SC Medicaid Member Handbook 04 2013 PDF

South Carolina
Handbook
Member
WellCare Caring for You
Welcome to WellCare! Were glad you joined our family. As you work with everyone here, youll see that we put you first. This means you get better care. You are our priority. We work hard to make sure you get the care you need to stay healthy. To do this, we work with many different providers to give you care. These include: Primary care providers (PCPs) Specialists Hospitals and other health care facilities Labs Pharmacies Your member handbook will tell you more about your benefits and how your health plan works. Please read it and keep it in a safe place. We hope it will answer most of your questions. If it doesnt, call us. Our toll-free number is 1-888-588-9842 (TTY/TDD 1-877-247-6272). Were here to answer all of your questions. You can also find us on the Web. Go to southcarolina.wellcare.com. Be on the lookout for your WellCare identification (ID) card. You should receive it in the mail within a few days of this handbook. Keep reading for more information about your ID card and how to use it.
Again, welcome to WellCare. We wish you good health!
Este manual incluye informacin importante. Para obtenerlo en espaol u otro idioma, llmenos. El nmero sin cargo es 1-888-588-9842 (TTY/TDD 1-877-247-6272). Tambin podemos proveerlo en sistema Braille o audio.
Table of Contents
The WellCare Dictionary.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Important Phone Numbers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 GETTING STARTED WITH US.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Check Your ID Card and Keep It with You at All Times . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Get to Know Your PCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Remember to Use Our 24-Hour Nurse Advice Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 In an Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Contact Us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Our Website . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Know Your Rights and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Hold onto this Handbook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Care Basics.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Medically Necessary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Making and Getting to Your Medical Appointments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Cost Sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 YOUR HEALTH PLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Services Covered by WellCare.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 The WellCare Extras! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Services Not Covered by WellCare.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Services Covered by Medicaid Fee-for-Service.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Transportation Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
How to Get Services Covered by WellCare.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Prior Authorization (PA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Services Available Without Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Utilization Management (UM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Second Medical Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 After-Hours Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Out-of-Area Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Post-Stabilization Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Pregnancy and Newborn Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Women, Infants and Children (WIC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Behavioral Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 What to Do in a Behavioral Health Emergency or if You Are Out of Our Service Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Preferred Drug List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Other Drugs You Can Get at the Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Care Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Transition of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Planning Your Care.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services . . . . . . . . . . . . . . . 34 Preventive Health Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Adult Preventive Health Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Pediatric Preventive Health Guidelines (Newborn to Age 21) . . . . . . . . . . . . . . . . . . . . . 40 Advance Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Member Grievance and Appeals Procedures.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Grievances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Expedited or Fast Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 State Fair Hearings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Continuation of Benefits During the Appeals Process . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 IMPORTANT MEMBER INFORMATION.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Remember to Renew Your Eligibility with the South Carolina Department of Health and Human Services (SCDHHS).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Enrollment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Open Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Reinstatement.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Disenrollment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Voluntary Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Involuntary Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Important Information about WellCare.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Plan Structure/Operations and How Our Providers Are Paid . . . . . . . . . . . . . . . . . . . . . 55 Evaluation of New Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Quality Improvement and Member Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Fraud, Waste and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 To Report Fraud, Waste or Abuse with WellCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 To Report Fraud, Waste or Abuse with South Carolina Medicaid . . . . . . . . . . . . . 57 Member Rights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Member Responsibilities.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 WellCare Notice of Privacy Practices.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
The WellCare Dictionary

As you read this handbook, youll see some words we use throughout it. Heres what we mean when we use them.
Words/Phrases
Advance Directive: A legal document, like a living will, that tells your doctor and family how you wish to be cared for if youre unable to make your wishes known yourself Appeal: A request for a review you can make when you dont agree with our decision to deny, reduce and/or end a service Benefits/Services: Health care thats covered by our plan Co-pay: A fee you should pay when you get certain care or fill a prescription Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Visits: Regular health exams for children Emergency: A very serious medical condition that must be treated right away Generic Drugs: A drug that has the same active ingredient as a brand-name drug and usually costs less Grievance: When you let us know that youre not happy with our plan, a provider or a benefit/service Identification (ID) Card: A card we give you that shows youre a member of our plan Immunizations: Shots that can help keep you and your children safe from many serious diseases Inpatient: When you get admitted to a hospital Managed Care Plan: A plan like ours that works with health care providers to give care to keep you and your family healthy
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Words/Phrases
Medically Necessary Services: Medical services you need to get well and stay healthy Member: You or someone who has joined our health plan Out-of-Network: A term we use when a provider is not contracted with our plan Outpatient: When you get treated at a medical facility, but are not admitted as an inpatient Post-Stabilization Services: Follow-up care after you leave the hospital to make sure you get better Pharmacy Network: A group of drug stores that plan members can use Preferred Drug List (PDL): A list of drugs that has been put together by doctors and pharmacists Prescription: A drug for which your doctor writes an order Prior Authorization (PA): When we need to approve care or prescriptions before you get them Primary Care Provider (PCP): Your personal doctor who helps manage all of your health care needs Provider: Those who work with us to give medical care, like doctors, hospitals, pharmacies and labs Provider Network: All of the providers who have a contract with us to give care to our members Specialist: A doctor who has been to medical school, trained and practices in a specific field of medicine Treatment: The care you get from doctors and facilities TTY/TDD: A special number to call if you have trouble hearing or have a speech impairment
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Important Phone Numbers
WellCare
Member Services TTY/TDD 24-Hour Nurse Advice Line Fraud, Waste and Abuse Hotline 1-888-588-9842 1-877-247-6272 1-800-919-8807 1-866-678-8355
State of South Carolina

South Carolina Department of Health and Human Services (SCDHHS) South Carolina Healthy Connections Choices 1-888-549-0820 1-877-552-4642
Getting Started with Us
Getting Started with Us
Here are a couple of important things to remember as you get started with WellCare.
Check Your ID Card and Keep It with You at All Times

Youll get your WellCare ID card in the mail. If you dont receive it, call us. Our toll-free number is 1-888-588-9842 (TTY/TDD 1-877-247-6272). Well send you another one. You can also order a new one through our website. Log on to southcarolina.wellcare.com. When you get your WellCare ID card, look it over. You want to make sure the information on it is correct. On it, youll find your: Primary care providers (PCPs) name, address and phone Medicaid ID number Effective date (the date you became our member)
Your Medicaid ID number The date your WellCare membership started Your name
Medicaid #: <000000000000> Effective Date: <XX/XX/XXXX> Member: <First MI. Last Name> Primary Care Provider: <Dr. First Last Name> <Group ID Name> <XXXX Main Street> <Suite XXXX> <City, ST XXXXX> Phone: <XXX-XXX-XXXX> Member ID #: <000000000000> Plan Name: <Plan Name>
Your WellCare ID number Your PCPs contact information
Our website How to contact us
Member Services............................ 1-888-588-9842 TTY/TDD 1-877-247-6272 24-Hour Nurse Advice Line.......... 1-800-919-8807 TTY/TDD 1-877-247-6272
WellCare of South Carolina P.O. Box 211699 Columbia, SC 29221 Medical claims are to be mailed to: WellCare Rx Bin: 603286 P.O. Box 31224 Rx PCN: 01410000 Tampa, FL 33631-3224 Rx GRP: 336257 Call 1-888-588-9842 24 hours a day, 7 days a week.
This ID card is not a guarantee of coverage. Go to our website or contact South Carolina Healthy Connections.
For emergencies, go to the nearest ER. Contact your primary care provider (PCP) as soon as possible.
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Remember, if you get a letter or voice message from a provider asking for your insurance/health plan information, call them right away. Give them your WellCare member Your WellCare ID card information on your ID card. If you get a bill has important information from a provider, give us a call. Well help to on it about your health plan. resolve the issue. By showing it, you can If your ID card is lost or stolen, call us. Or avoid getting a bill from log on to our website to get a new one. your provider.
Get to Know Your PCP

