Coventry Long Term Care Program - Aetna · 12/1/2015 · Coventry Health Care of Florida Long Term Care Enrollee Handbook Member Services 1-844-645-7371, TTY 711 i iii The health

Coventry Long Term Care Program Member Handbook

2016

1

Important Numbers 2 3

Service Phone, Fax, Email, Website Address

Coventry Health Care of Florida 1-844-645-7371 Relay 711 Fax: x-xxx-xxx-xxxx 24 hours a day, 7 days a week www.coventryflltc.com

1340 Concord Terrace Sunrise, FL 33323

Dental Services MCNA Dental

1-800-281-9724 TTY 711 Email: [email protected] Monday – Friday 8 a.m. – 8 p.m. www.mcnala.net

Vision Services Florida Optometric – Physicians Network

1-877-418-2025 Fax 1-305-418-7627 Email: [email protected] www.fopn.org

HearUSA 1-800-731-3277 Fax: 888 -888-0099 Monday – Friday 8 a.m – 8 p.m. www.HearUSA.com

For Eligibility questions: Florida Department of Children and Families - ACCESS

1-866-762-2237 TTY 711 Fax: 1-866-886-4342 Monday – Friday 8 a.m. – 5 p.m. www.myflfamilies.com

Fraud and Abuse Hotline You can report anonymously

Coventry Cares of Florida Compliance: 1-888-891-8910 Florida Medicaid Consumer Complaint Hotline: 1-888-419-3456 www.ahca.myflorida.com Special Investigation Unit (SIU) Hotline: 1-866-806-7020 Florida Attorney General 1-866-966-7226

Agency for Health Care Administration Medicaid Program Integrity 2727 Mahan Drive MS #6 Tallahassee, FL 32308

Grievance and Appeals Phone: 1-844-645-7371 TTY 711 Fax: 1-844-410-8655

Coventry Health Care of Florida Attn: Grievance & Appeals 1340 Concord Terrace Sunrise, FL 33323

Language Interpretation Services Call Coventry Health Care of Florida Member Services

1-844-645-7371 TTY 711

Non-Emergency Transportation (transportation to and from appointments for covered services)

Provided by Logisticare Reservations (call 3 business days ahead of time): Phone: 1-866-799-4463 Monday – Friday 8 a.m. – 5 p.m.

Nurse Advice Line 1-844-645-7371 TTY 711 Select the option for nurse line

http://www.mcnala.net/

http://www.ahca.myflorida.com/

24 hours a day, 7 days a week

After Hours Case Management Number

1-844-645-7371

Subscriber Assistance Program 1-850-419-3456

Abuse Hotline 1-800-96ABUSE or

1-800-962-2873

TTY 1-800-453-5145

Aging and Disability Resource Center 1-800-963-5337

Provider Name

Home Health Agency

Pharmacy Name

Meal Service

4

Coventry Health Care of Florida Long Term Care Enrollee Handbook Member Service 1-844-645-7371, TTY 711 ● www.coventryflltc.com i

COVENTRY LONG TERM CARE PROGRAM MEMBER HANDBOOK

Welcome to the Coventry Long Term Care (LTC) program. We are your Managed Long Term Care Plan.

Coventry Health Care of Florida, an Aetna company, (“Coventry”) will help you with this program’s services for your health, social service, and long term care needs. If you have any questions, please contact our Member Services Department, we are available 24 hours a day 7 days toll-free at 1-844-645-7371. Hearing or speech impaired, call FL Relay 711.

Your case manager will provide you with his or her direct phone number. You can call 24 hours a day, 7 days a week for urgent issues about your benefits and services.

In this Member Handbook, the Health Plan is called we, our, us, plan or Coventry. The enrollee or member is called you or your.

This Member Handbook is available in English and Spanish. It is also available upon request for other languages including Haitian Creole and Braille. For more information, call our Member Services Department toll free at 1-844-645-7371.

SI-OU TA VLÉ RÉCEVOI INFARMACION- SA EN CRÉOLE, TAMPRI RÉLÉ NAN NUMÉRO-SA 1-844-645-7371.

Coventry Health Care of Florida Long Term Care Enrollee Handbook Member Services 1-844-645-7371, TTY 711 ● www.coventryflltc.com i iii

TABLE OF CONTENTS COVENTRY LONG TERM CARE PROGRAM MEMBER HANDBOOK ................................i

TABLE OF CONTENTS ............................................................................................................iii ENROLLMENT

......................................................................................................................... 1

Medicaid Pending ................................................................................................................. 1

Open Enrollment ................................................................................................................... 2

Newborn Enrollment ............................................................................................................. 2

Enrollment Effective Date ..................................................................................................... 2

Disenrollment ....................................................................................................................... 3

Identification Card ................................................................................................................ 4

YOUR CASE MANAGER'S ROLE ........................................................................................... 5

COVERED SERVICES .............................................................................................................. 6

Nursing Homes ..................................................................................................................... 7

Enhanced Services ................................................................................................................ 8

Quality Enhancements........................................................................................................... 8

GETTING ACCESS TO SERVICES IN YOUR CARE PLAN ................................................... 9

Referral Process .................................................................................................................... 9

Determining Medical Necessity............................................................................................. 9

