1 Molina Community Plus Member Handbook Florida FL0213
2 Table of Contents Welcome to Molina Healthcare of Florida s Molina Community Plus Program...3 Enrollment Information...3 Eligibility and Reenrollment...4 Medicare Coverage...4 Your ID Card...4 Case Management Staff...5 Member Services...6 Where to Go For Care...6 Your Primary Doctor...7 Your Doctor Appointments...7 Provider Directory...7 Use of Participating Providers...8 Use of Out-of-Network Services...8 Oral and Written Translation/Interpretive Services...8 Authorization Process...9 Medical Necessity...9 Second Medical Opinion...11 Your Benefits...11 Medical Services...11 Emergency Care...12 Post-Stabilization...13 Non-Emergency Care Outside the Service Area...13 Hospital Care...13 What Do I Have to Pay For?...13 Complaints...13 Filing a Complaint...14 Grievance Process...14 Filing a Grievance...14 When you file a grievance...15
3 Appeal Process...15 File an Appeal...15 When you file an appeal...16 Continuing Benefits during appeal process...16 Expedited Appeal...16 File an Expedited Appeal...16 When you file an expedited appeal...17 Medicaid Fair Hearing and Statewide Assistance Panel...17 Disenrollment...18 Advanced Directives...18 Member Rights and Responsibilities...19 Your Membership Responsibilities...20 Abuse and Neglect...21 OTHER INFORMATION...21 Education and Information...21 Be Active In Your Health Care...22 Molina is Always Trying to Be Better...22 Notifying you of changes...22 Non-Discrimination...23 The Quality of Care You Receive is Important to Us...23 YOUR HEALTHCARE PRIVACY...25 Legal or Administrative Proceedings...27
4 Welcome to Molina Healthcare of Florida s Molina Community Plus Program Welcome to Molina Healthcare of Florida s Molina Community Plus. Molina Healthcare coordinates your health care coverage. They will also help with long-term care services to get you the right care at home. You and your family help choose and arrange for your care at home with the support of your personal Case Manager. The goal of the Molina Healthcare of Florida s Molina Community Plus Program is to help you live in your home by offering a wide range of medical coverage, home based care and community services. Your case manager will discuss your specific individual needs with you and coordinate services. Your Primary Doctor will manage your care when you are ill. They will order the necessary tests and X-rays. They will also arrange any necessary hospital and emergency care. Your Case Manager will: Assess your medical and long-term care services Assess your medical and home care needs Arrange the right services along with you and your family to meet your needs This handbook explains how to obtain medical care. It will help explain how to get home support and community services and provides information about your membership. If you have any questions, please contact: Case Management Molina Healthcare of Florida Enrollment Information To be eligible for Molina Community Plus Program you must be: 65 years of age or older Medicare Parts A and B eligible Medicaid eligible with incomes up to the Institutional Care Program level (ICP) Reside in the program s service area Be determined by CARES to be at risk of nursing home placement and meet one or more of the following clinical criteria: 1. Require some help with five or more activities of daily living (ADLs) 2. Require some help with four ADLs plus requiring supervision or administration of medication 3. Require total help with two or more ADLs 4. Have a diagnosis of Alzheimer s disease or another type of dementia and require assistance or supervision with three or more ADLs 5. Have a diagnosis of a degenerative or chronic condition requiring daily nursing services 6. Be determined by CARES to be a person who, on the effective date of enrollment, can be safely served with home and community-based services Welcome to the Molina family. 3
5 Eligibility and Reenrollment Our members must be eligible for Florida s Medicaid program. The Florida s Department of Children and Families (DCF) will decide if you qualify for Medicaid eligibility. The Comprehensive Assessment Review Evaluation Service (CARES) determines if a person is clinically eligible for the Molina Healthcare of Florida s Molina Community Plus Program. Once (CARES) determines you are eligible they will send your enrollment request to Molina Healthcare. A Molina Case Manager will explain the program and the services provided. The meeting will be face-to-face meeting within (5) five business days if you live in a community setting. If you live in a facility, it will be within (7) seven business days. Molina will remain your health plan if you lose your Medicaid eligibility but regain it with within 60 days. Medicare Coverage Members of Molina Healthcare will also have Medicare coverage. This will be through traditional Medicare or through a Medicare health maintenance organization. Your Medicare coverage is separate from your coverage with Molina Healthcare. Most of your medical services (such as doctor and hospital services) will be obtained through your Medicare coverage. Molina Healthcare offers coverage for