MICHIGAN. UnitedHealthcare Community Plan MIChild Member Handbook /12

Transcription

1 MICHIGAN UnitedHealthcare Community Plan MIChild Member Handbook /12

2 Welcome to UnitedHealthcare Community Plan As a Member of UnitedHealthcare Community Plan, your child will get MIChild Your child is important to us. We work hard to improve the health and quality of life for our Members. We look for ways to make our health program easy to use and better for your child every day. We are here to help you make good health decisions for your child. You choose your child s UnitedHealthcare Community Plan doctor a Primary Care Provider (PCP). PCP often for regular and preventive care. We want to answer any questions you have about your child s health program. We will help you choose or change your child s PCP, get care with a specialist or have Please read it carefully and keep it in a safe place for future use. It is our goal that when people ask you which health program your child has, you proudly say, UnitedHealthcare Community Plan. Great Choice! Welcome aboard and thank you for becoming a part of our UnitedHealthcare Community Plan family. Don Schmidt Jr. President/CEO UnitedHealthcare Community Plan January 2012 MIChild Member Handbook

3 Telephone Numbers UnitedHealthcare Community Plan MIChild Customer Service Call us to: Change your child s Primary Care Provider (PCP) Ask about UnitedHealthcare Community Plan doctors or other health care providers Ask about covered medications or other pharmacy questions Ask about covered benefits Ask for a list of UnitedHealthcare Community Plan doctors and hospitals, a Provider Directory Use the AT&T Language Line, interpretation services: We can help you in over 130 languages Get UnitedHealthcare Community Plan information or written materials Ask about UM decisions Vision Services, VSP (Vision Service Plan) To set up FREE services for your child s routine eye exams, frames and lenses. Or visit VSP at MIChild Helpline For MIChild benefits not covered by UnitedHealthcare Community Plan Dental Services The Department of Community Health (DCH) covers routine dental services, not UnitedHealthcare Community Plan. Your child can go to any dentist that accepts the MIChild program. UnitedHealthcare Community Plan can help you learn how to find a MIChild dentist. Michigan Enrolls Michigan Relay (Hearing Impaired) The Michigan Relay Center makes it possible for hearing-impaired and/or speech-impaired persons to call UnitedHealthcare Community Plan. They can be reached 24 hours a day, 7 days a week. These are ALL toll-free phone numbers! Michigan

4 Free Services for You: At-A-Glance Benefit Summary Your child can get these services FREE, when set up with their UnitedHealthcare Community Plan provider: Free covered SERVICES Doctor Services Hospital Services Medicine/Prescription/RX Maternity Care Eye Care Urgent and Emergency Care Services Other Services Office visit when your child is sick Office visit preventive, gynecological exams Preventive services: immunizations, Pap smears and sexually transmitted disease (STD) testing Allergy testing Hospital room, board Inpatient and outpatient surgical procedures Includes doctor services, all related surgical services, anesthesia, lab and x-ray X-ray and laboratory tests Written prescription from your child s PCP or UnitedHealthcare Community Plan specialist Pre- and post-partum visits Maternity delivery in hospital and well baby care in hospital Healthy First Steps Program to help new moms-to-be Vision Service Plan (VSP) Eye exams, designer-type frames (Altair eyewear) and prescription lenses After-hours urgent care and emergency room X-rays, laboratory and radiology Durable medical equipment (DME) Skilled nursing facility care Home health care Hospice care Physical, occupational and speech therapy Your child s PCP s 24-hour, 7-day-a-week phone number is on their UnitedHealthcare Community Plan ID card. This summary highlights the MIChild benefits. Read this MIChild Member Handbook and MIChild Certificate of Coverage for full details. MIChild Member Handbook

5 United Healthcare Community Plan MIChild Member Handbook

6 Table of Contents Welcome to UnitedHealthcare Community Plan Common Terms: What does it mean? The Basics What is UnitedHealthcare Community Plan? What Does UnitedHealthcare Community Plan Give My Child? Your Child s Eligibility If You Move Out of the UnitedHealthcare Community Plan Area Keep in Touch Your Child s UnitedHealthcare Community Plan MIChild ID Card UnitedHealthcare Community Plan Customer Service Department UnitedHealthcare Community Plan Customer Service If You Get a Bill How UnitedHealthcare Community Plan Works Your Child s Personal Doctor (PCP) Choosing Your Child s PCP Changing Your Child s PCP UnitedHealthcare Community Plan Doctors.. 10 Be Part of Your Child s Good Health New Medical Ideas Utilization Review Policy and Procedures Prior Authorization Quality Improvement Program Health Screenings Case Management Program Disease Management How UnitedHealthcare Community Plan Pays Our Providers When Your Child Needs a Specialist Specialist Services Out-of-Plan Specialty Services Self-Referral Services Your Child s Health Care Services Young Adults Young Women s Health Young Women Family Planning A Healthy Pregnancy UnitedHealthcare Community Plan s Healthy First Steps Visiting Your Child s PCP MIChild Member Handbook

