Pinellas County Health Plan (PCHP)

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1 Pinellas County Health Plan (PCHP) Information for new clients and those who may be eligible (Revised, August 2009) The Pinellas County Health Plan (PCHP) is a health care program for uninsured, low-income adults in Pinellas County. This is not a health insurance plan. Please read this handbook carefully. It will tell you what you need to know about this program. Please complete the following (participants only) My Medical Home is: Name: Address: Phone Number: If you have any questions that cannot be answered by your Medical Home, please call (727) or (727) For more information, visit the PCHP Web Site at

2 NOTE: If you are already enrolled, please skip to page four (4). The Pinellas County Health Plan (PCHP) The Pinellas County Health Plan (PCHP) began in October, People in this plan can be seen by a PCHP health care provider for free. This means that you will not have wait in long lines at the emergency room for minor problems. Now, you can go to a medical home, like a doctor s office, for all of your basic health care needs. This is a Health and Human Services Department program. It is funded by Pinellas County. Services may change at any time. To see what is currently covered by this plan, please turn to pages 4-7 of this handbook. Do I Qualify? You may be able to get care if you: Are a legal permanent resident or citizen of the United States. Are a Pinellas County resident. Are between the ages of 18 and 64. You can not get services if you are 65 years old or older. Meet Federal Poverty Guidelines for income (100% or less). Are uninsured and can not pay for the medical care you need. Are not eligible for Medicaid, Medicare, or another assistance program Have less than $2,000 dollars in assets (does not include your car or your home; examples: bank account or certificate of deposit) Limit applies to specialty and hospital care only

3 HOW DO I APPLY? To apply for PCHP services, you must: Visit your medical home (see page 8 for a list of medical homes). Provide proof of Pinellas County residency (see below). Provide proof of age (driver s license, Florida ID or birth certificate). Provide proof of identity (driver s license, Florida ID or social security card). Provide proof of citizenship (see below). Residency and Citizenship Documents Residency Documents: one of the following 1. Driver s license 2. Lease 3. Proof of home ownership 4. Utility bill 5. Voter ID 6. Library card 7. Mortgage papers 8. Rent receipt 9. Homestead exemption 10. Vehicle registration 11. School enrollment (children) 12. Food stamp referral 13. Cancelled mail from government agency 14. Bank statement 15. Criminal arrest record with home in Pinellas County 16. Declaration of domicile at clerk of court 17. Professional license 18. Florida ID 19. Written referral from a Pinellas County Social Service Agency verifying Pinellas County residency Citizenship Documents: one of the following 1. U.S. Birth Certificate 2. U.S. Passport 3. Certificate of Naturalization 4. INS forms I-551 or I Vital statistics confirmation 6. Green Card - 3 -

4 What Does My Plan Cover? Basic Services The providers in your medical home will help you with all your basic health care needs. Screenings, lab work, and prescriptions are part of this basic care. These services are free. Specialty Services Specialty services are more advanced treatments that can not be done by your provider in your medical home. Some limited specialty services may be provided as part of this plan. However, there are many services the plan does not cover. Please see pages 5-9 for a complete description. Your medical home provider will decide if you need specialty services. (Asset limit may apply) Other Services There are also case managers in your medical homes. These people will help you with personal concerns like transportation and housing. Nurses can help you manage illnesses such as diabetes or high blood pressure. Note: Emergency room services and transportation to the emergency room are not part of this plan. If you go to the emergency room, this plan will not pay for your visit. You may receive a bill for emergency room and ambulance services. Note: You may be asked to report your assets and sign a release of information form before you are able to get services outside your medical home

