MEMBER RESOURCES
Advance Directive
Advance Directive
Many people worry about their health care if they were not able to make their own decisions. The Patient Self-Determination Act, health care under Florida Law, lets you make choices about your health care. Some of your rights are to accept or refuse health or surgical care and the right to have an advanced directive.
Your Right to Decide
There may be times when you cannot make choices about your health care. You can then choose to have somebody make these choices for you. You can do this using an advanced directive.
What is an Advanced Directive
An advance directive is a written or spoken statement about how you want medical decisions made if you can’t make them yourself. Some people make advance directives when they get very sick or are at the end of their lives. Other people make advance directives when they are healthy. 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.
You may also pick a person to make health care choices for you if you become mentally or physically unable to make your own choices. An advanced directive may be in the form of a Living Will, a Healthcare Surrogate Designation, or both.
Make sure that someone, like your PCP, lawyer, family member, or case manager, knows that you have an advanced directive and where it is located.
If there are any changes in the law about advance directives, we will let you know within 90 days. You don’t have to have an advance directive if you do not want one.
If your provider is not following your advance directive, you can file a complaint with Member Services at 1-833-FCC-PLAN or the Agency by calling 1-888-419-3456.
You may also want to think about the following:
- If you have a healthcare surrogate. Give a copy of the form or the original to the person(s) you have named.
- Give a copy of your advanced directive to your doctor for your health file.
- Keep a copy of your advanced directive in a place where it can be found.
- Keep a card or note in your purse or wallet. It should state that you have an advanced directive and where it can be found.
- If you change your advance directive, make sure your doctor, lawyer and/or a family member has the latest copy.
Click here to complete your Health Care Advance Directives Wallet Card.
Click here to download advanced directive forms. You can also download an advanced directive form from this website: https://www.floridahealthfinder.gov/report-guides/advance-directives
What is a Living Will?
A Living Will tells the kind of medical care you want or do not want. These are in case you become unable to make your own choices. It is called a Living Will because it takes effect while you are still living.
Florida law provides a suggested form for a living will. You may also wish to speak to a lawyer or doctor to make sure that you have finished the Living Will rightly so that your wishes will be understood.
For more information speak with your case manager or call us at 1-833-FCC-PLAN or TTY 711.
What is a Healthcare Surrogate?
A Healthcare Surrogate Designation is a signed, dated and witnessed paper stating that another person can make health care choices for you. This is an important document to have in case you cannot make healthcare choices for yourself.
You may also name a second person if your first choice is not available. You can include details about any treatment care you want or do not want. Florida law also provides a form you can use for designation of a healthcare surrogate. You may also wish to speak to a lawyer or doctor. This is to make sure that you have finished the Healthcare Surrogate Designation right. You want to make sure that your wishes will be clear.
For more information speak with your care manager or call us at 1-833-FCC-PLAN or TTY 711.
Living Will or Healthcare Surrogate, which one should you choose?
A Living Will and Healthcare Surrogate Designation are two unique, yet alike forms. You can have two forms. Also, you can combine them into one form. Which form of advanced directive you use is your choice. You can change your mind or cancel it at any time. The only time an advanced directive may be used is when you cannot make healthcare choices for yourself. Once you are able to make these choices on your own again, the advanced directive will not be in effect. Your advanced directive will remain on ‘stand-by’. If you ever become disabled again and cannot make health care choices for yourself, your advanced directive will come into effect.
If your directive is not being followed, you can call the state’s complaint line at 1-888-419-3456.
Your primary care doctor must teach you about advanced directives. They should detail this in your health record.
You can also download more info about advance directives by going to the Agency for Health Care Administration website at www.floridahealthfinder.gov/report-guides/advance-directives
Complaints, Grievances, and Plan Appeals
We want you to be happy with us and the care you receive from our providers. Let us know right away if at any time you are not happy with anything about us or our providers. This includes if you do not agree with a decision we have made.
If you are not happy with us or our providers, you can file a complaint.
