Member Handbook

Transcription

Member Handbook

UniCare Health Plan of West Virginia, Inc.
Member Handbook
Mountain Health Trust
West Virginia Health Bridge
UWV-MHB-0006-15 08.15
Dear Member:
Welcome to UniCare Health Plan of West Virginia, Inc.! This is your member handbook. Here,
you will find:
• How your health plan works
• Which services are covered and which are not
• How you can get help understanding your benefits
• How you can get help if you have a problem with your plan or provider
• How you can contact a case manager for help with an ongoing health issue
• Your member rights and responsibilities
• How we keep your information private
• Free extra benefits to help keep you healthy
You should have already received your UniCare member ID card. Your ID card lists your
primary care provider (PCP). If you want to change your PCP, you can choose one from the
UniCare provider directory at unicare.com/medicaid. Just give us a call or send us the PCP
Selection Form found at the back of this book.
If you have not yet received your member ID card, please call our Customer Care Center toll
free at 1-800-782-0095 (TTY 1-866-368-1634) Monday through Friday from 8 a.m. until 6 p.m.
Tell the Department of Health and Human Resources (DHHR) if you move. If you move,
call your Department of Health and Human Resources (DHHR) caseworker. We may still be
your health plan if you stay in state. Call us to get a provider directory with a list of providers
near your new home. You also can find the provider directory at unicare.com/medicaid.
Get one-on-one help. Call or drop by our office in Charleston to talk with our staff. The
friendly staff is ready to serve you.
200 Association Drive, Suite 200
Charleston, WV 25311
1-888-611-9958
You also can call our 24-hour nurse help line, 7 days a week at 1-888-850-1108
(TTY 1-800-368-4424).
We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.
If you have speech or hearing loss, call the TTY line at 1-866-368-1634.
unicare.com/medicaid
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Nurse case management and social worker services
UniCare has nurse case managers and social workers to assist you with your health care
needs. They can help you set health goals. They can help make sure you are seeing the right
providers. Our social workers will also help you find assistance for housing, food and utilities.
To enroll in case management or to speak with a social worker, call our Customer Care Center
at 1-800-782-0095. Press option 1 for case management.
Make sure you use providers in the UniCare network
Unless it is an emergency, you must use providers in our network. If no one in our network can
give you the care you need, your PCP will get an OK from us to send you to a provider that is
not in our network.
For emergency or urgent care, you do not need to get an OK from us at all. You do not need
an OK from us or need to be referred by your PCP to get family planning care. You may go to
any qualified family planning provider.
UniCare is happy to offer access to health care services throughout West Virginia, except
Cabell and Wayne counties.
If you have any questions, or if you need this translated or in another format such as Braille,
large print or audio at no cost to you, please call our Customer Care Center toll free at
1-800-782-0095 (TTY 1-866-368-1634) Monday through Friday from 8 a.m. until 6 p.m.
Sincerely,
Mitch Collins
Health Plan President
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1-800-782-0095 (TTY 1-866-368-1634)
Table of Contents
How to get health care when you need it .............................................................................. 1
Let a nurse help you decide what to do.................................................................................. 1
Deciding where to go — urgent care center or emergency room? ......................................... 1
Urgent care center .............................................................................................................. 1
Emergency room ................................................................................................................ 1
How to get health care fast ................................................................................................. 1
Important STEPS to remember ............................................................................................... 5
Important phone numbers ...................................................................................................... 6
Benefits quick reference guide .............................................................................................. 8
Mountain Health Trust benefits .............................................................................................. 8
West Virginia Health Bridge benefits ...................................................................................... 9
Copays ............................................................................................................................. 10
Getting to know your health plan ......................................................................................... 12
Your UniCare member ID card ............................................................................................. 12
What is a primary care provider? ......................................................................................... 13
Initial health assessment ...................................................................................................... 14
Court-ordered care ............................................................................................................... 15
Provider directory ................................................................................................................. 15
Getting a second opinion ..................................................................................................... 20
What UniCare covers............................................................................................................. 21
What UniCare does not cover ............................................................................................... 34
What West Virginia Fee-for-Service MEDICAID covers ...................................................... 35
Emergency and urgent care services .................................................................................. 35
What is an emergency? ....................................................................................................... 35
Post-stabilization .................................................................................................................. 36
What to do when you need urgent care ............................................................................... 36
Your prescription drug benefits ........................................................................................... 36
Programs to help keep you healthy ..................................................................................... 40
For women ........................................................................................................................... 40
For you and your child.......................................................................................................... 40
For weight loss ..................................................................................................................... 41
For peace of mind ................................................................................................................ 41
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For tobacco cessation .......................................................................................................... 41
Disease Management .......................................................................................................... 42
Help with special services .................................................................................................... 43
How to resolve a problem with UniCare .............................................................................. 44
Filing a complaint ................................................................................................................. 45
Grievance and appeals for dental services .......................................................................... 49
State Fair Hearing ................................................................................................................ 51
If we can no longer serve you .............................................................................................. 53
Other INFORMATION you need to know .............................................................................. 53
Contacting Customer Care Center ....................................................................................... 53
If you have other insurance .................................................................................................. 54
Reporting waste, abuse and fraud ....................................................................................... 54
Advance directives (living wills) ............................................................................................ 55
Your member rights and responsibilities ............................................................................ 58
Definitions .............................................................................................................................. 61
Notice of Privacy Practices................................................................................................... 64
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HOW TO GET HEALTH CARE WHEN YOU NEED IT
Let a nurse help you decide what to do.
If you are unsure where to go for care, call our 24-hour nurse help line toll free at
1-888-850-1108 (TTY 1-800-368-4424). A nurse will help you decide which type of care makes
the most sense. Plus, you can find out how to treat yourself at home.
Deciding where to go — urgent care center or emergency room?
Urgent care center
Go to the urgent care center if you need care right away, but it isn’t an emergency.
• Minor allergic reactions
• Mild asthma
• Coughs, sore throat
• Bumps, cuts, scrapes
• Rashes, minor burns
• Sprains, strains
• Minor fevers, colds
• Minor headaches
• Ear or sinus pain
• Burning with urination
• Eye swelling, irritation, redness or pain
• Nausea, vomiting, diarrhea
• Animal bites
• X-rays
• Stitches
Emergency room
Go to the emergency room right away for:
• Any life threatening or disabling condition
• Sudden or unexplained loss of consciousness
• Chest pain; numbness in the face, leg or arm; difficulty speaking
• Severe shortness of breath
• High fever with stiff neck, mental confusion or difficulty breathing
• Coughing up or vomiting blood
• Cut or wound that won’t stop bleeding
• Major injuries
• Possible broken bones
How to get health care fast
Sometimes, you need health care when your primary care provider (PCP) can’t see you. You
still have choices. In a true emergency, call 911 or go to the emergency room.
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When you need urgent care now:
1. Call your PCP. Ask if you can get in right away.
2. Call our 24-hour nurse help line at 1-888-850-1108 and ask a nurse.
3. Go to an urgent care center, like the ones in this handbook.
When you visit one of the urgent care centers in this handbook, UniCare will help cover the
cost. Before you go, call the center and ask:
• What are your hours?
• Do you give the care I need?
Urgent care centers
EZ Care
324 A/B Penco Road
Weirton, WV 26062
304-224-1096
Ohio Valley Medical Quick
Care, Inc.
324 Pike St.
Marietta, OH 45750
740-374-4540
EZ Care
2107 Pike St., Suite 5
Parkersburg, WV 26101
304-424-7200
MedExpress Urgent
Care Weirton
218 Three Springs Drive
Weirton, WV 26062
304-723-3627
MedExpress Urgent Care
Parkersburg
1500 Grand Central Ave.
Suite 115
Vienna, WV 26105
304-485-3627
Huntington
3120 US Rte. 60
Huntington, WV 25705
304-522-3627
Wheeling
620 National Road
Suite 300
Wheeling, WV 26003
304-233-3624
Martinsburg
1355 Edwin Miller Blvd.
Suite A
Martinsburg, WV 25404
304-263-6753
Teays Urgent Care
113 Liberty Square
Shopping Center
Hurricane, WV 25526
304-757-4007
EZ Care
260 Russell Ave.
New Martinsville, WV
26155
304-398-4949
Ohio Valley Medical Quick
Care, Inc.
517 36th St.
304-485-1044
South Charleston
4812 Maccorkle Ave. SW
S. Charleston, WV 25309
304-768-3627
Charleston
5430 Maccorkle Ave. SE
304-925-3627
Braxton Health Associates
617 River St.
Gassaway, WV 26624
304-364-8941
Elm Grove
10 Elm Grove Crossing
Mall
Wheeling, WV 26003
304-242-4228
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Beckley
1709 Harper Road
Beckley, WV 25801
304-256-8671
Community Care of WV Inc.
11 N. Locust St.
Buckhannon, WV 26201
304-473-1440
Whitehall Medical
60 Roxbury Road
Fairmont, WV 26554
304-363-6600
Beckley Crossing
520 Beckley Crossing Ctr.
Beckley, WV 25801
304-252-6639
Medpointe of Harrison
County
469 Emily Drive
Clarksburg, WV 26301
304-423-5180
Cross Lanes
5161 Washington St., W.
Cross Lanes, WV 25313
304-755-5323
Primecare 12
702 Stafford Drive
Princeton, WV 24740
304-425-0085
Bridgeport Express Care,
Inc.
2 Chenoweth Drive
Bridgeport, WV 26330
304-842-3330
Morgantown
215 Don Knotts Blvd.
Suite 130
Morgantown, WV 26501
304-291-3627
Princeton
277 Greasy Ridge Road
Princeton, WV 24740
304-425-7615
Bridgeport
120 Medical Park Drive
Suite 100
304-842-3278
WVU Fast Care Center
1075 Van Voorhis Road
Suite 100
Morgantown, WV 26505
304-599-2273
Lewisburg
1318 Jefferson St. N.
Suite A
Lewisburg, WV 24901
304-645-2164
Bridgeport
1370 Johnson Ave.
304-842-7186
Elkins Express Care
1513 Harrison Ave.
Suite 18
Elkins, WV 26241
304-637-0180
Direct Care of Elkins
720 Beverly Pike
Elkins, WV 26241
304-636-4585
Health Matters Urgent Care
14302 Barton Blvd. S.W.
Cumberland, MD 21502
301-729-3278
Winchester Gateway
207 Gateway Drive
Winchester, VA 22603
540-535-1029
Direct Care of Parsons
307 Main St.
Parsons, WV 26287
304-478-2511
Jefferson Urgent Care
Route 340 N.
84 Somerset Blvd.
Somerset Village Shopping
Center
Charles Town, WV 25414
304-728-8533
Fairmont
630 Fairmont Ave.
Fairmont, WV 26554
304-363-6662
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Glen Dale
1585 Wheeling Ave.
Glen Dale, WV 26038
304-843-5381
Teays Valley
563 State Route 34
Hurricane, WV 25526
304-757-5063
Bluefield
4003 College Ave.
Suite B
Bluefield, VA 24605
276-322-2085
South Parkersburg
2832 Pike St.
Suite 1
304-489-3815
Community Care of WV Inc
7576 Seneca Trail
Hillsboro, WV 24946
304-924-6262
SE Emergency Physicians
124 Brookshire Lane
Beckley, WV 25801
304-255-9205
Wait times for appointments
We want you to be able to get care at any time. When your PCP’s office is closed, an
answering service will take your call. Your PCP should call you back within 30 minutes. Once
you talk to your PCP and set up an appointment, you will be able to see your PCP as follows:
Type of appointment
Emergency exam
Urgent (sick) exam
Nonurgent (sick) exam
Nonurgent routine exam
Specialty referrals
Time frame
Immediate access during office hours
Within 48 hours of request
Within 72 hours of request
Within 21 days of request
Within three weeks for routine referrals;
within 48 hours for urgent referrals
Travel times for appointments
Type of appointment
PCP office, pharmacy, and frequently used
specialists
Basic hospital services
Third party services
Federally qualified health centers and rural
health clinics
Travel time
30 minutes or less
45 minutes or less
60 minutes or less
30 minutes
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IMPORTANT STEPS TO REMEMBER
•
Keep your UniCare member ID card with you at all times. Show this ID card every time you
need health care services. Do not let anyone else use your UniCare ID card.
•
Your ID card lists your primary care provider (PCP). Check that the PCP listed is the one
you want. A PCP will be your main provider. Your PCP will give you an OK for needed
treatment. If you want to change your PCP, call us to let us know right away.
•
Set up an initial health assessment (IHA) or a first exam with your PCP as soon as you can.
If you are an adult, your first health review should be within 90 days after joining UniCare. A
child should be seen by a PCP within 60 days after joining the plan. During the first exam,
the PCP can learn about your health care needs and teach you ways to help you stay
healthy.
•
Call your PCP before you get medical care unless you have an emergency. Your provider’s
office will help you set up a time for care. If you need a ride to and from your provider visit,
call us. You may see a family planning provider, inside or outside of the UniCare network,
without an OK from your PCP.
•
If you have an emergency, get help right away. Call 911 or go to the nearest emergency
room for health care. You do not need an OK from us for emergency care. It does not
matter if you are inside or outside of our service area. You will be covered for emergency
care even if the provider is not part of the UniCare network. There is no extra cost to you
for emergency services inside or outside of our service area.
•
If you are not sure what to do, you can call our 24-hour nurse help line at 1-888-850-1108.
Have your UniCare ID card ready when you call. The nurse will ask for your member ID
number.
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IMPORTANT PHONE NUMBERS
Enrollment Broker
Call this number to join a new health plan or disenroll
from your current plan.
1-800-449-8466
UniCare Customer Care Center (CCC)
Call this number if you have questions about UniCare, pharmacy,
behavioral health, or if you would like to speak to a nurse to enroll
in case management.
1-800-782-0095
UniCare CCC TTY
1-866-368-1634
UniCare Office
Call this number for help with local resources.
1-888-611-9958
Scion Dental
Call this number for help finding a dentist or to learn more
about your dental benefits.
1-877-408-0917
Scion Dental TTY
1-800-508-6975
24-hour nurse help line
Call this number to talk in private with a nurse 24/7, even on
holidays.
1-888-850-1108
24-hour nurse help line TTY
1-800-368-4424
National Poison Control Center
Call this number for poison prevention advice and help
with treatment. The line is open 24 hours a day, 7 days a week.
1-800-222-1222
Utilization Management/Prior Authorization
1-866-655-7423
Call this number for help with services that need an OK from UniCare
before you receive the care.
Vision Service Plan
Call this number for help finding an eye doctor or to learn more
about your vision benefits.
1-800-877-7195
Vision Service Plan TTY
1-800-428-4833
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West Virginia Department of Health and Human Resources
(DHHR)
1-877-716-1212
Call this number if you move, change your phone number or become pregnant. You can also
call this number for nonemergency transportation to your provider visit or other covered
service.West Virginia Relay Service
1-800-982-8772
This number allows people who have a hearing or speech loss to
communicate with a trained person who can help them speak with
someone who uses a regular telephone.
West Virginia Relay Service TTY
1-866-368-1634
The TTY number is for members with hearing or speech loss only.
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BENEFITS QUICK REFERENCE GUIDE
Mountain Health Trust benefits
Children (0 up to 21 years )
Ambulatory surgical center services
Inpatient services

