is considered at each step. Then a decision is made. There may be another step to take if you are still not happy with the decision.

This section tells you what to do if you have problems getting the care you think we should provide. We use the word “provide” to mean things such as:

• Authorizing care

• Paying for care

• Arranging for someone to provide care

• Continuing to provide a medical treatment your child has been getting

Problems might include:• You are not getting the care you want

• You feel that this care is covered by Staywell

• We will not authorize the medical treatment your doctor wants to give you and you believe that this treatment is covered by the plan

• You are told that coverage for a treatment you get will be reduced or stopped and you feel that this could harm your health

• You got care that you believe was covered by Staywell and we have refused to pay

Step 1—The Initial Decision

First, we make an “initial decision” about care or payment for care. This is also called a “service authorization decision” or “action.” We explain how the benefits we cover apply in your case. You can ask for a “fast initial decision.” This is for a decision that needs to be made quickly. You or someone you appoint can see your case file. This can include medical records. It may also have other related items. You can ask for the written rules we used to make the decision. You can also ask to see a summary of our written appeals policies and procedures.

Step 2—Appealing the Initial Decision

You can ask us to review our initial decision. This is called an “appeal.” It is also called a “request for reconsideration.” You can ask for a “fast appeal.” This is for health care requests that need quick decisions. We’ll review your appeal. Then we’ll decide to keep our initial decision or change it.


How do you file your appeal of the initial decision?

You, someone you appoint or your doctor may file this appeal. First, you must give them written consent. You must let us know someone else is doing this for you. You can do this by writing us a letter. Or you can fill out an Appointment of Representation form. You can get this from Customer Service.

A representative may file for the estate of a member who has died. He or she must have proper documents.

You may file a verbal or written appeal. A verbal appeal must come with a written appeal request that is signed. (This is not needed with a fast appeal.)

A verbal appeal can be filed by calling Customer Service.

A written appeal should be mailed to:

Staywell Health Plan Attn: Appeals Department P.O. Box 31368 Tampa, FL 33631-3387

Or faxed to 1-866-201-0657.

What if I want to appeal a decision made about a prescription? Do I do anything different?

You can still call us. But appeals about prescriptions or medications go to a different address. Send your appeal to:

Staywell Health Plan Attn: Pharmacy Appeals Department P.O. Box 31398 Tampa, FL 33631-3387

Or fax it to 1-888-865-6531. Be sure to ask for a fast appeal.

We’ll send you a letter within 10 calendar days after we get your appeal. It will let you know we got your appeal. We will not send one if it is a request for a fast appeal. You’ll get a decision letter if we are able to resolve the appeal within 10 calendar days.

How soon must I file my appeal?

Appeal within 30 calendar days of the date of our notice to you.

What if I want a fast or expedited appeal?

For both appeals processes, we can give you a fast appeal. Your doctor must say that waiting could seriously harm your health. Or you may ask for a fast appeal on your own. Call Customer Service for help. Or you can send an appeal to:

Staywell Health Plan P.O. Box 31368 Tampa, FL 33631-3387

Or fax it to 1-866-201-0657. Be sure to ask for a fast review.

We’ll decide if you need a fast decision. We’ll try to call you if we decide your health does not require it. We’ll also send you a letter within 2 days. It will say you can get a fast review with a doctor’s support. The letter will also tell you how to file a grievance if you disagree. We’ll give you a standard review if you decide not to do a fast review. This usually takes 30 calendar days.


How can I present evidence and/or allegations of fact or law?

You may do this in your written request or in person. To do this in person, please call Customer Service. Tell us about your request. Someone will call you to set up a time to talk.

Can I review my case file?

You or someone you appoint may see the case file. You can see it before and during the appeal process. It can include medical records. It can also include other documents. Just call us if you want to see your case file.

How soon must we decide on your appeal?• For a decision about payment for care you have received:

- 30 calendar days after we get your appeal

• For a standard decision about your medical care or a prescription: - 30 calendar days after we get your appeal. We’ll make it sooner if your health calls for it. You can

get 14 more days if you ask or if we learn facts that will help you. You can ask for this extra time by writing to us or calling us. We’ll send you a letter if we take extra time. The letter will say why. We’ll also let you know the date we expect to make a decision.