7 Children s Health Children and Teens Well-Child Care Immunizations (Shots) Blood Lead Poisoning Urgent, Emergency and Out-of-Area Care After-Hours Care Urgent Care Emergency Care What to Do in an Emergency Situation Follow-Up Care Out-of-Area Care Covered Services Prescription Drugs Vision Services VSP (Vision Service Plan) Chiropractic Services Diagnostic Lab, X-ray and Imaging Durable Medical Equipment, Prosthetics and Orthotics End-Stage Renal Disease Services Home Health Services Hospice Hospital Care Short-Term Skilled Nursing Home Care Surgery Therapy Care Transplants Treatment for Sexually Transmitted Diseases Weight Reduction Federally Qualified Health Center (FQHC), Adolescent Health Centers, Tribal Health Centers Services Covered by MIChild But Not by UnitedHealthcare Community Plan Services Not Covered by MIChild Outreach Services Your Child s UnitedHealthcare Community Plan or the MIChild Helpline Children s Special Health Care Services (CSHCS) and Family Hotline Domestic Violence Substance Abuse and Addictions Mental Health Member Rights Member Responsibilities Grievance/Appeal Fraud, Waste and Abuse Support and Information Resources Michigan 3

8 Welcome to UnitedHealthcare Community Plan Thank you for choosing UnitedHealthcare Community Plan. We have put this handbook together for you. Please read it and make sure you know how UnitedHealthcare Community Plan works and how to get your child s FREE health care benefits. This is your child s key to UnitedHealthcare Community Plan as a new Member. This handbook, plus the UnitedHealthcare Community Plan MIChild Certificate of Coverage (COC) will tell you about: UnitedHealthcare Community Plan HMO FREE covered services UnitedHealthcare Community Plan doctors and providers Your child s benefits Your child s coverage Your child s rights and responsibilities If you have questions about the UnitedHealthcare Community Plan or the MIChild program covered benefits after reading this handbook, call our Customer Service department at If you have new ideas for UnitedHealthcare Community Plan, please let us know. We want to know what is important to you and your child. Tell us how we can help your child with new and improved services. If you need help reading this handbook, need it in another language or in an alternate format for your special needs, let us know so we will be able to get it for you. You can look at this Member Handbook, our Provider Directory and other information about this program on our website at UnitedHealthcare Community Plan may not cover all of your child s health care expenses. Read this MIChild Member Handbook and MIChild Certificate of Coverage carefully to find out which health care services are covered. Again, welcome! We are happy to have your child as part of our UnitedHealthcare Community Plan family. 4 MIChild Member Handbook

9 Common Terms What does it mean? Terms Action or Denial Beneficiary Benefits Covered Services Family Practice and General Practice Doctors Formal Appeal Grievance HMO Internal Medicine Doctors Medically Necessary Member Nurse Practitioner OB/GYN PCP Pediatricians Physician s Assistant Referral UM Decision UnitedHealthcare Community Plan Provider or Specialist Description A UnitedHealthcare Community Plan decision to deny or limit authorizations, services or payment A person determined eligible by the State of Michigan for the MIChild Program Health care services provided by Michigan MIChild Medically necessary health care services and benefits Doctors trained to treat adults and children A request to review a UnitedHealthcare Community Plan adverse determination or denial of payment A complaint submitted on behalf of a Member Health Maintenance Organization. A health plan where a PCP manages all your child s health care needs Doctors trained to treat adults The services, equipment or supplies necessary for the diagnosis, care or treatment of a Member s physical or mental condition according to accepted medical practices and standards A MIChild Program beneficiary enrolled with UnitedHealthcare Community Plan A registered nurse who has advanced training and certification Doctors trained to treat women Primary Care Provider (your child s personal doctor) Doctors trained to treat children and young adults A health professional who assists doctors When your child s PCP sends them to a specialist for a covered service UnitedHealthcare Community Plan decisions made with set criteria * See Utilization Review Policy and Procedures on page 11 for more detail Doctors, hospitals, pharmacies or other medical service providers your child must use for health care See the MIChild Certificate of Coverage for more definitions and details. Michigan 5

10 The Basics What is UnitedHealthcare Community Plan? UnitedHealthcare Community Plan is a Health Maintenance Organization (HMO). We offer health care services to Members eligible for Michigan MIChild and who are enrolled in UnitedHealthcare Community Plan. What Does UnitedHealthcare Community Plan Give My Child? With UnitedHealthcare Community Plan, your child will have a personal doctor to work with for FREE health care needs. Your child s personal doctor is called a Primary Care Provider or PCP. Your child will get most of their care from their PCP. The PCP will give your child the care they need or send them to a UnitedHealthcare Community Plan provider or specialist. UnitedHealthcare Community Plan provider or specialist are doctors, hospitals, labs, pharmacies, and other medical professionals who work together with UnitedHealthcare Community Plan to make sure your child gets the best care. UnitedHealthcare Community Plan may not pay for services your child gets if they did not have them approved by their PCP first or UnitedHealthcare Community Plan first. Your Child s Eligibility Your child must be eligible for the MIChild program to be enrolled with UnitedHealthcare Community Plan. If you find UnitedHealthcare Community Plan is not the right health plan for your child, you can change your child s health plan within the first 90 days of enrollment. After the first 90 days, your child is required to remain with UnitedHealthcare Community Plan for 12 months from the date of enrollment as long as your child is MIChild eligible. If You Move Out of the UnitedHealthcare Community Plan Area If you move out of the UnitedHealthcare Community Plan service area, you must contact MIChild for help in choosing a new MIChild health plan for your child. Keep in Touch Call MIChild right away if your name, address or phone number changes. Then call UnitedHealthcare Community Plan and let us know too. That way we can keep in touch to give you important information about your child s health benefits. 6 MIChild Member Handbook

