UnitedHealthcare Community Plan. Intellectually/Developmentally Disabled Benefits Supplement (TTY: 711) myuhc.com/communityplan KANSAS

Transcription

1 KANSAS UnitedHealthcare Community Plan Intellectually/Developmentally Disabled Benefits Supplement (TTY: 711) myuhc.com/communityplan 953-CST4074 2/ United HealthCare Services, Inc.

2 Important Telephone Numbers Member Services and Care Coordination (8 a.m. to 6 p.m. CST, Monday through Friday) TTY (Hard-of-hearing) Fax /7 NurseLine SM (available 24 hours a day, 7 days a week) TTY Mental Health and Substance Use Disorder Services LogistiCare Transportation Services Non-Emergency Transportation Where s My Ride? Hotline Website myuhc.com/communityplan Address UnitedHealthcare Community Plan Grandview Dr., Suite #200 Overland Park, KS Your Health Providers My Care Coordinator: Phone: My Targeted Case Manager: Phone: Name: Phone: Name: Phone: Emergency Room: Phone: Pharmacy: Phone: If you have questions about your health plan, please call us. Our toll-free Member Services number is (TTY: 711, for the hard-of-hearing). NurseLine SM is a service mark of UnitedHealth Group, Inc. Health plan coverage provided by UnitedHealthcare of the Midwest, Inc. 2 UnitedHealthcare Community Plan Intellectually/Developmentally Disabled Supplement

3 Contents KanCare Intellectually/Developmentally Disabled Benefits...4 Eligible Program Services Guiding Principles for UnitedHealthcare Community Plan I/DD Program...6 Care Coordination...7 The Role of the Care Coordinator...7 Examples of How UnitedHealthcare Community Plan Can Help...7 What if I Have a Problem?...7 Transportation...10 Additional Information...11 Self Advocacy...11 Money Follows the Person...12 Kansas Department of Aging and Disability Services...12 KanCare Ombudsman...13 Grievances, Appeals and State Fair Hearings Member Rights and Responsibilities Additional ID/DD Benefits...8 Value Added Benefits (VAB) for UnitedHealthcare Community Plan of Kansas Members...8 Person-Centered Support Plan...8 Guardianship...9 Kansas 3

4 KanCare Intellectually/Developmentally Disabled Benefits This information is directed at the member. UnitedHealthcare Community Plan is also aware of the important role of the member s support team. Family, guardians or representatives can be a big help in getting the right services, and can use this information to assist in supporting the member. The Home and Community-Based Services Intellectual/Developmental Disability (HCBS I/DD) program is designed to provide critical long term care support services, in the community setting of choice for beneficiaries that would otherwise require institutionalization in an intermediate care facility for an ICF-ID (intermediate care facility for intellectual disabilities). The KanCare HCBS I/DD program is administered by the Kansas Department of Aging and Disability Services (KDADS). Consistent with the Developmental Disabilities Reform Act of 1995 (DDRA), the goals and objectives of the program center around the policy of the State to provide persons who have intellectual and/or developmental disabilities access to services and supports which allow for these persons opportunities for choice that increase their independence, productivity, integration and inclusion in the community. Further, this range of supports and services will be appropriate to each person and will be provided in a manner that affords the same dignity and respect to persons with intellectual or developmental disabilities that would be afforded to any person who does not have a disability. HCBS I/DD goals conform to the Developmental Disabilities Reform Act of 1995 (DDRA). The policy is to provide access to services that allow persons to be more independent. It is to help people with disabilities be a part of the community. It is to help them be more productive. This help is tailored to each person. It is given with dignity and respect. Kancare/UnitedHealthcare Community Plan is managing your HCBS I/DD services. You will be able to keep your same community providers, including your Targeted Case Manager. There are 13 services under the I/DD program. You may be getting some or all of them. They are: Assistive Services Day Supports Financial Management Service (FMS) Medical Alert Overnight Respite Personal Assistant Services (PAS) Residential Supports Sleep Cycle Support Specialized Medical Care Supported Employment Supportive Home Care (SHC) Wellness Monitoring Targeted Case Management (TCM) 4 UnitedHealthcare Community Plan Intellectually/Developmentally Disabled Supplement