long-term care services. They also offer payment of Medicare deductibles and coinsurance for authorized Medicare-covered services that are also Medicaid-covered services. These services are paid up to the Medicaid rate. If you are a member of a Medicare HMO, you will receive Medicare services according to the guidelines of that program. Please call the Member Services if you have any questions about payment for Medicare deductibles or coinsurance at Your ID Card You will receive a Molina membership ID card after you are enrolled with Molina. It is important that you carry the Molina ID card along with your Medicare card at all times. The Molina card is good for as long as you are an active member of the plan. You will need your Medicare and Molina ID card each time you receive medical services. Continue to use your Medicare ID card for the Medicare-covered services you are already familiar with, such as doctor office visits and hospital visits. Call Molina Member Services if: Your card is lost or stolen You need to make changes or corrections If you are hearing impaired call the TTY line at to get a new card. 4 Welcome to the Molina family.
6 Molina Community Plus Member: Date of Birth: Francine Woodson 08/13/1947 Identification #: BIN#: XXXXX Effective Date: 08/01/2011 Molina Community Plus Benefits - Molina Community Plus Benefits include acute care, long term care and case management services. Medicare is the primary carrier responsible for acute care and most behavioral health services; therefore, the PCP s name, address and telephone number are not listed. The member receives long term care and case management services only through Molina Healthcare. EMERGENCY SERVICES: Call 911 if you can. Or you can go to the nearest emergency room (ER). Call your Primary Care Provider (PCP) if you are not sure you need to go to the ER. Or call our 24-Hour Molina Healthcare Nurse Advice Line at , (Espanol) or (TTY). Call your PCP after all ER visits. Case Management or Member Services: Call Claims Submission: Molina Healthcare of Florida, Molina Community Plus Program, PO Box 22812, Long Beach, CA 9080 EDI Claims: Emdeon Payer #51062 or call nahealthcare.c o m Case Management Staff Our Case Management department is dedicated to helping you by coordinating your care. Molina Healthcare will provider you with a Case Manager who will have direct contact with you and your family. They will discuss the services you need with you, your caregiver, and your Primary Doctor. They will help you with: Your appointments Authorize Services Answer any questions Assess your needs on an ongoing basis Your Case Manager based on your medical needs, home situation and support available from your family and friends will develop a care plan combining your needs. Your plan of care will be developed as an aid to help you live independently. The care plan not only outlines your needed services but also outlines expectations from the service providers. As your needs change, your case manager will review information with you and change your care plan. If you have any questions regarding your plan of care, please call your Case Manager who will be available to assist you. Our Case management staff can arrange many services for you, such as: Occupational, Speech or Physical therapy Home delivered meals Assisted living services and/or personal care aides Coordination with hospitals and home health agencies Medical supplies and equipment The Case Manager s responsibilities include: Authorizing and coordinating service requests Communicating frequently with you and your family/caregiver during the assessment and ongoing reassessment of your needs Welcome to the Molina family. 5
7 Educating you and your family/caregiver about your plan of care, treatment goals and making adjustments as necessary Contacting your providers of care (doctors, therapists, etc) to discuss your ongoing needs You should contact your Case Manager if any of the following status changes occur: Change of your address or telephone number Get other health care coverage Are admitted to a hospital or nursing home Enroll in Hospice Member Services The Member Services Department is available to assist you, Monday through Friday, 8:00 a.m. to 7:00 p.m. You can reach a member service representative at or for TTY at They can assist you with the following requests: Your healthcare benefits Information on providers If you have an issue or complaint ID card requests A bill you may have received Or any other concern If you need assistance after hours, you may call Nurse Advice Line at A representative is available 24 hours a day to assist you. Where to Go For Care The chart below suggests where to go for medical services you may need: Possible Problem Emergency care Care needed outside of Molina s service area. Urgent Care Where to Go/Who to Call Call 911 or go to the nearest emergency room If you require emergency care, go to the nearest emergency room. If your need is not an emergency, follow the instructions, below for urgent or routine care or contact your primary doctor Call your Primary Doctor or our (24) Hour Nurse Advice Line at Welcome to the Molina family.