11 Your Child s UnitedHealthcare Community Plan MIChild ID Card Every Member of UnitedHealthcare Community Plan will get a UnitedHealthcare Community Plan MIChild ID card. Carry your child s UnitedHealthcare Community Plan ID card with you at all times. Your child s UnitedHealthcare Community Plan ID card will have their name, Member ID, MIChild Number, date of birth, effective date of coverage and their PCP s name and telephone number on it. Call the UnitedHealthcare Community Plan Customer Service department and ask for a new UnitedHealthcare Community Plan ID card if: You do not get a UnitedHealthcare Community Plan ID card for every child enrolled in the MIChild Program The information on your child s UnitedHealthcare Community Plan ID card is wrong Your child s UnitedHealthcare Community Plan ID card is lost, stolen or damaged When you use your child s UnitedHealthcare Community Plan ID card, you agree to give UnitedHealthcare Community Plan access to information to manage your child s health care and process claims. Health Plan (80840) Member ID: Member: SUBSCRIBER BROWN MIChild Number: PCP Name: DR. PROVIDER BROWN PCP Phone: (999) Payer ID: Rx Bin: Rx Grp: ACUMI Copay: OFFICE/SPEC/ER/UrgCare Rx PCN: 9999 $0/$0/$0/$0 Effective Date Deductible: $0 99/99/9999 MIChild 0501 Administered by UnitedHealthcare Community Plan, Inc. In an emergency go to nearest emergency room or call 911. Printed: 07/26/11 This card does not guarantee coverage. For coordination of care call your PCP For Members: TTY 711 Vision: For Providers: Medical Claims: Pharmacy Claims: Prescription Solutions, PO Box 29044, Hot Springs, AR For Pharmacists: Michigan 7

12 UnitedHealthcare Community Plan Customer Service Department It is important to us that you have someone to turn to for help with any questions. When you call the UnitedHealthcare Community Plan Customer Service department, our staff is ready to help you. If you speak a language other than English, we can get a translator to help on the phone. UnitedHealthcare Community Plan Customer Service Will Help You Find out what services are covered Learn about UnitedHealthcare Community Plan education programs Select or change your child s PCP If you have a problem getting your child s health care If you have an idea about how to make UnitedHealthcare Community Plan better Set up a visit to get your child s well child care and immunizations Learn how to get care with specialists, hospitals and pharmacies Learn about your child s Rights and Responsibilities If you have a problem or question about your child s health, call their PCP. If you need to know about your child s health care benefits, call us, we are here to help. If You Get a Bill As a UnitedHealthcare Community Plan Member, there are no copays or deductibles for covered services. If you receive a bill, do not throw it away. First, call the doctor, hospital, or other health care provider and make sure that they know your child is a UnitedHealthcare Community Plan Member. Tell them to send the bill to UnitedHealthcare Community Plan or call us for help. UnitedHealthcare Community Plan Toll free telephone 24 hours a day, 7 days a week Northwestern Highway, Suite 400 Southfield, MI MIChild Member Handbook

13 How UnitedHealthcare Community Plan Works Your Child s Personal Doctor (PCP) At UnitedHealthcare Community Plan, your child s personal doctor is the key to all health care. Your child s personal doctor is their Primary Care Provider or PCP. Most of their care will be given or arranged by their PCP. Call your child s PCP when you have a question or when they need care. See your child s PCP first for any care they need. Your child s PCP s phone number is on their UnitedHealthcare Community Plan MIChild ID card. If your child has an urgent problem, you can reach their PCP 24 hours a day, 7 days a week. Choosing Your Child s PCP There are several kinds of doctors who may be PCPs: Pediatricians Who treat children and teens Family practice and general practice doctors Who treat adults and children Internal medicine doctors Who treat adults Nurse practitioners Physician assistants You may pick the PCP for your child. If you did not pick a PCP for your child, one was chosen for you. You should pick a family practice PCP or pediatrician for your children under 18 years old. These PCP s have training to care for children. You can look at UnitedHealthcare Community Plan MIChild Provider Directory at to find a PCP or call us and ask for a copy. A UnitedHealthcare Community Plan Customer Service Representative can help find a PCP near your home, who speaks your language or has office hours that are best for you and your child. If your child has a chronic health condition like diabetes or end stage renal disease, you may be able to have a specialist take care of them as their PCP. Call us and we will help. If you choose a PCP in a hospital clinic or a health center, your child s medical records will be in one place but your child may not always see the same PCP. There are also certain health centers where your child might be seen by a resident doctor (a doctor who has finished medical school and is taking special training). Michigan 9

