UnitedHealthcare Community Plan Alliance Member Handbook

Transcription

1 CAPITAL AREA UnitedHealthcare Community Plan Alliance Member Handbook /11

2 Important Phone Numbers Member Services (8 a.m. 5:30 p.m., Monday Friday).... TTY: 711 NurseLine Services (24 hours a day, 7 days a week) TTY/TDD Department of Mental Health Hotline (24 hours a day, 7 days a week) For an emergency, dial 911 or go to your nearest IN NETWORK emergency room I Street, NW, #510 Washington, DC Local Phone: TTY: 711 (8 a.m. - 5:30 p.m. Monday - Friday) Website Your Health Providers Name: Phone: Name: Phone: Name: Phone: Emergency Room: Phone: Pharmacy: Phone: Alliance Member Handbook

3 Table of Contents Welcome to UnitedHealthcare Community Plan...2 How this handbook works....2 How this member handbook can help you....3 Your Member ID Card....3 Your Primary Care Provider (PCP)...4 How to change your PCP....4 Making an Appointment Changing or canceling an appointment....5 Getting care when your PCP s office is closed...5 How long it takes to see your doctor...5 Routine Care, Urgent Care and Emergency Care...6 Routine care....6 Urgent care....6 Emergency care....6 When You Are Out-of-Town...7 Support Services...8 Interpretation and translation services/ services for the deaf/hard-of-hearing and visually impaired....8 Specialty Care...8 How to get specialty care....8 Self-referral services....9 Birth control and other family planning services....9 Pharmacy services and prescription drugs.. 10 Disease management Services to Keep Adults Healthy...11 Recommendations for checkups ( screenings ) Preventive counseling Adult immunizations Pregnancy...12 Prenatal and postpartum care Having a baby Healthy First Steps pregnancy program...12 Your Health Benefits...13 Covered services Services we do not pay for...16 UnitedHealthcare Providers and Providers Who Are Not Part of UnitedHealthcare...16 Other Important Information...17 What to do if you move...17 What to do if you have a baby What to do if you adopt a child What to do if someone in your family dies...17 How to change your MCO What to do if you get a bill for a covered service Paying for non-covered services Advance directives What to do if you have other insurance...18 Complaints/Grievances, Appeals and Fair Hearings...19 Complaints/grievances...19 Appeals and fair hearing...19 Deadlines Appeals Expedited (emergency) appeals process Your rights during the process...20 Your Rights and Responsibilities...21 Protected Health Information...23 Notice of Privacy Practice Medical Information-Privacy Notice Financial Information-Privacy Notice Unitedhealth Group Health Plan Notice of Privacy Practices: Federal and State Amendments What Some Words Mean...33 Capital Area 1

4 Welcome to UnitedHealthcare Community Plan! We are happy to have you as a member. If you haven t received your UnitedHealthcare Community Plan member identification card in the mail, it will arrive shortly. Remember to take this card to all of your doctor appointments and show your card to your doctor s office staff. If you do not receive your identification card, please call Member Services at (TTY: 711). A UnitedHealthcare representative will contact you within sixty days of your enrollment to help you understand your benefits and services. These sessions will include, but will not be limited to, the following benefits and services: How to access services Member Services functions Review of member handbook Pharmacy and prescription services Complaint and grievance process Denials/appeals process After hours care Out-of-area care Care and disease management service Dental and vision services Member rights and responsibilities Health education program and services Role of the PCP Appropriate use of the In Network emergency room All enrollees identified during new member orientation who do not speak or read English will receive member materials in their preferred language. Here are some of the great benefits of being a UnitedHealthcare member: No copayments The Healthy First Steps program that helps pregnant members have a healthy pregnancy and a healthy baby. A dedicated and friendly Member Services team A Special Needs Unit (SNU) to help you find community-based services in your area Personalized health programs How this handbook works UnitedHealthcare Community Plan is a managed care plan that is paid by the District of Columbia to help you get health care. In this handbook we tell you about how UnitedHealthcare works, how to find doctors, how to call us, and what things we pay for. Telling you about these things can be hard to do and hard for everyone to read. Words used in health care and words used by your doctor can sometimes be hard to understand. Sometimes we have to tell you about laws that you need to know about. These also can be hard to understand. Some words that might have a different meaning from the one you know. To help you, we have explained these words in the back of this book. If you ever have any questions about things you read in this book or other questions about UnitedHealthcare, you can call Member Services at or visit www. uhccommunityplan.com and we will do our best to help you. 2 Alliance Member Handbook

