HELPING FLORIDA KIDS GROW UP HEALTHY

Transcription

Helping Florida
Kids
grow Up
HealtHy
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HELPING FLORIDA KIDS GROW UP HEALTHY
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STAYWELL KIDS MEMBER HANDBOOK
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TABLE OF CONTENTS
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Welcome to Staywell Kids! ..................................................................................................................................1
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Introduction................................................................................................................................................................2
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How to Use Your Child’s New Coverage........................................................................................................3
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How to Access Your Child’s New Health Care. ...........................................................................................3
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Covered Services, Benefits & Co-Payments ..................................................................................................7
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Pediatric New Member Questionnaire .......................................................................................................... 15
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Contacting Staywell Kids ..................................................................................................................................... 17
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Payments.................................................................................................................................................................... 21
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Cancellation of Your Child’s Policy................................................................................................................ 22
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Member Rights and Responsibilities .............................................................................................................. 22
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Important Definitions .......................................................................................................................................... 24
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WellCare Notice of Privacy Practices ........................................................................................................... 25
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Do you speak a language other than English? If so, we have interpreters who can help. There
is no cost to you for this service. You can get information in different formats, too. This
includes large print, Braille and audio tapes. Just call to let us know. Someone can help you
weekdays from 7 a.m. to 7 p.m. Eastern. Call 1-866-698-5437. TTY/TDD users, call
1-877-247-6272.
¿Habla un idioma diferente al inglés? En ese caso, tenemos intérpretes que pueden ayudarle.
No hay ningún costo para usted por este servicio. También puede obtener información en
diferentes formatos. Esto incluye letras de mayor tamaño, sistema Braille y cintas de audio.
Simplemente llámenos para hacérnoslo saber. Nuestro personal le prestará asistencia los días
hábiles de 7 am a 7 pm, hora del este. Llame al 1-866-698-5437. Los usuarios de TTY/TDD
llamen al 1-877-247-6272.
Èske gen yon lòt lang pase Anglè ou pale? Si wi, nou genyen entèprèt ki kapab ede. Ou pap
gen pou peye anyen pou sèvis sa a. Ou kapab jwenn enfòmasyon nan fòma diferan tou. Sa
enkli nan lèt ki pi gran, Braille ak kasèt odyo. Jis rele nou pou kite nou konnen. Yon moun
kapab ede w pandan lasemèn apatide 7è dimaten jiska 7è diswa Fizo Orè Lès. Rele
1-866-698-5437. Itilizatè TTY/TDD rele 1-877-247-6272.
WELCOME TO STAYWELL KIDS!
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Dear Parent or Guardian:
Congratulations! You are now part of the caring Staywell Kids family!
Staywell Kids is committed to serving your child’s health care needs. We are proud to be a part of the
Florida Healthy Kids program in your area.
Florida Healthy Kids is a partnership that provides affordable health coverage for children ages 5 through 18.
Healthy Kids coverage is provided by licensed insurers like Staywell Kids. We have provided health coverage
in the state of Florida since 2003.
Since then, Staywell Kids has become one of the largest providers in the state. Staywell Kids is a partnership
between providers in your area, our company and you. Our goal is to give you the extra help you need to
see to your child’s health care.
These materials explain the services that are available to your child through our plan. They also talk about
how you can get those services. Please read through them carefully.
Please call Customer Service with any questions you may have. The toll-free number is 1-866-698-5437.
GETTING STARTED
You should have received your child’s Staywell Kids ID card in the mail. Please put it in a safe place.
Whenever your child needs health care, you must show this ID card to the health care provider. Make sure
you keep this card with you at all times.
Please also take the time to check the ID card. Check the primary care physician (PCP) name listed on the
card. Be sure the doctor listed is the same one your child has been seeing. In some cases, a new PCP was
chosen for your child. If you are not happy with this choice, simply choose another PCP from the provider
directory listing. To ask for a change, call us toll-free. The number is 1-866-698-5437.
COMPLETE THE NEW MEMBER QUESTIONNAIRE
There is a “New Member Questionnaire.” It is very important that you fill out this form. It will tell us about
your child’s health history. Then return it in the self-addressed, stamped envelope. This will help us offer the
quality care that meets your child’s needs.
LEARN HOW TO USE YOUR HEALTH CARE BENEFITS
It’s easy to use your Staywell Kids plan benefits. For non-emergency health needs, call your child’s PCP. The
number is listed on the ID card. The PCP will take care of all routine medical care for your child. He or she
will also set up specialist or hospital care if needed.
Staywell Kids also has a Nurse Advice Line. When you’re not sure what type of care your child needs, please
call the Personal Health Advisor. He/she can answer any health care questions that you may have. The tollfree number is 1-800-919-8807.
www.florida.wellcare.com | 1
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For a REAL MEDICAL EMERGENCY, go to the nearest emergency room.
This handbook talks more about your child’s health plan and how to get health care. Please read it carefully.
PLACE YOUR MONTHLY OVER-THE-COUNTER (OTC) PRODUCT ORDER
Also included in your new member kit is an OTC catalog. In it is a listing of products you can choose for your
OTC program benefit. Each month you can choose up to $15 worth of the items listed. We have three easy
ways to place your order.
1. Log into our secure member portal on our website. Go to www.florida.wellcare.com. Then follow the steps to place your order. 2. Use our automated phone service. Call 1-866-698-5437 and follow the instructions.
3. You can also talk with someone on our Customer Service team.
Call in your order each month. Your order will be shipped right to your front door..
CALL US WITH ANY QUESTIONS
We have friendly Customer Service staff. They are ready to help you with any questions you may have about
your child’s health care. Or you can visit our website at www.florida.wellcare.com. Click on the Medicaid link
and choose Florida. Then click on the Staywell Kids page.
Please note: For help in person, call Customer Service. The toll-free number is 1-866-698-5437. TTY/TDD users,
call 1-877-247-6272.
You may also call Customer Service or visit our website any time to:
• Request ID cards
• Change your PCP
• Get a list of doctors in the health plan
• Get a list of pharmacies in the health plan
INTRODUCTION
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WELCOME TO STAYWELL KIDS
Staywell Kids Health Plans has been serving Florida’s children since 2003. Our goal is to make sure that your
child’s health care needs are met at the highest standards. We ask that you read this handbook to help us
meet this goal. It will tell you about the benefits and other things you need to know.
WHAT IS HEALTHY KIDS? WHO IS ELIGIBLE?
Florida Healthy Kids is a nonprofit group. It was started by the state in 1990. Its aim was to provide affordable
health care for uninsured children. The program was first offered in 1992 in Volusia County. Today it is offered
statewide.
To Be Eligible for the Healthy Kids Program, A Child Must…
• Be between 5 and 18 years of age
• Be uninsured
• Not be eligible for Medicaid
• Be a U.S. citizen or a qualified non-citizen
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HOW TO USE YOUR CHILD’S NEW COVERAGE
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CHOOSING A PRIMARY CARE PHYSICIAN (PCP)
Once we know that your child may take part in Staywell Kids, we will assign him or her to a PCP in your area. If
you wish to change your child’s PCP, please call us. Our toll-free number is 1-866-698-5437.
