UnitedHealthcare Community Plan PAC Member Handbook

Transcription

1 MARYLAND UnitedHealthcare Community Plan PAC Member Handbook What you ll want to know about the Maryland Primary Adult Care Program / United Healthcare Services, Inc.

2 Important Telephone Numbers UnitedHealthcare Member Services (Available 24 hours a day, 7 days a week) TTY (Hard-of-hearing) /7 NurseLine Services Website Your Primary Care Provider (PCP) Name: Phone: Address: 2 UnitedHealthcare Community Plan PAC Member Handbook

3 Table of Contents Overview of PAC Part 1: Introduction to UnitedHealthcare Community Plan Access your information online Part 2: Enrollee Rights and Responsibilities Part 3: Your Health, Mental Health and Prescription Drug Benefits Table of benefits and services More information about your mental health benefits Mental health at a glance More Information about family planning and GYN benefits Common questions about family planning services Preventive care guidelines Recommended schedule of preventive care Additional PAC benefits for members with diabetes Part 4: What PAC Does Not Cover Optional services and applicable terms and conditions Notice of changing benefits or service locations Part 5: Information About Your Providers What is primary care? What is a PCP? Information about your PCP Selecting or changing providers List of primary care providers List of pharmacy providers Part 6: Information About Getting Care Making or canceling an appointment Referral to a specialist After-hours and urgent care Out-of-service-area coverage Family planning as a self-referral Health education programs Interpreter for those who do not speak English Interpreter for those who are hearing impaired Substance abuse treatment as a self-referral service Emergency department services Part 7: Information, Complaints, Grievances and Appeals UnitedHealthcare Community Plan consumer services and hotline information UnitedHealthcare Community Plan consumer advisory board How to make suggestions for changes in policies or procedures UnitedHealthcare internal complaint procedures Appeals Information about the state s complaint and appeal process State complaint process The state s decision on your appeal What kind of decisions can be appealed? Fair hearings Fraud and abuse How to report fraud and abuse Part 8: How to Change Your MCO When can I change my MCO? How do I change MCO? When can the state disenroll me from my MCO? Part 9: Keeping Your PAC Benefits Part 10: Notice of Privacy Practices Maryland 3

4 Overview of PAC PAC is a health care program PAC is a health care program to help adults with low incomes. Read this booklet to learn more about PAC and what is covered. Find out how to get care from your Managed Care Organization (MCO). Learn where to go for help. Keep this booklet for when you want to check on which health services PAC offers. People in PAC get: Prescription drugs for a small fee (co-pay). Free visits to a family doctor or nurse practitioner-also called primary care provider or PCP. Substance abuse treatment. Emergency department services. Diabetes care services when you have a need for them. Free visits to a counselor or psychiatrist for mental health services. Getting health services You filled out the PAC application form and qualified for the program. The state sent you a yellow and white PAC ID card in the mail. This ID card lets you start getting pharmacy and mental health services right away. You got your MCO enrollment packet. You had the chance to pick an MCO. If you did not pick, the state chose UnitedHealthcare Community Plan for you. Now you can get PAC services. Until now, your yellow and white PAC ID card covered all of your pharmacy and mental health services. If you did not get your yellow and white PAC ID card from the state, call the Enrollee Help Line at Now that you are enrolled in UnitedHealthcare Community Plan you must get your pharmacy services from UnitedHealthcare. UnitedHealthcare will also cover visits to your PCP for some mental health care, substance abuse treatment and emergency department visits. If you did not get your UnitedHealthcare ID card, call Member Services at or the Enrollee Help Line at Use your UnitedHealthcare ID card at the pharmacy, emergency department, for doctor visits and substance abuse treatment. You had the chance to pick an MCO. If you did not pick, the state chose UnitedHealthcare for you. Now that you are enrolled in UnitedHealthcare, doctor visits with your PCP are covered. You must use your UnitedHealthcare ID card to get most of your prescriptions. Always take both ID cards to the pharmacy. 4 UnitedHealthcare Community Plan PAC Member Handbook

5 PAC review at-a-glance You have chosen an MCO. If you didn t choose, the state assigned you to an MCO. If you want to change to a different MCO read page 27. You should now have your UnitedHealthcare Community Plan ID. Use your UnitedHealthcare ID card at the pharmacy and for your primary care visits. You should now have the name and phone number of your PCP. PAC covers visits to your PCP. PAC does not cover all doctor visits. Visits for specialty care, except substance abuse, are not covered. PAC does not cover any hospital services, except for emergency department visits. Read pages for more information on what is covered. If you have diabetes there are some special services you can get to help keep you healthy. Read page 16 for more information on what is covered. PAC covers outpatient mental health care. You can get mental health care from your PCP. If you need more services, then you or your PCP can ask for specialty mental health services. Call if you need mental health services that your PCP cannot provide. You will use your yellow and white PAC ID for these services. PAC does not pay for in hospital mental health or substance abuse care. Most outpatient specialty mental health and substance abuse services will be covered by PAC. Read page 12 in this booklet to learn more about the mental health services covered by PAC. Some mental health drugs and HIV/AIDS drugs will still be covered by your yellow and white PAC card. The pharmacist will know when to bill the State and when to bill UnitedHealthcare. Be prepared to pay the small co-pay for each of your prescriptions. Read pages in this booklet to learn more about what is covered by PAC. Maryland 5

