caring for you and your family. member handbook. reform

Caring for you and your family. Member Handbook. ReformMember Handbook
Reform
MEMBER INFORMATION UPDATE FORM It’s important that we have your current information. That way we can keep you up to date on your Staywell benefits and services. Please use this form to give us your address and phone number. If you move, please give us the changes.
You can also update it through our website. Go to www.florida.wellcare.com. Sometimes we need to release your medical history. Please read the Notice of Privacy Practices in this handbook. It explains the details. Then sign the statement below and return it to us. We’ve included a stamped envelope for you.
Questions? Call Customer Service at 18663347927 (TTY/TDD 18772476272) Monday–Friday, 7 a.m. to 7 p.m. Eastern.
Member Name:
Home Address:
Street City Zip Code
Phone Number: County in Which You Live:
I allow Staywell to release my medical facts as needed. I have read the Notice of Privacy Practices. I understand:
• How this information may be used
• When this information may be released
• How I can get this information

To Contact Us ............................................................................................................................... ..................................................1
The MediKids Program ............................................................................................................................... ................................2
Informed Consent ............................................................................................................................... .........................................3
HOW TO GET COVERED SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Covered Services............................................................................................................................... ............................................4
NonCovered Services ............................................................................................................................... ................................6
Services Available Without Authorization ...................................................................................................................... 7
Second Medical Opinion ............................................................................................................................... ............................8
What to Do in an Emergency ............................................................................................................................... ..................8
OutofArea Emergency Care ............................................................................................................................... ..................9
Pregnancy and Newborn Care ............................................................................................................................... ...............9
Prescriptions ............................................................................................................................... ....................................................9
GETTING BEHAVIORAL HEALTH SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 How to Get Behavioral Health Services .......................................................................................................................... 10
What to Do if You Need Help ............................................................................................................................... ................11
What to Do in an Emergency or if You Are Out of the Staywell Service Area ...........................................11
What is PostStabilization ............................................................................................................................... ........................ 12
Prevention Programs ............................................................................................................................... .................................. 12
OTHER PROGRAMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Personal Health Advisor (24Hour Nurse Helpline) .....................................................................................................13
Maternity Education and Prenatal Reward Program .................................................................................................13
Case and Disease Management . ............................................................................................................................... .......... 14
CommunityBased Programs ............................................................................................................................... ................. 14
PREVENTIVE HEALTH CARE GUIDELINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Adult Preventive Health Guidelines . ............................................................................................................................... . 15
Pediatric Preventive Health Guidelines—Newborn to 21 Years Old ................................................................ 17
ADVANCE DIRECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Your Medical Care Is Your Decision ............................................................................................................................... . 19
Advance Directives—Making Your Decision Known . ............................................................................................. 19
IMPORTANT INFORMATION ABOUT STAYWELL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Enrollment............................................................................................................................... ....................................................... 20
Open Enrollment ............................................................................................................................... ......................................... 20
Disenrollment ............................................................................................................................... ................................................. 21
Utilization Management Program ............................................................................................................................... ...... 23
Evaluation of New Technology ............................................................................................................................... ........... 23
Public Information About Staywell ............................................................................................................................... .. 24
MEMBER APPEALS AND GRIEVANCES PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Making an Appeal ............................................................................................................................... ........................................ 25
Medicaid Fair Hearing ............................................................................................................................... ................................ 27
Filing a Grievance ............................................................................................................................... ........................................ 28
Additional Help with Appeals and Grievances ............................................................................................................ 30

WELCOME TO STAYWELL! This is your member handbook. This book will tell you how your health plan works. Please read it carefully. Keep it in a safe place so you can refer to it when you need it.
GETTING STARTED It’s easy! Just follow these steps and you’ll be on your way to getting the health care you need.
1.)

You should have gotten your Staywell ID card in the mail. If you have not, please call us tollfree at 18663347927 (TTY/TDD 18772476272). Please take time to look at your ID card. Check the primary care physician (PCP) name on the card. The date your membership starts is also listed.
You need to give your ID card to the health care provider when you need care. It has details about your plan. Be sure to keep this card and your Medicaid Gold Card with you.
2.) Set up a visit with your PCP. You must do so within 90 days of joining. You must be seen within 30 days of joining the plan if you are pregnant.
Your PCP will take care of your basic medical care. He or she will set you up with specialists or hospital care if needed. Call your PCP at the number on your ID card for nonemergencies.
3.) You should also get your medical records. You can get these from the doctors you saw before you joined Staywell. Tell your PCP if you are taking any medicines that another doctor ordered for you. This will help your PCP when planning your care.
If you need or want to see your current medical records, ask your PCP. For help with this, call Customer Service.
4.) Get to know your Personal Health Advisor. Not sure what kind of care you need? Staywell has an advisor who can answer health care questions. It’s free! A trained professional is there for you at all times. Call toll free 18009198807.
IN AN EMERGENCY In a real medical emergency, call 911. Or go to the nearest emergency room. This handbook has a section called What to Do in an Emergency (page 8). Please read it. It has a list of examples of real medical emergencies.
TO CONTACT US Call Staywell Customer Service. We can help you weekdays, 7 a.m. to 7 p.m. Eastern. Call 18663347927 (TTY/ TDD 18772476272). Or visit our website at www.florida.wellcare.com. Then click on the Staywell page.
Do you speak a language other than English? If so, we offer interpreters for free. You can get material in different formats too. This includes large print, Braille and audio tapes. If you are hearingimpaired we can give you special help.
You can also call Customer Service or visit our website to:
• Ask for ID cards
• Get a list of doctors in the health plan
• Get a list of pharmacies in the health plan
• Update your contact information, like your address and phone number (You may also need to update this information with the Social Security Administration and/or the Department of Children and Families. See page 2 for more details.)
www.florida.wellcare.com | 1

