HEALTH CHOICE. Member Handbook Manual para Asociados

Transcripción

1 HEALTH CHOICE Member Handbook Manual para Asociados

2 Welcome to Thank you for choosing Prestige Health Choice for your health care needs We are happy to have you as a member Prestige Health Choice members deserve a health care plan that is easy to use and understand About Prestige Health Choice Dedicated to quality health care in your community Committed to programs that increase awareness of health and wellness Special programs for members with chronic conditions such as asthma, diabetes or heart disease We want to help you and your family members to be healthy Your Primary Care Physician How to Change PCPs or Health Plans Covered Services Expanded Special Health Programs Important Numbers Member Rights and Responsibilities Appeals and Grievance Process Loss of Eligibility Process Also included is: Provider Directory with our doctors, hospitals, pharmacies and other providers Membership Information Update Form Medical Records Release Form Health Assessment Form It is very important that you fill out the medical records Release and the Health Assessment Form Return only these forms in the stamped envelope with our return address right away There is no need the Membership Information Update form unless your information has changed Keep all other forms with you Someone from our Member Services staff will be calling you in the next 30 days This call is important It helps us find out about your health and each family member enrolled with Prestige It is especially important for your children so we make certain you are able to take them to see their doctor for their yearly check up Please call our Member Services Department free of charge if you need help in: Understanding any of our services or Hearing or vision impaired services Changing PCP s or going to another plan Call (TTY/TDD: ) to talk to a Member Services Representative for any questions Or, for a list of Prestige providers, go to our website at wwwprestigehealthchoicecom/psndirect Thank you, Cindy Meredith Prestige Member Services & Governmental Relations Director 6010MIA0411

3 Bienvenido a Gracias por preferir a Prestige Health Choice para sus necesidades de atención médica Nos complace tenerlo como asociado Los asociados de Prestige Health Choice merecen un plan de salud que sea fácil de usar y de entender En Prestige Health Choice Estamos: Dedicados a la atención médica de calidad en su comunidad Comprometidos a ofrecer programas para crear mayor conciencia de la salud y bienestar Compremetidos a ofrecer programas especiales para asociados que tengan afecciones crónicas como asma, diabetes o enfermedades cardiacas Queremos ayudar para que usted y su familia estén sanos Su médico de cabecera Cómo cambiar su médico de cabecera o el plan de salud Servicios cubiertos adicionales Programas especiales de salud Números importantes Derechos y responsabilidades de los asociados Proceso de apelación y quejas Proceso de pérdida de elegibilidad También se incluye: Directorio de proveedores con nuestros médicos, hospitales, farmacias y otros proveedores Forma para actualización de los datos del asociado Forma de autorización para divulgar el expediente médico del asociado Forma para la evaluación de salud Es muy importante que llene la autorización de divulgación del expediente médico y la forma para la evaluación de salud Devuelva solamente estas formas en el sobre con sello postal y con nuestra dirección de remitente, inmediatamente No hay ninguna necesidad de llenar la forma para actualizar los datos del asociado, a menos que, su información haya cambiado Guarde todas las otras formas con usted Alguien de nuestro personal de Servicios de Miembros le llamará en los 30 días siguientes Esta llamada es importante Esto nos ayuda a averiguar sobre su salud y cada miembro de familia matriculado con el Prestigio Es especialmente importante para sus hijos por lo que hacer ciertos de que eres capaz de llevarlos a ver a su médico para su cheque anual Por favor, lame al número gratuito de nuestro departamento de servicios para asociados si necesita ayuda para: Entender alguno de nuestros servicios o Obtener servicios para personas con impedimentos auditivos o del habla Cambiar el médico de cabecera o cambiar de plan Llame al (TTY/TDD: ) para hablar con un representante de servicios para asociados si tiene alguna pregunta Para ver la lista de proveedores de Prestige, vaya a nuestra página web wwwprestigehealthchoicecom/psndirect Gracias, Cindy Meredith Servicios al Asociado y Relaciones Gubernamentales de Prestige

4 TABLE OF CONTENTS I MEMBER INFORMATION 4 We Can Help You 4 Who is Eligible? 4 Understanding the Enrollment Process 4 Choosing Another Provider 5 Leaving Prestige 5 Coming Back to Prestige 5 Involuntary Disenrollment 5 Moving Outside the Prestige Service Area 5 II SERVICE INFORMATION 6 Prestige Services 6 Getting Services 9 1 Show Your Prestige Member Card 9 2 Call Your Primary Care Physician 9 Changing Your Primary Care Doctor 9 Where Do You Receive Your Medical Services? 9 How to Get Authorized Services? 9 What Happens When You Are Going to Have a Baby?10 Second Medical Opinion 10 Care Outside Your Service Area 10 Services Available Without Authorization 10 After-Hours Medical Care 10 Urgent Care 10 Emergency Care 11 1 STEPS FOR AN EMERGENCY 11 2 Out-of-Area Emergency Care 11 3 Emergency Planning for a Disaster 11 Receiving Other Prestige Services 12 1 Prescriptions 12 2 Dental Services 12 3 Hearing Services 12 4 Vision Services 12 Other Programs 12 III WHAT IS CONTINUITY OF CARE? 13 IV WHAT IS CARE MANAGEMENT? 13 V BEHAVIORAL HEALTH SERVICES 13 VI MEMBER RIGHTS 15 VII MEMBER RESPONSIBILITIES 15 VIII ADVANCE DIRECTIVES 16 IX MEMBER SATISFACTION INFORMATION 16 X GRIEVANCE AND APPEAL PROCESS 16 Understanding the Process 16 Contacting Prestige for Inquiries, Grievance or Appeals 17 Grievance and Appeal Procedures 17 1 Grievances 17 2 Appeals 18 3 Expedited Appeal 18 4 Medicaid Fair Hearing 18 5 y Assistance Program 18 XI FRAUD AND ABUSE 19 XII CONFIDENTIALITY 19 XIII QUESTIONS ABOUT PRESTIGE 19 XIV PHARMACY PROGRAMS 20 Important Phone Numbers 21 Prestige 21 Other Important Phone Numbers 21 Medicaid Area O ce Contact Information 22 FORMS 23 Medical Records Release Form Medical Records Release Form Designation of Health Care Surrogate 28 Appeal Form 30 Grievance Form 32 Living Will 34 Advance Directives Form 36 Membership Information Update Form 38 Health Assessment Form for New Members 40 Member Rights and Responsibilities 42

