2015 Medicaid Member Handbook and Welcome Kit

MAGELLAN COMPLETE CARE1-800-327-8613 www.MCCofFL.com

FLORIDA

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Introduction and First Steps. . . . . . . . . . . . . . . . . . . 2

About Magellan Complete CareSM . . . . . . . . . . . . 2

Welcome to Magellan Complete Care! . . . . . . . . 2

Please Call Today! . . . . . . . . . . . . . . . . . . . . . . . . . 2

Your Care Coordination Team . . . . . . . . . . . . . . . 3

Helpful Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . 4

These telephone numbers may also help you . . 4

Becoming a Member . . . . . . . . . . . . . . . . . . . . . . . 6

Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Open Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Pregnancy and Newborn Enrollment . . . . . . . . . 6

Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Member ID Card . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Enrollment & Disenrollment . . . . . . . . . . . . . . . . 7

Reinstatement Process . . . . . . . . . . . . . . . . . . . . . 8

How to Get Services . . . . . . . . . . . . . . . . . . . . . . . . . 9

Selecting a PCP . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Changing a PCP . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Access to Care/Appointment . . . . . . . . . . . . . . . . 9

Continuity of Care . . . . . . . . . . . . . . . . . . . . . . . . 10

Referral and Approval for Specialty, Ancillary and Hospital Care . . . . . . . . . . . . . . . 10

Access to Behavioral Health Services . . . . . . . 11

Getting Behavioral Health & Substance Abuse Services . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . 13

Emergency Services . . . . . . . . . . . . . . . . . . . . . . 13

Behavioral Health Emergencies . . . . . . . . . . . . 13

Please Let Us Know . . . . . . . . . . . . . . . . . . . . . . . 13

Did you seek care for an emergency? . . . . . . . . 13

Out of Area Emergency Services . . . . . . . . . . . 13

Covered Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Covered Service and Limitations . . . . . . . . . . . 14

Magellan Complete Care Expanded Services . . 18

Additional Notes for Covered Services . . . . . . 19

Services Not Covered by Magellan Complete Care . . . . . . . . . . . . . . . . . . . . . . . . . . 21

How to Get Medications . . . . . . . . . . . . . . . . . . . 21

Informed Consent for Certain Drugs . . . . . . . . 21

Improving Your Health . . . . . . . . . . . . . . . . . . . . . . 22

Member Rewards Program . . . . . . . . . . . . . . . . 22

Prevention Programs . . . . . . . . . . . . . . . . . . . . . 22

Case Management and Disease Management Programs . . . . . . . . . . . . . . . . . . . . 22

Child Health Check-Up/Vaccines . . . . . . . . . . . 23

Quality Benefit Enhancement Programs . . . . . 23

Review of New Treatment Options . . . . . . . . . . 23

Complaints, Grievances and Appeals Process . . . 24

Complaints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Grievances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Expedited Appeal . . . . . . . . . . . . . . . . . . . . . . . . 24

Medicaid Fair Hearing/ Subscriber Assistance Program . . . . . . . . . . . . 25

Protected Health Information . . . . . . . . . . . . . . . . 26

Protected Health Information . . . . . . . . . . . . . . 26

Release of Information on Sensitive Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Member Rights and Responsibilities . . . . . . . . . . . 27

Member Rights and Responsibilities . . . . . . . . 27

Second Medical Opinion . . . . . . . . . . . . . . . . . . 28

Reporting Abuse, Neglect, or Exploitation . . . 28

Reporting Fraud, Waste, and Abuse . . . . . . . . . 28

Living Wills and Advance Directives . . . . . . . . . . . 30

The Patient’s Right to Decide. . . . . . . . . . . . . . . 30

Questions About Health Care Advance Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

More Information on Health Care Advance Directives . . . . . . . . . . . . . . . . . . . . . . . 33

Helpful Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Grievance Form . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Appeals Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Living Will . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Designation of Health Care Surrogate . . . . . . . 43

Uniform Donor Form . . . . . . . . . . . . . . . . . . . . . 45

Health Care Advance Directives . . . . . . . . . . . . 47

Table of Contents

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About Magellan Complete CareSM

Magellan Complete Care has a lot of know-how in health care. We help our members with these services:

• Coordinating medical care with your doctors.

• Coordinating behavioral health services with medical care.

• Giving you the okay for specialty and hospital services.

• Quality management programs.

• Case management and disease management programs for members with special needs and conditions.

• Managing your pharmacy benefits.

To join Magellan Complete Care you must have Medicaid benefits and a Serious Mental Illness (SMI). Our plan specializes in linking your physical and behavioral health care. We make sure your care is coordinated and you have whole health care.

If you would like to learn more about Magellan Complete Care, please visit our website at www.MCCofFL.com.

You will be able to learn about our health plan. Learn about quality programs, healthy living programs, physician incentive programs and health education resources. You can also find performance measures and information about our plan’s performance.

Magellan Complete Care is a Managed Care Plan with a Florida Medicaid contract. The Florida Agency for Healthcare Administration (AHCA) oversees our plan. They have information on their website at www.fdhc.state.fl.us/medicaid.

Welcome to Magellan Complete Care! We are happy you are our member.

Your member handbook has important information. This handbook will help you better understand your health plan. This is also your certificate of coverage.

If you need the Member Handbook in a different language, please call Magellan Complete Care Customer Service. This service is available free of charge. Si necesita el manual de miembro en otro idioma, por favor llame a Magellan Complete Care.

We will help you with important steps to stay healthy!

Please Call Today!Call Magellan Complete Care Member Services at 1-800-327-8613 or 1-800-424-1694 TTY only and our member specialists will:

• Welcome you to Magellan Complete Care and answer your questions.

• If you have not chosen a primary care doctor (PCP), we will help you choose one over the phone.

• Help you schedule an appointment with your PCP.

• Help you visit your PCP within the first 90 days of enrollment to get a health assessment.

• Tell you about extra benefits.

• Tell you about special programs.

It will only take a few minutes, but it will help us to serve you better. If we don’t hear from you, we will try to call you to make it easier for you. We want to do everything we can to help you stay healthy.

Introduction and First Steps

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Your Care Coordination TeamMagellan Complete Care will connect you to your personal Health Guide who will help you:

• Find your way through the health care system.

• Make sure all of your doctors have a copy of your medical records.

• Help you with making appointments.

• Help you complete your health and wellness questionnaire.

• Connect to support services in your community.

We will work with you to choose a primary care doctor and primary behavioral health doctor. They will be part of your Care Coordination Team. Your team will also include you, your family or supports and others such as a case manager, as needed. Please let us know if someone on your care coordination team is not a good fit. You can choose a different Health Guide, Integrated Care Case Manager and/or Wellness Specialist within Magellan Complete Care, if one is available.

Helpful TipsBefore you go to your first primary care doctor (PCP) appointment, you may want to write down important information to share with him/her.

• Behavioral health provider name (if seeing one).

• Other specialists’ names.

• Your health conditions (for example, bipolar disorder, heart disease, asthma).

• Medications and how much you take.

• Questions or concerns you have about your health.

Please keep a copy of these documents handy:

• Member ID card.

• Member Handbook.

• Provider Directory.

You will need these documents as a member of our health plan.

If you need help with anything about your health or health plan, please call Customer Service toll free at 1-800-327-8613. If you are hearing impaired, call our TTY number at 1-800-424-1694. We are able to talk with you in any language or format at no charge to you. We are here for you 24 hours a day, seven days a week. If you have health questions, our Nurse Line is here for you.

If you have an emergency such as chest pain or trouble breathing, call 911 instead of the Nurse Line.

If your address changes, please contact us at 1-800-327-8613 and the State Medicaid Enrollment Broker to update your address.

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Contact InformationWe want to hear from you. You are not alone. Just give us a call for help. Magellan Complete Care’s telephone numbers are toll free.

We can answer your questions in any language. We can help you if you are hearing or vision impaired too. These services are free of charge.

Customer Service is available from 8:00 am – 7:00 pm at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694.

Nurses are available 24/7 to help with non- emergency health questions at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694.