8 Physical Exams Well or sick office visits Preventive Care Lab work Specialist visits Second Opinion Call you Primary Doctor Call your Primary Doctor or Case Manager Your Primary Doctor Your Primary Doctor will coordinate, arrange, and provide most of your medical needs. He or she will treat you if you are sick and can arrange the following services: Routine check-ups Referrals for consultations Routine diagnostics tests and lab tests Arrange hospitalization or outpatient treatments Your primary doctor may discuss your needs for certain services with your case manager. Your primary doctor, specialists and case manager will work together to make sure that you receive the care or services that you need. When making an appointment with your primary doctor, advise the office if it is a routine visit or an emergency. You may call your case manager if you need assistance in obtaining an appointment. In the event of an urgent situation or need care after regular hours, you may call your primary doctor or access our Nurse Advice Line. Nurse Advice can help you determine if you need to see a doctor right away. In case of an emergency, call 911. Your Doctor Appointments Please call your doctor s office directly to make a medical appointment or to change an appointment. If you need assistance scheduling appointments, call your case manager. If you need care after hours or urgent care, contact your primary doctor. Your primary doctor s office may send you to an after-hours clinic or urgent care center. You may also contact our 24-hour Nurse Advice Line at Provider Directory A complete list of Molina Community Plus network providers is available in our provider directory. All services must be obtained from participating providers listed in the provider directory, unless prior authorization is obtained. Changes occur in our Provider Directory all of the time due to Molina contracting with new providers. You can ask for an updated Provider Directory at any time by calling our toll-free number: Welcome to the Molina family. 7
9 For hearing impaired TTY You may also access our website at for the most current provider listing. Molina works to assure that our doctors and hospitals meet a set of standards. We want to provide you with the best care possible. Molina reviews whether a doctor should be added to the network. There are certain documents we request. These may include where the doctor went to school and if they are Board Certified. Molina also gathers advice from other doctors about the quality of care they provide. The information is treated as private. It is only shared with parties who are allowed to have access to the information under the law. Every three years all doctors and hospitals are reviewed to ensure they meet our set of standards. If you need detailed information about our credentialing process, you may call Member Services at If you need information about our providers such as their qualifications, the medical school, training or board certification, call Member Services Department at For information about our doctors and hospitals or if you need a list of our participating providers visit our website at or call our Member Services department at Use of Participating Providers It is necessary to use participating providers for services covered by Molina Healthcare. Molina Healthcare is not responsible for payment of services obtained from providers that are not authorized by Molina Healthcare except for Emergency and urgent services. Use of Out-of-Network Services As a new member of Molina Healthcare, you will be given a Provider Directory. You may select any provider from this list. Molina Healthcare will need to provide authorization for all long-term care services. Molina s network of providers include home care agencies, assisted living facilities, skilled nursing homes, consumable medical supply companies and others that provide service to members in our authorized service area. If you choose to use an out-of-network provider, you will be responsible to pay for these services. Oral and Written Translation/Interpretive Services Molina is able to assist you in many different languages. We will arrange for an interpreter to speak your language in order to communicate with your doctor or with a Molina Member Service Representative or Case Manager. The Interpreter can assist you with the following: Make an appointment Communicate with your doctor or nurse Assist in obtaining emergency care File a complaint Obtaining health education Assistance from a pharmacist regarding a medication 8 Welcome to the Molina family.