5 TABLA DE CONTENIDO I INFORMAĆION PARA ASODIADOS 45 Nosotros podemos ayudarle 45 Quién es elegible? 45 En qué consiste el proceso de inscripción 45 Cómo seleccionar otro proveedor 46 Para retirarse de Prestige 46 Para regresar a Prestige 46 6 Si se muda fuera del área de servicio de Prestige 46 II INFORMACIÓN SOBRE SERVICIOS 47 Servicios de Prestige 47 Prestige ofrece los siguientes servicios adicionales 49 Cómo recibir servicios 50 1 Presente su tarjeta de asociado de Prestige 50 2 Llame a su médico de cabecera 50 Cambio de médico de cabecera 50 Dónde recibe sus servicios médicos? 50 Cómo obtener servicios autorizados? 50 Qué pasa si va a tener un bebé? 51 Segunda opinión médica 51 Atención fuera de su área de servicio 51 Servicios disponibles sin autorización 51 Atención m 1 Centro de attención urgente 51 Servicios de emergencia 52 1 PASOS A SEGUIR EN CASO DE EMERGENCIAS 52 2 Atención de emergencia fuera del área 52 3 Plan de emergencia en caso de desastres 52 Para recibir otros servicios de Prestige 53 1 Recetas médicas 53 2 Servicios odontológicos 53 3 Servicios de la audición 53 4 Servicios de la vista 53 Otros Programas 53 III QUÉ ES LA CONTINUIDAD DE TRATAMIENTO? 54 IV QUÉ ES EL PROGRAMA DE CONTROL DE AFECCIONES CRÓNICAS? 54 V SERVICIOS DE SALUD MENTAL Y CONDUCTA 54 VI DERECHOS DE LOS ASOCIADOS 56 VII RESPONSABILIDADES DE LOS ASOCIADOS 56 VIII DOCUMENTO DE INSTRUCCIONES ANTICIPA- DAS SOBRE ATENCIÓN MÉDICA 57 IX INFORMACIÓN DE SATISFACCIÓN DEL ASOCIADO 57 X PROCESO DE APELACIÓN Y QUEJAS 57 En qué consiste este proceso 57 Comuníquese con Prestige si tiene preguntas, quejas o apelaciones 58 Procedimientos de apelación y quejas 58 1 Quejas 58 2 Apelaciones 59 3 Apelación agilizada 59 4 Audiencia justa ante Medicaid 59 5 Program 9 XI FRAUDE Y ABUSO 60 XII CONFIDENCIALIDAD 60 XIII PREGUNTAS SOBRE PRESTIGE 60 XIV PROGRAMA DE FARMACIA 61 Números Telefónicos Importantes 62 Prestige 62 Otros Números Telefónicos Importantes 62 Inform de Medicaid 62 FORMAS 23 Autorización Para Divulgar Expediente Médico Autorización Para Divulgar Expediente Médico Designación De Sustituto Para Decisiones Médicas 29 Formulario de Apelación 31 Formulario de Quejas 33 Testamento En Vida 35 Forma de Instrucciones Anticipadas 37 Formulario Para Actualizar Información Del Asociado 39 Evaluacion de Salud Para Nuevos Asociados 41 Derechos de Los Asociados 43