Please visit our website at www.MCCofFL.com

These telephone numbers may also help you:Florida Department of Children and FamiliesHours: 8:00 am to 5:00 pmToll free: 866-762-2237

State Medicaid Enrollment BrokerToll free: 1-877-711-3662TTY/TDD: 1-866-467-4970Web: www.flmedicaidmanagedcare.com

Local Medicaid office—Bay, Franklin, Gulf, Holmes, Jackson, and Washington CountiesOffice: 850-767-3400Toll free: 800-226-7690

Local Medicaid office—Calhoun, Gadsden, Jefferson, Leon, Liberty, Madison, Taylor, and Wakulla CountiesOffice: 850-412-4002Toll free: 800-248-2243

Local Medicaid office—Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia CountiesOffice: 904-798-4200Toll free: 800-273-5880

Local Medicaid office—Pasco and PinellasOffice: 727-552-1900Toll free: 800-299-4844

Local Medicaid office—Hardee, Highlands, Hillsborough, Manatee, and Polk CountiesOffice: 815-350-4800Toll free: 800-226-2316

Local Medicaid office—Brevard, Orange, Osceola, and Seminole CountiesOffice: 407-420-2500Toll free: 877-254-1055

Local Medicaid office—Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie CountiesOffice: 561-712-4400Toll free: 800-226-5082

Local Medicaid office—Broward CountyOffice: 954-958-6500Toll free: 866-875-9131

Local Medicaid office—Miami-Dade and Monroe CountiesOffice: 305-593-3000Toll free: 800-953-0555

Aging and Disabilities Resource CentersHours: 8:00 am – 5:00 pmToll free: 800-963 (ELDER)-5337 TDD: 850-414-2001Web: http://elderaffairs.state.fl.us/doea/arc.php

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Area 2 Agency Area Agency on Aging for North Florida, Inc.2414 Mahan DriveTallahassee, FL, 32308Office: 850-488-0055Web: www.aaanf.org

Area 4 Agency ElderSource, The Area Agency on Aging of Northeast Florida10688 Old St Augustine RoadJacksonville, FL 32257Office: 904-391-6600Web: www.myeldersource.org

Area 5 Agency Area Agency on Aging of Pasco-Pinellas, Inc.9549 Kroger Boulevard North, Suite 100St. Petersburg, FL 33702Office: 727-570-9696Web: www.agingcarefl.org

Area 6 Agency West Central Florida Area Agency on Aging, Inc.5905 Breckenridge Parkway, Suite FTampa, FL 33610Office: 813-740-3888Web: www.agingflorida.com

Area 7 Agency Senior Resource Alliance988 Woodcock Road, Suite 200Orlando, FL 32803Office: 407-514-1800Web: www.seniorresourcealliance.org

Area 9 Agency Your Aging Resource Center4400 N. Congress AvenueWest Palm Beach, FL 33407Office: 561-684-5885Web: www.youragingresourcecenter.org

Area 10 Agency Aging & Disability Resource Center of Broward County, Inc.5300 Hiatus RoadSunrise, FL 33351Office: 954-745-9567Web: www.adrcbroward.org

Area 11 Agency Alliance for Aging, Inc.760 NW 107th Avenue, Suite 214, 2nd floorMiami, FL 33172Office: 305-670-6500Web: www.allianceforaging.org

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Becoming a MemberTo join Magellan Complete Care, you must have Medicaid benefits and a serious mental illness (SMI). Eligibility is managed by the Florida Department of Children and Families (DCF) at 866-76-ACCESS (866-762-2237). Membership begins on the first day of any calendar month once you are approved by the State.

You have the right to choose a health plan. If you don’t choose a health plan, the State will choose one for you.

EnrollmentIf you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Magellan Complete Care or the state enrolls you in a health plan, you will have 90 days from the date of your first enrollment to try the Managed Care Plan. During the first 90 days, you can change plans for any reason. After the 90 days, if you are still eligible for Medicaid, you will be enrolled in the plan for the next nine months. This is called “lock-in.”

Open EnrollmentIf you are a mandatory enrollee, the State will send you a letter 60 days before the end of your enrollment year telling you that you can change plans if you want to. This is called “open enrollment.” You do not have to change Managed Care 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 Managed Care Plans during your 60 day open enrollment period.

Some Medicaid recipients are voluntary enrollees and can change health plans whenever they choose, for any reason. For example, people who reside in residential community facilities operated through DJJ or mental health treatment facilities can change plans at any time for any reason. To find out if you may change plans, call the Enrollment Broker:

Enrollment Broker / Choice CounselingHours: Mon – Thurs 8:00 am to 8:00 pm Fri 8:00 am to 7:00 pm Sat 9:00 am to 1:00 pmToll free: 1-877-711-3662TTY/TDD: 1-866-467-4970Web: www.flmedicaidmanagedcare.com

Pregnancy and Newborn EnrollmentGetting medical care during pregnancy is an important step in making sure that you and your baby are healthy. We will ask you if you are pregnant when you join the plan and you can call us at any time to let us know if you become pregnant. Magellan Complete Care would like to help you get the care you need during your pregnancy. You must call the Florida Department of Children and Families (DCF) to enroll your baby in Medicaid. They will provide you with your baby’s Medicaid number.

You may also call Medicaid Options for assistance in choosing a plan for your baby. Their toll free number is 1-888-367-6554 (TTY/TDD 1-800-653-9803).

Enrollment

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Member ID CardHere is a picture of a sample Member ID card. Please keep your card with you at all times and take it with you to your doctor visits.

English ID Card front:

back:

If you lose your card, please call Customer Service toll free at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694. Magellan Complete Care will send you a new card.

Enrollment & DisenrollmentSome Medicaid recipients may change Managed Care Plans whenever they choose, for any reason. To find out if you may change plans, call the Enrollment Broker 1-877-711-3662.

If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Magellan Complete Care or the state enrolls you in a plan, you will have 90 days from the date of your first enrollment to try the Managed Care Plan. During the first 90 days you can change Managed Care Plans for any reason. After the 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.”

If you are a mandatory enrollee, the state will send you a letter 60 days before the end of your enrollment year telling you that you can change plans if you want to. This is called “open enrollment.” You do not have to change Managed Care 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 may change Managed Care Plans during your 60 day open enrollment period.

Customer Service, Claims/Billing, and Transportation: 1-800-327-8613 (Monday – Friday 8 a.m. – 7 p.m. EST)

Emergency Services: Seek treatment at the nearest emergency room or urgent care center or call 911. Notify your doctor and the health plan within 48 hours or as soon as possible if you are admitted to the hospital.

Authorizations / Eligibility (Participating and Non-Participating Providers): 1-800-327-8613

Mail Claims to: Magellan Complete Care PO Box 2097 Maryland Heights, MO 63043

Payor ID#: 01260

Possession of an ID card does not guarantee eligibility or payment for services provided.

Member Name: xxxMEMBERNAMExxx Member #: xxMEMBERNBR-xx Group: xxxxxEnrollment Date: xx/xx/xxxx

Utilize Medicaid Participating PharmaciesBIN #: 016523 PCN #: 622 RxGroup: XXXXXXX

7600 Corporate Drive, Suite 600 Miami FL, 33126

MagellanCompleteCareofFL.com

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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. The following are state-approved cause reasons to change Managed Care Plans:

1. The enrollee moves out of the region, or the enrollee’s address is incorrect, and the enrollee does not live in a county where the Health Plan is authorized to provide services.

2. The provider is no longer with the Health Plan.

3. The enrollee is excluded from enrollment.

4. A substantiated marketing or community outreach violation has occurred.

5. The enrollee is prevented from participating in the development of his/her treatment plan.

6. 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.

7. The enrollee is in the wrong health plan as determined by the Agency.

8. The Health Plan no longer participates in the region.

9. The state has imposed intermediate sanctions upon the Health Plan, as specified in 42 CFR 438.702(a) (3).

10. The enrollee needs related services to be performed concurrently, but not all related services are available within the Health Plan’s network, or the enrollee’s PCP has determined that receiving the services separately would subject the enrollee to unnecessary risk.

11. The Health Plan does not, because of moral or religious objections, cover the service you seek.

12. The enrollee missed open enrollment due to a temporary loss of eligibility.

13. Other reasons per 42 CFR 438.56 (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 due to significant changes in the geographic location of services; an unreasonable delay or denial of service; lack of access to providers experienced in dealing with the enrollee’s health care needs; or fraudulent enrollment.

