- Member Handbook
- What is Ped-I-Care?
- Our Role
- Your Doctor
- Emergency Care
- Services for your Child
- Ped-I-Care is here for you
- Paying Your Premium
- Identification Card
- Member's Rights and Responsibilities
- Complaints and Grievances
- Description of Services
- Coordination of Care
- Referrals and Authorizations
- Contact Information
Ped-I-Care is a managed health care plan. We work closely with Children’s Medical Services (CMS) to provide your child’s health care. Ped-I-Care works with the Children’s Medical Services program. CMS cares for children with special health care needs. Ped-I-Care and CMS have a network of doctors and other providers to provide your child with the best care possible.
The Ped-I-Care program is run by the Department of Pediatrics at the University of Florida’s College of Medicine. The name Ped-I-Care comes from our full name: The University of Florida Pediatric Integrated Care System. Our staff and the doctors, nurses and other health care professionals in our network of providers are all very concerned about children and their health.
Our goal is to see that your child receives the best health care services possible.
We know that children with special needs often require more time and resources than other children. We hope to make your life a little easier. We will work closely with your doctors and your CMS Nurse Care Coordinator (NCC) to make sure your child gets the health care services he or she needs.
We at Ped-I-Care, with your CMS Nurse Care Coordinator, are responsible for making sure that your child gets the health care services he or she needs, including visits to various specialists, therapists, and hospital care.
We also want to make sure everyone works together. Communication is key. We want to hear from you. We want to know what you like about the care your child receives. We also want to know what changes you think will make it better. Our Member Services Department can answer your questions. We’ll also listen to your suggestions. Call us at 1-866-376-2456 and let us know what you think! Ask for Ped-I-Care Member Services.
Every child in Ped-I-Care will have a Primary Care Physician or “PCP”. Your PCP is normally a pediatrician or family doctor. He or she will coordinate all your child’s health care needs.
Your child’s PCP will watch over your child’s medical condition. He or she will make sure your child receives the special care needed for his/her well-being. Your PCP will get to know your child personally. He or she will provide regular check-ups and take care of routine problems. Your PCP will make referrals to specialists and other providers for the services your child needs. It is important to keep your PCP informed. That way, your child’s medical services can be coordinated. This will ensure your child’s care can be focused on his or her individual needs.
Always contact your PCP if you think your child needs medical treatment. Your PCP is responsible for referrals to other health care providers your child needs. Do not schedule any appointments for health care without involving your Primary Care Physician.
If you are out of town and think your child needs medical care, call your PCP. Remember that any care, other than emergency care, will need to be approved by your doctor.
If for any reason you want to change your child’s PCP, call Ped-I-Care Member Services at 1-866-376-2456. We will assign a new doctor as soon as possible. Once you choose a new PCP, please contact his or her office so they can request your child’s medical record. You’ll also need to schedule an office visit for your child to meet with your new PCP.
All doctors in Ped-I-Care have agreed to help our families at any time you need them. If your child is sick and you are not sure what to do, call your PCP or Specialist. Your doctor will help you decide the best treatment. Your doctor may tell you what you can do at home or may suggest that your child needs to be seen immediately.
If your doctor sends you to the emergency room, he or she should contact the hospital. He or she will tell them you are coming and describe the problem. Only when there is a medical emergency, should you take your child to an emergency room without contacting your doctor. A medical emergency is one that is an immediate threat to your child’s life or will cause serious permanent damage if not addressed immediately.
If you take your child to an emergency room, be sure to show them your child’s CMS/Ped-I-Care ID card so they will know how to contact us after the visit.
Please call your PCP within one day after taking your child to an emergency room. You’ll need to notify him or her of the visit and arrange for follow-up care, if necessary.
Ped-I-Care will pay for services that are provided or arranged by your PCP. Services provided by Ped-I-Care include:
- All doctor visits
- Hospital care
- Therapies (Physical, Respiratory, Speech and Occupational)
- Chiropractic services
- Vision services and glasses
- Hearing services and hearing aids
- Medical equipment
- Home health care
- Prescribed Pediatric Extended Care (PPEC)
- Laboratory work
- Radiology (X-Ray studies)
- Mental health services
- Skilled nursing facility
- Dental care
- Transportation
Children’s Medical Services (CMS) is responsible for providing: Prescription drug coverage / Pharmacy services
Please show your CMS/Ped-I-Care ID card to the provider for all of the above services. Your PCP or the CMS Nurse Care Coordinator can help with arrangements for any of these services.
More information about these services can be found under Description of Services.
We want to make sure that your child gets the services he or she needs to maintain or improve his or her health. To ensure this, we use a process called Utilization Management. Utilization Management ensures that services being considered by your doctors are provided in an appropriate and cost-effective manner.
Our Member Services Department will be happy to help you if you have any questions about services offered and how to obtain them.
Other than your monthly premium, there are no out of pocket costs for services covered by Ped-I-Care. It is very important that you pay your monthly premium to KidCare on time.
If you miss the payment deadline you may lose your health insurance and your Ped-I-Care coverage. It takes a minimum of 30 days to be reinstated.