5 This table shows most, but not all covered and uncovered services. The services described here must be approved by the provider in your medical home. Services are subject to change and dependent on available funding. Please ask your provider if you have any questions about the following: SERVICES PINELLAS COUNTY HEALTH PLAN (PCHP) COVERAGE GENERAL BENEFIT: PRIMARY, WELLNESS, & PREVENTION NO CAP, MEMBERS DO NOT PAY A PREMIUM OR COPAY ABORTIONS ACUPUNCTURE, BIOFEEDBACK, CHELATION THRAPY, CHIROPRACTIC, HYPNOTISM, HERBAL THERAPY MASSAGE ACUTE (EMERGENCY CARE) ALCOHOL AND SUBSTANCE ABUSE BEHAVIORAL HEALTH, INCLUDING PSYCHIATRIC CARE, ALCOHOL & SUBSTANCE ABUSE TREATMENT CANCER TREATMENT CARDIAC REHABILITATION CARDIAC DIAGNOSTIC TESTING CARPAL OR TARSAL TUNNEL SURGERY CIRCUMCISIONS CORRECTIONAL FAC CARE CUSTODIAL CARE DENTAL DIALYSIS DURABLE MEDICAL EQUIPMENT (DME) FOR SERVICES RELATED TO INTOXICATION OR USE OF ILLICIT DRUGS, NOR FOR ALCOHOL RELATED ILLNESSES. DRUG SCREENING IS COVERED MEDICAL HOME CONDUCTS SCREENING AND COMPLETES MENTAL HEALTH REFERRAL WHEN APPROPRIATE COVERED FOR PRIMARY SITE ONLY; FOR RECURRENCE, METASTASIS OR GI NON-COLORECTAL DIAGNOSES (ESOPHAGUS, HEPATOBILIARY, PANCREATIC, SMALL INTESTINE) COVERAGE BEFORE THE 180 DAY AFTER OPEN HEART SURGERY, MI, or MEDICALLY NECESSARY CARE JUSTIFIED BY A SPECIALIST MEDICAL HOME REVIEWS FOR NECESSITY: CAPPED MEDICALLY NECESSARY ONLY EXTRACTIONS ONLY: MEDICAL HOME CASE MANAGER COMPLETES REFERRAL - 5 -

6 SERVICES PINELLAS COUNTY HEALTH PLAN (PCHP) COVERAGE EMERGENCY ROOM EATING DISORDER TREATMENT EPIDURAL STEROID INJECTIONS/NERVE BLOCKS EXPERIMENTAL DRUGS/THERAPY/PROCEDURES EYE CARE FLU SHOTS & OTHER VACCINES GENETIC COUNSELING AND TESTING SEE ACUTE (EMERGENCY CARE) APPROVAL ON A CASE BY CASE BASIS: EPIDERAL STEROIDS ARE NON- SURGICAL INTERVENTIONAL OPTIONS FOR PATIENTS WHO HAVE FAILED CONSERVATIVE MANAGEMENT. TREATMENT MAY BE PROVIDED AS ONE OF A SERIES OF UP TO THREE INJECTIONS, AT INTERVALS OF NO LESS THAN ONE MONTH, BUT NO MORE THAN THREE INJECTIONS WITHIN TWELVE MONTHS.TREATMENT PLAN REVIEW REQUIRED TO SHOW PREVIOUS TREATMENT ATTEMPTED. MEDICALLY RELATED VISION PROBLEMS SUCH AS DIABETIC RETINOPATHY, EYE INJURIES, OR CATARACTS ARE COVERED PROVIDED IN MEDICAL HOME: BASED ON NATIONAL GUIDELINES GENDER IDENTIFICATION DISORDERS NOT COVERED INCLUDING GENDER REASSIGNMENT SURGERY AND MEDICATION THERAPY HEARING CARE HEPATITIS C HOME HEALTH HOSPICE HOSPITAL (INPATIENT) HYGIENE PRODUCTS INFERTILITY INFUSION THERAPY LABORATORY ROUTINE HEARING EXAMS ARE NOT COVERED; REFER TO DEAF SERVICE CTR.; MEDICALLY RELATED HEARING PROBLEMS, SUCH AS EAR INFECTIONS OR EAR INJURIES ARE COVERED, AS WELL AS HEARING SERVICES INVOLVED WITH SUCH HEARING PROBLEMS COVERAGE ONLY AT PARTICIPATING HOSPITALS (BAYFRONT, MORTON PLANT, MEASE, MEASE COUNTRYSIDE, AND ST. ANTHONY S) INCLUDED WITH ENCOUNTER RATE FOR MEDICAL HOME: SPECIALTY NETWORK TO USE PINCHD CONTRACT WITH LAB CORP - 6 -