14. To find out if you can change plans, call the State Medicaid Enrollment Broker, toll free: 1- 877-711- 3662.

Reinstatement ProcessKeeping your Medicaid benefits is critical. We do not want you to lose them. Here are a few things to remember:

• Contact your Enrollment Broker / Choice Counselors, toll free at 1-877-711-3662.

• Get your case status.

• Respond to all requested paperwork.

• Keep all scheduled appointments.

• If you miss an appointment, call and reschedule immediately. We can help you with transportation to your appointment, if needed.

If you lose your benefits, you can no longer be part of our plan. However, if you get your benefits back within 180 days, you will automatically be with Magellan Complete Care again. When you return, you will have the same PCP unless:

• The PCP is no longer available.

• You live in a different area.

• You choose another PCP.

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How to Get ServicesSelecting a PCPYour primary care doctor (PCP) is your personal doctor who will manage all of your health care.

You have the right to choose any PCP that is part of Magellan Complete Care. We have many PCPs to choose from. Please refer to your provider directory, our website or call us at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694. We can mail you a new provider directory if you need one. If you do not choose a PCP, Magellan Complete Care will choose one for you.

You may choose to have your whole family with the same PCP. You can choose a different PCP based on each family member’s needs.

A female member may choose an obstetrician/gynecologist (OB/GYN) as her PCP if the OB/GYN agrees to serve as the PCP. Please call us at 1-800-327-8613 or 1-800-424-1694 TTY only, if you would like to choose an OB/GYN as your PCP. We will work with you to choose a PCP for your baby before the baby is born.

The name and telephone number of your PCP can be found on:

• Your Welcome Letter.

• Provider Directory.

• Magellan Complete Care’s website at www.MCCofFL.com.

If you would like additional information about a doctor, like their professional qualifications, please call Customer Service. Professional qualifications include medical school attended, where your doctor did their residency after medical school, and board certification.

Changing a PCPIf you want to change your PCP, please call Customer Service toll free at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694.

Access to Care/AppointmentYou deserve the right to care. Providers in our network must make an appointment:

• Right away, if an emergency.

• In one day, if Urgent Care.

• In one week, if routine Sick Patient Care.

• In one month, if Well Care Visit.

If Magellan Complete Care cannot give you a needed and covered service by a provider in our network, we will cover these services by an out-of network provider well and timely. The services will be covered as long as Magellan Complete Care does not have a provider in network to give you the services.

Don’t forget to bring your Member ID card to each visit.

Some new members will need help making the change from their old health plan to their new one. We will ask you about appointments and treatment you were receiving before you joined Magellan Complete Care. We will help you make the change.

Once you have a Magellan Complete Care doctor, your doctor should see you within one hour of your appointment time.

Your primary care doctor (PCP) is ready to help you 24 hours a day and seven days a week. If you call at night or on the weekend, you will be told how to reach your doctor.

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Continuity of CareMagellan Complete Care will make sure that you keep getting the care your doctors give you today. For your first 60 calendar days with our plan, your doctor does not have to get an okay from us. Please call us if you have any questions or need any help with your appointments.

After the 60 days pass, if you wish to see a doctor that is not in the directory your PCP can contact us for an okay. We can also help you schedule a visit, tell your previous provider, and move your health records to your new provider. We can also help you with transportation to your appointment.

Referral and Approval for Specialty, Ancillary and Hospital CareIf you need to see a specialty doctor, you need an okay from your primary care doctor (PCP). Most other services need an okay from your primary care doctor (PCP) and Magellan Complete Care.

We have a team of nurses and behavioral health clinicians to review your doctor’s ask for an okay. They use notes from your doctor and a set of guides to decide if the service is medically necessary for you. Many health plans use the same guides. Call us at 1-800-327-8613 or 1-800-424-1694 TTY only, if you need more information. We can help you with getting a referral or if you want details on how we decide to okay your service. If we do not give your doctor an okay, we will send you and your doctor a letter and tell you how you can appeal.

Decisions for approved services are based on making sure the service is what you need and that it is a covered benefit. We do not reward or encourage staff to make decisions that result in less care than you need. We also do not reward doctors or others for issuing denials for services.

These services do not require prior approval:

• Emergency services and crisis stabilization.

• Post stabilization services or other post stabilization care.

• Some chiropractic services at a participating provider.

• Optometrist annual exam at a participating provider.

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• Some podiatric services at a participating provider.

• Dermatology services up to 5-times per year with no referral at a participating provider.

• Family planning services; these may be obtained from any participating Medicaid provider.

• Gynecology services including annual well woman exam and follow-up care as a result of the exam at a participating provider.

• Diagnosis and treatment of sexually transmitted disease when provided at the County Health Department.

• Routine outpatient behavioral health services such as evaluations, medication management, individual and/or family therapy.

Your provider directory lists doctors and hospitals that are part of our network. If you wish to see a doctor not in the directory, not in our network, your primary care doctor (PCP) can contact us for an okay and to let us know about your needs. We will only give the okay to see a doctor that is out of network when the type of doctor you need is not available in the Magellan Complete Care network. Normally, we do not pay for out-of-network care except emergency care and family planning services.

You may be able to see a specialty doctor without getting an okay each time. This is a standing referral for when you have a long-term illness. Your PCP will contact us to arrange this.

Access to Behavioral Health Services Taking care of your Behavioral Health condition is very important. To maintain good health and wellbeing Magellan Complete Care wants to make sure that you have the right care when you need it. We are here to support you in your recovery process. If you feel like you are having the following feelings or problems or they are getting worse, you may need to see your Behavioral Health provider right away:

• Constantly feeling sad.

• Feeling hopeless or helpless.

• Feelings of guilt.

• Feeling of worthlessness.

• Difficulty sleeping.

• Poor appetite.

• Weight loss.

• Loss of interest.

• Difficulty concentrating.

• Irritability.

• Constant pain such as headaches, stomach and back aches.

We are here to help you make sure that you get the behavioral health care you need to feel better. Your Health Guide and our Nurses available through the Nurse Line, can help you make appointments to make sure you see your provider quickly. If you need help with an urgent or emergency appointment please call us at 1-800-327-8613 or if you are hearing impaired please dial our TTY number 1-800-424-1694.

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Getting Behavioral Health & Substance Abuse Services You can get help in finding a behavioral health provider by calling 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694. You can also look in our provider directory or you can look on our website at www.MCCofFL.com. Someone is available to help you 24 hours a day and seven days a week.

If you call, you will be given the names of a number of providers in your local area. You can choose to call one for an appointment.

You do not need to call your primary care doctor (PCP) for a referral for behavioral health appointments. Some services do require an okay from us. Your provider will ask for an okay when it is needed.

Behavioral health and substance abuse services you can get include inpatient and outpatient hospital services and psychiatric doctor services. You can also get a wide range of behavioral health services. Sometimes you can get these services in the community, in your home, or in schools. Some of the behavioral health services you may seek for you or a family member include:

• Individual, family, and group therapy.

• Day treatment for adults and children.

• Individual and family assessments.

• Evaluations.

• Treatment planning.

• Psychosocial rehabilitation.

• Targeted case management.

• Therapeutic behavioral on-site services for children and adolescents.

If you want to change to a different provider or request help in finding a second opinion, we are available to assist you. Call Magellan Complete Care at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694.

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Emergency ServicesEmergency ServicesAn emergency is when you have severe pain, illness, behavioral health crisis or injury that could result in danger to you or your unborn child. Call 911 right away. In an emergency, you have the right to choose any hospital or other medical setting. You do not need to get approval from your PCP or Magellan Complete Care for emergency care.

Behavioral Health EmergenciesFirst, decide if you are having a behavioral health emergency. Do you think that you are a danger to yourself or others? If so, call 911 or go the nearest emergency room for help if you think you are in danger. Follow these steps even if the emergency room is not in our service area. If you need help right away or have a behavioral health emergency outside the plan’s service area, call 911.

Please Let Us KnowOnce you are in a safe place, please let us know or ask someone to let us know by calling the number on your ID card. You should also call your Health Guide. We will call your PCP or regular behavioral health provider. For out-of-area emergency care, when you are stable, we will help with plans to move you to in-network care when possible.

Did you seek care for an emergency?If you go to the hospital for an emergency, you need to make sure you get care after the emergency event, called Post Stabilization services. This may help to keep you from having another behavioral health emergency. Post-Stabilization services are covered services you get after emergency room care within or outside the Provider Network. These are services delivered to keep your condition stable after an emergency. Post-stabilization care services are provided and covered without asking for an okay.