Members have rights and responsibilities. The law says your health care providers must recognize your rights. It also says you must respect their rights. This handbook lists your rights and responsibilities (page 31, 32). You’ll also see them posted in your doctor’s office.
Want to know how to use your health benefits? This handbook can tell you.
You are now ready to begin using all of the health benefits you get with Staywell. We look forward to serving you.
MEMBER INFORMATION
ENROLLMENT IN STAYWELL Staywell serves people who qualify for the Medicaid program in Florida. This is a state and federal program. It gives health coverage to people with low incomes. Three basic groups can get Medicaid:
• People in the Supplemental Security Income (SSI) program
• Children and families
• Aged, blinded or disabled people, including people needing institutional care (also known as “SSIrelated” Medicaid)
A person must qualify to get Medicaid. The Social Security Administration sets rules for who can be in the SSI program. The Florida Department of Children and Families (DCF) decides who can be in the other programs. Need to know if you qualify? Call 18664543959 (TTY/TDD 18664674970). Ask to speak with a Choice Counseling representative. (This is a helpline that is sponsored by the state. It helps you join the plan of your choice.)
THE MEDIKIDS PROGRAM MediKids is a state insurance program. It is for children under age 5. Is your child in this program? If so, he or she is eligible for all of the Staywell services mentioned in this handbook. The same rules apply to them.
How does MediKids differ from Medicaid?
• Small monthly premium
• Child must not be a dependent of a state employee
• Child must not be over age 5
• May not have a Medicaid Fair Hearing
• Children must join during an open enrollment period
• Program is subject to available funds
• No copayment for services we provide for a child in MediKids
Interested in this program? Call MediKids at 18775060578.
YOUR IDENTIFICATION (ID) CARD Every member gets a Staywell ID card. Show this ID card and your Medicaid Gold Card to doctors when you want to get care. Show it to hospitals and pharmacies too. This card proves you are a member of our plan. Keep it with you at all times. Do not let anyone else use your card. If you do, you may lose your benefits
What do I do if I lose my ID card?
Call Staywell tollfree at 18663347927 (TTY/TDD 18772476272). A new card will be mailed to you right away. Need a new Medicaid card? Call your caseworker at DCF.
YOUR DOCTOR Your primary care physician (PCP) is the doctor who will care for you. Your PCP’s name, address and phone number are on your ID card. When you need care, call your PCP. Your PCP’s office will make an appointment for you.
Remember – you must see your PCP within 90 days of becoming a Staywell member. If you are a new member and pregnant, you must see your PCP within 30 days. You can find your membership start date on your ID card.
Your PCP can take care of most of your health care needs. There may be times you’ll need care from other kinds of doctors. There may also be times when you’ll need hospital care. Staywell offers services from many different kinds of doctors who provide other types of care. These doctors are called specialists. They are trained in special areas of medicine. Specialists include:
• Allergists (focus on treating allergies)
• Cardiologists (focus on treating heart problems)
• Dermatologists (focus on treating skin conditions)
• Podiatrists (focus on treating foot problems)
Your PCP may refer you to a specialist in the network. He or she may also refer you for hospital care. He or she will do this if they can’t give you the care you need. In most cases, you need a referral from your PCP to see another doctor. Staywell makes sure our providers are qualified to see you. You can learn more about your providers by calling us. We can tell you about a provider’s schooling or residency. We can tell you about their qualifications, or whether they accept new patients. You can also find these facts in your provider directory. Some of our providers may not have malpractice insurance. They must have a notice in their office saying so. Ask your doctor if you are not sure.
Some doctors may not perform certain services based on their own religious or moral beliefs.
CHANGING YOUR PRIMARY CARE PHYSICIAN (PCP) You can change your PCP at any time. To do so, check your provider directory. You should have received one with your welcome kit. You can also visit our website to use our online provider directory. It has the latest list of providers. Visit us at www.florida.wellcare.com.
When you have made your choice, call us. Our tollfree number is 18663347927 (TTY/TDD 18772476272). You can also change your PCP on our website. Visit www.florida.wellcare.com and click on the Staywell page.
Women can choose a doctor trained in obstetrics/gynecology (OB/GYN) as their PCP.
If you have family members enrolled with Staywell, they can each choose a different PCP. Or they can all use the same one. It depends on their needs.
INFORMED CONSENT We need your O.K. for all care except when your life is in danger. Sometimes your written O.K. is needed. You have a right to understand any procedure. You have a right to know the reasons why it is needed. If you do not want to have a procedure done, talk to your PCP. Your PCP will tell you about your choices. You make the final decision.