6 Congratulations You are now in the Prestige Health Choice (Prestige) health plan and we are here to provide you the health care you need This is your Member Handbook which will tell you how to get your health care under the Prestige plan Please have this handbook in an easy to place and read all of it I MEMBER INFORMATION We Can Help You Call Prestige with any questions you have Our Member Services Department will help you weekdays, 8 am to 7 pm, Eastern Time Call toll free at You may also use our automated service 24 hours a day, 7 days a week for the following: Request new member cards; Change your primary doctor; Ask for your over-the-counter products; Get a list of doctors in Prestige; Get a list of pharmacies in Prestige or how to use our mail order program; or Get information about children s dental services, transportation services or mental health services available through regular Medicaid Who is Eligible? Prestige serves children and adults who can be in Florida s Medicaid program The basic groups are: Individuals in Supplemental Security Income (SSI) program; Low-income children and families, including MediKids; and Aged, blind, and disabled people (also known as SSI-related Medicaid) We will call you now that you have become a Prestige Member or you can call us at our toll free number at Our Care Tell you about Prestige Ask questions about your health needs Answer any of your questions Interpretation services and alternative communication systems are available, free of charge, for all foreign languages Just call the Prestige Member Services Department Check our website at wwwprestigehealthchoice com for health education information and programs or call Member Services at our toll-free number at Some other Medicaid eligible groups may enroll in Prestige but are not required to so Call Medicaid Options at (TTY/TDD: ) to see if you are eligible The Florida Department of Children and Families (DCF) can tell you about other assistance programs such as food stamps, cash assistance and telephone assistance Understanding the Enrollment Process Medicaid will send you information on managed care plans in your area, like Prestige, after you re approved by DCF You are asked to pick your plan within 30 days If you do not, Medicaid will choose a plan for you Enrollment: If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Prestige or the state enrolls you in a health plan, you will have 90 days from the date of your first enrollment to try the health plan During the first 90 days, you can change health plans for any reason After 90 days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next nine months This is called lock-in 4 Open Enrollment: If you are a mandatory enrollee, the state will send you a letter 60 days before the end of your enrollment year telling you that you can change health plans if you want to This is called open enrollment You do not have to change plans IF you choose to change plans during open enrollment, you will begin in the new plan at the end of your current enrollment year Whether you pick a new plan or stay in the same plan, you will be locked into that plan for the next 12 months Every year you can change health plans during your 60-day open enrollment period

7 Disenrollment: If you are a mandatory enrollee and you want to change plans after the initial 90-day period ends or after your open enrollment period ends, you must have a state-approved good cause reason to change plans Call (TTY/TDD: ) to speak with a Medicaid Options representative if you have questions Choosing Another Provider You may pick a new Primary Care Provider (PCP) at any time You may also have all family members served by the doctors for each member If you want to have a new doctor, pick their name from the Provider Directory that we gave you when you became a Prestige Member and call the Prestige Member Services Department toll free at for help Leaving Prestige Some Medicaid recipients can change health plans whenever they choose, for any reason For example, people call Medicaid Options at You can not be in the Prestige plan if you lose your Medicaid Eligibility In addition, there are good cause reasons to disenroll from Prestige before your next open enrollment period Such reasons include, but are not limited to, the following: The enrollee moves out of the county, or the enrollee s address is incorrect and the enrollee does not live in a county where the plan is authorized to provide services The provider is no longer with the health plan The enrollee is excluded from enrollment A substantiated marketing or community outreach violation has occurred The enrollee is prevented from participating in the development of his/her treatment plan The enrollee has an active relationship with a provider who is not on the health plan s panel, but is on the panel of another health plan The enrollee is in the wrong health plan as determined by the Agency The health plan no longer participates in the county The state has imposed intermediate sanctions upon the The enrollee needs related services to be performed concurrently, but not all related services are available within the health plan network, or the enrollee s PCP has determined that receiving the services separately would subject the enrollee to unnecessary risk The health plan does not, because of moral or religious objections, cover the service the enrollee seeks The enrollee missed open enrollment due to a temponon-reform populations and 180 days or less for Reform populations Other reasons per 42 CFR 43856(d)(2), including, but not limited to, poor quality of care; lack of access to services covered under the contract; inordinate or inappropriate changes of PCPs; service access impairments of services; lack of access to providers experienced in dealing with the enrollee s health care needs; or fraudulent enrollment If you think you have good cause, call the toll free Medicaid Options at (TTY/TDD: ) Medicaid Options is a state-sponsored helpline that helps you enroll in the health plan of your choice Coming Back to Prestige You cannot be in the Prestige plan if you lose your Medicaid 60 days, Medicaid will put you in the Prestige plan and we will let you know in writing that you can get your health care Prestige will give you your original Primary Care Provider unless you tell us otherwise Involuntary Disenrollment Allow someone else to use your Prestige member card Miss 3 doctor appointments in a row within 6 months of time Lose your Medicaid eligibility Prestige can not disenroll you for the following: Preexisting medical conditions Changes in your health status Periodically missed appointments Moving Outside the Prestige Service Area If you move, please call Prestige Member Services to see you need You must notify the Department of Children and Families (DCF) at or Social Se curity (SSI) at After you call DCF or SSI to change your address, you must call Medicaid Options at (TDD: ) to choose a new plan 5

8 II SERVICE INFORMATION Prestige Services The following Table lists all the services covered by Prestige: COVERED SERVICES CHART Advanced Registered Nurse Practitioner Services Ambulatory Surgical Centers Behavioral Health Services Birth Center Services Child Health Check-Up Services Chiropractic Services County Health Department Services Durable Medical Equipment and Medical Supplies Dialysis Services Emergency Room Services Family Planning Services Freestanding Dialysis Centers Hearing Services Home Health Care Services Hospital Services Inpatient Hospital Services Outpatient Immunizations Independent Laboratory Services Licensed Midwife Services Optometric Services Physician Services Physician Assistant Services Podiatry Services Portable X-ray Services Prescribed Drugs Primary Care Case Management Services Rural Health Clinic Services Therapy Services: Occupational Therapy Services: Physical Therapy Services: Respiratory Therapy Services: Speech Transplant Services Vision Services 6