Your PCP is your partner in health. He or she will help arrange all of your medical care. This includes: Regular checkups Immunizations Referrals to other providers, like specialists
We encourage all of our new members to visit their PCPs within the first 90 days (3 months) of joining our plan. If youre pregnant, you should get prenatal care within 14 days of joining our plan. This way your PCP will be able to get to know your health history. Plus, he or she can create a plan of care for you. Be sure to get your medical records from any doctors youve seen in the past. This will be very helpful to your PCP. If you need help with this, call us toll-free at 1-888-588-9842 (TTY/TDD 1-877-247-6272). Well be happy to help. The PCPs in our network are trained in different specialties. Specialties like: Family and internal medicine General practice Geriatrics Pediatrics If you didnt decide on a PCP before joining our plan, we chose one for you. We made this choice based on: Where you may have received care or services before Women can choose a womens health specialist as a PCP for preventive and routine care.
GETTING STARTED WITH US
Dont forget to keep your WellCare ID card with you at all times. Youll need to show it every time you get care. It has important information on it about your health plan. By showing your card, you can avoid getting a bill from a provider.
Where you live Your language preference (like English or Spanish) If the PCP is accepting new patients If youre not happy with our PCP choice, you can change your PCP at any time. When choosing your new PCP, remember: Our providers are sensitive to the needs of many cultures We have providers who speak your language and understand your traditions and customs We can tell you about a providers schooling, residency and qualifications You can pick the same PCP for your entire family or a different one for each family member (depending on each family members needs) We have a few ways for you to look for PCPs and other providers. Our printed provider directory: We mailed one to you with this handbook In it, weve listed providers by county and specialty Find a Provider: This is a tool on our website You can search for a provider within a certain distance of your home Because were always adding new providers to our network, this is the best way to get our most current provider network information Call us: We can help you find a provider right over the phone To change your PCP, call us. Call toll-free 1-888-588-9842 (TTY/TDD 1-877-247-6272). You can request the change through our website too. PCP changes made between the 1st and 10th of the month will go into effect right away. Changes made after the 10th of the month will take effect at the beginning of the next month. Well send you a new ID card with your new PCP listed on it.
If your PCP or other provider decides to leave our network, well send you a letter 30 calendar days ahead of time. The letter will give you details about the change and how were handling it.
We have nurses to take your call any day of the week. You can call anytime youre not sure how to handle a health-related problem. One of our nurses will help you decide what kind of care you need. You can get help with problems like: Back pain A cut or burn A cough, cold or the flu Dizziness or feeling sick to your stomach A crying baby When you call, a nurse will ask some questions about your problem. Give as many details as you can; for example, where it hurts or what it looks and feels like. The nurse can then help you decide if you: Can care for yourself at home Need to see a doctor or go to an urgent care center or the hospital Remember, a nurse is always there to help. Consider calling our Nurse Advice Line before calling your doctor or going to the hospital. But if you think it is a real medical emergency, call 911 or go to the nearest emergency room.
24-Hour Nurse Advice Line toll-free number: 1-800-919-8807 (TTY/TDD 1-877-247-6272)
In an Emergency
Call 911 or go to the nearest emergency room. Well talk more about emergencies later in this handbook.
Remember to Use Our 24-Hour Nurse Advice Line
Contact Us
Call us with any questions you have. Were here to help MondayFriday, 8 a.m. to 5 p.m. Member Services toll-free number: 1-888-588-9842 (TTY/TDD 1-877-247-6272) Call us any time you need help with: Updating your contact information, like your mailing address and phone number Getting a replacement ID card Finding and choosing a provider Making an appointment with a provider Filing a grievance or an appeal Its important for us and the South Carolina Department of Health and Human Services (SCDHHS) to know if there is a major change in your life. For example, if you: Move Your family size changes, like you get married or divorced, have a baby or adopt a child or experience the death of your spouse or child Start a new job or your income changes Get health insurance from another company If you speak a different language or need something in Braille, large print or audio, we can help. We have translation and alternative format services (including sign language). We can even arrange to have a translator or sign language interpreter at your appointments. Just give us a call. There is no cost to you for this. If you call us after business hours with a non-urgent request, leave a message. Well call you back within 1 business day. To write to us, send your request to: WellCare of South Carolina Attn: Member Services P.O Box 31370 Tampa, FL 33631-3370
You may be able to find answers to your questions on our website. Log on to southcarolina.wellcare.com for information on/about: Our member handbook, provider directory or the Find a Provider search tool How we protect your privacy Your member rights and responsibilities Member newsletters Pediatric and adult preventive health Pregnancy care Childhood obesity, lead poisoning, asthma, diabetes and chronic kidney disease Our website: southcarolina.wellcare.com On our website, you can also: Update your address and phone number Request a change to your PCP
Know Your Rights and Responsibilities

As a member of our plan, you have rights and responsibilities. Keep reading to learn more.
Hold onto this Handbook

Youll find very valuable information in this handbook. Information about: Your covered benefits and services and how to get them Advance directives (learn more about these in the Advance Directives section later in this handbook) How to use our grievance and appeals process for when youre not happy with our health plan or a decision we made How we protect your privacy If you lose it, call us. Well send you a new one. You can also find it on our website.
Our Website
Care Basics
Youll get your care from doctors, hospitals and others who are in our provider network. We or a network doctor must approve your care. Well pay for approved care. If you get a service that we do not approve, you may have to pay for it yourself.
Medically Necessary
We approve care that is medically needed or necessary. This just means the care: Is for an illness that would put your health in danger Follows accepted medical practices Is provided in a safe, proper and cost-effective place, depending on the diagnosis and how sick you are Is not for convenience only Is needed when there is no better or less costly care, service or place available
Making and Getting to Your Medical Appointments

We have guidelines to make sure you get to your medical appointments in a timely manner.* (This is also called access to care.) This table will give you an idea of the furthest distance you should have to drive to get to a medical appointment.
Types of Provider
PCPs Specialists
Distance to the Provider from Your Home

30 miles 50 miles
*The doctors in our network must offer you the same office hours as patients with other insurance. When you arrive at your appointment, you should only have to wait up to 45 minutes (for a scheduled appointment). southcarolina.wellcare.com | 11
How long you should wait for an appointment depends on the kind of care you need. Keep these times in mind as youre setting your appointments.
Type of Appointment
Type of Care
Appointment Time
Right away (both in and out of our service area), 24 hours a day, 7 days a week (prior authorization is not required for emergency services) Within 48 hours of your request 4 to 6 weeks of your request 4 to 6 weeks of your request Right away (both in and out of our service area), 24 hours a day, 7 days a week (prior authorization is not required for emergency services) Within 48 hours of your request 4 to 6 weeks of your request
Emergency
Medical
Urgent Routine/wellness PCP visits Specialist visit
Emergency Behavioral Health Urgent Routine visit
Cost Sharing
You may have to make a small co-payment, or co-pay for short, when you get care. Be sure to read the Services Covered by WellCare section for co-pay amounts. There are no co-pays for: Children under age 19 Federally recognized Native Americans Emergency care Pregnant women Institutionalized individuals
Your Health Plan
Services Covered by WellCare
Members of the Health Opportunity Accounts (HOA) program Here are a couple of important things to remember when getting your care: Well pay for approved care If you get a service that we do not approve, you may have to pay for it yourself Sometimes we may not have a provider in our network who can give you needed care; if this happens, well cover the care out-of-network (at no additional cost to you), but you will need to get approval first from us or your PCP This is not a complete list of covered services. For questions about covered services, give us a call. We can be reached toll-free at 1-888-588-9842 (TTY/TDD 1-877-247-6272).
If a benefit changes at any time, well send you a letter 30 calendar days ahead of time. The letter will give you details about the change and how were handling it. (Changes can include adding or ending a benefit.)
YOUR HEALTH PLAN
Covered Services and Any Limits

Abortions and related services Covered only in the case of rape or incest or if the members life is in danger Allergy testing and treatment Ambulance transportation Ambulatory Surgical Center (ASC)/Short Procedure Unit (SPU) services Behavioral health inpatient services (at a general hospital) Behavioral health outpatient facility services Certified Registered Nurse Practitioner services Chiropractic services Limited to manual manipulation of the spine to treat vertebrae misalignment Limited to 1 treatment/visit a day, up to 8 treatments/visits each year Communicable disease (HIV/AIDS, STDs, syphilis, TB) services Directly observed therapy for TB Education and counseling Testing Treatment
Co-Pays
$0
$3.30 $0 $3.30 $25 $25 $3.30
$1.15
$3.30

Durable medical equipment (DME) and supplies Items that are not covered include wheelchair accessories and ramps, gloves, car/individual lifts, etc. Repairs not covered under the manufacturers warranty are covered Replacement is covered if the equipment is still medically necessary at the time of replacement Early and Periodic Screening, Diagnosis and Treatment (EPSDT)/Well-child services Physicals for sports are not covered Emergency medical services
Co-Pays
$3.40 (equipment under a rent-to-purchase plan will have the co-pay split evenly among the 10-month rental payment schedule)
$0 $0 $0 (for members age 19 and under); $3.30 (for members ages 20 and 21) YOUR HEALTH PLAN
Eye exams for members under age 21 (once each year)
Family planning services Annual visit Contraception and supplies Family planning and HIV counseling Lab tests Pregnancy testing Federally Qualified Health Center (FQHC) services Hearing services (for members under age 21) Cochlear implants Ear molds 4 for each ear, every year Hearing aids fittings, related hearing services, testing $0
$0
$3.30

Home health services Home health aide visits Skilled nursing visits Therapy visits occupational, physical and speech therapies Up to 50 visits each year Services that are not covered include full-time nursing, drugs, home-delivered meals, homemaker services, routine supplies and home health services provided in a nursing home and/or institution Hysterectomy services (when medically necessary) Advance written and verbal notification to the member that she will be permanently unable to have children is required; the notification must be signed and dated by the member Hysterectomies are not covered if done only to prevent pregnancy Inpatient hospital services (physician care and rehabilitation) Institutional long-term care facilities/nursing homes Limited to the first 90 continuous days Maximum limit of covered days is 120 Internal prosthetic devices Lab and X-ray services and diagnostic tests Maternity services Birthing centers for obstetrical and newborn care Prenatal, delivery and postpartum services and nursery charges
Co-Pays
$3.30
$0
$25 per admission
$0 $3.40 $0
$0

Optometrist services (for members under age 21) Outpatient hospital (non-emergency) services Outpatient pediatric AIDS clinic services Outpatient rehabilitative therapy services Physician services Physical therapy, occupational therapy, speech therapy and audiology Pharmacy services Podiatry services Preventive and Rehabilitative Services for Primary Care Enhancement (PSPCE/RSPCE) Evaluation of health status and needs Identification of risk factors Development of care plan Education and counseling Rural Health Clinic (RHC) services Sterilization services (for members age 21 and older who are mentally competent, not in an institution, and have consented to the service) Advanced informed consent to the member is required
Co-Pays
$3.30 $3.40 $0 $3.40 $3.30 $0 $3.40 $1.15 YOUR HEALTH PLAN
$0
$3.30
$0

Transplant services Bone marrow, cornea, heart, kidney, liver, lung, multivisceral, pancreas, small bowel All services provided 72 hours before surgery, posttransplant services following discharge and posttransplant pharmacy services
Co-Pays
$0
The WellCare Extras!

