Member Handbook Mountain Health Trust West Virginia Health Bridge

Transcription

1 Member Handbook Mountain Health Trust West Virginia Health Bridge UWV-MHB

2 Member Handbook Mountain Health Trust and West Virginia Health Bridge (TTY ) UWV-MHB

3 Important Phone Numbers: Name Description Phone Number Behavioral health care Any mental health care concern (TTY ) Behavioral health (mental health/substance use disorder) Sometimes, dealing with all of the tasks of a home and family can lead to stress. Stress can lead to depression and anxiety. It can also lead to marriage, family and/or parenting problems. Stress can also lead to alcohol and drug abuse. If you or a family member is having these kinds of problems, you can get help. Call the UniCare Health Plan of West Virginia, Inc. Customer Care Center at (TTY ). You can also get the name of a behavioral health specialist who will see you if you need one. Your benefits include many medically needed services, such as: Inpatient mental health care Outpatient mental health care and/or substance abuse treatment Mental health rehabilitative treatment services You don t need a referral from your PCP to get these services or to see a behavioral health specialist in your network. If you think a behavioral health specialist does not meet your needs, talk to your PCP. He or she can help you find a different kind of specialist. There are some treatments and services your PCP or behavioral health specialist must ask UniCare to approve before you can get them. Your doctor will be able to tell you what they are. If you have questions about referrals and when you need one, contact the Customer Care Center at (TTY ). UWV-MEM

4 Dear Member: Welcome to! This is your member handbook. Here, you will find: How your health plan works Which services are covered and which are not How you can get help understanding your benefits How you can get help if you have a problem with your plan or provider How you can contact a case manager for help with an ongoing health issue Your rights and responsibilities How we keep your information private Free extra benefits to help keep you healthy You should have already received your UniCare member ID card. Your ID card lists your primary care provider (PCP). If you want to change your PCP, you can choose one from the UniCare provider directory at. Just give us a call or send us the PCP Selection Form found at the back of this book. If you have not yet received your member ID card, please call our Customer Care Center toll free at (TTY ) Monday through Friday from 8 a.m. until 6 p.m. Tell the Department of Health and Human Resources (DHHR) if you move. If you move, call your Department of Health and Human Resources (DHHR) caseworker. We may still be your health plan if you stay in state. Call us to get a provider directory with a list of providers near your new home. You also can find the provider directory at. Get one-on-one help. Call or drop by our office in Charleston to talk with our staff. The friendly staff is ready to serve you. 200 Association Drive, Suite 200 Charleston, WV You also can call our 24-hour nurse help line, 7 days a week at (TTY ). UWV-MHB WV MHB ENG 11.16

5 Nurse case management and social worker services UniCare has nurse case managers and social workers to assist you with your health care needs. They can help you set health goals. They can help make sure you are seeing the right providers. Our social workers will also help you find assistance for housing, food and utilities. To enroll in case management or to speak with a social worker, call our Customer Care Center at Press option 1 for case management. Make sure you use providers in the UniCare network Unless it is an emergency, you must use providers in our network. If no one in our network can give you the care you need, your PCP will get an OK from us to send you to a provider that is not in our network. For emergency or urgent care, you do not need to get an OK from us at all. You do not need an OK from us or need to be referred by your PCP to get family planning care. You may go to any qualified family planning provider. UniCare is happy to offer access to health care services throughout West Virginia, except Cabell and Wayne counties. If you have any questions, or if you need this translated or in another format such as Braille, large print or audio at no cost to you, please call our Customer Care Center toll free at (TTY ) Monday through Friday from 8 a.m. until 6 p.m. Sincerely, Mitch Collins Health Plan President UWV-MHB WV MHB ENG 11.16

