Pinellas County Health Plan (PCHP)

Pinellas County Health Plan (PCHP) Information for new clients and those who may be eligible

(Revised, August 2009) The Pinellas County Health Plan (PCHP) is a health care program for uninsured, low-income adults in Pinellas County. This is not a health insurance plan.

Please read this handbook carefully. It will tell you what you need to know about this program. Please complete the following (participants only) My Medical Home is: Name:__________________________________________ Address: _ ______________________________________ Phone Number: __________________________________

If you have any questions that cannot be answered by your Medical Home, please call (727) 464-8400 or (727) 582-7781.

For more information, visit the PCHP Web Site at http://www.pinellascounty.org/humanservices/medical-home.htm

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NOTE: If you are already enrolled, please skip to page four (4).

The Pinellas County Health Plan (PCHP) The Pinellas County Health Plan (PCHP) began in October, 2008. People in this plan can be seen by a PCHP health care provider for free. This means that you will not have wait in long lines at the emergency room for minor problems. Now, you can go to a “medical home,” like a doctor’s office, for all of your basic health care needs.

This is a Health and Human Services Department program.

It is funded by

Pinellas County. Services may change at any time. To see what is currently covered by this plan, please turn to pages 4-7 of this handbook.

Do I Qualify? You may be able to get care if you: • Are a legal permanent resident or citizen of the United States.

• Are a Pinellas County resident. • Are between the ages of 18 and 64. You can not get services if you are 65 years old or older. • Meet Federal Poverty Guidelines for income (100% or less). • Are uninsured and can not pay for the medical care you need. • Are not eligible for Medicaid, Medicare, or another assistance program • Have less than $2,000 dollars in assets (does not include your car or your home; examples: bank account or certificate of deposit) Limit applies to specialty and hospital care only.

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HOW DO I APPLY? To apply for PCHP services, you must: • Visit your medical home (see page 8 for a list of medical homes). • Provide proof of Pinellas County residency (see below). • Provide proof of age (driver’s license, Florida ID or birth certificate). • Provide proof of identity (driver’s license, Florida ID or social security card). • Provide proof of citizenship (see below).

Residency and Citizenship Documents Residency Documents: one of the following 1. Driver’s license 2. Lease 3. Proof of home ownership 4. Utility bill 5. Voter ID 6. Library card 7. Mortgage papers 8. Rent receipt 9. Homestead exemption 10. Vehicle registration 11. School enrollment (children) 12. Food stamp referral

13. Cancelled mail from government agency 14. Bank statement 15. Criminal arrest record with home in Pinellas County 16. Declaration of domicile at clerk of court 17. Professional license 18. Florida ID 19. Written referral from a Pinellas County Social Service Agency verifying Pinellas County residency

Citizenship Documents: one of the following 1. U.S. Birth Certificate 2. U.S. Passport 3. Certificate of Naturalization

4. INS forms I-551 or I-151 5. Vital statistics confirmation 6. Green Card

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What Does My Plan Cover? Basic Services The providers in your medical home will help you with all your basic health care needs. Screenings, lab work, and prescriptions are part of this basic care. These services are free. Specialty Services Specialty services are more advanced treatments that can not be done by your provider in your medical home. Some limited specialty services may be provided as part of this plan. However, there are many services the plan does not cover. Please see pages 5-9 for a complete description. Your medical home provider will decide if you need specialty services. (Asset limit may apply) Other Services There are also case managers in your medical homes. These people will help you with personal concerns like transportation and housing. Nurses can help you manage illnesses such as diabetes or high blood pressure.

Note: Emergency room services and transportation to the emergency room are not part of this plan. If you go to the emergency room, this plan will not pay for your visit. You may receive a bill for emergency room and ambulance services.

Note: You may be asked to report your assets and sign a release of information form before you are able to get services outside your medical home.

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This table shows most, but not all covered and uncovered services. The services described here must be approved by the provider in your medical home. Services are subject to change and dependent on available funding. Please ask your provider if you have any questions about the following: SERVICES

PINELLAS COUNTY HEALTH PLAN (PCHP) COVERAGE

GENERAL BENEFIT: PRIMARY, WELLNESS, & PREVENTION

NO CAP, MEMBERS DO NOT PAY A PREMIUM OR COPAY

ABORTIONS ACUPUNCTURE, BIOFEEDBACK, CHELATION THRAPY, CHIROPRACTIC, HYPNOTISM, HERBAL THERAPY MASSAGE

NO COVERAGE

ACUTE (EMERGENCY CARE)