ACCESS TO COVERED SERVICES Staywell has providers that can get our members quick service. For most services, average response/travel time can and should be:
Location Time
Specialists Within 1 hour
Urgent Care Within 24 hours (1 day)
Routine Sick Care Within a week of request
Physical Exams Within a month of request
Followup Care As needed
OUTOFNETWORK CARE We want to make sure you get the care that you need. Sometimes we don’t have a network provider who can give you covered services. In that case we’ll cover the services outofnetwork. A doctor in the network must approve that care. We’ll make sure your cost is no more than it would be if the services were innetwork.
The plan pays for just the care it approves. You may have to pay for care the plan doesn’t approve. The plan approves care that is medically needed. Services that are medically needed include those that:
• Are for an illness that would place your health in danger
• Follow accepted medical practices
• Are given in a safe, proper and costeffective place, depending on the diagnosis and how sick you are
• Are not for convenience only
• Are not custodial
• Are needed when there is no better or less costly care, service or place available
HOW TO GET COVERED SERVICES Staywell contracts with providers. These providers give care to our members. A plan doctor or Staywell must approve all of your care.
There is no copayment for any service given by Staywell. Staywell will pay for the cost of approved care. You may have to pay for care that is not approved by the plan.
COVERED SERVICES Staywell offers the same covered services as Medicaid. But with Staywell, there are no copayments.
Some Medicaid care may not be covered by Staywell. There may be cost sharing with these Medicaid services too. Call Customer Service for help with this. You can reach us at 18663347927 (TTY/TDD 18772476272).
Here is a list of some of the covered services. For details, visit our website. Go to www.florida.wellcare.com.
Chiropractic services
Dental:
• Diagnostic services
• CHCUP dental screening
• Adjunctive and emergency services
• Fluoride varnish application in a physician’s office under CHCUP is limited to children up to three and one half (3 ½) years (42 months) of age
Members over 21 years of age –
• Full and partial denture services
• Medically necessary emergency dental procedures (oral examinations, necessary Xrays, extractions, and incision and drainage of abscess) to alleviate pain or infection
Durable medical equipment and medical supplies
Early intervention services
Freestanding dialysis center services
• To receive a covered service within the state, except when:
− Receiving dialysis at a freestanding clinic; and
− Is being furnished either for free or by a third party insurance
Emergency –
Vision services (medically necessary)
WELLCARE EXTRA BENEFITS/SPECIAL PROGRAMS • Overthecounter Items – $300 a year for overthecounter drugs and supplies – that’s $25 dollars a month
for items like diapers, sunscreen, aspirin, vitamins and more – more than 100 items to choose from, mailed right to your home (refer to your OTC brochure for the list of products and how to place your order)
• Free baby stroller – To qualify, expectant mothers must attend at least six (6) prenatal doctor visits before the birth of their baby
• Free maternity education booklet – Tips to help you stay well while you are pregnant
• Free 24hour, 7dayaweek health advice – When you call your Personal Health Advisor
• Personal help – Setting doctor appointments, getting rides to your doctor visits, social services and more
• Free referrals and guides to free community programs – Programs that help with domestic violence, stopping smoking and drug/alcohol abuse
• All materials are available in English, Spanish and other languages – Upon request
• Free flu shots
• Online facts and education – Available at www.florida.wellcare.com
MEDICAID EXTRA BENEFITS Enhanced Benefits Reward$ Program – This program is designed to reward you for taking part in activities that can improve your health. These activities are known as healthy behaviors. They will earn you credits that you can later use to buy healthrelated items at the pharmacy. You do not have to do anything to enroll in this program.
You can use your Enhanced Benefits credits to buy healthrelated items at any Florida Medicaid participating pharmacy. You must have your Gold Card or a government issued ID to use your earned credits.
For more details about this program:
• Go to www.fdhc.state.fl.us/Medicaid/Enhanced_Benefits/index.shtml
• Call the Enhanced Benefits Call Center at 18664218474.
• A claim form is included in the back of this handbook.
NONCOVERED SERVICES
The following services are not covered by the health plan:
NONCOVERED SERVICES
Community substance abuse services, except as required by this Contract
Residential care
Clubhouse services

