Healthy Futures
Start with a Plan.
Member
Handbook
Advocate
WellCare Advocate
Managed Long Term Care Plan
Member Handbook
Healthy Futures Start with a Plan.
MEMBER HANDBOOK – ADVOCATE
TABLE OF CONTENTS
Welcome to WellCare Advocate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Getting Help from the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Important Things for You to Know as a New Plan Member . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Eligibility and Enrollment in the WellCare Advocate Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Services Covered by the WellCare Advocate Managed Long Term Care Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Services Not Covered by WellCare Advocate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
How Our Providers Are Paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
What Do I Do If . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Service Authorizations and Plan Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Other Decisions About Your Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Grievances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Disenrollment from the Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Member Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Member Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Information About WellCare of New York, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Notice of Privacy Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Advance Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Health Care Proxy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Health Care Proxy Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
WELCOME TO WELLCARE ADVOCATE
Welcome to the WellCare Advocate Managed Long Term Care Plan.
This plan has been specially designed for people with Medicaid who need health and supportive long-term care
services, like home care and personal care. These services help members stay in their homes and communities
for as long as possible.
As a plan member, you have more community-based service options than are available in regular Medicaid.
These options include but are not limited to: personal care services in the home, nursing services, physical and
occupational therapies and adult day health care. The services offer the help you need and make it possible for
you to be more active and independent. A Care Manager will help you and your caregivers find your way in the
health care system. A Care Manager is a health care professional, usually a nurse or a social worker. He or she
will work with your doctor. They will review your health and long-term care needs with you. They will also help
you decide on the services that will help you to be as independent and healthy as possible.
In addition, your Care Manager will:
• Approve services that are medically necessary
• Arrange and monitor the services and care that you need
• Coordinate your medical and long-term care with all of your providers
• Provide information to your doctors or to the hospital to help you get the best care
As a plan member, you need to be committed to your care. It’s important that you be active, use only the
services that you need, try to do more for yourself, and do as much as you can yourself to manage and
monitor your own chronic conditions.
This member handbook will help you understand:
• How the plan works
• The benefits that the plan provides to you
• How to request a service
• How to contact and work with your Care Manager
• How to contact Member Services
• How to file a complaint or grievance
• How to disenroll from the plan
The coverage explained in this handbook is in effect from the date you enroll in the plan. Enrollment in the
plan is voluntary.
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GETTING HELP FROM THE PLAN
If you need help from the plan, you can call your Care Manager or Member Services.
HELP FROM YOUR CARE MANAGER
Your Care Manager is your main connection to the plan. He or she will be in regular contact with you. When you
need help or have a question, call your Care Manager.
You can call your Care Manager during business hours. Call Monday through Friday, from 8 a.m. to 6 p.m. He
or she can help you arrange services, assist with a provider, coordinate care with your doctor, and answer your
questions about things like your benefits, medical care, or medicines. If your Care Manager cannot help you, then
he or she will make sure that you talk with someone who can.
My Care Manager’s Name: ______________________________________________________
Phone Number: _______________________________________________________________
Sometimes you may need to call your Care Manager after business hours, on holidays, or on weekends. At these
times, a nurse will answer the phone. The nurse may be able to answer many of your questions and assist you
if you are not feeling well. Also, the nurse will let your Care Manager and doctor (if appropriate) know that you
called, why you called, and what he or she told you to do.
HELP FROM MEMBER SERVICES
You can call Member Services Monday through Friday, from 8 a.m. to 6 p.m. Call with questions about your
benefits, claims, replacing a lost ID card, or if you have a complaint or service appeal. You can also call your Care
Manager and they will assist you in getting these issues resolved with WellCare Member Services.
Member Services Toll-Free Phone Number: 1-866-661-1232
If you do not speak English, we can help. We want you to know how to use your health care plan, no matter what
language you speak. Just call us and we will find a way to talk to you in your own language. We have translation
services available.
We also have information in large print, Braille, and audible media. Our TTY phone number is 1-877-247-6272.
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IMPORTANT THINGS FOR YOU TO KNOW AS A NEW PLAN MEMBER
MEMBER ID CARD
After you join, we will send a welcome letter that confirms your enrollment and start date. Your member ID
card should arrive within 14 days of when your membership becomes effective. Your card identifies you as a plan
member and has your member identification number. If you need care before the card comes, your welcome
letter is proof that you are a member.
Keep your member ID card with your Medicaid benefit card and your Medicare card, if needed. You will need
these cards to get services that the plan does not cover.
Please carry all of your health care ID cards at all times, including any private health insurance cards, as well as
Medicare or Medicaid cards. Each time you go for care, be sure to show them to your provider.
HOW TO GET CARE AND SERVICES
Care Management Services
You and your doctor will work with your Care Manager to decide on the services that you need and to develop
a Care Plan.
Your Care Plan outlines the services you need. The Care Plan includes the specific types of services that will be
provided and the number of visits or personal care hours that will be covered. It also tells you the length of time
that services have been authorized.
We will update your Care Plan at least every 6 months. We will update it more often if there is a change in your
condition and when service authorizations come to an end.
Your Care Manager will:
• Answer your questions about your health or medical care
• Monitor your care and health status
• Work with your doctors to help make sure that you are getting the right care at the right time
• Work with you and your doctor to review and update your Care Plan regularly
• Review your requests for services
• Arrange for and monitor services provided by the plan
• Coordinate care and services with all of your providers
• Work with your doctor and other providers if you need to go in the hospital
• Plan for your care needs when you leave the hospital
• Assist with doctors and appointments and make certain you have transportation to those services
Your Care Manager will contact you a few days before your enrollment becomes effective to see how you are
doing and to make sure that your Care Plan is still right for you. This contact is called a new member orientation.
Your Care Manager will talk to you on the phone often and a reassessment nurse will visit at least every 6 months.
He or she will also talk to your caregivers, your doctor, and other providers. He or she will work closely with the
home care agency providing services to you, with other community providers, and with your doctors.
If you are hospitalized, your Care Manager will work with your doctor and the hospital to plan for a fast and
smooth transition back to the community.
You may be receiving care that will continue when you join the plan. In this case, your Care Manager will contact
your provider and arrange for services to be transitioned to your new plan.
Member Services: 1-866-661-1232 (TTY/TDD: 1-877-247-6272) | 3
Coordinating Benefits and Services
Please make sure to let us know if you have other health insurance. This includes Medicare. We will coordinate
benefits with the health insurance that you have.
If you have Medicare, you will continue to have the same benefits and services as you do today. There are no
changes to your coverage and you do not need to have Medicare services approved by WellCare. We will work
with your Medicare providers and will pay the co-payments and deductibles for any services covered by the plan.
Your Care Manager will help you with services that are covered by Medicare, such as doctor and hospital visits.
Medicaid will continue to pay co-payments or deductibles for services covered by Medicaid that are not part of
this plan. Your Care Manager will coordinate services that are not part of the services covered by the plan, such
as mental health services.
Transitional Care
When you become a plan member, you may be under the care of a health care provider. You may continue
treatment even if the provider is not in our network (for example, if you are receiving dental care and the
treatment is not finished).
You may continue treatment for up to 60 days from when you join the plan. Your provider must agree to accept
payment at the plan rate, follow our policies, and agree to provide us with medical information about your care.
Sometimes, a provider may choose to leave the plan network. Your care may be continued for up to 90 days.
When you become a member, you may be receiving community-based long-term care services from another
program. You will continue to receive the same services you are receiving for at least 90 days after enrollment.
However, during the first 30 days, you may receive a person-centered service plan and care management
assessment which could lead to a reduction of your services after the first 90 days of enrollment have passed.
If there is a reduction, you will be notified prior to the reduction talking effect.
ELIGIBILITY AND ENROLLMENT IN THE WELLCARE ADVOCATE PLAN
ELIGIBILITY FOR MANAGED LONG TERM CARE
You are eligible to enroll in the plan if you:
• Have Medicaid; or you are eligible for Medicaid
• Are a Medicaid-eligible New Yorker age 18 or older
• Are determined eligible for the plan using an assessment tool designated by DOH
• Live in the plan’s service area – this includes Bronx, Kings (Brooklyn), Manhattan, Queens, Orange, Rockland,
Albany, Ulster, Erie, Nassau, Suffolk, Richmond (Staten Island) and Westchester counties.