Were excited to offer extra benefits and special programs to our members. Things like: Member Loyalty Program provides gift cards for seeing your PCP in the first 90 days of joining our plan New moms and babies are eligible for diaper rewards Assistance with Boys and Girls Club fees at participating clubs
Services NOT Covered by WellCare

We do not cover the following services. This is not a complete list of non-covered services. For questions about non-covered services, give us a call. We can be reached toll-free at 1-888-588-9842 (TTY/TDD 1-877-247-6272).
Non-Covered Services
Cosmetic procedures Experimental and investigational procedures Hypnotherapy Services provided outside of the U.S. YOUR HEALTH PLAN
Services Covered by Medicaid Fee-for-Service

These services are covered by Medicaid fee-for-service (or the SCDHHS Medicaid Plan). To get them, youll need to show your South Carolina Healthy Connections Medicaid ID card. Call us with any questions you have about these services. You can also contact SCDHHC toll-free at 1-888-549-0820
Services Covered by SCDHHS

Certain behavioral health services: Targeted case management services Intensive family treatment services Therapeutic day services for children Out-of-home therapeutic placement services for children Inpatient psychiatric hospital and residential treatment facility services Dental services: Preventive, restorative and surgical services are covered for members under age 21 Emergency dental services are covered for members over age 21 SCDHHS is partnered with DentaQuest to provide dental care; call DentaQuest toll-free at 1-888-307-6552 (TTY/TDD 1-800-466-7566) to: Get more information about covered services Find a provider in your area Set up an appointment Developmental Evaluation Services (DECs): These are medically necessary services for members under age 21 who may have developmental delays, learning disabilities or other disabling conditions Family planning services through the Medicaid Adolescent Pregnancy Prevention Services (MAPPS) program: These services are for at-risk youths and include Counseling Education Services are provided in schools, office settings and homes
Services Covered by SCDHHS

Home- and community-based waiver services Non-emergency transportation: Keep reading for more details Nursing home care after 90 continuous days (WellCare covers the first 90 continuous days) Pregnancy prevention for targeted populations Substance abuse treatment services
Transportation Services
Each broker has a toll-free telephone number to schedule transportation services and is available MondayFriday from 8 a.m. to 5 p.m. In an emergency, call 911 for a ride to the hospital. YOUR HEALTH PLAN For non-emergency transportation, please call a transportation broker listed in the following table. In most cases, we ask that you call 3 days before you need the service.
LogistiCare
Region 1 If you live in one of these counties, call: 1-866-910-7688 Region 2 If you live in one of these counties, call: 1-866-445-6860
Counties Served
Abbeville, Anderson, Cherokee, Edgefield, Greenville, Greenwood, Laurens, McCormick, Oconee, Pickens, Saluda and Spartanburg Aiken, Allendale, Bamberg, Barnwell, Calhoun, Chester, Clarendon, Fairfield, Kershaw, Lancaster, Lee, Lexington, Newberry, Orangeburg, Richland, Sumter, Union and York Beaufort, Berkeley, Charleston, Chesterfield, Colleton, Darlington, Dillon, Dorchester, Florence, Georgetown, Hampton, Horry, Jasper, Marion, Marlboro and Williamsburg
Region 3 If you live in one of these counties, call: 1-866-445-9954
If you need help arranging non-emergency transportation, give us a call. Our toll-free number is 1-888-588-9842 (TTY/TDD 1-877-247-6272). Well be happy to help. southcarolina.wellcare.com | 22
How to Get Services Covered by WellCare

Call your PCP when you need regular care. He or she will send you to see a specialist for tests, specialty care and other covered services that he or she does not provide. Be sure your PCP approves you to see a specialist. We will cover this care. If your PCP does not provide an approved service, ask him or her how you can get it.
Prior Authorization (PA)

Prior authorization (or PA for short) means we must approve a service or prescription drug before you can get it. Your PCP/specialist should contact us to ask for this approval. If we do not approve the request, well let you know. Plus, well give you details about how to file an appeal. (Keep reading for more on appeals.)
Prior Authorization How To

Type of Request Decision Time Frame Who Can Request One Your provider Your provider How to Request Call: 1-888-588-9842 Fax: 1-877-297-3112 Call: 1-888-588-9842 Fax: 1-877-297-3112
Standard* (for non14 calendar days emergency care) Expedited/Fast** (for urgent care) 72 hours
*Sometimes we may need more time to make a standard decision. This may be because we need more information and its in your best interest. If so, well take up to 14 more calendar days. **Sometimes we may need more time to make a fast decision. If so, well take up to 48 more hours. There are some instances when a PA is not needed from us: If you move to our plan from another managed care plan or Medicaid fee-forservice and have an existing PA for a medical service, your service will continue until your provider releases you or you complete the treatment
If youre taking a prescription for major depression, schizophrenia or bi-polar disorder that was prior authorized by your previous managed care plan or Medicaid fee-for-service, we will continue to cover it up to 60 days (from when you become our member)
Services Available Without Authorization

You dont need approval from us or your PCP for the following services: Dialysis DME purchases under $250 and orthotics and prosthetics under $500 Emergency or urgent care services Emergency transportation services Observation services Select outpatient procedures (please call us for a complete list of these procedures) Even though you dont need approval for these services, you will need to pick a network provider. Look through your provider directory to find one. Remember to use our online provider search tool Find a Provider. Its on our website. Log on to southcarolina.wellcare.com. When youve made your choice, call to set up an appointment. Remember to take your ID card with you. YOUR HEALTH PLAN Routine lab tests and X-ray services
Utilization Management (UM)

Utilization management (UM) is a common process used by health plans. Its how we make sure members get the right care at the right place. It also helps us control costs and deliver good care at the same time. Our UM program has four parts. They are: 1. Prior authorization getting our approval before getting a service 2. Prospective reviews making sure the care is right for you before you get it 3. Concurrent reviews reviewing your care as you get it to see if something else might be better for you 4. Retrospective reviews finding out if the care you got was appropriate
At times, we may deny coverage for services or care. (All medically necessary denial decisions are made by a doctor.) Here are some things you should know about this decision process: Decisions are based on the best use of care and services The people who make decisions dont get paid to deny care (no one does) We do not promote denial of care in any way Call us if you have questions about our UM program. Call toll-free 1-888-588-9842 (TTY/TDD 1-877-247-6272).
Second Medical Opinion

Call your PCP when you want a second opinion about your care. He or she will ask you to pick another doctor in our network. If you cant find one, dont worry. Youll be able to choose a doctor outside of our network. (You wont have to pay for this.) The second-opinion doctor may order some tests for you. If so, these tests must be done by a provider in our network. Your PCP will review the second opinion. He or she will then decide the best way to treat you. You may have to pay for services you get when you go to a doctor who is not in our network without approval.
A second medical opinion can be requested by anyone who is allowed to act on your behalf. This includes a: Parent Guardian Social worker
After-Hours Care
What if you get sick or hurt when your PCPs office is closed? If its not an emergency, call our 24-hour Nurse Advice Line. Or you can call your PCP. His or her number is on your ID card. Your PCPs office will have a doctor on call. This on-call doctor is available 24 hours a day, 7 days a week. He or she will call you back and tell you what to do. You may go to an urgent care center if you cant reach your PCPs office. You dont need a PA to go to an urgent care center. If you do go to an urgent care center, be sure to call your PCPs office the next day for follow-up care.
Urgent Care
You may need urgent care for a health problem that isnt an emergency, but needs treatment within 48 hours. This could be something like: An injury Illness Severe pain If you have one of these problems, try calling our 24-hour Nurse Advice Line. One of our nurses will try and help you over the phone. Or you can call your PCP. He or she can tell you how to treat it. Our advice line or your PCP may tell you to go to an urgent care center for help. Urgent care center services do not require a PA. When you get to the center, show your WellCare ID card. Also, ask the staff to call us. Be sure to let your PCP know if you receive care at an urgent care center so you can get follow-up care. You can also go to an urgent care center when you travel outside of South Carolina. YOUR HEALTH PLAN
Emergency Care
A medical emergency is when your health is in grave danger. An emergency is when the condition could cause: Bodily injury Damage to an organ or other body part Injury to yourself or others Harm to yourself or others due to alcohol or drug abuse Harm to your health For moms-to-be, it may be an emergency if you think: There is no time to go to your doctors regular hospital Going to another hospital may cause harm to you and your baby Youre in labor Here are some examples of an emergency: Broken bones or cuts requiring stitches Heart attack or severe chest pains Shortness of breath Poisoning Heavy blood loss Loss of consciousness
Call your PCP or our Nurse Advice Line if youre not sure if its an emergency. In an emergency, you can: Call 911 Call an ambulance if you dont have 911 in your area Go to the nearest hospital emergency room (ER) right away The choice is yours. You dont need a PA for emergency care that is provided at an urgent care center or ER. When you get to the ER, show your WellCare ID card. Also, ask the staff to call us. The ER doctor will decide if your visit is an emergency. If your condition is not an emergency and your health is not in danger, you can choose to stay. But you may have to pay for the care if you do.
Out-of-Area Emergency Care

Its important to get care when you are sick or hurt. That goes for when you are traveling too. If you have a medical emergency while traveling, go to the nearest hospital. It doesnt matter if you are not in our service area. When you get to the hospital, remember to: Show your WellCare ID card Ask the staff to call us for instructions on how to file your claim Let your PCP know what has happened If you have to pay for this visit, let us know. Well tell you how you can ask to be reimbursed for the visit. But it is very important that you keep copies of your medical reports, bills and proof of payment. We will need these to reimburse you.
Post-Stabilization Care
After an ER visit, call your PCP within 24 to 48 hours. You may need to get follow-up care until your health gets better. This is called post-stabilization care. You dont need a PA for post-stabilization care, which we cover. But you must need this care to maintain, improve or resolve your medical condition.
Pregnancy and Newborn Care

When you find out you are pregnant, taking care of yourself can help you and your unborn baby stay healthy. Here are some very important things to do when you get the news. Think of this as your baby checklist.
Baby To Do List Let these people know Im having a baby:

Family WellCare at 1-888-588-9842 SCDHHS (South Carolina Department of Health and Human Services) My PCP
Schedule my first prenatal visit and talk with the doctor about future prenatal
visits and those after baby gets here
Start thinking about which doctor to pick for baby

I need to have this done before baby gets here
Once baby is here, call SCDHHS to get his/her

