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Rights and Responsibilities

SECTION 1 Our plan must honor your rights as a member of the plan

Section 1.1 We must provide information in a way that works for you (in languages other than English, in Braille, or other alternate formats, etc.)

To get information from us in a way that works for you, please call Customer Service (phone numbers are printed on the back cover of your EOC).

Our plan has free language interpreter services available to answer questions from non-English speaking members. We also have materials available in languages other than English that are spoken in the plan’s service area. We can also give you information in Braille or other alternate formats if you need it. If you are eligible for Medicare because of a disability, we are required to give you information about the plan’s benefits that is accessible and appropriate for you.

If you have any trouble getting information from our plan because of problems related to language or disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and tell them that you want to file a complaint. TTY users call 1-877-486-2048.

Section 1.2 We must treat you with fairness, respect, and dignity at all times

Our plan must obey laws that protect you from discrimination or unfair treatment.

We do not discriminate based on a person’s race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area.

If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services’ Office for Civil Rights 1-800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights.

If you have a disability and need help with access to care, please call us at Customer Service (phone numbers are printed on the back cover of your EOC). If you have a complaint, such as a problem with wheelchair access, Customer Service can help.

Section 1.3 We must ensure that you get timely access to your covered services and drugs

As a member of our plan, you have the right to choose a primary care provider (PCP) in the plan’s network to provide and arrange for your covered services (In your EOC, Chapter 3 explains more about this). Call Customer Service to learn which doctors are accepting new patients (phone numbers are printed on the back cover of your EOC). You also have the right to go to a women’s health specialist (such as a gynecologist) without a referral.

As a plan member, you have the right to get appointments and covered services from the plan’s network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays.

If you think that you are not getting your medical care or Part D drugs within a reasonable amount of time, Chapter 9, Section 11 of your EOC tells what you can do. (If we have denied coverage for your medical care or drugs and you don’t agree with our decision, Chapter 9, Section 5 of your EOC tells what you can do.)

Section 1.4 We must protect the privacy of your personal health information

Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.

Your “personal health information” includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information.

The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice”, that tells about these rights and explains how we protect the privacy of your health information.

How do we protect the privacy of your health information?

We make sure that unauthorized people don’t see or change your records.

In most situations, if we give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you.

There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law. For example, we are required to release health information to government agencies that are checking on quality of care.

Because you are a member of our plan through Medicare, we are required to give Medicare your health information including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to federal statutes and regulations.

You can see the information in your records and know how it has been shared with others

You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your health care provider to decide whether the changes should be made.

You have the right to know how your health information has been shared with others for any purposes that are not routine.

If you have questions or concerns about the privacy of your personal health information, please call Customer Service (phone numbers are printed on the back cover of your EOC).

WellCare Notice of Privacy Practices[SFF2]

This notice describes how medical information 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 August, 2013

We are required by law to protect the privacy of health information that may reveal your identity. We are also required by law to provide you with a copy of this Privacy Notice which 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 Health Plan, Inc.
  • Exactus Pharmacy Solutions, Inc.
  • Harmony Health Plan of Illinois, Inc.
  • Harmony Health Plan of Illinois, Inc., operating in Missouri as Harmony Health Plan of Missouri
  • Missouri Care, Incorporated
  • WellCare Health Insurance of Arizona, Inc., operating in Hawai‘i as ‘Ohana Health Plan, Inc.
  • WellCare Health Insurance Company of Kentucky, Inc., operating in Kentucky as WellCare of Kentucky, Inc.
  • WellCare Health Plans of New Jersey, Inc.
  • WellCare of Connecticut, Inc.
  • WellCare of Florida, Inc., operating in Florida as HealthEase and Staywell
  • WellCare of Georgia, Inc.
  • WellCare of Louisiana, Inc.
  • WellCare of New York, Inc.
  • WellCare of Ohio, Inc.
  • WellCare of South Carolina, Inc.
  • WellCare of Texas, Inc., operating in Arizona as WellCare of Arizona, Inc.
  • WellCare Prescription Insurance, Inc.
  • Windsor Health Plan, Inc.
  • Sterling Life Insurance Company

We may change our privacy practices from time to time. If we make any material revisions to this 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.

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.

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 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.

Section 1.5 We must give you information about the plan, its network of providers, and your covered services and your rights and responsibilities

As a member of our plan, you have the right to get several kinds of information from us. (As explained in Section 1.1, you have the right to get information from us in a way that works for you. This includes getting the information in languages other than English and in Braille or other alternate formats.)