• Are able to stay safely at home at the time you join the plan
• Are expected to need care management and at least one or more of the following services for more than
120 days from the date that you join the plan:
– Adult day health care
– Consumer Directed Personal Assistance Services
– Home health aide services in the home
– Nursing services in the home
– Personal care services in the home
– Private duty nursing
– Rehabilitation therapies in the home
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You may also join if you have Medicare. Your Care Manager will coordinate your Medicare benefits and services for you.
You are not eligible to join the WellCare Advocate Managed Long Term Care Plan if you are:
• A resident of a psychiatric, a residential care or an intermediate care facility for the mentally retarded (ICF/MR) or an
Assisted Living Program (ALP)
• An inpatient or resident of a facility operated by the State Office of Mental Health (OMH), the Office of Alcoholism
and Substance Abuse Services (OASAS), or the New York State Office for People With Developmental Disabilities
(OPWDD);
• Enrolled in another Medicaid managed care or managed long-term care plan;
• Receiving services from waiver programs (Traumatic Brian Injury, Nursing Home Transition & Diversion), an OPWDD
day treatment program, or a hospice program;
•Expected to be Medicaid eligible for less than six (6) months or eligible for Emergency Medicaid;
•Individuals eligible for Medicaid benefits only with respect to tuberculosis-related services;
•In the family planning expansion program or in the Foster Family Care Demonstration;
•Under the age of 65 and in the Centers for Disease Control and Prevention breast and/or cervical cancer early
detection program and need treatment for breast or cervical cancer, and are not otherwise covered under
creditable health coverage; or
•In receipt of Limited Licensed Home Care Services.
HOW TO ENROLL
You may learn about the plan in different ways:
• Your doctor, your provider, or staff from a community organization or agency may refer you. They may think you
are eligible for the plan and could benefit from the services available.
• You or a family member may learn about the plan through our sales staff, at your doctor’s office, or in a community
setting.
• You may already be a member of another WellCare health plan or pharmacy plan and be identified by one of
our staff as needing the kinds of services available through this program. Staff may include a nurse in our Medical
Management Department, a case manager, a disease management nurse, the plan’s Medical Director, a plan
pharmacist, or a Member Services representative.
We follow up on each referral, regardless of the source, in the order in which we receive them. You will be contacted
by telephone by an enrollment coordinator. The coordinator will provide you with information about managed longterm care, eligibility, and plan options. The coordinator will also ask you some basic questions to find out if you meet
basic eligibility (for example, that you live within our service area, or that you have Medicaid).
If you do not have Medicaid but think that you might be eligible, we will help you apply for coverage. The coordinator
may need to find out if you meet the minimum eligibility requirements for enrollment. He or she may ask questions like:
• Do you currently receive home care services?
• Do you need help with certain tasks like bathing or dressing?
• How many medications do you take?
• Do you need help taking them?
If you meet basic eligibility for the plan, an enrollment nurse will visit you at your home. The nurse will meet with
you and your family, if they help you stay at home. He or she will review your needs and tell you about the WellCare
Advocate Plan. The nurse will ask you questions about your health care and evaluate your medical care needs.
If you meet the minimum eligibility requirements and would like to join, the nurse will complete a comprehensive
assessment. With input from you, your caregivers, and your doctors, he or she will develop a Care Plan. The nurse may
need to meet with you several times to do this.
Member Services: 1-866-661-1232 (TTY/TDD: 1-877-247-6272) | 5
To finish, you’ll need to sign an enrollment agreement. Enrollment is processed by NY Medicaid Choice (NYMC),
your Local Department of Social Services (LDSS) or an entity designated by the state for review and approval.
Your Medicaid eligibility will be verified by the NYC Human Resources Administration (HRA) or your LDSS.
Medicaid surplus is the difference between your monthly income and the Medicaid income limit. If your income
is above the Medicaid income limit, you are required to pay the difference to the health plan to cover a portion
of your health care coverage. Your surplus payment is determined by the HRA or your LDSS.
The effective date of your enrollment depends on when the process is done. Completed applications that are
processed by noon on the 20th of the month generally take effect on the first day of the next month.
If you decide that you do not want to enroll, you may stop your application for enrollment at any time before
the effective date. We will refer you to other providers if you need services.
REASONS FOR DENYING ENROLLMENT
Your enrollment will not be accepted if:
• You do not meet the clinical, age, service need, or service area eligibility requirements.
• You cannot live safely in your home.
• You were a member of the plan in the past and you were involuntarily disenrolled and the reasons for the
disenrollment have not changed or been resolved.
WellCare can advise you if you are not eligible. You may choose to withdraw your application. If you do not
withdraw your application, WellCare will send your application to NY Medicaid Choice (NYMC), your Local
Department of Social Services (LDSS) or an entity designated by the state to review your application. They will
decide if you are eligible or not. They will let you and WellCare know the decision.
SERVICES COVERED BY THE WELLCARE ADVOCATE MANAGED
LONG TERM CARE PLAN
COVERED SERVICES
The plan provides you with services that are medically necessary. Medically necessary means any service required
to prevent, diagnose, correct or cure conditions in the enrollee that cause acute suffering, endanger life, result
in illness or infirmity, interfere with such enrollee’s capacity for normal activity, or threaten some significant
handicap.
That is, they are needed to prevent or treat your illness or disability.
Your Care Manager will help identify covered services and will select providers to work with you. You may have
to get prior authorization from your Care Manager or a referral from your doctor to get these services.
SERVICE DESCRIPTIONS
This is a summary description of your covered benefits.
• Adult Day Health Care – a supervised nursing home-based program. Members receive any of the following
medically necessary services: nursing care, physical therapy, occupational therapy, speech therapy, nutritional
counseling, therapeutic recreational activities, social work counseling, podiatry, dental services, and personal
care, such as bathing and grooming. This service is generally provided as a substitute for in-home personal
care and/or when extensive rehabilitation services are required.
• Community-Based Physical Therapy, Occupational Therapy, and Speech Therapy – facility-based services
usually provided in an outpatient setting for when a member requires more extensive services that cannot be
provided in the home, or that are provided more effectively in an outpatient setting. Medicaid coverage of
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physical therapy, occupational therapy, and speech therapy outside the home is limited to 20 visits each per
calendar year, except for children under age 21 and the developmentally disabled.
• Consumer Directed Personal Assistance Services (CDPAS) – the provision of some or total assistance with
personal care services, home health aide services and skilled nursing tasks by a consumer-directed personal
assistant, who may include any relative, excluding a spouse or parent, under the instruction, supervision and
direction of a consumer or the consumer’s designated representative. The designated representative may not
also be the consumer-directed personal assistant.
• Dental Care – members receive up to 2 routine dental exams per year. These include medically necessary
cleaning and restorative dental care, such as fillings and dentures. You do not need prior authorization to see
a dentist. However, you must use a dentist that is in our network. If you need a specific dental service that
requires prior authorization, your dentist will directly contact Healthplex, our dental network provider.
• Durable Medical Equipment (DME), Prosthetics, and Orthotics* – medically necessary durable medical
equipment, prosthetics and orthotics. Your Care Manager will work with your provider to arrange for home
delivery and pick up and for equipment maintenance and repair for DME.
If you have any medical equipment or devices, please let us know when you join the plan. We will coordinate
with your current DME vendor if the equipment is rented. Prosthetics and orthotics are obtained through
network providers. DME, prosthetics and orthotics require a prescription. They also must be authorized by
your Care Manager. *Prescription footwear and inserts are limited to use in conjunction with a lower limb
orthotic brace, as part of a diabetic treatment plan, or if there are foot complications in children under age 21.
• Environmental Supports – medically necessary home modifications or equipment to help members stay
safely in their home. Examples include purchasing an air conditioner for a member with respiratory problems,
installing a ramp or widening doorways to accommodate a wheelchair, and housekeeping/chore services.
• Eye Care – covered benefits include eye exams and eyeglasses or medically necessary contact lenses. Low
vision aids are covered if needed to help you function independently. Generally, you can get new eyeglasses
every 2 years. New lenses may be ordered more often (for example, if your vision changes more than onehalf diopter). If you break your glasses, they can be repaired. Lost eyeglasses or broken frames that cannot be
repaired will be replaced with the same prescription and style of frame.