You can change your child’s primary care provider (PCP) at any time. Just call Customer Service. Call Monday
through Friday, 7 a.m. to 7 p.m. Eastern. All changes made between the 1st and 10th of the month will become
effective right away. Changes made after the 10th of the month will become effective the 1st of the next month.
We will send your child a new ID card and letter. The letter will let you know that your child’s PCP has been
changed and the date he or she can start seeing the new PCP.
THE PCP WILL BE RESPONSIBLE FOR…
• All routine medical care and prescriptions.
• Giving you an after-hours number so you have access to care 24 hours a day.
• Referrals to see a specialist. The PCP will decide if this kind of visit is needed.
• Authorizations for any services your child must have.
YOUR CHILD’S IDENTIFICATION (ID) CARD
After Florida Healthy Kids lets us know that your child can be part of our plan, an ID card will be sent to you in
the mail. A Staywell Kids welcome packet will also be sent. It will have details about how to get health care.
Keep your child’s ID card with you at all times. You will need it to get care. When you first arrive at the
provider’s office, be sure to show your child’s ID card. This way the provider will be able to verify your child’s
Staywell Kids membership and benefits. It will also help you avoid getting a bill from the provider.
If you do not get your child’s ID card, please call Customer Service at 1-866-698-5437 to let us know.
HOW TO ACCESS YOUR CHILD’S NEW HEALTH CARE
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PRIMARY CARE PHYSICIAN (PCP)
After your child is approved by Florida Healthy Kids, Staywell Kids will assign a PCP. Please make an
appointment with this PCP as soon as possible. This will let the PCP learn about your child’s health care needs.
It can also help keep small problems from becoming big ones.
If you have changed your child’s PCP, ask that your new PCP get copies of records from the previous PCP. The
PCP will coordinate all of your child’s health care needs. This includes well-child checkups and needed shots.
SPECIALISTS
Your child’s PCP will decide if your child needs to see a specialist. Please do not make an appointment with a
specialist without talking with your PCP first.
Please note — visits to a dermatologist and gynecologist do not require PCP approval.
You may have to pay for these charges if your PCP has not authorized the visit.
Be sure your PCP gives you approval to see a specialist. Call your PCP for help if you need care by a doctor
that is not participating with the plan.
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You can learn more about your providers by calling Customer Service. They can tell you about a provider’s
schooling or residency, qualifications, or whether he or she accepts new patients. You can also find this
information in your provider directory.
CREDENTIALING
Staywell Kids makes sure our doctors are fit to see your child. We check their education and training. We look
at their experience. Call Customer Service at 1-866-698-5437 if you have questions about this.
HOW DOCTORS ARE PAID
Staywell Kids works hard to give your children the health care they need. This means we work with many
doctors. You may ask how they are paid. You may ask if how they are paid will affect your doctor’s use of
referrals. You may also ask if it will affect other services you need. Call Customer Service for more details.
QUALITY IMPROVEMENT AND MEMBER SATISFACTION INFORMATION
We are always looking at ways to improve care and service for our members. Each year we select certain things
to review for quality. We check to see how we are doing in those areas. We may also check to see how our
providers are doing.
We want to know if our members are happy with the care and service they get. Want to know about our
quality ratings? Just call Customer Service.
You can ask about how satisfied members are with the Plan. You can also provide comments or suggestions
about:
• How we are doing
• How we can improve on our services
EVALUATION OF NEW TECHNOLOGY
We look at new technology every year. We also look at the ways we use the technology we have. The findings
help us:
• Determine how new advancements can be included in the benefits that members receive
• Make sure that members have fair access to safe and effective care
• Make sure we are aware of changes in the industry
The review of new technology is done in the following areas:
• Behavioral health procedures
• Medical devices
• Medical procedures
• Pharmaceuticals
To learn more, call Customer Service.
MALPRACTICE
Some of our providers may not have malpractice insurance. If they do not, they must have a notice in their
office that states so. If you are not sure if your doctor has it, please ask your doctor.
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ACCESS TO MEDICAL SERVICES
Staywell Kids has medical staff under contract to offer prompt service for all members as follows:
1. Travel time to medical services.
• Within 20 minutes to the doctor’s office.
• Within 60 minutes to the hospital.
• Within 60 minutes to a specialist.
Travel time may be extended under extreme circumstances, such as distance to access medical services. If you
have questions, please call Customer Service at 1-866-698-5437.
• Emergency care right away—both in and out of the Plan’s service area.
• Urgent care within 24 hours. Urgent care is for a problem that is not life-threatening. It could cause serious
illness or disability unless medical care is received.
• Routine sick care within a week of the request.
• Physical exams within a month of the request.
• Follow-up care as needed.
OUT-OF-NETWORK
We want to make sure you get the care that you need. If we don’t have a network provider who can give you
covered services you need, we’ll cover these services out-of-network. We’ll make sure that the cost to you is
no more than it would be if the services were done in-network.
You can get care from doctors, hospitals and others who are part of our provider network. A doctor in the plan
network or the plan must approve your care. The plan pays for the care it approves. You may have to pay for
care the plan doesn’t approve. The plan will approve care that is medically needed. Services that are medically
needed:
• Are for an illness that would place your health in danger
• Follow accepted medical practices
• Are given in a safe, proper and cost-effective place, depending on the diagnosis and how sick you are
• Are not for convenience only
• Are not custodial
• Are needed when there is no better or less costly care, service or place
MEDICAL RECORDS
It is important that you request the release of your child’s medical records from doctors he/she has seen
before joining Staywell Kids. Please contact Customer Service if you need help asking for this information. You
can ask your PCP for your child’s current medical records. If you need any help with this, call us. The toll-free
number is 1-866-698-5437.
OTHER COVERED SERVICES
If you have questions about how to get any covered services not outlined here, contact your child’s PCP to
coordinate care.
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THE FOLLOWING IS THE DEFINITION OF URGENTLY NEEDED SERVICES
Urgently needed services are for illnesses or injuries that, if not treated in a timely manner, could lead to an
emergency.
They could cause:
• A problem with bodily function
• A chronic illness
• The need for a more complex treatment
Examples:
• Abdominal pain that doesn’t go away
• Dizziness and you don’t know why
• Signs of dehydration
You should call your child’s PCP at the 24-hour number provided to get urgently needed services.
EMERGENCY SERVICES
If your child becomes seriously ill or injured, you should take these steps.
1. Go the nearest emergency room (ER) or call 9-1-1.
2. Show your child’s ID card to the ER staff.
3. Ask that the ER staff contact your child’s PCP. He/she can decide the right follow-up care.
4. If your child is admitted to the hospital, make sure that the PCP or the Plan has been told.
OUT-OF-AREA EMERGENCY CARE
It is important to get care when you are sick or hurt. If your child gets sick while traveling, call Customer Service.