Medicaid # and then call WellCare with it
If SCDHHS doesnt put baby on WellCare,

call 1-888-588-9842 to fix
WellCare can h elp me make my baby appo intments! 1-888-588-984 2 (TTY/TDD 1-87 7-247-6272)
Names??? Clothes???
You should see your PCP within 14 days of joining our plan. Make sure to go to all your prenatal and postpartum (after birth) visits. Just as important as keeping your appointments is letting us know when you become pregnant. We can provide you with helpful information about having and caring for your baby.
YOUR HEALTH PLAN
A few reminders: If you have a baby while youre a WellCare member, he or she will automatically be added to WellCare, and well cover him or her from birth (unless you tell SCDHHS that you want him or her added to a different health plan before giving birth) You must let SCDHHS know (call 1-888-549-0820) that you are pregnant; once you have your baby, you need to call SCDHHS again to get his or her Medicaid number Give us your babys Medicaid number after you get it from SCDHHS If your baby is not automatically added to WellCare, call 1-888-549-0820 to have him or her changed over to our plan Choose a PCP for your baby before he or she is born; if you dont, well choose one for you
Women, Infants and Children (WIC)

WIC is a special nutrition program. Its for women (pregnant and those who have recently delivered), infants and children. The program provides: Nutrition education Nutritious food Referrals to other health, welfare and social services Support for breastfeeding mothers If you are pregnant, ask your PCP about WIC. To see if youre eligible and to apply for this program, call your local WIC agency. You will need to schedule an appointment to talk with them. Youll also need to provide proof of South Carolina residency and your income. For more details about WIC, go to the South Carolina WIC website at www.scdhec.gov/health/mch/wic/index.htm.
Behavioral Health Care

Your mental or behavioral health is an important part of staying healthy. If you experience any of the symptoms below, call us. Well give you the names and phone numbers of providers who can help. You can search for a provider on our website too. Log on to southcarolina.wellcare.com. Always feeling sad Feeling hopeless and/or helpless Feelings of guilt or worthlessness
Problems sleeping No appetite Weight loss or gain Loss of interest in the things you like Problems paying attention Being upset Your head, stomach or back hurts, and your doctor hasnt found a cause Drug or alcohol problems As a reminder, you must get a PA to see a provider who is not in our network. Youll have to pay for the care if you dont.
What to Do in a Behavioral Health Emergency or if You Are Out of Our Service Region
Do you feel youre a danger to yourself or others? Do you think youre having a behavioral health emergency? Call your PCP or our nurse advice line if youre not sure if its an emergency. In a behavioral health emergency, you can: Call 911 Call an ambulance if you dont have 911 in your area Go to the nearest hospital emergency room (ER) right away The choice is yours. You dont need a PA for a behavioral health emergency. The doctor who treats you for your behavioral health emergency may feel you need post-stabilization care. You dont need a PA for post-stabilization care. But it must be needed to maintain, improve or resolve your medical condition. Remember to follow up with your PCP within 24 to 48 hours after you leave the hospital. The hospital where you get your emergency care may be out of our service area. If so, youll be taken to a network facility when youre well enough to travel. Refer back to the Emergency Care section of this handbook for more information about what to do in an emergency. YOUR HEALTH PLAN
Prescriptions
Prescriptions must be written by one of our network providers. (Your PCP must approve a prescription from an out-of-network provider.) Once you have your prescription,
go to any network pharmacy to get it filled. Our provider directory lists all of the pharmacies who take our plan. You can search for one on our website too. Or call us and well help find one near you. At the pharmacy, youll need to show your WellCare ID card when you pick up your prescription. There is a $3.40 co-pay for drugs. Remember, there are no co-pays for: Children under age 19 years old Federally-recognized Native Americans Pregnant women Members age 21 and older can receive up to 7 prescriptions per month, of which only 4 may be brand. You can get more prescriptions per month, if medically necessary, through the PA process. These limits do not apply to children age 20 and younger.
Preferred Drug List

We have a Preferred Drug List, or PDL for short. This is a list of drugs that has been put together by doctors and pharmacists. Our network providers use this list when they prescribe a drug for you. To see our PDL, go to our website at southcarolina.wellcare.com. The PDL will include drugs that may have limits, like:
Keep your co-pays low with generic drugs. They can cost less and work the same as brand-name drugs. Ask your provider or pharmacist for a generic drug option, if available.
Age or gender limits Prior authorization (PA) Quantity limits Step therapy For those drugs that require a PA (and are not on our PDL), your provider will need to send us a Coverage Determination Request (CDR). There are some medications we will not cover. They include: Those used for eating problems or weight gain Those used to help you get pregnant Those used for erectile dysfunction Those that are for cosmetic purposes or to help you grow hair DESI (Drug Efficacy Study Implementation) drugs and drugs that are identical, related or similar to such drugs southcarolina.wellcare.com | 31
Investigational or experimental drugs Those used for any purpose that is not medically accepted
Other Drugs You Can Get at the Pharmacy

There are some over-the-counter (OTC) drugs you can get at the pharmacy with a prescription. Some of these drugs we cover include: Diphenhydramine (for allergy relief) Meclizine (to help with motion sickness) H2 receptor antagonists (to treat acid reflux and ulcers, such as ranitidine) Ibuprofen (pain reliever for headaches, toothaches and back pain) Multivitamins/multivitamins with iron Insulin Insulin syringes Non-sedating antihistamines (allergy relief that wont make you sleepy) To get these items, simply take your Iron prescription to a network Topical antifungals such as clotrimazole pharmacy. Youll also Urine test strips need to show them your Coated aspirin WellCare ID card. Antacids such as aluminum hydroxide Proton pump inhibitors (also help with acid reflux and ulcers, such as omeprazole) For questions about prescriptions, call us. We can be reached at 1-888-588-9842 (TTY/TDD 1-877-247-6272).
Care Management
We understand you may have special care needs. To help with these, we have a care management program. The goal of this program is to help you understand how to take care of yourself and maintain good health. You may qualify for care management services if you: Have a child with special health care needs Have a chronic illness that requires coordination of many services Have a serious or long-term health condition, like asthma, diabetes, hypertension, coronary artery disease (CAD), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), HIV/AIDS or a high-risk pregnancy southcarolina.wellcare.com | 32
YOUR HEALTH PLAN
Have cancer Have had a transplant Need help with getting care and/or using your medical services Suffer from depression While in the program, youll work with a care manager. He or she will work with you to help coordinate your care needs. To do this, he or she: May ask you questions to get more information about your condition Will work with your PCP to arrange services you need and help you understand your illness Will provide information to help you understand how to care for yourself and how to access services, including local resources We may contact you to talk about care management if: You ask about the program Your PCP thinks the program would help you We think you may qualify for these services To learn more about or to sign up for this no-cost program, give us a call. Call toll-free at 1-888-588-9842 (TTY/TDD 1-877-247-6272).
Transition of Care
Getting the care you need is very important to us. Thats why well work with you to make sure you get your care when: Youre leaving another health plan and just starting with us One of your providers leaves our network You leave our health plan to go to another one We want to be sure you continue to see your doctors and get your medications. Please call or have your provider call 1-888-588-9842 if you: Take regular medication(s) that need(s) authorization See a specialist Get therapy (for example, occupational or physical therapy) Use durable medical equipment, like oxygen or a wheelchair Receive in-home services (for example, wound care or in-home infusion)
Planning Your Care
Here we want to give you information about prevention and planning for your care needs.
Early & Periodic Screening, Diagnosis and Treatment (EPSDT) Services

We have an Early Periodic Screening, Diagnosis and Treatment (EPSDT) program. This program provides needed care for children up to age 21. EPSDT care may include services like: A comprehensive history and physical exam Behavioral and mental health assessment Growth and development chart Vision, hearing and language screening Nutritional health and education Lead risk assessment and testing, as appropriate Age-appropriate immunizations Dental screening and referral to a dentist Referral to specialists and treatment, as appropriate Any needed services as part of a treatment plan that is approved by us as medically necessary Regular preventive dental and treatment services, including screening examinations Preventive dental treatment (scaling and polishing), following the American Academy of Pediatrics guidelines A big part of the EPSDT program is the well-child checkup. Your childs PCP will do this checkup to make sure that your child is growing up healthy. During one of these checkups, your childs PCP will: Do a comprehensive head-to-toe physical and mental health exam Give any needed immunizations (shots) Do any needed blood and urine tests YOUR HEALTH PLAN
Look into your childs mouth and check his or her teeth Test your child for tuberculosis (TB) and lead (when age-appropriate) Give you health tips and information based on your childs age Talk to you about your childs growth, development and eating habits Measure your childs height, weight, blood pressure, vision and hearing These well-child checkups are done at certain ages. (Well talk about these a little later in this section.) Its also very important that you get your child in to see his or her PCP for these checkups. They can help to find health concerns before they become bigger problems. Also, your child can get his or her needed immunizations. Best of all, these checkups are done at no cost to you. So make sure to schedule your childs checkup today. If you need help setting up an appointment, call us. And dont forget, if you need to cancel the appointment, reschedule it as soon as you can.
Preventive Health Guidelines

The following are guidelines for preventive care. Weve provided these to help you remember to see your PCP. Your PCP will tell you when you and your family are due for your checkups. He or she will also remind you when you and your family need certain screenings and immunizations. To help you stay on top of getting your recommended exams, we may call you. Or we might send you a letter. We do this as a reminder for you. So if you get a call or letter about your yearly flu shot or your child missing a well-child checkup, pay attention to it. These reminders are meant to help you and your family stay healthy. Please remember these are suggested guidelines. They do not replace your PCPs judgment. You should always talk with your PCP about the care thats right for you and your family.
Adult Preventive Health Guidelines