6 200 Association Drive, Suite 200 Charleston, WV (TTY ) Table of Contents How to get health care when you need it...1 Let a nurse help you decide what to do...1 Deciding where to go urgent care center or emergency room?...1 Urgent care center...1 Emergency room...1 How to get health care fast...1 Important STEPS to remember...9 Important phone numbers...10 Benefits quick reference guide...12 Mountain Health Trust benefits...12 West Virginia Health Bridge benefits...13 Copays...14 Getting to know your health plan...16 Your UniCare member ID card...16 What is a primary care provider?...17 Initial health assessment...18 Provider directory...19 Getting a second opinion...24 What UniCare covers...25 What UniCare does not cover...38 What West Virginia MEDICAID covers...39 Emergency and urgent care services...39 What is an emergency?...39 Post-stabilization...40 What to do when you need urgent care...40 Your prescription drug benefits...40 Programs to help keep you healthy...45 Healthy Rewards...45 For women...45 For you and your child...46 For weight loss and fitness...46 For members with asthma...47 UWV-MHB WV MHB ENG 11.16

7 For peace of mind...47 For tobacco cessation...47 For members with congestive heart failure...47 Disease Management...47 Help with special services...49 How to resolve a problem with UniCare...50 Filing a complaint...51 Grievance and appeals for dental services...55 State Fair Hearing...57 If we can no longer serve you...59 Other INFORMATION you need to know...59 Contacting Customer Care Center...59 If you have other insurance...60 Reporting waste, abuse and fraud...60 Advance directives (living wills)...61 Your rights and responsibilities...64 Definitions...67 Notice of Privacy Practices...70 UWV-MHB WV MHB ENG 11.16

8 HOW TO GET HEALTH CARE WHEN YOU NEED IT Let a nurse help you decide what to do. If you are unsure where to go for care, call our 24-hour nurse help line toll free at (TTY ). A nurse will help you decide which type of care makes the most sense. Plus, you can find out how to treat yourself at home. Deciding where to go urgent care center or emergency room? Urgent care center Go to the urgent care center if you need care right away, but it isn t an emergency. Minor allergic reactions Mild asthma Coughs, sore throat Bumps, cuts, scrapes Rashes, minor burns Sprains, strains Minor fevers, colds Minor headaches Ear or sinus pain Burning with urination Eye swelling, irritation, redness or pain Nausea, vomiting, diarrhea Animal bites X-rays Stitches Emergency room Go to the emergency room right away for: Any life threatening or disabling condition Sudden or unexplained loss of consciousness Chest pain; numbness in the face, leg or arm; difficulty speaking Severe shortness of breath High fever with stiff neck, mental confusion or difficulty breathing Coughing up or vomiting blood Cut or wound that won t stop bleeding Major injuries Possible broken bones How to get health care fast Sometimes, you need health care when your primary care provider (PCP) can t see you. You still have choices. In a true emergency, call 911 or go to the emergency room. UWV-MHB WV MHB ENG 11.16

9 When you need urgent care now: 1. Call your PCP. Ask if you can get in right away. 2. Call our 24-hour nurse help line at and ask a nurse. 3. Go to an urgent care center, like the ones in this handbook. When you visit one of the urgent care centers in this handbook, UniCare will help cover the cost. Before you go, call the center and ask: What are your hours? Do you give the care I need? Urgent care centers EZ Care Ohio Valley Medical Quick EZ Care 324 A/B Penco Road Care, Inc Pike St., Suite 5 Weirton, WV Pike St. Parkersburg, WV Marietta, OH MedExpress Urgent MedExpress Urgent Care MedExpress Urgent Care Care Weirton Parkersburg Huntington 218 Three Springs Drive 1500 Grand Central Ave US Rte. 60 Weirton, WV Suite 115 Huntington, WV Vienna, WV MedExpress Urgent Care MedExpress Urgent Care Teays Urgent Care Wheeling Martinsburg 113 Liberty Square 620 National Road 1355 Edwin Miller Blvd. Shopping Center Suite 300 Suite A Hurricane, WV Wheeling, WV Martinsburg, WV EZ Care Ohio Valley Medical Quick MedExpress Urgent Care 260 Russell Ave. Care, Inc. South Charleston New Martinsville, WV th St Maccorkle Ave. SW Parkersburg, WV S. Charleston, WV MedExpress Urgent Care Braxton Health Associates MedExpress Urgent Care Charleston 617 River St. Elm Grove 5430 Maccorkle Ave. SE Gassaway, WV Elm Grove Crossing Charleston, WV Mall Wheeling, WV UWV-MHB WV MHB ENG 11.16