If he/she has an emergency while traveling, go to a hospital. It doesn’t matter if you are not in the Plan’s service
area. The Plan will cover services only within the United States and not outside the country. Show your child’s
ID card. Call your child’s PCP as soon as you can. Ask the hospital staff to call Staywell Kids. 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.
AFTER-HOURS MEDICAL CARE
In some cases, your child may get sick or hurt when his or her PCP’s office is closed. If it is not an emergency,
call the PCP. (The number is on your child’s ID card.) The 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 child’s doctor, go to an urgent care center.
You can also call the Personal Health Advisor (our free 24-hour nurse advice line) at 1-800-919-8807.
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COVERED SERVICES, BENEFITS & CO-PAYMENTS
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You may have to make a small co-payment when your child gets routine care. We may deny the service if you
do not pay a co-payment for such services. (There are some cases when you would not have to pay. Florida
Healthy Kids decides these cases. Call Customer Service for more details.)
Some doctors may not give some types of care. This may be due to their religious or moral beliefs. The plan
cannot deny services for these same reasons.
CO-PAYMENT
SERVICE
IMPORTANT NOTES
(due at the time
of service)
Covered only:
Abortions
If the pregnancy is the result of an act of rape or incest,
or
$0
When a physician has found that the abortion is needed
to save the life of the mother
Ambulatory surgery
center services
$0
For children who are 5 to 18 years of age
Screening services include:
• A comprehensive physical examination
• A comprehensive health and developmental history
• Developmental appraisal (including mental,
emotional and behavioral)
• Anticipatory guidance and health education
Child health checkups
• Measurements
• Dental/oral health assessment
$0
• Vision and hearing tests
• Certain laboratory procedures
• Lead risk assessment
Immunizations, as needed, to be given at the time of
screening services
Checkup schedule: 5 to 18 years of age — one exam
each year
continues
CO-PAYMENT
SERVICE
IMPORTANT NOTES
(due at the time
of service)
Covered services include evaluation and treatment done
on one or more areas of the body
Chiropractic services
Treatment consists of manual manipulation or adjustment
with application of controlled force to re-establish normal
function (mobility and range of motion to the spine)
$5
Limited to 24 visits a year
Manual manipulation done on patients who don’t have
back issues is not covered
Cosmetic procedures
Dental services
Not covered
Not covered
Talk with your child’s PCP to coordinate care
*Pre-authorization required
Includes, but not limited to items like:
• Medical supplies (such as colostomy, ureterostomy,
gastrostomy or surgical dressings)
• Diabetic supplies (lancets, glucose testing strips),
nebulizers, infusion pumps, wheelchairs and hospital
beds
Durable medical
equipment (DME)
Members 5 years through 18 years of age with a
physical or mental condition that results in chronic
incontinence — diapers, briefs, protective underwear,
pull-ons, liners, shields, guards, pads and undergarments
may be reimbursed up to a combined total of $200 per
calendar month
$0
Devices and equipment that are primarily and
customarily used for non-medical purposes are not
covered; some items include comfort or convenience
items, physical fitness equipment, incontinence items,
and safety alarms and alert systems
Covered services include:
Emergency room
(ER) services
• Visits to an ER or other licensed facility if needed
immediately due to an injury or illness, and delay means
risk of permanent damage to the member’s health
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$10 per visit
(not collected
if admitted or
approved by your
child’s PCP)
CO-PAYMENT
SERVICE
IMPORTANT NOTES
Experimental and
investigational
procedures
Not covered
(due at the time
of service)
Not covered
• Planning and referral
Family planning
services
• Education and counseling
• Initial examination
$0
• Diagnostic procedures and routine laboratory studies
• Contraceptive drugs (such as IUD, Depo-Provera,
Lunelle and cervical caps) and supplies
Hearing services
Routine hearing screenings must be provided by your
child’s PCP
Hearing aids are covered only when needed to help
treat a medical condition
$0
Home health care
services
• Prescribed visits by both registered and licensed
practical nurses to provide skilled nursing services
on a part-time, intermittent basis
$5 per visit
Hospice care
• Reasonable and necessary services to manage
terminal illness
$5 per visit
Covered mental health services include:
Inpatient mental
health and substance
abuse services
• Care for psychological or psychiatric evaluation and
treatment by a licensed mental health professional
Substance abuse services include:
$0
• Coverage for care for drug and alcohol abuse,
including counseling and placement assistance
Inpatient services
Pre-authorization is required
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$0
CO-PAYMENT
SERVICE
IMPORTANT NOTES
(due at the time
of service)
• Maternity care
• Newborn care
Maternity services and
newborn care
• Prenatal and postnatal care
• Initial inpatient care of adolescent participants,
including nursery charges and initial pediatric or
neonatal examination
$0
• Infant is covered for up to three days following
birth or until infant is transferred to another
medical facility, whichever comes first
Coverage includes:
• Regular nursing services
• Rehabilitation services
• Drugs and biologicals
Nursing facility
services
• Medical supplies
• Use of appliances and equipment furnished by
the facility
$0
• Limited to no more than 100 days in a contract
(Oct.-Oct.) year
Nutritional counseling
• Preventive, treatment and follow-up services,
including dietary counseling and nutritional
education
Outpatient hospital
services
$0
$0
Covered mental health services include:
Outpatient mental
health and substance
abuse services
• Care for psychological or psychiatric evaluation and
treatment by a licensed mental health professional
Substance abuse services include:
• Coverage for care for drug and alcohol abuse,
including counseling and placement assistance
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$5 per visit
CO-PAYMENT
SERVICE
IMPORTANT NOTES
(due at the time
of service)
Podiatry (foot)
services
• Diagnosis, medical, surgical, mechanical, manipulative
and electrical treatment services limited to ailments
of the human foot or leg
$5 per visit
• Limited to one visit a day, totaling two visits a
month
Physical, occupational
and speech therapies
(done within an office
or a hospital)
• Physical, occupational, respiratory and speech
therapies for short-term rehabilitation where
significant improvement in the member’s condition
will result
$5 per visit
• Limited up to 24 treatment sessions within a 60-day
period per episode or injury, with the 60-day period
beginning with the first treatment
Generic prescriptions (31-day supply)
Prescriptions
Brand-name prescriptions (available only if no generic is
available or if the brand name is considered medically
necessary)
$5 per
prescription
Well-child care visits
Primary care physician
(PCP) services
• Office visits
• Medical and surgical care and consultation
$0
• Diagnosis
• Treatment
Includes, but not limited to, items such as:
• Leg, arm and neck braces
Prosthetic and
orthotic devices
• Diabetic and custom-molded shoes
• Artificial limbs
• Breast prostheses
• Prosthetic eyes
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$0
CO-PAYMENT
SERVICE
IMPORTANT NOTES
(due at the time
of service)
• Office visits
Specialist services
• Medical and surgical care and consultation
• Diagnosis
$5 per visit
• Treatment
Must be referred by your PCP
Sterilization
Not covered:
• Tubal ligation
Organ transplantation services include:
• Pre-transplant, transplant and post discharge
services
• Treatment of complications after transplant
Transplant services
Coverage is available for transplants and medically
related services if:
$0
• Deemed necessary and appropriate within the
guidelines set by the Organ Transplant Advisory Council
or the Bone Marrow Transplant Advisory Council
Emergency ambulance transportation:
• Emergency transportation as determined to be
medically necessary in response to an emergency
situation
• Emergency air ambulance transportation
Transportation
• Services are covered when the transport is a critical
emergency situation in which loss of life, limb, or
essential body or organ function is jeopardized, and time
constraints make the use of land ambulance impractical
$10
per service
Not covered:
• Non-emergency transportation
Your child must have a failed vision screening by his/
her PCP
Vision services
Limited to:
• One pair of glasses (Medicaid frames with plastic or
SYL non-tinted lenses) every two years unless head
size or prescription changes
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$5 per visit for
refractions
$10 per visit
for corrective
lenses
EXTRA STAYWELL KIDS BENEFITS AT NO COST
$0 co-payments for primary care provider (PCP) services
$0 co-payments for urgent care visits
Get up to $180 in FREE over-the-counter (OTC) items each year. That’s $15 each month to buy items such
as sunscreen, aspirin, vitamins and more. OVER 100 items to choose from.