If you want any of the following kinds of information, please call Customer Service (phone numbers are printed on the back cover of your EOC):

  • Information about our plan. This includes, for example, information about the plan’s financial condition. It also includes information about the number of appeals made by members and the plan’s performance ratings, including how it has been rated by plan members and how it compares to other Medicare health plans.
  • Information about our network providers including our network pharmacies.
    • For example, you have the right to get information from us about the qualifications of the providers and pharmacies in our network and how we pay the providers in our network.
    • For a list of the providers and pharmacies in the plan’s network, see the Provider & Pharmacy Directory.
    • For more detailed information about our providers or pharmacies, you can call Customer Service (phone numbers are printed on the back cover of your EOC).[SFF3] 
  • Information about your coverage and the rules you must follow when using your coverage.
    • In Chapters 3 and 4 of your EOC, we explain what medical services are covered for you, any restrictions to your coverage, and what rules you must follow to get your covered medical services.
    • To get the details on your Part D prescription drug coverage, see Chapters 5 and 6 of your EOC plus the plan’s List of Covered Drugs (Formulary). These chapters, together with the List of Covered Drugs (Formulary), tell you what drugs are covered and explain the rules you must follow and the restrictions to your coverage for certain drugs.
    • We look at new technology when requested by a member. The findings are reviewed annually to determine how new advancements can be included in the benefits that members receive, to make sure that members have fair access to safe and effective care, and to make sure that we are aware of changes in the industry. New technology may include behavioral health procedures, medical devices, medical procedures, and pharmaceuticals, for example.
    • If you have questions about the rules or restrictions, please call Customer Service (phone numbers are printed on the back cover of your EOC).
  • Information about why something is not covered and what you can do about it.
    • If a medical service or Part D drug is not covered for you, or if your coverage is restricted in some way, you can ask us for a written explanation. You have the right to this explanation even if you received the medical service or drug from an out-of-network provider or pharmacy.
    • If you are not happy or if you disagree with a decision we make about what medical care or Part D drug is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appeal. For details on what to do if something is not covered for you in the way you think it should be covered, see Chapter 9 of your EOC. It gives you the details about how to make an appeal if you want us to change our decision. (Chapter 9 also tells about how to make a complaint about quality of care, waiting times, and other concerns.)
    • If you want to ask our plan to pay our share of a bill you have received for medical care or a Part D prescription drug, see Chapter 7 of your EOC.

Section 1.6 We must support your right to make decisions about your care

You have the right to know your treatment options and participate in decisions about your health care

You have the right to get full information from your doctors and other health care providers when you go for medical care. Your providers must explain your medical condition and your treatment choices in a way that you can understand.

You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following:

  • To know about all of your choices. This means that you have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. It also includes being told about programs our plan offers to help members manage their medications and use drugs safely.
  • To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments.
  • The right to say “no.” You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to stop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full responsibility for what happens to your body as a result.
  • To receive an explanation if you are denied coverage for care. You have the right to receive an explanation from us if a provider has denied care that you believe you should receive. To receive this explanation, you will need to ask us for a coverage decision. Chapter 9 of your EOC tells how to ask the plan for a coverage decision.

You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself

Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in one of these situations. This means that, if you want to, you can:

  • Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself.
  • Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself.

The legal documents that you can use to give your directions in advance in these situations are called “advance directives.” There are different types of advance directives and different names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives.

If you want to use an “advance directive” to give your instructions, here is what to do:

  • Get the form. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare.
  • Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it.
  • Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can’t. You may want to give copies to close friends or family members as well. Be sure to keep a copy at home.

If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital.

  • If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you.
  • If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.

Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive.

What if your instructions are not followed?

If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with Florida Department of Health.

Section 1.7 You have the right to make complaints and to ask us to reconsider decisions we have made

If you have any problems or concerns about your covered services or care, Chapter 9 of your EOC tells what you can do. It gives the details about how to deal with all types of problems and complaints.

As explained in Chapter 9 of your EOC, what you need to do to follow up on a problem or concern depends on the situation. You might need to ask our plan to make a coverage decision for you, make an appeal to us to change a coverage decision, or make a complaint. Whatever you do – ask for a coverage decision, make an appeal, or make a complaint – we are required to treat you fairly.

You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, please call Customer Service (phone numbers are printed on the back cover of your EOC).

Section 1.8 What can you do if you think you are being treated unfairly or your rights are not being respected?

If it is about discrimination, call the Office for Civil Rights

If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights.

Is it about something else?

If you believe you have been treated unfairly or your rights have not been respected, and it’s not about discrimination, you can get help dealing with the problem you are having:

  • You can call Customer Service (phone numbers are printed on the back cover of your EOC).
  • You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3 of your EOC.
  • Or, you can call Medicare 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Section 1.9 You have the right to make recommendations as well as get more information about your rights and responsibilities

You have the right to make recommendations regarding the plan’s member rights and responsibilities policy.