Services Available Without Prior Authorization .................................................................... 9

Disaster/Emergency Plan .................................................................................................... 10

Contingency Plan ............................................................................................................... 10

Participant Directed Options ............................................................................................... 10

EMERGENCY SERVICES ..................................................................................................... . 11

What To Do In An Emergency ............................................................................................ 11

Prior Authorization Is Not Required For Emergency Services ............................................. 11

Out Of Area Emergency Care.............................................................................................. 11

YOUR FREEDOM OF CHOICE WITH NETWORK PROVIDERS ........................................ 12

CONSEQUENCES OF CARE FROM OUT-OF-NETWORK PROVIDERS ............................ 12

SERVICES NOT COVERED ................................................................................................... 13

Excluded Services ............................................................................................................... 13

MEMBER RIGHTS AND RESPONSIBILITIES...................................................................... 14

Your Rights........................................................................................................................ 14

Your Responsibilities .......................................................................................................... 15

REPORTING FRAUD, ABUSE AND OVERPAYMENTS...................................................... 16

Reporting Abuse, Neglect And Exploitation ........................................................................ 16


The health plan provides various options for reporting suspected/confirmed fraud, abuse or overpayment. These include: .............................................................................................. 16

• The Special Investigative Unit (SIU) ……………………………………………………………………………….16

• The Bureau of Medicaid Program Integrity......................... 16

• Member Services Department …………………………………………………………………………………………16

• Health Plan Medicaid Compliance Officer ………………………………………………………………16

GRIEVANCE AND APPEALS ................................................................................................ 17

Grievances .......................................................................................................................... 17

Filing a Grievance/Appeal................................................................................................... 17

Notice of Case Action ........................................................................................................ . 17

Appeals ............................................................................................................................... 17

Review by Agency and the Subscriber Assistance Program ............................................... 18

Requesting a Fair Hearing ................................................................................................... 18

Continuation of Benefits ..................................................................................................... 18

CONFIDENTIALITY OF YOUR RECORDS .......................................................................... 18

Protected Health Information .............................................................................................. 18

Member Privacy.................................................................................................................. 18

INFORMATION YOU CAN RECEIVE UPON REQUEST .................................................... 19

ALTERNATIVE COMMUNICATION SYSTEMS .................................................................. 20

Moral or Religious Objections............................................................................................ 20

Behavioral Health ............................................................................................................... 20

Educational and Consumer Resources ................................................................................. 20

ACCESS OTHER BENEFITS .................................................................................................. 21

Emergency and Non- Emergency Transportation................................................................. 21

How to get Medical Care.................................................................................................... 21

Medical Appointments with Your Doctor ........................................................................... 21

Second Opinion................................................................................................................... 21

Changing Your Doctor ........................................................................................................ 21

ADVANCE DIRECTIVES ...................................................................................................... . 22

Questions and Answers about a Living Will ........................................................................ 23

Who may Complete a Living Will? ...................................................................................... 23

When does the Living Will take effect?................................................................................ 23

What are the Witnessing Requirements? ............................................................................. 23

How may I Appoint a Health Surrogate in my Living Will? ................................................. 24


Can I write Special or Additional Instructions about my Health Care? ............................. 24

What if a Health Care Provider refuses to Comply with my Living Will? .......................... 24

For Assistance in Preparing an Advance Directive .............................................................24

Durable Power of Attorney for Health Care Decisions ........................................................24

LIVING WILL .........................................................................................................................25

DESIGNATION OF HEALTH CARE SURROGATE..............................................................26

TELEPHONE DIRECTORY ................................................................................................... . 29

HANDBOOK SIGNATURE PAGE ......................................................................................... 31

NOTES ..................................................................................................................................... 33

Coventry Health Care of Florida Long Term Care Enrollee Handbook Member Services 1-844-645-7371, TTY 711 ● www.coventryflltc.com 4

ENROLLMENT Please tell us when you have a change to your:

Name

Address

County of residence

Telephone number

Please also give your updates to:

Department of Children and Families (DCF)

Social Security Administration (SSA)

We will accept all members who meet the requirements. We accept members in the order Department of Elder Affairs (DOEA) CARES sends them. We do not discriminate due to race, color, or national origin. We do not use any rules that discriminate for anything, including race, color, or national origin.

If you are a mandatory enrollee required to enroll in a managed care plan, once you are

enrolled in Coventry Health Care of Florida or the state enrolls you in a plan, you will have

120 days from the date of your first enrollment to try out our managed care plan. During

the first 120 days, you can change managed care plans for any reason. After the 120 days, if

you are still eligible for Medicaid, you will be enrolled in our managed care plan for the next

nine months. This is called “lock-in”.

Medicaid Pending A person who is Medicaid Pending is someone who:

Applies for the program

CARES says can be in the program

DCF has not yet determined financial eligibility

We provide Medicaid Pending services.

Once DCF decides your financial eligibility, we will send CARES the decision and provide a copy of the Notice of Case Action or verification of eligibility upon receipt.

If DCF says you are not financially eligible, we may remove you from our plan and ask you to return money paid on your behalf for:

Documented services

Claims

Copayments

Deductibles that have been paid for you

We will send you an itemized bill for services. The bill and related papers are part of our case notes.


