UniCare Health Plan of West Virginia, Inc. Member Handbook

Transcription

UniCare Health Plan of West Virginia, Inc.
Member Handbook
UWV-MHB-0003-14 12.14
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 doctor
• 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 doctors near your
new home. You also can find the Provider Directory online at unicare.com/medicaid.
Get one-on-one help. Our ommunity Resource enter (R) sounds pretty formal, but it’s
really just an office where you can talk to our staff. Drop by or call any time during business
hours. The friendly staff is ready to serve you.
1207 Quarrier St., First Floor
Charleston, WV 25301
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., ® Registered mark of WellPoint, Inc.
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Nurse case management and social worker services
UniCare has nurse case managers and social workers to assist you with your health care needs.
They can help you set health goals. They can help make sure you are seeing the right doctors.
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 the UniCare 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.
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,
Tadd Haynes
Director, Medicaid Field Operations
Table of Contents
Introduction – How to get health care when you need it ........................................................ 1
Part 1 – Important things to do .............................................................................................. 5
Part 2 – Important phone numbers ........................................................................................ 6
Part 3 – Benefits quick reference guide .................................................................................. 8
Part 4 – How to use your health plan ................................................................................... 11
Part 5 – What UniCare covers .............................................................................................. 21
Part 6 – What UniCare does not cover.................................................................................. 33
Part 7 – What Medicaid covers ............................................................................................ 34
Part 8 – Emergency and urgent care services........................................................................ 35
Part 9 – Your prescription drug benefits ............................................................................... 36
Part 10 – Programs to help keep you healthy ....................................................................... 40
Part 11 – Help with special services...................................................................................... 44
Part 12 – How to resolve a problem with UniCare ................................................................ 45
Part 13 – If we can no longer serve you ................................................................................ 52
Part 14 – Other things you need to know ............................................................................. 53
Part 15 – Your member rights and responsibilities ............................................................... 57
Part 16 – Definitions ............................................................................................................ 60
Part 17 – Notice of Privacy Practices .................................................................................... 63
Introduction – 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
• ut or wound that won’t stop bleeding
• Major injuries
• Possible broken bones
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How to get health care fast
Sometimes, you need health care when your primary care provider (PP) can’t see you. You still
have choices. In a true emergency, call 911 or go to the emergency room.
When you need urgent care now:
1. Call your PCP. Ask if you can get in right away.
2. Call the 24-hour nurse help line 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
1-304-224-1096
Ohio Valley Medical Quick
Care, Inc.
324 Pike St.
Marietta, OH 45750
1-740-374-4540
Ez Care
2107 Pike St., Suite 5
Parkersburg, WV 26101
1-304-424-7200
Medexpress Urgent
Care Weirton
218 Three Springs Drive
Weirton, WV 26062
1-304-723-3627
Medexpress Urgent Care
Parkersburg
1500 Grand Central Ave.
Suite 115
Vienna, WV 26105
1-304-485-3627
Huntington
3120 US Rte. 60
Huntington, WV 25705
1-304-522-3627
Wheeling
620 National Road
Suite 300
Wheeling, WV 26003
1-304-233-3624
Mid-Ohio Valley Medical
Group, Inc.
701 Grand Central Ave.
(Walmart)
Vienna, WV 26105
1-304-865-1107
Teays Urgent Care
113 Liberty Square
Shopping Center
Hurricane, WV 25526
1-304-757-4007
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We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095. If you have speech or hearing loss, call the TTY line at 1-866-368-1634.
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Ez Care
260 Russell Ave.
New Martinsville, WV 26155
1-304-398-4949
Ohio Valley Medical Quick
Care, Inc.
517 36th St.
Parkersburg, WV 26101
1-304-485-1044
Medexpress Urgent Care S
Charleston
4812 Maccorkle Ave. SW
S. Charleston, WV 25309
1-304-768-3627
Charleston
5430 Maccorkle Ave. SE
Charleston, WV 251-304
1-304-925-3627
Braxton Health Associates
617 River St.
Gassaway, WV 26624
1-304-364-8941
Med Plus
2048 Vip Way
Pleasant Valley, WV 26554
1-304-366-6200
Beckley
1709 Harper Road
Beckley, WV 25801
1-304-256-8671
Care Xpress
11 North Locust St.
Buckhannon, WV 26201
1-304-473-1440
Whitehall Medical
60 Roxbury Road
Fairmont, WV 26554
1-304-363-6600
Primary Care Plus
124 Brookshire Lane
Beckley, WV 25801
1-304-255-9205
Medpointe of Harrison
County
469 Emily Drive
Clarksburg, WV 26301
1-304-423-5180
Healthplex Express Care
51 Southland Drive
Suite 1200
Fairmont, WV 26554
1-304-363-2018
Primecare 12
702 Stafford Drive
Princeton, WV 24740
1-304-425-0085
Bridgeport Express Care, Inc.