Inpatient hospital care

Inpatient rehabilitation

Inpatient behavioral health and
substance abuse

Inpatient psychiatric services
Outpatient services

Diagnostic X-ray, laboratory services
and testing

Physical therapy

Speech therapy

Occupational therapy

Behavioral health
Physician/NP/NMW/FQHC/RHC services

Primary/Preventive care visits

Physician office visits

Specialty care

Podiatry
Cardiac and pulmonary rehabilitation
Dental services

Orthodontics
Home health
Durable medical equipment

Orthotics and prosthetics
Family planning services and supplies
Hospice
Ambulance
Prescriptions
Chiropractic services
Tobacco cessation
Diabetes management
Skilled nursing
Vision
Hearing
EPSDT (Well-child visits)
Behavioral health rehabilitation
 Residential treatment
Psychological services
Adults (21 years and older)
Inpatient services
 Inpatient hospital care

Inpatient behavioral health and
substance abuse
Outpatient services
 Diagnostic X-ray, laboratory services
and testing
 Physical therapy
 Speech therapy
 Occupational therapy
 Behavioral health
 Primary/Preventive care visits
 Physician office visits
 Specialty care
 Podiatry
Dental services (Emergency treatment)
Home health

Orthotics and prosthetics
Hospice
Ambulance
Prescriptions
Tobacco cessation
Diabetes management
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The services below are covered through West Virginia Fee-For-Service Medicaid, not
through UniCare. For information on how to use these services, look at the section of
the handbook that explains what West Virginia Fee-For-Service Medicaid covers.
Drugs for the treatment of hemophilia
Nursing home services
Nonemergency transportation
Birth to 3 services
Abortion
Abortion
Personal care services
School based services
*There are additional services to those included on this list. If you have questions on whether a
service is covered, look at the services in the covered services section of the handbook or give
us a call.
West Virginia Health Bridge benefits
Children (0 up to 22 years)
Inpatient services