Open enrollment If you are a mandatory enrollee, the state will send you a letter 60 days before the end of your

enrollment year telling you that you can change 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 the 60 day open enrollment

period.

Newborn enrollment

If you become pregnant, you must tell the Florida Department of Children and Families Services.

When your baby is born, you must sign up your baby with the Florida Department of Children and

Families Services. This ensures your baby has Medicaid. You should also call our

Member Services Department.

Enrollment effective date

To be in the program you must meet the financial and clinical requirements set by:

Department of Elder Affairs (DOEA)

Department of Children and Families (DCF)

A case manager will contact you and schedule a personal visit:

Within 5 business days of when you enroll if you are living at home

Within 7 business days if you are in a nursing facility

Your case manager will visit you in-person and explain the program. When you are approved

for the program, your enrollment starts at 12:01 a.m. on the first day of the next calendar

month.

When you are enrolled in our Plan, you get a package of papers, including:

Over the counter medication form with instructions

Notice of Privacy Practices

Authorization to use or disclose personal information

Welcome newsletter

Member Handbook

Provider Directory

Postage paid, pre-addressed envelope for address corrections and completed forms.

Your LTC Identification Card will come in a separate mailing which will include your welcome letter


with your effective enrollment date. If you do not receive your ID card within 5 days please contact Member Services to request one. We are available 24 hours a day 7 days toll-free at 1-844-645-7371. Hearing or speech impaired, call FL Relay 711.

If you lose eligibility but regain it within 60 days, you will be put back into our plan automatically in

the next enrollment cycle. We will send a letter to each person who returns to our plan. The letter

will show the effective date of the reinstatement. You can ask for a new member package.

Disenrollment

Disenrollment means you leave The Managed Care Plan. If you chose to join the Managed Care Plan you may leave the Managed Care Plan anytime. We will not stop you from leaving the Managed Care Plan. Remember to use our services and network providers until we finish your disenrollment. Call the Choice Counseling Center to:

Get a disenrollment form Find out if you may change plans

We do not help with disenrollment requests. We do not help the Choice Counselor in the

disenrollment process. You can disenroll anytime. Talk to your case manager to start the

disenrollment process:

If you ask to leave the Plan on or before the 15th day of the month, you leave the Plan the first day of the following month

If you ask to leave the Plan after the 15th day of the month, you leave the Plan the first day of the second month after the request was received

If you are a mandatory enrollee and you want to change plans after the initial 120-day period ends, or after your open enrollment period ends, you must have a state-approved good cause reason to change managed care plans. The following are state-approved cause reasons to change to a new managed care plan:

The enrollee does not live in a region where the managed care plan is authorized to provide services, as indicated in Florida Medicaid Managed Information System (FLMMIS).

The provider is no longer with the managed care plan. The enrollee is excluded from enrollment. A substantiated marketing or community outreach violation has occurred. The enrollee is prevented from participating in the development of his or her treatment

plan or plan of care.

The enrollee has an active relationship with a provider who is not on the managed care plan’s panel, but is on the panel of another managed care plan. “Active relationship” is defined as having received services from the provider within the six months preceding the disenrollment request.

The enrollee is in the wrong managed care plan as determined by the Agency. The managed care plan no longer participates in the region.


The State has imposed intermediate sanctions upon the managed care plan, as specified in 42 CFR 438.702(a)(3). The enrollee needs related services to be performed concurrently, but not all related

services are available within the managed care plan’s network, or the enrollee’s PCP has determined that receiving the services separately would subject the enrollee to unnecessary risk.

The managed care plan does not, because of moral or religious objections, cover the service the enrollee seeks.

The enrollee missed open enrollment due to a temporary loss of eligibility. Other reasons per 42 CFR 438.56(d)(2) and s. 409.969(2), F.S., 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.

Some 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 at 1-877-711-3662.

Identification (ID) card You should carry your Coventry Long Term Care Plan ID card with you all the time. When you go

to the doctor or hospital, show them your Coventry Long Term Care Plan ID card. This will help

them manage service and pay providers. Only you may use your card. No one else may use it.

If you lose your ID card or if you need to change it, call the Member Services Monday

through Friday, 8 a.m. to 7 p.m. toll-free at 1-844-645-7371. Hearing or speech impaired, call

TTY 711.

Coventry Health Care of Florida Long Term Care Enrollee Handbook Member Services 1-844-645-7371, TTY 711 ● www.coventryflltc.com i 5

YOUR CASE MANAGER ROLE We will assign a case manager when you enroll in our plan. The case manager is your contact person. Your case manager helps you arrange your services.

Your case manager will contact you within 5 business days after you join our plan. If you live in a nursing facility, the case manager will contact you within 7 business days after you join our plan.

Your case manager and you will discuss what services are right for you. Your case manager and you will choose a provider for services.

We will not pay for services if you choose a provider who:

Is not part of our plan network

We have not authorized

Contact your case manager for all your needs, including:

If you change where you live

If your condition needs more services

If you need to go to the hospital

Your case manager:

Is in charge of evaluating your needs for your living arrangements and support system.

Will make a plan of care with you, your caregiver, and your doctor. Your case manager will put together the services to help keep you living in the community.

Will look at your plan of care every 90 days.