5 How this member handbook can help you This member handbook tells you: How to get health care What services we will pay for (we call this, what services are covered by us) What services we can t pay for How to pick your primary care provider What to do if you get sick What you should do if you have a complaint (also called a grievance ) or want to change ( appeal ) a decision by UnitedHealthcare This member handbook gives you basic information about how UnitedHealthcare Community Plan works and its rules. Please call Member Services if you have any questions. Your Member ID Card After you sign up for UnitedHealthcare Community Plan and you have picked a primary care provider (PCP), we will send you a member ID card in the mail. This card lets your doctors, hospitals, drug stores and others know that you are a member of UnitedHealthcare. Please make sure that the information on your member identification card is correct. If there are any problems, or if you have lost your card, call UnitedHealthcare Member Services at Your member ID card looks like this: On the back of your card you can find a Member Services telephone number, a number for providers to call and UnitedHealthcare s website address at Each UnitedHealthcare member has his or her own card. Your children will also have their own cards. You must keep your children s cards so they don t get lost. It is against the law to let anyone else use your member ID card or Medicaid card. Member ID number Member name Member s Alliance number Member s PCP PCP s phone number PCP s address Number for provider s use when submitting claims Pharmacy information Member s health plan Please remember to carry your member ID card with you at all times. Always show your card before receiving any medical care or getting medicine at a pharmacy. Capital Area 3

6 Your Primary Care Provider (PCP) When you join UnitedHealthcare Community Plan, one of our doctors will be assigned to you as your main doctor. This person is called your primary care provider or PCP. Your PCP will help you and your family get the health care you need. If you need a Provider Directory please contact Member Services at It is important to call your PCP first when you need care. If you had a doctor before you signed up with UnitedHealthcare, please call Member Services at We can help you stay with that doctor if you would like. How to change your PCP You can change your PCP anytime. Just pick a new PCP from the Provider Directory. Call Member Services at once you have picked a new PCP. If you need help picking a new PCP, Member Services can help you. Making an Appointment With Your PCP 1. Have your member ID card and a pencil and paper close by. 2 Call your PCP s office. Look for your PCP s phone number on the front of your member ID card. You can also find it in your provider directory or online at 3. Tell the person who answers that you are a UnitedHealthcare Alliance member. Tell them you want to make an appointment with your PCP. 4. Tell the person why you need an appointment. For example: - You or a family member is feeling sick - You hurt yourself or had an accident - You need a check up or follow-up care 5. Write down the time and date of your appointment. 6. Come to your appointment on time and bring your member ID card with you. 7. If you need help making an appointment, please call Member Services at If you are a new member of UnitedHealthcare Community Plan, you should make an appointment for your first health check-up as soon as possible. 4 Alliance Member Handbook

7 Changing or canceling an appointment It is very important to come to your appointments and to be on time. If you need to change or cancel your appointment, please call the doctor at least 24 hours before your appointment. For some appointments, you may have to call more than 24 hours before to cancel. If you do not show up for your appointment or if you are late, your doctor may decide you cannot be his or her patient. Getting care when your PCP s office is closed If you need to speak to your PCP when the office is closed, call your PCP s office and leave a message with the person who answers the phone when the office is closed. Be sure to give the person who answers your phone number. Someone will call you back as soon as possible. You can also call our 24/7 NurseLine services at If you think you are having an emergency, call 911 or go to the emergency room. If you think you are having an emergency, call 911 or go to the emergency room of a network provider. Alliance members do not have coverage for any service that you get from an out of network provider, including emergency services. You will be responsible for the charges for the out of network services. How long it takes to see your doctor Your doctor s office must give you an appointment within a certain number of days after you call. The table below shows how long it will take to get an appointment. Please call if you cannot get an appointment during these time periods. Type of visit Urgent visit Routine visit Follow-up visit Adult wellness visits Non-urgent appointments with specialists (by referral) Your condition You are hurt or sick and need care within 24 hours to avoid getting worse. Examples of urgent care conditions are sprains, sore throats or rising temperatures. You have a minor illness or injury or you need a regular checkup, but you don t need an urgent appointment. You need to see your doctor after a treatment you just had to make sure you are healing well. You are having your first appointment with a new doctor You are due for a regular adult checkup You are due for a prostate exam, a pelvic exam, a PAP smear or a breast exam Your PCP referred you to see a specialist for a nonurgent condition Appointment time frame Within 24 hours Within 30 days Within 1-2 weeks depending on the kind of treatment Within 30 days or sooner if necessary Within 30 days Capital Area 5