  • You can call Customer Service (phone numbers are printed on the back cover of your EOC).

You have the right to get more information about your rights.

There are several places where you can get more information about your rights:

  • You can call Customer Service (phone numbers are printed on the back cover of your EOC).
  • You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3 of your EOC.
  • You can contact Medicare.
    • You can visit the Medicare website to read or download the publication “Your Medicare Rights & Protections.”
    • Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

SECTION 2 You have some responsibilities as a member of the plan

Section 2.1 What are your responsibilities?

Things you need to do as a member of the plan are listed below. If you have any questions, please call Customer Service (phone numbers are printed on the back cover of your EOC). We’re here to help.

Get familiar with your covered services and the rules you must follow to get these covered services. Use your Evidence of Coverage (EOC) booklet to learn what is covered for you and the rules you need to follow to get your covered services.

  • Chapters 3 and 4 of your EOC give the details about your medical services, including what is covered, what is not covered, rules to follow, and what you pay.
  • Chapters 5 and 6 of your EOC give the details about your coverage for Part D prescription drugs.

If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us. Please call Customer Service to let us know (phone numbers are printed on the back cover of your EOC).

  • We are required to follow rules set by Medicare and Medicaid to make sure that you are using all of your coverage in combination when you get your covered services from our plan. This is called “coordination of benefits” because it involves coordinating the health and drug benefits you get from our plan with any other health and drug benefits available to you. We’ll help you coordinate your benefits. (For more information about coordination of benefits, go to Chapter 1, Section 7 of your EOC.)

Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card and your Medicaid card whenever you get your medical care or Part D prescription drugs.

Help your doctors and other providers help you by giving them information, asking questions, and following through on your care.

  • To help your doctors and other health providers give you the best care, learn as much as you are able to about your health problems and give them the information they need about you and your health. Follow the treatment plans and instructions that you and your doctors agree upon.
  • You have the responsibility to understand your health problems and help set treatment goals that you and your doctor agree to.
  • You have the responsibility to follow the treatment plans and instructions that you and your doctors agree upon.
  • Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and supplements.
  • If you have any questions, be sure to ask. Your doctors and other health care providers are supposed to explain things in a way you can understand. If you ask a question and you don’t understand the answer you are given, ask again.

Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor’s office, hospitals, and other offices.

Pay what you owe. As a plan member, you are responsible for these payments:

  • In order to be eligible for our plan, you must have Medicare Part A and Medicare Part B. For most WellCare Access (HMO SNP) members, Medicaid pays for your Part A premium (if you don’t qualify for it automatically) and for your Part B premium. If Medicaid is not paying your Medicare premiums for you, you must continue to pay your Medicare premiums to remain a member of the plan.
  • For most of your drugs covered by the plan, you must pay your share of the cost when you get the drug. This will be a co-payment (a fixed amount) or coinsurance (a percentage of the total cost). Chapter 6 in your EOC tells what you must pay for your Part D prescription drugs.
  • If you get any medical services or drugs that are not covered by our plan or by other insurance you may have, you must pay the full cost.
  • If you disagree with our decision to deny coverage for a service or drug, you can make an appeal. Please see Chapter 9 of your EOC for information about how to make an appeal.
  • If you are required to pay a late enrollment penalty, you must pay the penalty to keep your prescription drug coverage.
  • If you are required to pay the extra amount for Part D because of your yearly income, you must pay the extra amount directly to the government to remain a member of the plan.

Tell us if you move. If you are going to move, it’s important to tell us right away. Call Customer Service (phone numbers are printed on the back cover of your EOC).

  • If you move outside of our plan service area, you cannot remain a member of our plan. (Chapter 1 in your EOC tells about our service area.) We can help you figure out whether you are moving outside our service area. If you are leaving our service area, you will have a Special Enrollment Period when you can join any Medicare plan available in your new area. We can let you know if we have a plan in your new area.
  • If you move within our service area, we still need to know so we can keep your membership record up to date and know how to contact you.
  • If you move, it is also important to tell Social Security (or the Railroad Retirement Board). You can find phone numbers and contact information for these organizations in Chapter 2 of your EOC.

Call Customer Service for help if you have questions or concerns. We also welcome any suggestions you may have for improving our plan.

  • Phone numbers and calling hours for Customer Service are printed on the back cover of your EOC.
For more information on how to reach us, including our mailing address, please see your EOC.


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Y0700_WCM_21424E Last Updated On: 10/1/2018
Welcome Prescription Drug Plan members! We have important information to share with you about your 2019 plan. Read More. ×
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