Florida KidCare is the state of Florida’s high-quality, low-cost health and dental insurance program for children. There are four Florida KidCare partners. Each partner provides insurance to different groups of children:

• The Florida Healthy Kids Corporation runs Florida Healthy Kids for children ages 5 through the end of age 18.
• The Agency for Health Care Administration runs Medicaid for children from birth up to age 1 and MediKids for children ages 1 up to 4.
• The Department of Health runs the Children’s Medical Services Managed Care Plan for children from birth up to age 19 with special health care needs.
• The Department of Children and Families runs the Behavioral Health Network for children ages 5 up to 19.

Florida Healthy Kids is health and dental insurance for children whose families meet certain income and other eligibility requirements. The health and dental insurance benefits are provided by insurance companies using a managed care model.

The goal of managed care is to provide high-quality health care at low costs. The Florida Healthy Kids insurance companies use many approaches to do this, but two of the main approaches are:

• Creating a provider network. Network doctors and other health care providers agree to certain rules, like how quickly the doctor must give enrollees an appointment or, if a specialist is needed, the doctor must refer enrollees to a network specialist. Except for emergencies, enrollees must see a network provider.
• Having rules about when and what kinds of services, supplies, devices, and other products are covered. Florida Healthy Kids insurance companies only pay for medically necessary services.

No. Your child’s health insurance company is Community Care Plan. Community Care Plan is your primary source of information about the covered benefits and services available to your child.

You can change insurance companies only at certain times and for certain reasons.

Log into your online account to change insurance companies during your child’s first 90 days of enrollment or during your child’s annual renewal period.

Call Florida KidCare at 1-888-540-KIDS (5437) to change companies if your child no longer lives in the plan’s service area.

You may also call Florida KidCare to change companies for one of these reasons:

• Your child’s doctor does not, because of moral or religious obligations, provide a service your child needs.
• Your child needs related services to be done at the same time and your child’s primary care provider determines that receiving the services separately would subject your child to unnecessary risk, but not all related services are available in the plan’s network.
• Your child has an active relationship with a health care provider who is not in the plan’s network, but who is in the network of another subsidized plan in the area.
• The plan is no longer available in the area where your child lives.
• The Florida Healthy Kids Corporation requires the insurance company to take action to improve quality of care.
• Other reasons determined by the Florida Healthy Kids Corporation, including, but not limited to, lack of access to services or providers with the appropriate experience to provide care to your child.

You can pick one of the health insurance companies available where you live. You can find out which insurance companies are available in your area using the interactive map at www.healthykids.org/benefits/providers/map.php, or by finding your county on the list on pages 10 and 11 of the Member Handbook.

No, Community Care Plan cannot disenroll your child directly.

If Community Care Plan believes that your child is not eligible for Florida Healthy Kids, Community Care Plan may ask the Florida Healthy Kids Corporation to review and verify your child’s eligibility. When an eligibility review request is made, Community Care Plan must include the reason why the child may not be eligible and how the information was obtained.

The Florida Healthy Kids Corporation will determine whether a child can remain enrolled.

Call Florida KidCare at 1-888-540-KIDS (5437) and tell them you want to disenroll your child. Coverage ends at 11:59 p.m. on the last day of the month during which you call to cancel coverage. In other words, if you call on January 15th to cancel your child’s coverage, your child will have coverage through January 31st.

You may re-enroll your child in Florida Healthy Kids as long as eligibility requirements are met. Call Florida KidCare at 1-888-540-KIDS (5437) to find out if you need to go through the application process again and when your child’s coverage can start.

The chart below shows some of the reasons a child may lose eligibility for Florida Healthy Kids and when coverage ends.

*Does not include any applicable eligibility and enrollment dispute period

Florida Healthy Kids covers important benefits like:

• Well-child visits
• Office visits to your PCP (Primary Care Provider)
• Office visits to specialists (doctors who focus on one area of health)
• Immunizations (shots your child gets to avoid illnesses like the flu or measles)
• Prescription drugs
• And more!

The chart on page 15 of the Member Handbook lists all covered services.

Community Care Plan provides all covered benefits and does not exclude any benefits (see page 15 of the Member Handbook because of moral or religious objections). If your child’s doctor will not provide services because of moral or religious objections, call Community Care Plan. Community Care Plan will help you access those services.

Except for emergency situations, your child must see a network provider for the services to be covered. You may also need to get a referral from your child’s PCP to see a specialist. See Provider Network section of the Member Handbook for more information about this requirement.

