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Medicare : Coverage Decisions, Exceptions, Appeals and Complaints

Our plan must honor your rights as a member of the plan. As a WellCare member, you have the right:
 

  • To receive information in a way that works best for you (in languages other than English, in Braille, in large print, or other alternative formats, etc.).
  • To be treated with fairness, respect, and dignity at all times.
  • To receive timely access to your covered services and drugs, as applicable.
  • To have the privacy of your personal health information protected.
  • To receive information about our organization, your plan, its network providers and covered services.
  • To participate with practitioners in making decisions about your healthcare.
  • To make complaints, or appeals, and to ask us to reconsider decisions we have made.
  • To a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
  • To make recommendations, as well as get more information, about WellCare’s member rights and responsibilities policy.

 

What are your responsibilities?
 

  • Get familiar with your covered services and the rules you must follow to get these covered services.
  • If you have any other health insurance coverage, or prescription drug coverage, in addition to our plan, you are required to tell us.
  • Tell your doctor and other health care providers that you are enrolled in our plan.
  • Help your plan, doctors and other providers help you by giving them information, asking questions, and following through on your care.
  • Understand your health problems and participate in developing mutually agreed-upon treatment goals.
  • Follow the treatment plans and instructions for care that you and your doctors agreed upon.
  • Be considerate.
  • Pay what you owe.
  • Tell us if you move.
  • Call Customer Service for help if you have questions or concerns.

 

You also have certain Rights and Responsibilities upon disenrollment. If you disenroll, remember the following during the disenrollment process:
 

  • Until your membership ends, you must continue getting your medical service and drugs through our plan, as applicable.
  • If your WellCare plan includes prescription drug coverage, you should continue to use our network pharmacies to get your prescription drugs filled until your membership in our plan ends.
  • If you are hospitalized on the day that your membership ends, you will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins).
  • We cannot ask you to leave our plan for any reason related to your health.
  • You have the right to make a complaint if we end your membership in our plan.

 

WellCare must end your membership in the plan if any of the following happen:
 

  • If you do not stay continuously enrolled in Medicare Part A and Part B.
  • If you move out of our service area.
  • If you are away from our service area for more than six months (If you move or take a long trip, you need to call Customer Service to find out if the place you are moving or traveling to is in our plan's area.).
  • If you become incarcerated (go to prison).
  • If your WellCare plan includes prescription drug coverage and you lie or withhold information about other insurance you have that provides prescription drug coverage.
  • If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan (We cannot make you leave our plan for this reason unless we get permission from Medicare first.).
  • If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan (We cannot make you leave our plan for this reason unless we get permission from Medicare first.).
  • If you let someone else use your membership card to get prescription drugs (We cannot make you leave our plan for this reason unless we get permission from Medicare first. However, if we end your membership because of this reason, Medicare may have your case investigated by the Inspector General.).
  • If your WellCare plan includes prescription drug coverage and you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare may disenroll you from our plan and you may lose your prescription drug coverage.

 

For more information on Member Rights and Responsibilities including disenrollment procedures and situations, please review our Evidence of Coverage


Y0070_NA023899_WCM_WEB_ENG CMS Approved


Last modified: 12/02/2013

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