Inpatient Hospital Care

Inpatient Rehabilitation

Inpatient Behavioral Health and
Substance Abuse
Outpatient services

Diagnostic X-ray, laboratory services
and testing

Physical therapy

Speech therapy

Occupational therapy

Behavioral health
 Specialty care
 Podiatry
Home health
 Orthotics and prosthetics
Hospice
Ambulance
Prescriptions
Inpatient services
 Inpatient Hospital Care
 Inpatient Behavioral Health and
Substance Abuse
 Inpatient Rehabilitation
Outpatient services
 Diagnostic X-ray, laboratory services
and testing
 Physical therapy
 Speech therapy
 Occupational therapy
 Behavioral health
 Specialty care
 Podiatry
Home health
 Orthotics and prosthetics
Hospice
Ambulance
Prescriptions
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Children (0 up to 22 years)
Tobacco cessation
Diabetes management
Skilled nursing
Vision
Dental services
Hearing
EPSDT (Well-child visits)
Behavioral health rehabilitation
 Residential treatment
Tobacco cessation
Diabetes management
Skilled nursing
Dental services (Emergency treatment)
The services below are covered through West Virginia Fee-For-Service Medicaid, not
through UniCare. For information on how to use these services, look at the section of
the handbook that explains what Fee-For-Service Medicaid covers.
Abortion
Abortion
School based services
*There are additional services to those included on this list. If you have questions on whether a
service is covered, look at the services in the covered services section of the handbook or give
us a call.
Copays
Under your plan, you may have to make copays for some services. Copays may apply to West
Virginia Health Bridge and Mountain Health Trust members. A copay is an amount you pay
when you receive certain services. You are required to pay the copays listed below until you
and all family members in your household enrolled in the plan get to the household copay
maximum. Your household copay maximum is based on your household income. You are
assigned to a tier based on your household size and income for the quarter.
Tier
Tier 1
Tier 2
Tier 3
Gross quarterly income range
$0-$1,436.25
$1,436.26-$2,872.50
$2,872.51 and above
Copay maximum
$8
$71
$143
You will have no copays for the rest of the quarter once your household meets its copay
maximum. You also may self-attest (report to us) that you have met the copay maximum.
Call our Customer Care Center when you meet your copay maximum. Keep all your household
copay receipts to show that you have met the copay maximum.
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There are no copays for behavioral health services.
You will start each quarter with $0 in copays and build toward your copay maximum. The
tables below show the services for which your plan requires copays and the amount of
those copays.
Total cost of drug
Copayment
$0.00-$5
$0
$5.01-$10
$0.50
$10.01-$25
$1
$25.01-$50
$2
$50.01 and above
$3
Covered service
Inpatient hospital care
Office visit (physicians and nurse
practitioners)
Nonemergency use of the
emergency room (hospital only)
Nonemergent surgical procedures
given in a physician’s office,
ambulatory surgical center or any
other outpatient setting excluding
emergency rooms
Tier 1
$0
$0
Tier 2
$35
$2
Tier 3
$75
$4
$8
$8
$8
$0
$2
$4
These members are excluded and will have no copays:
 Children under 21 years of age
 Pregnant women, including pregnancy-related services up to 60 days postpartum
 Members of a Native American tribe or Alaskan natives
 Members receiving hospice services
 Members in nursing homes
 Members in an intermediate care facility
 Members receiving services for mental retardation
 Members getting behavioral health services
 Members getting emergency services (includes three-day emergency supply of medicine)
 Members getting family planning services
 Members getting services through Medicaid waiver programs
 Members getting services through the Breast and Cervical Cancer Treatment program
 Members getting services for provider-preventable conditions
 Members getting diabetic testing supplies, insulin syringes or needles
 Members getting approved home infusion supplies
 Members getting vaccines administered at the pharmacy
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GETTING TO KNOW YOUR HEALTH PLAN
If you have questions about signing up for Medicaid, your local Department of Health and
Human Resources (DHHR) can help you.
Your UniCare member ID card
UniCare has two types of member ID cards. You will either get a Mountain Health Trust or
West Virginia Health Bridge ID card.
Always carry your UniCare and Medicaid ID cards with you. Show both of these cards to your
provider when you go for health care services. Look on your UniCare ID card for the following
important information:
 Your name
 Your UniCare member ID number
 The date your UniCare insurance began (also called the effective date)
 Your PCP’s name, phone number and address
 UniCare’s name, address and toll-free phone number
 The phone number for our 24-hour nurse help line
 The phone number for vision care services
 The phone number for dental car services
 What you should do in an emergency
You are the only one who can get health care services with your UniCare member ID
card. If you let someone else use your card, you may not be able to stay in our plan. You will
get a new UniCare ID card if:
 You change your PCP
 Your PCP’s address or phone number changes
 You lose your ID card
If you did not get your UniCare member ID card yet, or if you need a new one, please call us
right away.
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What is a primary care provider?
Your UniCare member ID card has the name, phone number and address of the primary care
provider (PCP) you chose or the PCP assigned to you. Your PCP will be your main health care
provider. Your PCP works with us, as needed, to connect you to the right provider at the right
time and in the right place. UniCare will try to give you a PCP with an office no more than
30 minutes from your home.
A PCP can be any of these types of providers:
 Pediatrician (a doctor who takes care of babies and children)
 Family and general practitioner (a doctor who takes care of babies, children and adults)
 Nurse practitioner or physician assistant (someone who works in a provider’s office and
treats you, within limits)
 Internist
 Obstetrician/gynecologist (OB/GYN)
Patient-Centered Medical Home
The Patient-Centered Medical Home helps you partner with your PCP. They will lead a team of
health care providers. These are people like nurse practitioners, nurses, physician assistants,
behavioral health providers, dental and eye care providers, physical therapists, pharmacists,
and social workers. This group will work with you in all parts of your care.
PCPs for pregnant women and newborn babies
If you are pregnant, call us right away. If you are in the last trimester of your pregnancy and
you just joined our health plan, you may be allowed to stay with your current provider whether
that provider is in our network or not.
When you call us, we will sign you up for our prenatal program, Taking Care of Baby and Me ®.
It will help you learn how to take care of yourself while you are pregnant. You will get a
prenatal packet that includes a booklet on planning a healthy pregnancy and a postpartum
packet after you deliver your baby.
You may even qualify for gift card rewards when you attend your prenatal visits and after you
complete your postpartum exam on time. Your baby also may qualify for rewards for
completing well-child checkups. We also can help you choose a PCP for your baby.
Enrolling a newborn baby and changes to family makeup
Any newborn whose mother has UniCare will have UniCare for at least 30 days after birth. As
soon as your baby is born, call your Department of Health and Human Resources (DHHR)
caseworker or inform the Change Center at 1-877-716-1212.
If you have not called UniCare to choose a PCP for your baby, you can call us after your baby
is born. If you do not choose a PCP for your baby, we will choose one for you.
You also should tell UniCare and DHHR about other changes to your family. Call your DHHR
caseworker or the Change Center at 1-877-716-1212 if:
 You move
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You change your phone number
You have changes to your insurance
The number of people in your household changes (e.g., adoption, death, etc.)
You become pregnant
Initial health assessment
All new members should see their PCP for an initial health assessment (IHA) within 90 days
after joining UniCare. A child should be seen within 60 days after joining. The first meeting with
your PCP is important. It’s a time to get to know each other and review your health status.
Your provider will help you stay healthy.
During the IHA, your PCP will:
 Get to know you and talk about your health
 Learn your medical history
 Give you health information you need
 Teach you ways to help make your health better or to stay healthy
 Give you the results of your IHA
Call your PCP to make an appointment today.
Making an appointment with your PCP
Call your PCP’s office during regular business hours (the phone number is on your UniCare ID
card). Let the staff know you are a UniCare member. Have your UniCare member ID card and
your Medicaid ID card with you when you call. You may be asked for the member ID numbers
on the cards.
Your IHA will be scheduled within 21 days from the date you call. You may have to wait longer
for preventive care visits (shots and checkups or routine tests and exams). You should receive
a routine care appointment within 21 days. You should receive an urgent appointment within
48 hours.
Make sure to bring your UniCare member ID card with you when you visit your provider. Be on
time for your visits. Call your PCP’s office as soon as you can if:
 You will be late
 You cannot keep your appointment
You should not need to wait more than 45 minutes after you get to your provider’s office. Your
PCP may not be able to see you if you are late. If you cancel your appointment, someone at
your PCP’s office can help you set up a new one.
Changing your PCP
Most of the time, it is best to keep the same PCP, so they can get to know your health needs
and history, but you can change your PCP at any time for any reason. If you want to do so, call
us. We want you to be happy with your PCP.
If you want to change your PCP, please note:
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When choosing a new PCP, you must choose a provider who will see new patients. We
can help you find one. A request to change your PCP may be denied if the PCP you want is
not taking new patients.
If you choose a PCP who is not taking new patients, we will help you choose
another one.
It’s important to know that when you change PCPs often, your health care may not be as
easy as it could be.
Your PCP change will be effective on the date the change is made.
You can begin seeing your new PCP on the day you ask for the change.
You will get a new UniCare member ID card with your new PCP’s name on it.
It’s important to have your medical records sent to your new PCP.
UniCare, or your PCP, may ask you to change your PCP if:
 UniCare no longer works with your PCP
 You are not able to get along or agree with your PCP
 You keep making appointments and not showing up for them
 You are often late for your appointments
 You are rude or abusive to the staff of UniCare or your PCP’s office
 You disrupt the PCP’s office
If you choose to go to a provider who is not your PCP, call us first. We will try to make that
provider your PCP. We will tell you in writing if we need to change your PCP.
Court-ordered care
UniCare will reimburse providers for court-ordered treatment services covered by UniCare
under the Medicaid State Plan. The court order would be the reason for the service to be
medical necessary.
Provider directory
When you joined UniCare, you may have picked a PCP. If you did not choose a PCP, UniCare
can choose one for you. To change your PCP, look through the provider directory and pick
one. Call us to let us know your choice.
Our provider directory lists the providers who work with UniCare. It also tells you their address,
phone number, office hours and languages spoken. You can find our provider directory at
unicare.com/medicaid. Or call us to request one.
Look in the provider directory to find a PCP who is right for you or your family member:
 PCPs for children are listed under Family Practice, Pediatrics or General Practice.
 PCPs for pregnant women are listed under Family Practice, Obstetrics and Gynecology or
General Practice. You may choose a certified nurse-midwife from the Obstetrics section.
 PCPs for adults are listed under Family Practice, Internal Medicine or General Practice.
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You need to choose a PCP who is taking new patients. You can learn more about this in your
provider directory or call us at 1-800-782-0095 (TTY 1-866-368-1634) Monday through Friday
from 8 a.m. until 6 p.m. If you need help finding a PCP who is taking new patients, call us.
To find out more about a provider (such as the provider’s specialty, medical school
background, residency training or board certifications), visit these websites:
 West Virginia Board of Medicine at www.wvdhhr.org/wvbom
 American Medical Association (AMA) at www.ama-assn.org
 Click the DoctorFinder button
 American Board of Medical Specialties (ABMS) at www.abms.org
 Click on Consumers
If you want help, you may call the West Virginia Board of Medicine at 1-304-558-2921 or
call us.
Prior authorization for health care services
Your PCP will manage your health care needs and may send you to a different provider if you
need special care. Your PCP will talk with you about the best way for you to get the care
you need.
If you don’t get an OK when it is required for a service, you will have to pay for the cost of the
service. Some types of care do not need an OK from your PCP:
 Family planning
 OB/GYN care from UniCare providers
 Emergency care
 Vision care
Your PCP may need to get a prior authorization (approval) from us for some services for us to
pay for them. You will need an OK from Scion Dental for some dental services. To get an OK
from us, both UniCare and your PCP or specialist, agree that the services or care you get is
medically necessary.
Medically necessary means that items or services that have been given or will be given to a
patient are needed to treat a medical condition and are not mainly for the ease of the patient,
provider or other health care provider.
Examples are:
 To find the cause of an illness or treatment of illness or injury
 To help a body part that is not normal work better
 To prevent illness
 To help a child or young adult meet the right growth and development levels
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Services that require an OK from us include but are not limited to:
 Inpatient and outpatient hospital care
 Surgery, including outpatient ambulatory surgical care
 All infusion therapies
 CT, MRI, MRA, PET, special X-rays and tests
 Organ transplants
 High cost and custom-made durable medical equipment like crutches, wheelchairs, special
beds, etc.
 Cataract glasses and lenses; this can also include surgery to remove a cataract and insert
a lens
 Hearing aids and services that have to do with hearing aids
Getting an OK will take no more than seven calendar days, or if urgent, no more than three
working days. See What UniCare covers to check service limits. Your PCP can tell you more
about this.
We may ask your PCP why you need to see a specialist. We may not OK the care you or your
PCP requests. We will send you and your provider a letter explaining why we would not cover
the care you ask for. The letter also will tell you how to appeal.
You can get this member handbook in other formats, such as Braille, by calling us. If you have
questions, you or your provider can call our Customer Care Center at 1-800-782-0095
(TTY 1-866-368-1634).
Some types of care do not need an OK from your PCP:
 Family planning
 OB/GYN care from UniCare providers
 Emergency care
 Vision care
Routine care
Routine care is the regular care you get from your PCP, such as checkups, to help keep you
healthy. You can call your PCP to make an appointment for routine care. UniCare will try to
give you a PCP with an office no more than 30 minutes from your home. The hospital you go
to for basic care should be no more than 45 minutes from your home.
Urgent care
A medical condition is urgent if it is not an emergency but should have medical care within 48
hours. Call your PCP if you have an urgent medical condition. If you cannot reach your PCP:
 Call us at 1-800-782-0095, 8 a.m. to 6 p.m.
 Call our 24-hour nurse help line at 1-888-850-1108. A nurse can answer your questions in
private and help you with self-care. In an emergency, call 911 right away. The 24-hour
nurse help line is not meant to replace the medical advice of your provider.
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After-hours care
You can reach your PCP at the number on your UniCare ID card. After normal business hours,
leave your name and phone number with the answering service. Either your PCP or an on-call
provider will call you back. You also can call the 24-hour nurse help line.
Out-of-area care
You never know when or where you will get sick or injured. That is why UniCare asks you to
carry your UniCare ID card with you at all times. UniCare can still help if you get sick when you
are outside of the UniCare service area.
If you are outside of the UniCare service area and your problem is not an emergency or you
are not sure if it is, call:
 Your PCP at the number on your UniCare member ID card
 UniCare at 1-800-782-0095
 Our 24-hour nurse help line at 1-888-850-1108
If you think you have an emergency, call 911 or go to the nearest emergency room. UniCare
covers emergencies anywhere in the United States at no extra cost to you.
You are not covered for services received outside the United States. Do not use an emergency
room for routine care. UniCare does not cover emergency room visits for routine care, whether
the visits are made inside or outside our service area.
Pregnancy care
Call us when you know you are pregnant. Our staff will make sure that your provider and
hospital are with UniCare. We will sign you up for our maternity program Taking Care of Baby
and Me®.
This program is for you if you are going to be a new mom. It is part of your health benefits and
costs you nothing. When you are pregnant, you will get:
 A prenatal packet that includes a booklet and brochures to help you learn about pregnancy
and childbirth
 A phone survey to find out if there are risks to you or your baby
 The chance to join health classes to learn about care and child care
 A postpartum packet with a booklet on infant care, postpartum depression and reminders
on seeing your provider for checkups
 Information on gift card rewards you can earn for attending prenatal and postpartum visits
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Please note that state law makes sure that you get your first prenatal care visit. It requires that
your provider fit you into their schedule as follows:
 If you are in your first trimester (months one, two or three), your provider must make your
office visit within 14 calendar days from the date you call.
 If you are in your second trimester (months four, five or six), your provider must make your
office visit within seven calendar days from the date you call.