Complaints
If you are not happy with us or our providers you can call us at any time at 1-833-FCC-PLAN or TTY 711. We will try to solve your issue within 1 business day.
If you are not happy with the choice made on your complaint you may file a formal grievance with Florida Community Care.
Filing a Grievance?
If you want to file a grievance, write us or call us at any time. Call us to ask for more time to solve your grievance if you think more time will help.
To file a grievance, you can:
Call Member Services 8 a.m. to 8 p.m. Monday through Friday (ET) at 1-833-FCC-PLAN or TTY 711.
Or write us a letter telling us why you are not happy. Be sure to include:
- Your first and last name
- Your Enrollee ID card number
- Your address and telephone number
Mail the letter to:
Florida Community Care
Attn: Grievances and Appeals
4601 NW 77th Ave,
Miami, FL 33166
1-833-FCC-PLAN
We will review your grievance and send you a letter with our decision within 90 days. If we need more time to solve your grievance, we will send you a letter with our reason and tell you about your rights if you disagree.
If you would rather have someone speak for you, let us know. Another person can act for you. You have the right to review your grievance file at any time.
Appeals
If you do not agree with a decision we made about your services, you can ask for an Appeal.
To file an appeal, you can:
Call Member Services 8 a.m. to 8 p.m. Monday through Friday (ET) at 1-833-FCC-PLAN or TTY 711.
Or write us a letter telling us why you are not happy. Be sure to include:
- Your first and last name
- Your Enrollee ID card number
- Your address and telephone number
Mail the letter to:
Florida Community Care
Attn: Grievances and Appeals
4601 NW 77th Ave,
Miami, FL 33166
1-833-FCC-PLAN
You can write us, or call us and follow up in writing, within 60 days of our decision about your services. Ask for your services to continue within 10 days of receiving our letter, if needed. Some rules may apply.
We will send you a letter within 5 business days to tell you we received your appeal. We will also help you complete any forms that are needed. We will review your appeal and send you a letter within 30 days to answer you.
Expedited or Fast Appeals
If you think waiting for 30 days will put your health in danger, you can ask for an Expedited or “Fast” Appeal. Write us or call us within 60 days of our decision about your services.
To ask for an Expedited or "Fast" Appeal, you can:
Call Member Services 8 a.m. to 8 p.m. Monday through Friday (ET) at 1-833-FCC-PLAN or TTY 711 within 60 days of our decision about your services.
Or write us a letter telling us why you are not happy. Be sure to include:
- Your first and last name
- Your Enrollee ID card number
- Your address and telephone number
Mail the letter to:
Florida Community Care
Attn: Grievances and Appeals
4601 NW 77th Ave
Miami, FL 33126
1-833-FCC-PLAN
We will give you an answer within 48 hours after we receive your request. We may also call you the same day if we do not agree that you need a fast appeal, and send you a letter within 2 days.
Discrimination Complaints
Florida Community Care complies with all Federal civil rights laws and does not exclude people or treat them differently in admission to, access to, or employment in its programs, services, or activities on the basis of race, color, national origin, age, disability, or sex.
In accordance with federal law, communication aids and services are provided free of charge in order ensure equal opportunity and effective communication.
If you believe we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you may submit a discrimination complaint with Florida Community Care.
Case Management
If you have a medical condition or illness that requires extra support and coordination, we may assign a case manager to work with you. Your case manager will help you get the services you need. The case manager will work with your other providers to manage your health care. If we provide you with a case manager and you do not want one, call Member Services at 1-833-FCC-PLAN or TTY 711 to let us know.
If you are in the LTC program, we will assign you a case manager. You must have a case manager if you are in the LTC program. Your case manager is your go-to person and is responsible for coordinating your care. This means that they are the person who will help you figure out what LTC services you need and how to get them.
If you have a problem with your care, or something in your life changes, let your case manager know and they will help you decide if your services need to change to better support you.
Changing Case Managers
If you want to choose a different case manager, call Member Services at 1-833-FCC-PLAN or TTY 711. There may be times when we will have to change your case manager. If we need to do this, we will send a letter to let you know.