14 How UnitedHealthcare Community Plan Works (cont.) Changing Your Child s PCP We want you to be happy with your child s PCP. We want your child s PCP to know your child and any medical needs they have. If you want to change your child s PCP, the UnitedHealthcare Community Plan Customer Service department will help you. When you change your child s PCP, you will get a new UnitedHealthcare Community Plan ID card with the new PCP s name and phone number on it. It is important that you, your child, your child s PCP and other UnitedHealthcare Community Plan providers have a good relationship. You will all need to work with each other well so your child can get the medical care they need. You need to set up and follow your child s medical plan together. If you do not follow your child s medical plan with your child s UnitedHealthcare Community Plan providers, we can: ask you to select a new PCP for your child, select a new PCP for your child or ask your child s PCP to find a new UnitedHealthcare Community Plan provider for your child. If your or your child s non-compliant behavior continues, we may request that the Department disenroll your child from UnitedHealthcare Community Plan. UnitedHealthcare Community Plan Doctors If you want to know how UnitedHealthcare Community Plan chooses doctors and checks their credentials, call us or write to ask for more details. Visiting Your Child s PCP It is important that you set up a visit for your child to meet their PCP and to transfer records from their old doctor. Let your child get to know their PCP and let them get to know your child. Then, when your child gets sick, their PCP will be able to give them better care. To set up a visit, change a visit or cancel a visit with your child s PCP, call the phone number on your child s UnitedHealthcare Community Plan ID card. Take your child to see their PCP when they become a UnitedHealthcare Community Plan Member. Then set up a visit once each year even if your child is not sick. Your child s well-visit will help you and your child s PCP know about any health problems before they get serious. Be Part of Your Child s Good Health Work with your child s PCP or other UnitedHealthcare Community Plan providers to improve their health. Talk to your child s doctors about any care they need. When you are active in your child s health plan, you build strong relationships with their doctors. Let them know if your child has problems or if your child s health changes. Keep notes and take them with you to your child s next visit. Share your concerns and ask questions. 10 MIChild Member Handbook

15 New Medical Ideas UnitedHealthcare Community Plan regularly reviews new technology. UnitedHealthcare Community Plan covers new medical treatments and medicines after we review information aboutits safety and effectiveness. UnitedHealthcare Community Plan doctors and pharmacists review requests for new medical treatment and medicines. We review scientific evidence from medical literature to help decide whether UnitedHealthcare Community Plan should approve the use of the equipment, procedure or medicine. Utilization Review Policy and Procedures UnitedHealthcare Community Plan has policies and steps we follow in decision making about approving medical services. We want to make sure that the health care services provided are medically necessary, right for your child s condition and are provided in the best care facility. UnitedHealthcare Community Plan makes sure that quality care is delivered. The criteria used in UnitedHealthcare Community Plan decision-making are available to you and your child s doctor if you ask for it. No UnitedHealthcare Community Plan employee or provider is rewarded in any way for not giving your child the care or services they need or for saying that your child should not get them. A UM (Utilization Management) Decision is when UnitedHealthcare Community Plan looks at the appropriateness, medical need and efficiency of health care services, procedures and facilities against our set criteria. Included may be: discharge planning, concurrent planning, pre-certification, approval in advance and clinical case appeals. Also, it may cover proactive processes like concurrent clinical review, peer review and appeals from a provider, payer or patient/member. Prior Authorization In some cases, your child s PCP or specialist must get UnitedHealthcare Community Plan approval first by showing us that the service or equipment for your child is medically necessary and right for their condition. This is called a prior authorization. Quality Improvement Program UnitedHealthcare Community Plan has a quality improvement (QI) program to give your child quality health care and great customer service. UnitedHealthcare Community Plan Board of Directors is responsible for our QI program. The UnitedHealthcare Community Plan QI program makes sure that UnitedHealthcare Community Plan sets goals and takes action to improve how we are doing. If you would like more information about UnitedHealthcare Community Plan QI program or our progress toward our goals, call us and ask. Michigan 11

16 How UnitedHealthcare Community Plan Works (cont.) Health Screenings Health Screenings are physical exams and tests done by a doctor or other medical professional. Periodic medical exams may include a review of your child s medical history, a physical exam and special testing. Health screenings are important because they may find problems before your child feels sick or has serious life-threatening complications. For more information about health screenings and a recommended schedule, visit our website or call us. Case Management Program UnitedHealthcare Community Plan Case Management program has nurses to help high-risk, very sick Members with their health care needs and services. Our nurse case managers can help in certain areas like pediatrics, pregnancy, and kidney disease. Our nurse case managers can help your child get the care they need with your child s PCP. We want your child to be healthy and stay out of the emergency room (ER) and hospital. Disease Management Getting your child well and helping your child stay that way is one of our goals. That s why we offer programs to help our Members who have chronic illnesses or who are pregnant. If your child is living with a chronic illness or is pregnant, call us for more information. How UnitedHealthcare Community Plan Pays Our Providers UnitedHealthcare Community Plan pays our PCP s and specialists every time they see one of our Members. This is known as fee-forservice. We pay our hospitals and all other types of providers in the UnitedHealthcare Community Plan network the same way. They get paid each time they care for one of our MIChild Members. UnitedHealthcare Community Plan never holds back any payment to any of our providers for giving too much service. If you have any questions about these arrangements, call us. 12 MIChild Member Handbook