10 We can also arrange to have a person who knows sign language to assist you during your doctor appointments. Please contact Member Services or your Case Manager at least 24 hours prior to your appointment. If you are hearing impaired call our TTY line All Member materials are available in English and Spanish but are also available upon request in Braille or Audio format. All these services are at no cost to you. Please contact your case manager or Member Services if you need these services. Authorization Process In order for services to be covered by Molina Healthcare, you must follow procedures as outlined in your Member Handbook to ensure the services are authorized. There are two types of covered services: Home and Community Services are provided according to the member s care plan. The Case Management Department develops the care plan based on an assessment and other information. We work with you and your family/caregiver to improve your quality of life and keep you functioning at home for as long as possible. All home and community services address your health and social needs as outlined in your plan of care and authorized by your Case Manager. Medical Services are covered when they are determined to be medically necessary and are authorized by Molina Healthcare. However, you will receive most of your medical services from the Medicare program. Molina Healthcare is responsible for any copayments or deductibles for covered Medicare services that are also Medicaid covered services. Molina Healthcare does not pay for non-covered services or services provided by a non-medicaid/medicare provider. If you need to copy or to discuss our authorization, a description of our authorization process is available upon request. You may call member services or your case manager to request for the process in writing. Medical Necessity Covered medical services requested by the member or member s doctor are authorized when determined to be medically necessary and in keeping with the member s plan of care. Molina Healthcare will reimburse for services that do not duplicate another provider s service and are: Individualized, specific, consistent with impairments, symptoms or confirmed diagnosis of the illness or injury under treatment and not in excess of the member s needs Not experimental or investigational Reflect the level of services that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available Furnished in a manner primarily not intended for the convenience of the member, member s caregiver or the provider The fact that a provider has prescribed, recommended or approved medical or ancillary care, goods or services, does not, in itself, make such care, goods or services medically necessary or a covered service. If you need to understand how our decisions are made, a description of our authorization process is available upon request. You may call member services or your case manager to request for the process in writing or to speak to a medical staff. Welcome to the Molina family. 9
11 Second Medical Opinion All members may request a second medical opinion if you disagree with our decision. You may select to see a provider from our directory or a non-participating provider in our service area. If you choose a doctor in our network for your second opinion, you will not be charged a fee. You or your doctor may request the second opinion by contacting Member Services or your Case Manager. Your request will require an authorization. Your Benefits Home and Community Services: Adult Companion Services are services such as: o Non-Medical Care o Supervision o Socialization This service does not include hands-on nursing care Adult Day Health Center provides social and health activities in an organized day program at a center. Assisted Living Services are services such as: o Personal Care o Housekeeping o Medication Oversight o Social programs to assist the member in an assisted living facility Chore Services assist with heavy household chores and services to maintain your home as a clean and safe living environment Consumable Medical Supplies are disposable supplies necessary to appropriately care for the needs of the member such as: o Disposable Diapers o Gloves o Gauze o Tape Does not include items covered under the Medicaid home health services: o Personal Toiletries o Household items such as: Detergents Bleach Paper Towers Prescription Drugs Environmental Accessibility Adaptation Services are changes to the member s home to ensure safety. They can also help the member to function with greater independence in the home. Without these changes, the member would require institutional care. This excludes those adaptations or improvements 10 Welcome to the Molina family.