6 Part 1: Introduction to UnitedHealthcare Community Plan Quality primary health care for you UnitedHealthcare Community Plan is a managed care organization (MCO) that provides quality health care to Primary Adult Care (PAC) enrollees throughout the State of Maryland. With UnitedHealthcare, you can count on getting quality health care, plus the respect you deserve. Choose your own PCP UnitedHealthcare Community Plan has a large network of providers. This makes it easy for you to choose a primary care provider (PCP) you want to help meet your primary health care needs. In addition, we have a large network of pharmacies throughout the state that you can use to fill your prescriptions. 24-hour member services UnitedHealthcare Community Plan has a 24-hour Member Services line that you can call toll-free 24 hours a day, 7 days a week. A representative is always available to help whenever you need us. Member Services representatives speak a variety of languages and have access to translation and interpreter services when needed. We want you to be healthy UnitedHealthcare Community Plan wants to help you be as healthy as you can be. We re the right choice for your primary care needs. We will encourage you to get the preventive care you should have. Welcome to UnitedHealthcare Community Plan! 6 UnitedHealthcare Community Plan PAC Member Handbook

7 Access Your Information Online Manage Your Health Care Information 24/7 on myuhc.com As a member of a UnitedHealthcare Community Plan, you re just a click away from everything you need to take charge of your health benefits. Register on myuhc.com. The tools and new features can save you time and help you stay healthy. Registration on the site is free. Great Reasons to Use myuhc.com Look up your benefits Find a doctor Print an ID Card Find a hospital View claims history Keep track of your medical history, prescriptions and more on your Personal Health Record Take your own Health Assessment Learn how to stay healthy Register on myuhc.com Today Registration is easy and fast. Sign up today! Just visit Select Register on the Home Page. Follow the simple prompts. You re just a few clicks away from access to all types of information. Get more from your health care. Learn How to Stay Healthy Improve your health with an online Health Assessment Chat with a nurse in real-time You can view and print your ID Card online at myuhc.com/communityplan Maryland 7

8 Part 2: Enrollee Rights and Responsibilities As a Member of UnitedHealthcare Community Plan you have the right to: Be treated with respect, dignity and privacy. UnitedHealthcare Community Plan has policies in place to protect your privacy including oral, written and electronic protected health information (PHI). See our Privacy Policy on page 29. Receive information, including information on treatment options and alternatives in a manner you can understand. Participate in decisions regarding your health care, including the right to refuse treatment. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. Receive information about the Plan, its services, its practitioners and providers and members rights and responsibilities. An open discussion about medically necessary treatment options for your conditions, regardless of cost or benefit coverage. Make recommendations regarding the health plan s member rights and responsibilities policy. Request and receive a copy of your medical records and request that they be amended or corrected as allowed. Exercise your rights and to know that the exercise of those rights will not adversely affect the way UnitedHealthcare or our providers treat you. File appeals and grievances with us. See page 23. File appeals and grievances with the State. See page 24. State fair hearings. See page 26. Request that ongoing benefits be continued during an appeal or state fair hearing; however, you may have to pay for the continued benefits, if our decision is upheld in the appeal or hearing. See page 24. Receive a second opinion from another doctor in the UnitedHealthcare provider network if you don t agree with your doctor s opinion about the services that you need. Contact UnitedHealthcare s member services at for help with this. Receive other information about us such as how we are managed. You may request this information by calling UnitedHealthcare s member services at UnitedHealthcare Community Plan PAC Member Handbook

9 As a UnitedHealthcare Community Plan member, it is important you: Cooperate with those providing you with health care services. Provide all information as needed to the professional staff caring for you. Follow instructions and guidelines given by those providing health care services. Call after your enrollment to make an appointment for your health assessment. Call for appointments to minimize waiting time. Inform your doctor s office at least 48 hours in advance if you need to cancel your appointment. Call Member Services if you are not sure if you should call your doctor or go to the emergency room. If problems arise concerning the medical care you receive, make your feelings known. Every effort will be made to solve your problem. Learn more about keeping well and better managing any health care problems by taking advantage of health education services and classes available to you. Understand health problems and participate in developing mutually agreed upon treatment goals. Report any other health insurance coverage to your doctor or UnitedHealthcare. Report any public health problems such as Tuberculosis to your doctor. Maryland 9