 If you are in your third trimester, (months seven, eight or nine), your provider must make
your office visit within three business days from the date you call.
Your first visit allows your provider or other pregnancy provider to begin checking your
pregnancy as soon as possible. So don’t forget to make this office visit. If you think you have a
high-risk medical problem that will affect your pregnancy, ask your provider if you can be seen
right away. We want to make sure you get the best care for you and your baby.
Family planning
Family planning can help teach you how to:
 Be as healthy as you can before you become pregnant
 Keep from getting pregnant
 Keep you from getting diseases
Any member (including minors) may see a licensed family planning provider without getting an
OK from UniCare first. This includes providers who are not part of the UniCare network,
such as:
 Clinics
 OB/GYNs
 PCPs
 Certified nurse-midwives
Specialist care
Your PCP may send you to a specialist for special care or treatment.
 Your PCP will work with you to choose the specialist to give you the care you need.
 Your PCP’s office can help you make the appointment.
 Your PCP must send an OK to the specialist before he or she can give you care.
 Tell your PCP and the specialist as much as you can about your health, so that all of you
can decide what is best.
You should receive a routine appointment to see a specialist within three weeks of the request.
You should receive an urgent specialist appointment within 48 hours of the request.
Call us to let us know about seeing the same specialist each time without an OK first. The
Utilization Management (UM) nurses at UniCare may OK a number of visits with the same
specialist without your PCP setting up each visit. UniCare will try to find you a specialist with
an office no more than 30 minutes from your home.
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Standing referrals
This is a type of referral that may allow you to see the same specialist without getting an OK
for each visit. You may need a standing referral if:
 You have a health problem that needs special medical care over a long period of time.
 Your health problem:
 Puts your life at risk
 Gets worse over time
 Keeps you from doing all the things that healthy people can do
 Creates the need for your care to be managed by your specialist in the same
care center
If you have trouble getting a standing referral, call us. If, after you call, you still believe that
your needs have not been met, please see How to resolve a problem with UniCare.
You will need an OK from us to see a specialist. You will need our OK if the provider is inside
or outside of our network. If you don’t get our OK, you may have to pay for the treatment. If we
don’t approve the specialty services, we will send you a letter telling you why. We’ll also tell
you how you can appeal if you do not agree with us.
This is a summary of the UniCare specialist referral policy. Call us for a full copy of our policy.
Getting a second opinion
You might have questions about your illness or the care your PCP says you need. You may
want to get a second opinion from another provider. You should speak to your PCP if you want
a second opinion. You or your PCP also may ask us for help. You must get services from a
provider within our network. If there is no provider in our network that fits the care you need,
we will let you get a second opinion from a provider outside our network.
Getting a second opinion is helpful if:
 You have questions about a surgery your PCP says you need
 You have questions about finding the cause or treatment for an ongoing problem or a
health issue that could cause death
 If you think your problem could greatly weaken you or cause loss of a limb or body function
 Your PCP’s advice is not clear or is hard for you to understand
 Your PCP is unable to find the cause of your condition, or the PCP isn’t sure because test
results aren’t the same
 The treatment you are getting has not helped your medical problem within the time frame it
should
 You have tried to follow the treatment plan or talked with your PCP because you are
concerned about the cause or the treatment plan
You may use the UniCare grievance and appeal process if your PCP or specialist does not
allow you to get a second opinion. See How to resolve a problem with UniCare to learn how to
file a grievance or appeal.
This is only a summary of the UniCare policy on second opinions. You can call us to get a
full copy of the policy.
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Availability of Utilization Management staff
Your PCP and other providers work with you to decide what care is best. We always want you
to have the care you need. For some health care services, your provider may have to ask us
for our OK. This is so that we will pay for the services. This process is called Utilization
Management, or UM for short.
You should know that:
 We make payment rulings based on the care and services you need and the benefits
you have
 We base our rulings on whether or not the care is right for your health issues and is
medically necessary. See Definitions to learn more about medically necessary.
 We do not reward providers or other UM decision-makers for denying requests
 We do not offer money as a reward to UM decision-makers to push them to give
less care
WHAT UNICARE COVERS
Here are the kinds of care you can get through UniCare. Keep in mind that some of these
services must be OK’d by your PCP and/or us first. You may have to pay if you choose to
receive services that we do not cover. We only will pay for covered care that is medically
necessary.
If you have questions about how medical decisions are made or would like a copy of our
Utilization Management procedures, call our Utilization Management office at 1-866-655-7423.
The office is open Monday through Friday, 8 a.m. to 5 p.m. You can leave a message if you
call after business hours.
Call us if you are out of town and need help with an OK for medical care. You also can call us
if you have questions about which services are covered. Always carry your UniCare and
Medicaid ID cards with you.
Behavioral health services
You do not need a referral from your PCP to get behavioral health care from UniCare
providers. You may go directly to your provider. If you have questions, call us at
1-800-782-0095 (TTY 1-866-368-1634). Behavioral health care includes:
 Inpatient psychiatric services for children younger than age 21
 Outpatient behavioral health and psychiatric services
 Substance abuse treatment
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Chiropractors help keep the spine and other body parts straight.
We cover:
 Treatment to correct a partial dislocation
 X-rays
Limits:
We cover up to 24 visits per year.
Clinic services
Copays may apply.
Services from clinics (that are not part of a hospital):
 Health clinics
 Birthing centers
 Lab and radiology centers
 Health department clinics
 Rural health clinics
 Federally qualified health centers (FQHCs)
We cover:
 Provider services
 Nurse practitioner and physician assistant services
 Vaccines (shots) for children
 Supplies
 Visiting nurse care in certain shortage areas
Dental services for children
Routine dental services are for children younger than age 21. We cover medically needed
dental services for children younger than age 21. These services are provided by Scion
Dental. (Scion is an independent company that provides dental benefits on behalf of UniCare.)
Dental services may be given by a:
 Dentist or oral surgeon
 Orthodontist
 Periodontist
We cover:
 Diagnostic services
 Preventive treatment
 Restorative treatment
 Endodontic treatment
 Periodontal treatment
 Surgical procedures and/or extractions
 Orthodontic treatment (Orthodontic services will be covered for the entire time of treatment
even if the child is no longer eligible.)
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 Complete and partial dentures, including partial denture relines and repairs
 Oral and maxillofacial surgery services
 Adjunctive general services such as injectable medications
We do not cover:
 Experimental or investigational services
 Cosmetic procedures
 Dental services for the member’s convenience or the convenience of the
member’s caretaker
Fluoride varnish
Fluoride varnish is a covered benefit for children ages 6 months to 3 years who may be at high
risk of developing cavities. The fluoride varnish is given during the member’s dental visit. The
maximum number is two applications over one year.
Call your dentist’s office during normal business hours. Tell the staff you are a UniCare
member. Have your UniCare member ID card with you when you call. You may be asked for
the member ID number on the card. Your child should see the dentist at least once every
six months for any needed dental care.
If you need help finding a dentist, please call Scion Dental at 1-877-408-0917
(TTY 1-800-508-6975). You also can see the list of dentists in the network by visiting
unicare.com/medicaid.
Your dentist will need to get approval from UniCare for some services. This means both
UniCare and your dentist agree the services are medically needed. Getting an approval will
take no more than seven calendar days, or if urgent, no more than three calendar days. Your
dentist can tell you more about this. We may ask your dentist why you need this care. We may
not approve the service you or your dentist asks for. We will send you and your dentist a letter
that tells you why we would not cover the service. The letter also will let you know how to
appeal our decision.
Orthodontia services
Orthodontia services, covered for children up to age 21, must be medically necessary and
require prior authorization (approval) before the service is provided. Approved services will be
covered for the duration of the treatment. Medical necessity means at least one of the following
needs is met:
 Overjet in excess of 7mm
 Severe malocclusion associated with dento-facial deformity
 True anterior open bite
 Full cusp classification from normal (Class II or Class III)
 Palatal impingement of lower incisors into the palatal tissue causing tissue trauma
 Cleft palate, congenital or developmental disorder
 Anterior crossbite (two or more teeth, in cases where gingival stripping from the crossbite is
demonstrated and not correctable by limited orthodontic treatment)
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Unilateral posterior crossbite with deviation or bilateral posterior crossbite involving multiple
teeth including at least one molar
True posterior open bite (not involving partially erupted teeth or one or two teeth slightly out
of occlusion and not correctable by habit therapy)
Impacted teeth (excluding third molars) permanent anterior teeth only
EPSDT screening
EPSDT screening services are from the member’s primary medical providers at regular
intervals and whenever a problem is suspected. A member’s primary medical provider may
refer the member to a dentist based on their finding during the oral health screening. The oral
health screening does not replace a dental exam by a dentist.
These recommendations are for the care of children who have no other medical issues and are
developing normally. The first dental exam happens within six months of the eruption of the
first tooth and no later than 12 months of age. Exams should happen every six months or as
requested by a dentist.
If you have questions about your child’s dental benefits, you can call Scion Dental at
1-877-408-0917 (TTY 1-800-508-6975).
Dental services for adults
We cover emergency dental services for adults age 21 and older. These services may be
given by a dentist or oral surgeon.
We cover:
 Treatment of fractures of the upper or lower jaw
 Biopsy
 Removal of tumors
 Removal of a tooth when it is an emergency
 General anesthesia for dental procedures when medically necessary because the:
- Member has a developmental disability
- Member has other medical conditions that may complicate the dental work
Limits:
We do not cover temporomandibular joint (TMJ) surgery and treatment for adults. We cover
adult emergency dental services through Scion. If you are not sure you have a dental
emergency or if you have questions about emergency dental services, you can contact Scion
at 1-877-408-0917.
Durable medical equipment, supplies and prosthetic devices
All custom-made durable medical equipment (DME) requires prior authorization (approval).
Other DME also may require prior approval.
DME, supplies and prosthetic devices given by a provider are covered when they are medically
necessary. You may need an OK ahead of time from us for some of these items.
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We do not cover:
 Equipment and supplies only used for exercise
 Equipment and supplies only used for making a room or home more comfortable, such as:
- Air conditioners
- Air filters
- Air purifiers
- Spas
- Swimming pools
- Elevators
 Hygiene and beauty supplies
 Experimental or research equipment
 More than one piece of equipment that does the same thing
Early and periodic screening, diagnostic and treatment
Early and periodic screening, diagnostic and treatment (EPSDT) services are also called wellvisits. These visits are free for enrolled members younger than age 21. These include
screenings needed for your child’s PCP to understand any medical needs. During these visits,
the PCP will complete a physical exam and a complete health and developmental history.
Vaccines (shots) are part of these visits.
Children should go to the doctor for checkups even if they are not sick. They should have an
EPSDT checkup at birth and at:
 3-5 days old
 1 month
 2 months
 4 months
 6 months
 9 months
 12 months
 15 months
 18 months
 24 months
 30 months
 3 years
 then every year until age 21
We cover:
 Hearing
 Vision
 Dental exams
 Nutritional needs
 Health care, treatment and other actions to correct or improve any medical condition found
during an EPSDT screening
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Routine shots and immunizations
Lab tests, such as:
- Urinalysis
- Hemoglobin/hematocrit
- Tuberculin test (for high-risk groups)
- Blood lead testing
Ask your child’s PCP when you should bring your child back for the next EPSDT checkup.
Family planning
We cover these types of care to help you if you plan to have a family, want to know how to
avoid getting pregnant or want to know how to protect yourself against sexually transmitted
infections (STIs):
 Family planning, education and counseling
 Medical visits for birth control
 Annual cervical cancer screenings
 Pregnancy tests
 Lab tests
 Tests for sexually transmitted infections (STIs)
 Screening, testing, counseling, and referral for treatment for members at risk for human
immunodeficiency virus (HIV)
 Sterilization (see exceptions below)
 Prescriptions for oral, intravaginal and injectable contraceptives, diaphragms, contraceptive
patches and emergency contraception.
We do not cover:
 Sterilization for members younger than age 21
 Sterilization for members who live in inpatient facilities
 Treatment for members who cannot get pregnant
Hysterectomy and abortion are not considered family planning services. You do not need to
get an OK from your PCP for family planning care. Members may use any licensed family
planning clinic or provider. The provider does not have to be part of our network. If you choose
to see a family planning provider who is not part of our network, let your PCP know the
important medical information from these appointments so you can get the best health care.
Your family planning provider and your PCP will work together to make sure you get the
right care.
Family planning records are kept private. PCPs and other types of health care providers
should keep all family planning records private, even if the patient is a minor, unless the law
says it is OK. Your provider is allowed to share your medical information with other providers
who take care of you, public health officials or government agencies. UniCare is not
responsible for the privacy of medical records held by providers who are not part of
our network.
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Home health services
These are visits to your home to give you care for certain illnesses or injuries only. You must
get our OK for these types of visits.
We cover:
 Services from a licensed home health agency or visiting nurse group
 Physical, occupational and speech therapy
 Medical supplies
 Care from a health aide who works under a registered nurse (RN) or a therapist
 Breathing treatments
These types of buildings do not qualify as a home:
 Hospital nursing facility
 Intermediate care facility for the mentally retarded (ICF/MR)
 State institution
Hospice
If you are terminally ill and not expected to live beyond six months, your PCP can ask for
hospice care.
We cover these types of hospice care:
 Nursing care
 Provider care
 Medical care
 Social services
 Short-term inpatient care for pain control and to take care of symptoms
 Durable medical equipment
 Prescribed drugs
 Counseling and bereavement services
 Home health aide and homemaker services
Hospice will take care of all benefits that have to do with the terminal illness. If you choose
hospice, you give up the right to get other Medicaid services that have to do with the terminal
illness. If you choose hospice, you can change your mind at any time.
Hospital services
Your PCP can send you to any hospital in the UniCare network. See the provider directory for
a list of the hospitals that work with us. Go to the nearest hospital during an emergency.
Hospital services — Inpatient
Copays may apply.
These services include an overnight stay in a hospital. You need to get an OK from us ahead
of time each time you stay overnight in a hospital. You do not need an OK for an emergency or
for the birth of a baby.
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We cover:
 A hospital room with two or more beds
 Care in special units
 Operating rooms
 Delivery rooms
 Special treatment rooms
 Supplies
 Medical testing
 X-rays
 Drugs the hospital staff give you during your stay
 Giving you someone else’s blood
 Blood products
 Radiation therapy
 Chemotherapy
 Dialysis treatment
 Meals and special diets
 General nursing care
 Special duty nursing for medical reasons
 Anesthesia
 Respiratory therapy
 Bariatric surgery
 Diagnostic care
 Therapeutic care
 Rehabilitation care
 Psychiatric and substance abuse treatment
 Overnight hospital stay for dental work because of other medical problems or because
serious dental work is needed
 Setting up discharge planning, including continuing care, if needed
 Surgery to remove a breast or dissect a lymph node. If you have a breast removed or
lymph node dissected, you do not need an OK from us to decide how much time you will
spend in the hospital after surgery
 All problems from a breast removal surgery (including lymphedema)
 Surgery to reconstruct. This includes prosthetics or surgery to make your breasts look the
same after a breast is removed.
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Hospital services — Outpatient
Copays may apply. Outpatient hospital care must be given by:
 Hospitals
 Rural health clinics
We cover:
 Emergency room use
 Emergency dental services
 Giving you someone else’s blood
 Blood products
 Drugs given in the emergency room
 Hospital services that can be reasonably done so the patient does not have to stay
overnight:
- Supplies
- Medical testing
- X-rays
- Lab services
- ER and 23-hour observation stays