• For a fast decision about medical care or a prescription: - Up to 72 hours after we get your appeal. Sooner if your health requires it. You can get 14 more days

if you ask or if we learn facts will help you. You can ask for this extra time by writing. You may also call us. We’ll send you a letter if we take extra time. The letter will say why. We’ll also let you know the date we expect to make a decision.

We’ll mail you a letter either way. It will tell you about your appeal rights if the decision is not in your favor. We’ll also try to call you about standard decisions.

What if I’m not satisfied with the results of my Appeal?

Step 3—Appealing to the Subscriber Assistance Program (SAP)

You can file with the SAP. You can do this if you are not happy with our first decision. You can call the SAP at any time during the process. You must ask for a hearing within one year.

The SAP will only hear your case if it involves:

• Availability of health care services

• Benefit action or denial made by us

• Coverage of benefits

• How we handle or pay claims

You can call the SAP at:

Agency for Health Care Administration Subscriber Assistance Program Building 1, MS #26 2727 Mahan Drive Tallahassee, FL 32308 1-850-412-4502 | (toll-free) 1-888-419-3456

You may not ask for an SAP review if you also ask for a Medicaid Fair Hearing.


MEDICAID FAIR HEARING

You can ask for a Medicaid Fair Hearing. Just call the Department of Children and Family Services (DCFS) at:

Office of Public Assistance Appeals Hearings 1317 Winewood Boulevard Building 5, Room 203 Tallahassee, FL 32399-0700 1-850-488-1429

There is a deadline to ask for this. It must be within 90 days of the notice of action or initial decision.

Please note—you can’t have an SAP review and a Medicaid Fair Hearing.

How can I keep my benefits during the Medicaid Fair Hearing process?

In order for this to occur:

• The appeal must involve the end, stopping or reduction of treatment that had been previously approved

• The authorization period cannot have expired

• The services must have been ordered by an authorized provider

• You must file your appeal within 10 calendar days of the date of the notice of action if filing verbally

• If filing in writing via US mail, within 14 calendar days, or prior to the intended effective date of our proposed action

• You must ask for an extension of benefits

If we continue your benefits during the hearing process, the benefits will continue until one of the following occurs:

• 10 calendar days pass from a verbal request or 15 calendar days pass from a written (mailed) request from the date of the plan’s adverse decision; and you have not asked for a Medicaid Fair Hearing with continuation of benefits until a Medicaid Fair Hearing decision is reached

• A Medicaid Fair Hearing decision is made that is not in your favor

• The authorization expires or the authorized service limits are met

• You withdraw the appeal

You may have to pay for all costs that collect during the review if you lose the hearing. The plan may recover the cost of the services given to you during this process.

What happens if the Medicaid Fair Hearing rules in my favor?

We’ll approve and pay for services as quickly as possible. The plan will pay for services that were in dispute. We’ll do this:

• According to state policy and rules

• If the services were given while the hearing was ongoing

• If the final decision reverses our decision


FILING A GRIEVANCE

We want to know if you have any grievances. You must submit them within one year after the issue happened. Call us. We’ll try to fix the issue over the phone. You may also write to us. Mail your grievance to:

Staywell Health Plan Attn: Grievance Department P.O. Box 31368 Tampa, FL 33631-3387

It can also be faxed to us. Fax it to 1-866-388-1769.

As a member, you can file a grievance about problems such as:

• Doctor or office staff behavior

• Wait times

• Not getting information you need

• Unclean or poorly kept doctor’s office

• If you feel we should process your request for an appeal in the expedited 72 hours rather than the standard 30 calendar days

• If you feel we should process your request for a service in the expedited 72 hours rather than the standard 14 calendar days

• Involuntary disenrollment

• Office waiting times

• Quality of services

We’ll try to fix any problem you might have. We can solve many issues over the phone. These may be about:

• A lack of information

• A misunderstanding

• Bad information

You have rights outside the plan’s process. They are included in the Medicaid Fair Hearing section of this handbook.

Complaints that are not settled right away will go to a Grievance Coordinator (GC). We’ll send you a letter within 10 days. It will let you know we got your complaint. Or you’ll get a decision letter if the issue is settled.

A doctor will look at cases that involve medical issues. Once we get your grievance, the process will take 60 calendar days or less. It may take longer if more details must be gathered.

Up to 14 calendar days can be added to the process if we need more facts. We’ll let you know if this happens. You may also ask for extra time. To do so, ask your case representative. We’ll send you a letter if we need extra time. The letter will let you know when we expect to make a decision. It will also tell you what to do if you do not agree with the extra time.