If youre new to WellCare, you should get a baseline physical exam within the first 90 days of joining our plan. If youre pregnant, you should get this done within 14 days. Recommendations for periodic health exam visits for asymptomatic adults are: Age 18 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
18 years of age and older
Screening
Blood pressure, height, body mass index (BMI), alcohol use Cholesterol (non-fasting TC/HDL) Cholesterol (non-fasting TC/HDL) Cholesterol (non-fasting TC/HDL)
Timing
Each year from age 18 to 21; then, every 1 to 2 years or at PCPs recommendation Every 5 years (more often if elevated) Every 5 years (more often if elevated) Every 5 years (more often if elevated)
Men 35 to 65 years of age Women 45 to 65 years of age High-risk men and women 20 years of age and older Women 18 years of age and older who are sexually active (consider at age 12 if sexually active) Women 40 years of age and older Men and women 50 years of age and older Women 65 years of age and older (60 and older if at risk) 65 years of age and older, or younger if other risk factors present
Pap smear and chlamydia
Every 1-3 years and at PCPs recommendation
Baseline (first) mammography Colorectal (colonoscopy)
Every 1 to 2 years Periodically, depending upon test Every 2 years or at PCPs recommendations Every 2 years for routine exams or annually if diabetic or other risk factors
Osteoporosis (bone mass measurement) Vision (including glaucoma or diabetic retinal exam as needed), hearing
YOUR HEALTH PLAN
Immunizations
Tetanus-Diphtheria and acellular pertussis (Td/Tdap) Varicella (VZV) Measles, Mumps, Rubella (MMR)
Timing
Td: every 10 years, age 18 and older Tdap: substitute 1 dose of Tdap for Td (one-time administration) Susceptible adults only, age 18 and older: 2 doses Adults born during or after 1957 should receive 1-2 doses 65 years of age and older, all adults who smoke or have certain chronic medical conditions: 1 dose (may need a second dose if identified at risk) All adults annually All unvaccinated individuals who anticipate close contact with international adoptee or those with certain high-risk behaviors Adults at risk, age 18 and older: 3 doses College freshmen living in dormitories and others at risk, age 18 and older: 1 dose; meningococcal polysaccharide vaccine is preferred for adults older than 56 All previously unvaccinated women through 26 years of age: 3 doses Age 60 and older: 1 dose For eligible members who are at high risk and who have not previously received Hib vaccine: 1 dose
Pneumococcal polysaccharide (PPSV)
Flu shot
Hepatitis A vaccine (HepA)
Hepatitis B vaccine (HepB)
Meningococcal conjugate vaccine (MCV)
Human papillomavirus vaccine (HPV) Zoster Haemophilus Influenza type b (Hib)
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 prostate-specific antigen (PSA) test and rectal exam (for men over 40 years of age, at PCPs discretion)
Counseling
Calcium: 1,000mg a day for women 18 to 50 years of age; 1,200mg 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 Advance directives
YOUR HEALTH PLAN
References: American College of Gastroenterology. (2008). Recommendations on colorectal cancer. Retrieved from http://s3.gi.org/media/ACG2009CRCGuideline.pdf Centers for Disease Control and Prevention. (2012). CDC fact sheet: hepatitis C proposed expansion of testing recommendations, 2012. Retrieved from http://www. cdc.gov/nchhstp/newsroom/docs/HCV-TestingFactSheet NoEmbargo508.pdf Centers for Disease Control and Prevention. (2012). Recommended adult immunization schedule---United States, 2013. Retrieved from http://www.cdc.gov/ vaccines/schedules/downloads/adult/adult-schedule.pdf Centers for Disease Control and Prevention. (2006, June 29). Press release CDCs advisory committee recommends human papillomavirus virus vaccination. Retrieved from http://www.cdc.gov/media/pressrel/r060629-b.htm Cleveland Clinic. (2012). Cancer treatment. Retrieved from http://my.clevelandclinic.org National Institutes of Health. (2002). Third report of the National Cholesterol Education Program expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III): final report. Retrieved from http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf Office of the Surgeon General. (2004). Bone health and osteoporosis: a report of the Surgeon General. Rockville, MD: Office of the Surgeon General (US). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20945569 U.S. Preventive Services Task Force. (2007). USPSTF A-Z topic guide. Retrieved from http://www.uspreventiveservicestaskforce.org/uspstopics.htm
Pediatric Preventive Health Guidelines (Newborn to Age 21)

These guidelines are recommendations only. Other services may be needed.
Age
Newborn
Screening/Immunizations and Timing

Well-baby* checkup at birth Hearing test Newborn screening blood tests Immunizations: HepB shot Well-baby checkup if discharged less than 48 hours after delivery Newborn screening blood tests Immunizations: HepB (if not done at birth) Well-baby checkup Newborn screening blood test if not already completed Immunizations: second HepB Well-baby checkup Newborn screening blood test if not already completed Immunizations: RV, DTaP, Hib, PCV, IPV Well-baby checkup Immunizations: RV, DTaP, Hib, PCV, IPV Well-baby checkup Immunizations: RV, DTaP, Hib, PCV, IPV, HepB, flu shot Well-baby checkup Lab testing: blood lead Well-baby checkup Lab testing: blood lead, hemoglobin or hematocrit (blood counts) Immunizations: Hib, Measles, MMR, HepA (2-dose series between 12 and 15 months), Varicella, PCV, flu shot Dental visit** as needed Well-baby checkup Lab testing: DTaP shot between 15 and 18 months YOUR HEALTH PLAN
24 days
1 month
2 months 4 months 6 months 9 months
12 months (1 year)
15 months
Age
18 months
Screening/Immunizations and Timing

Well-baby checkup Immunizations: second HepA (6 months after the first dose) Dental visit Well-baby checkup Lab testing: blood lead Immunizations: flu shot Dental visit Well-baby checkup Dental visit Well-child* checkup Eye screening Immunizations: flu shot Dental visit twice a year
24 months (2 years) 30 months
3 years
Well-child checkup each year Eye screening 4 and 5 years Lab testing: urine test at age 5 Immunizations: MMR, DTaP, IPV, Varicella, flu shot each year Dental visit twice a year Well-child checkup every year Immunizations: flu shot every year Dental visit twice a year Human papillomavirus vaccine (HPV***) with a minimum age of 9 years Well-child checkup each year Immunizations: MCV, Tdap, HPV series, flu shot each year Dental visit twice a year Well-adolescent* checkup every year Females should have a pelvic exam and Pap smear between ages 18 and 21 Lab testing: urine by age 16 Immunizations: HPV series*** if not already completed, flu shot
610 years
11 and 12 years
1321 years
*Well-baby, -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 024 months and blood pressure at least every year beginning at age 3 **Dental visits may be recommended beginning at age 6 months. ***Subject to individual state coverage. 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 6 months 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: American Academy of Pediatrics, & Bright Futures. (2008). Recommendations for preventive pediatric health care. Retrieved from http://brightfutures.aap.org/pdfs/ AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf Centers for Disease Control and Prevention. (2012). Recommended immunization schedule for persons aged 0 through 6 years United States, 2012. Retrieved from http://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf Centers for Disease Control and Prevention. (2013). Recommended immunization schedule for persons aged 7 through 18 years United States, 2012. Retrieved http://www.cdc.gov/vaccines/who/teens/downloads/parent-version-schedule-718yrs.pdf Centers for Disease Control and Prevention. (2013). Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind United States, 2013. Retrieved http://www.cdc.gov/vaccines/ schedules/downloads/child/catchup-schedule-pr.pdf
YOUR HEALTH PLAN
Legal Disclaimer: Preventive health guidelines are based on guidelines from third parties available before printing. These guidelines are not a replacement for your doctors 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
Advance Directives
Some people may worry about the medical care they would get if they became too sick to make their wishes known. They may not want to spend months or years on life support. Others may want every step taken to lengthen their lives. You have the right to choose your own medical care. If you dont want a certain type of care, you have the right to tell your doctor you dont want it. To do this, you should complete an advance directive. This is a legal document. It tells others what kind of care you would want if you were unable to communicate it yourself. There are three types of advance directives: A living will A health care surrogate for health care decisions An anatomical donation A living will: States the kinds of care you want if you are unconscious and will not wake up Can be used for conditions that may lead to death Tells your doctor when to continue or stop care to keep you alive With a health care surrogate for health care decisions: You name a person you want to make physical and/or mental health decisions for you
Remember its your choice.
An anatomical donation: Tells someone that you wish to donate all or part of your body at death Can be an organ donation to someone in need of a transplant Can be a donation of your body to science We know that making these kinds of decisions can be hard. And you need to be ready to answer some tough questions. Here are some things to think about as you write your advance directives: It is your choice to fill one out It is your right under state law to make decisions regarding medical care, including the right to accept or refuse medical or surgical treatment Filling one out does not mean you want to commit suicide or homicide, or have physician-assisted suicide or euthanasia (mercy killing) Filling one out will not affect anything that is based on your life or death (for example, other insurance) You must be of sound mind to complete one You must be at least 18 years of age or an emancipated (legally-free) minor You must sign it; youll need at least one other person to sign it too After you fill one out, keep it in a safe place; you should give copies to someone in your family and your doctor You can make changes to it at any time A caregiver may not follow your wishes if they go against his or her conscience (if a caregiver cannot follow your wishes, he or she will help you find someone who can); otherwise, your wishes should be followed If they are not being followed, call the South Carolina Department of Health and Human Services at 1-888-549-0820 To get an advance directive, talk with your PCP. You can also talk with an attorney.
YOUR HEALTH PLAN
Member Grievance and Appeals Procedures

