Medicaid Member Handbook. Broward County

Transcription

1 Medicaid Member Handbook Broward County

2 Dear Member: Welcome to Better Health! We are glad to have you as a Member of our family. This is your Member Handbook and it will help you answer any questions you may have about your health Plan. Please take the time to learn about your benefits and how to use the Plan services. This will help you to make better choices. If you need anything please call our Member Services phone number found on the back of your Member ID card. You can also visit us online at A Member Services Representative will be here to help from 8:00 am to 7:00 pm, Monday through Friday. If you need help after hours, you may leave a voic message and a Member Services Representative will call you back the next business day. If you have an emergency and you cannot talk to your Doctor, please call 911 or go to the closest emergency room. Please remember to always keep your appointment with the Department of Children and Family Services (DCF) to recertify your Medicaid. This is very important for you and your family. Keeping your Medicaid is important so that you can get your health care. If your Medicaid is about to end, please call Access Florida at (866) In this handbook, the Plan or BH means Better Health. Welcome to our Better Health family. Better Health Page 1 APPRV 1/13

3 Table of Contents IMPORTANT PHONE NUMBERS... 5 ENROLLMENT INFORMATION... 6 Condition of Enrollment and Medicaid Reform... 6 Enrollment... 6 Open Enrollment... 6 Newborn Enrollment... 7 Disenrollment... 7 Loss of Medicaid Eligibility Reinstatement Process... 8 Woman, Infant and Children (WIC) Program... 8 MEMBER (ID) CARD... 9 Lost or Stolen Cards, Changes or Corrections... 9 CULTURAL COMPETENCY REQUIREMENTS HELPING YOU TO UNDERSTAND YOUR CARE YOUR DOCTOR Choosing Your Doctor (PCP) Medical Release Form First PCP Appointment Canceling an Appointment Changing Your PCP Notice of Changes Participating Doctors and Healthcare Doctors Access and Availability Continuation of Care ROUTINE CHECKUPS The Child Health Check-Up Program Prenatal Care and the Unborn Baby s Medicaid ID# Newborn Baby s Medicaid ID Number Activation Process PREVENTIVE HEALTH GUIDELINES SPECIALTY CARE Specialty Care Providers/Out of Network Second Medical Opinion DIFFERENT TYPES OF MEDICAL AND HOSPITAL CARE Emergency Care (ER) Out of Area Emergency Care After Hours Care Urgent Care Facilities Hospital Care ACCESS TO BEHAVIORAL HEALTH SERVICES Page 2 APPRV 1/13

4 What to Do If You Are Having a Problem What to do in an Emergency, or if you are out of the Plan service area Obtaining Behavioral Health Services Behavioral Health Limitations and Exclusions After Hours Care Urgent Care Facilities Hospital Care MEMBER SERVICES COVERED SERVICES Regular Medicaid Services Expanded Benefit Services Enhanced Benefits Reward$ Program What is a Healthy Behavior? Earning Credits Using your credits Five easy steps to earn and use credits Enhanced Benefits Universal Form REFERRAL OR AUTHORIZATION What is a Referral or Authorization? MEMBER RIGHTS AND RESPONSIBILITIES You Have the Right To: You have the Responsibility to: GRIEVANCE AND APPEALS Grievance Process Filing an Appeal Filing an Expedited Appeal Medicaid Fair Hearing Beneficiary Assistance Program ADVANCE DIRECTIVES You have the right to decide What is an Advance Directive? What is a Living Will? What is a Health Care Surrogate Designation? Do I have to write an Advance Directive under Florida law? Can I change my mind after I write a Living Will or designate a Healthcare Surrogate? What if I filled out an Advance Directive in another state and need treatment in a healthcare facility in Florida? What should I do with my Advance Directive if I pick to have one? Member Privacy and HIPAA COMPLAINTS Page 3 APPRV 1/13

5 Complaints to the Federal Government Complaints and Communications to Plan Copies of this Notice Reporting Fraud, Abuse or Overpayment Your identity will be protected Page 4 APPRV 1/13

6 IMPORTANT PHONE NUMBERS Plan 1701 Ponce de Leon Blvd, Coral Gables, Florida Member Services Department Hearing Impaired (Florida Relay) 711 Fax Number Access Florida (Recertify Medicaid Benefits) Hour Mental Health Crisis Adult Dental Services Department of Children and Families Area Offices Miami-Dade County Broward County Hillsborough County Orange County Osceola County Pasco County Pinellas County Polk County Seminole County Medicaid Area Offices Miami-Dade County Broward County Hillsborough County Orange County Osceola County Pasco County Pinellas County Polk County Seminole County Medicaid Choice Counseling Beneficiary Assistance Program Agency Consumer Complaint Hotline Fraud and Abuse Hotline Transportation Services Laboratory Services Enhanced Benefits Reward$ Program Poison Control Page 5 APPRV 1/13