2 Chenoweth Drive
Bridgeport, WV 26330
1-304-842-3330
Morgantown
215 Don Knotts Blvd.
Suite 130
Morgantown, WV 26501
1-304-291-3627
Princeton
277 Greasy Ridge Road
Princeton, WV 24740
1-304-425-7615
Premier Medical Urgent Care
700 Genesis Blvd.
1-304-623-6330
WVU Fast Care Center
1075 Van Voorhis Road
Suite 100
Morgantown, WV 26505
1-304-599-2273
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Lewisburg
1318 Jefferson St. N.
Suite A
Lewisburg, WV 24901
1-304-645-2164
Medbrook Medical Associates
1370 Johnson Ave.
1-304-842-7186
Direct Care of Elkins
720 Beverly Pike
Elkins, WV 26241
1-304-636-4585
Health Matters
Urgent Care
14302 Barton Blvd. SW
Cumberland, MD 21502
1-301-729-3278
Direct Care of Parsons
307 Main St.
Parsons, WV 26287
1-304-478-2511
Jefferson Urgent Care
Route 340 N.
Somerset Village Shopping
Center
Charles Town, WV 25414
1-304-728-8533
Elkins Express Care
1513 Harrison Ave., Suite 18
Elkins, WV 26241
1-304-637-0180
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Part 1 – Important things to do
• 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 is a provider who will be your main doctor. 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 doctor 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.
• all your PP before you get medical care, unless you have an emergency; Your doctor’s
office will help you set up a time for care. If you need a ride to and from your doctor 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.
• If you are not sure what to do, you can call MedCall, the 24-hour nurse help line. Have your
UniCare ID card ready when you call. The nurse will ask for your ID card number.
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Part 2 – Important phone numbers
Automated Health Systems
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
or if you would like to speak to a nurse to enroll in case management.
TTY Line
1-800-782-0095
1-866-368-1634
Community Resource Center (UniCare)
Call this number for help with local resources.
1-888-611-9958
Scion Dental
TTY Line
1-877-408-0917
1-800-508-6975
MedCall – 24-hour Nurse Help Line
Call this number to talk in private with a nurse.
TTY Line
1-888-850-1108
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 (UniCare)
Call this number for help with services that need an OK from UniCare
before you receive the care.
1-866-655-7423
Vision Service Plan (VSP)
Call this number for help finding an eye doctor or to learn more
about your vision benefits.
TTY Line
1-800-877-7195
1-800-428-4833
West Virginia Department of Health and Human Resources (DHHR)
1-877-716-1212
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West Virginia Relay Service
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.
TTY Line
1-800-982-8772
1-800-982-8771
TTY lines are only for members with hearing or speech loss.
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Part 3 – enefits quick reference guide
Children (0 to 21 years)
Inpatient services
 Inpatient hospital care
 Inpatient rehabilitation
Outpatient services
 Diagnostic X-ray, laboratory
services and testing
 Physical therapy
 Speech therapy
 Occupational therapy
Physician/NP/NMW/FQHC/RHC services
 Primary/preventive care visits
 Physician office visits
 Specialty care
 Podiatry
Cardiac and pulmonary rehabilitation
Dental
 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)
Adults (21 years and older)
Inpatient services
 Inpatient hospital care
Outpatient services
 Diagnostic X-ray, laboratory services
and testing
 Physical therapy
 Speech therapy
 Occupational therapy
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
Tobacco cessation
Diabetes management
Vision (medically necessary)
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Children (0 to 21 years)
Adults (21 years and older)
The services below are among those covered by Medicaid, but not set up by UniCare. For
information on how to get these services, look at Part 7 What Medicaid covers.