NO COVERAGE NO COVERAGE FOR SERVICES RELATED TO INTOXICATION OR USE OF ILLICIT DRUGS, NOR FOR ALCOHOL RELATED ILLNESSES. DRUG SCREENING IS COVERED

ALCOHOL AND SUBSTANCE ABUSE BEHAVIORAL HEALTH, INCLUDING PSYCHIATRIC CARE, ALCOHOL & SUBSTANCE ABUSE TREATMENT

NO COVERAGE

MEDICAL HOME CONDUCTS SCREENING AND COMPLETES MENTAL HEALTH REFERRAL WHEN APPROPRIATE

CANCER TREATMENT

COVERED FOR PRIMARY SITE ONLY; NO COVERAGE FOR RECURRENCE, METASTASIS OR GI NON-COLORECTAL DIAGNOSES (ESOPHAGUS, HEPATOBILIARY, PANCREATIC, SMALL INTESTINE)

CARDIAC REHABILITATION

COVERAGE BEFORE THE 180 DAY AFTER OPEN HEART SURGERY, MI, or MEDICALLY NECESSARY CARE JUSTIFIED BY A SPECIALIST

CARDIAC DIAGNOSTIC TESTING

MEDICAL HOME REVIEWS FOR NECESSITY: CAPPED

CARPAL OR TARSAL TUNNEL SURGERY

NO COVERAGE

CIRCUMCISIONS

MEDICALLY NECESSARY ONLY

CORRECTIONAL FAC CARE

NO COVERAGE

CUSTODIAL CARE

NO COVERAGE

DENTAL

EXTRACTIONS ONLY: MEDICAL HOME CASE MANAGER COMPLETES REFERRAL

DIALYSIS

NO COVERAGE

DURABLE MEDICAL EQUIPMENT (DME)

LIMITATIONS, EXCLUSIONS and CAPS EXIST

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SERVICES


EMERGENCY ROOM

NO COVERAGE SEE ACUTE (EMERGENCY CARE)

EATING DISORDER TREATMENT

EPIDURAL STEROID INJECTIONS/NERVE BLOCKS EXPERIMENTAL DRUGS/THERAPY/PROCEDURES

NO COVERAGE APPROVAL ON A CASE BY CASE BASIS: EPIDERAL STEROIDS ARE NONSURGICAL INTERVENTIONAL OPTIONS FOR PATIENTS WHO HAVE FAILED CONSERVATIVE MANAGEMENT. TREATMENT MAY BE PROVIDED AS ONE OF A SERIES OF UP TO THREE INJECTIONS, AT INTERVALS OF NO LESS THAN ONE MONTH, BUT NO MORE THAN THREE INJECTIONS WITHIN TWELVE MONTHS.TREATMENT PLAN REVIEW REQUIRED TO SHOW PREVIOUS TREATMENT ATTEMPTED. NO COVERAGE MEDICALLY RELATED VISION PROBLEMS SUCH AS DIABETIC RETINOPATHY, EYE INJURIES, OR CATARACTS ARE COVERED

EYE CARE FLU SHOTS & OTHER VACCINES

PROVIDED IN MEDICAL HOME: BASED ON NATIONAL GUIDELINES

GENETIC COUNSELING AND TESTING

NO COVERAGE

GENDER IDENTIFICATION DISORDERS

NOT COVERED INCLUDING GENDER REASSIGNMENT SURGERY AND MEDICATION THERAPY

HEARING CARE

ROUTINE HEARING EXAMS ARE NOT COVERED; REFER TO DEAF SERVICE CTR.; MEDICALLY RELATED HEARING PROBLEMS, SUCH AS EAR INFECTIONS OR EAR INJURIES ARE COVERED, AS WELL AS HEARING SERVICES INVOLVED WITH SUCH HEARING PROBLEMS

HEPATITIS C

NO COVERAGE

HOME HEALTH


HOSPICE

NO COVERAGE

HOSPITAL (INPATIENT)

COVERAGE ONLY AT PARTICIPATING HOSPITALS (BAYFRONT, MORTON PLANT, MEASE, MEASE COUNTRYSIDE, AND ST. ANTHONY’S)

HYGIENE PRODUCTS

NO COVERAGE

INFERTILITY

NO COVERAGE

INFUSION THERAPY


LABORATORY

INCLUDED WITH ENCOUNTER RATE FOR MEDICAL HOME: SPECIALTY NETWORK TO USE PINCHD CONTRACT WITH LAB CORP

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SERVICES


1 PER BODY PART, ANNUALLY MRI/CT/PET NURSING HOME

NO COVERAGE

OBSTETRICAL/FERTILITY OCCUPATIONAL, PHYSICAL AND SPEECH THERAPY (OUTPATIENT)