12 to the home that are of general use and are not of direct medical or remedial benefit to the member Escort Services assists members who require an individual to accompany them to a medical appointment. Escorts are not permitted to transport members in an individual vehicle Family Training Services will help train family members who provide care for you Financial Assessment/Risk Reduction gives guidance regarding financial activities such as bill paying Home Delivered Meals are for members who have difficulty preparing food and nutritional supplements for members who have a medical need Homemaker Services are household activities, such as meal preparations and routine chores Molina Healthcare Nurse Advice Line is available 24 hours a day, 7 days a week to help answer medical questions you may have. The number is Nursing Facility Services are available for members who require such services. Medicare covers skilled nursing home services. The Florida Department of Children and Families will determine a patient s financial responsibility Nutritional Assessment/Risk Reduction gives guidance and education about nutrition to you and your family Occupational, Physical & Speech Therapy Services is treatment to restore, improve or maintain impaired functions aimed at increasing or maintaining the enrollee s ability to perform tasks required for independent functioning when determined through a multidisciplinary assessment to improve a member s capability to live safely in the home setting Respiratory Therapy is treatment of conditions that interfere with respiratory functions or other deficiencies of the cardiopulmonary system. Personal Care Services is in-home assistance with: Bathing Dressing Eating Personal Hygiene Personal Emergency Response Systems is an electronic device that helps a member at high risk to get help at home in an emergency. Limited to members who live alone or who are alone for significant parts of the day and who would otherwise require extensive supervision Respite Care Services is personal care or supervision provided to a member on a short-term basis due to the need for relief or absence of a family member or caregiver Medical Services The following is a summary of the medical services covered by Molina Healthcare. Molina covers services to the extent they are not covered by Medicare or any other insurance Chiropractic Services is covered under Medicare Community Mental Health Services is outpatient treatment of mental health and substance abuse or inpatient treatment when the condition may present a danger to the person or to others. Services must be under the care of a psychiatrist. Medicare primarily covers these services.) Dental Services is offered by Molina. Services include no cost for an annual examination, x-rays, and Welcome to the Molina family. 11
13 fluoride treatment (every six months) Emergency Services/Post Stabilization Services are services requiring immediate medical care brought about by severe pain or other acute symptoms resulting in serious consequences to the health of the member. Emergency services do not require prior authorization Hearing Services includes exam and evaluation every three years. Limit of one hearing aid per ear every three years, including repairs. Cochlear implants are covered per Medicaid/Medicare guidelines one per lifetime, including repair. Hearing services require prior authorization and need to be medically necessary Home Health Services are nursing visits by a licensed nursing professional if ordered by a doctor and medically necessary, which include occupational therapy, physical therapy, speech therapy, home health aide and skilled nursing. Hospice Services are end of life services offered to members and primarily covered by Medicare Independent Laboratory and Portable X-Ray Services includes lab and x-ray services and primarily covered by Medicare Inpatient Hospital includes: Room & Board Nursing Care Medical Supplies All Diagnostics Medicare primarily covers these services Doctor Services includes all services performed by a doctor when medically necessary to treat a particular injury, illness or disease. Medicare primarily covers these services Outpatient Hospital Services includes all diagnostic procedures or services provided in a hospital outpatient setting. Medicare primarily covers these services Over the Counter Pharmacy, Molina will pay up to $25 maximum per household per month for specific over the counter items purchased at a Molina contracted pharmacy Podiatry Services, Medicare primarily covers services other than routine foot care Prescription Drugs, Medicare primarily covers medically necessary drugs prescribed by a physician and provided at a licensed pharmacy Transportation, emergency medical transportation is covered. Medicare primarily covers these services Vision Services covers eye exams and one pair of eyeglasses per year including repair. Vision services require prior authorization and need to be medically necessary Emergency Care An emergency is a medical condition caused by an acute symptom or severe pain that you believe immediate attention and may result in: 1. Serious jeopardy to your health 2. Serious impairment to your bodily functions 3. Serious dysfunction of any bodily organ or part. 12 Welcome to the Molina family.