10 Part 3: Your Health, Mental Health and Prescription Drug Benefits You have your MCO. You have your PCP. You have your UnitedHealthcare Community Plan ID card. Now you can get all the PAC health services. UnitedHealthcare won t charge you for any of your PAC health care benefits except for your co-pays for prescription drugs. Be sure to take time to make appointments for routine health screenings. Keep your appointments. Do your part to be healthy. Read page 14 for more information on when you should have certain routine health screenings. Table of benefits and services The table lists all the services you can get with PAC. If you have questions about what is covered. Call UnitedHealthcare Community Plan Member Services at Or you can call the state s Enrollee Help line at To be covered by PAC, you must use your PCP and UnitedHealthcare ID card to get the services listed. Some MCO s may offer more services than the ones listed. Read page 18 for more information about any additional services your MCO offers. Your Benefits What It Means Rules About the Benefits Primary Care Services Lab & Diagnostic Services The basic health services you need to take care of your general health needs. These tests help your PCP see if you have a certain health condition or disease. These tests are covered: Lab tests, such as urine test, including toxicology screening, CBC, blood glucose, Pap tests and PSA. EKG Chest x-ray, x-rays to detect fractures Mammograms You must use your PCP. Care with specialist and hospital stays are not covered. Tests must be ordered by your PCP, family planning or substance abuse provider. Talk to your provider about which tests are covered. You must go to a lab or imaging center in the UnitedHealthcare network. If the test is not covered or if you go out of network, you may be charged. 10 UnitedHealthcare Community Plan PAC Member Handbook

11 Your Benefits What It Means Rules About the Benefits Pharmacy Services Family Planning Routine Gynecologist (GYN) Care Primary Mental Health Services These are covered: Prescription drugs. These are drugs you get with an order from your PCP. Insulin, needles and syringes. Coated aspirin for arthritis. Iron pills. Birth control pills and devices. Latex condoms from the drug store (just show your PAC and MCO ID) Office or clinic visit Birth control method, such as birth control pills, IUDs, injectables, patches. Latex condoms. A pharmacist can give you condoms without a doctor s order. Yearly check-ups at the gynecologist Lab tests such as pap smears Primary mental health services are basic mental health services provided by your PCP. Only drugs you get with a prescription are covered. Coated aspirin for arthritis and iron pills for low iron blood are also covered. UnitedHealthcare may charge you a co-pay of up to $7.50 for brand name drugs and $2.50 copay for generic drugs. Mental health and HIV/Aids drugs are covered by your yellow and white PAC ID card. For these you must pay a co-pay of $7.50 for brand names and $2.50 for the generic drugs. PAC does not pay for permanent sterilization. You must use your PCP or a GYN provider who is in the UnitedHealthcare network. If more than basic mental health services are needed, your PCP will refer you to the Public Mental Health System for specialty mental health services. Your PCP may refer you for extra mental health services outside UnitedHealthcare. Or, you may ask for these specialty services. Call the Public Mental Health System at for specialty mental health treatment. Maryland 11

12 Part 3: Your Health, Mental Health and Prescription Drug Benefits (cont.) Your Benefits What It Means Rules About the Benefits Community Based Substance Abuse Treatment Emergency Department Evaluation Family group and individual Counseling Methadone treatment Community-based intensive outpatient treatment Services provided in a hospital emergency department Inpatient treatment is not covered. Services provided at hospitals are not covered. Must be a true medical emergency (see page 22). You may be responsible for the doctor bill. Not covered if you are admitted to the hospital. More information about your mental health benefits Visits to your PCP for mental health care are covered by UnitedHealthcare Community Plan. If your PCP thinks you need specialty mental health services you can get those services too. You can get most specialty mental health services through the Public Mental Health System. Just call for an appointment at You do not need a referral from your PCP. When you go for the mental health visit, show the office staff your yellow and white ID card. You will not be charged for the visit. Are there any mental health services that are not covered by PAC? Yes, inpatient care and day treatment programs (also known as partial hospitalization) are not covered. If you need them you can still get them but you may have to pay a small fee. Mental health at a glance How do I get mental health services through PAC? If you think you need mental health services you can do any of these things: Talk to your PCP. Call the UnitedHealthcare Member Service line at Call the Public Mental Health System at Talk to your PCP now if you are feeling low, blue, depressed or having thoughts of harming yourself. Your PCP will ask you questions to help decide if you need mental health treatment. The PCP may decide that he or she can help. Or, the PCP may help refer you to the Public Mental Health System. The Public Mental Health System toll-free help line is open 24 hours a day, 7 days a week. 12 UnitedHealthcare Community Plan PAC Member Handbook