We’ll send you a letter telling you the outcome of the case. You may not agree with our decision. You have the right to send your grievance in writing to ask for a Medicaid Fair Hearing. You must ask for a Fair Hearing within 90 days of our original decision. Make your request to:

Office of Public Help Appeals Hearings 1317 Winewood Boulevard Building 5, Room 203 Tallahassee, FL 32399-0700 1-850-488-1429

You do not have to do this. If you do ask for one, you must send your request in writing. You must do this within 30 calendar days after you get our decision. Send it to the Grievance Committee. You will have less time to file an appeal to the state if you file a second-level grievance.

You may also present your case to the GC in person or by phone. To do this, please include this in your request. Our committee meets every Thursday from 9 a.m. to 10 a.m. Eastern. We will contact you to set up a meeting date.

You will have 10 minutes to present your side of the case. Members may then ask questions. You will be sent a decision letter within five business days of the meeting.

The second-level process takes 30 calendar days or less in most cases.

What happens if you do not agree with the second-level findings? You can ask the SAP to hear your case. You must finish the plan’s grievance process. Then they will hear your case. Be sure to ask for a hearing within one year after the event in question.

In order for the SAP to hear your grievance, the following must be met:

• Your grievance was filed in writing

• You submitted your request within one year of when the issue you are grieving about occurred

• Your issue concerns the quality of health care services you have received or your issue involves the contractual relationship between you and us

EXHAUSTION OF GRIEVANCE PROCEDURES You may ask for a Medicaid Fair Hearing following these guidelines:

• It can be before or after a grievance and appeal and

• It is within ninety (90) days after getting the original decision

ADDITIONAL HELP WITH APPEALS AND GRIEVANCESYou can call the agency listed below during or after the appeals or grievance process:

Agency for Health Care Administration Subscriber Assistance Program Building 1, MS #262727 Mahan Drive Tallahassee, FL 32308 1-850-412-4502 | (toll-free) 1-888-419-3456

We keep track of all appeals and grievances. We report them to the state. This also helps us give members better service.


MEMBER RIGHTSAs a member, you have the right:

• To get details about what the plan covers and how to use its services and plan providers

• To have your privacy protected

• To know the names and titles of doctors and others who treat you

• To talk openly about care needed for your health, no matter the cost or benefit coverage

• To freely talk about care options and risks involved

• To have this information shared in a way you understand

• To know what to do for your health after you leave the hospital or office

• To refuse to take part in research

• To create an advance directive

• To suggest ways the plan can improve

• To voice complaints or appeals about the organization or the care it provides

• To have a say in the plan’s member rights

• To have all these rights apply to the person who can legally make health care decisions for you

• To have all health plan staff members observe your rights

• To use these rights no matter what your sex, age, race, ethnic, economic, educational or religious background

• To receive information about the organization, its services its practitioners and providers and members rights and responsibilities

• To participate with practitioners in making decisions about their health care

• To a candid discussion of appropriate or medical necessary treatment options for their conditions, regardless of cost or benefit coverage

• To make recommendations regarding the organization’s member rights and responsibilities

• To be treated with respect and with due consideration for dignity and privacy

• To receive info on available treatment options and alternatives, presented in a manner appropriate to the member’s condition and ability to understand

• To participate in decisions regarding health care, including the right to refuse treatment

• To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation

• To ask for and receive a copy of medical records, and ask that they be amended or corrected

− Requests must be received in writing from the member or the person choosen to represent him/her

− The records will be provided at no cost

− The records will be sent within 14 days of receipt of the request

To be furnished health care services in accordance with federal and state regulations

The State must make sure a member is:

• free to exercise their rights and

• the exercise of those rights does not adversely affect the way the health plan and its providers or the State agency treat the member


MEMBER RESPONSIBILITIESAs a member, you have the responsibility:

• To know how Staywell works by reading this handbook

• To carry your ID card and Medicaid Gold Card with you at all times and to present them when you get health care services

• To get non-emergency care from a primary doctor, to get referrals for specialty care, and to work with those giving you care

• To be on time for appointments

• To cancel or set a new time for appointments ahead of time

• To report unexpected changes to your provider

• To respect doctors, staff and other patients

• To help set treatment goals that you and your doctor agree to

• To follow the treatment plan you and your provider agree on

• To understand medical advice and ask questions if you do not

• To know about the medicine you take, what it is for, and how to take it

• To provide information needed to treat you

• To make sure your doctor has your previous medical records

• To tell us within 48 hours, or as soon as you can, if you are in a hospital or go to an emergency room

• To supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care

• To understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible


WELLCARE NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective Date of this Privacy Notice: July 15, 2010

We are required by law to protect the privacy of health information that may reveal your identity. We are also required by law to provide you with a copy of this Privacy Notice which describes not only our legal duties and health information privacy practices, but also the rights you have with respect to your health information.