8 Routine Care, Urgent Care and Emergency Care Here are three kinds of health care you may need: routine care, urgent care, or emergency care. Routine care is the regular care you get from your PCP. Routine care is also care you get from other doctors that your PCP sends you to. Routine care can be check-ups, physicals, health screenings and care for health problems like diabetes, hypertension and asthma. If you need Routine care, call your PCP s office and ask to make an appointment. Urgent care is medical care you need within 24 hours, but not right away. Urgent care issues are those when you or a family member needs care, treatment or advice within 24 hours (examples of urgent care conditions are sprains, sore throats or rising temperatures). Urgent care services are medically necessary services which are required for an illness or injury that would not result in further disability or death if not treated immediately, but require professional attention and have the potential to develop such a threat if treatment is delayed longer than 24 hours. If you need urgent care, call your PCP s office. If your PCP s office is closed, leave a message with the person who answers the phone. Then call our 24/7 NurseLine services at A nurse will help you decide if you need to go to the doctor right away. The nurse can tell you how to get care. You should not have to go to the emergency room or use an ambulance for routine or urgent care. Emergency care is medical care you need right away for a serious, sudden (sometimes lifethreatening) injury or illness. An emergency condition is a medical condition that shows itself by sudden or serious symptoms (including severe pain). The symptoms should be such that the average person (prudent layperson), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. If you are not sure if you are having an emergency, or if you would like additional information about medical conditions, please call our 24/7 NurseLine services at Emergency medical services are needed to assess or stabilize an emergency medical condition that is found to exist using the prudent layperson standard and during emergency ambulance transportation. Some examples of emergencies are: Heart attacks Severe chest pains Accidents Severe bleeding Major burns Loss of consciousness Serious breathing difficulties Spinal injuries Colds and sore throats are not usually emergencies. If you are not sure if you are having an emergency, call your PCP. If the office is closed, a message will give you further instructions. Go to the nearest In Network emergency room when you have an emergency. 6 Alliance Member Handbook

9 If you receive emergency treatment, you should call UnitedHealthcare Community Plan within 24 hours, or as soon as possible ( ). This number is listed on your UnitedHealthcare Community Plan ID card. You will need to call your PCP as soon as possible after the emergency is under control. WHAT TO DO IF YOU HAVE AN EMERGENCY: 1. Call or go to your nearest In Network emergency room. 2. Show the emergency room (ER) your UnitedHealthcare Community Plan member ID card. 3. Alliance members do not have coverage for any service outside of the network including emergency services. 4. As soon as you can, call your PCP. When You Are Out-of-Town When you need to see a doctor or get medicine when you are out-of-town, you should: For routine care: You must call us and ask if we will pay for you to see a doctor or other provider when you are out of town. If UnitedHealthcare Community Plan does not say it will pay for the care, you will have to pay for the care yourself. If you need medicine from a doctor while you are out-of-town, generally UnitedHealthcare only covers medications in limited, non-routine circumstances such as emergencies. You can go to any participating pharmacy in the UnitedHealthcare network. Call Member Services if you need help finding a pharmacy. This number is also on the back of your UnitedHealthcare ID card. We will assist the pharmacist in processing any urgentlyneeded medications. For urgent care: Call your PCP. If your PCP s office is closed, call our 24/7 NurseLine services at A nurse will help you decide if you need to go to the doctor right away. The nurse can tell you how to get care. You do not have to go to the emergency room or use an ambulance for routine or urgent care. For emergency care: If you have an emergency, including a mental health or alcohol or other drug emergency, go to the nearest In Network emergency room (ER) to get care right away. If you go to the In Network emergency room, you should ask the ER staff to call your PCP. If you go to the emergency room, you should call Member Services as soon as you can. Alliance members do not have coverage for any service outside of the network including emergency services. Capital Area 7

10 Support Services Interpretation and translation services/services for the deaf/hard-of-hearing and visually impaired Interpretation services UnitedHealthcare Community Plan will provide oral interpretation services if you need them, including at the hospital. Please call Member Services at to get interpretation services. Please call us before your doctor s appointment if you will need interpretation services. Interpreter services are usually provided over the telephone. If you need an interpreter to be with you at your doctor s appointment, you must let us know 5 days before the appointment. Translation Services If you get information from UnitedHealthcare Community Plan and need it translated into another language, please call Member Services at Services for the deaf/hard-of-hearing and visually impaired If you are deaf or hard of hearing, call Member Services via our national relay service by calling 711. If you have trouble seeing, call Member Services at We can give you information on an audio tape, in Braille or in large print. Interpretation and translation services and services for the deaf/hard-ofhearing and visually impaired are FREE. Specialty Care How to get specialty care If you need specialty services, your PCP will help you find a specialist. If you need further assistance, please call Member Services and they will assist you. If you want to see a specialist, but UnitedHealthcare Community Plan says it will not pay for the specialist, you can: Make an appointment with another doctor in UnitedHealthcare s network and get a second opinion. Go to the specialist and pay for the visit yourself. Appeal our decision (see page 19 on appeals). Ask for a fair hearing (see page 19) 8 Alliance Member Handbook