13 The help line is run by mental health staff called care managers. The care manager is trained to handle your call and will help you get the services you need. If the Public Mental Health System finds you do not need specialty mental health services, they will call your PCP (with your permission). This way you can get any needed follow-up care with your PCP. Can I see the same mental health provider I used before I got in PAC? If you saw a provider in the past for mental health services and want to go back to him or her, let your care manager know. Every effort will be made to get you to the same provider. Does it take a long time to get into mental health specialty care? How quickly you are seen for specialty mental health care depends on the type of treatment you need. The list below lists the time rules for getting an appointment with a mental health specialist: Emergency When PMHS care manager finds that your problem is an emergency, you will be seen the same day. This is most often within 4 hours. Urgent When the PMHS care manager finds that you have a pressing crisis and need to see a mental health specialist quickly, you will be seen by the next day. This is most often within 24 hours. Scheduled When you need to see someone for an evaluation, a visit for specialty care will be scheduled within 10 working days. More information about family planning and GYN benefits You can get the help you need to be healthy before pregnancy. You can also learn ways to plan when you want to have a baby or if you don t want to get pregnant. This kind of care is referred to as family planning. Family planning includes gynecological (GYN) exams. For those women who do not need or want family planning, routine GYN care is covered. Common questions about family planning services Can I get family planning services with PAC? Yes. Talk to your PCP about your needs and options. You may want help spacing your children or putting off pregnancy until you are ready. Your breast exam, Pap smear, medicines and lab tests will all be covered. What does family planning self-referral option mean? Self-referral means that you can decide on your own to go to a family planning provider outside of UnitedHealthcare Community Plan. That means you don t need your PCP to refer you. UnitedHealthcare will still pay for this service. But before you go, call the doctor or clinic you want to go to. Tell them you are in the PAC program and that you are a member of UnitedHealthcare. Make sure the office has agreed to bill UnitedHealthcare directly. UnitedHealthcare will also pay for any related lab work and medicine that you get while at the visit. You must use a UnitedHealthcare network provider for other lab tests and pharmacy services. Maryland 13

14 Part 3: Your Health, Mental Health and Prescription Drug Benefits (cont.) What should I know about GYN services? Getting routine GYN check-ups is important even if you don t want or need family planning services. This means getting your breast exam and Pap smear to check for cancer. Going to the GYN helps you stop little problems before they become big health problems. In many cases your PCP will offer this service. If your PCP does not offer this care, call UnitedHealthcare Community Plan member service at They will direct you where to go for GYN care. UnitedHealthcare will pay for this routine check-up. You must go to where UnitedHealthcare sends you for GYN care. Will my bill be covered if I have a GYN problem and my PCP thinks I should see a gynecologist? Your PCP may advise you to see a gynecologist because you are experiencing a GYN problem. UnitedHealthcare will not cover the office visit to the gynecologist. UnitedHealthcare does not pay for specialty care, surgery or hospital care. Read pages in this booklet to learn more about the services that are not covered by PAC. Preventive care guidelines Health screenings are physical exams and tests performed by a doctor or other qualified health professional. Preventative care includes periodic medical exams that may include a review of your medical history, a physical exam and diagnostic testing. Health screenings are very important. They often reveal problems before you feel sick or develop serious life-threatening conditions. This guide should only be used as a reference. Check with your doctor to determine the health screens that are right for you. You can also stay healthy by following these tips: Eat healthy foods. Don t smoke. Avoid drugs and excessive alcohol use. Drive safely and wear your seat belt. Exercise regularly. Brush and floss your teeth daily. Use sunscreen. Control stress. 14 UnitedHealthcare Community Plan PAC Member Handbook

15 Recommended schedule of preventive care Age in Years Heart Health Blood Pressure Cholesterol Diet Diabetes Aspirin to prevent heart attack Abdominal aortic aneurysm Men and women at least every 2 years Men at risk Men Men at risk Women at risk Women Women at risk Men and women with high cholesterol and those at risk for heart disease and diabetes Men at risk Women at risk Men and women at risk for heart disease Men Women Once for men who have ever smoked Cancer Breast cancer Cervical cancer Colorectal cancer Women at least every 3 years Women every 1 to 2 years Men and women Health Risks Tobacco use Obesity Alcohol misuse Sexual Health Chlamydia Women Women at risk Gonorrhea Women Women at risk HIV Syphilis Men and women Men and women Men and women Men and women at risk Men and women at risk Bone Health Osteoporosis Women at risk Women Other Depression Immunizations Flu Pneumonia Men and women at risk Men and women Men and women, annually Men and women, once Source: Adult Preventive Care Timeline. AHRQ Publication No. APPIP06-IP001, June Agency for Healthcare Research and Quality, Rockville, MD. Used with permission. Maryland 15

16 Part 3: Your Health, Mental Health and Prescription Drug Benefits (cont.) Additional PAC benefits for members with diabetes If you have diabetes, UnitedHealthcare Community Plan and your PCP want to work with you so you can keep your blood sugar under control. That is why PAC covers additional services for people with diabetes. To have PAC pay for these services you must use providers in the UnitedHealthcare network. Benefits for PAC Members with Diabetes Diabetes Care Equipment and Supplies Vision Care Foot Care What it Means Diabetes education and diabetes nutrition education Equipment to help you get around more easily and devices to help you measure your blood sugar. Finger sticking devices Blood glucose meters Test strips Compression stockings Crutches and canes Walkers Eye exams by an eye doctor to correct vision or to find and treat eye diseases related to diabetes. Foot care when medically needed. Care to remove corns or calluses. Care to trim, cut or clip toenails. Special shoes, non-custom inserts and supports Rules About the Benefits Talk to your PCP about getting these services to help control diabetes. The basic health services you need to take care of your general health needs. People with diabetes can get one eye exam, contact lenses or one pair of glasses per year; and one replacement pair of glasses, if lost, stolen or broken. Foot care for people with diabetes may be limited to one visit every 60 days. Custom shoe inserts are not covered. 16 UnitedHealthcare Community Plan PAC Member Handbook