7 ENROLLMENT INFORMATION Better Health is a Provider Service Network (PSN). A PSN is a plan that was made by a group of health care providers. We give access to health care to Medicaid recipients. Condition of Enrollment and Medicaid Reform Temporary Assistance for Needy Families (TANF) and Supplemental Security Income (SSI) recipients must enroll with a reform health plan unless you have Medicare, another coverage, or you reside in a long-term facility, or are enrolled in a Medicaid program with limited benefits. You should speak with Medicaid Choice Counseling at (866) Eligible Medicaid recipients are given 30 days from their effective date to choose a reform health plan. If recipients do not choose within 30 days, the State will choose one for you. When you choose a health plan you are enrolled on your Medicaid effective date. You have 90 days to change your health plan. If you do not change your plan, you have to remain with Better Health for (9) months. Open enrollment is a yearly process. You may choose another plan during open enrollment period. We hope you stay with us. Enrollment If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Better Health or the state enrolls you in a health plan, you will have 90 days from the date of your first enrollment to try the health plan. During the first 90 days you can change health plans for any reason. After 90 days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next nine months. This is called lock-in. Open Enrollment If you are a mandatory enrollee, the state will send you a letter 60 days before the end of your enrollment year telling you that you can change plans if you want to. This is called open enrollment. You do not have to change health plans. If you choose to change plans during open enrollment, you will begin in the new plan at the end of your current enrollment year. Whether you pick a new plan or stay in the same plan, you will be locked into that plan for the next 12 months. Every year you can change health plans during your 60-day open enrollment period. Page 6 APPRV 1/13

8 Newborn Enrollment If you think you are pregnant, call your Primary Care Physician (PCP), your Doctor. They will refer you to an Obstetrician/Gynecologist (OB/GYN). Please call Plan at We can help with your prenatal care. One of our case managers can help you get the care you need. Your Primary Care Physician (PCP) and the Plan will notify the Department of Children and Families (DCF) that you are pregnant. The baby will be given a Medicaid ID number. As soon as you have your baby, call the Plan so that we can notify DCF. DCF will review your baby s Medicaid benefits. They will start the baby s Medicaid ID number. You can pick a pediatrician for your baby. Do this as soon as you know you are pregnant. If you have not selected a pediatrician, we can help you pick one. Your baby will stay on your plan until they: Are not eligible, or you disenroll the child. To disenroll your baby from Plan, call Medicaid Choice Counseling at Plan will provide coverage for your baby. This will only be for the first 3 months of your baby s life. Call your Choice Counselor to get Medicaid benefits for your baby. Disenrollment If you are a required enrollee and you want to change plans after the initial 90 day period ends or after your open enrollment period ends, you must have a state-approved good cause reason to change health plans. The following are state-approved cause reasons to change health plans: a. The enrollee moves out of the county, or the enrollee s address is incorrect and the enrollee does not live in a county where the health plan is authorized to provide services. b. The provider is no longer with the health plan. c. The enrollee is not allowed to enroll. d. A proven marketing or community outreach violation has occurred. e. The enrollee is prevented from participating in the development of his/her treatment plan. f. 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. g. The enrollee is in the wrong health plan as determined by the Agency. h. The health plan no longer participates in the county. Page 7 APPRV 1/13

9 i. The state has imposed immediate sanctions upon the health plan as specified in 42 CFR (a)(3). j. The enrollee needs related services to be performed at the same time, 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. k. The health plan does not, because of moral or religious objections, cover the service the enrollee seeks. l. The enrollee missed open enrollment due to a temporary loss of eligibility, defined as 60 days or less for non-reform populations and 180 days or less for Reform populations. m. Poor quality of care. n. Lack of access to services covered under the contract. o. Inordinate or inappropriate changes of PCPs. p. Service access limitations due to significant changes in the geographic location of services. q. Lack of access to providers experienced in dealing with the enrollee s health care needs. r. Fraudulent enrollment. Some Medicaid recipients can change health plans whenever they want, for any reason. For example, people who are eligible for both Medicaid and Medicare and children who receive SSI benefits can change plans at any time for any reason. To find out if you can change plans, call the Medicaid Program s Enrollment Broker, Medicaid Choice Counseling at As your Plan it is always important for us to know when you are having problems with the Plan or Plan doctors. Please call our Member Services Department fast and let the Representative know of the problem you are having. The Representative will help you. If you are a voluntary member you may disenroll from the Plan at any time. To disenroll, you need to call to call the Medicaid Choice Counseling toll free at Loss of Medicaid Eligibility Reinstatement Process If you are no longer receiving Medicaid benefits, you will have to leave Plan. If you get back your Medicaid benefits within 180 days from the day that you stopped getting Medicaid, you will become a Plan Member again. You will be assigned to the same PCP you had previously with the Plan. If the PCP is not available, you will have to pick another PCP. The Plan will send you a letter to remind you to renew your Medicaid benefits. Please call Access Florida at (866) it is important that you get information on when your Medicaid ends in order to make sure you can continue getting them. Woman, Infant and Children (WIC) Program Page 8 APPRV 1/13