Inpatient psychiatric care
Inpatient psychiatric care
Nursing home services
Nursing home services
Nonemergency transportation
Chemical dependency/mental health
Chemical dependency/mental health
services
services
Birth to age 3 services
Copays
Under your plan, you may have to make copays for some services. 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. We will send you a letter telling you when you reach your copay maximum. You also
may self-attest (report to us) that you have met the copay maximum. Call the Customer Care
Center at 1-800-782-0095 (TYY 1-866-368-1634) when you meet your copay maximum. Keep all
your household copay receipts to show that you have met the copay maximum.
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
$0;00-$5
$5;01-$10
$10;01-$25
$25;01-$50
$50;01 and above
Copayment
$0
$0;50
$1
$2
$3
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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 emergency services (includes 3-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
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Part 4 – How to use 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
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 PP’s name, phone number and address
 Uniare’s name, address and toll-free phone number
 The phone number for MedCall (the 24-hour nurse help line)
 The phone number for vision care 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 PP’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. What is a primary care provider (PCP)?
Your UniCare member ID card has the name, phone number and address of the 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. Your
PCP does not work for UniCare, but agrees to see our members.
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 doctor’s office and treats
you, within limits)
 Internist
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
Obstetrician/gynecologist (OB/GYN)
A PCP also can be a clinic such as a:
 Health department
 Federally qualified health center (FQHC)
 Rural health clinic (RHC)
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 doctor whether that
doctor 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
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) case
worker 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 if:
 You move.
 You change your phone number.
 You have changes to your insurance.
 The number of people in your household changes.
 You become pregnant.
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Initial health assessment (IHA)
All new members should see their PCP for an initial health assessment within 90 days after
joining UniCare. A child should be seen within 60 days after joining. The first meeting with your
PP is important; It’s a time to get to know each other and review your health status; Your
doctor 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
all your PP’s office during regular business hours (the phone number is on your Uniare 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 and your Medicaid ID card with you when you
visit your doctor; e on time for your visits; all your PP’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 doctor’s office; Your
PCP may not be able to see you if you are late. If you cancel your appointment, someone at
your PP’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.
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If you want to change your PCP, please note:
 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 is 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 Uniare member ID card with your new PP’s name on it;
 It is 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 Uniare or your PP’s office.
 You disrupt the PP’s office.
If you choose to go to a provider who is not your PCP, call us first. We will try to make that
doctor your PCP. We will tell you in writing if we need to change your PCP.
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 doctors 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.
You need to choose a PCP who is taking new patients. You can learn more about this in your
Provider Directory. If you need help finding a PCP who is taking new patients, call us.
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To find out more about a doctor (such as the doctor’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 (An OK from UniCare) 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.
Your PCP may need to get an OK 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,
doctor 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
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 and SPECT
 Organ transplants
 High cost and custom-made durable medical equipment. These might be crutches,
wheelchairs, special beds, etc.
 Cataract glasses and lenses. This can also include surgery to remove a cataract and insert a
lens
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 Hearing aids and services that have to do with hearing aids
Getting an OK will take no more than 14 calendar days, or, if urgent, no more than three
working days. See Part 5 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
doctor requests. We will send you and your doctor 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 letter in other
formats, such as Braille, by calling us. If you have questions, you or your provider can call our
CCC at 1-800-782-0095.
P.O. Box 91
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
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. If you have hearing or speech loss, call our TTY
line at 1-866-368-1634.
 Call our 24-hour nurse help line at 1-888-850-1108. If you have hearing or speech loss, you
may call the TTY line at 1-800-368-4424. 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 doctor.
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After-hours care
You can reach your PCP at the number on your UniCare ID card. After normal business hours,
leave your name and phone number with the answering service. Either your PCP or an on-call
doctor 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 (TTY: 1-866-368-1634).
 Our 24-hour nurse help line at 1-888-850-1108 (TTY: 1-800-368-4424).
If you think you have an emergency, call 911 or go to the nearest emergency room. UniCare
covers emergencies anywhere in the United States.
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 doctor 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’s part of your health benefits and
it’s at no charge to you; 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 doctor for checkups.
 Information on gift card rewards you can earn for attending prenatal and postpartum visits.
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Please note that state law makes sure that you get your first prenatal care visit. It requires that
your doctor fit you into their schedule as follows:
 If you are in your first trimester (months one, two or three), your doctor 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 doctor 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 doctor must make
your office visit within three business days from the date you call.
Your first visit allows your doctor 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 doctor 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 PP’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
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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.
Standing referrals
This is a type of referral that you may only need once and allows 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.