Important Things to Tell Your Case Manager
If something changes in your life or you don’t like a service or provider, let your case manager know. You should tell your case manager if:
- You don’t like a service
- You have concerns about a service provider
- Your services aren’t right
- You get new health insurance
- You go to the hospital or emergency room
- Your caregiver can’t help you anymore
- Your living situation changes
- Your name, telephone number, address, or county changes
Order Quality Initiative
Emergency and Urgent Situation
Emergency Care
You have a medical emergency when you are so sick or hurt that your life or health is in danger if you do not get medical help right away. Some examples are:
- Broken bones
- Bleeding that will not stop
- You are pregnant, in labor and/or bleeding
- Trouble breathing
- Suddenly unable to see, move, or talk
Emergency services are those services that you get when you are very ill or injured. These services try to keep you alive or to keep you from getting worse. They are usually delivered in an emergency room.
If your condition is severe, call 911 or go to the closest emergency facility right away. You can go to any hospital or emergency facility. If you are not sure if it is an emergency, call your PCP. Your PCP will tell you what to do.
The hospital or facility does not need to be part of our provider network or in our service area. You also do not need to get approval ahead of time to get emergency care or for the services that you receive in an emergency room to treat your condition.
If you have an emergency when you are away from home, get the medical care you need. Be sure to call Member Services when you are able and let us know.
Hospital Care
If you need to go to the hospital for an appointment, surgery or overnight stay, your PCP will set it up. We must approve services in the hospital before you go, except for emergencies. We will not pay for hospital services unless we approve them ahead of time or it is an emergency.
If you have a case manager, they will work with you and your provider to put services in place when you go home from the hospital.
Urgent Care
Urgent Care is not Emergency Care. Urgent Care is needed when you have an injury or illness that must be treated within 48 hours. Your health or life are not usually in danger, but you cannot wait to see your PCP or it is after your PCP’s office has closed.
If you need Urgent Care after office hours and you cannot reach your PCP, call your case manager at 1-833-FCC-PLAN.
You may also find the closest Urgent Care center to you by checking the Florida Community Care online directory. Follow these instructions:
- Select ‘Urgent Care’ from the Provider Type dropdown
- Select one of the following:
- by zip code
- by distance from a zip code
- by city/county/stateno preference
- Enter your zip code, city, county, or stateSelect any other options important to you (i.e.: languages spoken, etc.)
- Select ‘Search’
Behavioral Health Emergency
Are having a true behavioral health emergency? Do you think that you are a danger to yourself or others? Call “911” or go the nearest emergency room for care if you think you are.
Examples of emergency mental health problems include:
- Likely danger to self or others.
- The person is not able to carry out actions of daily life
- Harm that will likely cause death or serious harm to the body
How to Get Medical Care When You Are Out of the Service Region
If you are out of the area and have an emergency, go to the nearest emergency room or call 911. Show your primary Medicaid/Medicare insurance ID Card.
If you are away and have an urgent problem, go to an urgent care clinic. You may go to any primary care doctor where you are. Be sure to show your primary Medicare/Medicaid insurance ID card.
Out of Network Care
Florida Community Care expects you to get a referral before services are obtained. Services by out of network providers may not be paid unless prior authorization is obtained by your Case Manager.
Post Stabilization Services
Prior authorization is not needed required for emergency services or post stabilization care. This is whether you receive this care within or outside of the Florida Community Care network.
What to do in an Emergency?
An emergency is when you have severe pain, illness or injury. It could result in danger to you or your unborn child.
- Call 911 right away if you have an emergency or go to the nearest emergency room.
- Emergency rooms are for emergencies. Call your doctor before going unless your emergency is severe.
- You can call our 24-hour health advice line at 1-866-406-7136. You will be connected to a nurse. Have your Florida Community Care Long Term Care ID card number handy. The nurse may direct you to other care or may help you over the phone.