• Hearing Exams, Hearing Aids, and Hearing Aid Batteries – benefits include hearing exams and, if medically
necessary, hearing aids. You may access services directly through an audiologist in our network without
contacting the plan. However, plan authorization may be required for some services. If so, the audiologist will
contact us on your behalf.
• Home-Delivered Meals – home delivery of a prepared meal or meals to members who are not able to
prepare meals on their own.
• Home Health Aide (HHA) or Personal Care Services – medically necessary help with bathing, eating, dressing,
going to the toilet, walking, and health-related tasks provided under the supervision of a registered nurse.
Note that the plan benefits do not include HHA or personal care services for the sole purposes of safety
supervision, personal companionship, or to provide housekeeping or chore services.
• Home Health Care – includes nursing services and occupational, physical, and speech therapies provided in a
member’s home by the staff of a licensed home care services agency or a certified home health agency.
• Medical Social Services – initial and periodic evaluation of a member’s mental health status, social and
family supports, eligibility for entitlements and advance directives. Includes routine supportive counseling of
complex member and family needs.
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• Medical/Surgical Supplies** – medically necessary items for medical use which are used for a specific medical
condition and which are generally disposable, not reusable, and are used for specific medical purposes.
**Medicaid covered compression and support stockings are limited to coverage only for pregnancy or treatment
for venous stasis ulcers.
• Nutrition – assessment of nutritional needs, nutrition education, and nutritional counseling provided by a
nutritionist or registered dietitian
– Enteral formula limited to nasogastric, jejunostomy, or gastrostomy tube feeding; or treatment of an inborn
error of metabolism*
– Nutritional supplements: Coverage of enteral formula and nutritional supplements is limited to individuals who
cannot obtain nutrition through any other means, and to the following three conditions:
1) Individuals who are fed via nasogastric, jejunostomy, or gastrostomy tube;
2) Individuals with rare inborn metabolic disorders; and
3) Children up to age 21 who require liquid oral enteral nutritional formula when there is a
documented diagnostic condition where caloric and dietary nutrients from food cannot be
absorbed or metabolized
– Coverage of certain inherited disease of amino acid and organic acid metabolism will include modified solid
food products that are low protein or which contain modified protein
• Nutritional Supplements – enteral formulas for tube or oral feeding when a member has a diagnosis or condition
that prevents nutrients from being absorbed from food.
• Nursing Home Care (provided you are eligible for institutional Medicaid) – members may require short-term
nursing home admissions following a hospital stay to promote recovery. Or they may require a long-term stay
when the member, their caregivers, their physician, and WellCare find that it is no longer safe for the member to
remain in his or her home. If a member has Medicare, most short-term admissions are covered. If a member does
not have Medicare, we will cover medically necessary short-term nursing home admissions. We will cover longterm stays when the member has institutional Medicaid.
• Personal Emergency Response System (PERS) – an electronic device connected to the phone that a member can
activate if he or she is alone and there is an emergency.
• Podiatry – the plan covers the services of a licensed podiatrist to provide medically necessary foot care. Medicare
is usually the primary payer for these services, so you may access these services directly without contacting the
plan. We will pay your co-payments directly to the provider.
• Private Duty Nursing – continuous skilled nursing care provided in a member’s home by a licensed registered
professional or practical nurse, if medically necessary.
• Respiratory Therapy Services – in-home services provided by a licensed respiratory therapist. Includes teaching
how to use equipment, such as nebulizers or oxygen.
• Social Day Care – a supervised community-based program. Members can socialize with others and participate
in therapeutic recreational group activities that promote physical activity and social interactions. Members will
receive personal care services and a group meal.
• Non-Emergency Transportation – your Care Plan will indicate the transportation we will provide to help you get
to and from doctors’ appointments. We will provide ambulette, taxi, or car service, depending on your need. If
you are able to use public transportation, we will reimburse you directly.
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To schedule a ride, call your Care Manager or call Member Services directly. Please call 2 business days before
your appointment. If you call less than 2 business days before your appointment, we may not be able to meet
your need. Or you may have to wait longer than expected for pick up or return.
Member Services Toll-Free Phone Number: 1-866-661-1232
Your Care Manager: 1-800-405-7551
Tell your Care Manager or Member Services that you are in the WellCare Advocate Plan. He or she will contact
our transportation vendor.
Please be ready to answer these questions:
• Type of transportation you need (for example, car service, ambulette)
• Address where you need to be picked up
• Time you need to be picked up
• Address of where you are going
• Time that you will need to be picked up for the return trip
• Any special needs (for example, help getting in and out of the car, wheelchair, escort, etc.)
Traffic and other conditions are out of the control of WellCare and our transportation providers. We allow a
30-minute grace period before a pick up is considered late.
All covered services must be provided by WellCare network providers. WellCare Advocate members may choose
from among the WellCare network of providers which is made up of highly qualified providers who are located
throughout our service area for convenience.
Members and/or their providers must obtain prior approval from the plan for most services. Care Managers work
with members and their providers to review member needs, develop Care Plans, and approve medically necessary
services and care.
Your Care Manager will work with you and your family to arrange for all of your services as part of your Care
Plan. They are also able to help you identify a network provider or make an appointment for any services that
you require.
* If you have Medicare, these services may be paid for in whole or in part. Your provider will bill Medicare
directly. WellCare Advocate will pay co-payments or deductibles. If Medicare is the primary payer, you may
choose any provider that accepts it.
When Medicare stops paying for these services, you may need to change to a provider in our network. Please
note that if you have Medicare or any other insurance, WellCare Advocate is billed last.
You must use a provider in the plan network and obtain prior authorization from the plan where needed, as
explained below. You have a choice of providers. If you are not satisfied with your provider, you may choose
another one from our network. Your Care Manager can help you. Note that it may take up to 2 weeks for you to
be able to schedule an appointment with a new provider.
There may be times when you need a service that is covered by the plan, but you need help finding a provider.
We can help you find a provider in our network with the training, experience, or the scope of services that your
care requires.
Ask your Care Manager to help find a provider and for prior authorization to use a provider outside of the
network. You need prior authorization to use a provider outside of the network, except in the case of an
emergency.
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SERVICES NOT COVERED BY WELLCARE ADVOCATE
WellCare Advocate does not cover the following services that are covered by Medicare and/or Medicaid:
• Alcohol and substance abuse services
• Chronic renal dialysis
• Emergency services
• Emergency transportation
• Family planning services
• Inpatient hospital services
• Laboratory services
• Mental health services
• Outpatient hospital services
• Physician services, including services provided in an office setting, a clinic, a facility, or in the home
• Prescription and non-prescription drugs
• Radiology and radioisotope services
• Rural health clinic services
• Services provided by the New York State Office for People With Developmental Disabilities (OPWDD)
You can get these services from any provider who takes Medicaid and/or Medicare. If you are a member of a
Medicare Advantage plan, you must follow your plan’s rules and get services from a network provider. You may
choose to keep your other insurance coverage for your Medicare Part D Prescription Drug coverage.
If you have any questions about whether a benefit is covered, call your Care Manager. You can also call Member
Services.
HOW OUR PROVIDERS ARE PAID
You have the right to ask us if we have any special financial arrangement with our providers that might affect
your use of services. Call Member Services if you have specific concerns.
We want you to know that for certain covered services, such as vision and dental, providers are paid a set fee
each month for each member. This fee is called capitation. It stays the same whether a member uses the services
or not. For most covered services and for non-covered services, most of our providers are paid on a fee-forservice basis either by us, by Medicaid, or sometimes by Medicare. This means that they get a fee that they have
agreed to for each service they provide.
We pay all providers directly for the services you receive. A provider should not bill you for any covered services.
If a provider sends you a bill by mistake, do not pay the bill. Tell the provider that you are a member of WellCare
Advocate and that they should bill WellCare directly. If you have any questions, please call Member Services.
Welcome to WellCare Advocate | 10
WHAT DO I DO IF...
I Am Planning to Be Out of the Area
If you are planning to leave our service area, you must tell your Care Manager ahead of time. If you are receiving
services in your home, talk to your Care Manager at least 5 business days before you leave. We need to tell your
provider of your plans. If you think that you will need services, such as personal care, when you are out of the
area, talk to your Care Manager at least 2 weeks before you leave.
It is very important that you give us notice before you leave and return. If we do not have enough notice, we will
not be able to make any arrangements for your care and services. We need to know where you are going, where
you are staying, how long you plan to be away, and how we can reach you.