 Makes it that you need your care 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 Part 12 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 doctor. 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 doctor
within our network. If there is no doctor in our network that fits the care you need, we will let
you get a second opinion from a doctor 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 PP’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.
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 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 Part 12 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.
Availability of Utilization Management (UM) 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 doctor 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 Part 16 Definitions to learn more about medically necessary.)
 We do not reward doctors 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.
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Part 5 – What Uniare 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 PP 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, 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.
Abortion
An abortion ends a pregnancy. Your doctor will discuss this procedure with you if it is medically necessary. Your doctor needs to tell us in writing that the procedure is medically necessary.
We cover:
 Procedures to end the pregnancy if medically necessary.
 Medical actions needed to end an ectopic pregnancy.
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
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

Rural health clinics
Federally qualified health centers (FQHCs)
We cover:
 Doctor 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 under age 21.
We cover medically needed dental services for children under 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.)
 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
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all your dentist’s office during normal business hours; Tell the staff you are a Uniare 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 14 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.
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 21 years of age and older. These services may
be given by a:
 Dentist
 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.
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Durable Medical Equipment (DME), supplies and prosthetic devices
All custom-made durable medical equipment (DME) requires prior authorization. Other DME
also may require prior authorization.
DME, supplies and prosthetic devices given by a doctor are covered when they are medically
necessary. You may need an OK ahead of time from us for some of these items.
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
Part
Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
These services also are called well-visits. These visits are free for enrolled members under 21
years of age; These include screenings needed for your child’s PP 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.
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
 Routine shots and immunizations
 Lab tests, such as:
- Urinalysis
- Hemoglobin/hematocrit
- Tuberculin test (for high-risk groups)
- Blood lead testing
!sk your child’s PP when you should bring your child back for the next EPSDT checkup.
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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 contraceptives, diaphragms, injectable contraceptives and emergency
contraception.
We do not cover:
 Sterilization for members under 21 years of age
 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. Doctors should keep all family planning records
private, even if the patient is a minor, unless the law says it is OK. Your doctor is allowed to
share your medical information with other doctors 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.
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.
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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
Your PCP can ask for hospice care for you if you are terminally ill and not expected to live longer
than six months.
We cover these types of hospice care:
 Nursing care
 Doctor 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.
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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 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
 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.
Limits:
We do not cover any of the above services for adults in facilities for mental illness.
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Hospital services — Outpatient
Copays may apply.
Outpatient hospital care must be given by:
• Hospitals
• Rural health clinics
We cover:
 Emergency room use
 Emergency dental services
 Giving you someone else’s blood
 Blood products
 Drugs given in the emergency room
 Hospital services that can be reasonably done so the patient does not have to stay
overnight:
- Supplies
- Medical testing
- X-rays
- Lab services
- ER and 23-hour observation stays
 Physical, occupational and speech therapy
 Radiation therapy
 Chemotherapy
 Dialysis
 Services for dental work when a hospital outpatient facility must be used because of other
medical problems or when serious dental work is needed
 Surgical services; some surgical services need an OK ahead of time from us
Lab and X-ray services (not received in a hospital)
CT, MRI, MRA, PET and SPECT 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 doctor
 X-ray of the breast (mammogram)
Nurse practitioners
We cover care given by a nurse-midwife, nurse anesthetist, family nurse practitioner or
pediatric nurse practitioner.
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Physical or occupational therapy, speech pathology and audiology
These types of care are ordered by a doctor and are a part of that doctor’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 under 21 years of age may get hearing aid evaluations, hearing aids and
supplies, batteries, and repairs.
 Hearing aids are limited to members under 21 years of age and need an OK from us ahead
of time.
Physician (doctor) services
Copays may apply.
These types of care may be given to a member in a hospital, clinic or doctor’s office;
We cover:
 Visits to doctors 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 50 years of age and older who have
no symptoms
 Colorectal cancer screenings and lab tests for members under 50 years of age 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.
Podiatry services (foot care)
We cover:
 Treatment for health problems such as infections, inflammations, ulcers and bursitis
 Surgery for bunions or ingrown toenails
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

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 doctor within three business days from the
time you call.
We cover:
 Doctor visits and professional services for pregnancy, problems with a pregnancy, and afterdelivery 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 doctor
- An early discharge is a hospital stay of less than 48 hours for vaginal childbirth and less
than 96 hours for a C-section
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 wellchild visits
You’ll also have the opportunity to work with a nurse to assist you with your pregnancy.