 Physical, occupational and speech therapy
 Radiation therapy
 Chemotherapy
 Dialysis
 Services for dental work when a hospital outpatient facility must be used because of other
medical problems or when serious dental work is needed
 Surgical services; some surgical services need an OK ahead of time from us
 Behavioral health services, some services need an OK from us
Lab and X-ray services (not received in a hospital)
CT, MRI, MRA, PET and special X-rays must have an OK. This includes lab and ultrasound
services in a place other than a hospital outpatient unit.
We cover:
 All lab and X-ray services ordered and done by (or under the care of) a provider
 X-ray of the breast (mammogram)
Nurse practitioners
We cover care given by a nurse-midwife, nurse anesthetist, family nurse practitioner or
pediatric nurse practitioner.
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Physical or occupational therapy, speech pathology and audiology
These types of care are ordered by a provider and are a part of that provider’s written plan of
care. Covered care includes treatment or other services given by speech, physical or
occupational therapists or audiologists. This treatment is given to correct or improve
conditions.
Limits:
 All physical, occupational and speech therapy care needs an OK from us ahead
of time.
 Only members younger than age 21 may get hearing aid evaluations, hearing aids and
supplies, batteries, and repairs.
 Hearing aids are limited to members younger than age 21 and need an OK from us ahead
of time.
Provider services
Copays may apply.
These types of care may be given to a member in a hospital, clinic or provider’s office.
We cover:
 Visits to your PCP or other providers
 Routine physicals
 Fluoride varnish treatments for children between 6 months and 3 years of age
 Colorectal cancer screenings and lab tests for members age 50 and older who have
no symptoms
 Colorectal cancer screenings and lab tests for members younger than age 50 who
have symptoms
 Kidney disease screenings including:
- Blood pressure monitoring
- Lab tests for:
 Urine albumin
 Urine protein
 Serum creatinine
Limits:
 Certain procedures may need an OK ahead of time.
 We do not cover routine physical exams for a job, camp or sports program.
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Podiatry services (foot care)
We cover:
 Treatment for health problems such as infections, inflammations, ulcers and bursitis
 Surgery for bunions or ingrown toenails
 Care and treatment of fractures, dislocations and sprains
 Orthotic shoe inserts
Limits:
 Treatment of children is limited to acute conditions.
 We do not cover routine treatment for flat foot, nail trimming and dislocated foot.
Pregnancy and maternity care
When you know you are pregnant, call us right away. If you are in your last three months of
pregnancy, you should set up a time to see your provider within three business days from the
time you call.
We cover:
 Provider visits and professional services for pregnancy, problems with a pregnancy, and
after-delivery care when medically necessary
 Services given by a licensed nurse-midwife (a pregnant member can choose a nursemidwife as her PCP)
 Prenatal education classes
 A nurse case manager or care coordinator to work with you throughout your pregnancy if it
is high risk
 Tests that are needed such as ultrasound
 HIV testing, treatment and counseling
 Vaginal childbirth and cesarean sections (C-sections)
 Newborn exams
 A follow-up visit for the mother and the baby within two days of an early discharge when
ordered by the treating provider
- An early discharge is a hospital stay of less than 48 hours for vaginal childbirth and less
than 96 hours for a C-section
- A visit to your provider between 21-56 days after your delivery to make sure you are
healing well
If you are pregnant, you are automatically included in our maternity management program
Taking Care of Baby and Me at no cost. This program will help you learn how to take care of
yourself while you are pregnant. We will send you mailings that include:
 Planning a Healthy Pregnancy booklet
 Labor, delivery and beyond brochure
 Postpartum Nurture booklet — Your guide to keeping your baby safe and healthy
 Information on gift card rewards you can get for completing prenatal, postpartum and
well- child visits
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Wait times for appointments
We want you to be able to get care when you need it.
When you are pregnant, you should be able to see your provider as follows:
Type of appointment
First trimester
Second trimester
Third trimester
High-risk pregnancy
Postpartum exam
Time frame
Within 14 calendar days of request
Within seven calendar days of request
Within three business days of request
Within three business days of
identification or immediately if an
emergency exists
Three to eight weeks after delivery
You’ll also have the opportunity to work with a nurse to assist you with your pregnancy.
Ask your provider about childbirth classes, or call us to find out more.
Prescription drugs
Copays may apply.
Most drugs covered by UniCare can be filled for a maximum of a 34-day supply at a time.
Some medications may require an OK from UniCare before they can be filled at the pharmacy.
Please see Your prescription drug benefits for more information.
Private-duty nursing
This is for members younger than age 21 who need more one-on-one, continuous care than
they can get from a visiting nurse or at hospitals and skilled nursing facilities. We cover
24-hour nursing care if medically necessary.
Limits:
 These types of care need an OK from us ahead of time.
 These types of care are for children younger than age 21 only.
Transplants
Transplant services need an OK from us ahead of time. We cover these types of organ and
tissue transplants:
 Kidney
 Kidney/pancreas
 Liver
 Bone marrow
 Cornea
 Small intestine
 Multivisceral
 Heart
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Lung
Heart/lung
Transportation
We cover emergency transportation only when it’s used to get medical care and treatment for
an emergency. You do not need an OK from us ahead of time. See Part 8 Emergency and
urgent care services to learn more about emergency care and what to do in case of an
emergency.
Nonemergency transportation to medical appointments is covered. . An ambulance may be
needed for nonemergency transport when medically necessary. In this case, you will need an
OK from DHHR ahead of time. To learn more about how to get transport when you do not have
an emergency, see What West Virginia Fee-For-Service Medicaid covers.
Vision services
Professional eye care is given by:
 Optometrists
 Ophthalmologists
 Opticians
 Surgeons
Members who are diabetic may see an optometrist or ophthalmologist in the UniCare network
for an annual diabetic retinal exam without an OK from their PCP. Any future exams will need
an OK from your PCP.
We cover:
 Eye surgery (not cosmetic)
 One exam for children every 12 months
 Lenses and frames every 12 months
 Repairs that are needed
 First pair of eyeglasses and services after cataract surgery
 Contact lenses (if medically necessary)
Limits:
 Adult services are limited to medical necessity only.
 We do not cover prescription sunglasses and designer frames.
Children with Special Health Care Needs program providers
The Children with Special Health Care Needs (CSHCN) program provides specialty medical
care, diagnosis and treatment for disabled children and those who may be at risk of developing
disabling conditions. The CSHCN program provides case management and access to
specialty services through a system of outreach specialty clinics.
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WHAT UNICARE DOES NOT COVER
Some services are not covered under the UniCare plan. If you have any questions about what
is not covered, call us. You may have to pay for care you get if it is not covered by UniCare.
UniCare does not cover:
 Payment for any service or care you got before you became a UniCare member
 Long-term care services
 Care from a provider not in our network when you do not get the needed OK from us before
you get the service
 Any service not listed as covered
 Payment for care you got for health problems that were work-related
- If they can be paid for by workers’ compensation insurance, your employer or by a
disease law that has to do with your job
 Nursing facility care
 Acupuncture
 Experimental or investigational procedures
 Lab tests not ordered by a provider, unless it is an emergency
 Care given by Christian Science nurses
 Care given in a Christian Science sanitarium
 Care you get outside the U.S.
 Surgery or medications to help you get pregnant
 Sterilization of the mentally impaired
 Organ transplants not listed in What UniCare covers
 Cosmetic surgery that is done to change or reshape normal body parts so they look better
- This does not apply to reconstructive surgery to give you back the use of a body part or
to correct a deformity caused by an injury.
 Sex change surgery or treatments
 Routine physical exams for a job, camp or sports program
 Medical equipment, prescriptions, services and supplies that are:
- Not medically necessary
- Used only for your comfort or hygiene
- Used for exercise
- Personal or comfort items
- Experimental or still being researched
- Used for hygiene or beauty
- More than one piece of equipment that serves the same function
- Used only for making a room or home comfortable such as:
 Air conditioners
 Exercise equipment
 Air filters
 Spas and swimming pools
 Air purifiers
 Elevators
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WHAT WEST VIRGINIA FEE-FOR-SERVICE MEDICAID COVERS
Medicaid covers some types of care that UniCare does not. These services are called
carve-outs. Some of them may be limited or need an OK from DHHR ahead of time. To find
out more, call DHHR at 1-877-716-1212. You also can call UniCare. We will help set up these
types of care for you.
Hemophilia factors
Although most prescription drugs that are filled at the pharmacy are covered by UniCare,
factors that are used to treat hemophilia and that are filled at the pharmacy will remain carved
out and will continue to be paid for by Medicaid.
Services include getting you to and from Medicaid-covered medical appointments that you
have made. Please call DHHR at 1-877-716-1212 to learn more.
Personal care
Personal care is a community care program. You need a provider’s order and a nursing plan of
care to get personal care services such as help with grooming and hygiene, daily activities,
and nutrition.
EMERGENCY AND URGENT CARE SERVICES
What is an emergency?
An emergency medical condition is when symptoms are so severe that a person with an
average knowledge of medicine would reasonably believe that the lack of immediate medical
care could:
 Place your health (or the health of your unborn child) at serious risk.
 Impair the function of your body.
 Impair the function of a body part or organ.
You do not need an OK from us ahead of time for emergency care. Any provider or hospital
can treat a sudden or serious medical problem. You will be covered at no extra cost to you.
You may have to make a copay if you use the emergency room for a nonemergency visit.
What to do in an emergency
In an emergency, get help right away. Call 911 or go to the nearest emergency room for
medical care. You will be covered for emergency services even if the provider is not part of the
UniCare network. For emergency transport, call 911. You do not need an OK from UniCare
when it is an emergency. After you receive emergency services, you should call your PCP to
plan your follow-up care. You should do this for an emergency at home or away.
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Post-stabilization
This is the care you get after emergency medical care to keep your condition stable or improve
your condition. You have coverage for post-stabilization services (even if your provider is not
part of the UniCare network) if we OK the services. You also have coverage for poststabilization services if we did not respond to the provider’s request for an OK within one hour
of the request or if your provider could not contact us because it was after business hours or
on a weekend.
Post-stabilization services are most often delivered where emergency services are given. The
attending emergency physician or treating provider is in charge of deciding when the member
is stable enough for transfer to another building or discharge.
What to do when you need urgent care
An urgent medical condition is not an emergency, but needs medical care within 48 hours. This
is not the same as a true emergency. Call your PCP if it is urgent and you need medical help
within 48 hours. If you cannot reach your PCP, call our Customer Care Center or our 24-hour
nurse help line.
If you are away from home and need urgent care, call one of these right away:
 Your PCP at the number listed on your member ID card
 Our 24 hour nurse help line at 1-888-850-1108
 UniCare at 1-800-782-0095 (TTY 1-866-368-1634) Monday through Friday from
8 a.m. to 6 p.m.
YOUR PRESCRIPTION DRUG BENEFITS
Drugs that UniCare covers
West Virginia Medicaid uses a preferred drug list (PDL) and UniCare will continue to cover the
drugs on that PDL. There also are drugs that are not on the PDL that UniCare will cover. The
state’s PDL and other pharmacy benefit lists, such as the OTC covered list, can be viewed
online at http://www.dhhr.wv.gov/bms/BMS%20Pharmacy/Pages/default.aspx or at
unicare.com/medicaid.
Certain drugs on the PDL need an OK from us ahead of time or have limits based on medical
necessity.
A group of providers and pharmacists checks this list of drugs every three months. These
checks help make sure that the drugs on the list are safe and useful. Even though a drug is on
the list, your provider will choose which drug is best for you. If you would like to know if a drug
is on our list, please call us or go to unicare.com.
How to fill your prescriptions
Most of the time, only generic drugs are covered. When a drug is available as a generic, the
brand-name drug is usually not covered, unless the brand-name drug is preferred on the
state’s preferred drug list (PDL). Some drugs (including many brand-name drugs) need an OK
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from UniCare. In these cases, your provider must ask for an OK before you get the drug. Most
drugs that are covered by UniCare can be filled for a maximum of a 34-day supply at a time.
Drugs not on the PDL, or listed on the PDL as nonpreferred, require an OK from us ahead of
time. If your provider thinks you need to take a drug that is not on this list, your provider will
send us a request that tells us why you need the drug. In most cases, UniCare will be able to
notify you and your provider if the medication will be covered or not within 24 hours. If the
request is sent on a holiday or a weekend or if we need more information from your provider, it
may take longer. We will let your provider know if we OK your request. If we do not OK your
request, we will send you a letter that tells you the medical reasons why.
If you need to start the medication right away, you can ask your pharmacist to give you a
three-day emergency supply of the medication. The pharmacist can give you this three-day
emergency supply without having to call UniCare. There is no copay for this emergency
supply. This does not include medications that are covered under your medical benefit or
drugs that are excluded from Medicaid coverage.
Where to get your prescriptions filled
UniCare has contracts with a number of pharmacies in your area. These are called in-network
pharmacies. You should always use an in-network pharmacy to get your prescriptions.
You can find a list of these pharmacies in our provider directory online at unicare.com/medicaid.
Or call us and we can help you find a pharmacy in the network near you.
You may only use an out-of-network pharmacy if you have an emergency. If you have to go to
an out-of-network pharmacy in an emergency, ask them to call UniCare. If you are out-of-state,
have an emergency and need prescriptions, the pharmacy can call the pharmacy provider
number on the back of your member ID card to make sure your drugs are covered.
Rx Safe Choice program
Some members may require coordination of pharmacy benefits. These members can better
manage their health by using the same pharmacy for all their prescriptions. If you need this
coordinated care, you will be required to choose one pharmacy to fill your prescriptions. This is
called the Rx Safe Choice program. We will send you and your provider a letter if we believe
you will benefit from this program. You will have 30 days from the date of the letter to request a
change to your assigned pharmacy.
If you need help finding a UniCare network pharmacy close to you, call us. Our Customer Care
Center can help you find a pharmacy. You also can see a list of network pharmacies at
unicare.com/medicaid. If you disagree with our decision to include you in the Rx Safe Choice
program, you have the right to file a grievance or appeal. Please see How to resolve a problem
with UniCare for information about the process that you can use to file a grievance or appeal.
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Important things to know when you get your drugs
Some drugs may hurt you if you take them at the same time as certain other drugs. To protect
your health, we will let your provider and pharmacist know if we are concerned about the drugs
you take.
When you get your prescriptions, let the pharmacist know if you have other health insurance. If
you are covered by another health plan, that plan will pay first and UniCare will pay second.
The total of the two payments cannot be more than the total amount UniCare allows.
The kinds of drugs UniCare covers
We cover:
 Prenatal vitamins for women up to age 46
 Multivitamins for members younger than age 21
 Prescriptions for behavioral health conditions
 Drugs to help you stop smoking. These include:
- Nicotine patches, gum, lozenges and nasal spray
- Bupropion
 Diabetic supplies including:
– Blood glucose monitors (continuous blood glucose monitors are covered under your
medical benefit)
- Test strips
- Lancets
- Lancing devices
- Urine glucose testing strips
 Influenza, pneumonia, Hepatitis A, Hepatitis B, tetanus, tetanus-diphtheria (Td), and
tetanus-diphtheria-and-pertussis (Tdap) vaccines for adults 19 years of age and older
administered by a pharmacist. (Members up to 19 years of age have access to vaccines via
the Vaccines for Children Program.)
 Herpes zoster vaccine for adults age 50 and older administered by a pharmacist at a
pharmacy
 Specific over-the-counter drugs
 Compounded prescriptions
 Shots that you give yourself at home, such as insulin, are covered by your pharmacy
benefit. Most shots that must be given by your provider in his or her office are covered
under your medical benefit, not your pharmacy benefit, unless those drugs are listed on the
state’s preferred drug list (PDL)
 Prescriptions to replace most lost or stolen drugs, one time per year for each drug. You
must make a police report if the stolen medication is a controlled substance. Prescriptions
to replace certain lost or stolen medications, such as Suboxone or Sovaldi, are not
covered. If you lose your drugs, call us toll free at 1-800-782-0095 for help. We will help
you replace eligible lost drugs.
Limits on your prescription drug benefit
We do not cover these drugs. They are not eligible for a three-day emergency supply:
