Get the Most from Your Coverage
You Deserve Quality Healthcare. You also deserve to have the information you need to get the most from your coverage. Goals for quality are set and reviewed by your health plan to make sure you get the care you need.
This information is part of a Quality Program designed to improve the services and care you receive. It provides details about your coverage and services available to you.
Contact Member Services to learn more about the Quality Program.
Know Your Rights
Being a member means there are things you should expect from your health plan. These are some of your rights:
- You should have access to all the services available to members
- You should be treated with courtesy and respect
- You should be able to get a copy of your medical record
- You should know your medical data will be kept private. There are policies in place to guard your health records and protected health information.
It’s also important to know what you can do to get the most from your coverage:
- Ask questions if you don’t understand your rights
- Be sure to keep your scheduled appointments
- Keep your Member ID Card with you so you have it at appointments
- Tell your doctor if you have gotten care in an emergency room.
The full list of rights and responsibilities is in your Enrollee Handbook (PDF).
WellCare of Kentucky promises to keep your race, ethnicity, and Language (REL) information private. We use some of the following ways to protect your information.
- Keeping paper documents locked in file cabinets
- Requiring that all electronic information stays on physically secure media
- Maintaining your electronic information in password-protected files
We may use or share your REL info to perform our work. These activities may include:
- Finding health care gaps
- Making intervention programs
- Designing and directing outreach materials
- Telling health care professionals and doctors about your language needs
We will never use your REL information for approving, rate setting or benefit decisions. We will not give your REL information to unauthorized people.
Getting the Care You Need
Your PCP is the doctor you’ll see for routine checkups and care. Your PCP will help find other types of healthcare providers if you need one. You can also search Find-a-Provider on your health plan website.
As children get older, they should change from seeing a pediatrician to seeing an adult doctor. Teens don’t need checkups as often as young kids do, but they should see their PCP at least once a year. Regular visits will help them stay up to date on vaccines. If teens have a condition such as diabetes or asthma, it’s very important that they keep seeing their doctors and not miss a visit. Call your health plan if you need help finding an adult provider.
You should be able to schedule an appointment with your PCP and get medical care when you need it. You may have to wait a little longer to get in to see certain other types of providers, like specialists. Call your health plan if you can’t get an appointment in a timely manner.
Interpreter services are provided free of charge to you when talking with your health plan or doctors and during the grievance process. This includes American Sign Language and real-time oral interpretation by certified medical interpreters. Our interpreters have demonstrated proficiency in both English and the non-English language of the member.
If you need something translated into a language other than English, please call WellCare of Kentucky at 1-877-389-9457 (TTY: 711). We can also provide materials in other formats such as Braille, CD or large print.
If you need an interpreter for your medical appointment, contact WellCare of Kentucky before your appointment. We will arrange for an interpreter to be at your appointment.
You should get high quality medications and the right treatment for your conditions. Not all drugs are covered. Some may need to be approved before they’re covered.
The Preferred Drug List (PDL) is located on your health plan website. It is updated regularly and lists drugs that are covered by insurance. Talk to your doctor or pharmacist to review the PDL and answer questions about your medications.
The Utilization Management (UM) Department looks at your health records and may also talk with your doctor to decide if a service you need is covered.
These decisions are not based on financial reasons. Doctors and staff are not rewarded for saying no to care.
All UM decisions are based on:
- If the service is medically necessaryIf the service works well
- If the service is right for you
New medicines, tests and procedures come out every year. A team of doctors and other experts decide if new medical care will be covered by your health plan. Your plan covers care that is medically necessary. Not every new medical service is covered for all members.
If a service is denied, you have the right to appeal that decision. You will be sent a letter explaining how to make an appeal. All appeal requests are decided according to your request, condition and benefits.
Care Management is for members who may need extra help taking care of their health. Some people have several health conditions and see more than one doctor. Others need help arranging the services their doctors may have ordered. Working with a care manager lets you understand major health problems, work well with your doctors and get the care you need.
Get More Information
Your Enrollee Handbook is a great source for information about your coverage and benefits.
It also lists important phone numbers.
Call: You can also contact Member Services for additional help at 1-877-389-9457 (TTY 711). Translation services are available if you need them.
Call Member Services to get:
- A paper copy of your Enrollee Handbook (PDF), Privacy Notice or anything on your health plan website
- Help finding a doctor and making an appointment
- Help speaking with a care manager
- Help with an appeal for a service that’s been denied
- Help with a ride to your appointment
Your health plan website also has a lot of helpful information.
Visit it to find the Enrollee Handbook (PDF), Find-a-Provider tool, and the Preferred Drug List. You can also use it to help you manage your health.
Creating an online member account is free and easy. With it, you can:
- Find or change your PCP
- Request a new Member ID Card or print a temporary ID Card
- View and update your personal information
You can also send a message directly to your health plan from your member account.