Once you leave the hospital:

• It is important to follow-up with your doctor within twenty-four (24) to forty-eight (48) hours.

• You should schedule a visit to see a behavioral health provider for follow-up care. We can help you make this appointment and schedule transportation, if needed. We recommend you get an appointment before you leave the hospital. Please call us 1-800-327-8613 or 1-800-424-1694 TTY only, if you need help making an appointment.

Out of Area Emergency ServicesIf you are out of the service area, please get help from the nearest urgent care center or hospital. Please call us 1-800-327-8613 or 1-800-424-1694 TTY when you are out of the service area and have required urgent or emergency services. We would like to make sure that we are able to help you get the care you need.

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Covered ServicesCovered Service and LimitationsMagellan Complete Care covers Medicaid-covered services as specified in the contract with the State of Florida Agency for Health Care Administration. You are limited to how often you use some of these services and there are differences for adults and children. Please call us at 1-800-327-8613 or for hearing impaired 1-800-424-1694 TTY, if you have questions about benefit limits. Your Health Guide can also assist you. Magellan Complete Care has no co-pays for covered services. You do not have to pay money for any covered service if you visit a network provider. The following is a summary of the services that are covered by Magellan Complete Care.

Service Description

Adult Basic Dental Services Full dental services for all enrollees age 20 and below. Medically necessary oral and maxillofacial surgery for all eligible Medicaid recipients regardless of age. Emergency dental services to enrollees age 21 and older, and denture and denture-related services. Medically-necessary, emergency dental procedures to alleviate pain or infection to enrollees age 21 and older. Emergency dental care for enrollees 21 years of age and older is limited to a problem focused oral evaluation, necessary radiographs in order to make a diagnosis, extractions, and incision and drainage of an abscess. Full and removable partial dentures and denture-related services are also covered services for enrollees 21 years of age and older.

Child Health Check Up (CHCUP)/EPSDT

For children, CHCUP includes comprehensive health and developmental history, unclothed physical examination, developmental assessment, nutritional assessment, appropriate immunizations, laboratory testing, health education, dental screening, vision screening, hearing screening, diagnosis and treatment and referral and follow-up as appropriate.

Diabetes Supplies and Education Coverage for medically appropriate and necessary equipment, supplies, and services used to treat diabetes. This includes outpatient self-management training and educational services

Emergency Services Includes emergency medical care 24 hours a day, 7 days a week. You do not need approval from Magellan Complete Care, nor your PCP to go to the emergency room if you are having a medical situation.

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Service Description

Family Planning Services Family Planning Services includes information, referral education, counseling, diagnostic procedures and contraceptive drugs and supplies. Services are voluntary and you are permitted full freedom of choice of methods for Family Planning to help you plan a family size or help you space the time between having children.. You can go to any provider that participates with Medicaid for these services without a referral from your PCP.

Freestanding Dialysis Facility Services

Includes routine laboratory tests, dialysis-related supplies, ancillary and other items. Services include all services and procedures rendered by a participating provider when needed for preventive, diagnostic, therapeutic, or to treat a particular injury, illness or disease.

Hearing Services Hearing Services include examinations and evaluations necessary for the furnishing of one standard hearing aid every three years.

Durable Medical Equipment Medical items (limited to approved types of supplies and equipment, suitable for use in the home). Benefit includes prosthetics and orthotics and respiratory equipment and supplies.

Home Health Care Services and Durable Medical Equipment

Includes intermittent or part-time nursing services (R.N.or L.P.N.), personal care services by a home health aide, and medical items (limited to approved types of supplies and equipment, suitable for use in the home).

All services and equipment must be ordered by a participating provider. Your PCP must notify Magellan Complete Care for services or equipment that requires home health care. Home health care does not include homemaker services, Meals on Wheels, companion, sitter or social services.

Home Health Care Services and Private Duty Nursing Care

Magellan Complete Care covers home health services that are medically necessary. Home health services include home health visits (nurse and home health aide), private duty nursing and personal care services for children, therapy services medical supplies and durable medical equipment. Home healthcare does not include homemaker services, Meals on Wheels, companion, sitter or social services. Magellan Complete Care follows the state Medicaid Home Health Services Coverage and Limitations Handbook.

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Service Description

Hospital Ancillary Services When your provider authorizes these to be provided by the hospital: radiology, pathology, neurology, neonatology, and anesthesiology.

Immunizations According to childhood immunization schedule as approved by the appropriate Recommended Childhood Immunization Schedule for the United States.

Independent Laboratory and Portable X-Ray Services

Includes laboratory and X-ray services when ordered by a participating provider.

Inpatient Hospital Services Includes all items and services needed to give appropriate care during a stay at a participating hospital, including room and board, nursing care, medical supplies, and all diagnostic and therapeutic services. Magellan Complete Care covers a maximum of 45 inpatient days for the period from July 1 through June 30 (includes only non-emergency care at hospitals where prior notification was obtained by your PCP from Magellan Complete Care).

Interpreter Services If you are in need of interpreter services or are vision and/or hearing impaired, please call the Customer Service phone number on the back of your ID card. These services are free of charge for all foreign languages as well as the visually and/or hearing impaired.

Maternity Services Maternity services include the following: nursing assessment and counseling, Florida’s Health Start Prenatal Risk Screening, nutrition assessment, delivery and follow-up care, Florida’s Health Start Infant (Postnatal) Screening, and follow-up care.

Mental Health and Substance Abuse Services

Mental Health counseling and referral services or substance abuse services; Please call our Customer Service Team and your assigned Health Guide so that we can provide further information about all of these benefits. You can contact us at 1-800-327-8613

Outpatient Services Outpatient services provided in an outpatient hospital setting. Your PCP can obtain prior notification for health care services that may require notification.

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Service Description

Physician Services Includes all services and procedures rendered by a participating provider when needed for preventive, diagnostic, therapeutic, or to treat a particular injury, illness or disease. Excludes experimental procedures and cosmetic surgery. These physicians include: advanced registered nurse practitioner, physician assistant, podiatry, ambulatory surgical centers, community health departments, rural health clinic .services, federally qualified health centers, birthing centers, certified nurse midwives, chiropractic, psychiatrist and nursing care.

Prescribed Drugs Includes prescribed drugs currently covered by the Medicaid Program, when ordered by a participating provider and supplied by a licensed participating pharmacy.

Therapy Services:

Physical, Respiratory, Occupational and Speech therapies

Are covered for recipients under 21 years of age as medically necessary.

Transportation Urgent care transportation to and from your covered medical and dental appointments.

Medicaid eligible non-emergency transportation services are given through LogistiCare, 1-877-796-5843. Call them to make your appointment. Make your appointment 48 hours before you need to be picked up. If the transportation service is late to pick up, call 1-877-796-5843 to find out why it is late. Call 1-877-796-5843 if you need to cancel your transportation. If you have an emergency and need to be taken to the hospital, you must call 911.

You can also call our customer service for assistance at 1-800-327-8613.

Vision Services Vision services include eye exams and up to two pairs of standard eyeglasses per year. Contact lenses for cosmetic purposes are not covered.

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Magellan Complete Care Expanded Services

Service BenefitOK from Doctor and

Magellan Needed

Dental—expanded for adults – Maximum $1500 benefit

– Preventive services—one cleaning and oral exam every 6 months

– One x-ray per year

– Treatment for periodontal disease

Yes—for treatment of periodontal

disease

Home Health Visits—enhanced for non- pregnant adults

– Can exceed 3 visits per day Yes

Intensive Outpatient Therapy for Substance Abuse

– No limits when medically necessary Yes

Nutritional Counseling – Up to 15 visits per year Yes

OB Visits – 10-14 visits for routine pregnancy care

– No limit for high risk pregnancy care

– 1 postpartum home visit

No

Outpatient Hospital Services – Not limited to $1500 based on medical necessity and in lieu of hospital admission

Yes

Over the Counter Medication/Supplies

– Certain over the counter medications and supplies

– See drug and supply list on web site

Requires prescription

Post discharge meals – Post discharge from inpatient admission; Up to 48 hours for member and up to 3 family members; requires 48 hours notice by member

Yes

Primary Care Visits—enhanced for non-pregnant adults

– One per day

– Not limited to 2 per month

No

Vaccines—adult – Pneumonia, flu, shingles No

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Magellan Complete Care Expanded Services continued

Service BenefitOK from Doctor and

Magellan Needed

Vision Services – Routine eye exam and glasses once every 12 months

– Additional exams and glasses with OK from doctor

– For Specialty Fits (new wearers, historic, RGP, multi-focal, etc.), the enrollee must pay for any charges over $50, less a 20 percent discount

Yes—for services beyond the annual

benefit

Co-pays – Waived Yes

Additional Notes for Covered Services

Service BenefitOK from Doctor and

Magellan Needed

Dental—adult All dental treatment or surgery is considered necessary when the dental condition is likely to result in a medical condition if left untreated.