5 Eligible Program Services The following services are or may be offered: Assistive Services Something that improves your health, independence, productivity and inclusion in your community. This can be wheelchair modifications, ramps, lifts, modifications to your bathroom and kitchen. This can also be assistive technology to improve communication or mobility. This can be to help you with daily activities at home or at work. Day Supports Regular activities help you take part in your community. They include help in getting and keeping a job, if you want one. Examples of day supports are seeing others, recreation, transportation, education and job skill training. Medical Alert A monitoring system to help you if you have a medical emergency. Overnight Respite This is temporary care for a member when the primary caregiver needs time away. Personal Assistant Services This is available to members who self-direct all or part of their services and: Lives in an adult residential setting. Lives with family. Is 5 to 21 years old and lives with caregivers. Lives with a caregiver who is not a guardian. The Services are to help the person who could do the activity if they did not have a disability. The services can be provided at home or in the community. Some examples are bathing, grooming, feeding, mobility and exercise. They can include shopping, house cleaning, chores, meal preparation, laundry and help with managing money. Residential Supports Services for someone who lives in a residential setting and not with their family. Sleep Cycle Support Overnight help for someone who lives with their family or does not live at a residential facility. The worker giving the service must be immediately available for the member, but can sleep when not needed. The worker could: Call the doctor or hospital. Help in an emergency. Help the member turn over in bed. Help the member use the bathroom. Help with taking medicine at night. Specialized Medical Care This is longterm nursing support for medically fragile and technology dependent members. The level of care is care that would be given in a hospital if the nurse were not with the member. Supported Employment Help to find and hold a job. Supportive Home Care Help with daily living and care for a person living with family or a child age 5 to 21 who does not live with family. Wellness Monitoring Evaluation of a member s health by a nurse to make sure the member is getting the best care. Kansas 5

6 KanCare Intellectually/Developmentally Disabled Benefits (cont.) Financial Management Services (FMS) Provided for beneficiaries who are aging or disabled and will be provided within the scope of the Agency with Choice (AWC) model. Within the self-directed model and Kansas state law (K.S.A. 39-7,100), beneficiaries have the right to make decisions about, direct the provisions of and control the attendant care services received by such individuals including, but not limited to selecting, training, managing, paying and dismissing of a direct support worker. The beneficiary or beneficiary s representative has decision-making authority over certain services and takes direct responsibility to manage these services with the assistance of a system of available supports. FMS is included in these supports. Targeted Case Management (TCM) Services Services that assist individuals in gaining access to medical, social, educational and other services. These services may be provided during a transitional phase from institutional care with the exception of transition from incarceration. The primary intent of TCM services should always be related in some manner to the development, implementation, amendment, and coordination and/or monitoring of a service plan. Guiding Principles for UnitedHealthcare Community Plan Intellectually/Developmentally Disabled Program Providing person centered community support and services to members that would otherwise be institutionalized. Recognize and value the importance to collaborate with the member s current support team which includes the CDDO, CSP, and TCM. Commitment to support the member s preferred lifestyle. You can still access services through the Community Developmental Disability Organization (CDDO). Your CDDO will still determine your eligibility for the I/DD program each year. You can keep your targeted case manager (TCM). You can use the providers you want. Your Plan of Care will still be reviewed yearly by your TCM. It will be updated as your needs change. Any changes or reductions in the plan of care have to be approved by the Kansas Department for Aging and Disability Services (KDADS). You will also keep all of your medical providers. 6 UnitedHealthcare Community Plan Intellectually/Developmentally Disabled Supplement