HOW TO GET AUTHORIZED SERVICES Call your PCP when you need routine care. He or she will set up tests if you need them. Your PCP may also refer you to a specialist. We will pay for this care. This is care that is “medically necessary.” Medically necessary means health care services that are:
• Reasonable and needed to stop sickness or medical conditions, or provide early screening and/or treatments for conditions that cause suffering or pain, cause a deformity or could limit a function, threaten to cause a handicap or make one worse, or cause sickness or put a member’s life in danger
• Given at proper places and at the proper levels of care for the treatment of a member’s health problems
Following health care practice guidelines and standards that are approved by professionally known health care organizations or governmental agencies:
• In line with the diagnoses of the conditions
• Not interfering any more than needed to give a proper balance of safety, while being effective and efficient
• Not part of an experiment or investigation
• Not mainly for the ease of the member or provider
You’ll have to pay for care that is not approved. Call your PCP when you need care from a doctor not in the plan. For some services, we must give consent before you can get them. Your PCP will work with you to do that.
In some cases, you or your doctor may ask for a faster decision before you get services. This is called an “expedited” decision. Ask for this when waiting for a standard decision could place your life, health or daily functions in danger. You or your PCP can ask for a faster decision. Call Customer Service at 18663347927. TTY/TDD 18772476272. We can help Monday–Friday, 7 a.m. to 7 p.m. Eastern (except for holidays). Or fax us at 18132622907. Be sure to ask for a fast or expedited review.
Remember – be sure your PCP gives you the O.K. to see a specialist.
SERVICES AVAILABLE WITHOUT AUTHORIZATION You do not need approval from your PCP or Staywell to get these services from plan providers:
• Chiropractic
• Dermatology
• Medically necessary vision
• Traditional outpatient behavioral health and psychiatric (with the exception of psychological testing, electroconvulsive therapy, psychosocial rehabilitation, therapeutic behavioral onsite services (TBOS))
Also, female members can visit a plan OB/GYN once a year without approval. You don’t need consent from the plan. But you do need to choose one of these specialists from our provider directory. You should have gotten one with this handbook. If not, call us to ask for one. Call to make an appointment. Tell them you are a Staywell member. Show your ID card.
SECOND MEDICAL OPINION What if you want a second medical opinion about your health care? Call your PCP and ask for one. You may choose a plan doctor for the second opinion. We will pay for the second opinion when you choose a plan doctor. Please note – tests for a second opinion must be done by a plan doctor.
Your PCP will review your second opinion. He or she will decide on a treatment plan that is best for you.
HOW TO GET AFTERHOURS MEDICAL CARE In some cases, you may get sick or hurt when your PCP’s office is closed. If it is not an emergency, call your PCP. The number is on your ID card. Your PCP’s office will have a doctor on call. That doctor will call you back and tell you what to do. If you can’t reach your doctor, go to an urgent care center.
You can also call the Personal Health Advisor at 18009198807. (See the Personal Health Advisor section on page 13).
WHAT TO DO IN AN EMERGENCY A medical emergency is when you think that your health is in serious danger. An emergency is when the condition could cause:
• Bodily injury
• Damage to a body part
• Harm to yourself or others due to alcohol or drug abuse
• Harm to your health (this includes a momtobe and her unborn baby)
• Injury to yourself or others
• Organ damage
For momstobe, it may be an emergency:
• If you think there is no time to go to your doctor’s regular hospital
• If you think that going to another hospital may cause harm to you and your baby
• If you think that you are in labor
Some examples of emergencies are:
• Broken bones
• Poisoning
• Severe chest pains
In the case of an emergency, call 911. If you do not have 911 services in your area, call an ambulance. Or go to a nearby hospital emergency room (ER) right away. The choice is yours. If you’re not sure it is an emergency, call your doctor. Or call the Personal Health Advisor line at 18009198807. You do not need prior consent for emergency services.