Qualified members can receive up to $100 in hypoallergenic bedding to avoid asthma triggers. Call our
Disease Management team to learn more. (See the Case and Disease Management section for the toll
free phone number.)
Free membership to the Boys and Girls Club (where clubs are available) for members ages 6-18 (available
only during the school year). Call Customer Service to get more information.
CASE AND DISEASE MANAGEMENT
Staywell Kids has case and disease management programs. These programs are offered to members with longterm, complex or chronic health problems. Problems like:
• Asthma
• Diabetes
• Hypertension (high blood pressure)
Members can choose to take part in these programs. If they do, they will work with a case or disease manager.
Our case and disease managers are registered nurses (RNs). These nurses work with you and to help you
understand your child’s illness. They help you to get the health care services you need for your child by
working with you, your family and your providers. They work with you to help manage your child’s illness
through medical, social and community resources.
You can learn more about these programs by calling your PCP. Or call Customer Service. Call weekdays from
7 a.m. to 7 p.m Eastern. The toll-free number is 1-866-698-5437. TTY/TDD users may call 1-877-247-6272.
BEHAVIORAL HEALTH CARE
Need help finding a behavioral health provider in your area? Call 1-877-712-5340 (TTY/TDD 1-877-247-6272).
They will give you a choice of doctors and help you find one in your area. You can visit
www.magellanhealth.com/member.
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What to Do if You Need Help with a Behavioral Issue
If you have any of the feelings below, call 1-877-712-5340 (TTY/TDD 1-877-247-6272). You can get the names of
doctors who can help.
• Always feeling sad
• Feeling hopeless and/or helpless
• Feelings of guilt or worthlessness
• Problems sleeping
• No appetite
• Weight loss or gain
• Loss of interest in things you like
• Problems paying attention
• Being upset
• Your head, stomach or back hurts, and your doctor hasn’t found a cause
• Drug or alcohol problems
PRESCRIPTIONS
Prescriptions must be written or approved by a Staywell Kids doctor. They must be picked up at a pharmacy
that is part of the plan network. A list of pharmacies you can go to is in your provider directory. You can also
find them on the Web at www.florida.wellcare.com. Click on the Medicaid link and choose Florida. Then click
on the Staywell Kids page. Questions? Call Customer Service at 1-866-698-5437 (TTY/TDD: 1-877-247-6272).
Prescription drugs the Plan covers are on the Preferred Drug List (PDL). Doctors, pharmacists and nurses make
this list. The list also includes drugs that may have limits due to your age or gender. Your doctor will use the
PDL when writing you a prescription.
You can find a current PDL on the Web at www.florida.wellcare.com. Click on the Medicaid link and choose
Florida. Then click on the Staywell Kids page.
FILLING PRESCRIPTIONS
Having your child’s prescription filled is easy. Simply take it to one of these local pharmacies. Show your child’s
ID card.
• CVS
• Kmart
• Medicine Shoppes
• Publix
• Sweetbay
• Target
• Walgreens
• Wal-Mart
• Winn-Dixie
You will have to pay a co-payment when you pick up the prescription. Your co-pay covers a 31-day supply of
your child’s medicine.
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PEDIATRIC NEW MEMBER QUESTIONNAIRE
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It is important that we know about the health of your child. With your help, we can be sure your child gets
the best health care. This information is confidential.
We have a team of pediatric nurses waiting to serve you. Please fill out this questionnaire for each child.
Responding will not deny your child’s enrollment. Please return it in the enclosed envelope. You do not need
a stamp.
First Name:_____________________________________________ Today’s Date: _____________________
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Last Name: _____________________________________________ Enrollment Date:___________________
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Address: _______________________________________________ Member ID:_______________________
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Healthy Kids ID: _________________________________________ Phone: _____________________________
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Social Security #: _________________________________________
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Date of Birth:____________________ ❒ Male ❒ Female Height:________ Weight:________ Age: _______
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Parent/Legal Guardian Name: ________________________________________________________________
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Primary Care Physician Name: ________________________________________________________________
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1. When did your child last see the PCP? ❒ Never ❒ Less than 6 months ago ❒ Over 6 months ago
2. When was your child’s last well-child checkup? ________________________________________________
3. Are your child’s shots up-to-date? ❒ Yes ❒ No
4. Where did your child receive shots?__________________________________________________________
5. Has your child ever had a lead-level screening? ❒ Yes ❒ No
6. How was your child delivered? ❒ Vaginal (Normal Birth) ❒ C-Section
7. Birth Weight: ___________________________________ ❒ Full-term ❒ Premature
8. How long was your child in the hospital after birth? ____________________________________________
9. Did you have any problems with the birth or after? ____________________________________________
10. Has your child been DIAGNOSED with or SUSPECTED of having any of the following? (Check those that apply.)
❒
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❒
❒
❒
❒
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❒
Asthma/Breathing Problems
Developmental Delay
Anxiety
Behavioral Problems (attention deficit, with or without hyperactivity; alcohol or drug use)
Psychological Problems (depression, anxiety, abnormal thinking)
Nervous System Disorders
Encephalitis
Meningitis
Other Health-Medical Problems
Kidney/Urinary Problems
continues on back
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❒
❒
❒
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❒
❒
❒
❒
❒
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Bowel Problems�
Heart Problems�
Hepatitis/Liver Disease�
Endocrine Disorders�
Hyperthyroidism/Hypothyroidism�
Addison’s Disease�
Cushing’s Syndrome�
Sickle Cell Anemia�
Leukemia/Cancer�
Cystic Fibrosis�
❒
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Diabetes
Vision Problems
Hearing Problems
Ear Problems
Rheumatic Fever
Spina Bifida
Muscular Dystrophy
Orthopedic Problems
Hemophilia/Blood Disorder
Stroke
11. Are any of these conditions getting worse? ❒ Yes ❒ No If yes, please explain: _____________________
_____________________________________________________________________________________
12. Do you need information about any of them? ❒ Yes ❒ No If yes, please explain: ___________________
_____________________________________________________________________________________
13. How many times in the last 12 months has your child been to the ER? ❒ None ❒ 1 Time ❒ 2 Times or More
Reason: _______________________________________________________________________________
14. How many times in the last 12 months has your child been in the hospital? ❒ None ❒ 1 Time
❒ 2 Times or More Reason: ______________________________________________________________