17 Part 4: What PAC Does Not Cover PAC has limited benefits. PAC does not cover care provided by specialists or specialty care. This means that most of the services covered by PAC are limited to those services that your PCP can provide. There are some exceptions. They are listed below: Some specialty care is covered for people with diabetes. Read page 16 in this booklet for more information. And specialty mental health is covered. Read page 12 in this booklet for more information. Some substance abuse treatment services are covered. Some emergency department services are covered. Examples of services that PAC does not pay for include: Audiologists and hearing aids are not covered. Blood and blood products that may be needed if you are in an accident or need an operation are not covered. Case management services to coordinate all your health care appointments and care needs are not covered. UnitedHealthcare Community Plan is required to send you notices when routine health screenings are coming up. Specialty dental services are not covered. Dialysis for kidney disease is not covered. EPSDT services, including specialty, treatment or rehabilitation services needed to diagnose or treat problems of children, usually up to age 21, are not covered. Health programs to help you lose weight, eat right, exercise or quit smoking are not covered. Hospice care for people who are in the final stages of life is not covered. Hospital services including in-patient and out-patient services are not covered (except for some emergency department services). In-home help with activities of daily living, including home health nursing, private duty nursing, and home health aide care are not covered. Nursing home care or care in a long-term care facility is not covered. Oxygen and respiratory equipment is not covered. Pregnancy-related services are not covered and abortion is not covered. If you are pregnant, you should apply for full Medicaid benefits. Call Ask how to apply for the Maryland Children s Health Program (MCHP). MCHP covers prenatal care. Abortion is not covered by MCHP. Rehabilitation care of any type, including hospital care for people who have become disabled because of an accident or illness, is not covered. Rehabilitation services, including physical therapy, occupational therapy, speech therapy, are not covered. Specialty health care to diagnose and treat problems which cannot be managed by your PCP is not covered except for mental health, substance abuse, some emergency department services and diabetes care. Transportation is not covered. Maryland 17

18 Part 4: What PAC Does Not Cover (cont.) Your MCO may offer some additional services. Read page 18 for information about any optional services your MCO is offering. If you have questions about which services are covered by PAC, call UnitedHealthcare Community Plan Member Services at or call the Enrollee Help Line at Optional services and applicable terms and conditions Vision Care PAC members will receive one eye exam and one pair of glasses or contacts every year with one replacement pair of glasses if lost, stolen or broken within that period. Please call UnitedHealthcare Community Plan s Member Services for a participating eye doctor in your area at Notice of changing benefits or service locations Can PAC Benefits Be Stopped? Your health care coverage may be terminated if you move out of the State of Maryland outside of the UnitedHealthcare Community Plan service area or you become ineligible for enrollment in PAC per the State of Maryland. Can PAC Benefits Be Changed? If PAC benefits change, you will be notified in writing about the changes. You will be notified by letter 30 days before the benefits or services change. 18 UnitedHealthcare Community Plan PAC Member Handbook

19 Part 5: Information About Your Providers What is primary care? Primary care means exams, regular check-ups, shots and general care to keep you well, give you advice and to recommend special treatment when needed. It means you and your doctor work together to keep you well or see that you get the care you need. What is a PCP? A PCP is a primary care provider who is the primary coordinator of your care. Your PCP can be a doctor who is a family practitioner or an internal medicine doctor. Your PCP can also be a nurse practitioner. Your PCP will take care of most of your health care needs. When you choose a new PCP, you should call to make a first appointment so that your PCP can get to know you and your medical history and needs. Information about your PCP The UnitedHealthcare Community Plan PAC Provider Directory lists all of the providers who participate in the UnitedHealthcare PAC program. Primary care providers are listed by county. The directory has the name, address and phone number of the providers. You can contact the provider s office to find out office hours and languages spoken at that office. You can also call Member Services to get additional information about the providers in our network. Selecting or changing providers When you make your choice to enroll in UnitedHealthcare Community Plan, choose a participating provider s office that is convenient for you. Choose carefully because your primary care must be administered or arranged by the PCP that you choose. If you want to know more about a PCP, call UnitedHealthcare Member Services at If you wish to change your PCP, please call Member Services for help in making the change. List of primary care providers The UnitedHealthcare Community Plan PAC Provider Directory lists all of the primary care providers that are participating in the UnitedHealthcare network for the Primary Adult Care program. In addition, it lists the providers who provide services for diabetic members. Call UnitedHealthcare Member Services at for assistance in locating a provider or to receive a copy of the provider directory. Maryland 19