10 MedExpress Urgent Care Community Care of WV Inc. Whitehall Medical Beckley 11 N. Locust St. 60 Roxbury Road 1709 Harper Road Buckhannon, WV Fairmont, WV Beckley, WV MedExpress Urgent Care Medpointe of Harrison MedExpress Urgent Care Beckley Crossing County Cross Lanes 520 Beckley Crossing Ctr. 469 Emily Drive 5161 Washington St., W. Beckley, WV Clarksburg, WV Cross Lanes, WV Primecare 12 Bridgeport Express Care, MedExpress Urgent Care 702 Stafford Drive Inc. Morgantown Princeton, WV Chenoweth Drive 215 Don Knotts Blvd Bridgeport, WV Suite Morgantown, WV MedExpress Urgent Care MedExpress Urgent Care WVU Fast Care Center Princeton Bridgeport 1075 Van Voorhis Road 277 Greasy Ridge Road 120 Medical Park Drive Suite 100 Princeton, WV Suite 100 Morgantown, WV Bridgeport, WV MedExpress Urgent Care MedExpress Urgent Care Elkins Express Care Lewisburg Bridgeport 1513 Harrison Ave Jefferson St. N Johnson Ave. Suite 18 Suite A Bridgeport, WV Elkins, WV Lewisburg, WV Direct Care of Elkins Health Matters Urgent Care MedExpress Urgent Care 720 Beverly Pike Barton Blvd. S.W. Winchester Gateway Elkins, WV Cumberland, MD Gateway Drive Winchester, VA Direct Care of Parsons Jefferson Urgent Care 307 Main St. Route 340 N. MedExpress Urgent Care Parsons, WV Somerset Blvd. Fairmont Somerset Village Shopping 630 Fairmont Ave. Center Fairmont, WV Charles Town, WV UWV-MHB WV MHB ENG 11.16

11 MedExpress Urgent Care Glen Dale 1585 Wheeling Ave. Glen Dale, WV MedExpress Urgent Care South Parkersburg 2832 Pike St. Suite 1 Parkersburg, WV Emergency rooms Fairmont Regional Medical Center 1325 Locust Ave. Fairmont, WV MedExpress Urgent Care Teays Valley 563 State Route 34 Hurricane, WV Community Care of WV Inc 7576 Seneca Trail Hillsboro, WV Beckley ARH Hospital 306 Stanaford Road Beckley, WV MedExpress Urgent Care Bluefield 4003 College Ave. Suite B Bluefield, VA SE Emergency Physicians 124 Brookshire Lane Beckley, WV Summers County ARH Hospital 1500 Terrace St. Hinton, WV Williamson ARH Hospital 260 Hospital Drive S. Williamson, KY Kings Daughters Medical Center 2201 Lexington Ave. Ashland, KY Bluefield Hospital Company LLC 500 Cherry St. Bluefield, WV Boone Memorial Hospital 701 Madison Ave. Madison, WV Braxton County Memorial Hospital 1088 Hoylman Drive Gassaway, WV Broaddus Hospital One Healthcare Drive Philippi, WV UWV-MHB WV MHB ENG 11.16