While you are away, your Care Manager will call you to see how you are doing and to plan for your return. If
you have a problem or if your condition changes, please call your Care Manager at 1-800-405-7551. We need 5
business days’ notice to make arrangements for your return. If you are not able to provide enough notice, we will
make every effort to arrange for services once you return. However, we may not be able to do so.
If you are out of the area for 30 consecutive days or longer, you will be disenrolled from the plan. Please call your
Care Manager if you have any questions.
I Go to the Emergency Room or I Am Admitted to the Hospital
If you go to the emergency room, call your Care Manager as soon as possible. The sooner we know, the sooner
we can follow up with you and your doctor. We can see if there is anything that you need or that can be done so
you don’t need to go there again.
If you are admitted to the hospital, please call your Care Manager as soon as you can. If you are not able to call,
please ask a family member or friend to call for you.
Tell the hospital that you are a member of WellCare Health Plans. Show them your card. Ask them to contact us
so that we can work with them to arrange for after care.
I Need Emergency Care
An emergency is a medical or behavioral condition that comes on suddenly. You are afraid serious harm could
happen if you do not get care right away.
Examples of an emergency are:
•Bleeding that won’t stop or a bad burn
•Trouble breathing, convulsions, or loss of
consciousness
•Broken bones
•When you feel you might hurt yourself or others
•A heart attack or severe chest pain
Some examples of things that are not emergencies: colds, sore throats, stomach aches, minor cuts and bruises,
and sprained muscles.
What to Do If You Have an Emergency
• Call 911 or go to the emergency room. You do not need prior authorization from WellCare before getting
emergency care. You may use any provider.
• Call your doctor or your Care Manager if you are not sure if it is an emergency. Explain what is happening.
You will be told what to do at home, or told to go to your doctor’s office or the nearest emergency room. If
you are out of the area when you have an emergency, go to the nearest emergency room.
• If you return home during business hours, please call your Care Manager. Tell him or her what happened and
how you are doing. If you call after hours, please leave a message. Your Care Manager will follow up with
your doctor promptly.
Member Services: 1-866-661-1232 (TTY/TDD: 1-877-247-6272) | 11
SERVICE AUTHORIZATIONS AND PLAN ACTIONS
PRIOR AUTHORIZATION
Most covered services must be approved by your Care Manager before you receive them or continue receiving them.
This is called prior authorization. You or someone you trust can ask for prior authorization from the plan.
When you ask for prior authorization of a treatment or service, it is called a service authorization request. Your Care
Plan includes those services that have been identified as medically necessary and that have been authorized.
You or your health care provider may make a service authorization request by:
•Contacting your Care Manager directly
•Faxing a request to your Care Manager at 1-888-812-5862
•Sending a request in writing to–
WellCare Advocate – Service Authorization Request
110 Fifth Ave., 3rd Floor
New York, NY 10011
Services will be approved in a certain amount and for a specific period of time. This is called an authorization period.
CONCURRENT AUTHORIZATION
During an authorization period, you or your health care provider may ask us to consider approving more of a specific
service that has already been approved and is part of your Care Plan. In this case, we will re-evaluate your care to see if
you still need the level of care being provided. This is called a concurrent authorization.
What Happens After We Get Your Service Authorization Request
The health plan has a review team to be sure you get the services we authorized. Doctors and nurses are on the review
team. Their job is to be sure the treatment or service you asked for is medically needed and right for you.
They do this by checking your treatment plan against acceptable medical standards.
An action is any decision to deny a service authorization request, to approve it for an amount or time period that is less
than requested, or to reduce, suspend, or end a service that we have already approved and that you are now getting
within an authorization period. These decisions will be made by a qualified health care professional.
If we decide that the service is not medically needed, the decision will be made by a clinical peer reviewer. This
reviewer may be a doctor, a nurse, or a health care professional who typically provides the care you requested.
You can ask for the specific medical standards used to make the decision for actions related to medical necessity.
These standards are called clinical review criteria.
After we receive your request, we will review it under a standard or fast track process. You or your health care provider
can ask for a fast track review if it is believed that a delay will cause serious harm to your health. If the request for a fast
track review is denied, we will tell you.
Your request will be handled under the standard review process. In all cases, we will review your request as fast as your
medical condition requires us to do so, but no later than the time frames identified below.
We will tell you and your provider both by phone and in writing if your request is approved or denied. We will also tell
you the reason for the decision. We will explain what options for appeals or fair hearings you will have if you do not
agree with our decision.
Welcome to WellCare Advocate | 12
TIME FRAMES FOR SERVICE AUTHORIZATION REQUESTS
Prior Authorization
• Standard Review—– we will make a decision within 3 business days of when we have all the information we
need. You will hear from us no later than 14 days after we receive your request. We will tell you by the 14th
day if we need more information.
• Fast Track Review—we will make a decision and you will hear from us within 3 business days. We will tell you
by the 3rd business day if we need more information.
Concurrent Authorization
• Standard Review—– we will make a decision within 1 business day of when we have all the information we
need. You will hear from us no later than 14 days after we receive your request.
• Fast Track Review—we will make a decision within 1 business day of when we have all the information we
need. You will hear from us no later than 3 business days after we receive your request.
• In the case of a request for Medicaid covered home health care services following an inpatient admission, one
(1) business day after receipt of necessary information; except when the day subsequent to the request for
services falls on a weekend or holiday, seventy-two (72) hours after receipt of necessary information; but in
any event, no more than three (3) business days after receipt of the request for services. We may need more
information to make either a standard or fast track decision about your service authorization or concurrent
review request. In this case, the time frames above can be extended up to 14 days. We will:
- Write and tell you what information is needed. If your request is in a fast track review, we will call you
right away and send a written notice later.
- Tell you why the delay is in your best interest.
- Make a decision as quickly as we can when we receive the necessary information. You will hear from us
no later than 14 days from the original time frame.
You, your provider, or someone you trust may also ask us to take more time to make a decision. This may be
because you have more information to give the plan to help decide your case. You can write to us or call
1-866-661-1232.
You or someone you trust can file a grievance with the plan if you do not agree with our decision to take more
time to review your request.
We will contact you by the date our time for review has expired. If you are not satisfied with this answer, you
have the right to file an action appeal with us. See the Action Appeals section of this handbook.
OTHER DECISIONS ABOUT YOUR CARE
Sometimes we will do a review of the care you are already receiving. This is an internal review conducted by
WellCare to re-evaluate care and services. We do this to see if you still need the care or to evaluate the amount
of care you are receiving. If it is found that you do not need the services you are currently receiving, this can
result in a termination, reduction, or suspension of benefits. In most cases, we must tell you at least 10 days
before we change the service.
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GRIEVANCES
WellCare will try its best to deal with your concerns or issues as quickly as possible and to your satisfaction. You
may use either our grievance process or our appeal process, depending on what kind of problem you have.
There will be no change in your services or the way you are treated by WellCare staff or a health care provider
because you file a grievance or an appeal. We will maintain your privacy. We will give you any help you may need
to file a grievance or appeal. This includes providing you with interpreter services or help if you have vision and/or
hearing problems. You may choose someone (like a relative or friend or a provider) to act for you.
To file a grievance or to appeal a plan action, please our Member Services Department. Call Monday through Friday
between 8 a.m. and 6 p.m. at 1-866-661-1232. If you call us after hours, leave a message. We will call you back the next
business day. We will tell you if we need more information to make a decision. Or write to:
WellCare Health Plans
P.O. Box 31384
Tampa, FL 33631-3384
When you contact us, you will need to give us your name, address, telephone number and the details of the problem.
What is a Grievance?
A grievance is any communication by you to us of dissatisfaction about the care and treatment you receive from our
staff or providers of covered services. For example, if someone was rude to you or you do not like the quality of care
or services you have received from us, you can file a grievance with us.
The Grievance Process
You may file a grievance orally or in writing with us. The person who receives your grievance will record it, and
appropriate plan staff will oversee the review of the grievance. We will send you a letter telling you that we received
your grievance and a description of our review process. We will review your grievance and give you a written answer
within one of two time frames.
1. If a delay would significantly increase the risk to your health, we will decide within 48 hours after receipt of
necessary information.