9 Details of some of these services are given below: BENEFITS BEHAVIORAL HEALTH SERVICES Community mental health services Mental health targeted case management Intensive targeted case management PHYSICIAN SERVICES Physician Visit Preventive Care Visits Diagnosis & Treatment Pregnancy Tests Psychiatric Physician Services PRESCRIBED DRUG SERVICES Prescription drugs FAMILY PLANNING SERVICES Initial visit Annual visit Supply visit & supplies Counseling visits OUTPATIENT HOSPITAL SERVICES Emergency room visits Respiratory therapy Medical supplies, such as casts & splints Oxygen & blood transfusions, Outpatient surgical procedures Physical therapy Outpatient hospital services for psychiatric conditions INPATIENT HOSPTIAL SERVICES Full patient care Children & Adults: Inpatient hospital services for psychiatric conditions INDEPENDENT LAB & XRAY SERVICES Independent lab & x-ray HOME HEALTH SERVICES Part-time intermittent skilled nursing care Part-time intermittent home Portable x-rays used in the home Private duty nursing VISION CARE Routine eye exams Contact lenses Lenses and frames Ophthalmologic eye care (medical) HEARING SERVICES Hearing Exams Hearing Aids LIMITATIONS Must be medically necessary No co-payment No co-payments* Covered in full May use network pharmacy or mail order program** Must be on the Prestige Preferred Drug List One visit per year One visit per year Unlimited; no co-payment Covered in full; no co-payment Unlimited when medically necessary in outpatient hospital setting; no co-payment Elective services require pre-authorization 45 days per contract year A contract year is 7/1 through 6/30 No co-payments when using network facilities* Must be medically necessary No co-payments when using network health aide care skilled services providers* One per year No co-payments for medically necessary services from network eye doctor Two per year for children One every two years for frames for adults One pair lenses every 365 days No co-payments for medically necessary services from network eye doctors* One exam every 3 years Every 3 years when medically necessary *May require doctor referral ** Provided to members age 21 and over for augmentative and alternative communication systems 7

10 II SERVICE INFORMATION Pr ers the following expanded services: 1 In addition to ered by Medicaid, Prestige is pleased to er the following Ex vailable to our Members Dental Scheduled oral examinations and cleanings 2 per year Dental X-rays one set each two years Amalgam Restorations: rface Two surfaces Three surfaces Limit one per year Extractions four per year rgical Limit two per year These services can be obtained by calling Managed Care of North America (MCNA) at dentists adults (age 21 and older) including acute emergency dental procedures to alleviate pain or infection and dentures and denture-related procedures Contact your Prestige Member Services at for more information If the dental services you require are not covered by either Medicaid or Prestige you have the following options: Unlisted procedures may be obtained through MCNA fees are the responsibility of the member and are not covered by Medicaid or Prestige Specialty dental services (oral surgeon, endodontist, periodontist, and orthodontist) may be obtained 2 exceed twenty dollars ($2000) per household, per and birth control supplies Qualifying items can be obtained from all network pharmacies Go to the pharmacy counter and items will be processed through the prescription adjudication system 3 (Age 21 and ver) The following will be covered at only free-standing facilities when medically necessary: Physical Therapy valuation and twelve (12) daily visits per condition per contract year Speech Therapy valuation and twelve (12) daily visits per condition per contract year Adult Home Physical Therapy (Age 21 and Over) Home physical therapy: ne (1) physical therapy evalu- ation and four (4) physical therapy visits per condition per contract year when medically necessary 4 Newborn/Child Circumcisions Covered for newborns during inpatient delivery stay To get Medicaid services that Prestige does not have but you can still have under the Medicaid such as dental ser vices or transportation services, call the Prestige Member Services Department at They will tell you how you can get the services customary fees These fees are the responsibility of the member and are not covered by Medicaid or Prestige 8

11 Getting Services 1 Show Your Prestige Member Card Every member of Prestige will get a Prestige member card Show your member card and your Medicaid gold card to doctors when you want to get health care Show it to hospitals and pharmacies too This card shows you are a member of Prestige Keep it with you at all times Do not let anyone else use your card or you If you lose your Prestige member card, call Prestige Member Services Department, toll-free, at A new card will be mailed to you right away If you lose your Medicaid gold card, call your caseworker at the Department of Children and Families to receive a new card 2 Call Your Primary Care Physician Your Prestige Primary Care Physician (PCP) is the doctor who will care for you: Call your PCP at the phone number on your member card get care You must make an appointment to see your doctor within 90 days of the start of your membership in the plan If you are pregnant, you must see your doctor within 30 days of the start of your membership The start date of your membership with Prestige is printed on your member card Some of our providers may not have malpractice insurance so If you are not sure if your doctor has it, please ask your doctor check their education and training We look at their experience Call Member Services at if you have questions about this Some doctors may not perform certain services based on religious or moral beliefs If this happens to you, please call Member Services at Changing Your Primary Care Doctor If you want to change your doctor, call Prestige Member Services We will be happy to help you The toll-free phone number is Your family members who are in Prestige can each pick a on your needs Where Do You Receive Your Medical Services? Health care services for Prestige members are provided through doctors, hospitals and other providers who have said yes to giving you health care services through Prestige The Provider Directory we gave you lists all the providers you may see Prestige will pay for the cost of care that is approved by Prestige If your care is not approved by Prestige, you may have to pay for the cost of the care How to Get Authorized Services or to Request a Referral? Call your Primary Care Provider (PCP) for all your regular health care needs Your PCP may refer you to a Prestige specialist when needed Please call your PCP for any specialist referrals Remember to call Member Services if you need help If your doctor or Prestige does not arrange for or approve your regular care, you will have to pay the bill Be sure your doctor gives you approval if you need to see a specialist If you need care by a doctor that is not a participating Prestige doctor, call your PCP or Prestige Member Services for help You or your doctor may ask Prestige for a fast or expedited prior authorization decision Ask for this to get an approved or discontinued service for which you cannot wait because waiting could place your life, health, or daily functions in serious danger 9