20 Part 5: Information About Your Providers (cont.) List of pharmacy providers As a UnitedHealthcare Community Plan member, you may fill your prescriptions through one of our participating retail pharmacies and most independent phamacies. Whenever you need a covered prescription, visit any participating pharmacy and present your UnitedHealthcare PAC member ID card. If you wish to use a pharmacy not listed above, please call UnitedHealthcare Community Plan Member Services at You can also visit our web site at for a more up-to-date listing. Area-wide pharmacies: CVS Pharmacy Eckerd Pharmacy Giant Food Pharmacy Medicine Shoppe NeighborCare Pharmacy Rite Aid Pharmacy Safeway Pharmacy Sam s Pharmacy Shoppers Super Fresh Pharmacy Costco Pharmacy Target Pharmacy Wal-Mart Pharmacy Walgreens Pharmacy Weis Pharmacy 20 UnitedHealthcare Community Plan PAC Member Handbook

21 Part 6: Information About Getting Care Making or canceling an appointment When you need to see a provider you should schedule an appointment in advance. You may call the provider s office number on your member ID card to make an appointment. Making an appointment allows your doctor s office to prepare for your visit. If you think you have a medical problem that needs your primary care doctor s attention quickly, make sure you tell the person who is scheduling your appointment. Give your name and the UnitedHealthcare Community Plan number exactly as it appears on your UnitedHealthcare ID card. Tell the office that you are a PAC member. Once you have scheduled your appointment, write down the name of your doctor and the date and time of your appointment. Keep this written information handy. If you cannot keep an appointment, call your doctor to cancel at least 48 hours ahead. Please remember to cancel your appointment if you will not be able to be there. Referral to a specialist Depending on your condition, your PCP may not be able to treat you because the care you need is outside of his type of practice or you require a provider who is more experienced with that type of care. Your PCP will tell you what specialty care you need and give you a Statement of Needed Service (SONS) form to take when you go to the specialty provider. The PAC program does not cover and does not pay for specialists or specialty care. After-hours and urgent care Illnesses and injuries of a less serious nature than an emergency may require after hours care. If you are not sure what level of care you need, contact your PCP. If you need help contacting your PCP, call Member Services at You can also call UnitedHealthcare s 24-hour-a-day, 7-day-a-week NurseLine Services. You can talk to a nurse, day or night, to get advice on your medical problems. The nurse can also help you decide if you can wait to see your primary care provider or if you should seek immediate care. Call NurseLine toll-free at Out-of-service-area coverage UnitedHealthcare Community Plan and the PAC program do not cover any services that are provided outside of the service area (except some ER facility services). Routine medical care, such as check-ups, preventive care and non-emergency visits must be provided by your PCP in the service area. Family planning as a self-referral There are some services you can get any time from any doctor or clinic that accepts Medicaid. You do not have to go to a participating provider to receive routine family planning services. You can get birth control advice, birth control prescriptions and a pregnancy test. PAC members enrolled in UnitedHealthcare Community Plan may get these services from their PCP or from a participating GYN. Maryland 21

22 Part 6: Information About Getting Care (cont.) Health education programs There are many free health education classes and support groups available in your community. You can call your local health department or UnitedHealthcare Community Plan s Quality Department at extension for assistance in finding a health education program or to get educational materials. Interpreter for those who do not speak English Requests for special services such as an interpreter for members who do not speak English should be directed to Member Services at They can help with appointment arrangements. Interpreter for those who are hearing impaired Requests for special services such as an interpreter for members who are hearing-impaired should be directed to UnitedHealthcare Community Plan Member Services at If you have trouble hearing, you can call the Maryland Relay Service at and ask to be connected to Member Services. Substance abuse treatment as a self-referral service If you are in need of substance abuse treatment, you may self-refer to a certified substance abuse treatment provider for a Comprehensive Substance Abuse Assessment (CSAA). You may self-refer for the initial CSAA if the following conditions are met: You are not currently in substance abuse treatment; You have not received a self-referred CSAA during that calendar year; and The assessment provider is a certified substance abuse provider. You can also self-refer for other treatments such as individual and group counseling and detoxification. You must meet certain criteria to receive these services. Contact United Behavioral Health (UBH) at for more information. Emergency department services The PAC program covers some emergency department services. You may be responsible for the doctor s bill. Emergency room services are not covered if you are admitted to the hospital. If you have any questions call UnitedHealthcare Community Plan Member Services at Emergencies are those circumstances which endanger life or can cause permanent disablement. Examples of such conditions include: Suspected heart attack Heavy bleeding Poisoning Loss of consciousness Severe shortness of breath Suspected overdose of medication Serious burns Vomiting blood 22 UnitedHealthcare Community Plan PAC Member Handbook