 Drugs used for weight loss or weight gain
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Drugs used for cosmetic purposes like wrinkles or hair growth
Over-the-counter (OTC) drugs that are not on the preferred drug list (PDL) or the OTC lists
Drugs used in fertility treatment
Drugs used for erectile dysfunction
Herbal or homeopathic drugs
Nutritional supplements
Experimental drugs
Drugs for cough and cold symptoms, except those listed on the preferred drug list
Barbiturates, except for phenobarbital and mephobarbital, unless the barbiturate is
combined with another active ingredient
Vacation supplies and early refills of drugs
Prescriptions for any drugs that are not medically necessary
Drugs that duplicate a therapy that you are already taking
Drugs that are covered under your medical benefit
Note:
 Hemophilia factors will continue to be covered by West Virginia Fee-For-Service Medicaid.
(Hemophilia factors are drugs used to treat hemophilia.)
 Durable medical equipment (DME) and supplies will still be covered by your
medical benefit.
Pharmacy copays
Each quarter of the calendar year, every family has a maximum out-of-pocket (OOP) payment.
Your OOP is the most your family will ever need to pay in any given quarter. OOP payments
are for medical and pharmacy costs no matter how many healthcare services you get.
Pharmacy copays are based on the cost of the prescription. This table shows the copay that
will be charged for each prescription if the member is eligible to pay a
pharmacy copay.
Total cost of drug
$0.00-$5.00
$5.01-$10.00
$10.01-$25.00
$25.01-$50.00
$50.01 and above
Copay
$0.00
$0.50
$1.00
$2.00
$3.00
The following table shows the OOP for each tier level. Copays are based on the cost of
the drug:
Family out-of-pocket maximum per quarter based on income
Income tier level
Out-of-pocket maximum
1 (Up to 50.00% FPL)
$8
2 (50.01-100.00% FPL)
$71
3 (100.01% FPL and above)
$143
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These populations and services are exempt from copays:
 Pregnant women and new moms receiving pregnancy-related services up to 60 days postpartum
 Children younger than age 21
 Native American and Alaskan natives
 Preventive services for children younger than age 18
 Provider-preventable services
 Individuals in nursing facilities
 Individuals receiving hospice services, or covered through the Breast and Cervical Cancer
Treatment Program
 Family Planning services
 Emergency services including three-day emergency supplies
 Diabetic testing supplies syringes and needles
 BMS approved home infusion supplies
 Three-day emergency supplies
 Vaccines administered by a pharmacist
PROGRAMS TO HELP KEEP YOU HEALTHY
UniCare members do not have to pay to find out about these programs or join them. They are
all at no cost to our members. We hope you and your family use them. We want to help you to
be well and to stay that way.
For women
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Well-woman care, including information about healthy behaviors and the need for regular
exams, mammograms and cervical cancer screenings
Family planning can help teach you:
- How to be as healthy as you can before you get pregnant
- How to prevent pregnancy
- How to prevent sexually transmitted infections like HIV/AIDS
Pregnancy and childbirth classes give you knowledge to help you have a healthy
pregnancy.
Our maternity program Taking Care of Baby and Me provides educational materials to
help you have a healthy pregnancy. You will also have access to a nurse case manager or
care coordinator to assist you with your pregnancy if high risk, and to answer your
questions. The nurse will work closely with you and your provider to make sure you are
getting the services and resources you need for a healthy pregnancy. Plus, you get
rewards just for going to prenatal visits and your postpartum visit on time. Your baby also
may qualify for rewards for completing well child checkups.
For you and your child
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Well-child care programs to help you keep your child healthy. You can learn about healthy
behaviors for your child, the need for regular provider visits and shots (immunizations)
Parenting tips to learn how to care for your child
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Free magazines — Eating Well and Parents, compliments of UniCare
Gift card rewards — Earn gift cards for going to checkups on time
For weight loss
We’ve teamed up with Weight Watchers® to help members who are ready to lose weight. To
be eligible, you must be one of the following:
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Age 18 or older with a body mass index (BMI) greater than 25
Ages 10 to 17 and have a:
- BMI in the 85th percentile or above for age and gender
- Parent or guardian’s consent to take part in Weight Watchers
- Provider’s referral
If you want to sign up and attend Weight Watchers at no cost to you, please call our Customer
Care Center toll free at 1-888-611-9958. This offer is for new Weight Watchers members only.
Weight Watchers® is a registered trademark of Weight Watchers International, Inc., and is
used under license.
For peace of mind
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Our 24-hour nurse help line lets you talk in private with a nurse about your health. You can
reach a nurse 24 hours a day, 7 days a week. You also can call and listen to audiotapes on
over 300 health topics such as:
– Preventive health care
– High blood pressure
– Diabetes
– Sexually transmitted infections like HIV/AIDS
– Alcohol and drug problems
– How to be tobacco-free
– Pregnancy
For tobacco cessation
•
West Virginia’s Tobacco Quit Line is a free, phone-based counseling service. If you are
interested in this program, please call [1-877-966-8784 Monday through Friday, 8 a.m. to
8 p.m., and Saturday and Sunday 8 a.m. to 5 p.m.]. Services include:
– Individual coaching
– Resources for providers who want to improve patient outcomes
– Support for family and friends who want to help loved ones stop smoking
A free cellphone
When you sign up for a SafeLink® cellphone* through Lifeline, you get a free cellphone with up
to 350 minutes per month, plus 200 bonus minutes, free unlimited nationwide texting and
unlimited calls to our Customer Care Center.
*SafeLink Wireless® is a Lifeline-supported service. Lifeline is a government benefit program.
Only those who qualify may enroll in Lifeline. It can’t be transferred. It is limited to one per
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household. You may need to show proof of income or that you take part in the program to
enroll.
Disease Management
UniCare has a Disease Management program. A team of licensed nurses and social workers,
called Disease Management case managers, will teach you about your condition and help you
learn how to manage your care. Your PCP and our team of case managers will help you with
your health care needs.
Disease Management case managers provide support over the phone for members with:
 Diabetes
 HIV/AIDS
 Behavioral health conditions
- Bipolar disorder
- Major depressive disorder
- Substance use disorder
- Schizophrenia
 Heart conditions
- Coronary artery disease
- Congestive heart failure
- High blood pressure
 Lung conditions
- Asthma
- Chronic obstructive pulmonary disease (COPD)
Disease Management case managers work with you to set health goals and help make a plan
to reach them. As a member in the program, you will benefit from having a case manager who:
 Listens to you and takes the time to understand your needs
 Helps you make a care plan to reach your health care goals
 Gives you the tools, support and community resources that can help you improve your
quality of life
 Gives you health information to help you make better choices
 Helps coordinate care with your providers
As a UniCare member enrolled in the Disease Management program, you have certain rights
and responsibilities. You have the right to:
 Have information about Disease Management. This includes:
- Programs
- Services
- Our staff’s education and work experience
- Our contracts with other businesses
 Refuse to take part in or disenroll from the program
 Know which staff members help with your health care services and who to ask for a change
 Have case managers help you make choices with your providers about your health care
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Know about all Disease Management-related treatments. These include anything stated in
the clinical guidelines, whether covered or not by UniCare. You have the right to discuss all
options with your providers.
Have your personal and medical information kept private
- Know who has access to your information
- Know what Disease Management does to keep your information private
Be treated with courtesy and respect
Know our complaint (grievance) process:
- How to file a complaint
- Standards of timely response to complaints
- How to solve issues of quality
Get information you can understand
You have the responsibility to:
 Listen and know the importance of accepting or rejecting health care advice
 Provide UniCare with information needed to carry out our services
 Tell your case manager and your providers if you decide to disenroll from the Disease
Management program
If you have one of these conditions or would like to know more about Disease Management,
please call 1-888-830-4300 Monday through Friday from 8:30 a.m. to 5:30 p.m. Ask to speak
with a Disease Management case manager.
How to get other services
You can get help from a special program called Women, Infants and Children (WIC). The WIC
program gives healthy food to pregnant women and mothers of young children. WIC also will
tell you about foods that are good for you. If you have questions about WIC services, or wish to
enroll in the WIC program, call your DHHR caseworker for information.
HELP WITH SPECIAL SERVICES
Help in other languages
We provide free oral interpretation services in more than 140 languages. We want you to have
the right care, so we have:
 Staff members who can get you help in your language
 24-hour telephone interpreters
 Sign language and face-to-face interpreters
 Providers who can get you help in your language
If you need help in a language other than English during your medical visit, you can ask for an
interpreter at no cost. Call us Monday through Friday, 8 a.m. to 5 p.m., and we will get
someone who speaks your language.
You can call our 24-hour nurse help line at 1-888-850-1108 if you or your child need someone
to interpret for you in an emergency or after regular office hours.
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If you need the member handbook in a language other than English, we can translate it for you
at no cost. Call the Customer Care Center at 1-800-782-0095.
Help for members with hearing or speech loss
If you have hearing or speech loss, you may call our toll-free TTY line from 8 a.m. to 5 p.m.
Monday through Friday, at 1-866-368-1634. To get the help you need between 5 p.m. and
8 a.m. and on weekends, call the West Virginia Relay Service at 1-800-982-8772
(TTY 1-800-982-8771). After regular business hours, you can also call our 24/7 nurse help line
at 1-888-850-1108 (TTY 1-800-368-4424).
We can provide this member handbook and other important plan materials in different ways.
This is so people that do not see well can still learn about their plan. Here are the ways we can
do this:
 Large print
 A CD for listening to plan information
 Braille
 Audiotape
Please call us to get these other formats, or for help reading this handbook.
Americans with Disabilities Act
We meet the terms of the Americans with Disabilities Act (ADA) of 1990. This act protects you
from unfair actions by your health plan because of a disability. Please call us if you feel you
have not been treated the same as others because of a disability.
HOW TO RESOLVE A PROBLEM WITH UNICARE
We care about the quality of service that you get from us and our health care providers. If you
have a problem with us, we would like to talk with you. Here are some of the issues we can
help you with:
 Access to health care services
 Provider care and treatment
 Administrative issues
Please call us first at our Customer Care Center at 1-800-782-0095 (TTY 1-866-368-1634).
UniCare Health Plan of West Virginia, Inc. (UniCare) can help you with problems you may
have with your health care services, such as:
 Access to health care services
 Provider care and treatment
 Administrative issues
 A decision made by UniCare
Please talk to your provider if you have questions or concerns about your care. You can also
call our Customer Care Center at 1-800-782-0095 (TTY 1-866-368-1634).
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We can help you:
1. File a complaint with UniCare
2. Meet with UniCare
3. File an appeal of a:
- Service that is not approved
- Getting fewer services approved than you asked for
- Service ending that was approved before
- Failure to give timely service
4. File a request for an expedited appeal
5. Ask for a State Fair Hearing
6. File an appeal with the Office of the Insurance Commissioner
7. File an appeal with the Circuit Court
You will not have to pay for any of these. All members will be treated fairly for filing a
complaint, grievance or appeal.
We want to help. If you do not agree with a decision we made, or if you have a problem
with the care you received, you can file a complaint or a grievance with us.
Talk to your PCP first if you have questions or concerns about your care. If you still have
questions or concerns, call UniCare. We can help you. You will not be treated in a different
way for filing a complaint.
If you have questions about how we make medical decisions, call Utilization Management
Monday through Friday, 8 a.m. and 5 p.m. The phone number is 1-866-655-7423
(TTY 1-866-368-1634).
If you have a complaint or grievance
We want to help. You, or someone you choose to represent you, may file a complaint:
 In writing
 By phone
 By any electronic means
A complaint is a way for you, or someone you choose, to tell us when you are not happy with
something. If your request was a complaint, we will take care of the complaint within one
business day. We will either call or write you. If we are unable to resolve your complaint over
the phone, we will send it to the Customer Care Center. If the Customer Care Center can’t fix
your concern, your complaint will be sent to the Grievance and Appeals department. You can
choose not to be named when making a complaint.
Filing a complaint
You may file a complaint if there is a problem with the quality of health care or help that you
get. A complaint does not need to be about the denial of benefits for health care services.
Those are handled as appeals. You, or someone you choose to represent you, need to write
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what the problem was within one year from the date the problem happened, except as required
by law.
A grievance is when you are not pleased with any part of the health care service provided to
you or paid for by UniCare. To file a grievance, fill out a Member Grievance form. This form is
at local UniCare offices, provider offices and on our website. You may write UniCare to explain
the problem. You also can call us at 1-800-782-0095.
Tell us the details of why you are not happy with the health care services. Tell us who, what,
when, where and why. Attach any papers to the form or letter that will help us make our
decision.
Mail the form or letter to:
Grievance and Appeals Department
P.O. Box 91
Charleston, WV 25321-0091
FAX: 1-866-387-2968
If you can’t mail the form or letter, we can help. Call UniCare at 1-800-782-0095.
You may also receive information about the process in a language other than English at no
cost to you. Oral interpreter services are also available to you at no cost. If you want to use this
service, please call us at 1-800-782-0095 (TTY 1-866-368-1634).
You have the right to give proof, or claims of fact or law, for your complaint by telling us or
writing to us.
UniCare will look into your problem and send you a letter within 30 calendar days. UniCare can
ask for 14 more days if we need to know more. We will send you a letter telling you why more
time was needed. You may also ask for 14 more days if you need more time.
Meet with UniCare
You have the right to meet with UniCare during the grievance process. We can help you set up
a meeting. Call us at 1-800-782-0095.
File an appeal or a complaint with UniCare
If you would like to file an appeal or a complaint (grievance appeal), you must do so within 90
days from the date on the grievance resolution letter. You may file the grievance appeal in
writing to:
P.O. Box 91
FAX: 1-866-387-2968
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You have the right to have someone you trust act on your behalf to help you with your appeal.
You have the right to see and get copies of all papers that have to do with your grievance
appeal as allowed by law. You must ask for these copies. You may also ask for a copy of the
benefits and how the decision was made. This is no cost to you.
UniCare will look into your appeal and send you what we decide within 30 calendar days.
UniCare can ask for 14 more days if we need to know more. We will send you a letter telling
you why more time was needed. You may also ask for 14 more days if you need more time.
File an appeal
Appeal of a Denial of Service, a Reduction in Service, Termination of a Previously Authorized
Service, or a Failure to Provide Timely Service
You may appeal a decision for:
 Not getting a service you wanted
 Getting fewer services approved than you asked for
 A service ending that was approved before
 Failure to give timely service
You must file the appeal within 90 days from the date on the letter you got telling you of the
denial. You can file an appeal by calling the Customer Care Center at 1-800-782-0095 (TTY 1866-368-1634). You may also write to:
P.O. Box 91
FAX: 1-866-387-2968
You may also receive information about the process in a language other than English at no
service, please call us at 1-800-782-0095 (TTY 1-866-368-1634).
You have the right to have someone help you with your appeal. Written and signed appeals
must be filed even after you requested this by phone, except when an appeal needs to be
rushed through. If an appeal is rushed, it must be written. You do not have to pay to file an
appeal.
You have the right to give proof, or claims of fact or law, for your appeal either orally or in
writing. You have the right to see and get copies of all documents that have to do with your
appeal as allowed by law. You must ask for these copies. You may also ask for a copy of the
benefits and a copy of the document that explains how the decision was made. This is no cost
to you.
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UniCare will look into your appeal and send you a decision within 30 calendar days. UniCare
can ask for 14 more days if we need to know more. We will send you a letter telling you why
more time was needed. You may also ask for 14 more days if you need more time.
File a request for an expedited appeal
If you believe that the fact that we denied, ended, or reduced your services could seriously
place your health and well-being at risk, you may ask for a faster appeal.
UniCare will review your request. We will decide if the standard appeal review time frame
would put at risk your:
 Life
 Health
 Being able to attain, maintain, or regain your best level of function