12 Care Outside Your Service Area If you need care while away on a trip like a vacation from the Prestige service area (the county you live in), call us, toll-free, What Happens When You Are Going to Have a Baby? should: 1 Call your Prestige primary doctor immediately to make an appointment 2 Choose a Prestige pediatrician as soon as possible for your baby Just call Prestige Member Services toll free at Contact your caseworker from the Department of Children and Families (DCF) so the baby can receive his/ her Prestige member card before your baby is born 4 Notify Prestige and DCF as soon as your baby is born If your baby is not with Prestige for some reason, you can call Medicaid Options and ask them to put your baby with Prestige The telephone number for Medicaid Options is (TDD: ) Second Medical Opinion If you want a second medical opinion about your health care, call your PCP and ask for another one You pick another Prestige doctor unless a Prestige doctor is not available Tests that are ordered for a second medical opinion must be done by a Prestige provider Your PCP will review your second medical opinion and decide on a treatment plan that is best for you If you choose a Prestige doctor, the cost of the second medical opinion will be paid by Prestige If you choose a doctor that is not a Prestige doctor, you may have to pay for the second medical opinion To request a faster decision, call Member Services, toll-free, at Monday through Friday, 8 am to 7 pm Eastern Time (except for holidays) Be sure to ask for a fast or expedited review Services Available Without Authorization You do not need approval from your doctor or Prestige to get these services from participating providers: 1 Podiatry 2 Dermatology 3 Expanded adult dental 4 Chiropractor 5 Yearly eye exams and glasses 6 Family planning (any participating Medicaid provider) 7 Any follow-up visits that the OB-GYN doctor says that you need The number of visits and services available without an authorization may be limited Even though you do not need permission for these services, you DO need to pick one of these specialists from the Prestige provider directory for your health care Call to make an appointment Tell them you are a Prestige member and show them your Prestige member card After-Hours Medical Care If it is NOT an emergency and you get sick after the doctors printed on your member card Do not go to the hospital needed care Urgent Care If you are sick and it is not an emergency but requires immediate attention, please go to the nearest urgent care center Some examples are: Sprains and minor fractures Back strain and painful urination Cold and symptoms Muscle aches and pains Earaches Cuts, scrapes and minor wounds Minor eye injuries, infections and irritations Childhood Check-up Your child s health is important You need to make certain your child sees his or her doctor at least once each year call Prestige Member Services at

13 Emergency Care Prior authorization is not required for emergency services or post stabilization care regardless of whether you receive this care within or outside of the Prestige network If you have an emergency such as: 1 Heavy blood loss 2 Heart attack 3 Severe cuts requiring stitches 4 Loss of consciousness 5 Poisoning 6 Severe chest pains 7 Loss of breath 8 Broken bones Go to the nearest emergency room If you are not sure if it is an emergency, call your Prestige doctor Call 911 for emergency transportation if you need it An ambulance will take you to any hospital You will have to pay for the ride if it is NOT an emergency An emergency is a condition that you believe will cause the following if you do not get help at once: 1 Serious harm to your health (this includes a pregnant woman or her unborn baby); 2 Serious injury to the body; 3 Serious damage of a body part; or 4 Serious damage of an organ For pregnant women, these medical problems may be an emergency: If you think there is not enough 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 1 Steps For An Emergency 1 Show your Prestige member card at the emergency room 2 Ask the in the emergency room to call Prestige 3 Let your doctor know as soon as you can when you are in the hospital 4 Let him/her know if you received care in an emergency room The ER doctor will decide if your visit is an emergency If it is not an emergency, you will be given the choice to stay or leave the hospital If you choose to stay, you will have to pay for your care Prestige will cover follow-up care to emergency treatment that your doctor says is medically needed Whenever possible have the hospital call Prestige or your PCP if you have to be admitted to the hospital 2 Out-of-Area Emergency Care It is important to get care when you are sick or injured If you become ill while traveling, call Prestige, toll-free, at If you have a true emergency while traveling, go to the nearest medical facility It doesn t matter if you are not in the plan s service area 1 Show your Prestige member card 2 Call your doctor as soon as you can 3 Ask the at the ER to call the Prestige health plan If you have to pay for emergency services when you get them, put in it writing to our Claims Department They will need copies of your medical reports Send copies of itemized bills and include proof of payment Call Prestige, toll-free, at for the address 3 Emergency Planning for a Disaster If there is an emergency situation, like a hurricane, get to a place of safety Take your medicine with you If you need emergency services during the disaster, go to the nearest hospital emergency room Call your PCP or the Member Services Department when the disaster is over to report any care you received during the emergency 11