10 The Women, Infant and Children (WIC) Program gives help for, all pregnant women, breast-feeding women, postpartum women, infants, children up to 5 years of age. You can ask your doctor for a referral to the WIC Program to receive WIC Program services. MEMBER (ID) CARD Carry your Member ID card with you all the time. Each time you go the doctor or hospital, you have to show your Medicaid card and your Plan Member ID card. DO NOT let anyone use your card or you may be disenrolled from the Plan. Lost or Stolen Cards, Changes or Corrections If your ID card is lost or stolen, you can still receive care from your doctors, but you have to call the Member Services Department fast to get a new ID card. You have to also call the Member Services Department when you need to make changes, to the ID card like a name change or have an address change. You also have to report these changes to your Medicaid Case Worker. Here s what s on the card 1. Member Name the name of the person covered by the plan. 2. Member Number your personal Plan (ID) number. Your Member number is also your State assigned Medicaid ID Number. Please have this number when you call to make doctor appointments or when you call the Plan or write to the Plan. 3. Effective Date the first day your health benefits start with the Plan. 4. Doctor (PCP) Name the name of your Doctor (PCP). 5. Doctor (PCP) Phone Number the telephone number of your Doctor (PCP). 6. Behavioral Health Phone Number telephone number for behavioral health care services. Page 9 APPRV 1/13

11 CULTURAL COMPETENCY REQUIREMENTS- HELPING YOU TO UNDERSTAND YOUR CARE The Plan and its providers have to make sure that you have help understanding or talking in any language. The providers have to make sure that you receive translation services. This help is free to our Members. This service makes sure you understand all you need to know about your health and what you need to do. All Plan providers have to follow the Plan s Cultural Competency requirements. This means that they have to understand and respect what you believe and also help you understand everything you need to know about your health and what you need to do. The plan will help you if you (a) have any special needs, (b) cannot see good, (c) cannot hear good, (d) cannot read or understand something, and/or (e) do not speak English. The plan has a foreign language interpretation services and other systems that can help you for free. To receive these services, call Member Services at Choosing Your Doctor (PCP) YOUR DOCTOR When you sign up for the Plan you must pick a doctor (sometimes called a PCP ). If you do not pick one the Plan will pick one for you. You can ask to change your PCP by calling our Member Services number and a Representative will help you do this. You can ask that all your family members, who are on the Plan, get care from the same PCP, or you may pick different PCPs for each Member s. It is important that you see your PCP within the first 3 months of becoming our Member. You need to make an appointment with your PCP even if you are not sick, for a check-up. You also have to call your PCP every time you are sick, need medicine and/or need to have tests done. He or she will make sure that you get the care that you need. Medicaid and the Plan will not pay for any care or supplies if you go to a doctor that is not on that Plan or if you don t call your PCP first, except if you have an emergency. There are some services that you do not have to call your PCP before you get the services. Please refer to the Covered Services Section in this Member Handbook to find out what those services are. If you are pregnant, you may pick an OB/GYN in the Plan as your PCP. He or she will help you get all your medical care while you are pregnant. See your PCP right away if you are pregnant or think you are pregnant to make sure you see an OB/GYN doctor for care while you are pregnant. Getting care fast in your pregnancy will help your health and that of your baby s. Page 10 APPRV 1/13

12 Medical Release Form When you visit your PCP for the first time, it is important that you sign a Medical Release Form so that he/she can get your medical notes from your last PCP. In your Plan s new member packet, you received a Medical Release Form that you need to fill out. Please fill it out and take it to your first PCP appointment. With this form our PCP can get your medical information from your last PCP. First PCP Appointment Call your PCP s office at the telephone number on the front of your Member ID card and have your Member ID number. Let the PCP s office know that you are a new Member of Plan. When you make an appointment with your PCP tell them what the appointment is for. Tell them if you are sick. Write down the date and time of the appointment so that you do not forget it. If you need help getting your medical records to your new PCP, you can call our Member Services Department for help. Canceling an Appointment If you cannot go to an appointment please call your PCP fast. Try to call one day before your appointment. Calling fast to let them know let the doctor s office give your appointment to someone else who may need it. Changing Your PCP If you want to change your PCP, call our Member Services Department and a Representative will help you find a new PCP or help you change to the PCP you want. The Representative will tell you the date of the change. A new Member ID will be mailed to you with the name and phone number of your new PCP. Please use the new card when seeing your PCP or doctor. Notice of Changes If anything changes in your benefits or there are any other changes the Plan will let you know by mail. We will also let you know of your choices. Please tell us and your case worker at the DCF of any address changes, and call Member Services if you are moving to another county. We can tell you if you can stay on our Plan or if you need to disenroll. If you can stay in the Plan after your move, we will help you find a new PCP. Page 11 APPRV 1/13

13 Participating Doctors and Healthcare Doctors As a member, you can get information about the doctors that are with our Plan. If you wish to find out about your doctor(s), please call the Member Services Department. The Plan has doctors and other types of licensed providers like nurse practitioners, doctor s assistants and midwives. You can sometimes get care from any of these providers. In some areas when you join the Plan, you may pick a PCP who is in a group or a clinic. The doctor you pick will help to get all of your health care services. He/she will make sure that you get the care you need. He/she will also send you to other specialist doctors that belong to the plan, if you need it. The Plan will not pay for any care you get from doctors who are not on Plan, except for emergencies and urgently care. If a doctor you want to see is not on the Plan, you will need to call our Member Services Department to change your doctor to one that does participate with the Plan. Access and Availability The Plan s doctors have to see our members for care as follows: Emergency Medical Care 24 hours a day/7 days a week Urgent Care - within one day of request Routine Sick Care - within one week of request Preventive Care - within 30 days of request Routine Specialty Care within 14 days of request Continuation of Care If your doctor leaves the Plan while you are in active care, you can: Keep seeing this doctor until your treatment ends. This is only true for care and treatment that was started before the doctor left; or Until you select another Plan doctor; or During the next enrollment period ROUTINE CHECKUPS Regular check-ups, tests and vaccinations are important to your health. Regular check-ups can help find health problems before they get worst. You need to learn what you can do to stay healthy. Always ask your doctor about any health questions you have. Please see the preventive guidelines section of this handbook. It will show you what tests you need to have and when you should have them. The Child Health Check-Up Program Page 12 APPRV 1/13