NO COVERAGE: REFER PREGNANT WOMEN TO DEPARTMENT OF CHILDREN AND FAMILIES PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH THERAPY HAVE A COMBINED LIMIT OF THIRTY (30) TREATMENTS PER CALENDAR YEAR

ORGAN HARVESTING AND TRANSPLANTS

ORTHOPEDIC/NEURO SURGERY

PAIN MANAGEMENT: ACUTE INJURY, DENTAL, PRE AND POST SURGICAL

PAIN MANAGEMENT; CHRONIC PHYSICAL THERAPY

NO COVERAGE LIMITED COVERAGE: FOCUS ON ACUTE INJURIES OR EXACERBATIONS OR NEUROLOGICAL DEFICITS: JOINT REPLACEMENT ON CASE BY CASE BASIS, NO SPINAL SURGERY FOR CHRONIC ISSUES

PRESCRIPTION COVERAGE FOR CONTROLLED SUBSTANCES INCLUDING TRAMADOL, IS LIMITED TO SHORT –TERM EVENTSS ONLY CHRONIC PAIN MANAGEMENT IS NOT COVERED; SELECTED EXCEPTIONS FOR HEMATOLOGY/ONCOLOGY AND EPIDURAL STEROID INJECTIONS; SEE ABOVE FOR CONTROLLED SUBSTANCES AND TRAMADOL PRESCRIPTION COVERAGE LIMITATIONS

PRESCRIPTIONS

SEE OCCUPATIONAL THERAPY PRESCRIPTION COVERAGE USES A GENERIC BASED FORMULARY WITH A CONTRACTED VENDOR OR PRESCRIPTION ASSISTANCE PROGRAMS; CLIENT TO RETURN TO MEDICAL HOME FOR REVIEW OF ER OR HOSPITAL PRESCRIPTIONS; CONTROLLED SUBSTANCES PRESCRIPTIONS, INCLUDING TRAMADOL IS RESTRICTED. SEE PAIN MANAGEMENT

PROSTHETICS (BRACES)


RADIOLOGY AND OTHER DIAGNOSTIC TESTING SCREENINGS (BREAST, CERVICAL, PROSTATE, COLORECTAL, BONE DENSITY, ETC)

PROVIDED AT MEDICAL HOME: FREQUENCY BASED ON NATIONAL GUIDELINES

SECOND OPINIONS

NO COVERAGE

SEXUAL DYSFUNCTION

NO COVERAGE

SLEEP DISORDERS INCLUDING INSOMNIA

NO COVERAGE

SPECIALTY CARE


MEDICAL HOME REVIEWS FOR NECESSITY: CAPPED

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SERVICES


SPEECH THERAPY

SEE OCCUPATIONAL THERAPY

STERILIZATION PROCEDURE

NO COVERAGE: REFER TO PINCHD 727-462- MALE

STERILIZATION REVERSAL

NO COVERAGE MUST BE MEDICALLY NECESSARY AND NOT PRIMARILY FOR COSMETIC PURPOSES; THIS INCLUDES BUT IS NOT LIMITED TO IMPLANTS, AUMENTATION, REDUCTION, LIFTS/STRETCHES/INJECTIONS, SCAR REVISION, HAIR TRANSPLANTS, OBESITY AND RECONSTRUCTIVE SURGERY NOT COVERED

SURGICAL PROCEDURES TOTAL PARENTERAL NUTRITION

NO COVERAGE

TEMPORO MANDIBULAR JOINT SYNDROME

NO COVERAGE

WOUND CARE


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MY MEDICAL HOME Your PCHP medical home will be either at Pinellas County Health Department or at Community Health Centers of Pinellas, Inc. See below for a complete list of medical homes. Please write the name, location and phone number of your medical home on the front of this handbook. This is your first stop for all your non-emergency health care needs.

Walk-ins may be available.

Please call

ahead for hours. TIP: Have your citizenship and identity documentation ready on your first visit. See page 4 for details.

Please Note: We want your medical home to get a chance to get to know you and plan for your care. You can only change your medical home once per enrollment year.