We want you to let us know right away if you have any questions or concerns with your covered services or the care you receive. In this section well explain how you can tell us about these concerns. There are three ways to voice your concerns to us. Theyre called: Grievances Appeals State Fair Hearings State law allows you to voice a concern if you have any problems with us. The State has also helped to set the rules for how to do this. The rules include what we must do when we get a concern. If you file a grievance or an appeal, we must be fair. We cannot disenroll you from our plan or treat you differently.
Grievances
A grievance is when you tell us about a concern you have with our plan. It can be about a provider and/or a service, including: Quality-of-care issues Wait times during provider visits The way your providers or others act or treat you Unclean provider offices Not getting the information you need You can file a grievance by calling or writing to us. To do so by phone, call 1-888-5889842 (TTY/TDD 1-877-247-6272). To write us, mail to: WellCare of South Carolina Attn: Grievance Department P.O. Box 31384 Tampa, FL 33631-3384 You can fax it too. Our toll-free fax number is 1-877-297-3112.
You can file the grievance yourself. Or you can have someone file it for you. (This includes your PCP or another provider.) We must have your written permission before someone can file a grievance for you. If at any time you need help filing one, call us. If you wish to use a representative, he or she must complete an Appointment of Representative (AOR) statement. You and the person you choose to represent you who must sign the AOR statement. The form is located on our website at southcarolina.wellcare.com. Within 5 business days of getting your grievance, well mail you a letter. It will tell you we received your grievance. Well send you another letter with our decision within 60 calendar days or sooner. If our decision on your grievance is not in your favor, you will not be able to request a State Fair Hearing. But you can ask for a second review of your grievance; however, the grievance had to be about: Access to care or services Benefit coverage Payment for care of services You, your PCP/other provider or representative can request this review over the phone or in writing. To do so by phone, call us at 1-888-588-9842 (TTY/TDD 1-877-247-6272). To write us, mail to the address already provided. This second review request must be made within 30 calendar days of our grievance decision letter. Well send you a letter with our decision within 60 calendar days or sooner. YOUR HEALTH PLAN
Appeals
An appeal is a request for a review you can make when you dont agree with a decision we made about your care. Or it can be made if we take too long to make a care decision. You can ask for an appeal if: We deny or limit a service you or your doctor asks us to approve We reduce, suspend or stop services youve been getting that we already approved We do not pay for the health care services you get We fail to give services in the required timeframe We fail to give you a decision in the required timeframe on an appeal you already filed
We dont agree to let you see a doctor who is not in our network and you live in a rural area or in an area with limited doctors You dont agree with a decision we made regarding your medicine Youll get a letter from us when any of these actions occur. Its called a Notice of Action or NOA. You can file an appeal if you do not agree with our decision. You must file your appeal within 30 calendar days of receiving the NOA. You can file your appeal by calling or writing to us. To do so by phone, call 1-888-588-9842 (TTY/ TDD 1-877-247-6272). If you call in your appeal, you must follow up with a written, signed one. (Make sure to do this within 10 calendar days of calling in your appeal.)
Send Your Written Appeals Here

For appeal requests for medical services: WellCare of South Carolina Attn: Appeals Department P.O. Box 31368 Tampa, FL 33631-3368 Fax to: 1-866-201-0657 For appeal requests for pharmacy medications: WellCare of South Carolina Attn: Pharmacy Medication Appeals Department P.O. Box 31398 Tampa, FL 33631-3398 Fax to: 1-888-865-6531
You can file your appeal yourself. Or you can have someone (a family member or friend) file it for you. We must have your written permission before they can file an appeal for you. Your PCP or another provider can also file an appeal for you. That provider must have a record of your written permission to file the appeal. (The provider does not need to include this record when filing the appeal.) We can help you file an appeal as well. You can send us an appeal request after 30 calendar days. But you will need to show good cause for us to accept it. Examples of good cause can be: You didnt personally get our NOA or it came to you late You were very sick and unable to file your appeal on time
There was a death or serious illness in your immediate family An accident caused important records to be destroyed Documentation was hard to locate within the time limit You had incorrect or incomplete information concerning our appeals process Well send you a letter within 5 business days of getting your appeal. Itll let you know we received your appeal. We will review your appeal and send you a decision letter within 30 calendar days. You or your authorized representative can review the information we used to make our decision.
Expedited or Fast Appeals

There may be times when you or your provider will want us to make a faster appeal decision. This could be because you or your provider thinks that waiting 30 calendar days could seriously harm your health. If so, you can ask for an expedited or fast appeal. You or your provider must call or fax us to ask for a fast appeal. Our fax numbers are 1-866-201-0657 (for a medical appeal) and 1-888-865-6531 (for a pharmacy appeal). If your appeal request is filed verbally, written notice is not needed. If we decide you need a fast appeal, well call you with our decision. Well also send you a letter with our decision within 72 hours. If you ask for a fast appeal and we decide that one is not needed, we will: Change the appeal to the timeframe for a standard decision (30 calendar days) Make reasonable efforts to call you Follow up with a written letter within 2 calendar days Tell you over the phone and in writing that you may file a grievance about the denial of the fast appeal request
Additional Information
You or someone appealing for you can give us more information if you think it will help your appeal. You can do this by mail or in person. You can also ask to see the records in your appeal. You can do this at any time during the appeal process. You may ask us for up to 14 more calendar days to provide more information. We also may ask for 14 more calendar days to make a decision. We will do this if we think more information is needed and its in your best interest.
YOUR HEALTH PLAN
State Fair Hearings

You have the right to ask for a State Fair Hearing. This can only be done after our appeal decision. But you must ask for it within 30 calendar days of when you get our appeal decision letter. If your provider is going to represent you at the State Fair Hearing, he or she must get your signature in advance to authorize this. The provider cannot require you to appoint him or her as the representative as a condition of receiving services. To request a State Fair Hearing, write to: South Carolina Department of Health and Human Services Division of Appeals and Hearings P.O. Box 8206 Columbia, SC 29202-8206 By phone, call 1-800-763-9087. Remember, for a State Fair Hearing: You must request it within 30 calendar days of getting our appeal decision letter You can only request it after our appeal decision
Continuation of Benefits During the Appeals Process

You can ask that we continue to cover your medical services during the appeals process. To do this: You must file your appeal with us within 10 calendar days of our mailing the Notice of Action (NOA) to you or the date the service will be reduced, suspended or stopped Your appeal or request for a State Fair Hearing must involve an action were taking to reduce, suspend or stop a service we had already approved The service must have been ordered by an authorized provider The original time period covered by the approval we gave must not have ended You must ask for a continuation of benefits
If the State Fair Hearing is decided in your favor, well approve and pay for the care that is needed as quickly as possible. (This is if you didnt receive the care during the review of your case.) If our original appeal decision (to deny your appeal) remains the same, you may have to pay for the service(s) you received while waiting for the decision.
YOUR HEALTH PLAN
Important Member Information
Important Member Information
In this section, well touch on our enrollment and disenrollment processes. If you have any questions, call us. The number is 1-888-588-9842 (TTY/TDD 1-877-247-6272).
Remember to Renew Your Eligibility with the South Carolina Department of Health and Human Services (SCDHHS)
Youll receive a Medicaid review form from SCDHHS. Itll be sent when it is time to renew your eligibility. This form will tell you what you need to do and by what date. Be sure to provide all of the paperwork thats required. Here are some of the items you may need: Your Social Security number Information like your pay stub, child support, bank account details and other insurance you may have (through your job) Your monthly expenses (such as electric and phone bills) Remember: renew your eligibility with SCDHHS. If you dont, you may lose your WellCare benefits.
You can renew in these ways:

Fill out your Medicaid review form and return it as instructed Call SCDHHS at 1-888-549-0820 If you have any questions, give us a call. Or you can call SCDHHS at the number above.
IMPORTANT MEMBER INFORMATION
Enrollment
WellCare serves kids and adults who are eligible for South Carolinas Medicaid program. This program provides health plans for select groups of kids and adults with low incomes. A person must meet certain requirements for Medicaid. SCDHHS decides who is eligible. You must verify that you are still eligible for Medicaid every year. Youll get a Medicaid review form in the mail 60 days prior to your annual review date. Complete the form and return it to the SCDHHS eligibility office in your county.
Open Enrollment
You start a 12-month membership after you enroll or the State enrolls you in a health plan. You have 90 days to try the plan and change plans. At the end of 90 days, youll stay in your plan for the next 9 months before you can change plans again. After 9 months, youll be able to change plans as long as you are still eligible for Medicaid. This is called your Enrollment Anniversary. Outside your Enrollment Anniversary period, you will only be able to change plans if there is a good reason to do so. This is called having a good cause to change plans. A good cause could include: Moving out of your health plans service region Moral or religious reasons Requesting to be on the same health plan as other family members Poor quality of care Change of eligibility
Its important that you tell us and SCDHHS when you move. That way your Medicaid review form is sent to the right address. Make sure you complete this form. And do it quickly. If you dont, your WellCare benefits could end.
Reinstatement
If you lose your Medicaid eligibility and get it back within 60 days, the State will put you back in our plan. Well send you a letter within 10 days after you become a member again. You can choose your same PCP or pick a different one.
Disenrollment
Voluntary Disenrollment
You may ask to cancel your WellCare membership and change to another health plan during the first 90 days. You can do this without cause. This means you do not need a valid reason for doing so. Call South Carolina Healthy Connections Choices. Their tollfree number is 1-877-552-4642 (TTY/TDD 1-877-552-4670). Disenrolling from WellCare and changing to another plan will not affect your Medicaid eligibility. Instead, youll get Medicaid benefits from a new health plan. You may still file an appeal or grievance even if you have left our plan.
Involuntary Disenrollment
You may lose your WellCare membership if you: Go into a nursing home for more than 90 continuous days (if this happens, youll go back to Medicaid fee-for-service) Are placed in a state institution or into a place for the mentally handicapped Commit fraud or abuse health care services Act in a disruptive way and this attitude/behavior is not caused by a known illness Lose your Medicaid eligibility or can no longer be a member Move out of state Go on hospice Turn 65 or older Become eligible for Medicare Choose to participate in a home- or community-based waiver program Get insurance from a commercial health plan Go to jail You cannot be taken out of our plan for these reasons: Medical problems from before you were a member A change in your health Reduced mental capacity Disruptive behavior because of your special needs The amount of services you use Missed medical appointments Not following your PCPs plan for your care southcarolina.wellcare.com | 54
Important Information about WellCare

Here well talk about some of the things we do behind the scenes. Call us with your questions. We can be reached at 1-888-588-9842 (TTY/TDD 1-877-247-6272). Were available Monday through Friday, 8 a.m. to 5 p.m.
Plan Structure/Operations and How Our Providers Are Paid

You may have other questions about how our plan works. Questions like: Whats the make-up of our company? How do we run our business? How do we pay the providers who are in our network? Does how we pay our providers affect the way they authorize a service for you? Do we offer rewards to the providers in our network? If you do, call us and well answer them for you.
Evaluation of New Technology