Yes

Diabetes Care We cover all needed equipment, supplies, and services to treat diabetes, including self- management training and educational services if ordered by your doctor.

No

Family Planning Services May get services from any participating Medicaid provider

No

Inpatient Hospital Services Members over the age of 21 are limited to 45 days per Medicaid fiscal year

There is no limit for members under the age of 21 or for emergency care and pregnant adults.

Yes

Outpatient Services There is no limit for members under the age of 21. Yes

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Additional Notes for Covered Services continued

Service BenefitOK from Doctor and

Magellan Needed

Physician Services May be given by individuals who are not licensed physicians, including nurse practitioners and physician assistants, when under the direction of your PCP

Limited to one visit per day unless for an emergency, one new patient evaluation, one long term care facility visit per month

No

Therapeutic Group Care Therapeutic group care services or specialized therapeutic group care are community-based, psychiatric residential treatment services designed for recipients under the age of 21 years with moderate to severe emotional disturbances. They are provided in a licensed residential group home setting serving no more than 12 recipients. Providers must comply with the regulations and requirements listed in the Specialized Therapeutic Services Coverage and Limitations Handbook. A copy of the authorization form for this service can be found in our website under the provider section: “Authorizations”.

Yes

Women’s Health A female member, without an OK from her PCP, may visit a contracted obstetrician/gynecologist (OB/GYN) for one annual visit and for medically necessary follow up care as a result of that visit.

No

The benefit information provided is a brief summary, not a complete description of benefits; limitations and restrictions may apply and benefits may change. We provide coverage for all services identified by the State of Florida. No services are excluded due to religious or moral objections of Magellan Complete Care.

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Services Not Covered by Magellan Complete Care Routine, out of service area care is not covered by Magellan Complete Care. Only emergency services are covered. If you feel you need care while you are out of the service area call Magellan Complete Care at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694.

There are additional services that are covered directly through the Medicaid State Plan. Please call us at 1-800-327-8613 or our 1-800-424-1694 TTY only, for more information or contact the local Medicaid Office. Magellan Complete Care does not offer long-term care institutional services, institutional services for persons with developmental disabilities or state hospital services.

Under this plan, routine services that are provided by providers that are not part of the Magellan Complete Care Network are not covered unless there are special situations. For more information, contact Magellan Complete Care at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694.

How to Get MedicationsMagellan Complete Care covers prescription drugs and certain over-the-counter drugs. Please call us at 1-800-327-8613 or 1-800-424-1694 TTY only, for more information or visit the www.MCCofFl.com website for the Preferred Drug List.

• Go to a pharmacy that is signed up with Magellan Complete Care. See your Provider Directory or check the Provider Search online for a list of pharmacies near you. You can also call us at 1-800-327-8613 or 1-800-424-1694 TTY only, to help you find a pharmacy.

• At the pharmacy, show them your Magellan Complete Care ID card.

• Give them your prescription from your doctor.

Some medications require an okay from us before the prescription can be filled. Your doctor will call us to get the okay.

Informed Consent for Certain Drugs We require our doctors to get written permission “informed consent” from a parent or legal guardian before prescribing certain drugs to children under the age of 13. These drugs are psychotropic (psychotherapeutic) drugs and include antipsychotics, antidepressants, antianxiety medications, and mood stabilizers. Anticonvulsants and attention-deficit/hyperactivity disorder (ADHDS) medications (stimulants and non-stimulants) are not included at this time. Approval from us may also be required for prescriptions for these drugs. If you have questions, please call us at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694.

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Improving Your HealthMember Rewards ProgramMagellan Complete Care wants to encourage you to make healthy choices and take part in activities that will help keep you from getting sick. As a Magellan Complete Care member, you can get Member Rewards if you take part in specific activities. Magellan will offer programs to members who want to stop smoking, lose weight, or address any drug abuse problems. We will reward members who join and meet certain goals. These programs will be ready February 1, 2015.

You will receive information on how to earn Member Rewards from your Care Coordination Team. If you leave Magellan Complete Care, rewards can not be transferred to another health plan. You will lose access to earned rewards if you voluntarily disenroll from Magellan Complete Care or lose Medicaid eligibility for more than one-hundred eighty (180) calendar days. For more information, you can call Magellan Complete Care at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694.

Prevention Programs There are programs available to members that may help prevent or reduce the symptoms of mental illness and medical conditions and stay healthy. They work to find early signs of illness and help members work with their providers to manage their conditions. If signs are found early, the health plan can help members get the services they need to treat the illness. Getting care early may help slow down how fast or how bad your illness gets.

You can learn more about these programs. Please call Magellan Complete Care at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694..

Case Management and Disease Management ProgramsMagellan Complete Care has programs that will help you manage your chronic diseases. Some of the programs we offer are:

• Complex Case Management

• Asthma

• Hypertension

• Heart Failure

• Diabetes

• High Risk Maternity

• Cancer and Cancer Prevention

For more information, please call Customer Service toll free at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694. They can help you learn more about these programs. Your PCP can also help.

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Child Health Check-Up/VaccinesMagellan Complete Care promotes wellness visits for children. Child Health Check-Ups are an important part of our wellness program. These visits include many preventative screening services and other services to keep your child healthy. Magellan expects the following check-ups:

• Birth

• 2 – 4 days for newborns discharged in less than 48 hours after delivery

• 1 month

• 2 months

• 4 months

• 6 months

• 9 months

• 12 months

• 15 months

• 18 months

• 24 months

• 30 months

• Once every year for ages 3 – 20

Quality Benefit Enhancement ProgramsQuality Benefit programs help our members to improve their total health. Magellan partners with local community agencies and offers programs such as:

• Domestic Violence Prevention

• Children’s Programs

• Pregnancy Programs

• Pregnancy Prevention Programs

• Behavioral Health Programs

• Stop Smoking

• Substance Abuse Support

For more information visit our website at www.MCCofFL.com or call Magellan Complete Care at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694. They can help you learn more about these programs. Your PCP can also help.

Review of New Treatment OptionsMagellan Complete Care works closely with the Agency for Health Care Administration to determine what new treatment options can be covered as part of your benefits. Magellan reviews new treatment and technology options as part of the quality improvement commitment. Experimental treatments are not part of your benefits. For more information, call Magellan Complete Care at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694.

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Complaints, Grievances and Appeals ProcessComplaintsIf you are not happy with us, your provider, or your services for any reason, you or someone who can act for you, can tell us. We want to hear from you. You can call Magellan Complete Care Monday through Friday from 8:00 am to 7:00 pm. Please call 1-800-327-8613, or for hearing impaired 1-800-424-1694 TTY, e-mail us at CustomerService@MagellanCompleteCare.com, or you can send a letter to:

Magellan Complete CareAttn: Complaint CoordinatorPO Box 524083Miami, FL 33152

We will resolve your complaint as soon as we can. If we cannot give you an answer in one (1) day, your complaint will now be a grievance.

GrievancesA grievance is a formal complaint or a complaint that is not resolved in a day. You can call Magellan Complete Care Monday through Friday from 8:00 am to 7:00 pm. Please call 1-800-327-8613, or for hearing impaired 1-800-424-1694 TTY, e-mail us at CustomerService@MagellanCompleteCare.com, or you can send a letter to:

Magellan Complete CareAttn: Complaint CoordinatorPO Box 524083Miami, FL 33152

We can help you report a grievance. You must call within one (1) year of the issue. We must resolve your issue within 30 days. We will send you a letter with our answer.