14 Your child needs to have routine checkups as the preventive guidelines section of this Member Handbook says. As the parent, representative or caregiver of a child, it is up to you to make sure that your child(ren) are seen regularly by their PCP. The Plan covers the health care services and needs of your child. The Plan cover s Child Health Check-ups and health care services needed to prevent diseases. Lab tests (including lead screening) Unclothed physical exams Health and development history Routine immunization update Nutritional assessments Developmental assessments Hearing Screening Dental Screening Vision Screening Prenatal Care and the Unborn Baby s Medicaid ID# It is important to see a doctor on a regular basis during your pregnancy. The plan covers health care for all pregnant women. If you are pregnant or think you are pregnant, see your doctor right away and also tell your DCF Case Worker and the Plan. Seeing a doctor early and during your pregnancy helps to make sure that your baby and you are doing well. And letting your DCF Case Worker know that you are pregnant will help you get your Unborn baby a Medicaid ID # to use when the baby is born. Newborn Baby s Medicaid ID Number Activation Process When your baby is born you need to let the plan and your DCF Case Worker know. Please call the Member Services telephone number on the back of your ID card. This way, the DCF Case Worker can enter your baby s birth in their system and you can start using your new baby s Medicaid Card for his/her medical and health care needs. PREVENTIVE HEALTH GUIDELINES The Plan follows the below listed care guidelines based on the U.S. Preventive Services Task Force. The Plan s coverage and payment for some of the below screenings, lab work, and vaccinations, may be different from these guidelines depending on the doctor judgment, state or federal law and other circumstances. Please contact Member Services for questions about benefit coverage information. Persons with symptoms or at high risk for disease may need more care. Page 13 APPRV 1/13

15 CHILDREN YOUNGER THAN 10 YEARS Screenings Height/Weight-Regularly throughout infancy and childhood Blood Pressure-Periodically* throughout childhood Vision Screening-Once between ages 3-4 T4 and/or TSH-Optimally between day 2 and 6, but in all cases before discharge from the hospital PKU level-at birth Lead Test Screening-Done at 12 and 24 months old; and between 24 and 72 months if not previously screened. Immunizations DTaP or DTP-Five immunizations at 2, 4, and 6 months, between months and once betweenages 4-6 Polio-Four immunizations at 2 and 4 months, between 6-18 months and between ages 4-6 MMR-Two immunizations between months and between ages 4-6. If missed, give by ages H. influenzae type B (Hib)-Three or four immunizations, depending on the vaccine, at 2, 4, and 6 months and between months Hepatitis B-Three immunizations: beginning at Age 2 months or at age 6 months (depending on whether or not the vaccine used contains thimerosal). All three immunizations should be completed by age 18 months. If not immunized by age 11, three immunizations given according to your provider s recommendations. Pneumococcal Conjugate Vaccine-Four immunizations done at 2, 4, 6 and between months old Varicella-One immunization between months or older children, if missed, and no history of chicken pox *Frequency should be discussed with your provider. Things to Talk to Your Child s Doctor About: Diet and Exercise Limit fat and cholesterol intake, maintain caloric balance and emphasize grains, fruits and vegetables Regular physical activity Substance Use Effects of passive smoking Anti-tobacco message Dental Health Baby bottle tooth decay Regular dental visits Floss, brush and fluoride Injury Prevention Child safety car seats Bicycle helmet; avoid bicycling near traffic Lap and shoulder seat belts Smoke detector, flame retardant sleepwear Set hot water heater temperature lower than F Window and stair guards, swimming pool fence Page 14 APPRV 1/13

16 Safe storage of drugs, cleaning supplies, toxins, firearms and matches Poison control phone number CPR training for parents/caregivers YOUNG ADULTS YEARS Screenings Height/Weight-Periodically* Blood Pressure-Periodically* Papanicolaou (Pap) test-every one to three years sexually active females or beginning at age 18 Chlamydia screening-routine* screenings recommended for all sexually active females Rubella serology or vaccination history- Recommended for all females of childbearing age Immunizations Tetanus-diphtheria (Td)-Boosters between ages and then every 10 years* HPV (Human Papillomavirus) Between ages of Hepatitis B-If not previously immunized, one immunization at current (next) visit, one month later and six months later 9 MMR-Between ages if second dose was not received Varicella-Between ages if susceptible to chicken pox Rubella-Administered after age 12 females who are not pregnant Other Preventions Multivitamins with folic acid-females (Planning/capable of pregnancy) Diet and Exercise Limit fat and cholesterol intake, maintain caloric balance and emphasize grains, fruits and vegetables Regular physical activity Adequate calcium intake Substance Abuse Avoid underage drinking/illicit drug use Avoid tobacco use Sexual Behavior Sexually transmitted disease (STD) prevention/abstinence Avoid high-risk behavior Unintended pregnancy Injury Prevention Bicycle/motorcycle/ATV helmets-safety Lap and shoulder seat belts Smoke detectors Safe firearm handling Set hot water heater temperature lower than CPR training for parents/caregivers Dental Health Regular dental visits Floss, brush and fluoride ADULTS YEARS Screenings Height/Weight-Periodically* Blood Pressure-Periodically* Page 15 APPRV 1/13