14 Receiving Other Prestige Services 1 Prescriptions Prescriptions must be written or approved by a Prestige provider They must be picked up at a pharmacy that is part of the Prestige network A list of pharmacies you can go to is in your Prestige provider directory There is no cost to you for prescriptions Show your Prestige member card and your Medicaid gold card when you get your prescription A prescription written by a doctor who is not a part of the Prestige network, must be approved by your primary care doctor You must pick it up at a participating pharmacy or you may use our mail order delivery to your home There is no cost to you If you have questions, call the Prestige Member Services Department 2 Dental Services Children who need dental services get their care through a page 21 of this handbook) or Prestige Member Services at covered dental services (age 21 and older) including acute emergency dental procedures to alleviate pain or infection and dentures and denture-related procedures Contact your area Medicaid Services at for more information For your and how to get services 3 Hearing Services Prestige covers hearing services Medicaid Covered services include: Cochlear implants Diagnostic testing Hearing aids and/or hearing aid and dispensing Hearing aid repairs and accessories, and Newborn hearing screening Prestige provides hearing services to adults too Adult members of Prestige receive one hearing aid every three years, if medically necessary To obtain services, call HearX at If you have any questions regarding your hearing services, please contact our Member Services Department at from 8 am to 7 pm Eastern Time for help 4 Vision Services Prestige covers you for: One routine eye exam every year Additional eye exams if medically necessary Up to two pairs of eyeglasses for children Adult eyeglass frames are limited to one (1) pair every two (2) years, and adult eyeglass lenses are limited to one (1) pair every 365 days A second pair of eyeglass frames and a second pair of lenses may be provided during that period, after obtaining prior authorization To obtain services, call Advantica at If you have any questions regarding your vision services, please contact our Member Services Department at from 8 am to 7 pm EST for help When Your Life Changes If you move, get a new phone number, change or lose a job, or become pregnant, your DCF caseworker needs to know Please call Or, find your county office at wwwmyflfamiliescom/ contactu-us Other Programs In addition to the covered services listed in this handbook, there are other services available to you in your community Services Department at , regarding the following programs: Stop Smoking Drug and Alcohol Abuse Domestic Violence Pregnancy Prevention Prenatal/Postpartum Children s Health 12

15 III WHAT IS CONTINUITY OF CARE? If your doctor leaves Prestige while you are receiving medically necessary treatment, you have 6 months in which care will continue until: Your treatment is done, or You pick another doctor The care with your treating doctor must not go past 6 months If you are pregnant, you may continue care with your previous Obstetrician until your post-delivery check-up For new members, Prestige will honor any documentation of ongoing treatment for a period of one (1) month after IV WHAT IS CARE MANAGEMENT? Prestige has a care management program to help members with diseases such as asthma, diabetes, HIV/AIDS, and other chronic diseases You may be contacted: If you request care management If you meet criteria for one of our programs If your doctor requests that you be placed in the program Care Management takes immediate action to address follow-up with your PCP and other interventions to help you with your condition and stay healthy Call your doctor or our Member Services Department number located on your Prestige member card to learn more about these programs V BEHAVIORAL HEALTH SERVICES Behavioral health services you can get include inpatient and outpatient hospital services and psychiatric doctor services You and your children can also get a wide range of mental health and case management services You can get these services in the community, in your home and in schools Some of the services include: Individual, family, and group therapy Social rehabilitation Day treatment for adults and children Individual and family assessments Evaluations Treatment planning Call if you want to know more The staff will be happy to help you What to do if you are having a problem If you are having any of the following feelings or problems you should contact a Behavioral Health Provider: Constantly feeling sad Feeling hopeless and/or helpless Feelings of guilt Worthlessness Difficulty sleeping Poor appetite Weight loss Loss of interest Difficulty concentrating Irritability Constant pain such as headaches, stomach and back aches You do not need to call your PCP for a referral for an appointment An approval for services will be given at the time you call If you use a provider without getting an approval, you will have to pay the bill What to do in an emergency, or if you are out of the PsychCare service area First, decide if you are having a true behavioral health emergency Do you think that you are a danger to yourself or others? Call 911 or go the nearest emergency room for attention if you think you are Follow these steps even if the emergency facility is not in the Plan s service area If you need emergency Behavioral Health help outside the plan s service area, please tell the plan by calling the number on your ID card You should also call your PCP if you can and follow-up with your doctor within 24 to 48 hours 13

16 For out-of-area emergency care, when you are III TINUITY A RE? stable, plans will be made for transfer to an in-network facility Obtaining Behavioral Health Services If you need help finding a Behavioral Health Provider in your area you can call PsychCare Call You will be given the names of several providers in your local community from which you can choose to call for an appointment You can also choose a different behavioral health care coordinator or direct service behavioral health care provider within the Plan if one is available IV Behavioral Health Limitations and Exclusions Adults can get up to 45 inpatient days a year and unlimited outpatient behavioral health services with Medicaid Medicaid does not include a benefit for substance abuse treatment If you or a family member has a substance abuse problem, you should call your local Medicaid provider You can also ask our Behavioral Health staff to help you with a referral V B EHA HEALTH SERVICES Psychotropic Drug Consent Form Florida law requires a signed Consent Form if your provider wants your child, who is younger than 13 years old, to take psychotropic drugs This is important so you will find out why and what effects the medicine may have on your child The Consent Form is on our website Our website is wwwprestigehealthchoicecom The parent or legal guardian of the child signs the Consent Form Give the signed Consent Form to the doctor The doctor keeps the original signed Consent form in the Medical Record Keep a copy of the signed Consent Form Give a copy of the signed Consent form to the pharmacy Pharmacies have to get a copy of the signed Consent Form A pharmacy cannot give psychotropic drugs to a child without a copy of the signed Consent Form Please call our toll-free Member Services Call Center for help at