15. What medications does your child take? (List all medicines, including vitamins, prescriptions and OTC drugs.)
_____________________________________________________________________________________
_____________________________________________________________________________________
16. Do you have any questions about your child’s medications? ❒ Yes ❒ No
17. Is there any medical equipment in the home used by your child? ❒ Yes ❒ No
18. Is your child under the care of a home health nurse? ❒ Yes ❒ No
19. Do your child’s medical problems get in the way of play, school or day care? ❒ Yes ❒ No
If yes, please explain: ____________________________________________________________________
School Name:_____________________Phone:___________________School Nurse: _________________
20.Does your child have any limitations that get in the way of daily life? ❒ Yes ❒ No
21. Is your child being treated for psychiatric or behavioral problems? ❒ Yes ❒ No
22. Is your child now enrolled in Children’s Medical Services (CMS)? ❒ Yes ❒ No
23. Has your child ever been enrolled in CMS? ❒ Yes ❒ No
Thank you for taking time to let us know your child’s needs. Please mail back this form in the envelope
provided.
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CONTACTING STAYWELL KIDS
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FILING A GRIEVANCE
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Please let us know right away about problems with your health care. Call Customer Service with any questions
you may have. The toll-free number is 1-866-698-5437.
This section gives the rules for making complaints. State law says you have the right to make complaints about
any part of your medical care as a plan member. The state has helped set the rules about what you need to do
to make a complaint. There are also rules about what we must do when we get a complaint. We must be fair
in how we handle it. You cannot be dropped for making a complaint. You will not be penalized in any way.
WHAT ARE APPEALS AND GRIEVANCES?
You have the right to make a complaint about your child’s coverage or care. There are two types of
complaints. They are called “appeals” and “grievances.”
What is an appeal?
An appeal is a complaint you make when you want us to change a decision we made about your care. You can
file one when we:
• Deny or limit a service request
• Reduce or stop services you have been getting
• Refuse to pay for services that you think should be covered
• Fail to give services in the required timeframe
What is a grievance?
A grievance is the type of complaint you make if you have any other kind of problem with the Plan or one of
our plan providers.
For example, you would file a grievance if you have a problem with things such as …
• The quality of your child’s care
• Waiting times for appointments or in the waiting room
• The way your child’s doctors or others behave
• Being able to reach someone by phone or get the information you need
• The condition of the doctor’s office
Part I. Making complaints called “appeals”
This section tells you what to do if you have problems getting the care you think we should provide. We use
the word “provide” to mean things such as:
• Authorizing care
• Paying for care
• Arranging for someone to provide care
• Continuing to provide a medical treatment your child has been getting
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STEPS FOR REQUESTING CARE OR PAYMENT FROM STAYWELL KIDS
There are steps you can take to ask for the care or payment you want from us. Your request is considered
at each step. Then a decision is made. There may be another step you can take if you are not happy with the
decision.
STEP 1: THE INITIAL DECISION BY STAYWELL KIDS
First we make an “initial decision” about your child’s care or payment for care. This is also called an
“organizational determination.” We will say how we think the benefits we cover apply in your case. You can
ask for a “fast organizational determination.” This is for a decision that needs to be made quickly.
STEP 2: APPEALING THE INITIAL DECISION BY STAYWELL KIDS
You can ask us to rethink our initial decision. This is called an “appeal” or a “request for reconsideration.” You
can ask for a “fast appeal.” This is for health care requests that need quick decisions. We will review your appeal.
Then we will decide to stay with our original decision or change it.
HOW DO YOU FILE YOUR APPEAL OF THE INITIAL DECISION?
You, someone you appoint or your provider may file this appeal. You must let us know in writing if you are
naming someone to do this for you. An Appointment of Representation form can help you do this. You can get
this form from Customer Service.
You may file a verbal or written appeal. A verbal appeal must come with a written appeal request that is signed.
(This is not needed with a fast appeal.)
A verbal appeal can be filed by calling Customer Service.
A written appeal should be mailed to:
Staywell Kids Health Plan
Attn: Appeals Department
P.O. Box 31368
Tampa, FL 33631-3368
A written appeal can also be faxed to 1-866-201-0657.
WHAT IF I WANT TO APPEAL A DECISION ABOUT A PRESCRIPTION? DO I DO
ANYTHING DIFFERENT?
You can still call Customer Service. But appeals about prescriptions or medications go to a different address:
Attn: Pharmacy Appeals Department
P.O. Box 31398
Tampa, FL 33631-3398
You can fax it to 1-888-865-6531.
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HOW SOON MUST I FILE MY APPEAL?
Appeal within 30 calendar days of the date of our notice to you.
We will send you a letter within 10 calendar days after we get your appeal. It will let you know we got your
appeal. We will not send one if it is a request for a fast appeal. You will get a decision letter if we are able to
resolve the appeal within 10 calendar days.
What if I want a fast or expedited appeal?
You can ask for a fast appeal instead of a standard one. A doctor or representative can do this for you. Call
Customer Service for help. Or you can send an appeal to:
Staywell Kids
P.O. Box 31368
Tampa, FL 33631-3368
You can also fax it to 1-866-201-0657. Be sure to ask for a fast review.
Send an appeal for a decision we made on a prescription to:
Attn: Pharmacy Appeals Department
P.O. Box 31398
Tampa, FL 33631-3398
You can also fax it to 1-888-865-6531. Don’t forget to ask for a fast review. We will give you a fast appeal if your
doctor says waiting could seriously harm your health.
You may ask for a fast appeal without a doctor’s help. We will decide if you need a fast decision. We will try
to call you if we decide your health does not require it. We will also send you a letter within two days. It will
say you can get a fast review with a doctor’s support. The letter will also tell you how to file a grievance if you
disagree and feel you need a fast review. We will give you a standard review if you decide not to do a fast
review. This usually takes 30 calendar days.
What if i Would like to submit additional information? You or someone appealing for you may give us more information. You may do this throughout the appeal
review process.
The member or the member’s representative may examine the member’s case file. This includes medical
records (subject to HIPAA requirements). It also includes any other documents and records considered during
the appeals process.
hoW soon must We deCide on Your aPPeal?
• For a decision about payment for care your child has received: 30 days after we get your appeal
• For a fast decision about care: Up to 72 hours after we get your appeal
You can also ask us for up to 14 more days to give us more information. We may also ask for 14 more days if
we feel more information is needed and it is in your best interest.