Important Information Regarding Behavior & Fraud There are some behaviors that are disruptive and unsafe. These behaviors will cause you to be removed from the Pinellas County Health Plan. If you are removed from the plan, you will no longer get health care at your medical home. Examples of these poor behaviors include: • Rude, disruptive or abusive behavior in a medical, dental or county facility • Arriving intoxicated for your appointments • Failure to follow your provider’s recommended plan of care • Failure to inform your provider of any treatment or medications that others prescribe • Repeated failure to keep scheduled appointments • Drug seeking behavior / inappropriate attempts to secure controlled substances (narcotics) In addition: • If you are no longer eligible for the program, you will stop receiving PCHP services. • If you give false information, you will stop receiving PCHP services. • If you get workers’ compensation or an insurance or accident settlement, you must repay the PCHP for all services you have received. • Health and Human Services Department may sue you if you receive PCHP services unlawfully.

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MEDICAL HOMES LOCATIONS Pinellas County Health Department Sites Willa Carson Health Resource Center 1108 N. M. L. King Avenue, Clearwater (727) 467-9411 Pinellas Park Health Center 6350 76th Avenue N., Pinellas Park (727) 547-7780 St. Petersburg Health Center 205 Dr. M. L. King Street N., St. Petersburg (727) 824-6900 Rajendara A. Karkare, MD, PA 10875 Park Blvd., Suite C & D, Seminole (727) 392-8500 Turley Family Care Center 807 Myrtle Avenue, Clearwater (727) 467-2400 American Primary Care, Inc. 2595 Tampa Road, Suite P, Palm Harbor (727) 771-7200 Bestcare 1100 S. Fort Harrison Avenue, Clearwater (727) 365-9478 Professional Health Care of Pinellas, Inc 1839 Central Avenue, St. Petersburg (727) 322-1054

Community Health Centers of Pinellas Sites Johnnie Ruth Clarke Health Center 344 22nd St. S., St. Petersburg, FL, 33712, Tel. (727) 821-6701 Community Health Centers at Largo 12420 130th Ave. N., Largo, FL, 33774, Tel. (727) 587-7729 Community Health Centers at Tarpon Springs 247 S. Huey Avenue, Tarpon Springs, FL, 34689, Tel. (727) 944-3828 Community Health Centers at Pinellas Park 6237 66th Street, Pinellas Park, FL 33781, Tel. (727) 544-2284 Community Health Centers at Clearwater 1020 Lakeview Road, Clearwater, FL 33756, Tel. (727) 461-1439

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PRESCRIPTION SERVICES Where Do I Get My Prescriptions Filled? NORTH COUNTY Pharmacy Sweetbay Pharmacy

Phone (727) 787-3925

Fax (727) 772-0262

(727) 535-2636

(727) 524-3589

(727) 772-0500

(727) 772-0511

(727) 934-3400

(727) 934-3440

(727) 581-0440

(727)585-7500

(727) 441-8482

(727) 461-4386

Address 4665 66th St. North Kenneth City, FL 33709 2139 34th St. North St. Pete, FL 33713

Phone (727) 541-4649

Fax (727) 545-8917

(727) 323-2911

(727) 323-7163

Sweetbay Pharmacy

6851 Gulfport Blvd. South Pasadena, FL 33707

(727) 344-1471

(727) 347-2925

Sweetbay Pharmacy

3327 MLK (9th) St. North St. Pete, FL 33704

(727) 894-4282

(727) 823-2397

Sweetbay Pharmacy

6095 9th Ave.North. St. Pete, FL 33710

(727) 384-4914

(727) 345-5543

Sweetbay Pharmacy

7491 4th St. North. St. Pete, FL 33702

(727) 528-2123

(727) 528-2132

(727) 823-2309

(727) 821-3101

(727) 577-3170

(727) 578-2977

(727) 548-9170

(727) 548-9172

(727) 892-5781

(727) 892-5783

Sweetbay Pharmacy Promise Pharmacy Tarpon Discount Drugs Savon Pharmacy (Albertsons) Savon Pharmacy (Albertsons)

Address 1360 Tampa Road Palm Harbor, FL 34683 2460 East Bay Drive Largo, FL 33771 31818 US Hwy 19 North Palm Harbor, FL 34684 742 South Pinellas Ave Tarpon Springs, FL 34689 10500 Ulmerton Road Largo, FL 33771 2170 Gulf to Bay Blvd Clearwater, FL 33765

SOUTH COUNTY Pharmacy Sweetbay Pharmacy Sweetbay Pharmacy

Sweetbay Pharmacy Garon Pharmacy ASAP Pharmacy Neighborly Care Pharmacy

1734 22nd St. South St. Petersburg, FL 33712 8000 4th St. North St Petersburg, FL 33702 8609 66th St. North, Suite C Pinellas Park, FL 33782 330 5th St. North St. Petersburg, FL 33701

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Pinellas County Health Plan (PCHP)

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