Ask your doctor about childbirth classes, or call us to find out more.
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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 Part 9 Your prescription drug benefits for more information.
Private-duty nursing
This is for members under 21 years of age 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 under 21 years of age 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
 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 transports are covered by Medicaid and not UniCare. 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 Part 7 What Medicaid covers.
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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 (CSHCN) 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.
UniCare is encouraged, but not required, to contract with CSHCN providers. However, if we do
not contract with CSHCN providers, we must provide the same level and types of services as
those currently available through the CSHCN program. This includes access to multidisciplinary
care.
The CSHCN eligibility criteria and services are available from the West Virginia Bureau of
Medical Services (BMS). BMS will monitor compliance with this requirement.
If we fail to satisfy these requirements, we will be required to reimburse the traditional CSHCN
providers at the Medicaid fee rate.
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Part 6 – What Uniare 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
 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 doctor, 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 incompetent
 Organ transplants not listed in Part 5 What UniCare covers
 Cosmetic surgery that is done to change or reshape normal body parts so they look better
- This does not apply to reconstructive surgery to give you back the use of a body part or
to correct a deformity caused by an injury.
 Sex change surgery or treatments
 Routine physical exams for a job, camp or sports program
 Medical equipment, prescriptions, services and supplies that are:
- Not medically necessary
- Used only for your comfort or hygiene
- Used for exercise
- Personal or comfort items
- Experimental or still being researched
- Used for hygiene or beauty
- More than one piece of equipment that serves the same function
- Used only for making a room or home comfortable such as:
 Air conditioners
 Exercise equipment
 Air filters
 Spas and swimming pools
Air
purifiers

 Elevators
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Part 7 – What 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.
Behavioral health services
Your PCP can help you get behavioral health care with Medicaid providers. Behavioral health
care includes:
 Inpatient psychiatric services for children under 21 years of age
 Outpatient behavioral health services
 Behavioral health services for children under 3 years of age
Hemophilia factors
Although most prescription drugs that are filled at the pharmacy are covered by UniCare,
factors that are used to treat hemophilia and that are filled at the pharmacy will remain carved
out and will continue to be paid for by Medicaid.
Services include getting you to and from Medicaid-covered medical appointments that you
have made. Please call DHHR at 1-877-716-1212 to learn more.
Personal care
Personal care is a community care program; You need a doctor’s order and a nursing plan of
care to get personal care services such as help with grooming and hygiene, daily activities, and
nutrition.
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Part 8 – 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 doctor or hospital can
treat a sudden or serious medical problem. 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 followup care. You should do this for an emergency at home or away.
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 doctor is not part
of the UniCare network) if we OK the services. You also have coverage for post-stabilization
services if we did not respond to the doctor’s request for an OK within one hour of the request
or if your doctor could not contact us because it was after business hours or on a weekend.
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 PP at the number listed on your member ID card
• Medall at 1-888-850-1108 (TTY 1-800-368-4424)
• Uniare at 1-800-782-0095 (TTY 1-866-368-1634)
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Part 9 – 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.
Certain drugs on the PDL need an OK from us ahead of time or have limits based on medical
necessity.
Copays may apply.
Drugs exempt from copays include:
 Contraception/family planning medications
 Diabetic testing supplies, syringes and needles
 Three-day emergency supplies of medication
A group of doctors 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 doctor 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. Some drugs (including most brand-name drugs) need
an OK from UniCare. In these cases, your doctor 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 require an OK from us ahead of time. If your doctor thinks you need to
take a drug that is not on this list, your doctor 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 doctor 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 doctor, it may take longer.
If you need to start the medication right away, you can ask your pharmacist to give you a 3-day
emergency supply of the medication. The pharmacist can call the phone number on the back of
your ID card to ask for this 3-day emergency supply for you. We will let your doctor 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.
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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. 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 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 Part 12 How to resolve a
problem with UniCare for information about the process that you can use to file a grievance or
appeal.
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 doctor 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 less than 21 years of age.
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 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
 Flu and pneumonia vaccines for members 19 years of age and older if the vaccine is given by
a pharmacist at a pharmacy.
 Shots that you give yourself at home, such as insulin, are covered by your pharmacy benefit.
Most shots that must be given by your doctor in his or her office are covered under your
medical benefit, not your pharmacy benefit.