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HOW CAN YOUR CHILD KEEP GETTING BENEFITS WHILE THE APPEAL IS BEING
CONSIDERED?
In order for this to happen:
1. You must file your appeal within 10 days of the date of our notice if you are filing orally. You have 15 days if
you are filing in writing by U.S. mail, or before the date of our proposed action takes effect.
2. The appeal must involve stopping or reducing treatment we OK’d previously.
3. The services must have been ordered by an authorized provider.
4. The authorization period cannot have expired.
5. You ask for an extension of benefits.
You may have to pay for all costs accrued during the review process if your appeal is not decided in your
favor.
What if I’m not satisfied with the results of my appeal?
You may ask for a hearing if you are not happy with the appeal decision. You may do this by asking for a
hearing before the statewide Beneficiary Assistance Program. Do this by contacting the agency listed below.
The Agency for Health Care Administration
Beneficiary Assistance Program
2727 Mahan Drive, MS #26
Tallahassee, FL 32308
Local: 1-850-412-4502
Toll-free: 1-888-419-3456
You must complete our appeal process before you can contact the Beneficiary Assistance Program. You must
ask for a hearing within 365 days of our first-level decision.
You may also contact the agency below any time during the appeal process:
Department of Financial Services
Consumer Services
200 East Gaines Street
Tallahassee, FL 32299
Toll-free: 1-800-342-2762
PART 2. Making complaints called “Grievances”
We want to know if you have any grievances. Call Customer Service. They will try to fix the issue over the
phone. If the issue is not fixed right away, your complaint will be forwarded to the Grievance Department.
If you have a question about what type of complaint process to use, call Customer Service. Call Monday
through Friday, 7 a.m. to 7 p.m. Eastern. The toll-free number is 1-866-698-5437.
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As a Staywell Kids member, you have the right to file a grievance about problems such as:
• Quality of services your child received
• Office waiting times
• Doctor behavior
• Facilities
• Involuntary disenrollment.
• If you disagree with our decision to take the standard 30 days rather than the 72-hour time frame for appeals
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We will try to fix any problem you might have. We can solve many issues over the phone. These may be about:
• Bad information
• A lack of information
• A misunderstanding
Grievances must be submitted to the plan within 365 days. You can do this orally or in writing. Send your
written grievance to:
Staywell Kids
P.O. Box 31368
Tampa, FL 33631-3368
We will send you a letter within 10 days. It will let you know we got your complaint. A doctor will review your
case if your grievance involves medical issues.
The process will be completed within 60 days of when we get your formal grievance. The 60-day time is
stopped if more information is needed from outside the service area. It will start again when we have the
information.
Up to 14 calendar days can be added to the process. We will let you know if this happens. You may also ask
for extra time.
We will send you a letter telling you the outcome of the case.
PAYMENTS
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Payments are due on the first day of each month. It is very important to make your monthly premium
payments to Healthy Kids on time. If your payment is not received by the due date, then your child’s
coverage will be cancelled. If your account is cancelled for non-payment, your child will have to wait at least
30 days before coverage can begin again. Your child will not be eligible for services during this waiting period.
A coupon book was mailed to you by Healthy Kids to help you with your payments.
If you have lost your coupon book, you can call Healthy Kids at 1-800-821-5437. Ask that a new one be sent to
you. Payments can also be made by phone or online, 24 hours a day, 7 days a week.
Mailing address for payments:
Florida Healthy Kids Corporation
P.O. Box 31105
Tampa, Florida 33631-3105
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To make a payment by phone: 1-800-821-KIDS (5437)
To make a payment online: www.healthykids.org
Pay by cash: https://www.healthykids.org/pay/cash/index.php
Text: https://mypayments.bill2pay.com/login/kidcare
FRAUD AND ABUSE
Fraud occurs when your health care plan gets billed for a service that costs more than the service received.
Fraud also happens when your health care plan pays for a service that someone never used. If you know that
fraud occurred, tell us. Call our 24-hour hotline at 1-866-678-8355.
To learn more, call 1-866-698-5437. TTY/TDD users may call 1-877-247-6272.
CANCELLATION OF YOUR CHILD’S POLICY
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To cancel your child’s Healthy Kids coverage, you must let Healthy Kids know. They will let Staywell Kids know.
Your policy may also be ended for these reasons:
• You did not renew your child’s account by the due date
• It has been proven that you have acted wrongly in giving the information that determined eligibility
• Your premium is not received by the due date
• Your child no longer meets the eligibility requirements
• Your child moves outside of your county service area
How to Contact Healthy Kids:
Florida Healthy Kids Corporation
P.O. Box 591, Tallahassee, FL 32302
1-800-821-KIDS (1-800-821-5437)
MEMBER RIGHTS AND RESPONSIBILITIES
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Florida law says you have rights when you get medical care. You also must respect your providers’ rights.
You may ask for a copy of the full text of this law from your providers. A summary of your rights and
responsibilities is as follows:
YOUR CHILD HAS THE RIGHT TO TIMELY, APPROPRIATE CARE …
• A right to receive information about the organization, its services its practitioners and providers and member rights and responsibilities
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• A right to participate with practitioners in making decisions about their health care
• A right to a candid discussion of appropriate or medically necessary treatment options for their conditions,
regardless of cost or benefit coverage
• A right to make recommendations regarding the organization’s member rights and responsibilities
• A patient has the right to be treated with courtesy and respect, with appreciation of his/her individual dignity, and protection of his/her need for privacy
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• A patient has the right to a prompt and reasonable response to questions and requests
• A patient has the right to know who is providing medical services and who is responsible for his/her care
• A patient has the right to know what patient support services are available, including whether an
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interpreter is available if he/she does not speak English
• A patient has the right to know what rules and regulations apply to his/her conduct
• A patient has the right to get information concerning diagnosis, planned course of treatment, alternatives,
risks and prognosis, and the plan cannot keep the health care provider from giving this information to the
patient
• A patient has the right to refuse any treatment, except as otherwise provided by law
• A patient has the right to not be responsible for the plan’s debts in the event of bankruptcy
• A patient cannot be held liable for covered services for which the plan does not pay the provider, and
the provider cannot hold a patient responsible for any unpaid amounts due to the provider other than a
co-payment
YOUR CHILD HAS THE RIGHT TO TIMELY PROBLEM RESOLUTION …
• Make complaints and appeals without discrimination and expect problems to be fairly examined and appropriately addressed
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• Responsiveness to reasonable requests made for services
CONFIDENTIALITY IS YOUR RIGHT ...