It depends. Some services require a copayment, a specified amount you pay to the provider when your child receives services. A copayment is sometimes called a copay. Not all services require a copayment. Preventive services, like well-child visits and routine vision screenings, are free! American Indians and Alaskan Natives who meet certain requirements do not pay any copayments.

The Medical and Prescription Benefits sections includes information about the required copayments for common covered services.

Yes. Your out-of-pocket costs are limited to 5 percent of your family's gross annual income (income before taxes and other deductions) each plan year. Out-of-pocket costs for a Florida Healthy Kids health plan include any copayments you pay. Monthly premium wouldn't apply to a full-pay family's out-of-pocket costs. For subsidized enrollees, the monthly premium also counts.

The plan year is your child's continuous eligibility period. The continuous eligibility period is the 12 months following enrollment approval.

The preferred drug list may change from time to time. The current preferred drug list is available on our website: www.ccphealthykids.org. You will be notified if Community Care Plan makes a change to the preferred drug list that will impact your child’s current prescriptions.

Community Care Plan has a committee of physicians and medical professionals including pharmacists that decides which medications go on the preferred drug list. The committee considers issues like:

• How well a medication works for most people;
• Potential side effects or bad reactions; and
• The cost of a particular drug relative to comparable drugs.

Community Care Plan will cover the brand name medication if your child’s provider specifies “dispense as written” on the prescription. The phrase “dispense as written” tells the pharmacist not to make any substitutions. If your child’s doctor does not indicate “dispense as written” and you ask the pharmacist for the brand name medication, you may have to pay the full cost of the medication.

A network provider is a doctor, other health care professional, hospital, other health care facility, pharmacy, or medical supply company that has a contract with Community Care Plan to see Florida Healthy Kids enrollees.

Community Care Plan has a provider directory on its website so you can search for network providers in your area by name or provider type. The online provider directory is updated regularly when Community Care Plan receives new information from providers.

Community Care Plan also has a printable copy of the provider directory available. You can find this document on www.ccphealthykids.org or you can call:

Community Care Plan Member Services
Available Monday through Friday from 7:30 AM to 7:30 PM EST
1-866-930-0944 or TTY/TDD 1-855-655-5303

and request a copy. Community Care Plan will mail a copy to you for free. The copy is updated at least monthly, but it may not be as accurate as the online provider directory.

Remember to ask your doctor’s office if they still accept Community Care Plan – Florida Healthy Kids. Be sure to say Community Care Plan and Florida Healthy Kids, not just Florida Healthy Kids.

Please call:

Community Care Plan Member Services
Available Monday through Friday from 7:30 AM to 7:30 PM EST
1-866-930-0944 or TTY/TDD 1-855-655-5303

Ask the doctor to email a letter of interest to Community Care Plan at CCP.Provider@ccpcares.org. The letter should state that the provider would like more information on joining the Community Care Plan – Florida Healthy Kids network of providers.

When your child becomes a member of Community Care – Florida Healthy Kids, you have the right to choose from any PCP in our network. If you did not choose a PCP for your child, we will assign one. The name and phone number of the PCP are located on your child’s ID card.

You can choose a new PCP by visiting our provider directory at www.ccphealthykids.org. To choose a new PCP for your child, please call:

Community Care Plan Member Services
Available Monday through Friday from 7:30 AM to 7:30 PM EST
1-866-930-0944 or TTY/TDD 1-855-655-5303

You can also call Community Care Plan Member Services and we can assist in you in locating a new PCP for your child.

You may choose any network PCP that is accepting new patients. If your child already sees a network PCP who is not accepting new patients with the plan, your child’s doctor may be willing to continue seeing your child. Call and ask the doctor’s office. If your doctor agrees, call Community Care Plan and we can confirm with your child’s doctor and assign him or her as your child’s PCP. Not all doctors are able to accommodate this request. If your child’s doctor is not able to continue seeing your child, you must choose a new PCP.

You can search for a provider online at www.ccphealthykids.org or you can call:

Community Care Plan Member Services
Available Monday through Friday from 7:30 AM to 7:30 PM EST
1-866-930-0944 or TTY/TDD 1-855-655-5303

Call the doctor’s office and tell them:

• You want to make an appointment;
• If your child is a new patient;
• Why you want to see the doctor; and
• The name of your child’s plan which is Community Care Plan - Florida Healthy Kids

Ask these questions:

• Do I need to bring anything to the appointment?
• Are there forms I can fill out ahead of time?
• What do I do if I need to change or cancel?
• Is there a fee if I cancel an appointment?