17 When Your Child Needs a Specialist Specialist Services When your child s PCP sends them to see a specialist, it is called a referral. Your child s PCP will select the UnitedHealthcare Community Plan specialist. If you think your child s doctor is not sending them to a specialist you think they need, call us. For most specialty services, you will need to work with your child s PCP before they get care. Some specialist s services your child s PCP may refer them to are: Cardiologist services Oral surgeon services ENT (ears, nose and throat) services Orthopedic services Ophthalmologist services Home health services Endocrinologist services Self-Referral Services Most of the time you will work with your child s PCP first when they need medical care. But there are some kinds of care that you can set up for your child without being sent by their PCP. These are called self-referral services. UnitedHealthcare Community Plan self-referral services are listed below with the pages where they are discussed in this Member Handbook. UnitedHealthcare Community Plan providers must be used for all self-referral services. Vision services (pg. 24) Young women s health care (GYN) services (pg. 15) Pregnancy (OB) services (pg. 15) Pediatric services (pg. 17) Chiropractic services (pg. 24) Out-of-Plan Specialty Services Sometimes Members need to see a very specialized type of doctor. Your child s PCP will work with UnitedHealthcare Community Plan to get approval in advance, to find the specialist or service for them even if the provider is not a UnitedHealthcare Community Plan doctor. If your child sees a specialist without being sent by their PCP, you may have to pay the bill. Always work with your child s PCP first for any services they need. Michigan 13

18 Your Child s Health Care Services Young Adults UnitedHealthcare Community Plan wants your child to get the care they need to stay healthy. Your child should see their PCP regularly not just when they are sick. See your child s PCP at least once a year for a wellvisit checkup. Your child s PCP may: Check their blood pressure Check their blood sugar (for diabetes if they are at risk) Check their height and weight Give them a breast exam to screen for cancer (for young women) Give them a Pap smear to screen for cancer or sexually transmitted diseases (for young women) Advise them about substance abuse and mental health Talk with them about: Healthy eating The risks of tobacco use Family planning Quitting smoking Weight control Other things to keep them healthy 14 MIChild Member Handbook

19 Young Women s Health Young Women Young women may see any UnitedHealthcare Community Plan OB/ GYN for well woman care without being sent by their PCP. Young women who are sexually active should have a Pap smear every three years to screen for cervical cancer. Young women, ages 16 19, who are sexually active should have a Chlamydia test every year to screen for this sexually transmitted disease. Women s Health and Cancer Rights Act Women s health benefits include breast reconstruction services if elected after a mastectomy. Family Planning Family planning is an important part of staying healthy. Your child s PCP or a Family Planning Center can help plan when to have children. You can also get information and prescriptions for birth control like condoms and birth control pills. Family Planning Centers can teach your child about sexually transmitted diseases and give other tips for staying healthy. A Healthy Pregnancy Pregnant Members may see any UnitedHealthcare Community Plan OB/GYN for obstetrical care without being sent by their PCP (Maternity-prenatal, delivery, post-partum). If you think your daughter may be pregnant, see her PCP or a UnitedHealthcare Community Plan OB/ GYN right away. It is important to start prenatal care in the first 12 weeks. Your daughter should see her PCP or UnitedHealthcare Community Plan OB/ GYN throughout her pregnancy. Make sure she goes to all her visits when her PCP or UnitedHealthcare Community Plan OB/GYN tells her to. Make sure she goes to her doctor right after she has her baby for postpartum follow-up care (between days after her baby is born). If your daughter is still enrolled with UnitedHealthcare Community Plan when the baby is born, contact MIChild to find out if the baby is eligible for MIChild or another program. The DCH rules for MIChild do not allow a newborn to be covered under the mother s MIChild program automatically. You can call your child s PCP s or UnitedHealthcare Community Plan OB/GYN office anytime, day or night; 24 hours a day, 7 days a week. Your child s PCP or OB/GYN will help them get the best care. Michigan 15

20 Young Women s Health (cont.) Healthy First Steps If your daughter is pregnant, UnitedHealthcare Community Plan has a FREE program just for her and her baby. It is called Healthy First Steps. Your daughter and her growing baby are important to us. We want her to have a healthy pregnancy and healthy baby. UnitedHealthcare Community Plan has a special prenatal case manager to work with her and her doctors to make sure she and the baby get the care they need. The Healthy First Steps program can help teen mothers-to-be. Your daughter s prenatal case manager can: Help her set up prenatal care visits Help her find a doctor for her new baby Help her stay healthy Help her with special needs while she is pregnant Help her find out about: childbirth classes counseling services Find baby items and clothes and give her information about what to expect while she is pregnant Keep in touch with her and her doctor if she has any health problems It is good to get early and regular prenatal care and to keep all her visits with her doctor even if this isn t her first baby. Call to learn more! 16 MIChild Member Handbook