UniCare will tell Bureau for Medical Services (BMS) of your request. BMS will tell UniCare how
long it will take to resolve your appeal. If your request is denied after review, your appeal will
go through the standard appeal process. We will try as much as we can to tell you the decision
verbally. We will also send you a letter within two calendar days that tells you this.
You have the right to give proof, or claims of fact or law, for your appeal either orally or in
writing. But, be aware that you only have a certain amount of time to send what we need
during the faster appeal process.
If your request is approved, we will complete our review and tell you our decision within 72
hours. We will try as much as we can to tell you the decision verbally. We will also send you a
letter telling what we decide.
UniCare can ask for 14 more days if we need more from you. We will send you a letter to tell
you why more time is needed. You may also ask for 14 more days if you need more time.
Ask for a State Fair Hearing
If you are unhappy with UniCare’s decision on your appeal, you may file for a State Fair
Hearing. You must file within 90 days from the date on the letter you got telling you the
decision. You can only file for a State Fair Hearing after going through UniCare’s grievance
and appeals process.
You can only ask for a State Fair Hearing for:
 Not getting a service you wanted
 Getting fewer services approved than you asked for
 A service ending that was approved before
 Failure to get timely service
If you ask for a State Fair Hearing, the state will hear your case. They will give you a decision
in writing within 90 days from the date you filed the appeal. You do not have to pay for the
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appeal or the State Fair Hearing. You, or someone you trust, can send a written appeal to the
State by calling your local Department of Health and Human Resources.
You may keep your benefits while an appeal or a State Fair Hearing is pending if:
 You, or your provider acting on your behalf, asked for the appeal or State Fair Hearing
within 10 days from the date the notice of adverse action was mailed.
 The appeal is about a decision to stop or reduce services you are now getting.
 The services were ordered by an approved provider.
 The first period covered by the approved order has not ended.
 You ask for the services to your benefits to last longer.
Even if you ask to keep your benefits, you may have to pay the cost of services you get while
your appeal is pending. You may have to pay for the services you received, even if your
appeal is denied.
File an appeal with the Office of the Insurance Commissioner
If you do not agree with the decision by BMS, you can appeal to the Office of the Insurance
Commissioner. Send your appeal to:
The Office of the Insurance Commissioner
P.O. Box 50540
File an appeal with the Circuit Court
If you do not agree with what the Office of the Insurance Commissioner decided, you may
appeal to Circuit Court. Your appeal must be filed with the Court within 30 days after the
Insurance Commissioner’s order has been mailed.
For help, please call the UniCare Customer Care Center at 1-800-782-0095
(TTY 1-866-368-1634). We can translate or explain this process to you.
Grievance and appeals for dental services
Dental grievances
You can file a grievance if you have a problem with the quality of the dental care you receive.
To file a dental grievance, you or someone you choose should state the problem in writing
within one year from the date the problem happened. To do so, fill out a grievance form, or
write a letter telling Scion Dental about the problem. You can find these forms at provider
offices. The grievance form is also available at http://sciondental.com. Send your completed
form or letter to:
Scion Dental of West Virginia — Appeals
P.O. Box 1396
Milwaukee, WI 53201
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If you cannot mail the form or letter, you or someone you choose can call Scion and tell them
about your problem. You may call Scion at 1-888-983-4697. You also may receive information
about the grievance process in a language other than English at no cost to you.
Oral interpreter services are also available to you at no cost. If you want to use this service,
please call our Customer Care Center at 1-800-782-0095. UniCare and Scion will work
together with the interpreter.
Here are the things you need to tell us as clearly as you can:
 Who is involved in the grievance
 What happened
 When it happened
 Where it happened
 Why you are not happy with the dental care you received
Attach any documents that will help us look into the problem. If you need help, Scion will help
you file your grievance.
Scion will send you a letter within five calendar days after they get your grievance in the mail or
by phone. Scion will call you for issues that need to be taken care of right away and send you
a written response within three calendar days if your issue needs to be taken care of right
away. The letter will tell you about your right to meet face-to-face with staff at our local UniCare
office.
UniCare can help you set up a face-to-face meeting. Call us at 1-800-782-0095 for assistance.
The goal is to solve your problem.
Scion will ask the staff person who knows the most about your issue to review it:
• Quality of care issues (also called clinical quality issues) are looked into first by a
Grievance and Appeals associate, who then decides who will complete the final review.
• A dental director reviews all clinical quality issues, decides how serious they are and gives
recommendations on how to solve each problem.
• Administrative issues (also called quality of service issues) are reviewed by a UniCare
associate who consults with Scion to solve your problem.
Scion will send you a grievance resolution letter within 30 calendar days after they get your
grievance. Scion can ask for 14 more days if they need to know more. Scion will send you a
letter telling you why more time is needed. You may also ask for 14 more days if you need
more time.
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Dental appeals
You may file an appeal if Scion doesn’t approve a service, if Scion takes too long to approve it
or if there is a change to your request for services. You or someone you choose can ask for an
appeal. This must be done in writing and sent to:
Scion Dental of West Virginia — Appeals
P.O. Box 1396
Milwaukee, WI 53201
You also may file an appeal by calling Scion at 1-888-983-4697. You do not have to pay to file
an appeal.
Scion will send you an acknowledgment letter within five business days. It will tell you that
Scion got your appeal request. Scion will send you an appeal resolution letter within 30
calendar days from the date the initial appeal was filed. You, or someone you choose to help
you or speak for you, may extend the appeal for 14 calendar days. Scion also may extend the
appeal for 14 calendar days if Scion needs to find out more information about your request.
You will get a letter from Scion if the appeal is extended.
You may receive information about the appeals process in a language other than English at no
service, please call UniCare at 1-800-782-0095.
Your benefits may continue while your appeal is pending as long as you submit your appeal
within 10 days after Scion mails the Notice of Action letter, or the intended effective date of the
proposed action. You may have to pay for services you get while you wait for an answer about
your appeal if the final decision is not the same as what you asked for.
Expedited appeal
You may ask for an expedited appeal if Scion needs to make a decision quickly based on your
health status. Scion will process your request as quickly as they can, but Scion will not take
more than three calendar days from the date it received your appeal. The three-day limit may
be extended up to 14 days if you ask for it or Scion needs more information to make the
decision and the delay is in your interest. If Scion cannot make a decision within three calendar
days, it will send you a letter that gives you the reason for the delay.
State Fair Hearing
You or someone you choose to represent you may ask for a State Fair Hearing if:
 We have denied, deferred or modified a service
 If we have failed to give you timely service
You have 90 calendar days from the date on the Notice of Action letter to ask for a State Fair
Hearing. You must go through the UniCare Grievance and Appeals process before requesting
a State Fair Hearing.
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You, or someone you trust, can send a written appeal to the state by calling your local
Department of Health and Human Resources (DHHR). You can find the phone number and
address for your local office at http://www.dhhr.wv.gov/Pages/default.aspx or call DHHR at
1-877-716-1212. You also can request a State Fair Hearing in writing or by completing a
Request for Hearing form. The Request for Hearing form can be found at
http://www.dhhr.wv.gov/Pages/Search.aspx?q=request%20for%20hearing.
Please return the completed form to:
Board of Review
Bldg 6, Capitol Complex
When you request a State Fair Hearing, someone from the UniCare Grievance and Appeals
department will contact you to try to resolve the issue. If you are happy with the result, you will
need to call your local DHHR office and withdraw your request for the State Fair Hearing.
If you ask for a State Fair Hearing, you will get a letter from the hearing officer that tells you the
date and time of the hearing. The letter also will tell you what you need to know to get ready for
the hearing.
The hearing can be held by telephone. You can explain why you asked for this service. You
also can ask the hearing officer to check the information you sent in and to make a decision.
You or the person you chose to help you or speak for you may review your case file before or
during the hearing. DHHR will give you a final decision in writing within 90 calendar days from
the date you asked for the hearing.
You may keep your benefits while your State Fair Hearing is pending if you submit your appeal
within 10 days after we mail the Notice of Action letter to you or the date of the planned action.
You may have to pay for services you received while you were waiting for an answer if the final
decision is not the same as the one you asked for.
If you still have a problem with the decision, you can take your case to Circuit Court. You must
file with the Circuit Court within 120 calendar days of the date of your notice of the State Fair
Hearing decision.
Appeals after 90 calendar days
If you did not ask for a State Fair Hearing within 90 calendar days of the notice of the appeal
ruling, you may still be able to appeal the original ruling. You can use this process even if the
ruling does not have to do with us denying, deferring or modifying a service, or if we did not
give you timely service.
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To file this appeal, you must complete the UniCare internal grievance and appeals process
first. Your filing must be within one year from the date of the first ruling that you did not agree
with. You can appeal to the Insurance Commissioner by sending your appeal to:
The Office of the Insurance Commissioner
P.O. Box 50540
If you do not agree with what the Office of the Insurance Commissioner decides, you may
appeal to the Circuit Court. You must file your appeal within 30 calendar days after the
Insurance Commissioner’s order was mailed.
IF WE CAN NO LONGER SERVE YOU
Sometimes UniCare no longer can serve you. You may not be covered by UniCare if:
 You are disenrolled (removed) from our health plan
 You move out of our service area
Disenrollment
You may be asked to leave our health plan (disenroll) for these reasons:
 You no longer are eligible.
 You move out of our service area (If you move to a place that is served by other health
plans, you must re-enroll in a new health plan right away.)
 You are placed in a nursing facility, state institution or intermediate care facility for the
mentally impaired for more than 30 calendar days.
 You were signed up in error.
 Your plan ID card was misused.
 Fraud or misrepresentation happened.
You may change your health plan at any time for any reason. Call the enrollment broker at
1-800-449-8466 to disenroll from your current plan.
OTHER INFORMATION YOU NEED TO KNOW
Contacting Customer Care Center
Call us toll free at 1-800-782-0095 Monday through Friday from 8 a.m. to 6 p.m. Our staff is
trained to help you understand your health plan. We can tell you about:
 Eligibility
 Benefits
 How to use your behavioral health benefits
 How to get service
 How to choose or change your PCP
 How to use your pharmacy benefits Health plan information
 Dental and vision care
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