 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. Members with hearing or
speech loss can call the TTY line at 1-866-368-1634. We will help you replace eligible lost
drugs.
Limits on your prescription drug benefit
We do not cover:
 Drugs used for weight loss or weight gain
 Drugs used for cosmetic purposes like wrinkles or hair growth
 Over-the-counter (OTC) drugs without a prescription and not on the preferred drug list
(PDL) or the OTC list for end-stage renal disease
 Drugs used in fertility treatment
 Drugs used for erectile dysfunction
 Herbal or homeopathic drugs
 Nutritional supplements
 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
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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.
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Part 10 – 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 doctor visits and shots (immunizations)
 Parenting tips to learn how to care for your child
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:
 18 years of age and older with a body mass index (BMI) greater than 25
 10 to 17 years of age 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
- Doctor’s referral
If you want to sign up and attend Weight Watchers at no cost to you, please call our CRC toll
free at 1-888-611-9958. This offer is for new Weight Watchers members only.
® WEIGHT WATCHERS is the registered trademark of Weight Watchers International, Inc., and is
used under license.
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For your 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
• A free cellphone. When you sign up for a Safelink ® cellphone through UniCare, you get a
free cellphone with up to 250 minutes per month, plus 200 bonus minutes, free unlimited
nationwide texting and unlimited calls to the UniCare 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
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
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 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 doctors about your health care
 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 doctors.
 Have your personal and medical information kept private
- Know who has access to your information
- Know what DMCCU 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
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 Tell your case manager and your doctors 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. If you have
hearing or speech loss, please call the AT&T Relay Service toll-free at 1-800-855-2880. 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.
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Part 11 – 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 if you need someone to interpret for you after regular
office hours.
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 or their TTY line
at 1-800-982-8771. After regular business hours, you can also call MedCall at 1-888-850-1108.
The MedCall TTY line is 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.
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Part 12 – How to resolve a problem with Uniare
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. Give us a chance to help
you.
If you have a problem
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 us. 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 our
Utilization Management office Monday through Friday, 8 a.m. and 5 p.m. The phone number is
1-866-655-7423.
Complaints
A complaint is a way for you or someone you choose to tell us when you are not happy with
something. You can write, call, fax or email us to let know about your complaint. We will take
care of your complaint when we get it or send it to the right place for a final answer. You may
choose not to be named when making a complaint.
If our CCC staff cannot resolve your complaint, we will send it right away to a Member Advocate
for review. This is a person who is in charge of looking into and finding an answer to your
complaint. We will make a ruling within one business day after the Member Advocate review.
We will let you know what we decide by phone or in writing.
Grievances
You can file a grievance if you have a problem with the quality of the health care or
administrative service you receive. A grievance does not deal with the denial of benefits for
health care service. Those matters are handled as appeals (see Appeals below).
To file a 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 UniCare grievance form, or write
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a letter telling us about the problem. You can find these forms at UniCare offices and provider
offices. The grievance form is also available on our website.
Send your completed form or letter to:
Attn: Grievance and Appeals Department
P.O. Box 91
If you cannot mail the form or letter, you or someone you choose can call us and tell us about
your problem. You may also 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 CCC at 1-800-782-0095 (TTY 1-866-368-1634).
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 health care you received
Attach any documents that will help us look into the problem. If you need us to, we will help
you file your grievance.
We will send you a letter within five calendar days after we get your grievance. If we can, we
will call you for issues that need to be taken care of right away. We will send you a written
response within 24 hours. The letter will tell you about your right to meet face-to-face with
staff at our CRC in Charleston.
Our goal is to solve your problem. We 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 medical
director reviews all medical-related grievances, 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 UniCare staff to
solve your problem.
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We will send you a grievance resolution letter within 30 calendar days after we get your
grievance. We can ask for 14 more days if we need to know more. We 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.
Appeals
You may file an appeal if we don’t approve a service, if we take 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:
ATTN: Grievance and Appeals Department
P.O. Box 91
Fax: 1-866-387-2968
You also may file an appeal by calling our CCC at 1-800-782-0095 (TTY 1-866-368-1634). Written
and signed appeals must be filed even after you requested this by phone. This is except in the
case of an appeal that needs to be rushed through. You do not have to pay to file an appeal.
We will send you an acknowledgment letter within five business days. It will tell you that we got
your appeal request. We will send you an appeal resolution letter within 45 days from the date
the initial appeal was filed. You or someone you choose may extend the appeal for 14 calendar
days. We also may extend the appeal for 14 calendar days if we need to find out more
information about your request.