17 To be given information about coverage, services, and use of the health plan To receive considerate, respectful care and be treated with human dignity; and be provided appropriate privacy and to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation To know the names, titles, and credentials of all physicians and other health care professionals involved in your medical treatment To understand your medical condition and health status, recommended course of treatment, alternatives, and risks involved To actively participate in decisions regarding your medical care by having, to the degree known, complete information about your diagnosis, evaluation, treatment, and prognosis When medically inadvisable, to give the information to a person you chose or the legally authorized person To be informed of continuing health care requirements following discharge from the hospital or To refuse treatment, providing you choose to accept responsibility and the consequences of such a decision To be furnished health care services in accordance with federal and state regulations and to refuse to participate in any medical research projects To have any and all complaints forwarded to Prestige Member Services for appropriate response To have access and or copies of your medical records, have health information disclosures and records treated - dentially, and have the opportunity to approve or refuse their release, unless required by law, and to request that they be amended or corrected To complete an advance directive To make suggestions for improvement to Prestige To appeal unfavorable medical or administrative decisions by following the established grievance procedures of Prestige and the State To have all the above rights apply to the person having legal authority to make decisions regarding your health care To have all health plan personnel observe your member rights To exercise these rights without regard to sex, age, race, ethnic, economic, educational, or religious background The state must ensure that each enrollee is free to exercise his or her rights, and that the exercise of those rights does not adversely the way Prestige and its providers or the State agency treat the member VI MEMBER RIGHTS VII MEMBER RESPONSIBILITIES To understand how Prestige works by reading the Prestige member handbook To carry your Prestige ID card and Medicaid card with you at all times Present them to each provider (doctor, lab, hospital, pharmacy, etc) at the time services are being provided To select and seek all non-emergency care by appointment through your assigned Primary Care Doctor, to obtain a referral from your doctor for specialty care, and to cooperate with all persons providing your care and treatment To be on time for appointments or to notify the doctor s office well in advance if you need to cancel or reschedule an appointment To be respectful of the rights, property and environment of all health care professionals and other patients, and not be disruptive To be responsible for understanding and following medical advice concerning your treatment and to ask questions if you do not understand or need an explanation To understand the medications you take, know what they are, what they are for, and how to take them properly To provide accurate and complete medical information to all providers as may be required in the course of your treatment, including over the counter products, dietary supplements and any allergies or sensitivities To make sure your current doctor has been provided with copies of all previous medical records To notify Prestige within 48 hours, or as soon a possible, if you are hospitalized or receive emergency room care To inform your provider about any living will, medical power of attorney, or other directive that could your care 15

18 VIII ADVANCE DIRECTIVES Your Medical Care Your Decision The law says that you have a right to accept or refuse medical or surgical treatment This includes life-lengthening care Congress passed the Patient Self Determination Act It says that we must tell members how to use that right with the help of something called advance directives An advance directive is a legal paper It tells your doctors what type of treatment you want to get (or not get) if you are not able to tell them yourself There are two types of advance directives the Living Will and the Durable Power of Attorney for health care decisions You can change or cancel your decisions at any time If you do make changes, you should make them known to your doctor and family members A Living Will shows the type and amount of care you want if you are not conscious and will not wake up It can be used if you have a condition that will lead to death A Living Will tells your doctor when to keep up or stop care to lengthen your life Complaints about non-compliance with advance directive hotline at A Durable Power of Attorney for health care decision names the person you choose to make decisions for you It will be used if you are not able to make decisions It will also be used if you cannot make your decisions known to your doctor A Living Will or Durable Power of Attorney for health care decisions is used when and only when you cannot make decisions yourself It is used if you cannot make your wishes known to your doctor any Hospice or the Florida Medical Association Ask your doctor or call Prestige Customer Service for any help you may need IX MEMBER SATISFACTION INFORMATION Prestige wants to make sure that everyone receives the right medical care To make sure of this, Prestige works with our providers to go over your care This information includes member satisfaction If you have any questions or want information about the quality of Prestige care, please call Member Services at Or, you can check the Florida Agency for Health Care Administration s website for our performance outcome and website at wwwprestigehealthchoicecom X COMPLAINT, GRIEVANCE & APPEAL PROCESS Understanding the Process Prestige will make sure that all complaints, grievance and appeals are handled completely and quickly Complaints and Grievances are done by our Call Center or Grievance Coordinator We work closely with other Prestige departments and outside providers in looking at, asking questions attention of Prestige by our members The Appeals and Fair Hearing issues are handled by the Prestige Appeals Coordinator The Complaint, Grievance and Appeals Process is to make sure that Prestige: 1 resolves members problems promptly and at the lowest possible level, whenever possible; 2 reports the full extent of grievance activity to governmental oversight entities; and 3 uses grievance information to look at the data and improve performance Under no circumstances will Prestige take action against or take any discriminatory action against the member 16