7 Care Coordination The Role of the Care Coordinator You will get a Care Coordinator from UnitedHealthcare Community Plan of Kansas. The Care Coordinator will work with your TCM on your plan of care. You or your TCM will help make sure you have the services you need. Your Care Coordinator will help you understand your KanCare benefits. He or she will assist with doctor visits and find services. He or she will also help with access to specialists. If you do not have a care coordinator assigned already by UnitedHealthcare, one will be assigned for you when you become an I/DD program member. Our Care Coordinators: Act as a resource to the TCM, the member and the support team. Evaluate the plan of care. Review member status and visit the member in their home or other setting. Help develop an integrated plan of care. Participate in Person Centered Support Plan meeting, or provide input before and after meeting. Arrange access to services and supports. Arrange transitions of care. Examples of How UnitedHealthcare Community Plan Can Help Help to Assess: Do a Health Risk Assessment. Help to identify needs. Identify behavioral health needs. Help to Develop: Person Centered Support Plan (PCSP). Behavioral Support Plan (BSP). Help to Find: Health plan resources. Resources in the community. Help to Manage: Obtain supports to help meet Person Centered Support Plan goals. Connect to community and health plan supports. Help with non-medical issues. Manage complex care needs. Help assess need for any assistive services, including home modifications. Monitoring and Follow-Up: Help with on-going needs. Help with wrap around plans. Help prevent crises. The UnitedHealthcare Community Plan care coordination model is not limited to these items. We work with current I/DD services and supports to improve the outcomes. We want to be a resource to the service system. We try to build strong ties with the I/DD system. We will continue to learn about various roles and how we can help. What if I Have a Problem? You can always call your TCM, community service providers, CDDO or UnitedHealthcare Community Plan of Kansas Care Coordinator. If you cannot resolve your concerns, you can call the KanCare Ombudsman at Kansas 7

8 Additional ID/DD Benefits Value Added Benefits (VAB) for UnitedHealthcare Community Plan of Kansas Members Value added benefits are services that are not covered by KanCare but are offered by UnitedHealthcare Community Plan. In addition to these VAB I/DD services, members can access the VAB s for all UnitedHealthcare Community Plan members. Respite Care: The member must have a direct service worker, either Personal Attendant Services or supported home care. The member is eligible for a maximum of 40 hours per year. You can choose from current I/DD respite providers. The service does not need to be approved by the CDDO. Your Care Coordinator can help you access this benefit. Transportation to Job Related Activities: Members on the I/DD program can get six (6) one-way or three (3) round-trip rides a year to a job interview or to a job. This is to fill the gap with the member s transport plan. The ride will be from the current transportation network. You can reach them by calling the number on the back of your card. You will still get Targeted Case Management from your current TCM. This service has not changed. It is detailed below. Your TCM will still to be your primary contact. You and your TCM can also contact the Care Coordinator for help. The Care Coordinator can help you navigate the UnitedHealthcare Community Plan. He or she can help you understand your KanCare benefits. Definition of Services: Care Coordination services are to help the member get medical, social, educational and other needed services. Targeted Case Management Includes: 1. Assessment. 2. Making a support/care plan. 3. Referral and related activities. 4. Monitoring and follow-up activities. Person-Centered Support Plan Will I Still Have a Person-Centered Support Plan (PCSP)? Yes, your Targeted Case Manager will meet with you and your support team yearly to discuss your goals. Your Care Coordinator would like to be invited to the PCSP meeting to get to know you better. Even if your Care Coordinator does not go to the meeting, they can be a resource before and after the meeting. They can help make sure your needs are being met. 8 UnitedHealthcare Community Plan Intellectually/Developmentally Disabled Supplement