Have your schedule in front of you when you call so you know which days and times an appointment will work for you.

Your child’s doctor needs this card and may not see your child if you do not have it with you.

Your child’s PCP or primary dentist can provide most of your child’s medical services. He or she is the person who can help you make the best decisions about your child’s care, including when your child should see a specialist. Florida Healthy Kids requires a referral for most services that are not provided by your PCP or primary dentist because this helps ensure your child receives the most appropriate care. Plus, your PCP and primary dentist are the most up-to-date on your child’s medical and dental health.

1. Call your child’s PCP. Sometimes you will need to make an appointment to see the PCP. Depending on the type of specialist your child needs and how familiar the PCP is with your child’s issue, the PCP may not need to see your child first.

2. If your child’s PCP thinks your child should see a specialist, he or she will refer your child to a network specialist. Some PCP offices give you the referral for you to take with you to the specialist appointment. Others send the referral to the specialist for you. Be sure to confirm that the specialist’s office receives the referral.

3. Call the specialist to make an appointment. Be sure to do this in a timely manner or you may need to make another appointment with your child’s PCP. Some PCP offices will do this for you, but you need to let them know the days and times you can get to the appointment.

4. If the PCP gave you a referral, remember to take it with you to your child’s appointment.

Your child will need a referral for most services not provided by your child’s PCP. If your child sees a specialist without a referral, you may have to pay the full cost of that visit, which is much higher than your copayment. Your child may see some specialists without a referral. Please refer to the plan-specific handbook for more information.

Your child’s PCP may need to get prior authorization from Community Care Plan before Community Care Plan pays for a specific service. Your child’s provider is responsible for requesting prior authorizations, so you do not need to do anything. If Community Care Plan does not approve or cover a service, your child can still have the services, but you will have to pay for those services.

You can always call Community Care Plan Member Services if you have questions or concerns.

Florida Healthy Kids plans are required to make sure your child gets the services he or she needs. If there are not any network providers, please call:

Community Care Plan Member Services
Available Monday through Friday from 7:30 AM to 7:30 PM EST
1-866-930-0944 or TTY/TDD 1-855-655-5303

Community Care Plan will make other arrangements for your child to receive medically necessary covered services.

You can ask for a second opinion. A second opinion is when you take your child to another doctor about the same issue for which your child has already seen a doctor.

You can request a second opinion for a provider that is not in our network if a network provider is not available to provide the service for your child. Please ask your child’s PCP to request a second opinion for your child.

You should feel comfortable discussing your child’s health and treatment options with your child’s doctor. Ask questions when you do not understand something and ask about the pros and cons of a treatment option. Consider choosing a new doctor for your child if you often do not feel comfortable asking questions or you do not get the information you need.

Community Care Plan is required to have a network with enough providers to ensure enrollees have timely access to covered services.

Sometimes it is not possible for Community Care Plan to meet these requirements. Often, this is because not enough health care providers work in the area. Sometimes not enough health care providers will see children or accept the plans offered through Florida Healthy Kids.

If your child needs services from a certain type of provider, Community Care Plan can help you find one in your area. If there are no providers in the network nearby, Community Care Plan will arrange for your child to see an out-of-network provider. You must go through Community Care Plan to see an out-of-network provider unless your child requires emergency services.

Community Care Plan makes sure most enrollees can get to their doctors within a certain amount of time or a certain distance from their home. For example, if you live in a city (urban), you should be able to get to a network PCP in about 20 minutes or within 20 miles from your home. These are called network access standards.

The Florida Healthy Kids network access standards are:

Network providers agree to provide Florida Healthy Kids enrollees with appointments within the timeframes listed below. If a network provider tells you that you must wait longer than these timeframes, please call:

Community Care Plan Member Services
Available Monday through Friday from 7:30 AM to 7:30 PM EST
1-866-930-0944 or TTY/TDD 1-855-655-5303

• If your child experiences a life-threatening emergency and needs immediate care, please go to the nearest emergency room or call 911.
• Routine care – care that may be delayed without expectation that your child’s condition will get worse without care within a week – must be provided within seven (7) days of your request for services.
• Routine physical exam – an annual well-child exam – must be provided within four weeks of request for services.
• Follow-up care – care provided after treatment of a condition – must be provided as medically appropriate and as directed by your child’s health care provider.
• Urgent care – care required within twenty-four (24) hours to prevent the condition from becoming an emergency – must be provided within twenty-four (24) hours of request. Know where the closest urgent care center for this type of care is located. Urgent care centers are often open late and on weekends.