14 Emergency services and care in or out of the service area are covered. You can get Emergency care (24) hours a day, (7) days a week. You do not have to contact Molina Healthcare in an emergency, as prior authorization is not required. Call 911 or you should go to the nearest hospital emergency room right away. Notify your Primary Doctor and your Molina Healthcare Case Manager as soon as possible so that any follow-up care and other services may be coordinated and authorized. Post-Stabilization Covered services you get after your ER visit are called post stabilization care services. Post-stabilization services are provided and covered without prior authorization. Please notify your Molina Healthcare Case Manager as soon as possible so that any follow-up care and other services may be coordinated and authorized. Non-Emergency Care Outside the Service Area All non-emergent services must be received in our service area unless prior authorization is obtained. In the event that you happen to be outside of the service area, you must call your case manager or member services prior to receiving these services. Home and community based services are not covered outside the service area. Hospital Care Medicare is the primary payer for Inpatient Hospital Care. This includes all items and services necessary to provide appropriate care during a stay in a hospital, including: Room and Board Nursing Care Medical Supplies All Diagnostic Therapeutic Services Contact your Case Manager Services if you have questions regarding hospital care or if you receive hospital services. What Do I Have to Pay For? There are no copayments in this program for approved and covered medical services received. If you receive a bill from a provider and they are for approved covered services or for emergency services contact your Case Manager. Do not pay the bill until a member service representative assists you with this matter. You may have to pay for services that are not covered or if you receive care from a provider that is not participating with Molina unless it is an emergency. You may have to pay for services related to Assisted Living Facilities and/or Skilled Nursing Facilities. Complaints A complaint is when you are not happy with matters that are not related to a notice of action or when you have concerns or questions about your coverage. Member Services is there to answer questions and resolve your complaint in a timely manner. A Complaint is an informal part of the grievance process and we try to resolve them within 3 business days. If a complaint is not resolved by 3 business days, the complaint becomes a grievance. Welcome to the Molina family. 13
15 Filing a Complaint To file a complaint, you can call Member Services Department at , or for TTY call You may send the complaint in writing to: Molina Healthcare of Florida Att: Customer Service Department 8300 NW 33 rd Street Doral, FL Grievance Process A grievance is when you are not happy with any matter other than a denial, stopped or limited service. Examples of grievances are: Quality of Care or Service Provider courtesy Difficulty in obtaining information Facility cleanliness Wait times too long Failure to respect your member rights Filing a Grievance You, a representative, or your provider, with your written consent, have the right to file a grievance on your behalf. The request must be received within (1) year to the event that started your grievance. All Grievances are acknowledgement in writing once your request is received. Your grievance is reviewed and a decision is made within 90 calendar days of when the request is received. A grievance can be accepted by phone or in writing. You may do so by calling the Member Services Department, completing a Grievance and Appeal Form or by sending us a letter. The member service department is available to send you a grievance form or help you prepare and submit your grievance. If you are hearing or sight impaired you may call our TTY, you may call If you need assistance in another language, member services will assist you with an interpreter. Interpreter services are free to all members. Be sure to include these things: Your first and last name Your Molina ID number. It is on the front of your member ID card Your address and telephone number Explain the problem Signature and date Mail the form or your letter to: Molina Healthcare of Florida Att: Grievance and Appeals Coordinator PO Box Miami, FL Fax: Welcome to the Molina family.
16 When you file a grievance The Appeal and Grievance Coordinator will record and review your grievance. Once the review is completed and a decision is made, you will receive a written notice no later than 90 calendar days from the date your request is received. There are times when Molina may need additional information or you may request an extension. If you or Molina will need an extension, a (14) calendar day extension, with your consent, is granted. If the extension is granted, a letter will be sent to you within (5) business days explaining the reasons for the delay. A copy of the case file with the medical records and any other documents included in the process can be requested before or during the appeal process. Who can request information: Yourself Your representative Your provider, with your written consent In an event a member has passed away, the legal representative of the estate can act on behalf of the member. You may reach the Appeal and Grievance Coordinator by calling Member Services at , Monday through Friday, between 8:00 a.m. and 7:00 p.m. Appeal Process An appeal is a request to review a notice of action. A notice of action is a denied, stopped, or limited service. File an Appeal You, a representative, or your provider, with your written consent, have the right to file an appeal in your behalf. The request must be received within 30 calendar days from the