11 Self-referral services There are certain services you can get without getting prior permission from your PCP. These are called self-referral services. You may selfrefer to UnitedHealthcare Community Plan s participating providers; however, your PCP will work with you to direct your health care. UnitedHealthcare encourages you to work with your PCP to help coordinate access to specialty care. Some examples of self-referral services are listed below. Please call Member Services if you need more information. You DO NOT need a referral to: See your PCP. Receive services from your OB/GYN doctor in your network for routine or preventive services (females only). Receive family planning services. Receive services for sexually transmitted diseases (STDs). Receive immunizations (shots). Visit a vision provider in the network (vision services are covered only if you are under 21 years old). Receive emergency mental health services in an emergency room for conditions that are life-threatening and related to withdrawal of alcohol or narcotics. Birth control and other family planning services You can get birth control and other family planning services from any provider you pick. You do not need a referral to get these services. If you choose a family planning services doctor other than your PCP, tell your PCP. It will help your PCP take better care of you. Talk to your PCP or call UnitedHealthcare Community Plan Member Services at for more information on birth control or other family planning services. All birth control and family planning services are confidential. Family planning services include: Pregnancy testing Counseling for the woman and the couple Routine and emergency contraception Counseling and immunizations Screening for all sexually transmitted diseases Treatment for all sexually transmitted diseases Sterilization procedures (requires you to sign a form 30 days before the procedure) HIV/AIDS testing and counseling Family planning services do not include: Routine infertility studies or procedures Hysterectomy for sterilization Reversal of voluntary sterilization Abortions HIV/AIDS treatment Capital Area 9

12 Specialty Care continued HIV/AIDS testing, counseling and treatment: You can get HIV/AIDS testing and counseling: when you have family planning services, from your PCP, and from an HIV testing and counseling center. For information on where you can go for HIV testing and counseling, call Member Services at If you need HIV treatment, your PCP will help you get care. You can also call UnitedHealthcare s Special Needs Unit (SNU) at and ask to speak with a care manager. Pharmacy services and prescription drugs Pharmacies are where you pick up your medicine (drugs). If your doctor gives you a prescription, you must go to a pharmacy in the Alliance pharmacy network for Alliance members. You can find a list of all the pharmacies in the Alliance pharmacy network in the Alliance formulary or online at plan.com. To get a prescription filled: Pick a pharmacy that is part of the Alliance pharmacy network and is close to your work or home. When you have a prescription, go to the pharmacy and give the pharmacist your prescription and your Alliance member ID card. If you need help, please call Member Services at Sometimes, your doctor may need to get permission from UnitedHealthcare Community Plan for a drug that is not on the Alliance formulary. In the event the Alliance pharmacy is closed, and you need to fill your prescription, contact your MCO for permission to obtain your medication at an alternate pharmacy. You can get the medication: - For up to 72 hours or - For one full round of the medicine if you take it less than once a day. If you are out of town and you have an emergency or need urgent care, you will need to contact UnitedHealthcare at and we will help you find a pharmacy where you can get urgently-needed medications. Things to remember: You should not be asked to pay for your medicines. Call UnitedHealthcare Community Plan Member Services if the pharmacy or drug store asks you to pay. Disease management If you have a chronic illness or special health care need such as asthma, diabetes or congestive heart failure, we may include you in our disease management program. Depending on your condition, you may have a care manager. A care manager is someone who works for UnitedHealthcare Community Plan and who will help you get the services and information you need to control your illness and be healthier. 10 Alliance Member Handbook

13 Services to Keep Adults Healthy UnitedHealthcare Community Plan wants you to take care of your health. We also want you to sign up for health and wellness services we offer to you. Health and wellness services include screenings, counseling and immunizations. Recommendations for checkups ( screenings ) Please make an appointment and go see your PCP at least one time every year for a checkup. The list below tells you the type of things to talk with your PCP about during your checkup. Adult screening recommendations: Blood pressure and cholesterol (lipid disorder) screening Sexually transmitted diseases HIV/AIDS screening and testing Diabetes screening Tobacco use Alcohol and drug use Depression Colorectal cancer (50 years and older) Obesity Hepatitis C Screenings for women only Breast cancer screening (mammogram) Cervical cancer Osteoporosis (post-menopausal women) HPV screening Chlamydia Preventive counseling Preventive counseling is available to help you stay healthy. You can get preventive counseling on: Diet and exercise Alcohol and drug use Smoking cessation HIV/AIDS prevention You will also receive certain health education materials including: Member newsletters that are mailed out quarterly. The newsletters have articles and information on preventive health and wellness counseling. Yearly Flu & Pneumonia reminders Information on the DC Tobacco Free Families Quitline, QUITNOW ( ). UnitedHealthcare s Care Management and Special Needs programs offer support and counseling to help members achieve the best quality of life. Adult immunizations If you are an adult, you may need some immunizations (shots). Please talk to your PCP about which ones you may need. Screenings for men only Prostate cancer screening Abdominal aortic aneurysm Please make an appointment to see your PCP at least once a year for a checkup. Capital Area 11