21 Children s Health Children and Teens Children need to see their PCP too. Well-child checkups and immunizations are an important part in your child s health. Well-child care is important for anyone through the age of 18. The PCP can help keep your child or teen healthy. You may self-refer your child or teen to any UnitedHealthcare Community Plan pediatrician. Take your child or teen to their PCP at least once every year even if they are not sick for a wellchild visit! The best way to keep your child or teen healthy is to take them to their PCP for well-child checkups at the following ages: 1 14 days 2 months 4 months 6 months 9 months 12 months 15 months Then once every year from age 2 18 years Babies need checkups more often during their first year they need a total of six visits! If your child is chronically ill, they may be able to get special services through Children s Special Health Care Services (CSHCS) and Family Hotline. See Outreach Services, page 28 for more details. Well-Child Care Includes Your child or teen should see their PCP regularly. Remember to always reschedule any missed appointments as soon as possible. UnitedHealthcare Community Plan provides these important well-child services to Members through the age of 18: Immunizations (shots) to help prevent measles, mumps and other illnesses Lab tests (including blood lead level by age and risk) Physical exams with a full health history (physical and mental health development) Health education to give you information about healthy lifestyles and activity and how to avoid accidents and diseases (including help for parents and guardians) Checkups (exams) by a nurse or doctor Eye exams and eyeglasses (if needed) Diet evaluation and counseling Developmental and speech evaluations Height, weight and blood pressure checks Follow-up care for any problems found during exams Other health care, as needed Developmental assessment Parent education Fluoride varnish treatments Michigan 17

22 Children s Health (cont.) Immunizations (Shots) UnitedHealthcare Community Plan wants to help you keep your child healthy. During the first years of their life, you should take your child to the doctor every few months for well-child care. They will get their immunizations or shots that protect them from diseases. UnitedHealthcare Community Plan will pay for your child s shots it won t cost you any money. It is up to you to schedule the appointment and take your child for these shots. Your child s doctor can help you set up regular visits so your child gets all their shots. 18 MIChild Member Handbook

23 Blood Lead Poisoning Lead poisoning is dangerous to your child s health. If you live in an older home (built before 1978), your child may have a higher chance of lead poisoning. Blood lead tests can be part of regular care by your child s PCP. The test may only require a simple finger stick and one or two drops of blood. Michigan 19

24 Urgent, Emergency and Out-of-Area Care After-Hours Care Your child s PCP is available 24 hours a day, 7 days a week. Call your child s PCP at the number listed on their UnitedHealthcare Community Plan ID card for help anytime. Your child s PCP will call you back or have another doctor call you. Urgent Care If your child needs care, but it is not life threatening, call their PCP. Your child s PCP may be able to see them or direct them to the nearest UnitedHealthcare Community Plan Urgent Care Center. Examples when your child may need urgent care are: Ear aches Back pain Headache Flu Colds Coughs Sore throat Minor illness or injury Minor cuts Emergency Care Emergency care is life-threatening medical care that is needed right away. Emergency room services may only be used for treatment of a serious medical condition resulting from injury, sickness, or mental illness which arises suddenly and requires immediate care and treatment (generally within 24 hours of onset) to avoid jeopardy to your child s life or health. Examples of emergencies are: Chest pain Severe breathing problems or choking Severe wound or heavy bleeding Poisoning Broken bones Sudden loss of feeling or not being able to move A young woman in labor Severe pain in their stomach A serious accident Strong feeling that they might kill themself or another person Fainting or a severe dizzy feeling Severe spasms/convulsions Throwing up blood Miscarriage (when a pregnant young woman loses her baby) Damage to their eyes 20 MIChild Member Handbook

25 What to Do in an Emergency Situation If your child has an injury or sudden illness, call their PCP and follow the instructions you are given. If your child has an emergency condition, go directly to the nearest emergency room. Some medical emergencies require help by a trained professional right on the spot if your child is unconscious or cannot be easily moved. When minutes are at stake, emergency personnel can get to them faster than you can get them to a hospital. If you call 911, stay on the phone. Don t hang up until you are told to do so. The 911 operators will send police, firefighters, or ambulances, and can give you instructions on what to do until help arrives. In an emergency room, the hospital will give your child care to stabilize their emergency condition. Your child can not be moved to another hospital unless you agree to it and they are stabilized. If the hospital your child goes to, in an emergency, can not offer them the best care or the specialist they need is not available, the hospital may ask you to let them move your child some place else. They must give your child care to reduce any risk to their health (and the health of an unborn child if they are pregnant) and give medically supervised transportation. If your child goes to a non-unitedhealthcare Community Plan hospital, we may ask to have them moved, when they are stable, to a UnitedHealthcare Community Plan hospital. When your child is at a UnitedHealthcare Community Plan hospital, they can still get care with their PCP and UnitedHealthcare Community Plan doctors. If your child goes to an emergency room and is told to call their PCP instead, call and set up a visit. If you need help to do this, call the UnitedHealthcare Community Plan Customer Service department. If you are not sure if your child has an emergency, call their PCP first. Follow-Up Care Call your child s PCP after they are seen in any urgent care center or emergency room, even if they are out of the area. Call or have someone else call your child s PCP within 24 hours of the emergency. Your child must see their PCP for any follow-up care. Out-of-Area Care If your child has a health emergency when they are out of town or out of state, UnitedHealthcare Community Plan will cover the costs. Give the name and phone number of your child s PCP to the emergency room staff. Emergency If your child has a medical emergency while they are not in Michigan, take them to the nearest emergency room. Non-Emergency If your child needs non-emergency care while traveling outside of Michigan, call your child s PCP or UnitedHealthcare Community Plan Prior Authorization Department in order to obtain a Prior Authorization. Call your child s PCP if they get care from another doctor or hospital. All follow-up care must be arranged by your child s PCP. Michigan 21