Will change the Managed Care Plan of care when needed. Will work with discharge planners to plan your return home or to an assisted

living community if you are in the hospital or a nursing facility. Will inform you of your right to receive home and community-based services in a

home-like environment regardless of your living arrangement. Will provide you with information regarding the community integration and

personal goal planning process and your participation in that process.


COVERED SERVICES We work with care providers and doctors to make sure you get the right care. This is called utilization management. Always take full advantage of the benefits and services offered through Medicare. Call your doctor first for medical care. Call your case manager for services like:

Adult companion care – Helps you fix meals, do laundry, shop and light housekeeping.

Adult day health care – Activities in an organized program in the community.

Assistive care services – 24-hour services for residents in assisted living facilities, adult family care homes and residential treatment facilities.

Assisted living – Care for people living in a licensed Assisted Living Facility (ALF).

Attendant care – Hands-on support and health care for medically stable, physically handicapped people.

Behavioral management – Behavioral care that helps mental health or substance abuse.

Caregiver training – Training and counseling for people who provide unpaid support, training, companionship, or supervision.

Care coordination/Case management – A personal case manager to help you get community services, maintain Medicaid eligibility, and help with the care system.

Home accessibility adaptation services – Work within your home that you need to stay health or safe and so you can be more on your own and independent.

Home delivered meals – Healthy meals delivered to your home.

Homemaker services – Light housekeeping and chores.

Hospice – End of life help provided if you choose hospice.

Intermittent and skilled nursing – Extra nursing help if you do not need nursing supervision all the time or need it at a regular time.

Medical equipment and supplies – Extra repair and replacement for medical equipment and supplies.

Medication administration – Help so that you can't take medication by yourself.

Medication management – Review all your prescriptions and over-the-counter medications with a licensed nurse. The nurse works with your doctor to do this.

Nutritional assessment/Risk reduction services – Review, advice, hands-on-care, and guidance to you and your caregiver about healthy eating.

Nursing facility services – Services in a health care facility. When you are placed in a nursing facility, you continue to receive acute care services. However, the home and community-based long-term care waiver services stop.


Personal care – Help with hands-on care needs that are essential to your health and welfare.

Personal Emergency Response Systems (PERS) – A 24-hour emergency call system.

Respite care – Help for a caregiver. It gives the caregiver a break with daily care.

Occupational therapy – Helps you get back, keep, or improve functions so that you can stay independent.

Physical therapy – Helps you get back, keep, or improve functions. Helps your body do things better.

Respiratory therapy – Helps you with breathing.

Speech therapy – Helps you with talking.

Transportation – Transportation for you when it is not an emergency.

Nursing homes

If at any time it is found that you can no longer be cared for in your home, you may need to be moved to a nursing home or assisted living facility. This may be short-term or a permanent placement.

If you live in the nursing home, the standard rules for Medicaid will apply. You must assign your income to the nursing home except for a monthly personal needs allowance (some exceptions could apply with regard to spousal needs). The actual amount of your financial responsibility is determined by Medicaid during the financial eligibility process.

A person living in an assisted living facility is required to pay room and board. The personal responsibility for people living in assisted living facility includes an allowance for room and board. If necessary, your case manager will discuss the cost of both nursing home and assisted living facility placement.

Enhanced services

We offer some extra benefits to our members:

Seven day daily pill organizer for home and community-based enrollees

Emergency financial assistance in community settings – after attempting to help you find other funding, we will provide up to $250 per year to help you stay in the community or return to the community.

Support to move out of a nursing facility – will provide up to $250 per year to help you with moving expenses. This help is provided for you when you are moving from a skilled nursing facility into a community setting. This benefit may be used along with the emergency funding assistance. The total amount of assistance from both benefits will not be more than a total of $250 per year.


Over-the-Counter (OTC) benefit – a monthly $15 benefit that can be used for health care related items.

Dental services – coverage for semi-annual preventive cleaning, X rays every 2 years and annual dental exam.

Vision services – annual eye exam plus one of the following: one set of eyeglasses per year; or one set of hard contacts lenses per year; or one annual supply of soft contact lenses per year.

Hearing services – annual hearing test and annual hearing screen for hearing aid candidacy.

Shelf-stable meals – an emergency supply of 10 meals will be provided when there is an emergency such as a hurricane or other disaster or emergency situation.

Cellular phones – prepaid phones will be provided during your membership in this program. Replacement phones are limited to 1 every 2 years.

For details on these services and others, contact your case manager.

We do not require copayments or cost sharing for all covered services listed as an expanded benefit. Prior authorization is not required for these

Quality enhancements

We make sure you get needed services and community programs. These include:

Home safety concerns

Education on health risks and conditions

End-of-life issues

Screening for domestic violence

Your case manager will talk with about this. He or she will provide guidance and information

to community services.


GETTING ACCESS TO SERVICES IN YOUR CARE PLAN

Referral process

Your case manager will help you access the services you need. You can choose the provider you like from the Coventry Health Care of Florida LTC Provider Directory.

Determining medical necessity

Your case manager will help you coordinate the services you need after an assessment. The assessment reviews your:

Medical condition

Physical condition

Social situation

Environmental situation

Your case manager does an assessment with your caregiver, your physician and you. You get covered services based on what you need at the time or to keep living in the community.