14 Pregnancy If you are pregnant or think you are pregnant, it is very important that you go to your OB/GYN doctor right away. You do not need to see your PCP before making this appointment. If you are pregnant, you need to call: Income Maintenance Administration (IMA) at Member Services at Your PCP There are certain things that you need to get checked if you are pregnant. These will help make sure that you have a healthy pregnancy, delivery and baby. This is called prenatal care. You get prenatal care before your baby is born. Remember, if you are pregnant or think you are pregnant do not drink alcohol, use drugs or smoke. Prenatal and postpartum care Having a baby UnitedHealthcare Community Plan wants you to have a healthy baby. Call Member Services if you are pregnant. The health care a woman receives before the birth of her baby is known as prenatal care. Prenatal care is important. It helps the doctor see how the pregnancy is going. It helps to see if there are any problems. Even if a woman has been pregnant before, going to the doctor often while she is expecting is important. If you have a medical condition like diabetes or you are having twins, your pregnancy may be high risk. If your pregnancy is high risk, your doctor can help you join our high-risk pregnancy program. Healthy First Steps A program for our pregnant members Healthy moms are more likely to have a healthy baby. Pregnancy is an important time for women. It is a time to take good care of themselves and their unborn baby. Some women may have risk factors that can cause problems during pregnancy. These problems could cause early labor. A baby born too early may be sick or have to stay in the hospital. We want the best possible health for the mom and baby. We have a special program for pregnant members. Our Healthy First Steps program gives pregnant women the information, education and support they need during pregnancy. If you are pregnant, call to enroll in Healthy First Steps at We want to help you have a healthy pregnancy. Our staff will help you get the care you need. We can also help you get ready for the birth and care of your baby. See a doctor as soon as you think you are pregnant. If you have problems finding a doctor or getting an appointment, we can help you. We can also work with you to locate community services such as WIC, behavioral health care and social services. Let Healthy First Steps help you make your pregnancy the healthiest it can be. For more information about your children s health care or health care coverage, please contact Member Services at Once you have had your baby, call Member Services and your IMA caseworker at Alliance Member Handbook

15 Your Health Benefits Health services covered by UnitedHealthcare Community Plan The list below shows the health care services and benefits for all UnitedHealthcare Community Plan members. For some benefits, you have to be a certain age or have a certain need for the service. UnitedHealthcare will not charge you for any of the health care services in this list if you go to a network provider or hospital. If you have a question about whether UnitedHealthcare covers certain health care, call UnitedHealthcare Member Services at Benefit What you get Who can get this Primary Care Services Preventive, acute, and chronic health care All members services generally provided by your PCP. Specialist Services Health care services provided by specially trained doctors or advanced practice nurses. Does not include cosmetic services and surgeries except for surgery required to correct a condition resulting from surgery or disease, created by an accidental injury or a congenital deformity, or is a condition that impairs the normal function of your body. All members Laboratory Lab tests and X-rays. All members and X-ray Services Hospital Services Outpatient services (preventive, diagnostic, therapeutic, rehabilitative, or palliative services). Pharmacy Services (prescription drugs) Inpatient services (hospital stay) with the exception listed on the following page under Services we do not pay for. Inpatient psychiatric services. Prescription drugs included on the Alliance drug formulary are available only from Alliance program pharmacies. You can find the drug formulary at or by calling Member Services. The Alliance formulary may be obtained by having your doctor contact the UnitedHealthcare Pharmacy Department. Any member with a referral from their PCP or who has an emergency All members Capital Area 13

16 Benefit What you get Who can get this In Network Emergency Services A screening exam of your health condition and stabilization if you have an emergency medical condition, if the provider is in the network. Treatment for emergency conditions. All members Family Planning Podiatry Rehabilitation Services Prosthetic Devices Vision Care Home Health Services Pregnancy testing; counseling for the woman. Routine and emergency contraception. Voluntary sterilizations for members over 21 years of age (requires signature of an approved sterilization form by the member 30 days prior to the procedure). Screening, counseling and immunizations (including for HPV). Screening and preventive treatment for all sexually transmitted diseases. Does not include sterilization procedures for members under age 21. Special care for foot problems. Regular foot care when medically needed. Rehabilitation services, including physical, speech and occupational therapy. Replacement, corrective, or supportive devices prescribed by a licensed provider. Eye exams at least once every year and as needed; and eye glasses (corrective lenses) as needed. In-home health care services, including: Nursing and home health aide care. Home health aide services provided by a home health agency. Physical therapy, occupational therapy, speech pathology and audiology services. All members as appropriate All members All members All members Members under 21 All members Sub-Acute Care Sub-acute care for 30 consecutive days. All members Mental Health Services Inpatient mental health services. All members Nursing Home Care Full-time skilled nursing care in a nursing home. All members Hospice Care Support services for people who are dying. All members Transportation Services Transportation for emergency services. All members 14 Alliance Member Handbook