26 Covered Services UnitedHealthcare Community Plan covers medically necessary services when you and your child s PCP arrange their care. Your child is covered for: Physician charges for office, nursing home, and clinic visits and consultations for the diagnosis and treatment of an injury, illness or disease Surgery* Blood and blood storage when the Enrollee donates in preparation for scheduled surgery Cataract surgery and first lens implant(s) Technical surgical assistance when an intern, resident, or house officer is not available or qualified Inpatient* and outpatient medical care Anesthesia and oxygen* Treatment of accidental injuries if treated within 48 hours of injury Emergency medical treatment Family planning services Termination of pregnancy when determined medically necessary to save the life of the mother, or in cases of rape and/or incest* Inpatient* consultations including outpatient consultations Diagnostic and therapeutic EKG, x-ray, radium, isotope and radiation therapy Diagnostic laboratory and x-ray examinations including CAT, MRI, MRA, and PET scans Allergy testing Dermatology Peritoneal services and Hemodialysis services* Acupuncture services* Hearing services Dental/oral surgery services Chemotherapy Professional ambulance service for a trip to or from the hospital, skilled nursing facility, or home* Allergy extract and extract injection Papanicolaou (PAP) test once every 12 consecutive months Physical, occupational and speech therapy* Contraceptive devices requiring a prescription or physician insertion/removal* First contact lens obtained within one year of cataract surgery Chelation therapy for certain diagnosis* Eye and ear examinations for the diagnosis of an illness or injury Pain management Hypodermic syringes or needles prescribed by an attending physician Blood lead testing *May need to be approved in advance by UnitedHealthcare Community Plan. 22 MIChild Member Handbook

27 Your child is covered for these FREE services without being sent by their PCP: Obstetrical care with any UnitedHealthcare Community Plan OB/ GYN (prenatal and postpartum care) or certified nurse midwife Well-woman care from any UnitedHealthcare Community Plan OB/GYN Pediatrician visits by children age 18 and under to any UnitedHealthcare Community Plan pediatrician Certified nurse midwife services Certified pediatric and family nurse practitioner services Eye exams (every 12 months) Eye glasses (every 24 months), unless there is a prescription change Chiropractic care (24 visits every calendar year) Prescription Drugs When a UnitedHealthcare Community Plan doctor gives your child a prescription, take it to any UnitedHealthcare Community Plan pharmacy and show them your child s UnitedHealthcare Community Plan ID card. Prescription medicines are FREE to your child as a UnitedHealthcare Community Plan Member. You never have a copay. You will need a written prescription from your child s PCP or UnitedHealthcare Community Plan specialist to have their prescription filled. To find a UnitedHealthcare Community Plan Pharmacy, look in the UnitedHealthcare Community Plan Provider Directory, go to our website at or call us. For your child s safety, we urge you to select a single pharmacy to get your child s drugs from. You should get to know the pharmacist and build a relationship. If the UnitedHealthcare Community Plan pharmacy tells you they can not fill your child s prescription or that you have to pay, do not leave the pharmacy until you ask for details and do not pay for it yourself. As a UnitedHealthcare Community Plan Member, your child s medicine is free! Ask them to call UnitedHealthcare Community Plan or your child s doctor. You may need a prior authorization or another medication that is covered. If it is too soon for your child to get a re-fill, they can tell you when it is OK to come back and get it. UnitedHealthcare Community Plan uses a formulary also called a Preferred Drug List for your child s prescription coverage. A formulary is a list of medicines that a health plan will cover. Having a formulary helps your child s doctor prescribe medicines for them. New drugs and forms of treatment are being introduced every year, and UnitedHealthcare Community Plan adds drugs to its formulary as needed. For a copy of the formulary, call us or go to see it. Most medicines used by UnitedHealthcare Community Plan Members are included in our formulary. There are both brand name and generic drugs on the formulary. UnitedHealthcare Community Plan requires that generic drugs be used when available. If a specific medication is not listed on the formulary, your child s doctor may request it through the UnitedHealthcare Community Michigan 23