2.For all other types of grievances, we will notify you of our decision within 45 days of receipt of necessary
information, but the process must be completed within 60 days of the receipt of the grievance. The review
period can be increased up to 14 days if you request it, or if we need more information and the delay is in your
interest.
Our answer will describe what we found when we reviewed your grievance and our decision about your grievance.
How do I Appeal a Grievance Decision?
If you are not satisfied with the decision we make concerning your grievance, you may request a second review of
your issue by filing a grievance appeal. You must file a grievance appeal in writing. It must be filed within 60 business
days of receipt of our initial decision about your grievance. Once we receive your appeal, we will send you a written
acknowledgement telling you the name, address and telephone number of the individual we have designated to
respond to your appeal. All grievance appeals will be conducted by appropriate professionals, including health care
professionals for grievances involving clinical matters, who were not involved in the initial decision.
For standard appeals, we will make the appeal decision within 30 business days after we receive all necessary
information to make our decision. If a delay in making our decision would significantly increase the risk to your
health, we will use the expedited grievance appeal process. For expedited grievance appeals, we will make our appeal
decision within 2 business days of receipt of necessary information. For both standard and expedited grievance
appeals, we will provide you with written notice of our decision. The notice will include the detailed reasons for our
decision and, in cases involving clinical matters, the clinical rationale for our decision.
Welcome to WellCare Advocate | 14
What is an Action?
When WellCare denies or limits services requested by you or your provider; denies a request for a referral;
decides that a requested service is not a covered benefit; reduces, suspends or terminates services that we
already authorized; denies payment for services; doesn’t provide timely services; or doesn’t make grievance or
appeal determinations within the required time frames, those are considered plan “actions”. An action is subject
to appeal. (See How do I File an Appeal of an Action? below for more information.)
Timing of Notice of Action
If we decide to deny or limit services you requested or decide not to pay for all or part of a covered service, we
will send you a notice when we make our decision. If we are proposing to reduce, suspend or terminate a service
that is authorized, our letter will be sent at least 10 days before we intend to change the service.
Contents of the Notice of Action
Any notice we send to you about an action will: Explain the action we have taken or intend to take; Cite the
reasons for the action, including the clinical rationale, if any; Describe your right to file an appeal with us (including
whether you may also have a right to the state’s external appeal process); Describe how to file an internal
appeal and the circumstances under which you can request that we speed up (expedite) our review of your
internal appeal; Describe the availability of the clinical review criteria relied upon in making the decision, if the
action involved issues of medical necessity or whether the treatment or service in question was experimental or
investigational; Describe the information, if any, that must be provided by you and/or your provider in order for
us to render a decision on appeal.
If we are reducing, suspending or terminating an authorized service, the notice will also tell you about your right
to have services continue while we decide on your appeal; how to request that services be continued; and the
circumstances under which you might have to pay for services if they are continued while we were reviewing
your appeal.
How do I File an Appeal of an Action?
If you do not agree with an action that we have taken, you may appeal. When you file an appeal, it means that
we must look again at the reason for our action to decide if we were correct. You can file an appeal of an action
with the plan orally or in writing. When the plan sends you a letter about an action it is taking (like denying or
limiting services, or not paying for services), you must file your appeal request within 45 calendar days of the date
on our letter notifying you of the action. If you call us to file your request for an appeal, you must send a written
request unless you ask for an expedited review.
How do I Contact my Plan to File an Appeal?
We can be reached by calling Member Services Department. Call Monday through Friday between 8 a.m. and
6 p.m. at 1-866-661-1232. If you call us after hours, leave a message. We will call you back the next business day.
Or write to:
WellCare Health Plans
P.O. Box 31384
Tampa, FL 33631-3384
The person who receives your appeal will record it, and appropriate staff will oversee the review of the appeal.
We will send a letter telling you that we received your appeal and how we will handle it. Your appeal will be
reviewed by knowledgeable clinical staff who were not involved in the plan’s initial decision or action that you
are appealing.
Member Services: 1-866-661-1232 (TTY/TDD: 1-877-247-6272) | 15
For Some Actions, You May Request to Continue Service During the Appeal Process
If you are appealing a reduction, suspension or termination of services you are currently authorized to receive,
you may request to continue to receive these services while we are deciding your appeal. We must continue
your service if you make your request to us no later than 10 days from our mailing of the notice to you about
our intent to reduce, suspend or terminate your services, or by the intended effective date of our action, and
the original period covered by the service authorization has not expired. Your services will continue until you
withdraw the appeal, the original authorization period for your services has been met or until 10 days after we
mail your notice about our appeal decision, if our decision is not in your favor, unless you have requested a New
York State Medicaid Fair Hearing with continuation of services. (See Fair Hearing Section below.)
Although you may request a continuation of services while your appeal is under review, if your appeal is not
decided in your favor, we may require you to pay for these services if they were provided only because you
asked to continue to receive them while your appeal was being reviewed.
How Long Will it Take the Plan to Decide My Appeal of an Action?
Unless you ask for an expedited review, we will review your appeal of the action taken by us as a standard appeal
and send you a written decision as quickly as your health condition requires, but no later than 30 days from the
day we receive an appeal. (The review period can be increased up to 14 days if you request an extension or we
need more information and the delay is in your interest.) During our review, you will have a chance to present
your case in person and in writing. You will also have the chance to look at any of your records that are part of
the appeal review.
We will send you a notice about the decision we made about your appeal that will identify the decision we made
and the date we reached that decision.
If we reverse our decision to deny or limit requested services, or reduce, suspend or terminate services, and
services were not furnished while your appeal was pending, we will provide you with the disputed services as
quickly as your health condition requires.
In some cases you may request an “expedited” appeal. (See Expedited Appeal Process Section below.)
Expedited Appeal Process
If you or your provider feels that taking the time for a standard appeal could result in a serious problem to your
health or life, you may ask for an expedited review of your appeal of the action. We will respond to you with our
decision within 2 business days after we receive all necessary information. In no event will the time for issuing our
decision be more than 3 business days after we receive your appeal. (The review period can be increased up to 14
days if you request an extension or we need more information and the delay is in your interest.)
If we do not agree with your request to expedite your appeal, we will make our best efforts to contact you in
person to let you know that we have denied your request for an expedited appeal and will handle it as a standard
appeal. Also, we will send you a written notice of our decision to deny your request for an expedited appeal
within 2 days of receiving your request.
If the Plan Denies My Appeal, What Can I Do?
If our decision about your appeal is not totally in your favor, the notice you receive will explain your right to
request a Medicaid Fair Hearing from New York State and how to obtain a Fair Hearing, who can appear at the
Fair Hearing on your behalf, and for some appeals, your right to request to receive services while the hearing is
pending and how to make the request. If we deny your appeal because of issues of medical necessity or because
the service in question was experimental or investigational, the notice will also explain how to ask New York State
for an “external appeal” of our decision.
Welcome to WellCare Advocate | 16
State Fair Hearings
If we did not decide the appeal totally in your favor, you may request a Medicaid Fair Hearing from New York
State within 60 days of the date we sent you the notice about our decision on your appeal.
If your appeal involved the reduction, suspension or termination of authorized services you are currently
receiving, and you have requested a Fair Hearing, you may also request to continue to receive these services
while you are waiting for the Fair Hearing decision. You must check the box on the form you submit to request
a Fair Hearing to indicate that you want the services at issue to continue. Your request to continue the services
must be made within 10 days of the date the appeal decision was sent by us or by the intended effective date
of our action to reduce, suspend or terminate your services, whichever occurs later. Your benefits will continue
until you withdraw the appeal; the original authorization period for your services ends; or the State Fair Hearing
Officer issues a hearing decision that is not in your favor, whichever occurs first.
If the State Fair Hearing Officer reverses our decision, we must make sure that you receive the disputed services
promptly, and as soon as your health condition requires. If you received the disputed services while your appeal
was pending, we will be responsible for payment for the covered services ordered by the Fair Hearing Officer.
Although you may request to continue services while you are waiting for your Fair Hearing decision, if your Fair
Hearing is not decided in your favor, you may be responsible for paying for the services that were the subject of
the Fair Hearing.
State External Appeals
If we deny your appeal because we determine the service is not medically necessary or is experimental or
investigational, you may ask for an external appeal from New York State. The external appeal is decided by
reviewers who do not work for us or New York State. These reviewers are qualified people approved by New
York State. You do not have to pay for an external appeal.