This Privacy Notice applies to the following WellCare entities: • WellCare of Florida, Inc. • HealthEase of Florida, Inc. • WellCare of New York, Inc. • WellCare of Connecticut, Inc. • WellCare of Louisiana, Inc. • WellCare of Georgia, Inc. • WellCare of Ohio, Inc. • WellCare of Texas, Inc.

• WellCare Health Plans of New Jersey, Inc. • Harmony Health Plan of Illinois, Inc. • WellCare Prescription Insurance, Inc. • WellCare Health Insurance of Arizona, Inc. • WellCare Health Insurance of Illinois, Inc. • WellCare Health Insurance of New York, Inc. • WellCare Specialty Pharmacy, Inc.

We may change our privacy practices from time to time. If we make any material revisions to this Notice, we will provide you with a copy of the revised Notice which will specify the date on which such revised Notice becomes effective. The revised Notice will apply to all of your health information from and after the date of the Notice.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION

WellCare requires its employees to follow its privacy and security policies and procedures to protect your health information in oral (for example, when discussing your health information with authorized individuals over the telephone or in person), written or electronic form.

1. Treatment, Payment, and Business Operations. We may use your health information or share it with others to help treat your condition, coordinate payment for that treatment, and run our business operations. For example:

Treatment. We may disclose your health information to a health care provider that provides treatment to you. We may use your information to notify a physician who treats you of the prescription drugs you are taking.

Payment. We will use your health information to obtain premium payments, specialty pharmacy payments, or to fulfill our responsibility for coverage and the provision of benefits under a health plan, such as processing a physician claim for reimbursement for services provided to you.

Health Care Operations. We may also disclose your health information in connection with our health care operations. These include fraud and abuse detection and compliance programs, customer service and resolution of internal grievances.


Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose your health information to tell you about treatment options or alternatives, as well as health-related benefits or services that may be of interest to you.

Your Authorization. In addition to our use of your health information for treatment, payment or health care operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. You may also revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those as described in this Notice.

Family Members, Relatives or Close Friends Involved In Your Care. Unless you object, we may disclose your health information to your family members, relatives or close personal friends identified by you as being involved in your treatment or payment for your medical care. If you are not present to agree or object, we may exercise our professional judgment to determine whether the disclosure is in your best interest. If we decide to disclose your health information to your family member, relative or other individual identified by you, we will only disclose the health information that is relevant to your treatment or payment.

Business Associates. We may disclose your health information to a “business associate” that needs the information in order to perform a function or service for our business operations. Third party administrators, auditors, lawyers, and consultants are some examples of business associates.

2. Public Need. We may use your health information, and share it with others, in order to comply with the law or to meet important public needs that are described below:

• if we are required by law to do so; • to authorized public health officials (or a foreign government agency collaborating with such

officials) so they may carry out their public health activities; • to government agencies authorized to conduct audits, investigations, and inspections, as well as

civil, administrative or criminal investigations, proceedings, or actions, including those agencies that monitor programs such as Medicare and Medicaid;

• to a public health authority if we reasonably believe you are a possible victim of abuse, neglect or domestic violence;

• to a person or company that is regulated by the Food and Drug Administration for: (i) reporting or tracking product defects or problems, (ii) repairing, replacing, or recalling defective or dangerous products, or (iii) monitoring the performance of a product after it has been approved for use by the general public;

• if ordered by a court or administrative tribunal to do so, or pursuant to a subpoena, discovery or other lawful request by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain a court order protecting the information from further disclosure;

• to law enforcement officials to comply with court orders or laws, and to assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person;

• to prevent a serious and imminent threat to your health or safety, or the health or safety of another person or the public, which we will only share with someone able to help prevent the threat;