19 Contacting Prestige for Complaints, Grievance or Appeals You should let us know when you are unhappy about your care at Prestige You may let us know of your complaint, grievance or appeal orally or in writing You may request Prestige Member Services Customer Service Representative completing forms and other steps, including, but not limited to, providing interpreter services and a toll-free number for the hearing impaired Our Member Services Department will help you weekdays, 8 am to 7 pm, Eastern Time Call toll free at or FAX at You may also use our automated service 24 hours a day, 7 days a week Or, Tallahassee, FL, An Inquiry is a written or oral question or request for and Prestige rules Inquiries are not about member grievances or disagreements with Prestige decisions 2 A Complaint is a written or oral question about your dissatisfaction with Prestige that can be resolved within two business days of receipt of written question or call Members may contact Prestige by calling Member Services at or, in writing to: Prestige Health Choice PO Box 6003 Hauppauge, NY A Grievance is about your unhappiness or dissatisfaction about any thing other than an Action (Appeal) that is not resolved within two business days Possible reasons Grievance and Appeal Procedures for grievances include, but are not limited to, the quality of care, the quality of services provided and actions by persons such as rudeness of a Provider or employee or failure to respect the member s rights Members may contact Prestige by calling Member Services at or, in writing to: Prestige Health Choice PO Box 6003 Hauppauge, NY An Appeal is asking for a second review of a health care service decision Examples of when an appeal may occur are shown below: a The denial or limited approval of a requested service, including the type or level of service b The reduction, suspension or ending of a previously approved service c The denial, in whole or in part, of payment for a service d The failure to provide services in a timely manner, as by Medicaid e The failure of Prestige to act within sixty (60) days from the date Prestige receives a grievance, or thirty (30) days from the date Prestige receives an Appeal f For a resident of a rural area with only one (1) managed care entity, the denial of an member s request to exercise his or her right to obtain services outside the network An appeal will be handled quickly when a delay in making life, health or ability to obtain, maintain or regain maximum function the member or head of household must be given to allow any other individual the ability to act on their behalf 1 Grievances Prestige accepts member grievances by mail, phone, fax, or in person a For grievances received by phone, Prestige: has live phone coverage during normal business hours and days; and has a telephone system available after hours to take calls and responds to all such calls no later than the next business day after the call was recorded b For grievances received by mail, Prestige will: date stamp the grievance the day it is received, forward all grievances to Member Services, who will log the information into the appropriate tracking system c Prestige will resolve each grievance within 60 calendar 17 days from the day Prestige receives the initial oral or written grievance request d Prestige will notify you, in writing, within 90 calendar days of the results and date of the determination of the grievance e I f the decision is not in your favor, the notice will include: The right to ask for a Medicaid Fair Hearing and the process for getting contact information; and to the Agency for Health Care Administration if requested f Prestige may extend the grievance time frame by up to 14 calendar days if you request an extension or Prestige documents that there is a need for additional

20 information that is in your best interest If you have not requested the extension, Prestige will give you written notice for the reason of the delay grievance You can use the form in your Prestige Member Handbook or call Member Services to help you If you ask for a form from Prestige, we will mail within 3 working days 2 Appeals Prestige accepts member appeals by mail, phone, fax, or in person You have the right to make written or verbal appeal within 30 days of receiving a Notice of Action b If the decision is in your favor, Prestige will provide the services as quickly as your health status requires c You are allowed to review your c before and during the appeal process d If you are making a verbal request, you must follow up in writing within 30 calendar days of the date your receive a written denial e You have up to 1 year to an appeal if the denial is not in writing 3 Expedited Appeal You have the right to make an expedited verbal or written appeal b If your life or health are in danger, or it routine, you or your legal representative can expedited appeal 4 Medicaid Fair Hearing your normal an If you are not happy with either the Plan s action or Grievance or Appeal decision, you can ask for a Medicaid Fair Hearing You have up to 90 days after receiving the notice of action, or the notice of decision on a previously To request a hearing, contact the Department of Children and Families at: 5 Beneficiary Assistance Program If you do not agree with the plans appeal determina- Prestige must have the following information: Name, address, telephone number, and Member Card number details of what you did to this complaint What you would like Prestige to do Signature and date Prestige will send you a determination notice to let you or whoever is helping you know in writing that the grievance is done and will give the reasons for the decision f You will receive a written response from Prestige within 30 days of the date you sent your request telling you of the decision by Prestige g If more time is needed, both you and Prestige must agree on it If other information is needed, Prestige will have 14 extra days to make a decision and will notify you of the extended time If the case is about the medical care or the quality of care, then another doctor who has not been involved will be asked to review the case You have the right to keep services during the process If you choose to continue service, and the ruling from Prestige is not in your favor, you may have to pay for those services c These appeals will be handled within 72 hours d Notify Member Services immediately at and they will help you in completing the required information e Prestige shall provide oral notice by close of business on the day of disposition and written notice within two (2) calendar days 1317 Winewood Boulevard, Building 5, Room 203 Tallahassee, FL If you choose this service, you give up the right to have the You may contact them at: Agency for Health Care Administration Bureau of Managed Health Care Building 1, Room 339, MS Mahan Drive, Tallahassee, FL Toll-free