We study new technology every year. Plus, we look at the ways we use the technology we already have. We do this for a few reasons. They are to: Make sure were aware of changes in the industry See how new improvements can be used with the services we provide to our members Make sure that our members have fair access to safe and effective care We review the following areas: Behavioral health procedures Medical devices Medical procedures Pharmaceuticals
Quality Improvement and Member Satisfaction

Were always looking at ways to improve care and service for our members. Each year we select certain things to review for quality. We check to see how were doing in those areas. We may also check to see how our providers are doing in those same areas. We want to know if our members are happy with the care and services they get. Want to know about our quality ratings? Give us a call. You can ask about how satisfied members are with our plan too. You can also provide comments or suggestions about: How were doing How we can improve on our services
Fraud, Waste and Abuse

Billions of dollars are lost to health care fraud each year. What is health care fraud, waste and abuse? Its when false information is given on purpose. This can be done by a member or provider. This false information can lead to someone getting a service or benefit that is not allowed. Here are some other examples of provider and member fraud, waste and abuse: Billing for a more expensive service than what was actually given Billing more than once for the same service Billing for services you did not get Falsifying a patients diagnosis to justify tests, surgeries or other procedures that arent medically necessary Filing claims for services or medications not received Forging or altering bills or receipts Misrepresenting procedures performed to get payment for services that are not covered Sharing your own WellCare ID card with another person Using someone elses WellCare ID card Waiving patient co-pays or deductibles
To Report Fraud, Waste or Abuse with WellCare

If you know of any fraud that has occurred, call our 24-hour fraud hotline. The toll-free number is 1-866-678-8355. Its also private. You can leave a message without leaving your name. If you do leave a number, well call you back. Well call to make sure the information we have is complete and accurate. You can also report fraud on our website. Go to southcarolina.wellcare.com. Giving a report through the Web is private too.
To Report Fraud, Waste or Abuse with South Carolina Medicaid

To report suspected fraud, waste or abuse in South Carolina Medicaid: Call the SCDHHS Hotline toll-free at 1-888-364-3224, or Send an email to fraudres@scdhhs.gov
Member Rights
As our member, you have the right to: Get information about our plan, services, doctors and other health care providers As our member, you have certain rights and Get information about your rights and responsibilities. responsibilities Know the names and titles of doctors and other health providers caring for you Be treated with respect and due consideration for your dignity and privacy Have your privacy protected in accordance with the privacy requirements in 45 CFR parts 160 and 164 subparts A and E, to the extent that they are applicable Decide with your doctor on the care you get Talk openly about care you need for your health, no matter the cost or benefit coverage, and the treatment choices and risks involved (the information must be given in a way you understand) Have the risks, benefits and side effects of medications and other treatments explained to you Know about your health care needs after you get out of the hospital or leave the doctors office Refuse care, as long as you agree to be responsible for your decision Refuse to take part in any medical research File a grievance or an appeal about our plan or the care we provide; also, to know that if you do, it will not change how you are treated Not be responsible for our debts in the event of bankruptcy and not be held liable for: Covered services provided to you for which the government does not pay us Covered services provided to you for which the government or we do not pay the provider who furnished the services Payments of covered services under a contract, referral or other arrangement to the amount those payments are in excess of the amount you would owe if we provided the services directly
Be free from any form of restraint or seclusion used as a means of force, discipline, convenience or revenge, as specified in the federal regulations on the use of restraints and seclusion Ask for and get a copy of your medical records from your doctor; also, to ask that the records be changed/corrected if needed Requests must be received in writing from you or the person you choose to represent you The records will be provided at no cost They will be sent within 14 days of receipt of the request Have your records kept private Make your health care wishes known through advance directives Have a say in our member rights Appeal medical or administrative decisions by using our grievance and appeals process Exercise these rights no matter your sex, age, race, ethnicity, income, education or religion Have our staff observe your rights Have all the above rights apply to the person legally able to make decisions about your health care Be furnished quality services in accordance with 42 CFR 438.206 through 438.210, including: Accessibility Authorization standards Availability Coverage Coverage outside of network The right to a second opinion Receive health care services that are accessible, are comparable in amount, duration and scope to those provided under Medicaid fee-for-service and are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished Receive services that are appropriate and are not denied or reduced solely because of diagnosis, type of illness, or medical condition Receive all information, including but not limited to enrollment notices,
informational materials, instructional materials, available treatment options and alternatives in a manner and format that may be easily understood Receive assistance from both SCDHHS and us in understanding the requirements and benefits of our plan Receive oral interpretation services free of charge for all non-English languages, not just those identified as prevalent Be notified that oral interpretation is available and how to access those services As a potential member, to receive information about the basic features of managed care Which populations may or may not enroll in the program Our responsibilities for coordination of care in a timely manner in order to make an informed choice Receive information on our services, to include but not limited to: Benefits covered Procedures for obtaining benefits, including any authorization requirements Any cost-sharing requirements Service area Names, locations, telephone numbers of and non-English language spoken by current contracted providers, including at a minimum, primary care providers (PCPs), specialists and hospitals Any restrictions on your freedom of choice among network providers Providers not accepting new patients Benefits not offered by our plan but available to you and how to obtain those benefits, including how transportation is provided Receive a complete description of disenrollment rights at least annually Receive notice of any significant changes in the benefits package at least 30 calendar days before the intended effective date of the change Receive information on the grievance, appeal and State Fair Hearing procedures Receive detailed information on emergency and after-hours coverage, to include but not limited to: What constitutes an emergency medical condition, emergency services and poststabilization services That emergency services do not require prior authorization
The process and procedures for obtaining emergency services The locations of any emergency settings and other locations at which providers and hospitals furnish emergency services and post-stabilization services covered under our contract with SCDHHS Your right to use any hospital or other setting for emergency care Post-stabilization care services rules as detailed in 42 CFR 422.113(c) Receive our policy on referrals for specialty care and other benefits not provided by your PCP Exercise these rights without adversely affecting the way we, our providers or SCDHHS treat you
Member Responsibilities
As our member, you have the responsibility to: Read your member handbook to understand how our plan works Carry your member ID card at all times Give information that we and your doctors and providers need to give care Follow plans and instructions for care that you have agreed on with your doctor Understand your health problems Help set treatment goals that you and your doctor agree to Carry your Medicaid card at all times Show your member ID card to each provider Schedule appointments for all non-emergency care through your doctor Get a referral from your doctor for specialty care Cooperate with the people who provide your health care Be on time for appointments Tell the doctors office if you need to cancel or change an appointment Pay your co-payments to providers Respect the rights of all providers Respect the property of all providers Respect the rights of other patients Not be disruptive in your doctors office Know the medicines you take, what they are for and how to take them the right way Make sure your doctor has copies of all your previous medical records Let us know within 48 hours, or as soon as possible, if you are admitted to the hospital or get emergency room care Be responsible for cost-sharing only as specified under covered services co-payments
WellCare Notice of Privacy Practices WellCare Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. This notice describes how medical Please review itinformation carefully. about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Effective Date of this Privacy Notice: March 29, 2012 Revised as of May 14, 2013 Effective Date of this Privacy Notice: March 29, 2012 We are required by law to protect the privacy information that may reveal your Revised as of of health May 14, 2013 identity. We are also required by law to provide you with a copy of this Privacy Notice which We are required by law to protect the privacy ofprivacy health information reveal your describes our legal duties and health information practices, as that well may as the rights you identity. We are also required by law to provide you with a copy of this Privacy Notice which have with respect to your health information. describes our legal duties and health information privacy practices, as well as the rights you have with respect to your health information. This Privacy Notice applies to the following WellCare entities: Easy Choice Plan, Inc. applies to the WellCare Health Plans of New Jersey, Inc. ThisHealth Privacy Notice following WellCare entities: Exactus Pharmacy Solutions, WellCare of Connecticut, WellCare Health Plans ofInc. New Jersey, Inc. Easy Choice Health Plan, Inc.Inc. Harmony Health Plan of Illinois, Inc. WellCare of Florida, Inc. Inc. WellCare of Connecticut, Exactus Pharmacy Solutions, Inc. Harmony of Georgia, WellCare of Florida, Inc. Inc. HarmonyHealth HealthPlan Planof ofIllinois, Illinois,Inc., Inc. d/b/a WellCare Harmony Health Plan of Missouri WellCare of Louisiana, WellCare of Georgia, Inc. Inc. Harmony Health Plan of Illinois, Inc., d/b/a Missouri Care, Incorporated Harmony Health Plan of Missouri WellCare of New York, Inc. WellCare of Louisiana, Inc. WellCare Health Insurance of Arizona, Inc., Missouri Care, Incorporated WellCare of Ohio, WellCare of NewInc. York, Inc. operating as Ohana Health Plan, Inc. WellCare Health Insurance of Arizona, Inc., WellCare of South Inc. WellCare of Ohio,Carolina, Inc. WellCare Health Insurance of Illinois, Inc. operating as Ohana Health Plan, Inc. WellCare of Texas, Inc., operating WellCare of South Carolina, Inc. in Arizona WellCare Health Insurance of Illinois, Inc., WellCare Health Insurance Company of as WellCare of Arizona, Inc. d/b/a WellCare of Kentucky, Inc. WellCare of Texas, Inc., operating in Kentucky, Inc. WellCare Prescription Insurance, Arizona as WellCare of Arizona,Inc. Inc. WellCare Health Plans of New York, Inc. WellCare Health Insurance Company WellCare Prescription Insurance, Inc. of Kentucky, Inc., d/b/a WellCare of Kentucky, Inc. Wemay change our privacy practices fromInc. time to time. If we make any material revisions to this WellCare Health Plans of New York, Privacy Notice, we will provide you with a copy of the revised Privacy Notice which will specify the date on which such revised Privacy Notice becomes effective. The revised Privacy Notice will We may change our privacy practices from time to time. we of make material revisions to this apply to all of your health information and after the If date theany Privacy Notice. Privacy Notice, we will provide you with a copy of the revised Privacy Notice which will specify the date on which such revised Privacy Notice becomes effective. The revised Privacy Notice will apply to all of your health information from and after the date of the Privacy Notice. 5400753101
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How We May Use and Disclose Your Health Information Without Written Authorization
WellCare requires its employees to follow its privacy and security policies and procedures to protect your health information in oral (for example, when discussing your health information with authorized individuals over the telephone or in person), written or electronic form. The following are situations where we do not need your written authorization to use your health information or to share it with others. 1. Treatment, Payment, and Business Operations. We may use your health information or share it with others to help treat your condition, coordinate payment for that treatment, and run our business operations. For example: Treatment. We may disclose your health information to a health care provider that provides treatment to you. We may use your information to notify a physician who treats you of the prescription drugs you are taking. Payment. We will use your health information to obtain premium payments, specialty pharmacy payments, or to fulfill our responsibility for coverage and the provision of benefits under a health plan, such as processing a physician claim for reimbursement for services provided to you. Health Care Operations. We may also disclose your health information in connection with our health care operations. These include fraud, waste and abuse detection and compliance programs, customer service and resolution of internal grievances. Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose your health information to tell you about treatment options or alternatives, appointment reminders, and health-related benefits or services that may be of interest to you. Underwriting. We may use or disclose your health information for certain underwriting purposes. However, we will not use or disclose your genetic information for underwriting purposes. Family Members, Relatives or Close Friends Involved in Your Care. Unless you object, we may disclose your health information to your family members, relatives or close personal friends identified by you as being involved in your treatment or payment for your medical care. If you are not present to agree or object, we may exercise our professional judgment to determine whether the disclosure is in your best interest. If we decide to disclose your health information to your family member, relative or other individual identified by you, we will only disclose the health information that is relevant to your treatment or payment. Business Associates. We may disclose your health information to a business associate that needs the information in order to perform a function or service for our business operations. We will do so only if the business associate signs an agreement to protect the privacy of your health information. Third party administrators, auditors, lawyers, and consultants are some examples of business associates. southcarolina.wellcare.com | 64
2. Public Need. We may use your health information, and share it with others, in order to comply with the law or to meet important public needs that are described below: if we are required by law to do so; to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities; to government agencies authorized to conduct audits, investigations, and inspections, as well as civil, administrative or criminal investigations, proceedings, or actions, including those agencies that monitor programs such as Medicare and Medicaid; to a public health authority if we reasonably believe you are a possible victim of abuse, neglect or domestic violence; to a person or company that is regulated by the Food and Drug Administration for: (i) reporting or tracking product defects or problems, (ii) repairing, replacing, or recalling defective or dangerous products, or (iii) monitoring the performance of a product after it has been approved for use by the general public; if ordered by a court or administrative tribunal to do so, or pursuant to a subpoena, discovery or other lawful request by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain a court order protecting the information from further disclosure; to law enforcement officials to comply with court orders or laws, and to assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person; to prevent a serious and imminent threat to your health or safety, or the health or safety of another person or the public, which we will only share with someone able to help prevent the threat; for research purposes; to the extent necessary to comply with workers compensation or other programs established by law that provide benefits for work-related injuries or illness without regard to fraud; to appropriate military command authorities for activities they deem necessary to carry out their military mission; to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials; to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety, security and good order at the place where you are confined; in the unfortunate event of your death, to a coroner or medical examiner, for example, to determine the cause of death; to funeral directors as necessary to carry out their duties; and in the unfortunate event of your death, to organizations that procure or store organs, eyes or other tissues so that these organizations may investigate whether donation or transplantation is possible under law.
3. Completely De-Identified and Partially De-Identified Information. We may use and disclose completely de-identified health information about you if we have removed any information that has the potential to identify you. We may also use and disclose partially de-identified health information about you for public health and research purposes, or for business operations, if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified health information will not contain any information that would directly identify you (such as your name, street address, Social Security number, phone number, fax number, electronic mail address, Web site address, or license number).
Requirement for Written Authorization