• for research purposes; • to the extent necessary to comply with workers’ compensation or other programs established by

law that provide benefits for work-related injuries or illness without regard to fraud; • to appropriate military command authorities for activities they deem necessary to carry out their

military mission; • to the prison officers or law enforcement officers if necessary to provide you with health care, or

to maintain safety, security and good order at the place where you are confined;


• in the unfortunate event of your death, to a coroner or medical examiner, for example, to determine the cause of death;

• to funeral directors as necessary to carry out their duties; and • in the unfortunate event of your death, to organizations that procure or store organs, eyes or

other tissues so that these organizations may investigate whether donation or transplantation is possible under law.

3. Partially De-Identified Information. We may use and disclose “partially de-identified” health information about you for public health and research purposes, or for business operations, if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified health information will not contain any information that would directly identify you (such as your name, street address, Social Security number, phone number, fax number, electronic mail address, Web site address, or license number).

YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION

We want you to know that you have the following rights to access and control your health information.

1. Right to Access Your Health Information. You have the right to inspect and obtain a copy of your health information except for health information: (i) contained in psychotherapy notes; (ii) compiled in anticipation of, or for use in, a civil, criminal, or administrative proceeding; and (iii) with some exceptions, information subject to the Clinical Laboratory Improvements Amendments of 1988 (CLIA). If we use or maintain an electronic health record (EHR) for you, you have the right to obtain a copy of your EHR in electronic format, and you have the right to direct us to send a copy of your EHR to a third party you clearly designate.

If you would like to access your health information, please send your written request to the address listed on the last page of this Privacy Notice. We will ordinarily respond to your request within 30 days if the information is located in our facility, and within 60 days if it is located off-site at another facility. If we need additional time to respond, we will let you know as soon as possible. We may charge you a reasonable, cost-based fee to cover copy costs and postage. If you request a copy of your EHR, we will not charge you any more than our labor costs in producing the EHR to you.

We may not give you access to your health information if it: (1) is reasonably likely to endanger the life and physical safety of you or someone else; (2) refers to another person and your access is likely to cause harm to that person; or (3) a health care professional determines that your access as the representative of another person is likely to cause harm to that person or any other person. If you are denied access for one of these reasons, you are entitled to a review by a health care professional, designated by us, who was not involved in the decision to deny access. If access is ultimately denied, you will be entitled to a written explanation of the reasons for the denial.

2. Right to Amend Your Health Information. If you believe we have health information about you that is incorrect or incomplete, you may request in writing an amendment to your health information. If we do not have your health information, we will give you the contact information of someone who does. You will receive a response within 60 days after we receive your request. If we did not create your health information or your health information is already accurate and complete, we can deny your request and notify you of our decision in writing. You can also submit a statement that you disagree with our decision, which we can rebut. You have the right to request that your original request, our denial, your statement of disagreement, and our rebuttal be included in future disclosures of your health information.

3. Right to Receive an Accounting of Disclosures. You have the right to receive an accounting of disclosures of your health information made by us and our business associates. You may request such information for the six-year period prior to the date of your request. Accounting of disclosures will not include disclosures: (i) for payment, treatment or health care operations; (ii) made to you or your personal representative; (iii) you authorized in writing (iv) made to family and friends involved in your care or payment for your care; (v) for research, public health or our business operations; (vi) made to federal officials for national security and intelligence activities and (vii) incident to a use or disclosure otherwise permitted or required by law.


If you would like to receive an accounting of disclosures, please write to the address listed on the last page of this Privacy Notice. If we do not have your health information, we will give you the contact information of someone who does. You will receive a response within 60 days after your request is received. You will receive one request annually free of charge, but we may charge you a reasonable, cost-based fee for additional requests within the same twelve-month period.

4. Right to Request Additional Privacy Protections. You have the right to request that we place additional restrictions on our use or disclosure of your health information. If we agree to do so, we will abide by our agreement except in an emergency situation. We do not need to agree to the restriction unless the information pertains solely to a health care item or service that you have paid for out of pocket and in full.

5. Right to Request Confidential Communications. You have the right to request that we communicate with you about your health information by alternative means or via alternative locations provided that you clearly state that the disclosure of your health information could endanger you. If you wish to receive confidential communications via alternative means or locations, please submit your written request to the address listed on the last page of this Privacy Notice and how or where you wish to receive communications.