When we make a decision to deny an appeal for lack of medical necessity or on the basis that the service is
experimental or investigational, we will provide you with information about how to file an external appeal,
including a form on which to file the external appeal along with our decision to deny an appeal. If you want an
external appeal, you must file the form with the New York State Department of Financial Services within four
months from the date we denied your appeal.
Your external appeal will be decided within 30 days. More time (up to 5 business days) may be needed if the
external appeal reviewer asks for more information. The reviewer will tell you and us of the final decision within
two business days after the decision is made.
You can get a faster decision if your doctor can say that a delay will cause serious harm to your health. This is
called an expedited external appeal. The external appeal reviewer will decide an expedited appeal in 72 hours or
less. The reviewer will tell you and us the decision right away by phone or fax. Later, a letter will be sent that tells
you the decision.
You may ask for both a Fair Hearing and an external appeal. If you ask for a Fair Hearing and an external appeal,
the decision of the Fair Hearing officer will be the “one that counts.”
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DISENROLLMENT FROM THE PROGRAM
You Can Choose to Disenroll
You can ask to leave the WellCare Advocate Plan at any time for any reason.
If you would like to disenroll from the plan, call your Care Manager. You can request to disenroll from the plan
over the phone or make a request to your Care Manager. If you made the request over the phone, your Care
Manager will meet with you in person, as soon as possible, so that they can begin to plan for your care after
disenrollment and to request that you fill out a disenrollment form. This form says that you want to disenroll
from the plan and asks you why. If you wish to continue receiving community-based long-term services and you
live in a mandatory county, you must transfer to another managed long-term care plan.
The New York Medicaid Choice or local social services district will review your disenrollment request. If they
agree, they will tell us the expected disenrollment date. They will notify you of their decision and inform you of
your rights to a New York State Medicaid Fair Hearing. If you request a Fair Hearing, you will stay in the plan until
a decision has been made.
We will do our best to work with you to address or solve the problem that has triggered the disenrollment.
Under Certain Circumstances You Will Be Disenrolled From the Plan
You will have to leave the WellCare Advocate plan if you:
• Are no longer eligible for Medicaid benefits
• Move out of the service area permanently
• Are out of the plan’s service area for more than 30 consecutive days
• Are in the hospital for 45 consecutive days or longer
• Go in a residential program operated or funded by the Office of Mental Health (OMH), New York State
Office for People With Developmental Disabilities (OPWDD), or Office of Alcohol and Substance Abuse for
45 consecutive days or longer
• Need nursing home care but are not eligible for institutional Medicaid because of a transfer of resources
• No longer eligible because you are assessed as no longer requiring community-based long-term care services
or, for non-dual eligible enrollees, no longer meet the nursing home level of care as determined using the
assessment tool prescribed by the Department
• Join a 1915 (c) waiver program
• Are incarcerated
We may begin disenrollment if:
• You or a family member behaves in a way that prevents us from giving you the care you need
• You fail to pay the Medicaid surplus that you owe to the plan
• You are unwilling to fill out or submit necessary consent forms or releases
• You are dishonest and knowingly provide false information
If You Are Required to Leave the Plan or if We Request that You Leave the Plan
Your Care Manager will tell you and your providers that we intend to ask for approval for an involuntary
disenrollment from New York Medicaid Choice (NYMC) or the local social services district. We will let you know
that we are making this request, the reason, and the expected date of disenrollment.
NYMC or the local social services district will review each involuntary disenrollment. You will be disenrolled only
if they agree with us. If they agree, they will tell us the expected disenrollment date. They will notify you of their
decision and inform you of your rights to a New York State Medicaid fair hearing. If you request a Fair Hearing,
you will stay in the plan until a decision has been made.
We will do our best to work with you to address or solve the problem that has triggered the disenrollment.
Welcome to WellCare Advocate | 18
Helping to Plan for Your Continuing Care Needs
Before you can be disenrolled you will need a plan to continue to provide your care needs. Your Care Manager
will work with you, your doctor, and your caregivers to develop this plan. It will include referrals to another
managed long-term care plan or Medicaid managed care plan or alternative service, an enrollment broker or Adult
Protective Services, if necessary, and arrangements to transfer your care.
MEMBER RIGHTS
Your rights as a WellCare Advocate Managed Long Term Care Plan member:
• You have the right to receive medically necessary care.
• You have the right to timely access to care and services.
• You have the right to privacy about your medical record and when you get treatment.
• You have the right to get information on available treatment options and alternatives, presented in a manner
and language you understand.
• You have the right to get information in a language you understand; you can get oral translation services free
of charge.
• You have the right to get information necessary to give informed consent before the start of treatment.
• You have the right to be treated with respect and dignity.
• You have the right to get a copy of your medical records and ask that the records be amended or corrected.
• You have the right to take part in decisions about your health care, including the right to refuse treatment.
• You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline,
convenience, or retaliation.
• You have the right to get care without regard to sex, race, health status, color, age, national origin, sexual
orientation, marital status, or religion.
• You have the right to be told where, when, and how to get the services you need from your managed longterm care plan, including how you can get covered benefits from out-of-network providers if they are not
available in the plan network.
• You have the right to complain to the New York State Department of Health. You have the right to use the
New York State Fair Hearing system. You can also ask for an external appeal, where appropriate.
• You have the right to appoint someone to speak for you about your care and treatment.
MEMBER RESPONSIBILITIES
Your responsibilities as a WellCare Advocate Managed Long Term Care Plan member:
• To be an active participant in your care and make every effort to do as much as possible to help yourself be
as independent as possible and as healthy as you can be.
• To request and use the managed long-term care services that are most appropriate to your needs, and that
help you to be as independent as possible.
• Get the most out of being a member of a managed long-term care health plan by using services that are not
regularly available to you through Medicaid and still get the care that you need.
– Go to a social day care program instead of getting personal care at home so that you can be with other
people and keep physically fit and active.
– Get housekeeping services and home-delivered meals instead of having a home health aide so that you get
only help that you need.
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• To know about your chronic health care needs and learn as much as you can so that you know what’s
important, how to monitor your own care, and what to do when things change.
• To get prior authorization for services and treatments, as explained in your member handbook, except when
you have an emergency.
• To let your Care Manager know as soon as you can if you have had an emergency.
• To use network providers that are part of the WellCare network.
• To keep appointments or notify your provider and your Care Manager, if appropriate, if you are not able to
keep an appointment.
• To let your Care Manager know before time if you are planning on leaving the area.
• To make Medicaid surplus or “spend down” payments to WellCare Health Plans. The payment amount is
determined by the NYC Human Resources Administration (HRA) or your Local Department of Social
Services (LDSS).
• To ask for help and information from your Care Manager or Member Services if you do not understand
something or if you have concerns or problems.
• To let WellCare know if you have ideas about how we can make our plan better.
INFORMATION ABOUT WELLCARE OF NEW YORK, INC.
To learn more about WellCare of New York, Inc., call Member Services at 1-866-661-1232. You can ask for any of
the following information:
• Names, business addresses, and official positions of the members of WellCare of New York’s Board of Directors
• Most recent annual certified financial statement
• Information about member complaints related to WellCare Advocate
• Description of the criteria that are used to make decisions about services
• Description of WellCare’s procedures for protecting the confidentiality of medical and member records
• Description of the plan’s quality assurance program
• Procedures and qualifications that providers must meet to become part of WellCare’s network
Welcome to WellCare Advocate | 20
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.
Please review it carefully.
Effective Date of this Privacy Notice: March 29, 2012
Revised as of May 14, 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:
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Easy Choice Health Plan, Inc.
Exactus Pharmacy Solutions, Inc.
Harmony Health Plan of Illinois, Inc.
Harmony Health Plan of Illinois, Inc., d/b/a
Harmony Health Plan of Missouri
Missouri Care, Incorporated
WellCare Health Insurance of Arizona, Inc.,
operating as ‘Ohana Health Plan, Inc.
WellCare Health Insurance of Illinois, Inc.
WellCare Health Insurance of Illinois, Inc.,
d/b/a WellCare of Kentucky, Inc.
WellCare Health Plans of New York, Inc.
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WellCare Health Plans of New Jersey, Inc.
WellCare of Connecticut, Inc.
WellCare of Florida, Inc.
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.
53101
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.
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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.
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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.
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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.
Welcome to WellCare Advocate | 24
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.