23 Part 7: Information, Complaints, Grievances and Appeals UnitedHealthcare Community Plan consumer services and hotline information UnitedHealthcare Community Plan wants to quickly resolve questions and/or complaints about services or the payment of services. If you have an appeal, complaint or grievance about your health care services, call Member Services at or send a letter to UnitedHealthcare. If you prefer, Member Services will mail you a complaint form to complete. If you need help with submitting a complaint in writing (by letter or on the form), Member Services is available to help you. Questions regarding medical emergencies will be addressed within 24 hours. Other medical care issues will be addressed within 5 working days. Administrative issues will be addressed within 30 days. If you are not happy with a response to your complaint, you can have it reviewed again. Someone else at UnitedHealthcare will look at your case and make a decision. Remember if you have questions, call Member Services and they will be happy to explain the process to you. UnitedHealthcare Community Plan consumer advisory board UnitedHealthcare has a Consumer Advisory Board that meets every other month to provide advice and guidance to the plan. Any member of UnitedHealthcare is invited to participate in the Consumer Advisory Board Meeting. To find out more about the Consumer Advisory Board or to get information about the next meeting, call Member Services at How to make suggestions for changes in policies or procedures If you have a suggestion for changes in policies or procedures, you can contact: UnitedHealthcare Community Plan Member Consumer Advisory Board; or UnitedHealthcare Complaint and Appeals Department; or Visit one of UnitedHealthcare s Community Hubsites. For more information, call UnitedHealthcare Member Services UnitedHealthcare internal complaint procedures PAC enrollees shall have complaint and appeal rights for PAC covered services. If you have a complaint you can contact us at Request for an interpreter for members who do not speak English should be directed to Member Services at Appeals If your complaint is about a service you or a provider feels you need but we will not cover, you can ask us to review your request again. This is called an appeal. If you want to file an appeal you have to file it within 90 days from Maryland 23

24 Part 7: Information, Complaints, Grievances and Appeals (cont.) the date that you receive the letter saying that we would not cover the service you wanted. You can call us to file your appeal or you may also send your appeal in writing. We have a simple form you can use to file your appeal. Just call to get one. We will mail or fax the appeal form to you and provide assistance if you need help completing it. Once you complete the form, you should mail it to: UnitedHealthcare Member Appeals PO Box Salt Lake City, UT Your doctor can also file an appeal for you if you sign a form giving him or her permission. Other people can also help you file an appeal, like a family member or a lawyer. When you file an appeal, be sure to let us know any new information that you have that will help us make our decision. We will send you a letter letting you know that we received your appeal within 5 business days. While your appeal is being reviewed, you can still send or deliver any additional information that you think will help us make our decision. When reviewing your appeal we will: About an urgent medical problem you are having, it will be solved within 24 hours. About a medical problem but it is not urgent, it will be solved within 5 days. Not about a medical problem, it will be solved within 30 days. The appeal process may take up to 44 days if you ask for more time to submit information or we need to get additional information from other sources. We will send you a letter if we need additional information. If your doctor or UnitedHealthcare Community Plan feels that your appeal should be reviewed quickly due to the seriousness of your condition, you will receive a decision about your appeal within 3 business days. If we do not feel that your appeal needs to be reviewed quickly, we will try to call you and send you a letter letting you know that your appeal will be reviewed within 30 days. If your appeal is about a service that was already authorized and you were already receiving, you may be able to keep getting the service while we review your appeal. Contact us at if you would like to keep getting services while your appeal is reviewed. If you do not win your appeal, you may have to pay for the services that you received while the appeal was being reviewed. Once we complete our review, we will send you a letter letting you know our decision. If we decide that you should not receive the denied service, that letter will tell you how to file another appeal or ask for a State Fair Hearing. Information about the state s complaint and appeal process Getting Help from the State s Enrollee Help Line: If, after calling UnitedHealthcare Community Plan, you still have questions or are not satisfied, you can call the state s Enrollee Help Line for help. Examples of when to call the Enrollee Help Line include: You have a question or complaint about your health care; You have been unable to get an appointment for a covered service; 24 UnitedHealthcare Community Plan PAC Member Handbook

25 You have not been able to get a covered benefit or service you think you need; You received a bill for services that you think should be covered by PAC; You have to travel too far to get covered health care services; or For any problem that UnitedHealthcare has not solved to your satisfaction. Call to reach the State s Enrollee Help Line. Someone can help you Monday through Friday between 7:30 a.m. and 5:30 p.m. You can leave a recorded message at any other time and someone will call you back during business hours. When you call the Enrollee Help Line, you can ask your question or explain your problem to one of the Enrollee Help Line staff, who will: Work with UnitedHealthcare to discuss what you need or how to solve the problem; Answer your questions; and if necessary, Send your complaint to the Complaint Resolution Unit. This Unit may take the actions below: (1) Ask UnitedHealthcare to provide them information about your problem so that it can be resolved as soon as possible; (2) Work with UnitedHealthcare and provider to assist you in getting what you need; (3) Help you to get community services, if needed; or (4) Help you to appeal denials of covered services and give you the fair hearing process in writing. Read pages for information about the appeals process. State complaint process If I don t agree with a decision made by UnitedHealthcare, what do I do? You can contact the State s Enrollee Help Line at The Enrollee Help Line will give your appeal to the Complaint Resolution Unit. The Complaint Resolution Unit will attempt to resolve your appeal with the MCO in 10 business days. If it cannot be resolved in 10 business days, you will be sent a notice that gives you a choice to request a fair hearing or wait until the Complaint Resolution Unit has finished its review of the appeal. When the review is finished, you will receive the decision in writing. If you do not agree with the decision, you may have the option to request a fair hearing. The state s decision on your appeal When all of the facts about your MCO appeal have been reviewed by the state, the state will take one of the actions below: If the state decides that UnitedHealthcare Community Plan should provide the benefit or service, it can order UnitedHealthcare to do so right away and UnitedHealthcare will give you the benefit or service. If the state decides that UnitedHealthcare does not have to give you the benefit or service, you will be told that the State agrees with UnitedHealthcare. Read about the decisions that can be appealed below. Maryland 25