6. Right to Notice of Breach of Unencrypted Health Information. Our policy is to encrypt our electronic files containing your health information so as to protect the information from those who should not have access to it. If, however, for some reason we experience a breach of your unencrypted health information, we will notify you of the breach. If we have more than ten people that we cannot reach because of outdated contact information, we will post a notification either on our Web site (www.wellcare.com) or in a major media outlet in your area.

7. Right To Obtain A Paper Copy Of This Notice You have the right at any time to obtain a paper copy of this Privacy Notice, even if you receive this Privacy Notice electronically. Please send your written request to the address listed on the last page of this Privacy Notice or visit our Web site at www.wellcare.com.

MISCELLANEOUS

1. Contact Information. If you have any questions about this Privacy Notice, you may contact the Privacy Officer at 1-866-530-9491, call the toll-free number listed on the back of your membership card, visit www.wellcare.com, or write to us at:

WellCare Health Plans, Inc. Attention: Privacy Officer

P.O. Box 31386 Tampa, FL 33631-3386

2. Complaints. If you are concerned that we may have violated your privacy rights, you may complain to us using the contact information above. You also may submit a written complaint to the U.S. Department of Health and Human Services. If you choose to file a complaint, we will not retaliate in any way.

3. Additional Rights. Special privacy protections may apply to certain information involving HIV/AIDS, mental health, alcohol and drug abuse, sexually transmitted diseases, and reproductive health. Please see the attached chart entitled Information Regarding More Protective State Privacy Laws for WellCare Health Plans for additional information. If the law in the state where you reside affords you greater rights than described in this Notice, we will comply with these laws.


IMPORTANT PHONE NUMBERS

Your PCP

Staywell Customer Service 1-866-334-7927

TTY/TDD 1-877-247-6272

Personal Health Advisor 1-800-919-8807

Staywell Fraud and Abuse Hotline 1-866-678-8355

Area 2b – Calhoun, Gadsden, Jefferson, Leon, Madison 1-850-921-84741-800-248-2243

Area 3a – Putnam County 1-800-803-3245

Area 3b – Citrus, Hernando, Lake and Marion Counties 1-877-724-2358

Area 4 – Duval and Volusia Counties 1-800-273-5880

Area 5 – Pasco and Pinellas Counties 1-800-299-4844

Area 6 – Highlands, Hillsborough, Manatee and Polk Counties 1-800-226-2316

Area 7 – Brevard, Orange, Osceola and Seminole Counties 1-877-254-1055

Area 8 – Sarasota County 1-800-226-6735

Area 9 – Martin and Palm Beach Counties 1-800-226-5082

Area 10 – Broward County 1-866-875-9131

Area 11 – Dade County 1-800-953-0555

Local Plan Pharmacy

Other Health Provider



IMPORTANT INFORMATIONYou can change your primary care provider (PCP) at any time. Just call Customer Service. The number is 1-866-334-7927. TTY/TDD users, please call 1-877-247-6272. Call Monday–Friday, 7 a.m. to 7 p.m. Eastern.

All changes made between the 1st and 10th of the month will become effective right away. Changes made after the 10th of the month will become effective the 1st of the next month.

We will send you a new ID card and letter. The letter will let you know that your PCP has been changed and the date you can start seeing the new PCP.

INFORMACIÓN IMPORTANTEUsted puede cambiar su proveedor de cuidado primario (PCP) en cualquier momento. Sólo llame a Servicio al Cliente. El número es 1-866-334-7927. Los usuarios de TTY/TDD, por favor llamen al 1-877-247-6272. Llame de lunes a viernes de 7 am a 7 pm, hora del este.

Todos los cambios realizados entre el 1er y el 10o día del mes se harán efectivos inmediatamente. Los cambios realizados después del 10o día del mes se harán efectivos el 1er día del mes siguiente.

Le enviaremos una nueva tarjeta de ID y una carta. La carta le informará que su PCP ha sido reemplazado y la fecha en la que podrá comenzar a visitar su nuevo PCP.


Notes

P.O. Box 31387 • Tampa, Florida • 33631-3387

If you have any questions about information contained in this handbook, please call us.

1-866-334-7927 (TTY/TDD: 1-877-247-6272)

www.wellcare.com

FL017085_CAD_MHB_ENG State Approved 01262012

©WellCare 2012 FL_02_12

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