17 Total Blood Cholesterol-Periodically* males between ages 35-64, females between ages Fecal Occult blood test-annually* beginning at age 50 Sigmoidoscopy-Every 3 to 5 years beginning at age 50 Clinical breast exam-annually-females between ages Mammogram-Every one to two years females between ages 50-69** Papanicolaou (Pap) test-every one to three years sexually active females who have not had a hysterectomy Other Preventions Discuss hormone replacement therapy- Periodically*, peri- and post menopausal females Multivitamins with folic acid-females (Planning/capable of pregnancy) Provider Discussion Topics Diet and Exercise Limit fat and cholesterol intake, maintain caloric balance and emphasize grains, fruits and vegetables Regular physical activity Adequate calcium intake Substance Abuse Avoid alcohol/drug use Avoid tobacco use Sexual Behavior Unintended pregnancy Sexually transmitted disease (STD) prevention Avoid high-risk behavior Injury Prevention Bicycle/motorcycle/ATV helmets-safety Lap and shoulder seat belts Smoke detectors Safe firearm handling CPR training for parents/caregivers Dental Health Regular dental visits Floss, brush and fluoride *Frequency should be discussed with your provider. 10 ADULTS 65 YEARS AND OLDER Screenings Height/Weight-Periodically* Blood Pressure-Periodically* Papanicolaou (Pap) test-every one to three years-sexually active females who have not had a hysterectomy; consider discontinuing if previous regular screenings were normal* Fecal Occult blood test-annually Sigmoidoscopy-Every 3 to 5 years Clinical breast exam-annually-females between ages Mammogram-Every one to two yearsfemales between ages 65-69** Vision Screening-Annually Page 16 APPRV 1/13

18 Hearing Screening-Periodically* Other Preventions Discuss hormone replacement therapy- Periodically*, peri- and post menopausal females Provider Discussion Topics Diet and Exercise Limit fat and cholesterol intake, maintain caloric balance and emphasize grains, fruits and vegetables Regular physical activity Substance Abuse Avoid alcohol/drug use Avoid tobacco use Sexual Behavior Sexually transmitted disease (STD) prevention Avoid high-risk behavior Dental Health Regular dental visits Floss, brush, and fluoride Injury Prevention Lap and shoulder seat belts Bicycle and motorcycle helmets-safety Safe firearm handling Smoke detectors Set hot water heater temperature lower than CPR training for household members/caregivers *Frequency should be discussed with your provider. Your PCP and a Plan case manager will work with you. We will create a plan to help control your illness. This will improve your quality of life. Plan will contact you if you qualify for these programs. Please call Member Services at or call TDD Florida Relay 711. They can give you a copy of our quality improvements programs and information about our quality improvements and disease management programs. SPECIALTY CARE Specialty Care Providers/Out of Network If you think you need to see a specialist doctor you have to tell your PCP first. Many times your PCP will be able to help you. If your PCP thinks you need to see a specialist, he or she will recommend one for you. Before making an appointment to see a specialist, please call the Member Services Department to make sure that the specialist is with the Plan. Sometimes during the month, new doctors join the plan and some leave the plan after we send members our directory before we can update it. Page 17 APPRV 1/13

19 By joining the Plan, you have agreed to get all of your health care from Plan s PCPs, hospitals and other doctors. If you use a doctor that does not belong to the Plan without your PCP or the plan telling you to do so, you will have to pay that medical bill yourself. If you are in need of a specialist and the plan does not have a doctor in that specialty, you can select the doctor you want to see as long as the Plan knows this and approves it. Please contact Member Services for more information. Second Medical Opinion As a member of the Plan you can get a second medical opinion if you need surgery or if you have a serious injury or illness. You have to go to either a doctor that belongs to the Plan or you can go to a doctor that is not part of the Plan. You first have to let your PCP know so he/she can help you with the approval for the second medical opinion. If you go to a doctor not on the plan, you will have to pay 40% of the medical bill. If you go to a plan doctor you do not have to pay for the second opinion. Your PCP must be told about all the tests that the second medical opinion doctor orders before you have them done. Please, always call the Member Services Department to make sure that the test or treatment ordered by the second medical opinion doctor is covered. DIFFERENT TYPES OF MEDICAL AND HOSPITAL CARE Emergency Care (ER) A medical emergency is a serious medical injury or illness. It is something you do not expect, it is something that needs to be taken care of quickly so that it does not get worse and become a permanent or long lasting disease or injury. Here are some examples of emergencies: Miscarriage or pregnancy problems Rape Unusual or excessive bleeding Overdose/Poison Severe body pain Severe burns Severe shortness of breath Chest pain If you require emergency care: Go to the closest emergency room or call 911 Show your Plan member ID card, wherever you go to get care Ask the facility to call your Doctor after you have gotten care Call your Doctor for a follow-up visit after the emergency is over or you leave the hospital. APPRV 1/13 Page 18