Your care plan shows all services you may need after the case manager completes your assessment. Your case manager does this when you enroll and when needed. Your plan includes your:

Medical history

Health care needs

Living arrangement

Support system

You sign a copy of your care plan. This shows you agree with what it says and that you understand the services. Your doctor gets a copy of your managed care plan to keep your care consistent. If your care plan changes, you, your caregiver, family members, and your doctor all get copies. This makes sure everyone is working together.

Services available without prior authorization

In an emergency, eligible post-stabilization care services can be covered without our approval if:

You contact us and we do not respond within an hour. Or you cannot contact us.

You have an emergency and the doctor decides you need the treatment after the emergency.


Disaster/emergency plan Your case manager will provide information regarding how to develop a disaster or emergency plan. It will include information for your family and you when dealing with special medical needs and a special needs registry. It will have plans, all local shelter listings, and evacuation information. Plus you will get emergency preparedness information for people with disabilities and caregivers. All of which is available at the website www.floridadisaster.org.

If needed, this plan will be placed in your case file. Informational materials are available at the Federal Emergency Management Agency’s (FEMA) website at www.fema.gov or www.ready.gov. You can also register with the state’s Emergency Preparedness Special Needs Shelter Registry. For more information go to: www.doh.state.fl.us/phnursing/SpNS/SpecialNeedsShelter.html

Contingency plan

Your caregiver, case manager and you will develop a plan if something prevents you from getting services. Together you will decide the best way to make sure your needs are met. Your case manager works on making sure that any gap in your care is covered.

Participant directed options

In some cases you may choose to select someone you know to provide you with the following services through this program. Your case manager will talk to you about this option if you are interested and train you so you can manage your own care.

Attendant care services

Homemaker services

Personal care

Adult companion services

Intermittent and skilled nursing

EMERGENCY SERVICES

What to do in an emergency

After-hours and emergency coverage is provided. You have the right to use any hospital or other emergency location for emergency care. Go to the closest hospital emergency room or other emergency location you want.

You can also dial 911 on your telephone.


Prior authorization is not required for emergency services

You do not need authorization if you are admitted to the hospital or get services for an emergency. It does not matter where you received the emergency service.

Post-stabilization service (service you get after an emergency) is service the doctor thinks is necessary after the emergency condition has been taken care of. These services do not need prior authorization, but you should tell your case manager immediately.

Out of area emergency care

If you have an emergency away from home, go to the nearest emergency room or any emergency

location. Call your doctor as soon as you can.

YOUR FREEDOM OF CHOICE WITH NETWORK PROVIDERS Members can choose any providers that are in our network.

CONSEQUENCES OF CARE FROM OUT-OF-NETWORK PROVIDERS We do not pay for services that you receive from out-of-network providers if you did not get approval from us first.

If you need services from a non-contracted provider, you must get approval from us. We will determine if the service is available through a contracted provider before we authorize an out-of-network referral. You should contact your case manager before going to an out-of-network provider.

SERVICES NOT COVERED We do not cover certain services—except for urgent care outside of the service area

or for emergency care anywhere.

Also, we do not cover:

Acupuncture

Health services not authorized by us

Chiropractic services, except for manual manipulation for subluxation of the

spine when demonstrated by X-ray

Christian Science practitioners’ services

Cosmetic surgery - Services in connection with cosmetic surgery: cosmetic surgery (plastic and reconstructive), and any other service and supply to improve the covered persons appearance or perception, but is not expected to significantly restore normal bodily


functions, including, but not limited to, mammary reduction or augmentation, face lifts, cleft lip, cleft palate, varicose veins, correction of baldness; includes the diagnosis or treatment which arises as a complication of a non-covered cosmetic surgery

Experimental procedures and items which are items and procedures determined

by Medicaid not to be generally accepted by the medical community

Excluded services

If we do not cover a service you need but Medicaid does, you can get the services

through other Medicaid programs. This includes the Fee-For-Service Medicaid system.

Your case manager can help you get these services based on your need. We may get help

from the local area office or the Aging and Disability Resource Center. Your case manager

will tell you about costs you may have to pay.

MEMBER RIGHTS AND RESPONSIBILITIES

Your rights You have the right:

To be treated with respect and with due consideration for your dignity and privacy.

To receive information on available treatment options and alternatives, presented in a

manner appropriate to your condition and ability to understand.

To participate in decisions regarding your health care, including the right to refuse

treatment.

To be free from any form of restraint or seclusion used as a means of coercion, discipline,

convenience, or retaliation.

To request and receive a copy of your medical records, and request that they be amended

or corrected as specified in 45 CFR.165-524 and 164.526.

To request and receive a copy of written enrollee rights as specified in accordance with 42

CFR 438.100.

To be furnished health care services in accordance with federal and state regulations.

You are free to exercise your rights, and the exercise of those rights does not adversely

affect the way our plan and its providers treat you.

To a prompt and reasonable response to questions and requests.

To know what 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, upon request, full information and necessary counseling on the availability


of known financial resources for your care.

To get a copy of a reasonably clear and understandable, itemized bill and upon request,

to have the charges explained.

To treatment for any emergency medical condition that shall deteriorate from failure

to provide treatment.