You’ll need to show your Staywell and Medicaid ID cards at the ER. Ask the staff to call us. Also let your PCP know as soon as you can when you are in the hospital. Let him or her know if you got care in the ER.
The ER doctor will decide if your visit is an emergency. If it is not, you’ll be given the choice to stay or leave the hospital. If you choose to stay, you’ll have to pay for your care.
The plan will cover followup care that your doctor says you need. You do not need to get prior consent for care when you are recovering. This is true whether you get this care in or outof network.
OUTOFAREA EMERGENCY CARE It is important to get care when you are sick or hurt. If you get sick while traveling, call Customer Service. If you have an emergency while traveling, go to a hospital. It doesn’t matter if you are not in the plan’s service area. Show your ID card. Call your PCP as soon as you can. Ask the hospital staff to call Staywell.
If you have to pay for these services when you get them, write to our Claims Department. They will need copies of your medical reports. Send copies of bills. Be sure to include proof of payment.
PREGNANCY AND NEWBORN CARE If you have a baby while a plan member, the baby is also covered from birth. You must call the Department of Children and Families (DCF) to get your baby’s Medicaid ID number.
When you find out you are pregnant, taking care of yourself can help you and your unborn baby stay healthy. See your PCP right away. Be sure to go to all your prenatal visits. And go to all your postpartum visits after the birth. If you need help with this, call us.
You’ll also need to choose a doctor for your baby. That way your baby can get needed checkups and shots. You must do this by the time your baby is born. If you do not, we will choose a doctor for you.
Call your caseworker from the Department of Children and Families (DCF). They will give your baby a Medicaid number. Please call us with this number.
When your baby is born, tell Staywell and DCF. If DCF does not place your new baby on our plan, call Choice Counseling. The tollfree number is 18664543959 (TTY/TDD 18664674970).
PRESCRIPTIONS Staywell covers all medically necessary Medicaidcovered medications. We use a preferred drug list (PDL). These are the drugs that we prefer that your provider prescribe. We may also require that your provider gives us a prior authorization (PA) request. This will explain why a certain drug and/or a certain amount are needed. We must approve the request before you can get the medication.
Reasons why we may prior authorize a drug include:
• There is a generic or pharmacy alternative drug available
• The drug can be misused/abused
• There are other drugs that must be tried first

Some drugs may also have amount limits. Some drugs are never covered. Drugs for weight loss are one example. If we don’t approve a PA request, we will let you know. We will send you facts on how you can appeal the decision. We will also tell you about your right to a state hearing.
Please note: There is a ten (10) prescription limit per month for TANF members. SSI members have a 20 prescription limit per month. These prescriptions do not count toward the limits:
• Birth control
• HIV/AIDS drugs
There is no cost to you for prescriptions. Your PCP must approve a prescription from a nonplan doctor. You must pick it up at a plan pharmacy. Always show your Staywell ID card and your Medicaid Gold Card. There is no cost to you.
Questions about our PDL? Questions about drugs that need a PA? Please call us at 18663347927 (TTY/TDD 18772476272). You can also find those facts at www.florida.wellcare.com. Please note that our PDL and drugs that need a PA can change. Please check the status before you fill/refill a prescription.
GETTING BEHAVIORAL HEALTH SERVICES
HOW TO GET BEHAVIORAL HEALTH SERVICES Need help finding a behavioral health provider in your area? Call 18777125340 (TTY/TDD 18772476272). You can also search our provider directory. Or you can visit www.magellanhealth.com/member on the Web.
You’ll find the names of several providers. This includes hospital and psychiatric care providers. Pick those that you will need. Then call and set up a time to visit. You may also choose an alternative behavioral health case manager or direct service provider within the health plan, if one is available.
If you want to change to a different provider:
• Check your provider directory
• Call 18777125340 (TTY/TDD 18772476272)
Other types of care you may get include:
• Behavioral healthrelated inpatient hospital care
− Adults over age 21 and who are not pregnant: up to 45 days each year for nonemergency and up to 365 days for emergencies
− Children and adolescents up to age 21: up to 365 days
− Pregnant members: up to 365 days
• Day treatment for adults and children
• Evaluations
• Psychosocial rehabilitation
• Treatment planning
To learn more, call 18777125340 (TTY/TDD 18772476272).
WHAT TO DO IF YOU NEED HELP Are you having any of the feelings or problems listed below? If so, call 18777125340 (TTY/TDD 18772476272). Someone is available to help you 24 hours a day, 7 days a week.
• Always feeling sad
• Feeling hopeless and/or helpless
• Problems paying attention
• Poor appetite
• Weight loss
You do not need an approval from your PCP to see an outpatient behavioral health provider. The following services do require prior consent:
• Psychological testing
• Electroconvulsive therapy
• All inpatient behavioral health services
You must also get consent to see a provider who is not with the plan. You’ll have to pay for the care if you do not get consent.
Parental or guardian informed consent is required for psychotropic medications for children under age 13. (Examples of psychotropic medication include tranquilizers, sedatives and antidepressants.)
WHAT TO DO IN AN EMERGENCY OR IF YOU ARE OUT OF THE STAYWELL SERVICE AREA Is it a real behavioral health emergency? Do you feel you are a danger to yourself or others? If so, call 911. Or go to the nearest emergency room (ER). Even if you are out of our service area. You can also call us 24 hours a day, 7 days a week. Call your doctor too, if you can. Follow up with your PCP within 24 to 48 hours.
What if you are getting care when you are out of the area? We’ll help you get to a doctor in the network when you are able.