• Review and comment about your child’s personal health information and review medical records and/or
changes to your child’s personally identifiable health information
• Protection against unauthorized disclosure of his or her personal health information
• Approve the release of any information beyond Staywell Kids
• Have information used for research or performance measurement limited in that all data will be combined
• Authorize the use of his/her individually identifiable health information for any purpose including:
− The collection, use and sharing of data, unless the release of the information is required by law
− General consent is given when you submit the enrollment application for your child
− This authorizes the use of identifiable information that is needed for treatment, coordination of care,
conducting quality assessment, utilization review, fraud detection and specific and known oversight
reviews (such as state or accreditation organizations)
− This consent covers future, known or routine needs for the use of his or her health information
− Other consents, or special consents, will be obtained if specific member-identifiable information is
requested and is to be shared with another organization or agency
YOU HAVE THE RESPONSIBILITY TO …
• A patient is responsible for keeping appointments and, when he/she is unable to do so, for notifying the
health care provider or the health care facility
• A patient is responsible for providing to his/her health care provider, to the best of his/her knowledge,
accurate and complete information about present complaints, past illnesses, hospitalizations, medications
and other matters relating to health
• A patient is responsible for reporting unexpected changes in his/her condition to his/her health care provider
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• A patient is responsible for following the treatment plan recommended by his/her health care provider
• A patient is responsible for reporting to his/her health provider whether he/she understands a course of
treatment and what is expected of him/her
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• A patient is responsible for his/her actions if he/she refuses treatment or does not follow the health care
provider’s instructions
• A patient is responsible for ensuring that co-pays are paid as promptly as possible
• A patient is responsible for following health care facility rules and regulations affecting patient care and conduct
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• A responsibility to supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care
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• A responsibility to follow plans and instructions for care that they have agreed to with their practitioners
• A responsibility to understand their health problems and participate in developing mutually agreed-upon
treatment goals to the degree possible
IMPORTANT DEFINITIONS
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Contract year. Oct. 1 through Sept. 30.
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Coverage decisions. Choices the plan makes about benefits and what we will pay for a service.
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Emergency medical condition. This means care needed right away. Waiting would be too much of a risk. An average person would think someone’s health would be in danger without care. They might have very bad pain. They could even lose a body part. This also includes care for a pregnant woman and her unborn child.
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Health plan. Staywell Kids.
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Health plan member. Your child who is covered under the Healthy Kids Program.
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Illness. A sickness or disease.
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Member. Your child who is covered under the Healthy Kids Program.
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Participating provider. A facility or health care provider who offers services for plan members.
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PDL. Preferred drug list.
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Physician. A person who may practice medicine and does so within the scope of his/her license. Services must be covered under group health care plans per the laws of the local area where your child receives care. Plan (The Plan). Staywell Kids.
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Post-stabilization services. This means care after an emergency. It is care to help someone stay stable. The goal is to make sure you get well.
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Primary Care Physician (PCP). A person who may practice medicine or osteopathy in the local area where your child receives care. The PCP provides and helps direct all care for your child.
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Psychiatric Treatment Program. Offered by programs licensed to treat mental and nervous disorders. Also includes substance abuse rehabilitation.
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Service(s). Medical services or supplies provided to plan members under this group plan.
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We, Us, Our. Staywell Kids.
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WellCare Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed
and how you can get access to this information. Please review it carefully.
Effective Date of this Privacy Notice: March 29, 2012
We are required by law to protect the privacy of health information that may reveal your identity. We are also required by law
to provide you with a copy of this Privacy Notice which describes not only our legal duties and health information privacy
practices, but also the rights you have with respect to your health information.
This Privacy Notice applies to the following WellCare entities:
• WellCare of Florida, Inc.
• HealthEase of Florida, Inc.
• Harmony Health Plan of Illinois, Inc.
dba Harmony Health Plan of Missouri
• WellCare of New York, Inc.
• WellCare Prescription Insurance, Inc.
• WellCare of Connecticut, Inc.
• WellCare Health Insurance of Arizona, Inc.
operating as ‘Ohana Health Plan, Inc.
• WellCare of Louisiana, Inc.
• WellCare Health Insurance of Illinois, Inc.
• WellCare of Georgia, Inc.
• WellCare of Ohio, Inc.
• WellCare Health Insurance of Illinois, Inc.
dba WellCare of Kentucky, Inc.
• WellCare of Texas, Inc.
•� WellCare Health Insurance of New York, Inc.
• WellCare Health Plans of New Jersey, Inc.
• Exactus Pharmacy Solutions, Inc.
• Harmony Health Plan of Illinois, Inc.
We may change our privacy practices from time to time. If we make any material revisions to this Notice, we will provide you
with a copy of the revised Notice which will specify the date on which such revised Notice becomes effective. The revised
Notice will apply to all of your health information from and after the date of the Notice.
How We May Use and Disclose Your Health Information Without Written Authorization
WellCare requires its employees to follow its privacy and security policies and procedures to protect your health information in
oral (for example, when discussing your health information with authorized individuals over the telephone or in person), written
or electronic form.
1. Treatment, Payment, and Business Operations. We may use your health information or share it with others to help
treat your condition, coordinate payment for that treatment, and run our business operations. For example:
Y0070_NA018695_CAD_FRM_ENG State Approved 07232012
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©WellCare 2012 NA_04_12
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Treatment. We may disclose your health information to a health care provider that provides treatment to you. We may
use your information to notify a physician who treats you of the prescription drugs you are taking.
Payment. We will use your health information to obtain premium payments, specialty pharmacy payments, or to fulfill
our responsibility for coverage and the provision of benefits under a health plan, such as processing a physician claim for
reimbursement for services provided to you.
Health Care Operations. We may also disclose your health information in connection with our health care operations.
These include fraud and abuse detection and compliance programs, customer service and resolution of internal grievances.
Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose your health
information to tell you about treatment options or alternatives, as well as health-related benefits or services that may be
of interest to you.
Your Authorization. In addition to our use of your health information for treatment, payment or health care operations,
you may give us written authorization to use your health information or to disclose it to anyone for any purpose. You may
also revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization
while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any
reason except those as described in this Notice.
Family Members, Relatives or Close Friends Involved In Your Care. Unless you object, we may disclose your
health information to your family members, relatives or close personal friends identified by you as being involved in your
treatment or payment for your medical care. If you are not present to agree or object, we may exercise our professional
judgment to determine whether the disclosure is in your best interest. If we decide to disclose your health information
to your family member, relative or other individual identified by you, we will only disclose the health information that is
relevant to your treatment or payment.
Business Associates. We may disclose your health information to a “business associate” that needs the information in order to
perform a function or service for our business operations. Third party administrators, auditors, lawyers, and consultants are some
examples of business associates.
