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. UniCare Health Plan of West Virginia, Inc. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 WV MHB ENG 10 15 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 UniCare Health Plan of West Virginia, Inc. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 WV MHB ENG 10 15 UniCare Health Plan of West Virginia, Inc. 200 Association Drive, Suite 200 Charleston, WV 25311 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 1 WV MHB ENG 10 15 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 MedExpress Urgent Care Huntington 3120 US Rte. 60 Huntington, WV 25705 304-522-3627 MedExpress Urgent Care Wheeling 620 National Road Suite 300 Wheeling, WV 26003 304-233-3624 MedExpress Urgent Care 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. Parkersburg, WV 26101 304-485-1044 MedExpress Urgent Care South Charleston 4812 Maccorkle Ave. SW S. Charleston, WV 25309 304-768-3627 MedExpress Urgent Care Charleston 5430 Maccorkle Ave. SE Charleston, WV 251304 304-925-3627 Braxton Health Associates 617 River St. Gassaway, WV 26624 304-364-8941 MedExpress Urgent Care Elm Grove 10 Elm Grove Crossing Mall Wheeling, WV 26003 304-242-4228 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 2 WV MHB ENG 10 15 MedExpress Urgent Care 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 MedExpress Urgent Care 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 MedExpress Urgent Care 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 MedExpress Urgent Care Morgantown 215 Don Knotts Blvd. Suite 130 Morgantown, WV 26501 304-291-3627 MedExpress Urgent Care Princeton 277 Greasy Ridge Road Princeton, WV 24740 304-425-7615 MedExpress Urgent Care Bridgeport 120 Medical Park Drive Suite 100 Bridgeport, WV 26330 304-842-3278 WVU Fast Care Center 1075 Van Voorhis Road Suite 100 Morgantown, WV 26505 304-599-2273 MedExpress Urgent Care Lewisburg 1318 Jefferson St. N. Suite A Lewisburg, WV 24901 304-645-2164 MedExpress Urgent Care Bridgeport 1370 Johnson Ave. Bridgeport, WV 26330 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 MedExpress Urgent Care 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 MedExpress Urgent Care Fairmont 630 Fairmont Ave. Fairmont, WV 26554 304-363-6662 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 3 WV MHB ENG 10 15 MedExpress Urgent Care Glen Dale 1585 Wheeling Ave. Glen Dale, WV 26038 304-843-5381 MedExpress Urgent Care Teays Valley 563 State Route 34 Hurricane, WV 25526 304-757-5063 MedExpress Urgent Care Bluefield 4003 College Ave. Suite B Bluefield, VA 24605 276-322-2085 MedExpress Urgent Care South Parkersburg 2832 Pike St. Suite 1 Parkersburg, WV 26101 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 4 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 5 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 6 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 7 WV MHB ENG 10 15 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) Ambulatory surgical center services 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 Physician/NP/NMW/FQHC/RHC services Primary/Preventive care visits Physician office visits Specialty care Podiatry Cardiac and pulmonary rehabilitation Dental services (Emergency treatment) Home health Durable medical equipment Orthotics and prosthetics Family planning services and supplies Hospice Ambulance Prescriptions Chiropractic services Tobacco cessation Diabetes management Psychological services 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 8 WV MHB ENG 10 15 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 Drugs for the treatment of hemophilia Nursing home services Nursing home services Nonemergency transportation Nonemergency transportation Birth to 3 services Abortion Abortion Personal care services 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) Adults (21 years and older) Ambulatory surgical center services 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 Physician/NP/NMW/FQHC/RHC services Primary/Preventive care visits Physician office visits Specialty care Podiatry Cardiac and pulmonary rehabilitation Home health Durable medical equipment Orthotics and prosthetics Family planning services and supplies Hospice Ambulance Prescriptions Ambulatory surgical center services 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 Physician/NP/NMW/FQHC/RHC services Primary/Preventive care visits Physician office visits Specialty care Podiatry Cardiac and pulmonary rehabilitation Home health Durable medical equipment Orthotics and prosthetics Family planning services and supplies Hospice Ambulance Prescriptions 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 9 WV MHB ENG 10 15 Adults (21 years and older) Children (0 up to 22 years) Chiropractic services Tobacco cessation Diabetes management Skilled nursing Vision Dental services Hearing EPSDT (Well-child visits) Behavioral health rehabilitation Residential treatment Psychological services Chiropractic services Tobacco cessation Diabetes management Skilled nursing Dental services (Emergency treatment) Psychological services 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. Drugs for the treatment of hemophilia Drugs for the treatment of hemophilia Nursing home services Nursing home services Nonemergency transportation Nonemergency transportation Abortion Abortion Personal care services 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. 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 10 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 11 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 12 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 13 WV MHB ENG 10 15 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: 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 14 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 15 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 16 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 17 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 18 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 19 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 20 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 21 WV MHB ENG 10 15 Chiropractic services 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.) 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 22 WV MHB ENG 10 15 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) 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 23 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 24 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 25 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 26 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 27 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 28 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 29 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 30 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 31 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 32 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 33 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 34 WV MHB ENG 10 15 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. Nonemergency transportation 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 35 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 36 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 37 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 38 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 39 WV MHB ENG 10 15 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 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 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 40 WV MHB ENG 10 15 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: 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 • 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 41 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 42 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 43 WV MHB ENG 10 15 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). 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 44 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 45 WV MHB ENG 10 15 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 UniCare Health Plan of West Virginia, Inc. 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: Grievance and Appeals Department UniCare Health Plan of West Virginia, Inc. P.O. Box 91 Charleston, WV 25321-0091 FAX: 1-866-387-2968 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 46 WV MHB ENG 10 15 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: Grievance and Appeals Department UniCare Health Plan of West Virginia, Inc. P.O. Box 91 Charleston, WV 23521-0091 FAX: 1-866-387-2968 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 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 47 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 48 WV MHB ENG 10 15 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 Charleston, WV 25305-0540 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 49 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 50 WV MHB ENG 10 15 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 cost to you. Oral interpreter services are also available to you at no cost. If you want to use this 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 51 WV MHB ENG 10 15 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 Charleston, WV 25305 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 52 WV MHB ENG 10 15 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 Charleston, WV 25305-0540 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 53 WV MHB ENG 10 15 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 UniCare Health Plan of West Virginia, Inc. 200 Association Drive, Suite 200 Charleston, WV 25311 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 54 WV MHB ENG 10 15 • • • • 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 55 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 56 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 57 WV MHB ENG 10 15 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 58 WV MHB ENG 10 15 • • • • • • • • • • • • • • • • • • • • • • • • 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) 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 59 WV MHB ENG 10 15 • • • • • • 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 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 60 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 61 WV MHB ENG 10 15 • • • • • • • • • • • • • • • 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 62 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 63 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 64 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 65 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 66 WV MHB ENG 10 15 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. 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 67 WV MHB ENG 10 15 UniCare Health Plan of West Virginia, Inc. 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 ● 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): 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 UniCare Health Plan of West Virginia, Inc. UWV-MHB-0006-15 68 WV MHB ENG 10 15 unicare.com/medicaid 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 Health Plan of West Virginia, Inc. CL_WSSB_CVR19 WV MHB ENG 08.2015
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