There are a few ways to access care after normal business hours, depending on your child’s needs:

• Providers with extended hours
  • Some providers offer evening or weekend office hours.
  • Call the provider’s office or visit their website to find out when they are open.
• Urgent care centers
  • Urgent care centers see patients who need immediate, but not emergency attention and their PCP is not available.
  • Some urgent care centers require you to make an appointment while others allow walk-ins. Be sure to call ahead and ask.
• 24-hour Nurse Helpline: 1-833-925-0451
  • Nurses will answer your health questions twenty-four (24) hours, seven (7) days a week.
• Emergency room
  • If you child is experiencing a life-threatening emergency, call 911 or go to your nearest emergency room.

Call 911 or take your child to the emergency room if he or she has an emergency medical condition. This means an injury or illness, including severe pain, that needs care right away to avoid serious danger to your child’s life or pregnancy, or to avoid serious damage to your child’s health.

Avoid taking your child to the emergency room for common illnesses, such as colds or earaches with low fever. Your child’s PCP can effectively treat most childhood illnesses. Plus, your PCP knows the most about your child’s health history so they can help you make the best medical decisions. Using your child’s health history and routine screenings results in better treatment for your child, and the PCP may catch and treat other health issues before they become a problem.

An HRA is a series of questions about your child’s health as well as lifestyle. The answers to these questions aid our health care team in finding out what activities may put your child’s health at risk as well as what services we can offer you and your child to live his/her best life.

The HRA is included in the Welcome Package that you receive when your child is enrolled in Community Care Plan – Florida Healthy Kids. Community Care Plan offers incentives for completing this survey within ninety (90) days of enrollment. The quicker you complete it, the higher the incentive. If you need assistance or prefer to complete the HRA by phone, you can call:

Community Care Plan Member Services
Available Monday through Friday from 7:30 AM to 7:30 PM EST
1-866-930-0944 or TTY/TDD 1-855-655-5303

If your child moves from one Florida Healthy Kids plan to another Florida Healthy Kids plan without a break in coverage (this means your child did not go a month or more without Florida Healthy Kids coverage in between changing insurance companies), the plans will follow a standard transition of care policy to ensure your child gets the care he or she needs.

Your child’s new plan will cover any ongoing course of treatment the previous plan authorized for sixty (60) days. This means your child can:

• Receive planned services or treatment;
• Continue to see the same provider, even if the provider isn’t in the new plan’s network; and
• Continue to take the same prescription. You may be required to use a network pharmacy.

The best way to make sure this transition goes smoothly is to call your child’s new plan to tell them about the types of continued care your child needs.

It depends. Your child’s new plan will have your child’s PCP, or another appropriate doctor, review your child’s treatment plan during the first sixty (60) days after the plan change. This review will help ensure that needed services continue to be authorized. Your child may be required to see a network provider.

Yes. Exceptions to the standard sixty (60) days are:

• Maternity care: including prenatal and postpartum care through completion of postpartum care (six (6) weeks after birth);
• Transplant services: through the first post-transplant year;
• Radiation and chemotherapy: through the current round of treatment;
• Orthodontia: services will be continued without interruption until completed (or the benefit is exhausted, whichever comes first), but your child may be required to see a network orthodontist after the first sixty (60) days;
• Controlled substance prescriptions: if a new, printed paper prescription is required by Florida law, the new plan will help you schedule an appointment with the original prescribing provider, or a new provider if needed, so your child can get a new prescription without a medication gap.

No. Your child’s previous plan and new plan are responsible for coordinating the transfer of medical records and other necessary information between themselves and can assist providers with obtaining necessary medical records. In some situations, you may need to ask your child’s previous providers to send medical records to the new providers just like you would if your child were changing providers for any other reason.

Your child’s new plan will cover care performed by certain out-of-network providers during the transition of care period, as described in this section. If you receive a bill from one of these providers, call your child’s new plan and be prepared to send them a copy of the bill.

A grievance is a formal complaint you make to Community Care Plan – Florida Healthy Kids about some aspect of your child’s health care services.