WHAT IS POSTSTABILIZATION? Did you go to the hospital for a mental health emergency? If so, you need to make sure you get care after you leave. This may help you avoid another mental health emergency.
Poststabilization services are covered services you get after emergency room care. They can be inside or outside the network. These are services to keep you stable after an emergency. They are services covered without prior approval 24 hours a day, 7 days a week.
If you need this kind of care:
• Tell us if you called 911 or went to the emergency room.
• You must notify the plan as soon as possible so we can help you get the care you need. A friend can call for you.
• You should plan a visit to see a behavioral health provider for followup. Do this before you leave the hospital. Call us if you need help making an appointment.
PREVENTION PROGRAMS There are programs available to members that may help prevent mental illness. They work to find early signs of mental illness. If signs are found, we can help you get services to treat the illness. Getting care early may lessen the severity of the illness.
You can learn more about these programs. Call 18777125340 (TTY/TDD 18772476272).
BEHAVIORAL HEALTH LIMITATIONS AND EXCLUSIONS With Medicaid, adults can get:
• Substance abuse treatment not covered with Medicaid
• Behavioral healthrelated inpatient hospital care
− Adults over age 21 and who are not pregnant: up to 45 days each year for nonemergency and up to 365 days for emergencies
− Children and adolescents up to age 21: up to 365 days
− Pregnant members: up to 365 days
Note – There may be limits on some outpatient behavioral health services. Questions? Please call the plan.
OTHER PROGRAMS
PERSONAL HEALTH ADVISOR (24HOUR NURSE HELPLINE) (24HOUR NURSE HELPLINE)
Personal Health Advisor is your 24hour nurse advice line. You can call seven days a week, every day of the year. There is no charge for this service. Call the Personal Health Advisor at 18009198807 when you need health advice.
When you call, a nurse will ask you some questions about your problem. Give as many details as you can. Tell the nurse where it hurts, what it looks like and what it feels like.
The nurse can help you decide if you need to:
• Go to the doctor
• Go to the hospital
Remember: A nurse is always there to help. Call before you visit a doctor or go to the hospital. But if you think it is a real emergency, call 911 or your local emergency services first.
MATERNITY EDUCATION AND PRENATAL REWARD PROGRAM Staywell has a Maternity Education and Prenatal Reward Program for pregnant women.
We want to help you and your baby stay healthy. It is important that you see your doctor as soon as you know you are pregnant. As a member you’ll get an educational booklet. It is called Mommy & Baby Matters, Taking care of yourself and your baby. It will tell you how to care for yourself and your baby, before and after birth. One way you can do this is by going to all doctor visits before and after the birth.
Another part of the program is the Prenatal Reward Program. We invite you to join. Then attend at least six prenatal visits. If you do, you can get a new stroller. It is a reward for taking care of yourself and your baby.
To get your stroller, be sure that:
• Your doctor completes the Prenatal Reward form and signs it at each visit
• Your doctor faxes the completed form to us within 30 days
• The form is complete
• You are still a member when you deliver
• You are still a member at the time the stroller is shipped
We also have a High Risk Pregnancy program. It is for women with high risk factors.