17 Benefit What you get Who can get this Adult Wellness Services Immunizations. Members over 21 as appropriate Dental Benefits Hearing Benefits Durable Medical Equipment (DME) and Disposable Medical Supplies (DMS) Routine screening for sexually transmitted diseases. HIV/AIDS screening, testing and counseling. Breast cancer screening (women only). Cervical cancer screening (women only). Osteoporosis screening (post-menopausal women). HPV screening (women only). Prostate cancer screening (men only). Abdominal aortic aneurysm screening (men only). Screening for obesity. Diabetes screening. Screening for high blood pressure and cholesterol (lipid disorders). Screening for depression. Colorectal cancer screening (members 50 years and older). Smoking cessation counseling. Diet and exercise counseling. Mental health counseling. Alcohol and drug screening. General dentistry (including regular and emergency treatment) and orthodontic care for special problems. Check-ups twice a year with a dentist. Does not include routine orthodontic care. Includes X-rays, extractions and fillings. Diagnosis and treatment of conditions related to hearing, including hearing aids and hearing aid batteries. Durable Medical Equipment (DME). Disposable Medical Supplies (DMS). All members Orthodontic care only for members under 21 Members under 21 All members Capital Area 15

18 Your Health Benefits (cont.) Services we do not pay for Acupuncture. Alcohol and other drug abuse services. Chiropractic services. Cosmetic surgery. Deliveries (if you are pregnant, contact the Income Maintenance Administration at to determine eligibility for Medicaid. Deliveries are covered by Medicaid. Contact your IMA caseworker if you become pregnant to ensure Medicaid coverage). Experimental treatment and investigational services and items. Hearing services for members over 21. Infertility testing and services. Outpatient mental health services. Non-emergency transportation services. Open heart surgery. Organ transplantation. Private duty nursing. Sclerotherapy services and items. Services furnished in schools. Screening and stabilization services for emergency medical condition outside of the network including inside of the District. You will be responsible for the charges for the out of network services including emergency services Treatment for obesity. Vision Services for members over 21. Any covered services when furnished by providers that are not members of the network. UnitedHealthcare providers and providers who are not part of UnitedHealthcare Community Plan UnitedHealthcare Community Plan will pay for the care you get when you go to one of our doctors or other health care providers. We call these doctors and other health care providers our network providers. All these in-network doctors can be found in your provider directory. A doctor or provider who is not one of ours is called an out-ofnetwork provider. If you go to an out-of-network doctor, hospital or lab, you may have to pay for the care you get. You will not have to pay if you have asked us first and we have told you, usually in writing, that it is okay. We call this prior written authorization. Remember: You need to go to a provider in UnitedHealthcare Community Plan s network. Prior authorization (or prior approval) means approval for a health service that is not routinely covered by UnitedHealthcare Community Plan. You must get this approval before you receive the service. Call Member Services at to ask about getting a prior authorization. 16 Alliance Member Handbook

19 Other Important Information What to do if you move Call the District of Columbia (DC) Income Maintenance Administration (IMA) Change Center at Call UnitedHealthcare Community Plan Member Services at What to do if you have a baby Call DC Income Maintenance Administration (IMA) Change Center at Call UnitedHealthcare Community Plan Member Services at What to do if you adopt a child Call DC Income Maintenance Administration (IMA) Change Center at What to do if someone in your family dies Call DC Income Maintenance Administration (IMA) Change Center at Call UnitedHealthcare Community Plan Member Services at How to change your MCO You can change your MCO once a year within the 90 days after your anniversary date the month and date you first joined UnitedHealthcare Community Plan. The District of Columbia will send you a letter two months before your anniversary date. The letter tells you how to change MCOs. You will not be allowed to get health care from UnitedHealthcare anymore if you: Lose your Alliance eligibility for reasons such as: - You reside outside of the District of Columbia - You are over-income for the Alliance program Establish Social Security Income (SSI) eligibility Changing your MCO if you have a good reason You have the right to change your MCO at any time after the first 90 days of enrollment if you have a good reason. Examples of good reasons are poor quality of care and you can t see the providers you need. You may change your MCO if your PCP terminates from the UnitedHealthcare network, and you are unwilling or unable to select a new PCP. Call the DC HealthCare Alliance at if you would like more information on how to change MCOs. The D.C. government may remove you from UnitedHealthcare Community Plan if you: Let someone else use your member ID card, The District finds you committed fraud, or You do not follow your member responsibilities. Capital Area 17