20 If the emergency room doctor thinks that you do not have medical emergency but you think that you still want to get care in the hospital, you can do so, but you will have to pay the hospital and all other bills. In the case of an emergency, you do not have to call Plan. Call 911 or go to the emergency room (ER) closest to you. Please give the ER your Plan ID card. If you are not sure if you need to go to the emergency room, call your PCP. If you have to stay at the hospital because of an emergency, please tell the hospital to call the Plan within 24 hours of when you get there. If during the emergency you stay in a hospital that is not in the Plan you can stay there until the hospital doctor tells us that it is safe to move you and take you to another hospital. You will be taken to another hospital that is on the Plan only when you are stable and it is safe to move you. The doctors in the hospital will talk to and work with BH and your BH doctors. Out of Area Emergency Care If you have an emergency while you are not in the Plan service area, go to the ER closest to you. You can use any hospital for emergency care. Please call your PCP within (24) hours of going to the Emergency Room so they can help you get the care you need. All care, except for emergencies, must be approved by the plan to make sure they are paid. If the hospital or outpatient emergency facility does not accept Better Health, you may get a bill. If you get a bill, send the bill and copies of your hospital medical records to: After Hours Care Better Health Member Services Department 1701 Ponce de Leon Blvd. Coral Gables, Florida If you need care after regular office hours (except for emergencies) you must contact your PCP. PCPs are required to have coverage for patients 24 hours a day, seven days a week. Your PCP can: Give you directions by telephone Prescribe medication Ask you to come to his or her office Refer you to an emergency room or another doctor for care Ask that you make an appointment during regular office hours. You also can get after hours care at a participating urgent care facility for urgent or emergency conditions. APPRV 1/13 Page 19

21 Urgent Care Facilities Sometimes you may have a medical problem that is not serious, but your doctor s office is closed. If your PCPs office is closed, you can also select a medical or behavioral health doctor who has later office hours. You also can use urgent care centers. Hospital Care You can get health care at participating hospitals with approval from the plan, except in the case of a medical emergency. If you need to go to the hospital, keep the following in mind: Hospital care, including inpatient (overnight stay) and outpatient (one day only) care require your PCP to notify Plan. Hospital care is required within the service area, your PCP will arrange for admission to a Plan participating hospital. Plan will pay claims for covered care at participating hospitals when your PCP has notified Plan. Show your Plan Member ID card when you are admitted to the hospital. Please call Plan Member Services if you have any questions about prior approvals. ACCESS TO BEHAVIORAL HEALTH SERVICES Behavioral health services you can get include inpatient and outpatient hospital services and psychiatric services. You and your children can also get a wide range of mental health and case management services. You can get these services in the community, in your home and in schools. Some of the services include: Individual, family, and group therapy Social rehabilitation Day treatment for adults and children Evaluations Treatment planning Call (800) if you want to know more. The staff will be happy to help you. Access to Behavioral Health Services and Referrals: Urgent Care within one (1) day Routine Patient Care within one (1) week Well Care Visit within one (1) month What to Do If You Are Having a Problem APPRV 1/13 Page 20

22 If you are having any of the following feelings or problems, you should contact a Behavioral Health doctor: Constantly feeling sad Feeling hopeless and/or helpless Feelings of guilt Worthlessness Difficulty sleeping Poor appetite Weight loss Loss of interest Difficulty concentrating Irritability Constant pain such as headaches, stomach and backaches You do not need to call your PCP for a referral to a behavioral health provider. An approval for services will be given at the time you call the provider. If you use a provider without getting an approval, you will have to pay the bill. What to do in an Emergency, or if you are out of the Plan service area First, decide if you are having a true behavioral health emergency. Do you think that you are a danger to yourself or others? Call: 911 or go the nearest emergency room for attention if you think you are in danger of harming yourself or others. You do not need to get approval or a referral first for these services. Follow these steps even if the emergency facility is not in the Plan s service area. If you need emergency Behavioral Health help out of the plans service area, please tell the Plan by calling the number on your ID card. You should also call your PCP if you can and follow-up with your doctor within 24 to 48 hours. For out-of area emergency care, when you are stable, plans will be made for transfer to an in-network facility. Obtaining Behavioral Health Services If you need help finding a Behavioral Health Provider in your area, you can call (PsychCare) Behavioral Health Services at (800) You will be given the names of several providers in your local community from which you can choose to call for an appointment. You can also choose a different behavioral health care coordinator or direct service behavioral health care provider within the Plan if one is available. Behavioral Health Limitations and Exclusions Children and Pregnant Adults can get up to 365 inpatient days a year of inpatient care. Pregnant substance abusers can get up to 28 days of Inpatient Substance abuse treatment. Any child (0-13 years old) prescribed a Psychotropic medication must obtain an informed consent by their parent or legal guardian. Psychotropic medications include antipsychotics, antidepressants, anti-anxiety medications, and mood stabilizers. APPRV 1/13 Page 21