CASE AND DISEASE MANAGEMENT Staywell has case and disease management programs. These programs are for members with longterm, complex or chronic health problems such as:
• Asthma
• Hypertension (high blood pressure)
Members can choose to take part in these programs. If they do, they will work with a case or disease manager. Our case and disease managers are registered nurses (RNs). These nurses:
• Work with members to help them understand their illness
• Help members to get the health care services they need by working with the member, their family and providers
• Work with members to help manage their illness through medical, social and community resources
These programs are free to our members. To learn more, call 18666357045.
COMMUNITYBASED PROGRAMS There are other services you can get besides the ones listed in this handbook. You can get many of these in your community. The services include:
• Children’s programs
• Domestic violence programs
• Pregnancy prevention programs
• Stop smoking programs
Ask your PCP to find out more about these services. Or call Customer Service.
PREVENTIVE HEALTH CARE GUIDELINES Preventive health care guidelines are in this book for your use. You can use them to help you remember to see your PCP. They tell you when you and your family are due for checkups. They also remind you when you or members of your family are due for tests or shots.
These rules are only a general guide. They do not replace your PCP’s judgment. Always talk with your PCP to be sure you’re getting the right care.
Call your PCP if you or a family member misses an appointment.
Remember to see your PCP within 90 days of joining the plan.
ADULT PREVENTIVE HEALTH GUIDELINES Frequency of Physical Examination
All new members should get a baseline physical exam in the first 90 days as a member. Pregnant members should be seen in the first 30 days. The Cleveland Clinic’s recommendations for periodic health exam visits for asymptomatic adults are:
• Age 19 to 39 – every 1 to 3 years (Women should get an annual Pap smear – if 3 normal smears in a row, then 1 every 3 years)
• Age 40 to 64 – every 1 to 2 years based on risk factors
• Age 65 and older – every year
Age Screening Frequency
18 years of age and older Blood pressure, height, body mass index (BMI), alcohol use
Each year from age 18 to 21. Then, every 1 to 2 years or at PCP recommendation
Men 35 to 65 years of age Cholesterol (nonfasting TC/HDL) Every 5 years (more often if elevated)
Women 45 to 65 years of age Cholesterol (nonfasting TC/HDL) Every 5 years (more often if elevated)
Highrisk men and women 20 years of age and older Cholesterol (nonfasting TC/HDL) Every 5 years (more often if elevated)
Women 18 to 25 years of age who are sexually active (consider at age 12 if sexually active)
Chlamydia Each year and at PCP’s recommendation
Women 18 to 65 years of age (or 3 years after onset of sexual activity, whichever comes first)
Pap smear Every 1 to 3 years
Women 40 years of age and older
Mammography Every 1 to 2 years
50 years of age and older Colorectal Periodically depending upon test
Women 65 years of age and older (60 and older if at risk)
Osteoporosis Routinely
TetanusDiphtheria and acellular pertussis (Td/Tdap)
Td: every 10 years, 19 years and older Tdap: substitute 1 dose of Tdap for Td (onetime administration)
Varicella (VZV) Susceptible adults only, 18 years of age and older: 2 doses
Measles, Mumps, Rubella (MMR)
Adults 19–49 years of age who do not show evidence of immunity: 1–2 doses
Pneumococcal 65 years of age and older: 1 dose
Flu 6 months of age and older: every year
Hepatitis B vaccine Adults at risk, 18 years of age and older: 3 doses
Meningococcal conjugate vaccine
College freshmen living in dormitories and others at risk, 18 years of age and older: 1 dose
Humanpapillomavirus (HPV) *All previously unvaccinated women through 26 years of age: 3 doses
* Subject to individual state coverage
Prevention
Talk about aspirin to prevent cardiovascular events Men: 40 years of age and older periodically Women: 50 years of age and older periodically
Talk about breast cancer (for women at high risk)
Talk about prostatespecific antigen (PSA) test and rectal exam (for men after 40 years of age per PCP’s discretion)
Counseling
Calcium: 1,000mg a day for women 18 to 50 years of age; 1,200 to 1,500mg a day for women 50 years of age and older
Folic acid: 0.4mg a day for women of childbearing age; 4mg a day for women who have had children with Neural Tube Defects (NTDs)
Breastfeeding: women after giving birth
Quitting tobacco; drug and alcohol use; STDs and HIV; nutrition; physical activity; sun exposure; oral health; injury prevention; polypharmacy
References: Guide to Clinical Preventive Services, 2007: Recommendations of the U.S. Preventive Services Task Force, 2007 Press Release CDC’s Advisory Committee Recommends Human Papillomavirus Virus Vaccination June 29, 2006 Recommended Adult Immunization Schedule – United States, 2009 Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) May 2001 Bone Health and Osteoporosis: A Report of the Surgeon General (2004) Cleveland Clinic www.cchs.net/health/healthinfo Periodic Health Exams and Cancer Screening ACG Recommendations on Colorectal Cancer Screening for Average and Higher Risk Patients in Clinical Practice, April 2008
PEDIATRIC PREVENTIVE HEALTH GUIDELINES — NEWBORN UP TO 21 YEARS OLD These guidelines for pediatric preventive health are recommendations only. Other services may be needed for the individual.
Age Screening and Frequency
Newborn Wellbaby checkup* at birth Hearing test Newborn screening blood tests and HepB shot
2–4 days Wellbaby checkup if discharged less than 48 hours after delivery Newborn screening blood tests Immunizations: HepB if not done at birth
1 month Wellbaby checkup Newborn screening blood test if not already completed Immunizations: second HepB
2 months Wellbaby checkup Newborn screening blood test if not already completed Immunizations: RV, DTaP, Hib, PCV, IPV
4 months Wellbaby checkup Immunizations: RV, DTaP, Hib, PCV, IPV
6 months Wellbaby checkup Immunizations: RV, DTaP, Hib, PCV, IPV, HepB, flu
9 months Wellbaby checkup Lab testing: blood lead
12 months (1 year)
Wellbaby checkup Lab testing: blood lead, hemoglobin or hematocrit Immunizations: Hib, MMR, HepA, Varicella, PCV, flu Dental visit** as need identified
15 months Wellbaby checkup Lab testing: urine and blood lead if not done at 9 months or 12 months
18 months Wellbaby checkup Immunizations: second HepA (6 months after the first dose) Dental visit
24 months (2 years)
30 months Wellbaby checkup
4 and 5 years
Wellchild checkup each year Eye screening Lab testing: urine test at age 5 years Immunizations: MMR, DTaP, IPV, Varicella, flu each year Dental visit twice a year
6 to 10 years Wellchild checkup every year Immunizations: flu every year Dental visit twice a year
11 and 12 years Wellchild checkup each year Immunizations: MCV, Tdap, HPV series, flu each year Dental visit twice a year
13 to 21 years
Welladolescent checkup every year Females should have a pelvic exam and Pap smear between ages 18 and 21 years Lab testing: urine by age 16 Immunizations: HPV series if not already completed, flu every year
NOTES: * Wellbaby, child and adolescent checkups/physical exam with infant totally undressed or older child undressed and suitably
covered, health history, developmental and behavioral assessment, health education (sleep position counseling from 09 months, injury/violence prevention and nutrition counseling), height, weight, test for obesity (BMI), vision and hearing screening, head circumference at 0–24 months and blood pressure at least every year beginning at age 3.
** Dental visits may be recommended beginning at age 6 months. The following services are provided as needed:
• Hemoglobin or hematocrit at ages 4, 18, 24 months and 3 years through 21 years. • Lead risk assessments and/or testing from age 3 to age 6 years. • Tuberculosis risk assessments and/or testing from age 12 months through age 21 years. • Cardiovascular disease risk assessments and cholesterol screening from age 2 years through age 21 years. • Sexually transmitted infections testing from age 11 years through age 21 years. • “Catch up” on any shots that have been missed at an earlier age.
References: 2008 Bright Futures /American Academy of Pediatrics (www.aap.org). Committee on Practice and Ambulatory Medicine Recommendations for Preventive Pediatric Health Care, PEDIATRICS, Vol. 105 (3), March 2000, pages 645646, Copyright © 2000 by the AAP. Recommended Immunization Schedules for Persons Aged 018 Years – United States, 2009 approved by the Advisory Committee on Immunization Practices (ACIP) www.cdc.gov/vaccines/recs/schedules/childschedule.htm#printable, the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Catchup Immunization Schedule for Persons Aged 4 Months Through 18 Years Who Start Late or Who Are More Than 1 Month Behind, United States2009, approved by the Advisory Committee on Immunization Practices (www.cdc.gov/nip/acip/), 2008 Bright Futures/American Academy of Pediatrics (www.aap.org) and the American Academy of Family Physicians (www.aafp.org). American Dental Association (www.ada.org/).

