Caring for you and your family. Member Handbook. ReformMember
Handbook
Reform
MEMBER INFORMATION UPDATE FORM
It’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.florida.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 18663347927
(TTY/TDD 18772476272) Monday–Friday, 7 a.m. to 7 p.m. Eastern.
Member Name:
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
To Contact Us ...............................................................................................................................
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The MediKids Program ...............................................................................................................................
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Informed Consent ...............................................................................................................................
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HOW TO GET COVERED SERVICES . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 4
Covered Services...............................................................................................................................
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NonCovered Services ...............................................................................................................................
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Services Available Without Authorization ......................................................................................................................
7
Second Medical Opinion ...............................................................................................................................
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What to Do in an Emergency ...............................................................................................................................
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OutofArea Emergency Care ...............................................................................................................................
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Pregnancy and Newborn Care
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Prescriptions
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GETTING BEHAVIORAL HEALTH SERVICES . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . .10
How to Get Behavioral Health Services ..........................................................................................................................
10
What to Do if You Need Help ...............................................................................................................................
................11
What to Do in an Emergency or if You Are Out of the Staywell Service Area ...........................................11
What is PostStabilization ...............................................................................................................................
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Prevention Programs ...............................................................................................................................
.................................. 12
OTHER PROGRAMS . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.13
Personal Health Advisor (24Hour Nurse Helpline) .....................................................................................................13
Maternity Education and Prenatal Reward Program
.................................................................................................13
Case and Disease Management . ...............................................................................................................................
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CommunityBased Programs ...............................................................................................................................
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PREVENTIVE HEALTH CARE GUIDELINES . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . .14
Adult Preventive Health Guidelines . ...............................................................................................................................
. 15
Pediatric Preventive Health Guidelines—Newborn to 21 Years Old ................................................................
17
ADVANCE DIRECTIVES . . . . . . . . . . . . . . . . . . . . . . . .
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Your Medical Care Is Your Decision
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. 19
Advance Directives—Making Your Decision Known . .............................................................................................
19
IMPORTANT INFORMATION ABOUT STAYWELL . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . 20
Enrollment...............................................................................................................................
....................................................... 20
Open Enrollment ...............................................................................................................................
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Disenrollment ...............................................................................................................................
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Utilization Management Program ...............................................................................................................................
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Evaluation of New Technology ...............................................................................................................................
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Public Information About Staywell
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.. 24
MEMBER APPEALS AND GRIEVANCES PROCEDURES . . . . . . . . . . . . .
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Making an Appeal ...............................................................................................................................
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Medicaid Fair Hearing ...............................................................................................................................
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Filing a Grievance ...............................................................................................................................
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Additional Help with Appeals and Grievances ............................................................................................................
30
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 STARTED
It’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 tollfree at
18663347927
(TTY/TDD 18772476272). 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 nonemergencies.
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 18009198807.
IN AN EMERGENCY
In 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 8). 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 18663347927
(TTY/
TDD 18772476272). Or visit our website at www.florida.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 hearingimpaired we can give
you special help.
You can also call Customer Service or visit our website to:
• Ask for ID cards
•
Get a list of doctors in the health plan
•
Get a list of pharmacies in the health plan
•
Update your contact information, like your address and phone number (You may also need to update this
information with the Social Security Administration and/or the Department of Children and Families. See
page 2 for more details.)
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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 INFORMATION
ENROLLMENT IN STAYWELL
Staywell 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 “SSIrelated”
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 18664543959
(TTY/TDD 18664674970).
Ask to speak with a Choice Counseling
representative. (This is a helpline that is sponsored by the state. It helps you join the plan of your choice.)
THE MEDIKIDS PROGRAM
MediKids 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.
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 copayment for services we provide for a child in MediKids
Interested in this program? Call MediKids at 18775060578.
YOUR IDENTIFICATION (ID) CARD
Every 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
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What do I do if I lose my ID card?
Call Staywell tollfree at 18663347927
(TTY/TDD 18772476272). A new card will be mailed to you right away.
Need a new Medicaid card? Call your caseworker at DCF.