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 our CCC at 1-800-782-0095 (TTY 1-866-368-1634).
Your benefits may continue while your appeal is pending as long as you submit your appeal
within 10 days after our mailing of 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 (fast) appeal if we need to make a decision quickly based on your
health status. We will process your request as quickly as we can, but we will not take more than
72 hours from the date we received your appeal. The 72-hour limit may be extended up to 14
days if you ask for it or we need more information to make the decision and the delay is in your
interest. If we cannot make a decision within 72 hours, we will send you a letter that gives you
the reason for the delay.
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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
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 (TTY 1-800-508-6975). 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 the UniCare CCC at 1-800-782-0095 (TTY 1-866-368-1634). 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 the CRC in Charleston.
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:
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• 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 was needed. You may also ask for 14 more days if you need
more time.
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 (TTY 1-800-508-6975). 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 14 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 the UniCare CCC at 1-800-782-0095 (TTY 1-866-368-1634).
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.
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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 3-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.
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 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.
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.
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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.
To file this appeal, you must complete the UniCare internal grievance and appeals process first.
Your filing must be within one year from the date of the first ruling that you did not agree with.
You can appeal to the Insurance Commissioner by sending your appeal to:
The Office of the Insurance Commissioner
P.O. Box 50540
If you do not agree with what the Office of the Insurance Commissioner decides, you may
appeal to the Circuit Court. You must file your appeal within 30 calendar days after the
Insurance ommissioner’s order was mailed;
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Part 13 – 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 MCOs, you
must re-enroll in a new MCO right away.)
 You are placed in a nursing facility, state institution or intermediate care facility for the
mentally retarded 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.
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Part 14 – Other things you need to know
Contacting our Customer Care Center
Call us toll free at 1-800-782-0095, Monday through Friday, from 8 a.m. to 6 p.m. (If you have
hearing or speech loss, you may call our TTY 1-866-368-1634.) Our staff is trained to help you
understand your health plan. We can tell you about:
 Eligibility
 Benefits
 How to get service
 How to choose or change your PCP
 Health plan information
 Dental and vision care
 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, Automated Health Systems, at 1-800-449-8466 and our CCC 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 AHS at 1-800-449-8466 to choose a
new health plan.
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
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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:
Attn: Program Integrity Unit
1207 Quarrier St.
Charleston, WV 25301
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
• Type of provider (doctor, 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.
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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 doctor will know what you want.
You have the right to set up papers with this information for your doctor 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, doctor’s offices 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.
Review of member records
By joining our health plan and accepting the health care benefits listed in this book, 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 CCC 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 doctor know if the treatment is medically necessary and
if we approve it.
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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 CCC.
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). They do not need an OK ahead of time from their
PCP.
Family planning records are kept private. Doctors 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 doctor is allowed to share your medical information with other doctors 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.
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. You will hear
no later than 30 calendar days before the effective date of the change. UniCare services can
change without your agreement.
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Part 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 the Customer Care Center toll free at 1-800-782-0095. If you have hearing or speech loss,
call the TTY line toll free at 1-866-368-1634. You can also get a copy of the report from the
West Virginia Department of Health and Human Resources.
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, doctors 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 doctors and other providers about your health
care needs
• Be told about other treatment choices or plans for care in a way that fits your condition
• Get news about how doctors 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 doctors 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 doctor 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
• Choose your PCP from the PCPs in our Provider Directory that are taking new patients
• Use providers who are in our network
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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
Make an advance directive (also called a living will)
Tell us your concerns about UniCare and the health care services you get
Question a decision we make about coverage for care you got from your doctor
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 EOC and other member materials in other formats such as large print, audio CD
or Braille at no charge 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 doctors 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 doctor to set up
treatment goals you agree on
• Ask questions about any medical issue and make sure you understand what your doctor
tells you
• Follow the care plan and instructions that you have agreed on with your doctors or other
health care professionals
• Do the things that keep you from getting sick
• Make and keep medical appointments and tell your doctor 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 doctor tells you
• 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 doctors with respect and courtesy
• Know and follow the rules of your health plan
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• 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 us and your DHHR caseworker when you change your address, family status or other
health care coverage
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Part 16 – Definitions
Here are some of the terms used in this book:
Benefits are the health care services covered under this plan.