28 Covered Services (cont.) Plan prior authorization process. Talk to your child s doctor, pharmacist or our Customer Service department if you have any questions about the UnitedHealthcare Community Plan Drug Formulary. If your child is a new Member and they are already taking a medicine that is not listed on our formulary, you can call our Customer Service department. Your child may be able to get an interim supply of medicine until they can see their new UnitedHealthcare Community Plan doctor or get another drug. Vision Services VSP (Vision Services Plan) ( ) Your child does not need to be sent by their PCP for FREE routine eye services. Eye exams, designer type frames (Altair eyewear) and prescription lenses are covered when your child sees a UnitedHealthcare Community Plan-VSP vision provider. UnitedHealthcare Community Plan has easy to use vision services. VSP provides all routine vision services to UnitedHealthcare Community Plan Members. At a VSP office, your child will get all the services they need. Your child can get their exam, designer type frames (Altair eyewear) and lenses at a onestop, easy to use office. To find the VSP office near you, call the VSP Member Services Department Monday Friday from 9 a.m. to 9 p.m. or visit them at To get your child designer type frames, ask for Altair eyewear. UnitedHealthcare Community Plan covers routine vision services that include: Routine eye exams, every 12 months Frames and lenses are covered every 24 months, unless there is a prescription change Replacements are covered in some circumstances If your child selects a frame not covered by UnitedHealthcare Community Plan, you are liable for the difference in cost Some special features on frames or lenses may not be covered Contact lenses when medically necessary to correct visual impairment when glasses are insufficient to do so Non-routine eye exams for the treatment of a medical eye condition are covered. UnitedHealthcare Community Plan contracts with VSP so your child can get their vision services. If your child is a diabetic, it is important that they have a dilated eye exam every year to screen for conditions that could cause blindness. UnitedHealthcare Community Plan covers an eye exam every year for our Members with diabetes. Chiropractic Services Chiropractic care visits from any participating chiropractor for up to 24 visits every calendar year. Diagnostic Lab, X-ray and Imaging Your PCP will set up any medically necessary lab work, x-rays, and imaging. 24 MIChild Member Handbook

29 Durable Medical Equipment, Prosthetics and Orthotics Special services such as durable medical equipment, prosthetics and orthotics, and other medical supplies when ordered by the Member s PCP and authorized in advance by UnitedHealthcare Community Plan are Covered Services when provided by a Participating Durable Medical Equipment (DME) Provider. UnitedHealthcare Community Plan reserves the right to require use of the least costly medically effective durable medical equipment and prosthetic or orthotic devices. Equipment that is not conventional or not medically/clinically necessary as determined by us, or if for the convenience of the Member or caregivers will not be covered. We may substitute one type of brand of DME for another when the items are comparable in meeting your child s medical needs. All maintenance and repairs that result from misuse or abuse are your responsibility. The decision to rent, purchase, repair or replace DME is up to UnitedHealthcare Community Plan at our discretion. Coverage for DME is limited to one piece of same use equipment. We will cover the repair or replacement fitting and adjustment required as a result of normal use, body growth or body change. We will not cover replacement of lost DME. Equipment must be appropriate for home use. End-Stage Renal Disease Services Your child s PCP and specialist will set up all medically necessary end stage renal disease services, like dialysis. Home Health Services Home Health Services are covered up to 120 days per calendar year for Members who need follow-up medical care after being discharged from the hospital or who have a serious ongoing medical condition. Visiting nurses perform the medical services in the home. Your child s PCP or specialist can get this kind of care set up. Hospice Hospice is medical care for people who are terminally ill. If your child needs Hospice care, talk to your child s PCP to get it set up. Hospice is covered up to 210 days (two periods of 90 days and one period of 30 days). Hospital Care Unless it is a life-threatening emergency, your child s PCP will decide if they need hospital care. Your child s PCP will arrange in advance for their hospital stay when necessary. Orthopedic shoe inserts are covered when prescribed by a physician. Michigan 25

30 Covered Services (cont.) Short-Term Skilled Nursing Home Care Your child s PCP will decide and work with you and your family if your child needs shortterm skilled nursing home care. Your child s PCP will make all the arrangements in advance when necessary. Your child is covered for 120 days per admission with a 90-day lapse in between admissions. Surgery Unless it is a life-threatening emergency, your child s PCP will set up in advance any surgery they may need. Second surgical opinions are covered. Therapy Care Physical therapy, occupational therapy, and speech therapy are covered when set up by your child s PCP. Therapy Care is limited to a combined maximum of 60 visits per calendar year. Transplants Some Members need to have an organ or tissue transplant. Your child s PCP and specialist will manage their transplant when medically necessary and approved in advance by UnitedHealthcare Community Plan. Treatment for Sexually Transmitted Diseases Your child should get treatment for sexually transmitted diseases as soon as possible. Talk to your child s PCP, OB/GYN or family planning center about preventing, testing and treating sexually transmitted diseases. Weight Reduction Weight loss counseling is covered for morbid obesity when prescribed by a UnitedHealthcare Community Plan provider and delivered by a UnitedHealthcare Community Plan provider. Federally Qualified Health Center (FQHC s), Rural Health Centers (RHC s), Child and Adolescent Health Centers (CAHC s), Tribal Health Centers (THC s) Your child can go to any FQHC, RHC, CAHC, or THC without being sent by their PCP even if it is not a UnitedHealthcare Community Plan provider. You will not have an extra copay. 26 MIChild Member Handbook

31 Services Covered by MIChild But Not by UnitedHealthcare Community Plan These services are covered through MIChild but UnitedHealthcare Community Plan does not cover them Mental Health/Substance Abuse Dental services Services provided by a school district Services Not Covered by MIChild These services are not covered by MIChild Elective abortions Routine transportation Inpatient and Outpatient Mental Health and Substance Abuse services Experimental procedures, treatment plans or medications Elective or cosmetic surgery, unless medically necessary Services from a doctor or other health care provider who is not a UnitedHealthcare Community Plan provider (Except when your child is sent by their PCP and it is approved in advance by UnitedHealthcare Community Plan) Services for treatment of infertility Michigan 27