Please remember that your KidCare premiums are due by the 1st of the month for the following month’s coverage. You must make your payment even if you have not received your coupon book. You can make your payment by any of the following methods:
- Mailing a check or money order with payment coupon to: Florida KidCare, PO Box 31105, Tampa, FL 33631-3105. Remember to write your child’s member number on your check or money order.
- Over the internet at http://www.flkidcarepayments.com/ or
- By telephone, 24 hrs. a day, 7 days a week at 1-800-821-KIDS (5437).
Select the prompt to "make an automated payment". VISA, MasterCard and Discover are accepted. You also can make payments directly from your checking or savings account. The system will let you know if a fee will be charged.
If you are having trouble with your monthly payments, talk to your CMS Nurse Care Coordinator right away (see page 14). Don’t lose this great opportunity to provide your children good quality health care!
Ped-I-Care will pay for all covered services as long as they are provided or arranged by your PCP. If you seek medical care without involving your PCP, Ped-I-Care will not be able to pay for the service. Ped-I-Care will not pay for services obtained outside the Ped-I-Care program.
If you obtain services outside the network on your own, you may have to pay for these services yourself. If you take your child to the emergency department and the doctor says the situation is not an emergency, you should call your PCP for treatment.
You will receive a CMS/Ped-I-Care identification card. Please check it to make sure all the information is correct. If there is an error, please call Ped-I-Care Member Services so we can correct it.
You should always have the ID card with you. You will need to show it every time you seek health care for your child.
Member Rights and Responsibilities
Rights
Each CMS/Ped-I-Care member/family has a right to:
- Be treated with respect, courtesy and dignity
- Protection of your child’s privacy
- A prompt, courteous, and responsible response to your questions
- Information about your child's condition, treatment plan alternatives, and expected outcome
- Expect that your child's medical and personal information be kept confidential. Personal information will only be released if you give permission or the release is required by law
- Participate in decisions about the care of your child
- Receive information about Ped-I-Care and CMS and our services
- Express complaints or grievances regarding the program or care provided
Responsibilities
Members and their family members are responsible for:
- Giving health care providers accurate and complete information regarding your child's health
- Reporting unexpected changes in your child’s health to the specialist caring for your child, your child’s PCP, or the CMS Nurse Care Coordinator
- Using specialty and related services only when referred by your PCP
- Presenting your child’s CMS/Ped-I-Care ID card to each health care provider before receiving services (carry it with you at all times)
- Notifying Ped-I-Care Member Services and KidCare of address or telephone number changes
- Following the treatment plan outlined by your doctors or, if this is not possible, requesting a new plan of treatment
- Notifying your PCP within one business day if you use the emergency room for services
If you have a complaint or concern about the services your child receives from a Ped-I-Care Provider, contact Member Services. You can also contact us if you have a concern about Ped-I-Care policies. Our staff will listen to your complaints. We’ll do our best to handle the problem. You also may contact your CMS Nurse Care Coordinator. However, Ped-I-Care will want to hear your concerns directly from you.
You have a right to express any complaints about the services your child receives. Ped-I-Care has an obligation to respond to your complaint. After looking into the complaint, Ped-I-Care will call you and send you a written response. If you are not satisfied with the response, you may file a grievance.
A grievance is a strong statement of dissatisfaction. It must be submitted in writing. Please contact Member Services to request a grievance form. We will send you the grievance form within 3 days of your request. Ped-I-Care’s Grievance Committee will review your complaint and make a decision on what to do. Ped-I-Care is required to follow up on grievances in writing within 60 days, unless you and Ped-I-Care agree to allow more time. If you need help filling out the Grievance form, please contact Member Services (1-866-376-2456) and someone will help you.
If you are not satisfied with the response to your grievance, you may request a meeting with the Grievance Committee. This will allow you to discuss your issue and present your point of view. After this meeting, the decision of the Grievance Committee will be sent to you in writing. If you still are not satisfied with the response, you may appeal to the Statewide Children’s Medical Services Network Grievance Panel.
If you would like the complete description of the complaint and grievance procedure, we will send it to you. Call Member Services at 1-866-376-2456. You can also write to us at:
Ped-I-Care
1701 SW 16th Avenue, Building A
Gainesville, FL 32608
or ask your CMS Nurse Care Coordinator for help.
Well Child Care:
Children should receive health check-ups at:
- 12 months
- 15 months
- 18 months
- 24 months
- Once a year from age 3 to 21 years
A Well Child Check-up includes:
- Hearing screening
- Vision screening
- Dental screening
- Health and developmental history
- Immunizations (when needed)
- Treatment as needed
Hospital Care: All approved hospital services will be covered. This includes room and board, nursing care, medical supplies, and all diagnostic and therapeutic services.
Laboratory and Radiology (X-Ray): Laboratory and X-ray studies (including X-Ray, CT scan and MRI) ordered by your child's doctor are covered. These must be provided by facilities in the Ped-I-Care network (see Provider Directory).