20 Other Important Information (cont.) What to do if you get a bill for a covered service If you get a bill for a covered service that is in the list above, call Member Services at Paying for non-covered services If you decide you want a service that we do not pay for and you do not have written permission from UnitedHealthcare Community Plan, you will have to pay for the service yourself. If you decide to get a service that we do not pay for, you must sign a statement that you agree to pay for the service yourself. Remember to always show your member ID card and tell doctors that you are a member of UnitedHealthcare before you get services. Advance directives An advance directive is a legal document you sign that lets others know your health care choices. It is used when you are not able to speak for yourself. Sometimes this is called a living will or a durable power of attorney. An advance directive can let you pick a person to make choices about your medical care for you. An advance directive also lets you say what kind of medical treatment you want to receive if you become too ill to tell others what your wishes are. It is important to talk about an advance directive with your family, your PCP, or others who might help you with these things. If you want to fill out and sign an advance directive, ask your PCP for help during your next appointment, or call Member Services at and they will help you. What to do if you have other insurance If you are a member of UnitedHealthcare Community Plan and eligible for Alliance, you must tell us right away if you have any other health insurance. Please call Member Services at and tell us right away. 18 Alliance Member Handbook

21 Complaints/Grievances, Appeals and Fair Hearings UnitedHealthcare Community Plan and the D.C. government both have ways that you can file a complaint about the care you get or the services UnitedHealthcare provides to you. You may choose how you would like to complain as described below. Complaints/grievances If you are unhappy with something that happened to you, you can file a complaint/ grievance. Examples of why you might file a complaint/grievance include: You feel you were not treated with respect UnitedHealthcare Community Plan has denied payment for a service you believed is covered You are not satisfied with the health care you got It took too long to get an appointment To file a complaint/grievance, you should call Member Services at Your doctor can also file a complaint/ grievance for you. You should file a complaint/grievance as soon as possible and no later than 90 days after the thing you are unhappy about. UnitedHealthcare will usually give you a decision within 30 days but may ask for extra time (but not more than 44 days total) to give a decision. Appeals and fair hearings If you believe your benefits were unfairly denied, reduced, delayed or stopped, you have a right to file an appeal with UnitedHealthcare Community Plan and request a fair hearing with the D.C. Office of Administrative Hearings. To file an appeal with UnitedHealthcare, call Member Services at To file a request for a fair hearing, call or write the District government at: D.C. Office of Administrative Hearings 441 4th Street, N.W. Suite 450-North Washington, DC Telephone Number: Deadlines You must file an appeal or request a fair hearing within 90 days of getting UnitedHealthcare Community Plan s notice of action. If you want to continue receiving the benefit during your fair hearing or appeal, you must request the fair hearing or appeal within the later of the follow - Within 15 days from UnitedHealthcare s postmark of the Notice of Action or - The intended effective date of UnitedHealthcare s proposed action (or, in other words, when the benefit is to stop). - Your provider may file an appeal on your behalf with your written permission. You may also choose to have your provider with you at the hearing. Appeals If you call and give your appeal over the phone, UnitedHealthcare Community Plan will summarize your appeal in a letter and send you the letter for you to sign. Be sure to read the letter carefully. You must sign the letter and return it to UnitedHealthcare in order to have an appeal. Your appeal will be decided by UnitedHealthcare within 14 calendar days from the date your appeal was received. Capital Area 19

22 Complaints/Grievances, Appeals and Fair Hearings (cont.) If UnitedHealthcare needs more time to get information and the District decides this would be best for you, or if you or your advocate requests more time, UnitedHealthcare may increase this time period for the decision by 14 calendar days. UnitedHealthcare must give you written notice of the extension. You will receive written notice of UnitedHealthcare s decision about your appeal in the mail. If you are not happy with UnitedHealthcare s decision about your appeal you may request a fair hearing. Expedited (Emergency) appeals process If your appeal is determined to be an emergency, UnitedHealthcare Community Plan will give you a decision within 3 calendar days. An appeal is considered an emergency if it would be harmful or painful to you if you had to wait for the standard time frame of the appeal procedure. All appeals filed by members with HIV/AIDS, mental illness or any other condition that requires attention right away, will be resolved and communicated back to the member within 24 hours of filing the appeal. Your rights during the complaints/grievances, appeals and fair hearings process You have the right to a fair hearing. You may request a fair hearing from the Office of Administrative Hearings at any time before, during or after you have filed an appeal with UnitedHealthcare Community Plan, but no more than ninety (90) days from the date Notice of Action is mailed. You have a right to keep receiving the benefit we denied while your appeal or fair hearing is being reviewed. To keep your benefit during an appeal or fair hearing, you must file the appeal or request the fair hearing within a certain number of days - this could be as short as 15 days from the postmark of the MCO s Notice of Action. You have the right to have someone from UnitedHealthcare help you through the grievance and appeals process. You have a right to represent yourself or be represented by your family caregiver, lawyer or other representative. You have a right to have accommodations made for any special health care need you have. You have a right to adequate TTY/ TTD capabilities, and services for the visually impaired. You have a right to adequate translation services and an interpreter. You have a right to see all documents related to the complaint/grievance, appeal or fair hearing. If you have any questions about the complaints/ grievances and appeals/fair hearings process, please call Member Services at Alliance Member Handbook