2. Public Need. We may use your health information, and share it with others, in order to comply with the law or to meet
important public needs that are described below:
• if we are required by law to do so;
• to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry
out their public health activities;
•� to government agencies authorized to conduct audits, investigations, and inspections, as well as civil, administrative or criminal
investigations, proceedings, or actions, including those agencies that monitor programs such as Medicare and Medicaid;
• to a public health authority if we reasonably believe you are a possible victim of abuse, neglect or domestic violence;
•� to a person or company that is regulated by the Food and Drug Administration for: (i) reporting or tracking product defects or
problems, (ii) repairing, replacing, or recalling defective or dangerous products, or (iii) monitoring the performance of a product
after it has been approved for use by the general public;
•� if ordered by a court or administrative tribunal to do so, or pursuant to a subpoena, discovery or other lawful request by
someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain a court
order protecting the information from further disclosure;
•� to law enforcement officials to comply with court orders or laws, and to assist law enforcement officers with identifying or
locating a suspect, fugitive, witness, or missing person;
• to prevent a serious and imminent threat to your health or safety, or the health or safety of another person or the public,
which we will only share with someone able to help prevent the threat;
• for research purposes;
•� to the extent necessary to comply with workers’ compensation or other programs established by law that provide benefits
for work-related injuries or illness without regard to fraud;
• to appropriate military command authorities for activities they deem necessary to carry out their military mission;
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• to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety,
security and good order at the place where you are confined;
• in the unfortunate event of your death, to a coroner or medical examiner, for example, to determine the cause of death;
• to funeral directors as necessary to carry out their duties; and
• in the unfortunate event of your death, to organizations that procure or store organs, eyes or other tissues so that these
organizations may investigate whether donation or transplantation is possible under law.
3. Partially De-Identified Information. We may use and disclose “partially de-identified” health information about you
for public health and research purposes, or for business operations, if the person who will receive the information signs
an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified health
information will not contain any information that would directly identify you (such as your name, street address, Social
Security number, phone number, fax number, electronic mail address, Web site address, or license number)
Your Rights to Access and Control Your Health Information
We want you to know that you have the following rights to access and
control your health information.
1. Right to Access Your Health Information. You have the right to inspect and obtain a copy of your health information
except for health information: (i) contained in psychotherapy notes; (ii) compiled in anticipation of, or for use in, a civil,
criminal, or administrative proceeding; and (iii) with some exceptions, information subject to the Clinical Laboratory
Improvements Amendments of 1988 (CLIA). If we use or maintain an electronic health record (EHR) for you, you have the
right to obtain a copy of your EHR in electronic format, and you have the right to direct us to send a copy of your EHR to a
third party you clearly designate.
If you would like to access your health information, please send your written request to the address listed on the last page
of this Privacy Notice. We will ordinarily respond to your request within 30 days if the information is located in our facility,
and within 60 days if it is located off-site at another facility. If we need additional time to respond, we will let you know as
soon as possible. We may charge you a reasonable, cost-based fee to cover copy costs and postage. If you request a copy
of your EHR, we will not charge you any more than our labor costs in producing the EHR to you.
We may not give you access to your health information if it: (1) is reasonably likely to endanger the life and physical safety
of you or someone else; (2) refers to another person and your access is likely to cause harm to that person; or (3) a health
care professional determines that your access as the representative of another person is likely to cause harm to that
person or any other person. If you are denied access for one of these reasons, you are entitled to a review by a health care
professional, designated by us, who was not involved in the decision to deny access. If access is ultimately denied, you will
be entitled to a written explanation of the reasons for the denial.
2. Right to Amend Your Health Information. If you believe we have health information about you that is incorrect or
incomplete, you may request in writing an amendment to your health information. If we do not have your health information,
we will give you the contact information of someone who does. You will receive a response within 60 days after we receive
your request. If we did not create your health information or your health information is already accurate and complete, we
can deny your request and notify you of our decision in writing. You can also submit a statement that you disagree with
our decision, which we can rebut. You have the right to request that your original request, our denial, your statement of
disagreement, and our rebuttal be included in future disclosures of your health information.
3. Right to Receive an Accounting of Disclosures. You have the right to receive an accounting of disclosures of your
health information made by us and our business associates. You may request such information for the six-year period prior
to the date of your request. Accounting of disclosures will not include disclosures: (i) for payment, treatment or health care
�
operations; (ii) made to you or your personal representative; (iii) you authorized in writing; (iv) made to family and friends
involved in your care or payment for your care; (v) for research, public health or our business operations; (vi) made to federal
officials for national security and intelligence activities and (vii) incident to a use or disclosure otherwise permitted or
required by law.
If you would like to receive an accounting of disclosures, please write to the address listed on the last page of this Privacy
Notice. If we do not have your health information, we will give you the contact information of someone who does. You will
receive a response within 60 days after your request is received. You will receive one request annually free of charge, but we
may charge you a reasonable, cost-based fee for additional requests within the same twelve-month period.
4. Right to Request Additional Privacy Protections. You have the right to request that we place additional restrictions
on our use or disclosure of your health information. If we agree to do so, we will abide by our agreement except in an
emergency situation. We do not need to agree to the restriction unless the information pertains solely to a health care item
or service that you have paid for out of pocket and in full.
5. Right to Request Confidential Communications. You have the right to request that we communicate with
you about your health information by alternative means or via alternative locations provided that you clearly state that
the disclosure of your health information could endanger you. If you wish to receive confidential communications via
alternative means or locations, please submit your written request to the address listed on the last page of this Privacy
Notice and how or where you wish to receive communications.
6. Right to Notice of Breach of Unencrypted Health Information. Our policy is to encrypt our electronic files
containing your health information so as to protect the information from those who should not have access to it. If,
however, for some reason we experience a breach of your unencrypted health information, we will notify you of the
breach. If we have more than ten people that we cannot reach because of outdated contact information, we will post a
notification either on our Web site (www.wellcare.com) or in a major media outlet in your area.
7. Right To Obtain A Paper Copy Of This Notice. You have the right at any time to obtain a paper copy of this Privacy
Notice, even if you receive this Privacy Notice electronically. Please send your written request to the address listed on the
last page of this Privacy Notice or visit our Web site at www.wellcare.com.
Miscellaneous
1. Contact Information. If you have any questions about this Privacy Notice, you may contact the Privacy Officer at
1-866-530-9491, call the toll-free number listed on the back of your membership card, visit www.wellcare.com, or write
to us at:
WellCare Health Plans, Inc. Attention: Privacy Officer P.O. Box 31386 Tampa, FL 33631-3386
2. Complaints. If you are concerned that we may have violated your privacy rights, you may complain to us using the contact
information above. You also may submit a written complaint to the U.S. Department of Health and Human Services. If you
choose to file a complaint, we will not retaliate in any way.
3. Additional Rights. Special privacy protections may apply to certain information involving HIV/AIDS, mental health, alcohol
and drug abuse, sexually transmitted diseases, and reproductive health. If the law in the state where you reside affords you
greater rights than described in this Notice, we will comply with these laws.
�
Notes
�
Notes
�
Helping Florida Kids
grow Up Healthy
�
P.O. Box 31387 • Tampa, Florida • 33631-3387
If you have any questions about the information
in this handbook, please call us.
1-866-698-5437 (TTY/TDD 1-877-247-6272)
47899
www.florida.wellcare.com
FL017058_CAD_MHB_ENG State Approved 08242012
©WellCare 2012 FL_08_12

HELPING FLORIDA KIDS GROW UP HEALTHY

Transcription

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