To know if medical treatment is for purposes of experimental research and to give

your consent or refusal to participate in such experimental research.

To get, upon request, prior to treatment, a reasonable estimate of charges for medical

care.

To choose a provider from the list of providers within Coventry’s LTC provider network.

To maintain all member records and information in a confidential manner.

Your responsibilities You are responsible:

For providing to your care provider and case manager, to the best of your knowledge,

accurate and complete information about present complaints, past illnesses,

hospitalizations, medications and other matters relating to your health and well-being.

For reporting unexpected changes in your condition to your care provider and case

manager. For following the treatment plan recommended by your care provider and the

care plan developed with your case manager.

For keeping appointments and, when you are unable to do so for any reason, for notifying

the care provider, care facility and case manager as applicable.

For your actions if you refuse treatment or if you do not follow the care provider’s

instructions.

For assuring that the financial obligations of your care are fulfilled as promptly as possible.

For giving information to your case manager needed to assist you in getting the services you

need.

For helping the case manager in developing a care plan that will best meet your needs.

For following instructions and advice that you agree with from those providing your care

and services.

For giving information to the case manager of any changes in your needs or services.

For contacting your case manager before you arrange for services from providers.

For using providers, such as home health agencies, homemaker services, assisted

living facilities or skilled nursing facilities listed in the Coventry LTC Provider Directory

or approved by us.


For notifying us if you decide to disenroll from the program.

For presenting your ID card when seeking services from Coventry’s LTC contracted

providers.

REPORTING FRAUD, ABUSE AND OVERPAYMENTS

To report suspected fraud or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll-free at 1-888-419-3456 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 1-866-966-7226 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.

Reporting abuse, neglect and exploitation

If you are victim of abuse, neglect or exploitation or you suspect someone you know is a victim of abuse, neglect or exploitation, report this immediately by calling the toll-free abuse hotline at 1-800-96-ABUSE.

CONTACT INFORMATION FOR FRAUD, ABUSE & OVERPAYMENT

We provide various options for reporting suspected/confirmed fraud, abuse or overpayment. These include:

The Special Investigative Unit (SIU) at 1-866-806-7020; FAX 724-778-6827

www.CoventrySIU.com

The Florida Medicaid Consumer Complaint Hotline:at 1-888-419-3456 or

http://ahca.myflorida.com/Executive/Inspector_General/medicaid.shtml

Member Services Department at 1-844-645-7371

Health Plan Medicaid Compliance Officer at 1-844-645-7371

https://apps.ahca.myflorida.com/InspectorGeneral/fraud_complaintform.aspx

http://www.coventrysiu.com/

http://ahca.myflorida.com/Executive/Inspector_General/medicaid.shtml


GRIEVANCE AND APPEALS

A grievance is a formal complaint about a doctor or service. An appeal is a formal complaint about

a service that is denied.

A grievance may be filed orally or in writing within one year of the incident.

An appeal may be filed orally or in writing within thirty (30) days of receiving the notice of

action. If the appeal is filed orally (except for an expedited appeal), it must be followed up with a

written notice within ten (10) calendar days of calling in your appeal. five (5) days of getting your

appeal, we will tell you in writing that we got your appeal unless you ask for an expedited appeal.

You can ask for an “expedited appeal” if you or your provider think that waiting thirty (30) days for

a decision could put your life, health, or your ability to attain, maintain, or regain maximum

function in danger. You can call us or write to us, but you need to make sure that you ask use to

expedite the appeal. We may not agree that your appeal needs to be expedited, but you will be

told of this decision. We will still process your appeal under normal time frames. If we do need to

expedite, you will get our decision within three (3) working days after we receive the appeal

request. This is true whether you asked for the expedited appeal by phone or in writing.

Call: 1-844-645-7371, (TTY 711) we are available 24 hours a day 7 days a week.

Write: Grievance & Appeals Dept., 1340 Concord Terrace, Sunrise, FL 33323

NOTE: If you call, you still need to send a written request within 10 calendar days of calling.

We can assist you with the filing of a grievance or appeal or a doctor can file for you with your permission. No action will be taken against the doctor. During the process, you can examine your health records and other documents. Once you have filed, you are not required to follow up. You can ask for your services to continue if

you are receiving a service that was reduced, suspended or terminated, and you file your appeal

with Coventry Health Care no later than 10 days after a Notice of Action letter was mailed OR no

later than 10 days after the first day our action will take place. Be sure to tell us that you want

your services to continue.

However, if the final decision is not in your favor, you may have to pay for care.

We will resolve your grievance and provide notice of our decision within 90 calendar days. We will

resolve your appeal and provide notice of our decision within 45 calendar days. If more time or

more information is needed, we will let you know.


SUBSCRIBER ASSISTANCE PROGRAM / MEDICAID FAIR HEARING: If you don’t agree with the decision, you can ask for a review by the Subscriber Assistance Program (SAP):

Before filing with the SAP, you must complete our appeal process.

You must submit the appeal to the SAP within one (1) year after receipt of the final decision letter from us.

The SAP will not consider an enrollee appeal that has already been to a Medicaid Fair Hearing.