For enrollees with Medicare coverage, to get emergency services, you should follow the instructions of your primary Medicare insurance.
Enrollees have the right to use any hospital or other settings for emergency care.
Member Rights & Responsibilities
As an enrollee of Florida Community Care, it is important that you know your rights and responsibilities. These rights and responsibilities are provided to you in accordance with the Florida Patient’s Bill of Rights and Responsibilities.
Rights
As a recipient of Medicaid and a member in a Plan, you also have certain rights. You have the right to:
- Be treated with courtesy and respect
- Have your dignity and privacy respected at all times
- Receive a quick and useful response to your questions and requests
- Know who is providing medical services and who is responsible for your care
- Know what member services are available, including whether an interpreter is available if you do not speak English
- Know what rules and laws apply to your conduct
- Be given information about your diagnosis, the treatment you need, choices of treatments, risks, and how these treatments will help you
- Say no any treatment, except as otherwise provided by law
- Be given full information about other ways to help pay for your health care
- Know if the provider or facility accepts the Medicare assignment rate
- To be told prior to getting a service how much it may cost you
- Get a copy of a bill and have the charges explained to you
- Get medical treatment or special help for people with disabilities, regardless of race, national origin, religion, handicap, or source of payment
- Receive treatment for any health emergency that will get worse if you do not get treatment
- Know if medical treatment is for experimental research and to say yes or no to participating in such research
- Make a complaint when your rights are not respected
- Ask for another doctor when you do not agree with your doctor (second medical opinion)
- Get a copy of your medical record and ask to have information added or corrected in your record, if needed
- Have your medical records kept private and shared only when required by law or with your approval
- Decide how you want medical decisions made if you can’t make them yourself(advanced directive)
- To file a grievance about any matter other than a Plan’s decision about your services
- To appeal a Plan’s decision about your services
- Receive services from a provider that is not part of our Plan (out-of-network) if we cannot find a provider for you that is part of our Plan.
- Speak freely about your health care and concerns without any bad results
- Freely exercise your rights without the Plan or its network providers treating you badly
- Get care without fear of any form of restraint or seclusion being used as a means of coercion, discipline, convenience or retaliation
- Receive information on beneficiary and plan information
- Obtain available and accessible services covered under the Plan (includes In Lieu of Services (ILOS)
LTC Members have the right to:
- Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation
- Receive services in a home-like environment regardless where you live
- Receive information about being involved in your community, setting personal goals and how you can participate in that process
- Be told where, when and how to get the services you need
- To be able to take part in decisions about your health care.
- To talk openly about the treatment options for your conditions, regardless of cost or benefit
- To choose the programs you participate in and the providers that give you care
Responsibilities
As a recipient of Medicaid and a member in a Plan, you also have certain responsibilities. You have the responsibility to:
- Give accurate information about your health to your Plan and providers
- Tell your provider about unexpected changes in your health condition
- Talk to your provider to make sure you understand a course of action and what is expected of you
- Listen to your provider, follow instructions and ask questions
- Keep your appointments or notify your provider if you will not be able to keep an appointment
- Be responsible for your actions if treatment is refused or if you do not follow the health care provider's instructions
- Make sure payment is made for non-covered services you receive
- Follow health care facility conduct rules and regulations
- Treat health care staff with respect
- Tell us if you have problems with any health care staff
- Use the emergency room only for real emergencies
- Notify your case manager if you have a change in information (address, phone number, etc.)
- Have a plan for emergencies and access this plan if necessary for your safety
- Report fraud, abuse and overpayment
LTC Members have the responsibility to:
- Tell your case manager if you want to disenroll from the Long-term Care program
- Agree to and participate in the annual face-to-face assessment, quarterly face-to-face visits and monthly telephone contact with your case manager
Patient Responsibility
You have to pay for the patient responsibility when you live in a facility, like an assisted living facility or adult family care home. Patient responsibility is the money you must pay towards the cost of your care. DCF will tell you the amount of your patient responsibility. Patient responsibility is based on your income and will change if your income changes.