denied, stopped or limited service. All appeals are acknowledged in writing once your request is received. Your appeal is reviewed and a decision is made within 30 calendar days of when the request is received. An appeal can be accepted by phone, but must be followed by written notice within 10 calendar days of the verbal request. The member service department is available to help you prepare and submit your appeal. If you are hearing or sight impaired you may call our TTY line at If you need assistance in another language, member services will assist you with an interpreter. Interpreter services are free to all members. Be sure to include these things: Your first and last name Your Molina ID number. It is on the front of your member ID card Your address and telephone number Explain the problem Signature and date Mail the form or your letter to: Molina Healthcare of Florida Att: Grievance and Appeals Coordinator PO Box Miami, FL Fax: Welcome to the Molina family. 15
17 When you file an appeal The Appeal and Grievance Coordinator will record and review your appeal. Once the review is completed and a decision is made, the coordinator will send you a written decision no later than 30 calendar days from the date your request is received. There are times when Molina may need additional documentation or you may request an extension. If you or Molina will need an extension, a (14) calendar day extension, with your consent, is granted. If the extension is granted by Molina s request, a letter will be sent to you within (5) business days explaining the reasons for the delay. You, your representative, or your provider, with your written consent, have the opportunity before or during your appeal process to request a copy of the case file, including medical records and any other documents included in the process. In an event a member has passed away, the legal representative of the estate can act in behalf of the member. You may reach the Appeal and Grievance Coordinator by calling Member Services at , Monday through Friday, between 8:00 a.m. and 7:00 p.m. Continuing Benefits during appeal process You may want to continue your benefits during or pending an appeal or fair hearing. You, your representative, or your provider, with your written consent, may request continuation of benefits. Upon your request, Molina must continue to cover your benefits during the appeal process if: The appeal is filed within 10 days of the date of the notice of action The appeal involves termination, suspension, or reduction of a previously approved treatment An authorized provider has ordered the services The approval period is still in effect If benefits continue or are reinstated while the appeal or fair hearing is pending, your benefits continue until: You withdraw the appeal or fair hearing request Ten days from the date of our first decision if you have not requested a fair hearing A fair hearing decision is made and not in your favor Your authorization expires or your service limits are met If you requested continuation of benefits and the decision is not in your favor you may be responsible for the cost of services provided to you. Expedited Appeal When you consider your service to be urgent and feel that the time frame of a formal process would risk your life, health, or ability to function, you may file an expedited appeal. File an Expedited Appeal You, a representative, or your provider, with your written consent, have the right to file an appeal in your behalf. Your expedited appeal is reviewed and a decision is made within 72 hours of when the request is received. An expedited appeal can be accepted by phone or in writing. The member service department is available to help you prepare and submit your expedited appeal. If you are hearing or sight impaired you may call our TTY, you 16 Welcome to the Molina family.
18 may call If you need assistance in another language, member services will assist you with an interpreter. Interpreter services are free to all members. Be sure to include these things: Your first and last name Your Molina ID number. It is on the front of your member ID card. Your address and telephone number. Explain the problem. Signature and date Mail the form or your letter to: Molina Healthcare of Florida Att: Grievance and Appeals Coordinator PO Box Miami, FL Fax: When you file an expedited appeal The Appeal and Grievance Coordinator will record and review your expedited appeal. Once the review is completed and a decision is made, the coordinator will send you a written decision and a verbal notice of the decision within 72 hours of the time your request is received. If your expedited appeal is not approved, we will notify you in writing within 2 days that your appeal will be resolved through our standard appeal process time frame of 30 calendar days. You, your representative, or your provider, with your written consent, have the opportunity before or during your appeal process to request a copy of the case file, including medical records and any other documents included in the process. In an event a member has passed away, the legal representative of the estate can act in behalf of the member. Medicaid Fair Hearing You, a representative, or your provider, with your written consent, also have the right to file a Medicaid Fair Hearing during the grievance or appeal process. If you disagree with the decision, you have the right to file an appeal with Molina or to request a Medicaid Fair Hearing. You do not need to file an appeal before you request a fair hearing. If you would like to request a fair hearing, you must do so no later than 90 calendar days from the date of decision. If you choose to file a fair hearing without filing a grievance or an appeal with Molina, you must ask for the hearing within 90 calendar days from the date you received the notice of action or denied, stopped or limited services. You can request a fair hearing by calling or sending a letter to: Department of Children and Families Office of Public Assistance Appeals Hearings 1317 Winewood Blvd. Bldg. 5 Room 203 Tallahassee, FL Note: If you request a fair hearing, you do not have the right to request the Subscriber Assistance Program review your request. Welcome to the Molina family. 17