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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.
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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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ADVANCE DIRECTIVES
There may come a time when you can’t decide about your own health care. By planning in advance, you can
arrange now for your wishes to be carried out. First, let family, friends, and your doctor know what kinds of
treatment you do or don’t want. Second, you can appoint an adult you trust to make decisions for you. Be sure
to talk with your PCP, your family, or others close to you so they will know what you want. Third, it is best if you
put your thoughts in writing. The documents listed below can help. You do not have to use a lawyer, but you
may wish to speak with one about this. You can change your mind and these documents at any time. We can
help you understand or get these documents. They do not change your right to quality health care benefits. The
only purpose is to let others know what you want if you can’t speak for yourself.
HEALTH CARE PROXY
With this document, you name another adult that you trust (usually a friend or family member) to decide about
medical care for you if you are not able to do so. If you do this, you should talk with the person so they know
what you want.
CPR AND DNR
You have the right to decide if you want any special or emergency treatment to restart your heart or lungs if your
breathing or circulation stops. If you do not want special treatment, including cardiopulmonary resuscitation (CPR),
you should make your wishes known in writing. Your PCP will provide a DNR (Do Not Resuscitate) order for your
medical records. You can also get a DNR form to carry with you and/or a bracelet to wear that will let any
emergency medical provider know about your wishes.
ORGAN DONOR CARD
This wallet-sized card says that you are willing to donate parts of your body to help others when you die. Also,
check the back of your driver’s license to let others know if and how you want to donate your organs.
HEALTH CARE PROXY
Appointing Your Health Care Agent in New York State
The New York Health Care Proxy Law allows you to appoint someone you trust (for example, a family member or
close friend) to make health care decisions for you if you lose the ability to make decisions yourself. By appointing
a health care agent, you can make sure that health care providers follow your wishes. Your agent can also decide
how your wishes apply as your medical condition changes. Hospitals, doctors, and other health care providers must
follow your agent’s decisions as if they were your own. You may give the person you select as your health care
agent as little or as much authority as you want. You may allow your agent to make all health care decisions or
only certain ones. You may also give your agent instructions that he or she has to follow. This form can also be
used to document your wishes or instructions with regard to organ and/or tissue donation.
About the Health Care Proxy Form
This is an important legal document. Before signing, you should understand the following facts.
1. This form gives the person you choose as your agent the authority to make all health care decisions for you,
including the decision to remove or provide life-sustaining treatment, unless you say otherwise in this form.
“Health care” means any treatment, service, or procedure to diagnose or treat your physical or mental condition.
Welcome to WellCare Advocate | 28
2. Unless your agent reasonably knows your wishes about artificial nutrition and hydration (nourishment and water
provided by a feeding tube or intravenous line), he or she will not be allowed to refuse or consent to those
measures for you.
3. Your agent will start making decisions for you when your doctor determines that you are not able to make
health care decisions for yourself.
4. You may write on this form examples of the types of treatments that you would not desire and/or those
treatments that you want to make sure you receive. The instructions may be used to limit the decision-making
power of the agent. Your agent must follow your instructions when making decisions for you.
5. You do not need a lawyer to fill out this form.
6.You may choose any adult (18 years of age or older), including a family member or close friend, to be your
agent. If you select a doctor as your agent, he or she will have to choose between acting as your agent or as
your attending doctor because a doctor cannot do both at the same time. Also, if you are a patient or resident
of a hospital, nursing home, or mental hygiene facility, there are special restrictions about naming someone who
works for that facility as your agent. Ask staff at the facility to explain those restrictions.
7.Before appointing someone as your health care agent, discuss it with him or her to make sure that he or she is
willing to act as your agent. Tell the person you choose that he or she will be your health care agent. Discuss
your health care wishes and this form with your agent. Be sure to give him or her a signed copy. Your agent
cannot be sued for health care decisions made in good faith.
8.If you have named your spouse as your health care agent and you later become divorced or legally separated,
your former spouse can no longer be your agent by law, unless you state otherwise. If you would like your former
spouse to remain your agent, you may note this on your current form and date it or complete a new form
naming your former spouse.
9 Even though you have signed this form, you have the right to make health care decisions for yourself as long as
you are able to do so, and treatment cannot be given to you or stopped if you object, nor will your agent have
any power to object.
10.You may cancel the authority given to your agent by telling him or her or your health care provider orally
or in writing.
11.Appointing a health care agent is voluntary. No one can require you to appoint one.
12.You may express your wishes or instructions regarding organ and/or tissue donation on this form.
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FREQUENTLY ASKED QUESTIONS
Why should I choose a health care agent?
If you become unable, even temporarily, to make health care decisions, someone else must decide for you. Health
care providers often look to family members for guidance. Family members may express what they think your
wishes are related to a particular treatment. However, in New York State, only a health care agent you appoint has
the legal authority to make treatment decisions if you are unable to decide for yourself. Appointing an agent lets
you control your medical treatment by:
• Allowing your agent to make health care decisions on your behalf as you would want them decided
• Choosing one person to make health care decisions because you think that person would make the best decisions
• Choosing one person to avoid conflict or confusion among family members and/or significant others
You may also appoint an alternate agent to take over if your first choice cannot make decisions for you.
Who can be a health care agent?
Anyone 18 years of age or older can be a health care agent. The person you are appointing as your agent or your
alternate agent cannot sign as a witness on your Health Care Proxy Form.
How do I appoint a health care agent?
All competent adults, 18 years of age or older, can appoint a health care agent by signing a form called a Health
Care Proxy. You don’t need a lawyer or a notary, just 2 adult witnesses. Your agent cannot sign as a witness. You
can use the form printed here, but you don’t have to use this form.
When would my health care agent begin to make health care decisions for me?
Your health care agent would begin to make health care decisions after your doctor decides that you are not
able to make your own health care decisions. As long as you are able to make health care decisions for yourself,
you will have the right to do so.
What decisions can my health care agent make?
Unless you limit your health care agent’s authority, your agent will be able to make any health care decision that
you could have made if you were able to decide for yourself. Your agent can agree that you should receive
treatment, choose among different treatments, and decide that treatments should not be provided, in
accordance with your wishes and interests. However, your agent can only make decisions about artificial nutrition
and hydration (nourishment and water provided by feeding tube or intravenous line) if he or she knows your
wishes from what you have said or what you have written. The Health Care Proxy Form does not give your agent
the power to make non-health care decisions for you, such as financial decisions.
Why do I need to appoint a health care agent if I’m young and healthy?
Appointing a health care agent is a good idea even though you are not elderly or terminally ill. A health care agent
can act on your behalf if you become even temporarily unable to make your own health care decisions (such as
might occur if you are under general anesthesia or have become comatose because of an accident). When you again
become able to make your own health care decisions, your health care agent will no longer be authorized to act.
How will my health care agent make decisions?
Your agent must follow your wishes, as well as your moral and religious beliefs. You may write instructions on your
Health Care Proxy Form or simply discuss them with your agent.
How will my health care agent know my wishes?
Having an open and frank discussion about your wishes with your health care agent will put him or her in a better
Welcome to WellCare Advocate | 30
position to serve your interests. If your agent does not know your wishes or beliefs, your agent is legally required
to act in your best interest. Because this is a major responsibility for the person you appoint as your health care
agent, you should have a discussion with the person about what types of treatments you would or would not
want under different types of circumstances, such as:
• Whether you would want life support initiated/continued/removed if you are in a permanent coma
• Whether you would want treatments initiated/continued/removed if you have a terminal illness
• Whether you would want artificial nutrition and hydration initiated/continued/withdrawn/withheld and
under what types of circumstances
Can my health care agent overrule my wishes or prior treatment instructions?
No. Your agent is obligated to make decisions based on your wishes. If you clearly expressed particular wishes, or
gave particular treatment instructions, your agent has a duty to follow those wishes or instructions unless he or
she has a good faith basis for believing that your wishes changed or do not apply to the circumstances.
Who will pay attention to my agent?
All hospitals, nursing homes, doctors and other health care providers are legally required to provide your health
care agent with the same information that would be provided to you and to honor the decisions by your agent
as if they were made by you. If a hospital or nursing home objects to some treatment options (such as removing
certain treatment), they must tell you or your agent BEFORE or upon admission, if reasonably possible.
What if my health care agent is not available when decisions must be made?