23 Your Rights and Responsibilities You have a right to: Be treated with respect and dignity. Know that when you talk with your doctors and other providers its private. Have an illness or treatment explained to you in a language you can understand. Participate in decisions about your care. Receive a full, clear and understandable explanation of treatment options and risks of each option so you can make an informed decision. Refuse treatment or care. Be free of physical and chemical restraints. Be able to see your medical records and to request that they be fixed if they are wrong. Choose an eligible PCP from within UnitedHealthcare Community Plan s network and to change your PCP. Make a complaint ( grievance ) about the care provided to you and receive an answer. Request an appeal or a fair hearing if you believe UnitedHealthcare was wrong in denying, reducing or stopping a service or item. Receive family planning services and supplies from the provider of your choice. Obtain medical care without unnecessary delay. Receive information on advance directives and choose not to have or continue any life-sustaining treatment. Receive a copy of this UnitedHealthcare member handbook. Continue treatment you are currently receiving until you have a new treatment plan. Receive interpretation and translation services free of charge if you need them. Refuse oral interpretation services. Get an explanation of prior authorization procedures. Receive information about UnitedHealthcare, its services, and its providers and practitioners. Receive information about UnitedHealthcare s financial condition and any special ways we pay our doctors. Obtain summaries of customer satisfaction surveys. Receive UnitedHealthcare s Dispense As Written policy for prescription drugs. Receive UnitedHealthcare s member rights and responsibilities policy and make recommendations for it. To be free from seclusion as a means of coercion, discipline, convenience or retaliation. Capital Area 21

24 Your Rights and Responsibilities (cont.) You are responsible for: Treating those providing your care with respect and dignity. Following the rules of the D.C. HealthCare Community Plan Alliance Program and UnitedHealthcare Community Plan. Following instructions you receive from your doctors and other providers. Going to appointments you schedule or that UnitedHealthcare schedules for you. Telling your doctor at least 24 hours before the appointment if you have to cancel. Asking for more explanation if you do not understand your doctor s instructions. Going to the emergency room when you have a medical emergency. Telling your PCP about medical and personal problems that may affect your health. Reporting to Income Maintenance Administration (IMA) and UnitedHealthcare if you or a family member have other health insurance. Trying to understand your health problems and participate in developing treatment goals. Helping your doctor in getting medical records from providers who have treated you in the past. Telling UnitedHealthcare if you were injured as the result of an accident or at work. 22 Alliance Member Handbook

25 Protected Health Information We train our employees to make sure that they handle your protected health information the right way. This includes information that is spoken, written or electronic. Unless authorized by you, we will not provide any of your protected health information to anyone outside the company or to anyone who is not a business associate under contract with the company for any reason beyond the requirements of your treatment, payment for services, and our health care operations. Notice of Privacy Practices MEDICAL INFORMATION - PRIVACY NOTICE This says how medical information about you may be used and shared. It says how you can get access to this information. Read it carefully. Effective January 1, 2011 We 1 are required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or disclose that information to others. You also have rights regarding your health information that are described in this notice. We are required by law to abide by the terms of this notice. The terms information or health information in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care. We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide to you a revised notice by direct mail or electronically as permitted by applicable law. In all cases, we will post the revised notice on your health plan website, com. We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future. How We Use or Disclose Information We must use and disclose your health information to provide that information: To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. We have the right to use and disclose health information for your treatment, to pay for your health care and to operate our business. For example, we may use or disclose your health information: For Payment of premiums due us, to determine your coverage, and to process claims for health care services you receive, including for subrogation or coordination of other benefits you may have. For example, we may tell a doctor whether you are eligible for coverage and what percentage of the bill may be covered. For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care. For example, we may disclose information to your physicians or hospitals to help them provide medical care to you. Capital Area 23