BMS stands for the Bureau for Medical Services. This is the West Virginia agency that runs the
Medicaid program.
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 behavioral health
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 doctor, hospital, agency or other person who has a license or is
authorized to give health care services.
Some health care providers include:
• Audiologist is a provider who tests your hearing.
• Certified nurse-midwife is a registered nurse who cares for you during pregnancy and
childbirth.
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• 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.
• 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 doctor.
• Nurse practitioner or physician’s assistant is a person who works in a clinic or doctor’s
office and:
- Finds out what’s wrong with you
- Treats you, within limits
• Obstetrician/gynecologist (O/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 doctor.
• 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, doctor 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
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Member is a person approved by the state of West Virginia to enroll in UniCare.
OK by UniCare means you received an approval ahead of time from us. You can learn more
about this in Part 4 How to use 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 Uniare for use as the ﬁrst line of drug therapy;
Primary care provider (PCP) is the doctor you choose for most of your health care. This person
helps you get the care you need. Your PCP must OK most care ahead of time, unless it is an
emergency.
Prior authorization (OK by UniCare) refers to the approval you get from us before you get a
service.
Reconstructive surgery is done to correct a problem with a part of your body. This problem
could be caused by:
• A birth defect
• Disease
• Injury
Making that part look or work better must be medically necessary.
Skilled nursing facility is a place that gives you 24-hour-a-day skilled professional nursing care.
Urgent medical condition is not an emergency, but is a condition that should have medical care
within 48 hours.
Utilization review is a process that allows UniCare and your health care providers to work
together to decide if a service you ask for is medically necessary.
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Part 17 – Notice of Privacy Practices
The original effective date of this notice was April 14, 2003.
Please read this carefully.
This tells you who can see your protected health information (PHI) with and without your OK.
It also tells 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 protected health information (PHI), safe for our members. That means if
you’re a member right now or if you used to be;
We get information about you from state agencies for Medicaid after you become eligible and
sign up for our health plan. We also get PHI from your doctors, 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, doctors 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 doctors, hospitals and others get you the care you need
 For payment
– To share information with the doctors, clinics and others who bill us for your care
– When we say we’ll pay for health care or services before you get them
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 For health care business reasons
– To help with audits, fraud and abuse 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 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 anything but your care,
payment, everyday business, research or other things not in this notice. Other things could be
selling it or using it to sell things to you. We have to get your written OK before we share
psychotherapy notes from your doctor 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 workers’ 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 doctor or
health clinic.
 You can ask us to change the medical record we have for you if you think something is
wrong or missing.
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 Sometimes, you can ask us not to share your PHI; ut 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 another
way. We can do this if sending it to the address we have for you may put you in danger.
 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.
 If you pay the whole bill for a service, you can ask your doctor not to share the information
about that service with us.
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 another address or to send it 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 hasn’t been kept private;
What if you have questions?
If you have questions about our privacy rules or want to use your rights, please call our CCC.
What if you have a complaint?
We’re here to help; If you feel your PHI hasn’t been kept safe, you may call the or contact
the DHHR at 1-877-716-1212. Nothing bad will happen to you if you complain.
We reserve the right to change this 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
unicare.com/medicaid.
As we told you in our Health Insurance Portability and Accountability Act (HIPAA) notice, we
must follow state laws if they say we need to do more than the Federal HIPAA Privacy Rule. This
notice tells you about your rights and what the state laws say we have to do.
65
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WV MHB ENG 12.14
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 may use your PI to make decisions about your:
– Health
– Habits
– Hobbies
We may get PI about you from other people or groups like:
– Doctors
– Hospitals
– Other insurance companies
We may share PI with people or groups outside of our company without your OK in some
cases.
We’ll let you know before we do anything where we have to give you a chance to say no.
We’ll tell you how to let us know if you don’t want us to use or share your PI;
You have the right to see and change your PI.
We make sure your PI is kept safe.
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WV MHB ENG 12.14
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. If you have hearing or speech loss, you may call the TTY line at 1-866-368-1634.
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:
UWV-MHB-0003-14
WV MHB ENG 12.14
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):
_____
UniCare Health Plan of West Virginia, Inc., ® Registered mark of WellPoint, Inc.
CL_WSSB_CVR16
WV MHB ENG 12.14

UniCare Health Plan of West Virginia, Inc. Member Handbook

Transcription

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