7 SERVICES PINELLAS COUNTY HEALTH PLAN (PCHP) COVERAGE MRI/CT/PET NURSING HOME OBSTETRICAL/FERTILITY OCCUPATIONAL, PHYSICAL AND SPEECH THERAPY (OUTPATIENT) ORGAN HARVESTING AND TRANSPLANTS ORTHOPEDIC/NEURO SURGERY 1 PER BODY PART, ANNUALLY : REFER PREGNANT WOMEN TO DEPARTMENT OF CHILDREN AND FAMILIES PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH THERAPY HAVE A COMBINED LIMIT OF THIRTY (30) TREATMENTS PER CALENDAR YEAR LIMITED COVERAGE: FOCUS ON ACUTE INJURIES OR EXACERBATIONS OR NEUROLOGICAL DEFICITS: JOINT REPLACEMENT ON CASE BY CASE BASIS, NO SPINAL SURGERY FOR CHRONIC ISSUES PAIN MANAGEMENT: ACUTE INJURY, DENTAL, PRE AND POST SURGICAL PAIN MANAGEMENT; CHRONIC PHYSICAL THERAPY PRESCRIPTIONS PROSTHETICS (BRACES) RADIOLOGY AND OTHER DIAGNOSTIC TESTING SCREENINGS (BREAST, CERVICAL, PROSTATE, COLORECTAL, BONE DENSITY, ETC) SECOND OPINIONS SEXUAL DYSFUNCTION SLEEP DISORDERS INCLUDING INSOMNIA SPECIALTY CARE PRESCRIPTION COVERAGE FOR CONTROLLED SUBSTANCES INCLUDING TRAMADOL, IS LIMITED TO SHORT TERM EVENTSS ONLY CHRONIC PAIN MANAGEMENT IS NOT COVERED; SELECTED EXCEPTIONS FOR HEMATOLOGY/ONCOLOGY AND EPIDURAL STEROID INJECTIONS; SEE ABOVE FOR CONTROLLED SUBSTANCES AND TRAMADOL PRESCRIPTION COVERAGE LIMITATIONS SEE OCCUPATIONAL THERAPY PRESCRIPTION COVERAGE USES A GENERIC BASED FORMULARY WITH A CONTRACTED VENDOR OR PRESCRIPTION ASSISTANCE PROGRAMS; CLIENT TO RETURN TO MEDICAL HOME FOR REVIEW OF ER OR HOSPITAL PRESCRIPTIONS; CONTROLLED SUBSTANCES PRESCRIPTIONS, INCLUDING TRAMADOL IS RESTRICTED. SEE PAIN MANAGEMENT MEDICAL HOME REVIEWS FOR NECESSITY: CAPPED PROVIDED AT MEDICAL HOME: FREQUENCY BASED ON NATIONAL GUIDELINES - 7 -

8 SERVICES PINELLAS COUNTY HEALTH PLAN (PCHP) COVERAGE SPEECH THERAPY STERILIZATION PROCEDURE STERILIZATION REVERSAL SURGICAL PROCEDURES TOTAL PARENTERAL NUTRITION TEMPORO MANDIBULAR JOINT SYNDROME WOUND CARE SEE OCCUPATIONAL THERAPY : REFER TO PINCHD MALE MUST BE MEDICALLY NECESSARY AND NOT PRIMARILY FOR COSMETIC PURPOSES; THIS INCLUDES BUT IS NOT LIMITED TO IMPLANTS, AUMENTATION, REDUCTION, LIFTS/STRETCHES/INJECTIONS, SCAR REVISION, HAIR TRANSPLANTS, OBESITY AND RECONSTRUCTIVE SURGERY NOT COVERED - 8 -