Appeals If we do not give your doctor an okay for a service and you disagree (“adverse determination”), you can ask us to take a second look at our decision. The services that you are getting may continue but you may have to pay them if at the end of the process the services are not okayed. You must let us know that you want a second look within 30 days of receiving the notice from us letting you know that the services were not approved . You can call us at 1-800-327-8613, or for hearing impaired 1-800-424-1694 TTY, or send a letter to:

Magellan Complete CareAttn: Complaint CoordinatorPO Box 524083Miami, FL 33152

If you call us, you must also write us within 10 days, unless you are asking for an expedited appeal. We will have another person look at the decision. We will send you a letter with our final answer within 30 days.

Expedited AppealIf you need a decision right away, please let us know it is urgent. This occurs when your health status is in danger. We will give you an answer within 72 hours.

While you wait for our answer, you can continue to receive care. However, if the final decision is not in your favor, you may have to pay for the care.

If you need help filing a grievance or appeal, please call us toll free at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694. We are here from 8:00 am – 7:00 pm Monday – Friday.

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Here is who can help you file a grievance or appeal:

• Magellan Complete Care

• You

• Your Legal Guardian

• Doctor

Medicaid Fair Hearing/ Subscriber Assistance ProgramIf you do not agree with Magellan Complete Care’s decision, you can ask for a Medicaid Fair Hearing or review by the Subscriber Assistance Program (SAP).

Medicaid Fair Hearing

You do not need to go through the appeal process before you ask for a fair hearing. You can ask for a fair hearing by calling or writing. You may ask for a fair hearing any time up to 90 days after you get our decision on your appeal.

You may ask for a fair hearing by calling 1-850-488-1429 or writing to:

Mail:

Department of Children and FamiliesOffice of Appeal HearingsBuilding 5, Room 2551317 Winewood BoulevardTallahassee, FL 32399-0700

Fax: 1-850-487-0662

Email: Appeal_hearings@dcf.state.fl.us

Your provider can ask for a fair hearing for you, but you must give your written approval to the provider.

Subscriber Assistance Program

If you do not like our appeal decision, you have one year after you get the final decision letter to request a review by the Subscriber Assistance Program (SAP). You must finish your appeal process first. If you ask for a fair hearing, you cannot have a SAP review. To ask for a SAP review, call (888) 419-3456 (toll-free) or send your request to:

Agency for Health Care Administration

Subscriber Assistance Program

2727 Mahan Drive, Mail Stop #45

Tallahassee, FL 32308

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Protected Health InformationProtected Health InformationMagellan Complete Care follows the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We have rules to protect your health information (PHI). This includes oral, written and electronic PHI. Examples of information that will be protected:

• Member name.

• Member ID number.

• Member address.

• Member telephone.

• Social Security number.

• Date of Birth.

• Health Status.

• Name of the doctors that provide you care.

The Notice of Privacy Practices lists your rights under HIPAA. You have the right to see, correct, and get copies of your PHI. Magellan Complete Care can use PHI for health plan activities. This includes paying doctor bills or the care we give you. We may have to share this information if required by state or federal law.

Your Health Guide will go over the authorization, use and disclosure form. This form asks if you want to share your information with other people to coordinate all of your health care. Your Health Guide will give you the form or you can call Customer Service. You can cancel your permission at any time.

If you need help with completing the form, please contact your Health Guide or call Customer Service toll free at 1-800-327- 8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694.

Release of Information on Sensitive ConditionsRelease of information about protected and sensitive conditions and services, including psychotherapeutic services, require specific release from you prior to sharing with other providers. The Magellan Complete Care Authorization to Use and Disclose Protected Health Information (AUD) form is used to indicate the conditions for which release is permitted. This form can be found at www.MCCofFL.com.

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Member Rights and ResponsibilitiesMember Rights and ResponsibilitiesMagellan Complete Care wants you to know that as a member you have:

• A right to receive information about Magellan Complete Care, its services, its practitioners and providers and member rights and responsibilities.

• A right to be treated with respect and recognition of your dignity and their right to privacy.

• A right to participate with practitioners in making decisions about your health care.

• A right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.

• A right to voice complaints or appeals about Magellan Complete Care or the care it provides.

• A right to make recommendations regarding Magellan Complete Care’s member rights and responsibilities policy.

• A responsibility to supply information (to the extent possible) that Magellan Complete Care and its practitioners and providers need in order to provide care.

• A responsibility to follow plans and instructions for care that you have agreed to with their practitioners.

• A responsibility to understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.

Magellan Complete Care has also adopted the Florida Patient’s Bill of Rights and Responsibilities. Your doctors have a copy of this in their office.

You have the right to:

• Be treated with courtesy and respect

• Protection of privacy

• Receive a prompt response to questions and requests

• Know who is providing your medical services and care

• Know what services are available. This includes if you need an interpreter because you don’t speak English

• Know what rules and regulations apply to your conduct

• Be given the truth about your health status

• Refuse any treatment, except as otherwise provided by law

• Be given full information and counseling on the availability of known financial resources for your care

• Know whether the health care provider or facility accepts Magellan Complete Care’s contract rates

• Receive, prior to treatment, a reasonable estimate of cost

• Receive a copy of an itemized bill. If you want to have the charges explained, your doctor has to do so.

• Receive medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment

• Receive treatment for any emergency medical condition that will deteriorate from failure to provide treatment

• Know if medical treatment is for purpose of experimental research. If it is, then you can refuse or accept the services

• Express complaints regarding any violation of your rights

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You are responsible for:

• Giving your provider accurate information about your past and present health status

• Reporting unexpected changes in your health status

• Telling your provider if you understand what is expected of you

• Following the treatment plan recommended by your provider

• Keeping doctor appointments

• If you can’t keep the appointment, notify the provider you can’t come

• Knowing what will happen to you if you ignore the provider’s treatment plan

• Making sure financial responsibilities are met

• Following the provider’s conduct rules and regulations

Second Medical OpinionYou have the right to a second medical opinion at no cost to you. Please contact Customer Service for assistance toll free at 1-800-327-8613. If you are hearing impaired, call our TTY number toll free at 1-800-424-1694.

Reporting Abuse, Neglect, or ExploitationYou can report abuse, neglect, or exploitation by calling the abuse hotline at 800-96-ABUSE. The Florida Abuse Hotline serves as the central reporting center for allegations of abuse, neglect, and/or exploitation for all children and vulnerable adults in Florida.

Reporting Fraud, Waste, and Abuse• Fraud refers to a false action that is used to

gain something of value.

• Waste is the misuse of services.

• Abuse refers to overused or unneeded services.

Magellan Complete Care is dedicated to conducting business in a legal manner. We are committed to preventing, detecting and reporting fraud, waste and abuse. Also, the Bureau of Medicaid Program Integrity wants to prevent fraud, waste and abuse. They check on anybody including members, providers, and vendors who may be trying to commit fraud, waste or abuse against the Medicaid Program. They also:

• Recover overpayments.

• Issue warnings.

• Send possible fraud cases for investigation.

Examples of Fraud, Waste and Abuse:

• Medical services that are not needed.

• Billing for services that were not provided.

• Billing for services not covered by Medicaid.

• Billing twice for the same service.

• Using a billing code to get extra payments.

• Using another person’s identity to get Medicaid services.

• Making false documents by changing: − The date of service for a claim

− Prescriptions

− Medical records

− Referral forms

• Paying or taking a bribe.

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What you can do:

If you think someone or a provider is committing fraud, waste and abuse, please report it. The Magellan Complete Care Corporate Compliance hotline is available 24 hours a day, seven days a week. It is handled by an outside company. Callers do not have to give their names. All calls will be investigated and will remain confidential.

• Corporate Compliance Hotline: 800-915-2108

• Compliance Unit Email: Compliance@MagellanHealth.com

• Magellan Complete Care Special Investigation Unit at 877-269-7624

• You can also contact Magellan’s Corporate Special Investigations Unit at 800-755-0850 or SIU@MagellanHealth.com.

To report suspected fraud and/or abuse in Florida Medicaid call the Consumer Complaint Hotline toll free at 888-419-3456 or complete a Medicaid Fraud and Abuse Complaint Form, which is available online at https://apps.ahca.myflorida.com/InspectorGeneral/fraud_complaintform.aspx.

