Tampa RGN HMO DIR AUG 2013.pdf - Simply Healthcare Plans

5What is “urgently needed care”? (this is differentfrom a medical emergency.)“Urgently needed care” is a non-emergency situationwhere you need medical attention right away for anunforeseen injury or illness.What is the difference between a “medicalemergency” and “urgently needed care”?The main difference between a “medical emergency” and“urgently needed care” is the seriousness of the conditionand/or the perceived endangerment of your health.A “medical emergency” is when you believe that yourhealth is in serious danger. “Urgently needed care” is carethat you get for an unforeseen injury or illness but yourhealth is not considered to be in serious danger.Most urgent care may be handled by your PCP. However,if you are out of the service area and require “urgentlyneeded care”, Simply Healthcare Plans, Inc. will pay forthe services.Getting the care you need urgently when you are inthe plan’s service area…If you have a sudden illness or injury that is not a medicalemergency and you are in the Plan’s service area, pleasecontact your PCP. If your PCP office is closed, pleasecontact the PCP’s after-hour service. If you require TTYaccess to your PCP, call the Florida Relay Service 711. Ifyou feel you need immediate medical attention, please goto the nearest Urgent Care Center or Emergency Room.Please keep in mind that if you have an urgent need forcare while you are in the Plan’s service are, you should getthis care from network providers. In most cases, the Planwill not pay for “urgently needed care” that you get froman out-of-network provider while you are in the plan’sservice area.Getting the care you need urgently when you areoutside the plan’s service area…Simply Healthcare Plans, Inc. covers “urgently neededcare” that you get from out-of-network providers when youare outside the Plan’s service area. If you need urgent carewhile you are outside the plan’s service area, you shouldcall your PCP. If you are treated for an urgent conditionwhile out of the service area, we prefer you return to theservice are to get follow-up care through your PCP.However, we will cover follow-up care that you get fromout-of-network providers outside the Plan’s service area aslong as the care you are getting still meets the “urgentlyneeded care” definition. We also cover renal dialysis(kidney) services that you get when you are outside theplan’s service area.You must use plan providers except in emergency orurgent care situations or for out-of-area renal dialysis orother services. If you obtain routine care from out-ofnetworkproviders neither Medicare nor Simply HealthcarePlans, Inc. will be responsible for the costs.What is the service area for SimplyHealthcare Plans, Inc.The counties in our service area are listed below:Hillsborough, Hernando, Pasco, Pinellas and PolkCountiesHow do you find Simply Healthcare Providersin your area?A Provider Directory is sent to each member of SimplyHealthcare Plans, Inc. every year. The Provider Directorylists participating providers in the service area.Use the index at the back of the directory to locate byprovider name or zip code. Beginning on page 209If you have any questions about Simply Healthcare Plans,please call our Member Services Department at 1-877-577-0115. From October 1, 2012 through February 14,2013 our hours of operation are 8 a.m. to 8 p.m. 7 days aweek. From February 15, 2013 until September 30, 2013our hours of operation are Monday through Friday 8 a.m.to 8 p.m. You may leave us a voice mail message afterhours,Saturdays, Sundays and holidays and we will returnyour call the next business day. TTY/TDD users should call711. Or, visit www.mysimplymedicare.com.Tampa RegionSimply Healthcare Medicare Provider/Pharmacy Directory