Transportation help
Complaints, grievances and appeals
If you have other insurance
To be able to enroll in Medicaid, you must report all insurance information to the program. Call
the enrollment broker at 1-800-449-8466 and our Customer Care Center if you are covered by
another health plan.
Call us if you:
 Have a workers’ compensation claim
 Are waiting for a decision on a personal injury or medical malpractice lawsuit
 Have an auto accident
We can, and should, know about everyone giving you care. We need to know this to pay for
your health care. We will not share this information with anyone except your health care
provider and others as the law allows.
How to choose or change your health plan
You can change your health plan for any reason by calling 1-800-449-8466 to choose a new
health plan. To disenroll from UniCare, call the enrollment broker at 1-800-449-8466.
What to do if you get a bill
In most cases, you should not get a bill from our providers. You may have to pay for charges if:
• You agree to pay for service ahead of time that we do not cover or approve
• You agree ahead of time to pay for care from a provider who does not work with us, and
you did not get our OK ahead of time
If you get a bill and do not think you should have to pay for the charges, call us. Please tell us
the date of service, the amount being charged, and why you were billed. Have the bill with you
when you call us. Sometimes a provider may send you a statement that is not a bill.
Reporting waste, abuse and fraud
If you think that a member or a provider has committed waste, abuse or fraud, you have a
responsibility to report it. To report waste, abuse or fraud, gather as much information as
possible. You can report providers/members directly to your health plan by:
• Calling our Customer Care Center at 1-800-782-0095.
• Writing to:
Program Integrity Unit
When reporting a provider, let us know:
• Name, address and phone number of the provider
• Name and address of the facility (hospital, nursing home, home health agency, etc.)
• Medicaid number of the provider and facility, if available
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•
•
•
•
Type of provider (provider, physical therapist, pharmacist, etc.)
Names and the phone numbers of other witnesses who can aid in the investigation
Dates of events
Summary of what happened
When reporting a member, let us know:
• The person’s name
• The person’s date of birth and social security number, if available
• The city where the person lives
• Specific details about the waste, abuse or fraud
Keeping your information private
By accepting the benefits described in this member handbook, you agree to have UniCare or
any person or third party we may assign to go over your medical records. This is for the
purposes of utilization review, quality assurance and peer review.
The Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices in
this member handbook describes the UniCare privacy policies and procedures.
Access to your medical records
Federal and state laws allow you to see your medical records at any time. Ask your PCP for
your records first. If you have a problem getting them from your PCP, call us.
Advance directives (living wills)
An advance directive (also called a living will) is a legal document that states how you want to
be treated if you cannot talk or make decisions.
For instance, you can name your spouse as the person who will make decisions about your
health care if you cannot. We will give advance directive information to your family member if
you can’t talk or make decisions when you join our health plan.
You may want to list the types of care you do, or do not, want to receive. For instance, some
people do not want to be put on life-support machines if they go into a coma. Your PCP will
note your living will in your medical records. That way, your provider will know what you want.
You have the right to set up papers with this information for your providers and other health
care professionals to use. These are called advance directives for health care. Ask your family,
your PCP or someone you trust to help you. You can find the forms you need at drug stores,
hospitals, providers’ and lawyers’ offices. You may change or cancel your advance directive at
any time.
We will give our adult members information that reflects state law changes regarding advance
directives as soon as possible, but no later than 90 days after the start date of the change.
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Review of member records
By joining our health plan and accepting the health care benefits listed in this handbook, you
agree to let us look at your medical records for utilization review, quality assurance and peer
review.
How to suggest changes in our policies and services
UniCare has a Community Advisory Committee (CAC) to give members a say about our
policies and services. CAC members inform, direct and suggest ideas about issues involving
our services. Call our Customer Care Center if you would like to join the CAC.
New medical treatments
We want you to benefit from new medical treatments, so we review them on a routine basis. A
group of PCPs, specialists and medical directors decide if the treatment:
• Is approved by the government
• Has shown, in a reliable study, how it affects patients
• Will help patients as much as, or more than, treatments we use now
• Will improve the patient’s health
The review group looks at all of the information. The group then decides if the treatment is
medically necessary. They will let your provider know if the treatment is medically necessary
and if we approve it.
Quality Improvement
At UniCare, we want to make your health plan better. To do this, we have a Quality
Improvement (QI) program. Through this program, we:
• Evaluate our health plan in order to improve it
• Track how happy you are with your PCP
• Track how happy you are with us
• Use the information we get to make a plan to improve our services
• Carry out our plan to help make your health care better
You may ask us to send you information about our QI program. This will include a description
of the program and a report on our progress in meeting our improvement goals. Call our
Customer Care Center.
Accreditation report
UniCare is accredited by the National Committee for Quality Assurance (NCQA). You can
request a summary of our accreditation report by calling our CCC.
Fair treatment of minors
Minors are treated as adults when it comes to birth control, pregnancy or family planning
(except for sexual sterilization). Our members who are 13 years of age or older may refer
themselves to any network or out-of-network OB/GYN for yearly exams and regular health
care services (including cervical cancer screenings) at no cost to you. They do not need an OK
ahead of time from their PCP.
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Family planning records are kept private. PCPs and other healthcare providers should keep all
family planning records private, even if the patient is a minor, unless the law says it is OK to
share your information with others. Your provider is allowed to share your medical information
with other providers who take care of you, public health officials or government agencies.
UniCare is not responsible for the privacy of medical records held by providers who are not
part of your health plan network.
Privacy of minors
All information, records, and data collected and maintained by UniCare or its subcontractors
that relate to enrolled children is protected from unauthorized disclosure. UniCare restricts the
release of information on minors to authorized persons, and associates follow a rigorous
verification and authentication process prior to the release of information on minors. UniCare's
policy limits the disclosure of information concerning enrolled children to purposes directly
related to the administration of the Medicaid program in accordance with 42 C.F.R. §431.302.
Program or site changes
We will tell you before we change the place where you get your health care services. If your
health care program changes, we will tell you 30 calendar days before the change. UniCare
services can change without your agreement.
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YOUR MEMBER RIGHTS AND RESPONSIBILITIES
The following information is about your UniCare Health Plan of West Virginia, Inc.
(UniCare) member rights.
Each year, UniCare submits its annual report to the Bureau for Medical Services (BMS) of the
West Virginia Department of Health and Human Resources by April 1. This report includes a
description of the services, personnel and the financial standing of UniCare.
The annual report is available to members by request only. To get a copy of the report, you
can call our Customer Care Center. You can also get a copy of the report from the West
Virginia Department of Health and Human Resources.
You have the following rights as a UniCare member. We will not treat you unfairly for
exercising your rights.
Member rights
As a member of our health plan, you have the right to:
• Learn about your rights and responsibilities
• Get the help you need to understand this book
• Learn about us, our services, providers and other health care providers
• See your medical records as allowed by law
• Have your medical records kept private unless you tell us in writing that it’s OK for us to
share them or it is allowed by law
• Be part of honest talks about your health care needs and treatment options no matter the
cost and whether your benefits cover them
• Be part of decisions that are made by your providers and other providers about your health
care needs Accessible services
• Ask for and get medical record copies within 30 days of request
• Ask that medical records be changed within 60 days of your request
• Be given health care services listed in this contract
• Be told about other treatment choices or plans for care in a way that fits your condition, in a
way you understand
• Get news about how providers are paid
• Find out how we decide if new technology or treatment should be part of a benefit
• Be treated with respect, dignity and the right to privacy all the time
• Know that we, your providers and your other health care providers cannot treat you in a
different way because of your age, sex, race, national origin, language needs or degree of
illness or health condition
• Talk to your provider about things that are private
• Have problems taken care of fast, including things you think are wrong, as well as issues
about getting an OK from us, your coverage or payment of service
• Be treated the same as others
• Get care that should be done for medical reasons
• Be free from any form of restraint or seclusion used as a means of coercion, discipline,
convenience or retaliation
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Choose your PCP from the PCPs in our provider directory that are taking
new patients
Use providers who are in our network
Get medical care in a timely manner
Get services from providers outside our network in an emergency
Refuse care from your PCP or other caregivers
Be able to make choices about your health care
Get information about the way UniCare is run and organized.
Make an advance directive (also called a living will)
Tell us your concerns about UniCare and the health care services you get
Give input on changes in policies and procedures
Question a decision we make about coverage for care you got from your provider
File a complaint or an appeal about UniCare, any care you get or if your language needs
are not met
Ask how many grievances and appeals have been filed and why
Tell us what you think about your rights and responsibilities and suggest changes
Ask us about our QI program and tell us how you would like to see changes made
Ask us about our utilization review process and give us ideas on how to change it
Know that the date you joined our health plan is used to decide your benefits
Know that we only cover health care services that are part of your plan
Know that we can make changes to your health plan benefits as long as we tell you about
those changes in writing
Ask for this handbook and other member materials in other formats such as large print,
audio CD or Braille at no cost to you
Ask for an oral interpreter and translation services at no cost to you
Use interpreters who are not your family members or friends
Know you will not be held liable if your health plan becomes bankrupt (insolvent)
Know your provider can challenge the denial of service with your OK
Member responsibilities
As a member of our health plan, you have the responsibility to:
• Tell us, your providers and other health care providers what they need to know to treat you
• Learn as much as you can about your health issue and work with your provider to set up
treatment goals you agree on
• Ask questions about any medical issue and make sure you understand what your provider
tells you
• Follow the care plan and instructions that you have agreed on with your providers or other
health care professionals
• Do the things that keep you from getting sick
• Make and keep medical appointments and tell your provider at least 24 hours in advance
when you cannot make it
• Always show your member ID card when you get health care services
• Use the emergency room only in cases of an emergency or as your provider
tells you (at no additional cost to you)
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Tell us right away if you get a bill that you should not have gotten or if you have
a complaint
Treat all UniCare staff and providers with respect and courtesy
Know and follow the rules of your health plan
Know that laws guide your health plan and the services you get
Know that we do not take the place of workers’ compensation insurance
Tell UniCare and your DHHR caseworker when you change your address, family status or
other health care coverage
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DEFINITIONS
Here are some of the terms used in this handbook:
BMS stands for the Bureau for Medical Services. This is the West Virginia agency that runs the
Medicaid program.
Benefits are the health care services covered by UniCare.
Brand-name prescription drug means a prescription drug that has been patented and is
produced by only one manufacturer.
Copays are small amounts that you may be required to pay for some covered services.
Cosmetic surgery is done to change or reshape normal body parts so they look better.
DHHR stands for the Department of Health and Human Resources for the state of West
Virginia. This agency takes care of carve-out services not covered by UniCare such as
personal care services.
Disenroll means to stop using the health plan because you are no longer eligible or you
change your health plan.
Emergency medical condition is a sudden, serious medical condition where the presenting
symptoms are of sufficient severity that a prudent layperson with an average knowledge of
health and medicine would reasonably believe that the lack of immediate medical care could:
• Place your health (or the health of your unborn child) at serious risk
• Impair the function of your body
• Impair the function of a body part or organ
Generic prescription drug means a pharmaceutical equivalent of one or more brand-name
drugs. It must be approved by the Food and Drug Administration as meeting the same
standards of safety, purity, strength and effectiveness as the brand-name drug.
Health care provider means any provider, hospital, agency or other person who has a license
or is authorized to give health care services.
Some health care providers include the following:
• Audiologist is a provider who tests your hearing.
• Certified nurse-midwife is a registered nurse who cares for you during pregnancy and
childbirth.
• Certified registered nurse anesthesiologist is a registered nurse certified to
give you anesthesia.
• Chiropractor is a provider who treats problems of the spine or other body parts.
• Dentist is a doctor who takes care of your teeth and mouth.
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Family practitioner is a doctor who treats general medical conditions for people of all
ages.
General practitioner is a doctor who treats common medical problems for people of all
ages.
Licensed vocational nurse is a licensed nurse who works with your provider.
Nurse practitioner or physician’s assistant is a person who works in a clinic or
provider’s office and:
- Finds out what’s wrong with you
- Treats you, within limits
Obstetrician/gynecologist (OB/GYN) is a doctor who takes care of a woman’s health (this
includes when she is pregnant or giving birth).
Occupational therapist is a provider who helps you regain daily skills and activities after
an illness or injury.
Optometrist is a doctor who takes care of your eyes and vision.
Pediatrician is a doctor who treats children from birth through their teen years.
Physical therapist is a provider who helps you build your body’s strength after an illness
or injury.
Podiatrist or chiropodist is a doctor who takes care of your feet.
Psychiatrist is a doctor who treats mental health issues and prescribes drugs.
Registered nurse is a nurse with more training than a nurse who has a license to perform
certain duties with your provider.
Respiratory therapist is a provider who helps you with your breathing.
Speech pathologist is a provider who helps you with your speech.
Surgeon is a doctor who can operate on you.
Home health agencies and visiting nurse associations are groups through which you can
get skilled nursing care and other services in your home.
Inpatient care means you have to stay the night in the hospital or other facility for the medical
care you need.
Medically necessary means that items or services that have been given or will be given to a
patient are needed to treat or prevent a medical condition and are not mainly for the ease of
the patient, provider or other health care provider.
Examples are:
• To find the cause of an illness or treatment of illness or injury
• To help a body part that is not normal work better
• To prevent illness
• To help a patient meet the right growth and development levels
Member is a person approved by the state of West Virginia to enroll in UniCare.
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OK by UniCare means you received an approval ahead of time from us. You can learn more
about this in Getting to know your health plan, under the heading Prior authorization (an OK
from UniCare) for health care services.
Outpatient care is care you get when you do not have to stay overnight in a hospital or other
place of treatment.
Preferred drug list (PDL) means a list of brand-name and generic prescription drugs and
supplies preferred by UniCare for use as the ﬁrst line of drug therapy.
Primary care provider (PCP) is the provider you choose for most of your health care. This
person helps you get the care you need. Your PCP must OK most care ahead of time, unless it
is an emergency.
Prior authorization (OK by UniCare) refers to the approval you get from us before you get
a service.
Reconstructive surgery is done to correct a problem with a part of your body. This problem
could be caused by:
 A birth defect
 Disease
 Injury
Making that part look or work better must be medically necessary.
Skilled nursing facility is a place that gives you 24-hour-a-day skilled professional
nursing care.
Urgent medical condition is not an emergency, but is a condition that should have medical
care within 48 hours.
Utilization review is a process that allows UniCare and your health care providers to work
together to decide if a service you ask for is medically necessary.
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NOTICE OF PRIVACY PRACTICES
The original effective date of this notice was April 14, 2003. The most recent revision date is
shown in the footer of this notice.
Please read this notice carefully. This tells you who can see your protected health
information (PHI). It tells you when we have to ask for your OK before we share it. It tells
you when we can share it without your OK. It also tells you what rights you have to see
and change your information.
Information about your health and money is private. The law says we must keep this kind of
information, called PHI, safe for our members. That means if you’re a member right now or if
you used to be, your information is safe.
We get information about you from state agencies for Medicaid after you become eligible and
sign up for our health plan. We also get it from your providers, clinics, labs and hospitals so we
can OK and pay for your health care.
Federal law says we must tell you what the law says we have to do to protect PHI that’s told to
us, in writing or saved on a computer. We also have to tell you how we keep it safe. To protect
PHI:
 On paper (called physical), we:
– Lock our offices and files
– Destroy paper with health information so others can’t get it
 Saved on a computer (called technical), we:
– Use passwords so only the right people can get in
– Use special programs to watch our systems
 Used or shared by people who work for us, providers or the state, we:
– Make rules for keeping information safe (called policies and procedures)
– Teach people who work for us to follow the rules
When is it OK for us to use and share your PHI?
We can share your PHI with your family or a person you choose who helps with or pays for
your health care if you tell us it’s OK. Sometimes, we can use and share it without your OK:
 For your medical care
– To help providers, hospitals and others get you the care you need
 For payment, health care operations and treatment
– To share information with the providers, clinics and others who bill us for your care
– When we say we’ll pay for health care or services before you get them
– To find ways to make our programs better, as well as giving your PHI to health
information exchanges for payment, health care operations and treatment. If you don’t
want this, please visit www.unicare.com/health-insurance/about-us/privacy for more
information.
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For health care business reasons
– To help with audits, fraud and abuse prevention programs, planning, and everyday work
– To find ways to make our programs better
For public health reasons
– To help public health officials keep people from getting sick or hurt
With others who help with or pay for your care
– With your family or a person you choose who helps with or pays for your health care,
if you tell us it’s OK
– With someone who helps with or pays for your health care, if you can’t speak for
yourself and it’s best for you
We must get your OK in writing before we use or share your PHI for all but your care, payment,
everyday business, research or other things listed below. We have to get your written OK
before we share psychotherapy notes from your provider about you.
You may tell us in writing that you want to take back your written OK. We can’t take back what
we used or shared when we had your OK. But we will stop using or sharing your PHI in
the future.
Other ways we can — or the law says we have to — use your PHI:
 To help the police and other people who make sure others follow laws
 To report abuse and neglect
 To help the court when we’re asked
 To answer legal documents
 To give information to health oversight agencies for things like audits or exams
 To help coroners, medical examiners or funeral directors find out your name and cause of
death
 To help when you’ve asked to give your body parts to science
 For research
 To keep you or others from getting sick or badly hurt
 To help people who work for the government with certain jobs
 To give information to worker’s compensation if you get sick or hurt at work
What are your rights?
 You can ask to look at your PHI and get a copy of it. We don’t have your whole medical
record, though. If you want a copy of your whole medical record, ask your provider or
health clinic.
 You can ask us to change the medical record we have for you if you think something is
wrong or missing.
 Sometimes, you can ask us not to share your PHI. But we don’t have to agree to your
request.
 You can ask us to send PHI to a different address than the one we have for you or in some
other way. We can do this if sending it to the address we have for you may put you in
danger.
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You can ask us to tell you all the times over the past six years we’ve shared your PHI with
someone else. This won’t list the times we’ve shared it because of health care, payment,
everyday health care business or some other reasons we didn’t
list here.
You can ask for a paper copy of this notice at any time, even if you asked for this one
by email.
What do we have to do?
 The law says we must keep your PHI private except as we’ve said in this notice.
 We must tell you what the law says we have to do about privacy.
 We must do what we say we’ll do in this notice.
 We must send your PHI to some other address or in a way other than regular mail if you
ask for reasons that make sense, like if you’re in danger.
 We must tell you if we have to share your PHI after you’ve asked us not to.
 If state laws say we have to do more than what we’ve said here, we’ll follow
those laws.
 We have to let you know if we think your PHI has been breached.
We may contact you
You agree that we, along with our affiliates and/or vendors, may call or text any phone
numbers you give us, including a wireless phone number, using an automatic telephone dialing
system and/or a prerecorded message. Without limit, these calls or texts may be about
treatment options, other health-related benefits and services, enrollment, payment, or billing.
What if you have questions?
If you have questions about our privacy rules or want to use your rights, please call our
Customer Care Center at 1-800-782-0095. If you’re deaf or hard of hearing, call
1-866-368-1634.
What if you have a complaint?
We’re here to help. If you feel your PHI hasn’t been kept safe, you may call our Customer Care
Center or contact the Department of Health and Human Resources (DHHR) at 1-877-7161212. Nothing bad will happen to you if you complain.
We reserve the right to change this Health Insurance Portability and Accountability Act
(HIPAA) notice and the ways we keep your PHI safe. If that happens, we’ll tell you about the
changes in a newsletter. We’ll also post them on the Web at www.unicare.com/healthinsurance/about-us/privacy.
Your personal information
We may ask for, use and share personal information (PI) as we talked about in this notice.
Your PI is not public and tells us who you are. It’s often taken for insurance reasons.
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We may use your PI to make decisions about your:
– Health
– Habits
– Hobbies
We may get PI about you from other people or groups like:
– Providers
– Hospitals
– Other healthcare providers
– Other insurance companies
We may share PI with people or groups outside of our company without your OK in some
cases.
We’ll let you know before we do anything where we have to give you a chance to say no.
We’ll tell you how to let us know if you don’t want us to use or share your PI.
You have the right to see and change your PI.
We make sure your PI is kept safe.
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Primary Care Provider (PCP) Selection Form
If your UniCare member ID card does not show the primary care provider (PCP) of your
choice, or if you wish to change your PCP for any reason, please follow these directions:
●
Call the UniCare Customer Care Center at 1-800-782-0095 to speak with someone who
can help you.
OR
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Complete this form and return it to us within 30 days.
You may choose one PCP for your whole family, or each family member may choose a
different PCP. You must list each family member on the form even if you select the same PCP.
We will send you new ID cards within five days after we receive your completed form. Always
carry your ID card with you.
□ Please check this box if you are pregnant.
When you are done filling out this form, just mail it back in the envelope we provided. No
stamp is needed.
Choose the PCP who’s right for you. Send this form back today!
Look in our provider directory and give us your first and second choices for a PCP.
Please print your information below.
Your Name (please print):
City:
State:
ZIP code:
Please check this box if you have moved in the last year. If you move, please remember to
call our Customer Care Center at 1-800-782-0095.
Your Daytime Telephone Number:
Your Signature:
Choose a new PCP
Member Name (First and Last):
Member ID Number:
First Choice — PCP Name (First and Last):
Second Choice — PCP Name (First and Last):
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We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095. If you have speech or hearing
loss, call the TTY line at 1-866-368-1634.
CL_WSSB_CVR19
WV MHB ENG 08.2015

Member Handbook

Transcription

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