An appeal is a written request you make to Community Care Plan to review Community Care Plan’s decision to deny a service or payment.

You may file a grievance when you are dissatisfied about something other than your child’s benefits, such as:

• A doctor’s behavior;
• The quality of care or services your child receives; or
• Long office waiting times.

You can file a grievance anytime by mail, phone, fax or email:

Community Care Plan will send you an acknowledgment letter within five (5) calendar days of getting your verbal or written grievance. From this date, Community Care Plan will review and make a final decision about your grievance within ninety (90) calendar days.

You may file an appeal when you receive an adverse benefit determination, such as when:

• A request for service has been limited or denied;
• An existing service has been decreased or discontinued; or
• Community Care Plan has issued a denial of payment.

Appeals may be filed in writing or verbally within sixty (60) calendar days from the date that you receive a notice of adverse determination for your child. You must file a written appeal ten (10) calendar days after you file a verbal appeal. You may file an appeal in the following ways:

Community Care Plan will make a decision and notify you within thirty (30) calendar days of receiving your appeal request.

If Community Care Plan doesn’t have enough information to process the appeal and the delay is in your best interest, they may ask for fourteen (14) more calendar days. If you need to provide more information, you may also request an extension of fourteen (14) calendar days.

You may appoint an authorized representative or a provider to act on your behalf.

Community Care Plan can also help you complete forms and answer questions related to the grievances and appeals process. Call our Member Services Line and ask for the Grievance & Appeals Coordinator.

You can request an expedited (fast) appeal if you or your provider feels that waiting the standard thirty (30) calendar days for an appeal decision would put your child’s life, pregnancy, or health at risk.

If Community Care Plan agrees that the appeal needs to be expedited, we will make a decision and inform you within seventy-two (72) hours after receiving the appeal. If Community Care Plan does not agree with the request for an expedited appeal, Community Care Plan will let you know, and the timeframe will go back to the standard appeal timeframe of thirty (30) calendar days.

Unlike a standard appeal, if you make your request for an expedited appeal verbally, and if Community Care Plan agrees that it needs to be expedited, you do not need to follow up with a written appeal request.

If your appeal request was not approved, you can request an independent review. The appeal decision notice you receive from Community Care Plan will tell you how. You may also call our Member Services Line and ask for the Grievance & Appeals Coordinator.

Send a letter or an email to the Florida Healthy Kids Corporation with the reasons you think the decision is wrong. Your dispute must be received within ninety (90) calendar days from the date on the decision notice (letter or email from Florida KidCare). You can:

• Email the letter to resolve@healthykids.org; or
• Mail the letter to:
  Florida Healthy Kids Corporation,
  P.O. Box 980
  Tallahassee, Florida 32302.
  Remember to put your family account number in your letter.

The Florida Healthy Kids Corporation will respond to your dispute in writing. If the decision is not in your favor, you can send a second dispute to senior management at the Florida Healthy Kids Corporation. If that decision is not in your favor, you can send your dispute to the Agency for Health Care Administration. Each of these steps will be described in detail in any denial letters sent to you.

Anna notices that documents from her son’s insurance company show that he received an MRI two (2) weeks ago. Anna is sure that her child did not receive an MRI. If the doctor intentionally billed the plan for an MRI that her child did not receive, the doctor committed fraud.

Anna’s son had his annual well-child check-up last month, which included a routine basic metabolic panel (a blood test that evaluates important measurements like blood sugar and calcium levels). The results came back great.

Today Anna’s son has a sore throat and she takes him to the doctor to be tested for strep throat. The doctor orders the strep test and also orders another basic metabolic panel. The doctor might be committing abuse since Anna’s son recently had good results and this test won’t help the doctor figure out the cause of a sore throat.

Most Florida Healthy Kids families pay monthly premiums of $15 or $20, but the total cost of coverage is much higher! The rest of your child’s Florida Healthy Kids coverage is paid for with state and federal tax dollars. When providers or other people receive payments or benefits, they should not, those tax dollars are wasted instead of going to children who need services.

If you think a doctor or someone else who works at a medical office or facility, like a hospital or surgical center, may have committed fraud or abuse, you can report it to Community Care Plan. Call Community Care Plan Special Investigations Unit at 954-622-3489 or email your report to ccp.siu@ccpcares.org.

If you think Community Care Plan has committed fraud or abuse, please report the details to the Florida Healthy Kids Corporation by calling 1-850-701-6104 or emailing resolve@healthykids.org.