We may use your health information for treatment, payment, health care operations or other purposes described in this Privacy Notice. You may also give us written authorization to use your health information or to disclose it to anyone for any purpose. We cannot use or disclose your health information for any reason, except those described in this Privacy Notice, unless you give us a written authorization to do so. For example, we require your written authorization for most uses and disclosures of psychotherapy notes (where appropriate), uses and disclosures of health information for marketing purposes, and disclosures that constitute a sale of your health information. Marketing is a communication about a product or service that encourages recipients of the communication to purchase or use the product or service. You may revoke your authorization in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.
Your Rights to Access and Control Your Health Information

We want you to know that you have the following rights to access and control your health information.
1. Right to Access Your Health Information. You have the right to inspect and obtain a copy of your health information except for health information: (i) contained in psychotherapy notes; (ii) compiled in anticipation of, or for use in, a civil, criminal, or administrative proceeding; and (iii) with some exceptions, information subject to the Clinical Laboratory Improvements Amendments of 1988 (CLIA). If we use or maintain an electronic health record (EHR) for you, you have the right to obtain a copy of your EHR in electronic format. You also have the right to direct us to send a copy of your EHR to a third party that you clearly designate. If you would like to access your health information, please send your written request to the address listed on the last page of this Privacy Notice. We will ordinarily respond to your request within 30 days if the information is located in our facility, and within 60 days if it is located off-site at another facility. If we need additional time to respond, we will let you know as soon as possible. We may charge you a reasonable, cost-based fee to cover copy costs and postage. If you request a copy of your EHR, we will not charge you any more than our labor costs in producing the EHR to you. We may not give you access to your health information if it: (i) is reasonably likely to endanger the life and physical safety of you or someone else as determined by a licensed health care professional; (ii) refers to another person and a licensed health care professional determines that your access is likely to cause harm to that person; or (iii) a licensed health care professional determines that your access as the representative of another person is likely to cause harm to that person or any other person. If you are denied access for one of these reasons, you are entitled to a review by a health care professional, designated by us, who was not involved in the decision to deny access. If access is ultimately denied, you will be entitled to a written explanation of the reasons for the denial. 2. Right to Amend Your Health Information. If you believe we have health information about you that is incorrect or incomplete, you may request in writing an amendment to your health information. If we do not have your health information, we will give you the contact information of someone who does. You will receive a response within 60 days after we receive your request. If we did not create your health information or your health information is already accurate and complete, we can deny your request and notify you of our decision in writing. You can also submit a statement that you disagree with our decision, which we can rebut. You have the right to request that your original request, our denial, your statement of disagreement, and our rebuttal be included in future disclosures of your health information.
3. Right to Receive an Accounting of Disclosures. You have the right to receive an accounting of disclosures of your health information made by us and our business associates. You may request such information for the six-year period prior to the date of your request. Accounting of disclosures will not include disclosures: (i) for payment, treatment or health care operations; (ii) made to you or your personal representative; (iii) that you authorized in writing; (iv) made to family and friends involved in your care or payment for your care; (v) for research, public health or our business operations; (vi) made to federal officials for national security and intelligence activities; (vii) made to correctional institutions or law enforcement; and (viii) of an incident related to a use or disclosure otherwise permitted or required by law. If you would like to receive an accounting of disclosures, please write to the address listed on the last page of this Privacy Notice. If we do not have your health information, we will give you the contact information of someone who does. You will receive a response within 60 days after your request is received. You will receive one request annually free of charge, but we may charge you a reasonable, cost-based fee for additional requests within the same twelve-month period. 4. Right to Request Additional Privacy Protections. You have the right to request that we place additional restrictions on our use or disclosure of your health information. If we agree to do so, we will put these restrictions in place except in an emergency situation. We do not need to agree to the restriction unless (i) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and (ii) the health information relates only to a health care item or service that you or someone on your behalf has paid for out of pocket and in full. You have the right to revoke the restriction at any time. 5. Right to Request Confidential Communications. You have the right to request that we communicate with you about your health information by alternative means or via alternative locations. If you wish to receive confidential communications via alternative means or locations, please submit your written request to the address listed on the last page of this Privacy Notice. You must clearly state in your request that the disclosure of your health information could endanger you and list how or where you wish to receive communications.
6. Right to Notice of Breach of Unencrypted Health Information. We are required by law to maintain the privacy of your health information, and to provide you with this Privacy Notice containing our legal duties and privacy practices with respect to your protected health information. Our policy is to encrypt our electronic files containing your health information so as to protect the information from those who should not have access to it. If, however, for some reason we experience a breach of your unencrypted health information, we will notify you of the breach. If we have more than ten people that we cannot reach because of outdated contact information, we will post a notification either on our Web site (www.wellcare.com) or in a major media outlet in your area. 7. Right to Obtain a Paper Copy of this Notice. You have the right at any time to obtain a paper copy of this Privacy Notice, even if you receive this Privacy Notice electronically. Please send your written request to the address listed on this page of this Privacy Notice or visit our Web site at www.wellcare.com.
Miscellaneous
1. Contact Information. If you have any questions about this Privacy Notice, you may contact the Privacy Officer at 1-888-240-4946 (TTY/TDD 1-877-247-6272), call the toll-free number listed on the back of your membership card, visit www.wellcare.com, or write to us at: WellCare Health Plans, Inc. Attention: Privacy Officer P.O. Box 31386 Tampa, FL 33631-3386 2. Complaints. If you are concerned that we may have violated your privacy rights, you may complain to us using the contact information above. You also may submit a written complaint to the U.S. Department of Health and Human Services. If you choose to file a complaint, we will not retaliate or take action against you for your complaint. 3. Additional Rights. This Privacy Notice explains the rights you have with respect to your health information, including access and amendment rights, under federal law. Some state laws provide even greater rights, including more favorable access and amendment rights, as well as more protection for particularly sensitive information, such as information involving HIV/AIDS, mental health, alcohol and drug abuse, sexually transmitted diseases, and reproductive health. To the extent the law in the state where you reside affords you greater rights than described in this Privacy Notice, we will comply with these laws.
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