Legal Disclaimer: Preventive health guidelines are based on guidelines from third parties available before printing. These guidelines are not a replacement for your doctor’s medical advice. He/She may have more current details. You should always talk with your doctor(s) about what care and treatment is right for you. The fact that a service or item is in these guidelines is not a guarantee of coverage or payment. Members should look at their own plan coverage papers to see what is or is not a covered benefit. WellCare does not offer medical advice or provide medical care, and does not guarantee any results or outcomes. WellCare does not warrant or guarantee, and shall not be liable for:
• information in these guidelines • information not in these guidelines • any recommendations made by independent third parties from whom any of the information was obtained
Version: 01/2009 (revised)
ADVANCE DIRECTIVES
YOUR MEDICAL CARE IS YOUR DECISION The law says you can refuse care. This includes care that keeps you alive.
Congress passed the Patient Self Determination Act. It states that we must tell you about your right to advance directives.
ADVANCE DIRECTIVES — MAKING YOUR DECISION KNOWN An advance directive is a legal paper. It tells others what your wishes are. It says what type of care you want to get – or not – if you are unable to tell a doctor yourself.
You can have an advance directive for your physical health. You can have a separate one for your mental health.
Make sure you tell your doctor and family that you have an advance directive. You can change or cancel your advance directive at any time. If you do, make sure to tell your doctor and family about the change.
Do my caregivers have to follow my advance directives? Yes. As long as your advance directives follow state law. A caregiver may not wish to follow your wishes. They may go against his or her conscience. If so, he or she will help you find someone else who will follow your wishes.
Other than for conscience reasons, your wishes should be followed. If they are not, complaints can be made to the Consumer Complaint Hotline. Call 18884193456.
There are three types of advance directives:
• A living will
• An anatomical donation
What is a living will? It states the type of care you want if you are unconscious and will not come to. It can be used for conditions that will lead to death. It tells your doctor when to continue or stop care to keep you alive.
What is a health care surrogate for health care decisions? This is when you name the person you want to make physical and/or mental health decisions for you. It will be used if you are not able to make choices for yourself. It will also be used if you can’t tell your doctor about the care you want. You can also name an alternate surrogate.

What is an anatomical donation? This states that you wish to donate all or part of your body at death. This can be an organ donation to persons in need. Or it can be a donation of your body to help train health care workers. You can show your choice to be an organ donor:
• On your driver’s license
• On a state ID card
• In a living will
• By signing a uniform donor form
How can I get an advance directive? You can call any of the below to get help with advance directives:
• An attorney
• Your PCP
IMPORTANT INFORMATION ABOUT STAYWELL
ENROLLMENT If you are a mandatory enrollee required to enroll in a plan, once you are enrolled in Staywell or the state enrolls you in a health plan, you will have 90 days from the date of your first enrollment to try the plan. During the first 90 days you can change health plans for any&

caring for you and your family. member handbook. reform

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