9 The Person-Centered Support Plan (PCSP) is to help you get the support you need to have the lifestyle you want. The PCSP helps put the choice in your hands. The PSCP is made up of: 1. A planning team Your TCM helps you decide who needs to be on your team. This can be family members, people in the community, your Care Coordinator and other people you want involved. 2. A Person-Centered Plan Your plan reflects your needs and lifestyle choices. The plan is built around your wishes. It respects your hopes, dreams and fears. When you help make up your plan, you will need fewer supports. 3. A plan that takes all the time needed to make sure it is right for you. Guardianship Some individuals with I/DD services have a court-appointed or legal guardian. We recognize that your guardian is a vital part of your support team. If you have a guardian they: Can My Guardian or Parent Talk to the MCO About My Services or Care? If you are a minor (under the age of 18), your parent or legal guardian is your main contact for the MCO. If you are an adult with a legal guardian, we may need to verify our ability to speak with them. If you want someone other than a legal guardian to speak with the MCO, you must sign a release. Let your Care Coordinator know of anyone you want to talk with your MCO. Your TCM and service providers do not need a release to talk to us. The guardian should coordinate with the State of Kansas at to ensure they are listed as the responsible person on the member s enrollment file. UnitedHealthcare Community Plan does require the guardian to mail their certification to P.O. Box 8208, Kingston, NY In urgent situations, we could also provide the member with a fax number to a supervisor. Once on file, there should be no need to update the document annually. Must approve all services and medical care. Have the right to make decisions for you with your input. Kansas 9

10 Transportation Transportation Medical transportation is covered for some medical care. If you have no other way to get to the doctor, live in an area with no public transportation or cannot use public transportation due to a health condition or disability, call our Transportation Services (LogistiCare) at Your ride will be comfortable and safe. If you need help, you may bring someone to the appointment to help you. If you are a guardian or are assisting the member, you can also call to set up the ride. Include this information when you call for a ride. How to Schedule a Ride 1. Call LogistiCare at Call at least 3 business days before your appointment. Urgent Care and same day rides are accepted. Rides can be scheduled up to 30 days in advance. 2. Call Monday to Friday from 8:00 a.m. 8:00 p.m. 3. Give them this information: a. The address of your medical provider/appointment. b. If you need a wheelchair lift or a special vehicle. 4. They will ask you for: a. Your ID number (on your member ID card) b. Your first and last name c. The address of your appointment d. Your appointment time and location e. Your date of birth Before You Are Picked Up LogistiCare will call to ask you if you still need a ride. You will then know the name of the company that will be picking you up. When Your Ride Is Late Call if your ride is late. When You Need a Ride Home After Your Appointment Call for a ride home if you did not set up a return time. If You Have a Complaint If you have a complaint about the transportation service, call Member Services at (TTY: 711). LogistiCare also has a website that members can use to schedule rides. Remember to call 911 if you have an emergency. 10 UnitedHealthcare Community Plan Intellectually/Developmentally Disabled Supplement

11 Additional Information Self Advocacy UnitedHealthcare Community Plan Supports Your Right to Advocate for Yourself This information is from the Self Advocate Coalition of Kansas (SACK). What Is a Self Advocate? A person who speaks up for himself or herself and lets others know what he or she thinks. Being a Self Advocate Means Solving problems and making decisions that affect you. Speaking for yourself. Knowing your rights and responsibilities. Contributing to your community. Changes that you or a friend need in your own services and supports. Examples of Problems You Can Have a Voice in: You may need help with your money or banking. You or your friend do not like their job. You are having trouble getting around town. Your friend doesn t like where they live. 4 Steps to Change Make a plan and take action. 1. What is the problem? 2. Who can fix it? Who can make the changes you want? 3. What should I do? Ask for what you want and get support for your idea. 4. Did I get the change I wanted? If not, make changes to your plan and get back to work. If you did get the changes you wanted, CELEBRATE! Advisors to Self Advocates From the Self Advocate Coalition of Kansas If you are an advisor helping a person to be a self advocate, here are some tips: You work for the self advocacy group. Your job is to support the decision of the self advocate. Allow the self advocate to try things for themselves first. They will ask for your help if they need it. Everyone has the right to make mistakes. When making plans, check for understanding from the self advocate. Help the person to understand their rights and responsibilities. The advisor is a positive role model. The advisor helps provide information on resources in the community. The advisor advises on how to run a meeting with caregivers. Ask key questions to check for understanding. Use short words and sentences. Make sure information is easy to understand. Kansas 11