If you report suspected fraud and your report results in a fine, penalty or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Attorney General’s Fraud Rewards Program, toll free 866-966-7226 or 850-414-3990. The reward may be up to twenty-five percent (25%) of the amount recovered, or a maximum of $500,000 per case (Section 409.9203, Florida Statutes). You can talk to the Attorney General’s Office about keeping your identity confidential and protected.

You can report suspected fraud, waste, and abuse to the Florida Department of Financial Services Division of Insurance Fraud: Contact the DFS Fraud Hotline at 1-800- 378-0445.

You can also contact the U.S. Department of Health & Human Services Office of Inspector General at 1-800-447-8477 or by e-mail to HHSTips@oig.hhs.gov or by mail to the address below.

U.S. Department of Health and Human ServicesOffice of Inspector GeneralATTN: OIG HOTLINE OPERATIONSPO Box 23489Washington, DC 20026

More information is available at:

• http://ahca.myflorida.com/Medicaid/abuse/index.shtml

• http://ahca.myflorida.com/Executive/Inspector_General/complaints.shtml

• http://oig.hhs.gov/fraud

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Living Wills and Advance DirectivesLiving Wills and Advanced Directives help you to choose about life support. If you are seriously ill and can no longer help yourself this document tells the doctors your wishes. If the policies and procedures of your provider or the facility do not support or conflict with your Advance Directives, Magellan Complete Care will help you change providers or move you to another facility. You will find copies of these forms on page 43 and 45.

Magellan Complete Care provides these policies and procedures to any member who is 18 and older. These policies describe:

• Your rights under state law, including the right to accept or refuse medical care and surgery and the right to formulate advanced directives [plans for the future of your care].

• Magellan Complete Care’s written policies providing more information regarding those rights, including information about limitations regarding how the advance directives [or plan] are executed.

• When advanced directive are not followed there are laws to protect you and you may file a complaint with AHCA.

• Your doctor can share more information about these documents. You can also call Customer Service toll free at 1-800-327-8613. If you are hearing impaired, call toll free at 1-800-424-1694 TTY.

The Patient’s Right to DecideEvery competent adult has the right to make decisions concerning his or her own health, including the right to choose or refuse medical treatment.

When a person becomes unable to make decisions due to a physical or mental change, such as being in a coma or developing dementia (like Alzheimer’s disease), they are considered incapacitated. To make sure that an incapacitated person’s decisions about health care will still be respected, the Florida legislature enacted legislation pertaining to health care advance directives (Chapter 765, Florida Statutes). The law recognizes the right of a competent adult to make an advance directive instructing his or her physician to provide, withhold, or withdraw life-prolonging procedures; to designate another individual to make treatment decisions if the person becomes unable to make his or her own decisions; and/or to indicate the desire to make an anatomical donation after death.

By law hospitals, nursing homes, home health agencies, hospices, and health maintenance organizations (HMOs) are required to provide their patients with written information, such as this pamphlet, concerning health care advance directives. The state rules that require this include 58A-2.0232, 59A-3.254, 59A-4.106, 59A-8.0245, and 59A-12.013, Florida Administrative Code.

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Questions About Health Care Advance DirectivesWhat is an advance directive?

It is a written or oral statement about how you want medical decisions made should you not be able to make them yourself and/or it can express your wish to make an anatomical donation after death. Some people make advance directives when they are diagnosed with a life-threatening illness. Others put their wishes into writing while they are healthy, often as part of their estate planning.

Three types of advance directives are:

• A Living Will

• A Health Care Surrogate Designation

• An Anatomical Donation

You might choose to complete one, two, or all three of these forms. This pamphlet provides information to help you decide what will best serve your needs.

What is a living will?

It is a written or oral statement of the kind of medical care you want or do not want if you become unable to make your own decisions. It is called a living will because it takes effect while you are still living. You may wish to speak to your health care provider or attorney to be certain you have completed the living will in a way that your wishes will be understood.

What is a health care surrogate designation?

It is a document naming another person as your representative to make medical decisions for you if you are unable to make them yourself. You can include instructions about any treatment you want or do not want, similar to a living will. You can also designate an alternate surrogate.

Which is best?

Depending on your individual needs you may wish to complete any one or a combination of the three types of advance directives.

What is an anatomical donation?

It is a document that indicates your wish to donate, at death, all or part of your body. This can be an organ and tissue donation to persons in need, or donation of your body for training of health care workers. You can indicate your choice to be an organ donor by designating it on your driver’s license or state identification card (at your nearest driver’s license office), signing a uniform donor form (seen elsewhere in this pamphlet), or expressing your wish in a living will.

Am I required to have an advance directive under Florida law?

No, there is no legal requirement to complete an advance directive. However, if you have not made an advance directive, decisions about your health care or an anatomical donation may be made for you by a court-appointed guardian, your wife or husband, your adult child, your parent, your adult sibling, an adult relative, or a close friend.

The person making decisions for you may or may not be aware of your wishes. When you make an advance directive, and discuss it with the significant people in your life, it will better assure that your wishes will be carried out the way you want.

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Must an attorney prepare the advance directive?

No, the procedures are simple and do not require an attorney, though you may choose to consult one.

However, an advance directive, whether it is a written document or an oral statement, needs to be witnessed by two individuals. At least one of the witnesses cannot be a spouse or a blood relative.

Where can I find advance directive forms?

Florida law provides a sample of each of the following forms: a living will, a health care surrogate, and an anatomical donation. Elsewhere in this pamphlet we have included sample forms as well as resources where you can find more information and other types of advance directive forms.

Can I change my mind after I write an advance directive?

Yes, you may change or cancel an advance directive at any time. Any changes should be written, signed and dated. However, you can also change an advance directive by oral statement; physical destruction of the advance directive; or by writing a new advance directive.

If your driver’s license or state identification card indicates you are an organ donor, but you no longer want this designation, contact the nearest driver’s license office to cancel the donor designation and a new license or card will be issued to you.

What if I have filled out an advance directive in another state and need treatment in Florida?

An advance directive completed in another state, as described in that state’s law, can be honored in Florida.

What should I do with my advance directive if I choose to have one?

• If you designate a health care surrogate and an alternate surrogate be sure to ask them if they agree to take this responsibility, discuss how you would like matters handled, and give them a copy of the document.

• Make sure that your health care provider, attorney, and the significant persons in your life know that you have an advance directive and where it is located. You also may want to give them a copy.

• Set up a file where you can keep a copy of your advance directive (and other important paperwork). Some people keep original papers in a bank safety deposit box. If you do, you may want to keep copies at your house or information concerning the location of your safety deposit box.

• Keep a card or note in your purse or wallet that states that you have an advance directive and where it is located.

• If you change your advance directive, make sure your health care provider, attorney and the significant persons in your life have the latest copy.

If you have questions about your advance directive you may want to discuss these with your health care provider, attorney, or the significant persons in your life.

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More Information on Health Care Advance DirectivesBefore making a decision about advance directives, you might want to consider additional options and other sources of information, including the following:

• As an alternative to a health care surrogate, or in addition to, you might want to designate a durable power of attorney. Through a written document, you can name another person to act on your behalf. It is similar to a health care surrogate, but the person can be designated to perform a variety of activities (financial, legal, medical, etc.). You can consult an attorney for further information or read Chapter 709, Florida Statutes.

• If you choose someone as your durable power of attorney be sure to ask the person if he or she will agree to take this responsibility, discuss how you would like matters handled, and give the person a copy of the document.

• If you are terminally ill (or if you have a loved one who is in a persistent vegetative state) you may want to consider having a pre-hospital Do Not Resuscitate Order (DNRO). A DNRO identifies people who do not wish to be resuscitated from respiratory or cardiac arrest. The pre-hospital DNRO is a specific yellow form available from the Florida Department of Health (DOH). Your attorney, health care provider, or an ambulance service may also have copies available for your use. You, or your legal representative, and your physician sign the DNRO form. More information is available on the DOH website, www.doh.state.fl.us or www.MyFlorida.com (type DNRO in these website search engines) or call 850-245-4440.

• When you are admitted to a hospital the pre-hospital DNRO may be used during your hospital stay or the hospital may have its own form and procedure for documenting a Do Not Resuscitate Order.