YOUR DOCTOR
Your 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.florida.wellcare.com.
When you have made your choice, call us. Our tollfree number is 18663347927
(TTY/TDD 18772476272).
You can also change your PCP on our website. Visit www.florida.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 CONSENT
We 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.
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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
Specialists Within 1 hour
Urgent Care Within 24 hours (1 day)
Routine Sick Care
Within a week of request
Physical Exams
Within a month of request
Followup Care As needed
OUTOFNETWORK 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 outofnetwork. 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
innetwork.
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 costeffective 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
HOW TO GET COVERED SERVICES
Staywell contracts with providers. These providers give care to our members. A plan doctor or Staywell must
approve all of your care.
There is no copayment 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 SERVICES
Staywell offers the same covered services as Medicaid. But with Staywell, there are no copayments.
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 18663347927
(TTY/TDD 18772476272).
Here is a list of some of the covered services. For details, visit our website. Go to www.florida.wellcare.com.
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Chiropractic services
Dental:
• Diagnostic services
• CHCUP dental screening
•
Adjunctive and emergency services
•
Fluoride varnish application in a physician’s
office under CHCUP is limited to children up
to three and one half (3 ½) years (42 months)
of age
Members over 21 years of age –
•
Full and partial denture services
• Medically necessary emergency dental
procedures (oral examinations, necessary
Xrays, extractions, and incision and drainage of
abscess) to alleviate pain or infection
Durable medical equipment and medical supplies
Early intervention services
Freestanding dialysis center services
•
To receive a covered service within the state,
except when:
−
Receiving dialysis at a freestanding clinic; and
−
Is being furnished either for free or by a third
party insurance
Emergency –
Vision services (medically necessary)
WELLCARE EXTRA BENEFITS/SPECIAL PROGRAMS •
Overthecounter Items – $300 a year for overthecounter drugs and supplies – that’s $25 dollars a month
for items like diapers, sunscreen, aspirin, vitamins and more – more than 100 items to choose from, mailed
right to your home (refer to your OTC brochure for the list of products and how to place your order)
•
Free baby stroller – To qualify, expectant mothers must attend at least six (6) prenatal doctor visits before
the birth of their baby
•
Free maternity education booklet – Tips to help you stay well while you are pregnant
•
Free 24hour, 7dayaweek health advice – When you call your Personal Health Advisor
•
Personal help – Setting doctor appointments, getting rides to your doctor visits, social services and more
•
Free referrals and guides to free community programs – Programs that help with domestic violence,
stopping smoking and drug/alcohol abuse
•
All materials are available in English, Spanish and other languages – Upon request
• Free flu shots
•
Online facts and education – Available at www.florida.wellcare.com
MEDICAID EXTRA BENEFITS
Enhanced Benefits Reward$ Program
– This program is designed to reward you for taking part in activities that
can improve your health. These activities are known as healthy behaviors. They will earn you credits that you can
later use to buy healthrelated items at the pharmacy. You do not have to do anything to enroll in this program.
You can use your Enhanced Benefits credits to buy healthrelated items at any Florida Medicaid participating
pharmacy. You must have your Gold Card or a government issued ID to use your earned credits.
For more details about this program:
•
Go to www.fdhc.state.fl.us/Medicaid/Enhanced_Benefits/index.shtml
•
Call the Enhanced Benefits Call Center at 18664218474.
•
A claim form is included in the back of this handbook.
NONCOVERED SERVICES
The following services are not covered by the health plan:
NONCOVERED SERVICES
Community substance abuse services, except as required by this Contract
Residential care
Clubhouse services
HOW TO GET AUTHORIZED SERVICES
Call 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 18663347927.
TTY/TDD 18772476272. We can help Monday–Friday, 7 a.m. to 7 p.m. Eastern (except for holidays). Or fax
us at 18132622907. 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 AUTHORIZATION
You do not need approval from your PCP or Staywell to get these services from plan providers:
• Chiropractic
• Dermatology
• Medically necessary vision
•
Traditional outpatient behavioral health and psychiatric (with the exception of psychological testing,
electroconvulsive therapy, psychosocial rehabilitation, therapeutic behavioral onsite 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.