You may appoint an alternate agent to decide for you if your health care agent is unavailable, unable or unwilling
to act when decisions must be made. Otherwise, health care providers will make health care decisions for you
that follow instructions you gave while you were still able to do so. Any instructions that you write on your
Health Care Proxy Form will guide health care providers under these circumstances.
What if I change my mind?
It is easy to cancel your Health Care Proxy, to change the person you have chosen as your health care agent, or
to change any instructions or limitations you have included on the form. Simply fill out a new form. In addition,
you may indicate that your Health Care Proxy expires on a specified date or if certain events occur. Otherwise,
the Health Care Proxy will be valid indefinitely. If you choose your spouse as your health care agent or as your
alternate, and you get divorced or legally separated, the appointment is automatically cancelled. However, if you
would like your former spouse to remain your agent, you may note this on your current form and date it or
complete a new form naming your former spouse.
Can my health care agent be legally liable for decisions made on my behalf?
No. Your health care agent will not be liable for health care decisions made in good faith on your behalf. Also, he
or she cannot be held liable for costs of your care, just because he or she is your agent.
Is a Health Care Proxy the same as a living will?
No. A living will is a document that provides specific instructions about health care decisions. You may put such
instructions on your Health Care Proxy Form. The Health Care Proxy allows you to choose someone you trust to
make health care decisions on your behalf. Unlike a living will, a Health Care Proxy does not require that you
know in advance all the decisions that may arise. Instead, your health care agent can interpret your wishes as
medical circumstances change and can make decisions you could not have known would have to be made.
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Where should I keep my Health Care Proxy Form after it is signed?
Give a copy to your agent, your doctor, your attorney, and any other family members or close friends you want.
Keep a copy in your wallet or purse or with other important papers, but not in a location where no one can
access it, like a safe deposit box. Bring a copy if you are admitted to the hospital, even for minor surgery, or if
you undergo outpatient surgery.
May I use the Health Care Proxy Form to express my wishes about organ and/or tissue donation?
Yes. Use the optional organ and tissue donation section on the Health Care Proxy Form and be sure to have the
section witnessed by 2 people. You may specify that your organs and/or tissues be used for transplantation,
research, or educational purposes. Any limitation(s) associated with your wishes should be noted in this section
of the proxy. Failure to include your wishes and instructions on your Health Care Proxy Form will not be taken to
mean that you do not want to be an organ and/or tissue donor.
Can my health care agent make decisions for me about organ and/or tissue donation?
No. The power of a health care agent to make health care decisions on your behalf ends upon your death. Noting
your wishes on your Health Care Proxy Form allows you to clearly state your wishes about organ and tissue donation.
Who can consent to a donation if I choose not to state my wishes at this time?
It is important to note your wishes about organ and/or tissue donation so that family members who will be
approached about donation are aware of your wishes. However, New York law provides a list of individuals who
are authorized to consent to organ and/or tissue donation on your behalf. They are listed in order of priority:
Your spouse, a son or daughter 18 years of age or older, either of your parents, a brother or sister 18 years of age
or older, a guardian appointed by a court prior to the donor’s death, or any other legally authorized person.
HEALTH CARE PROXY FORM INSTRUCTIONS
Item (1)
Write the name, home address, and telephone number of the person you are selecting as your agent.
Item (2)
If you want to appoint an alternate agent, write the name, home address, and telephone number of the person
you are selecting as your alternate agent.
Item (3)
Your Health Care Proxy will remain valid indefinitely unless you set an expiration date or condition for its expiration.
This section is optional and should be filled in only if you want your Health Care Proxy to expire.
Item (4)
If you have special instructions for your agent, write them here. Also, if you wish to limit your agent’s authority
in any way, you may say so here or discuss them with your health care agent. If you do not state any limitations,
your agent will be allowed to make all health care decisions that you could have made, including the decision to
consent to or refuse life-sustaining treatment. If you want to give your agent broad authority, you may do so
right on the form.
Simply write: “I have discussed my wishes with my health care agent and alternate, and they know my wishes,
including those about artificial nutrition and hydration.” If you wish to make more specific instructions, you could
say:
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• “If I become terminally ill, I do/don’t want to receive the following types of treatments....”
• “If I am in a coma or have little conscious understanding with no hope of recovery, then I do/don’t want the
following types of treatments....”
• “If I have brain damage or a brain disease that makes me unable to recognize people or speak and there is no
hope that my condition will improve, I do/don’t want the following types of treatments....”
• “I have discussed with my agent my wishes about ____________ and I want my agent to make all decisions
about these measures.”
Examples of medical treatments about which you may wish to give your agent special instructions are listed
below. This is not a complete list:
• Electric shock therapy
• Artificial respiration
• Artificial nutrition and hydration • Antibiotics
• Transplantation
• Blood transfusions
• Cardiopulmonary resuscitation
• Surgical procedures
• Abortion
• Antipsychotic medication
• Dialysis
• Sterilization
Item (5)
You must date and sign this Health Care Proxy Form. If you are unable to sign yourself, you may direct someone
else to sign in your presence. Be sure to include your address.
Item (6)
You may state wishes or instructions about organ and/or tissue donation on this form. A health care agent cannot
make a decision about organ and/or tissue donation because the agent’s authority ends upon your death. The law
does provide for certain individuals in order of priority to consent to an organ and/or tissue donation on your
behalf: your spouse, a son or daughter 18 years of age or older, either of your parents, a brother or sister 18 years
of age or older, a guardian appointed by a court prior to the donor’s death, or any other legally authorized person.
Item (7)
Two witnesses, 18 years of age or older, must sign this Health Care Proxy Form. The person who is appointed your
agent or alternate agent cannot sign as a witness.
Member Services: 1-866-661-1232 (TTY/TDD: 1-877-247-6272) | 33
NOTES
Welcome to WellCare Advocate | 34
NOTES
Member Services: 1-866-661-1232 (TTY/TDD: 1-877-247-6272) | 35
Welcome to WellCare Advocate | 36
HEALTH CARE PROXY FORM
(1) I,
hereby appoint
(name, home address, and telephone number)
s my health care agent to make any and all health care decisions for me, except to the extent that I
a
state otherwise. This proxy shall take effect only when and if I become unable to make my own health
care decisions.
(2) Optional: Alternate Agent
If the person I appoint is unable, unwilling, or unavailable to act as my health care agent, I hereby appoint
(name, home address, and telephone number)
as my health care agent to make any and all health care decisions for me, except to the extent that I
state otherwise.
(3) Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall
remain in effect indefinitely. (Optional: If you want this proxy to expire, state the date or conditions
here.) This proxy shall expire (specify date or conditions):
(4)Optional: I direct my health care agent to make health care decisions according to my wishes and
limitations, as he or she knows or as stated below. (If you want to limit your agent’s authority to make
health care decisions for you or to give specific instructions, you may state your wishes or limitations
here.) I direct my health care agent to make health care decisions in accordance with the following
limitations and/or instructions (attach additional pages as necessary):
In order for your agent to make health care decisions for you about artificial nutrition and hydration
(nourishment and water provided by feeding tube and intravenous line), your agent must reasonably
know your wishes. You can either tell your agent what your wishes are or include them in this section.
See instructions for sample language that you could use if you choose to include your wishes on this
form, including your wishes about artificial nutrition and hydration.
Member Services: 1-866-661-1232 (TTY/TDD: 1-877-247-6272) | 37
(5) Your Identification (please print)
Your Name:
Your Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date:
Your Address:
(6) Optional: Organ and/or Tissue Donation
I hereby make an anatomical gift, to be effective upon my death, of:
(check any that apply)
q Any needed organs and/or tissues
q The following organs and/or tissues:
q Limitations:
If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will
not be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise
authorized by law, to consent to a donation on your behalf.
Your Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date:
(7) Statement by Witnesses (Witnesses must be 18 years of age or older and cannot be the health care
agent or alternate.)
I declare that the person who signed this document is personally known to me and appears to be of
sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or
her) this document in my presence.
Date:
Date:
Witness 1 Print Name:
Witness 2
Print Name:
Signature: Signature:
Address: Address:
State of New York
Andrew M. Cuomo, Governor
Department of Health
Nirav R. Shah, M.D., M.P.H., Commissioner
1430 12/0
NY024639_CAD_MHB_ENG State Approved 10172013
©WellCare 2013 NY_10_13
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