26 Part 7: Information, Complaints, Grievances and Appeals (cont.) What kind of decisions can be appealed? You have the right to appeal the following decisions made by the state. When the state: Agrees with UnitedHealthcare Community Plan that a benefit or service you are receiving should be reduced or terminated; Agrees with UnitedHealthcare that a benefit or service is not medically necessary. Fair hearings To appeal one of the state s decisions, you must request that the state file a notice of appeal with the Office of Administrative Hearings on your behalf. This will be your appeal against the state. UnitedHealthcare Community Plan staff may appear as witnesses for the state at the appeal hearing. The Office of Administrative Hearings will set a date for the hearing. The hearing must be held and a decision must be made within 90 days from the date you requested the Fair Hearing. If the Office of Administrative Hearings decides against you, you may appeal to the state s Board of Review. You will get the information on how to appeal to the Board of Review with the decision from the Office of Administrative Hearings. If the Board of Review decides against you, you may appeal to the Circuit Court. Fraud and abuse People who are dishonest on purpose to get Primary Adult Care Program may lose their health care benefits, be fined or jailed. Fraud and abuse for PAC members can be things like: Providing false information or hiding facts to get or keep PAC. Letting someone else use your PAC ID card. Selling or giving your prescription medicines to anyone else. Fraud and abuse for PAC providers can be things like: Billing UnitedHealthcare for services that were never given or billing twice for the same service. If you know of fraud and abuse in the PAC program, you must tell PAC about it. But you don t have to tell them your name. How to report fraud and abuse Tell us in one of the following ways: UnitedHealth Group maintains a 24-hour toll free telephone line, known as the Compliance Help Line, at Callers may choose to remain anonymous. Call PAC Fraud hotline at Online at then click on Report Fraud. Write the DHMH Medicaid Program Integrity, Recipient Fraud and Abuse Unit, 201 West Preston Street, Room 520, Baltimore, Maryland 21201, Fax: or UnitedHealthcare Community Plan PAC Member Handbook

27 Part 8: How to Change Your MCO When can I change my MCO? You will be able to change MCOs at least once a year. There are some special circumstances for the first year of PAC. Read about when you can change below. You can change MCOs once a year on the anniversary of your enrollment. Every year around the time you first signed up with UnitedHealthcare Community Plan, you will be mailed a notice from the state asking if you would like to change MCOs. You will have 21 days from the date the state mails the notice to give your answer. You may choose to stay with UnitedHealthcare or you may decide to select another MCO near where you live. You do not need to have a reason for this yearly change. What are the approved for cause reasons which will let me change MCOs at any time? You may change your MCO and join another MCO near where you live for any of the following reasons: Within 90 days of initial enrollment in the PAC program; If you move to another county where UnitedHealthcare does not offer care; If you move or become homeless and find that there is another MCO closer to where you live or have shelter which would make getting to appointments easier; If you or any member of your family has a doctor in a different MCO and the adult member wishes to keep all family members together in the same MCO; You wish to continue to receive care from your primary care provider (PCP) and the PCP s contract with UnitedHealthcare has been terminated by UnitedHealthcare for one of the following reasons: (1) reasons other than quality of care; (2) The provider and UnitedHealthcare cannot agree on a contract for certain financial reasons; or (3) UnitedHealthcare has been purchased by another MCO. How do I change MCO? Contact the state s Enrollment Broker at If you meet one of the requirements and decide you want to change your MCO you will need to give the following information: The reason you are requesting the change; and If you are moving, to what county and city will you be moving to. When can the state disenroll me from my MCO? The state will remove you (disenroll you) from UnitedHealthcare Community Plan if: You no longer qualify for PAC benefits; You no longer qualify to be in an MCO because you are now in another state program which does not enroll its members in MCOs; You are admitted into an intermediate facility for mentally retarded persons; You are an inmate of a public institution; You are in an MCO that no longer has a contract to provide care in the State of Maryland; or You were not validly enrolled in the MCO. If you are still eligible for PAC benefits you will be enrolled in another MCO. Maryland 27