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SECOND MEDICAL OPINION
What 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 AFTERHOURS 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 18009198807. (See the Personal Health Advisor section on
page 13).
WHAT TO DO IN AN EMERGENCY
A 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 momtobe and her unborn baby)
• Injury to yourself or others
• Organ damage
For momstobe, 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
• 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 18009198807. You do not need prior consent for
emergency services.
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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 followup 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 outof
network.
OUTOFAREA EMERGENCY CARE
It 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 CARE
If 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
Choice Counseling. The tollfree number is 18664543959
(TTY/TDD 18664674970).
PRESCRIPTIONS
Staywell covers all medically necessary Medicaidcovered 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
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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.
Please note: There is a ten (10) prescription limit per month for TANF members. SSI members have a 20
prescription limit per month. These prescriptions do not count toward the limits:
• Birth control
• HIV/AIDS drugs
There is no cost to you for prescriptions. Your PCP must approve a prescription from a nonplan 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 18663347927
(TTY/TDD
18772476272). You can also find those facts at www.florida.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.
GETTING BEHAVIORAL HEALTH SERVICES
HOW TO GET BEHAVIORAL HEALTH SERVICES
Need help finding a behavioral health provider in your area? Call 18777125340
(TTY/TDD 18772476272). You
can also search our provider directory. Or you can visit www.magellanhealth.com/member
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
• Call 18777125340 (TTY/TDD 18772476272)
Other types of care you may get include:
•
Behavioral healthrelated inpatient hospital care
−
Adults over age 21 and who are not pregnant: up to 45 days each year for nonemergency and up to 365
days for emergencies
−
Children and adolescents up to age 21: up to 365 days
−
Pregnant members: up to 365 days
•
Day treatment for adults and children
• Evaluations
• Psychosocial rehabilitation
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• Treatment planning
To learn more, call 18777125340
(TTY/TDD 18772476272).
WHAT TO DO IF YOU NEED HELP
Are you having any of the feelings or problems listed below? If so, call 18777125340
(TTY/TDD 18772476272). Someone is available to help you 24 hours a day, 7 days a week.
• Always feeling sad
• Feeling hopeless and/or helpless
• Problems paying attention
• 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
•
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.
Parental or guardian informed consent is required for psychotropic medications for children under age 13.
(Examples of psychotropic medication include tranquilizers, sedatives and antidepressants.)
WHAT TO DO IN AN EMERGENCY OR IF YOU ARE OUT OF THE STAYWELL SERVICE
AREA
Is 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.
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WHAT IS POSTSTABILIZATION?
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.
Poststabilization 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, 7 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 followup. Do this before you leave
the hospital. Call us if you need help making an appointment.
PREVENTION PROGRAMS
There 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 18777125340
(TTY/TDD 18772476272).
BEHAVIORAL HEALTH LIMITATIONS AND EXCLUSIONS
With Medicaid, adults can get:
•
Substance abuse treatment not covered with Medicaid
•
Behavioral healthrelated inpatient hospital care
−
Adults over age 21 and who are not pregnant: up to 45 days each year for nonemergency and up
to 365 days for emergencies
−
Children and adolescents up to age 21: up to 365 days
−
Pregnant members: up to 365 days
Note – There may be limits on some outpatient behavioral health services. Questions? Please call the
plan.
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OTHER PROGRAMS
PERSONAL HEALTH ADVISOR (24HOUR NURSE HELPLINE)
(24HOUR NURSE HELPLINE)
Personal Health Advisor is your 24hour 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 18009198807
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
• 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 PROGRAM
Staywell 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.
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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)
ADVANCE DIRECTIVES
YOUR MEDICAL CARE IS YOUR DECISION
The 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 KNOWN
An 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 18884193456.
There are three types of advance directives:
• A living will
• 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.
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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
• Your PCP
IMPORTANT INFORMATION ABOUT STAYWELL
ENROLLMENT
If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Staywell or the state
enrolls you in a health plan, you will have 90 days from the date of your first enrollment to try the plan.
During the first 90 days you can change health plans for any&