The address and toll-free telephone number for enrollee appeals to the SAP are:

Agency for Health Care Administration Subscriber Assistance Program Building 3, MS #45 2727 Mahan Drive Tallahassee, Florida 32308

850-412-4502 1-888-419 3456 (toll-free)

Ask for a Medicaid Fair Hearing (within 90 days of getting the final decision letter from the Health Plan). You may seek a Medicaid Fair Hearing without going through the Health Plan’s entire grievance and appeal process.

Office of Appeal Hearings 1317 Winewood Boulevard Building 5, Room 255 Tallahassee, FL 32399-0700 850-488-1429

If you ask for a Medicaid Fair Hearing, and you are receiving benefits that were reduced, suspended or terminated, you have the right to keep getting those services until a final decision is made in the Fair Hearing. To do so, you must file the request for the Medicaid Fair Hearing with the Office of Appeal Hearings no later than 10 days after the Notice of Action letter was mailed or before the first day our action will take place, whichever is later. Be sure to tell the hearing officer that you want your services to continue. You may have to pay for the cost of those benefits if the Medicaid Fair Hearing upholds our action. NOTE: If you ask for a Medicaid Fair Hearing, you give up the right to the Subscriber Assistance

Program.

CONFIDENTIALITY OF YOUR RECORDS

Protected health information


We respect your right to privacy. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH), we have procedures to keep your protected health information (PHI) safe. The following information is not given to anyone unless the information is necessary for your health or required by state or federal law. We code your information when we give it out to keep it safe.

Name, address, telephone

Social security number

Date of birth

You can let others see your health records by completing a special authorization form. Call Member Services for more information.

Member privacy

All member information is protected. And it is stored in a locked and secure place. We keep all member records and information private. Member records are only available to authorized people.


ITEMS YOU CAN GET ON REQUEST You can call the Member Services toll-free number at 1-844-645-7371 to learn:

A description of our quality assurance program. It focuses on patient results. It helps acute and long-term care. Our Quality Assurance Committee meets to talk about: Service availability

Continuity of care

Quality of care

Information about how well we do. This includes:

Enrollee satisfaction

Plan scores for specific areas of service

Quality improvement

Information about how our plan works and any special pay for doctors.

ALTERNATIVE COMMUNICATION SYSTEMS We offer interpretation services at no cost for those members whose primary language is not English. Services are also available for alternate communication systems at no cost to the member such as vision or hearing impaired.

Members that need to access this service can do so by contacting their case manager or call Member Services 1-844-645-7371 for help. To obtain information about our structure and operation or physician incentive plan, call Member Services at 1-844-645-7371.

Moral or religious objections

We provide all covered services. However, we may not provide, pay for, or cover counseling or refer for services based on moral or religious reasons. We will notify the Agency of Health Care Administration within 120 calendar days before implementing the policy and notify enrollees within 30 calendar days before implementing the policy.

Behavioral health

Your case manager will provide you information to receive behavioral health screening and assessment services for any potential behavioral health problems.

Educational and consumer resources

Your case manager will help you locate services and information about the services you need whether they are provided by this program or not. This includes housing information. Some


of the resources you can use are the Agency’s Health Finder website, www.FloridaHealthfinder.gov and the Department of Elder Affair's Florida Affordable Assisted Living consumer website http://elderaffairs.state.fl.us/faal/.

ACCESS OTHER BENEFITS

Emergency and non-emergency transportation

We can help you with transportation. This includes coordinating transportation with Florida Commission for the Transportation Disadvantaged Program and other transportation providers

Please call Member Services or your case manager when you need help. You may need to pay for part of transportation services.

For emergency transportation dial 911.

How to get medical care

If you have Medicare, you can get all your medical care through your Medicare doctors, hospitals and pharmacies.

Medical appointments with your doctor

Call your doctor any time you need medical care. Show your Medicare Card and your LTC Plan ID Card when you visit your doctor, hospital, or skilled nursing facility.

If you are in a Medicare HMO, follow their handbook and instructions for services. If you are on

Original Medicare, you can get services from any doctor that accepts Medicare. Be sure to present

both your Medicare Card and your LTC Plan ID Card.

Second opinion

If you think your doctor’s care is not helping you get better, you can see another doctor at no extra cost. Tell your doctor that you want a second opinion. Contact your case manager if you need help.

Changing your doctor

If you want to change your Medicaid doctor and need help, please tell your case manager.

http://elderaffairs.state.fl.us/faal/)


ADVANCE DIRECTIVES A Living Will or Advance Directive lets you tell your wishes about life support or other issues about your health. It becomes necessary when you are seriously ill or have an illness that will lead to death or in times when you cannot speak for yourself. It also allows you to have someone to speak for you when you can no longer speak for yourself. You have the right to direct your care by giving your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. Your case manager will inform you when you join the program about your rights under the State laws when applicable. If there are any changes in the State law, we will tell you as soon as possible, but no later than 90 calendar days after the effective change.

Your case manager will review the Advance Directive forms with you and explain and assist you with filling them out as needed. You should also speak to your doctor to educate you about how Advance Directives or a Living Will shall be executed. If you need more help with this or additional information, discuss with your case manager. Once your Advance Directive is completed you, your case manager and your doctor should have copies.