19 Disenrollment You may request disenrollment from Molina at any time and for any reason. Molina will send your disenrollment request to the state for processing. If the state receives your disenrollment request before their monthly processing deadline, disenrollment will be effective the first day of the next calendar month. If the request is received after the state s monthly processing deadline, disenrollment will be effective on the first day of the second calendar month following the month the request was received. To request disenrollment you may call our Member Services team at or send the request in writing. Member Services may send you a disenrollment form and help to resolve any problems that you may be experiencing. Let the Member Services team know if you would like someone to come to your home and assist you with filling out the disenrollment form. Send the signed and completed form to: Molina Healthcare of Florida Attention: Case Management 8300 NW 33 rd Street, Suite 400 Doral, FL Fax: Advanced Directives Florida Statute (FS) Chapter 765 on Health Care Advance Directives (also known as an Advance Directive ) states that every adult has the right to make choices about his or her own health, including the right to have or not have medical care. You can implement this right. This right allows you to make an Advance Directive to let your family and doctor know what care you want, don t want or when to stop care that will prolong your life in case of a serious illness. An Advance Directive is a form that helps others gives you the care that you want even when you are not able to make those decisions for yourself. An Advance Directive can list the name of someone you trust as an agent to make these choices for you if you are not able to do so. Molina will inform you of state law changes no later than (90) calendar days after the effective change. Advance Directives should be: In writing Signed by you According to the state laws Witnessed by someone other than your agent Why do you need to have an Advance Directive? You could have an accident or get sick. You might live with a mental or physical illness that leaves you unable to make decisions at times. If you do not have an Advance Directive, those making choices for you may not know what you want. Worse yet, your family and friends could argue over the care you should get or they could disagree about who gets to make choices for you. Help your family and friends to help you name an agent and tell your agent and family about your health care wishes. When should I make an Advance Directive? The best time to make an Advance Directive is before you need one! You need one before you become too sick to make your own choices about the care you want to receive or refuse. It is good for anyone at any age to have 18 Welcome to the Molina family.
20 an Advance Directive. It can be changed or cancelled at any time. The Plan has policies related to Advance Directives including a statement of a limitation regarding the implementation of advance directives as a matter of conscience. How Can I get More Information on Advance Directives? We can tell you more about Advance Directives. Call Member Services Mon - Fri 8:00 a.m. to 7:00 p.m. at We can also talk with you about Molina s Advance Directive policies. More information on Advance Directives can also be found on the Florida Department of Elder Affairs website at english/docs/eol.pdf or the State of Florida website at or by calling the Florida Department of Elder Affairs at If you have an Advance Directive and your health care provider will not follow it, you or your agent can file a complaint with Molina Member Services at or with the Florida Department of Elder Affairs at Member Rights and Responsibilities As a member of Molina Healthcare, you have the following rights: To be treated with courtesy and respect, with appreciation of your individual dignity, and with protection of your need for privacy To a prompt and reasonable response to questions and requests To know who is providing medical services and who is responsible for your care To know what patient support services are available, including whether an interpreter is available if you do not speak English To know what rules and regulations apply to your conduct To be given health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis To be able to take part in decisions about your health care. To have an open discussion about your medically necessary treatment options for your conditions, regardless of cost or benefit To refuse any treatment, except as otherwise provided by law To be given, upon request, full information and necessary counseling on the availability of known financial resources for your care If you are eligible for Medicare, to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate To receive, upon request, prior to treatment, a reasonable estimate of charges for medical care To request and receive a copy of your care plan, and to request that they be amended or corrected To receive information on available treatment options and alternatives, presented in a manner appropriate to your condition and ability to understand To receive a copy of reasonably clear and understandable, itemized bill and, upon request, to have the charges explained To impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap, or source of payment To treatment for any emergency medical condition that will deteriorate from failure to provide treatment Welcome to the Molina family. 19