12 Additional Information (cont.) Give advice only when asked or when more information is needed to make a good decision. Help the self advocate when asked or if they need help to make a good decision. A good advisor does not do it all! Know Your Rights and Responsibilities From the Self Advocate Coalition of Kansas You have the right to speak out for yourself. You have the responsibility to be involved in making your support plan. You have the right to be treated with dignity and respect. You have the duty to treat others as you want to be treated. You have the right to make decisions and have responsibilities. You are responsible for your actions. You have the right to be free from abuse, neglect and exploitation. To report suspected abuse, neglect or exploitation, call the Kansas Protection Report Center at Make sure to let your TCM know of any concerns you have about your rights and responsibilities. Money Follows the Person The Money Follows the Person (MFP) program provides MFP services to help a person transition from an Intermediate Care Facility for Intellectual Disability (ICF/ID) or a nursing facility back into the community. The people served by this grant include persons with an Intellectual or Developmental Disability. This is a voluntary program for persons living in institutional settings. If you are getting Home & Community-Based services, you are not eligible for the MFP program. All MFP services require prior authorization (PA). Contact your Care Coordinator to learn more. MFP beneficiaries must live in one of the following MFP Housing Options: 1. Home owned or leased by the beneficiary or beneficiary s relative. 2. Leased apartment or home with lockable egress. The space must include separate living, sleeping, bathing and cooking areas. 3. Community-based residence for no more than four unrelated individuals (I/DD only). Kansas Department of Aging and Disability Services The KanCare HCBS I/DD program is administered by the Kansas Department of Aging and Disability Services (KDADS). KDADS: General Info: Greg Wintle, I/DD Program Manager Greg.Wintle@kdads.ks.gov KanCare: I/DD Program: Visit our website often. We will post videos, answer your questions, update information, and share upcoming events and training sessions. 12 UnitedHealthcare Community Plan Intellectually/Developmentally Disabled Supplement

13 KanCare Ombudsman The KanCare consumer Ombudsman is available to help consumers who receive longterm care and home and community-based services through KanCare with their rights and responsibilities. The Ombudsman can help you: When you need help with a concern or filing a grievance. When you need help with a problem you can t solve by speaking with your KanCare plan. When you do not think that you are getting the care that you need. When you feel your rights are being violated. Call this toll-free number to reach the KanCare Ombudsman: Kansas 13

14 Grievances, Appeals and State Fair Hearings What Is a Grievance? A grievance is an expression of dissatisfaction about any matter other than an Action. Examples include but are not limited to: You are unhappy with the quality of your care. The doctor you want to see is not a UnitedHealthcare Community Plan doctor. You are not able to receive culturally competent care. You got a bill from a provider for a service that should be covered by UnitedHealthcare Community Plan. Rights and dignity. Any other access to care issues. What Should I Do if I Have a Grievance? You or someone acting for you can file a grievance by calling or writing to UnitedHealthcare Community Plan. Call (TTY: 711) or write to: Grievance and Appeals P.O. Box Salt Lake City, UT If you need help writing or filing a grievance, call Member Services at (TTY: 711). If someone else is going to file for you, we need your written permission. If you are a person with disabilities, you may call UnitedHealthcare Community Plan at (TTY: 711) to file a grievance. We will review your grievance and send our decision within 30 days of getting your grievance. We will send you a letter with the decision. What Is an Appeal? An appeal is your request for a review of an Adverse Action. An Action is when we: Deny or limit a service you want; Reduce, suspend or terminate payment for a service you are getting; Fail to authorize a service in the required time; or Fail to respond to a grievance or appeal in the required time. How Do I File an Appeal With UnitedHealthcare Community Plan? You or someone acting for you can file an appeal by calling or writing to UnitedHealthcare Community Plan. Call (TTY: 711) or write to: Grievance and Appeals P.O. Box Salt Lake City, UT You must file your appeal within 30 days from the date you get a Notice of Action. If you need help writing or filing an appeal, call Member Services at (TTY: 711). If you file an appeal, we will send you a letter within 5 business days telling you that we got your appeal. 14 UnitedHealthcare Community Plan Intellectually/Developmentally Disabled Supplement