9 MY MEDICAL HOME Your PCHP medical home will be either at Pinellas County Health Department or at Community Health Centers of Pinellas, Inc. See below for a complete list of medical homes. Please write the name, location and phone number of your medical home on the front of this handbook. This is your first stop for all your non-emergency health care needs. Walk-ins may be available. Please call ahead for hours. TIP: Have your citizenship and identity documentation ready on your first visit. See page 4 for details. Please Note: We want your medical home to get a chance to get to know you and plan for your care. You can only change your medical home once per enrollment year. Important Information Regarding Behavior & Fraud There are some behaviors that are disruptive and unsafe. These behaviors will cause you to be removed from the Pinellas County Health Plan. If you are removed from the plan, you will no longer get health care at your medical home. Examples of these poor behaviors include: Rude, disruptive or abusive behavior in a medical, dental or county facility Arriving intoxicated for your appointments Failure to follow your provider s recommended plan of care Failure to inform your provider of any treatment or medications that others prescribe Repeated failure to keep scheduled appointments Drug seeking behavior / inappropriate attempts to secure controlled substances (narcotics) In addition: If you are no longer eligible for the program, you will stop receiving PCHP services. If you give false information, you will stop receiving PCHP services. If you get workers compensation or an insurance or accident settlement, you must repay the PCHP for all services you have received. Health and Human Services Department may sue you if you receive PCHP services unlawfully

10 MEDICAL HOMES LOCATIONS Pinellas County Health Department Sites Willa Carson Health Resource Center 1108 N. M. L. King Avenue, Clearwater (727) Pinellas Park Health Center th Avenue N., Pinellas Park (727) St. Petersburg Health Center 205 Dr. M. L. King Street N., St. Petersburg (727) Rajendara A. Karkare, MD, PA Park Blvd., Suite C & D, Seminole (727) Turley Family Care Center 807 Myrtle Avenue, Clearwater (727) American Primary Care, Inc Tampa Road, Suite P, Palm Harbor (727) Bestcare 1100 S. Fort Harrison Avenue, Clearwater (727) Professional Health Care of Pinellas, Inc 1839 Central Avenue, St. Petersburg (727) Community Health Centers of Pinellas Sites Johnnie Ruth Clarke Health Center nd St. S., St. Petersburg, FL, 33712, Tel. (727) Community Health Centers at Largo th Ave. N., Largo, FL, 33774, Tel. (727) Community Health Centers at Tarpon Springs 247 S. Huey Avenue, Tarpon Springs, FL, 34689, Tel. (727) Community Health Centers at Pinellas Park th Street, Pinellas Park, FL 33781, Tel. (727) Community Health Centers at Clearwater 1020 Lakeview Road, Clearwater, FL 33756, Tel. (727)

11 Where Do I Get My Prescriptions Filled? NORTH COUNTY Pharmacy Address Phone Fax 1360 Tampa Road (727) (727) Palm Harbor, FL Promise Pharmacy Tarpon Discount Drugs Savon Pharmacy (Albertsons) Savon Pharmacy (Albertsons) PRESCRIPTION SERVICES 2460 East Bay Drive Largo, FL US Hwy 19 North Palm Harbor, FL South Pinellas Ave Tarpon Springs, FL Ulmerton Road Largo, FL Gulf to Bay Blvd Clearwater, FL SOUTH COUNTY (727) (727) (727) (727) (727) (727) (727) (727) (727) (727) Pharmacy Address Phone Fax th St. North (727) (727) Kenneth City, FL th St. North St. Pete, FL (727) (727) Garon Pharmacy ASAP Pharmacy Neighborly Care Pharmacy 6851 Gulfport Blvd. South Pasadena, FL MLK (9 th ) St. North St. Pete, FL th Ave.North. St. Pete, FL th St. North. St. Pete, FL nd St. South St. Petersburg, FL th St. North St Petersburg, FL th St. North, Suite C Pinellas Park, FL th St. North St. Petersburg, FL (727) (727) (727) (727) (727) (727) (727) (727) (727) (727) (727) (727) (727) (727) (727) (727)

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