Emergency Care: If your child has a medical emergency, take him or her to the nearest emergency department. You do not need approval for emergency care. You do not have to pay for emergency care. However, the doctor in the emergency center may determine your child's problem is not an emergency. You will be told this before your child is treated. If the situation is not an emergency, contact your PCP.
Home Health: Ped-I-Care covers medically necessary nursing services and personal care services. This includes skilled nursing, private nursing, and home health aides. These services must be requested by your PCP and approved by Ped-I-Care. Meals on Wheels, homemaker, and babysitting services are not covered.
Durable Medical Equipment: Ped-I-Care also pays for medical equipment your child needs. An authorization for these items is required.
Therapy Services: Ped-I-Care covers medically necessary therapy services. This includes physical therapy, respiratory therapy, speech therapy and occupational therapy. These services must be requested by your PCP and approved by Ped-I-Care.
Vision Care: Ped-I-Care covers vision services, eye exams and eyeglasses. No referral or authorization is required for an optometrist or optician. A referral from your PCP is required from your PCP is required to see an ophthalmologist.
Hearing Services: Ped-I-Care covers check-ups and hearing aids. These services must be requested by your PCP and approved by Ped-I-Care.
Family Planning: Ped-I-Care covers family planning services from any family planning provider.
Your child will have a CMS Nurse Care Coordinator who will assist you with managing and coordinating your child's care. Your Nurse Care Coordinator will assist you in arranging the following services:
Transportation: Transportation is covered by Ped-I-Care. It may be arranged based on need by the local CMS Area Office. Please call your child's CMS Nurse Care Coordinator to arrange for transportation.
Dental Care: Dental care is covered by Ped-I-Care. It may be arranged by your child’s CMS Nurse Care Coordinator. Please call your child's CMS Nurse Care Coordinator to arrange for dental care.
Nutrition Services: Nutrition services may be covered by the local CMS Area Office. It may be arranged by your child’s CMS Nurse Care Coordinator. Please call your child's CMS Nurse Care Coordinator to arrange for nutrition care.
Prescription Drugs: Prescription drugs and infusion products are covered by CMS. Your doctor will give you a prescription and tell you where it can be filled. Please present your CMS/Ped-I-Care identification card to the pharmacy. Prescription information is on the back of the card. For any problems or special pharmacy issues, please call your child's CMS Nurse Care Coordinator.
Ped-I-Care believes it is very important that your child’s Primary Care Physician (PCP) be aware of and coordinate all of your child’s care and treatments. This helps ensure that the various treatments your child receives are appropriate and cost effective. To make sure your PCP is involved in coordinating your child’s health care, most specialty services are available only at your PCP’s request. This request is called a referral. Some services also require an additional approval called an authorization.
Listed below is a list of services that require a referral or authorization. Please do not schedule any of these services without first contacting your PCP.
The following services require a referral from your child’s PCP:
- Specialist visits (Specialists who wish to refer to another Specialist will need to involve the PCP in the referral process)
- Chiropractic visits
- Hearing services
The following services require Ped-I-Care authorization:
- Any out-of-network service
- Hospital inpatient admissions (except emergencies, but please notify your PCP within 24 hours if your child is seen in the emergency room or an urgent care center)
- Certain outpatient diagnostic services:
- MRA/MRI
- PET Scan
- Colonoscopy/Endoscopy
- Durable Medical Equipment (unless the item is provided as part of a covered serviced in a physician’s office setting)
- Select hearing items (including hearing aids, cochlear implant devices)
- Home health care
- Rehabilitation services (Physical Therapy, Respiratory Therapy, Occupational Therapy, Speech/Language Therapy)
- Hospice
- Portable X-Ray (provided at home)
A referral or authorization is NOT required for the following services:
- Visits to see your PCP
- Services (shots, tests, durable medical equipment, etc.) provided as part of a covered service in your doctor’s office
- Laboratory tests
- EKG and EEG
- Radiology (X-rays)
- Eye exams/checkups performed by an optometrist
- Covered eyeglasses
- Podiatry
Your PCP will know how to request a referral or authorization for services needed for your child. The referral and authorization information needed by your PCP is on your child’s member I.D. card. If you have any questions about the referral and authorization process, please contact your PCP or your CMS Nurse Care Coordinator.
Contact your CMS Nurse Care Coordinator at your local CMS Area Office:
G.L. Schiebler CMS Center
1701 SW 16th Avenue, Building B
Gainesville, FL 32608
Phone: 352-334-1400
Fax: 352-334-1389
CMS – Daytona Beach
421 Keech Street
Daytona Beach, FL 32114
Phone: 386-238-4980
Fax: 386-254-3937
CMS - Ocala
1515 E. Silver Springs Blvd, Ste.215
Ocala, FL 34470
Phone: 352-369-2100
Fax: 352-369-2134
CMS – Jacksonville
910 North Jefferson Street
Jacksonville, FL 32209
Phone: 904-360-7070
Fax: 904-798-4569
Contact Ped-I-Care Member Services at:
Ped-I-Care
1701 SW 16th Ave
Gainesville, FL 32608
Phone: 352-334-1705
Toll Free: 866-376-2456
Fax: 352-955-6518