23 The health plan will provide the following services in accordance with Medicaid guidelines and the Behavioral Health Services Coverage and Limitation Handbook: Inpatient Hospital Services for Behavioral Health and substance abuse Conditions Outpatient Hospital Services for Behavioral Health and substance abuse Conditions Mental Health physician services Community Mental Health Services Mental Health Targeted Case Management Mental Health Intensive Targeted Case Management If you or a family member has a substance abuse problem, you should call your local Medicaid provider. You can also ask our Behavioral Health staff to help you with a referral. The following services are not covered by the plan: Specialized therapeutic Foster Care Therapeutic Group Care Services Behavioral Health Overlay Services Residential Care Community Substance Abuse Services Sub-acute Inpatient Psychiatric Program (SIPP) Services Clubhouse Services Comprehensive Behavioral Assessment; and Florida Assertive Community Treatment Services (FACT) APPRV 1/13 Page 22

24 After Hours Care If you need care after regular office hours (except for emergencies), you must contact your behavioral health provider. Providers are required to have coverage for patients 24 hours a day, seven days a week. Always call your behavioral health provider. Identify yourself as a Better Health Enrollee. Your PCP or mental health provider can: Give you directions by telephone Prescribe medication Ask you to come to his or her office Refer to an emergency facility or another provider for care Ask you to make an appointment during regular office hours. You also may seek healthcare at a participating urgent care facility. Urgent Care Facilities Sometimes you may have a medical problem that is not serious, but your provider s office is closed. If your PCP s office is closed, you can use select Behavioral Health Providers who have later office hours. You can also use urgent care centers Hospital Care As a Better Health Enrollee, you may receive health care at participating hospitals. If you need to go to the hospital, keep the following in mind: Hospital care is required within the service area, you PCP will arrange for admission to a BH hospital. Make sure your PCP admits you to a BH hospital. Hospital services, including inpatient (overnight stay) and outpatient (one day only) services require your PCP to notify BH. BH will pay claims for covered services at participating hospitals when your PCP has notified BH. Please call BH Enrollee Services if you have any questions about prior approvals. BH will pay claims for emergency medical conditions. (Please read Medical Emergency Care on Page 17 for more information.) Show your BH Enrollee ID card when you go to the hospital for any care and also when you are admitted to the hospital MEMBER SERVICES The Plan Member Services Representatives are here to help you and to answer questions you may have, from 8:00 am to 7:00 pm on Monday to Friday. Our Staff can: APPRV 1/13 Page 23

25 Help you get your covered services Change Member ID cards Make changes to your address and telephone numbers Change your PCP Send you a doctor list Give you information on our corporate structure and operations Help you with claims or billing issues Describe our quality benefit enhancements Help you when you become pregnant and when your baby is born Listen and help you with a problem Give you a copy of information on Clinical Practice Guidelines Give you information about our Quality Performance ratings and measures Give you free interpreter services for all foreign languages Help with grievance and appeal questions COVERED SERVICES As a Provider Service Network (PSN), Better Health provides access to care for medical, dental and behavioral health services. The full list of services and coverage can be found in the Florida Medicaid Summary of Services Handbook. You must receive covered services from a participating Better Health provider except in the case of an emergency or urgently needed care. Please remember that our list of Plan doctors changes from time to time. It is your job to make sure that your PCP or health care doctor is in the Plan. You can look in the doctor listing we sent you or use the most up to date provider listing that is on the BH website at or call Member Services at , for the Hearing Impaired call Florida Relay 711 If one of the doctors in the Plan does not want to do a service or send you for a service because of moral or religious objections, the doctor nor Plan has to provide information on how and where to get the service. Below is a list of services that are covered under Florida Medicaid and the Plan: Primary Care Physician Services (PCP) Well Adult Exams each year Well-child exams for children under age 21. Shots (immunizations) Specialist doctor visits Mammogram and pap smear exams Family planning services and supplies* Diagnostic services (x-ray, lab) Prenatal and postpartum pregnancy care. This includes at risk pregnancy services and women s health services* Certified Nurse Midwife* APPRV 1/13 Page 24

26 Speech and hearing services including hearing aids Physical and Occupational Therapy Emergency Services Outpatient Hospital Services In-patient Hospital Services limited to 45 days for adults, including behavioral health. Children through age 21 and pregnant adults 365 days per year, including behavioral health. Behavioral Health and Substance Abuse Services. Independent psychologist services are only available to children under the age of 21 Prescription drugs. Medical Supplies Durable Medical Equipment (DME) Vision Services, including eyeglasses Certified Nurse Practitioner Services Podiatry foot care Home Health Care Behavioral Health Services Neurology and Neuromuscular testing Non-emergent /Non Specialized Transportation Oral Maxillofacial Surgery Rehabilitation Services, such as physical therapy, speech therapy and occupational therapy Pain Management Programs, including evaluations, injections and other services Pregnancy Trans-vaginal Ultrasounds Procedures, Surgeries In-patient/Out-patient at hospital and surgery centers Prosthetics, Orthotics and Implants Radiology such as CT, MRI, MRA, PET and SPECT Scans Skilled Nursing Facility Admission Sleep Studies Certified Nurse Midwife Services Certified Nurse Practitioner Federally Qualified Health Care (FQHC) Services Rural Health Care (RHC) Services Interpreter Services Post Stabilization Services Maternity Services Diabetic Supplies and Education Doctor care includes care done by a doctor, advanced registered nurse practitioner, or doctor s assistant. Members do not need to get an approval for these services only: PCP visits Family planning Federally Qualified Health Center (FQHC) APPRV 1/13 Page 25