• If a person chooses to donate, after death, his or her body for medical training and research the donation will be coordinated by the Anatomical Board of the State of Florida. You, or your survivors, must arrange with a local funeral home, and pay, for a preliminary embalming and transportation of the body to the Anatomical Board located in Gainesville, Florida. After being used for medical education or research, the body will ordinarily be cremated. The remains will be returned to the loved ones, if requested at the time of donation, or the Anatomical Board will spread the remains over the Gulf of Mexico. For further information, contact the Anatomical Board of the State of Florida at 800-628-2594 or www.med.ufl.edu/anatbd.

• If you would like to learn more on organ and tissue donation, please visit the Joshua Abbott Organ and Tissue Donor Registry at www.DonateLifeFlorida.org where you can become organ, tissue and eye donors online. If you have further questions about organ and tissue donation you may want to talk to your health care provider.

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• Various organizations also make advance directive forms available. One such document is “Five Wishes” that includes a living will and a health care surrogate designation. “Five Wishes” gives you the opportunity to specify if you want tube feeding, assistance with breathing, pain medication, and other details that might bring you comfort such as what kind of music you might like to hear, among other things. You can find out more at:

Aging with Dignity www.AgingWithDignity.org888-594-7437

Other resources include:American Association of Retired Persons (AARP)www.aarp.org(Type “advance directives” in the website’s search engine)

Your local hospital, nursing home, hospice, home health agency, and your attorney or health care provider may be able to assist you with forms or further information.

Brochure: End of Life Issueswww.FloridaHealthFinder.gov888-419-3456

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Helpful Forms

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Grievance FormMail to: Magellan Complete Care Attn: Grievance and Appeals Department PO Box 524083 Miami, FL 33152

Need assistance? Please call 1-800-327-8613 or our TTY number at 1-800-424-1694

Member Name: | Member ID:

Address:

Cell Phone Number: | Home Telephone Number:

Date problem occured:

Where did this happen:

Did you call anyone at Magellan or the doctor's office for help? � Yes � No

If yes, what is their name and telephone number?

Name: | Telephone Number:

Please describe the problem that you experienced:

Did you ask anyone to resolve the problem you encountered? � Yes � No

What is the best time to speak with you? � 8:30 am – 12:30 pm � 1:00 pm – 5:00 pm

I understand that Magellan Complete Care will (1) contact me within 5-working days of receipt of this form; (2) I will be notified by Magellan Complete Care regarding their initial findings; (3) I will be notified of my Rights to an appeal if I’m not satisfied with Magellan Complete Care’s findings.

Signature of Member/Representative/Legal Guardian Date

Print Name of Member/Representative/Legal Guardian

Contact Telephone Number: | Relationship if not Member:

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Appeals FormThank you for contacting Magellan Complete Care. All appeals must be submitted in writing to:

Magellan Complete CareAttn: Grievance and Appeals DepartmentPO Box 524083Miami, FL 33152

Need assistance? Please call 1-800-327-8613 or our TTY number at 1-800-424-1694

Member Name: | Member ID:

Address:

Cell Phone Number: | Home Telephone Number:

The following items are included with my appeal:

� Copy of the original claim

� Medical Records enclosed

� Proof of Eligibility

� Prior authorization from Magellan Complete Care

� Other documents

What is the best time to speak with you? � 8:30 am – 12:30 pm � 1:00 pm – 5:00 pm

I have received a copy of my Appeal Rights in my Member Handbook. If I need assistance with understanding my Rights, Magellan Complete Care will assist in explaining this to me.

Signature of Member/Representative/Legal Guardian Date

Print Name of Member/Representative/Legal Guardian

Contact Telephone Number: | Relationship if not Member:

Type of Appeal: � Regular appeal � Expedited appeal (must demonstrate proof of medical emergency)

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Living WillDeclaration made this _____ day of ___________________ , 20_____ , I, _______________________________________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am mentally or physically incapacitated and

_________ (initial) I have a terminal condition,

or _________ (initial) I have an end-stage condition,

or _________ (initial) I am in a persistent vegetative state,

and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

I do _____, I do not _____ desire that nutrition and hydration (food and water) be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying.

It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

In the event I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration:

Name ____________________________________________________________________________________________________________

Street Address ____________________________________________________________________________________________________

City _____________________________________________ State ______________ Phone _____________________________________

I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.

Additional Instructions (optional): ___________________________________________________________________________________

__________________________________________________________________________________________________________________

Signed ___________________________________________________________________ Date __________________________________

Witness #1 _______________________________________________________________________________________________________

Street Address ____________________________________________________________________________________________________

City _____________________________________________ State ______________ Phone _____________________________________

Witness #2 _______________________________________________________________________________________________________

Street Address ____________________________________________________________________________________________________

City _____________________________________________ State ______________ Phone _____________________________________

At least one witness must not be a husband or wife or a blood relative of the principal.

Definitions for terms on the Living Will form:

“End-stage condition” means an irreversible condition that is caused by injury, disease, or illness which has resulted in progressively severe and permanent deterioration, and which, to a reasonable degree of medical probability, treatment of the condition would be ineffective.

“Persistent vegetative state” means a permanent and irreversible condition of unconsciousness in which there is: The absence of voluntary action or cognitive behavior of any kind and an inability to communicate or interact purposefully with the environment.

“Terminal condition” means a condition caused by injury, disease, or illness from which there is no reasonable medical probability of recovery and which, without treatment, can be expected to cause death.

These definitions come from section 765.101 of the Florida Statues. The Statutes can be found in your local library or online at www.leg.state.fl.us.

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Designation of Health Care SurrogateName: ___________________________________________________________________________________________________________

In the event that I have been determined to be incapacitated to provide informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my surrogate for health care decisions:

Name ____________________________________________________________________________________________________________

Street Address ____________________________________________________________________________________________________

City _____________________________________________ State ______________ Phone _____________________________________

If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate surrogate:

Name ____________________________________________________________________________________________________________

Street Address ____________________________________________________________________________________________________

City _____________________________________________ State ______________ Phone _____________________________________

I fully understand that this designation will permit my designee to make health care decisions and to provide, withhold, or withdraw consent on my behalf; or apply for public benefits to defray the cost of health care; and to authorize my admission to or transfer from a health care facility.

Additional instructions (optional): ___________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

I further affirm that this designation is not being made as a condition of treatment or admission to a health care facility. I will notify and send a copy of this document to the following persons other than my surrogate, so they may know who my surrogate is.

Name: ____________________________________________________________________________________________________________

Name: ____________________________________________________________________________________________________________

Signed ___________________________________________________________________ Date __________________________________

Witnesses:

1. _____________________________________________________________________________________________________________

2. _____________________________________________________________________________________________________________

At least one witness must not be a husband or wife or a blood relative of the principal.

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Uniform Donor FormYou can use this form to indicate your choice to be an organ donor. Or you can designate it on your driver’s license or state identification card (at your nearest driver’s license office) .

The undersigned hereby makes this anatomical gift, if medically acceptable, to take effect on death. The words and marks below indicate my desires:

I give: (a) ________ any needed organs or parts

(b) ________ only the following organs or parts for the purpose of transplantation, therapy, medical research, or education:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

(c) ________ my body for anatomical study if needed. Limitations or special wishes, if any:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Signed by the donor and the following witnesses in the presence of each other:

Donor’s Signature ______________________________________________________ Donor’s Date of Birth ______________________

Date Signed _______________________________________ City and State ________________________________________________

Witness #1 _______________________________________________________________________________________________________

Street Address ____________________________________________________________________________________________________

City _____________________________________________ State ______________ Phone _____________________________________

Witness #2 _______________________________________________________________________________________________________

Street Address ____________________________________________________________________________________________________

City _____________________________________________ State ______________ Phone _____________________________________

You can use this form to indicate your choice to be an organ donor. Or you can designate it on your driver’s license or state identification card (at your nearest driver’s license office).

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Health Care Advance DirectivesThe card below may be used as a convenient method to inform others of your health care advance directives. Complete the card and cut it out. Place in your wallet or purse. You can also make copies and place another one on your refrigerator, in your car glove compartment, or other easy to find place.

Health Care Advance Directives

I, ________________________________________ have created the following Advance Directives:

� Living Will

� Health Care Surrogate Designation

� Anatomical Donation

� Other (specify) ___________________________

Contact Information:

Name __________________________________________

Address ________________________________________

Phone __________________________________________

Signature ______________________________________

Date ___________________________________________FO

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