We will provide these policies and procedures to all enrollees age 18 years or older. We will advise enrollees of their rights under State law, including the right to accept or refuse medical treatment and the right to formulate advance directives. Our written policies respecting the implementation of those rights, including a statement of a limitation regarding the implementation of Advance Directives as a matter of conscience; and the information must include a description of State law and must reflect changes in State law as soon as possible, but no later than ninety (90) calendar days after the effective change. It is your choice whether you want to fill out an Advance Directive. According to law, no one can deny you care or discriminate against you based on whether or not you have signed an Advanced Directive. If you have signed an Advanced Directive, and you believe that a doctor or hospital has not followed the instructions in it, you may file a complaint with the Agency for Health Care Administration (AHCA) Consumer Hotline.

The following information describes your legal rights and the steps you can take in advance to protect yourself and your family if an illness or accident prevents you from participating in decisions about your medical treatment.

Under Florida law, every adult can make certain decisions about their medical treatment. The law allows for the respect of your rights and personal wishes even if you are too sick to make choices yourself.


You have the right, under certain cases, to accept or reject medical treatment. This includes procedures to keep you alive by artificial means.

You may list your preferences in a Living Will. Your Living Will has your personal wishes about treatment to keep you alive in the case of serious illness that could cause death. You have the right to revoke your Advanced Directives at any time.

You may choose to name another person, or surrogate, who may decide for you if you are unable to do so yourself. This surrogate may act on your behalf for a brief time during the life threatening illness. Any limits to the power of a surrogate should be clearly expressed.

Questions and answers about the Living Will

The Living Will lets you express your wishes about life support. It becomes effective when you are in a terminal condition and cannot speak for yourself. It also allows you to appoint someone to speak on your behalf (a surrogate) when you can no longer speak for yourself. If you do not appoint a surrogate in your living will, or in a separate ‘Designation of Health Care Surrogate” document, a surrogate chosen from your family or friends will be appointed for you, if possible.

However, in order for you to maintain control over who will become your surrogate, you should make the choice in your Living Will.

Who may complete a Living Will?

If you are at least 18 years of age and of sound mind you may complete a Living Will.

When does the Living Will take effect?

The Living Will takes effect when all of the following conditions are met: your Living Will is given to your attending physician. Your attending physician and a consulting physician determines that you have a terminal condition and there is no medical probability that your will recover; and your surrogate, if any, is satisfied:

You have no reasonable chance of recovering competency

Your condition is terminal

Any limitations that you have expressed in writing or orally have been considered and satisfied

What are the witnessing requirements?

Your Living Will must be signed before two witnesses, at least one of whom is neither your spouse nor a blood relative. If you are physically unable to sign, you may instruct one of the witnesses to sign the living will for you in your presence.


How may I appoint a health surrogate in my Living Will?

A space is provided for you to designate another person who is at least 18 years old (called your “surrogate”) to carry out your decisions about medical care. Your surrogate can only make medical decisions for you if you are in a terminal condition as described in your Living Will. It is also advisable to name a replacement surrogate in case the person you choose becomes unable or unwilling to act for you.

Can I write special or additional instructions about my health care?

You may customize your Living Will to meet your needs, as long as the basic provisions of the Living Will are kept intact. You may list your wishes about particular treatments that you do not want to get, such as surgery, cardiac resuscitation, respirator, artificial or tube feeding, hydration, etc. It is especially important to specify whether or not you would want artificial tube feeding.

NOTE: If you would like to refuse life-sustaining treatment during pregnancy in the event you are in a terminal condition and can no longer speak for yourself, you must specifically state that your surrogate can make this decision.

What if a health care provider refuses to comply with my Living Will?

Health care provider who refuses to comply with your Living Will or the treatment decision of your surrogate must make “reasonable efforts” to transfer you to the care of another health care provider who will give effect to your Living Will. A health care provider who is unwilling to carry out your wishes because of moral or ethical beliefs must either pay the costs of transferring you to another health care provider, or carry out your wishes.

For assistance in preparing an Advance Directive

You may call a lawyer, your local Legal Aid Office, or the Florida Medical Association. You may call the State’s Subscriber Assistance Program at 850-419-3456 or toll free at 1-888-412-4502 if you have a complaint regarding your Advance Directives.

Durable Power of Attorney for health care decisions

A Durable Power of Attorney for health care allows you to choose a person to make medical decisions for you if you cannot make those choices for yourself. That person is usually a relative or close friend that you trust to make health choices like you would make for yourself, if you were able.


LIVING WILL

Declaration made this ___ day of 2___ ,I, _________________ willfully and voluntary 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 intent ion 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 Zip Phone


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

Additional instructions:

Signed:

Wit ness____________________________________________

Address

City________________State____ Zip________

Phone________________________

Witness____________________________________________

Address

City________________State____ Zip ________

P ho ne___________________

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


DESIGNATION OF HEALTH CARE SURROGATE

Name

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

Signature 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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HANDBOOK SIGNATURE PAGE

I agree I have a member handbook for Coventry Health Care of Florida’s Long Term Care Program.

Signature Date

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NOTES

Documents

Coventry Long Term Care Program - Aetna · 12/1/2015 · Coventry Health Care of Florida Long Term Care Enrollee Handbook Member Services 1-844-645-7371, TTY 711 i iii The health