27 Chiropractic Services (10- visits per calendar year) Dermatology (5-visits per calendar year) Immunizations provided by the county health department Podiatric Services (5-visits per calendar year) School Based Services Well woman exam with an OB/GYN (1- per calendar year) Emergency and Post-Stabilization Services ALL other services MUST have a referral from your PCP. To get any additional services available under Medicaid State Plan, please see the Florida Medicaid Summary of Services that can be found on the AHCA (Agency for Healthcare Administration) website. Regular Medicaid Services The following are some Medicaid services that are NOT covered by Plan, but you can get these services by calling your local Area Medicaid Office for information (see Important Phone Numbers page for a list of Area Medicaid Office Phone numbers): Prescription Drugs Expanded Benefit Services Adult Dental Cleaning 1 cleaning every six months Vision Benefit: Unlimited eye exams and eye glasses, when medically necessary Newborn Circumcision up to 12 weeks of age Adult Nutrition Therapy 12 visits per year. OTC Benefit: Up to $25.00 credit per house hold each month for selected OTC drugs and/or health supplies available through mail, fax and through certain pharmacies Enhanced Benefits Reward$ Program Florida Medicaid has a new program called the Enhanced Benefits Reward$ Program. This program is designed to reward you for taking part in activities that can improve your health. These activities, known as healthy behaviors, will earn credits that you can later use to buy health-related items at the pharmacy. As a Member of Better Health you do not have to do anything to enroll in this program. Beneficiaries with disabilities can receive these materials in alternative formats upon request at no additional charge. These formats include, but are not limited to: Braille, large print, CD- ROMs, and audiotapes. To receive these services contact: Enhanced Benefits Call Center 1-(866) APPRV 1/13 Page 26

28 What is a Healthy Behavior? Approved healthy behaviors include dental, vision and primary care (PCP) visits for adults and children. Other healthy behaviors include such things as getting flu shots and participating in stop smoking classes or alcohol and drug treatment programs. For a list of current, approved healthy behaviors, call the Enhanced Benefits Call Center at 1-(866) or go to the Florida Medicaid Web site at: Earning Credits You may earn credit for each healthy behavior. Each behavior has different limits during the year. The maximum credit is $125 per year. (July 1 through June 30) Deposits will be recorded on the first day of each month It may take up to 90 days after you complete a healthy behavior for the credits to show up in your account. You may also call the Enhanced Benefits Call Center to find out if you have credits. The program records your participation in two ways: When you visit the PCP and have a procedure that is an approved healthy behavior, your PCP reports this to Better Health so you will earn your credits. You submit an Enhanced Benefits Universal Form to Better Health that shows you participated in an approved healthy behavior not covered by Better Health. Using your credits You must provide your Florida Medicaid ID number and a picture ID. Credits in your account may be used to buy certain health-related items at the pharmacy The list of health related products and supplies are provided on the Florida Medicaid Web site at: You can t use your credits until the program sends you a letter stating that credits are in your account. It may take up to 90 days after you complete a healthy behavior for the credits to show up in your account. You may use your credits at any Florida Medicaid-participating pharmacy. Five easy steps to earn and use credits 1. You join an approved healthy behavior. APPRV 1/13 Page 27

29 2. You or your PCP, submit a completed Enhanced Benefits Universal Form or a claim to Better Health. 3. Better Health reports and submits information to Florida Medicaid. 4. Medicaid approves your credits and updates your account. You will get a statement in the mail. 5. You may begin using the credits you may have earned to buy approved items from the purchase lists. Enhanced Benefits Universal Form The Enhanced Benefits Universal Form is used to record an approved healthy behavior. These are not covered by Better Health. Such healthy behaviors include disease management programs alcohol and drug treatment programs programs to stop smoking weight loss and exercise programs flu shots for adults. You can find out which of these programs are free by calling Better Health Member Services at (800) The Enhanced benefits Universal Form is available on the Florida Medicaid Reform Web site at: or call the Enhanced Benefits Call Center: 1-(866) REFERRAL OR AUTHORIZATION What is a Referral or Authorization? A referral means you need your doctor s approval to get a service. Referrals may be written or by phone. Your PCP will take care of any referrals you need. We want you to go get the care you need. Some things that can happen are: Prior authorization: Also called an approval. This means your PCP calls Plan first. Then you can go to a specialist. Concurrent Review: This means Plan reviews your care as you get it. Retrospective Review: This means Plan checks your medical notes after you have gotten care. APPRV 1/13 Page 28