15 We will review your appeal and send you a decision within 30 business days of getting the appeal. The letter will tell the reason for our decision. We will tell you what to do if you don t like the decision. This letter will be a Notice of Action. Continuation of Care You can ask for services to continue during the appeal. However, you may need to pay for the health service if you continue the service while we are reviewing the appeal and we decide that you should not have received the service. What Can I Do if I Need Immediate Care? If you or your doctor wants a fast decision because your health is at risk, call Member Services at (TTY: 711) for an expedited review. UnitedHealthcare Community Plan will call you with our decision within 3 business days of getting your request for an expedited review. This time may be extended up to 14 days if you ask for this or if we show a need for more information and the delay is in your interest. If we ask for an extension, we will give you written notice of the reason. You will get a letter with our decision and the reason for our decision. We will tell you what to do if you don t like the decision. How Do I File a State Fair Hearing Request? If you disagree with an Action by UnitedHealthcare Community Plan, you or someone acting for you can file for a State Fair Hearing. You file with the Kansas Office of Administrative Hearings (OAH): You may file for a State Fair Hearing at the same time that you appeal to UnitedHealthcare Community Plan. For expedited appeals, you must first exhaust UnitedHealthcare Community Plan s appeal process before requesting an expedited State Fair Hearing. Or instead of appealing to UnitedHealthcare Community Plan, you may file for a State Fair Hearing. You must file for a State Fair Hearing within 30 days from the date you get a Notice of Action from UnitedHealthcare Community Plan. To request a State Fair Hearing, write to: Office of Administrative Hearings 1020 S. Kansas Avenue Topeka, KS The State Fair Hearing request form can be found online at How Do I Request Disenrollment From My Plan? You may choose to disenroll from our plan at any time for cause. If you have questions about this process, please call Member Services at (TTY: 711). Kansas 15

16 Rights and Responsibilities Uphold Member Bill of Rights As a UnitedHealthcare Community Plan member, you have rights and responsibilities. You need to fully understand them. The State of Kansas must ensure that each enrollee is free to exercise his or her rights. Using those rights must not adversely affect the way the health plan and its providers or the State treat the enrollee. Members Have the Right to: Members Have the Responsibility to: Get information about UnitedHealthcare Community Plan, our services and providers per federal and state regulations. Be treated with respect, dignity and privacy by UnitedHealthcare Community Plan personnel and providers. Treatments, tests or procedures must be kept private. Voice concerns about your care, file grievances and appeals about your plan or care and get timely responses. Get information on care options in a way that you can understand, regardless of cost or coverage. Work with your doctor and other caregivers to make decisions about care, including the right to refuse treatment. Be informed of, and refuse, any experimental treatment. Have coverage decisions and claims processed per regulatory standards. Make an advance directive to state the care you wish to get if you are unable to express your wishes. Be free from any form of restraint or seclusion used for coercion, discipline, convenience, retaliation or abuse/neglect/exploitation. Get a copy of your medical records and ask that they be amended. Use any hospital or facility for emergency care. Refuse any care or any service you object to on religious grounds. Give ideas for the rights and responsibilities of members. Be aware of your health issues and set goals for treatment. Know your benefits before getting treatment. Contact a health care provider when you have a medical need. Show your ID Card before getting care. Verify that your provider is in the UnitedHealthcare Community Plan network. Learn about UnitedHealthcare Community Plan procedures. Use ER services only for injury or illness that, if not treated immediately, could pose serious threat to your life or health. Keep your appointments. Provide information needed for your care. Follow the instructions of your providers. Notify Member Services of a change in address, family status or other coverage information. Notify Member Services if your ID Card is lost or stolen. Notify UnitedHealthcare Community Plan if you have a Workers Comp claim, a personal injury or medical malpractice law suit, or have been in a car accident. Never give your ID Card to someone else to use. 16 UnitedHealthcare Community Plan Intellectually/Developmentally Disabled Supplement

17 Notes Kansas 17

18