12 Buchanan General Hospital CAMC Teays Valley Hospital Camden Clark Memorial 1535 Slate Creek Road 1400 Hospital Drive Hospital Grundy, VA Hurricane, WV Garfield Ave Parkersburg, WV Berkley Medical Center 3500 Hospital Drive Martinsburg, WV Clinch Valley Medical Center 2949 West Front St. Richlands, VA Alleghany Regional Hospital One ARH Lane Low Moor, VA St. Joseph s Hospital 1824 Murdoch Ave. Parkersburg, WV Jackson General Hospital 122 Pinnell St. Ripley, WV Davis Memorial Hospital 812 Gorman Ave. Elkins, WV Hampshire Memorial Hospital 549 Center Ave. Romeny, WV East Ohio Regional Hospital 90 N. 4th St. Martins Ferry, OH Garrett Memorial Hospital 251 N. 4th St. Oakland, MD Grafton City Hospital 1 Hospital Plaza Grafton, WV Grant Memorial Hospital 117 Hospital Drive Petersburg, WV Greenbrier Valley Medical Center 1302 Maplewood Ave. Ronceverte, WV Jefferson Medical Center 300 South Preston St. Ranson, WV Logan Regional Medical Center 20 Hospital Drive Logan, WV Minnie Hamilton Health Care Center 186 Hospital Drive Logan, WV Monongalia County General Hospital 1200 J.D. Anderson Drive Morgantown, WV Monongalia County General Hospital 200 Wedgewood Drive, Suite 104 Morgantown, WV Montgomery General Hospital 401 6th Ave. Montgomery, WV UWV-MHB WV MHB ENG 11.16

13 Plateau Medical Center 430 Main St. Oak Hill, WV Ohio Valley Medical Center 2000 Eoff St. Wheeling, WV Pleasant Valley Hospital, Inc Valley Drive Point Pleasant, WV Pocahontas Memorial Hospital 150 Duncan Road Buckeye, WV Princeton Community Hospital th St. Princeton, WV Roane General Hospital 200 Hospital Drive Spencer, WV Potomac Valley Hospital of WV, Inc. 100 Pin Oak Lane Keyser, WV Raleigh General Hospital 1710 Harper Road Beckley, WV Rockingham Medical Center 2010 Health Campus Drive Harrison, VA Preston Memorial Hospital 150 Memorial Drive Kingwood, WV Reynolds Memorial Hospital 800 Wheeling Ave. Glen Dale, WV Shenandoah Memorial Hospital 759 South Main St. Woodstock, VA Sistersville General Hospital 314 South Wells St. Sistersville, WV Southeastern Ohio Regional Medical Center 1341 Clark St. Cambridge, OH St. Joseph s Hospital One Amalia Drive Buckhannon, WV St. Mary s Medical Center st Ave. Huntington, WV Stonewall Jackson Memorial Hospital 230 Hospital Plaza Weston, WV Summersville Memorial Hospital 400 Fairview Heights Road Summersville, WV Thomas Memorial Hospital 4605 MacCorkle Ave., SW South Charleston, WV Trinity Medical Center East & Trinity Medical Center West 4000 Johnson Road Steubenville, OH United Hospital Center 327 Medical Park Drive Bridgeport, WV UWV-MHB WV MHB ENG 11.16

14 War Memorial Hospital, Inc. One Healthy Way Berkeley Springs, WV Warren Memorial Hospital 1000 Shenandoah Ave. Front Royal, VA Webster County Memorial Hospital 324 Miller Mountain Drive Webster Springs, WV Weirton Medical Center 601 Colliers Way Weirton, WV Welch Community Hospital 454 McDowell St. Welch, WV WVU Ruby Memorial Hospital One Medical Center Drive Morgantown, WV Western Maryland Regional Medical Center Willowbrook Road Cumberland, MD Wetzel County Hospital Three E. Benjamin Drive New Martinsville, WV Wheeling County Hospital One Medical Park Wheeling, WV Williamson Memorial Hospital 859 Alderson St. Williamson, WV Winchester Medical Center 1840 Amherst St. Winchester, VA UWV-MHB WV MHB ENG 11.16

15 Wait times for appointments We want you to be able to get care at any time. When your PCP s office is closed, an answering service will take your call. Your PCP should call you back within 30 minutes. Once you talk to your PCP and set up an appointment, you will be able to see your PCP as follows: Type of appointment Emergency exam Urgent (sick) exam Nonurgent (sick) exam Nonurgent routine exam Specialty referrals Time frame Immediate access during office hours Within 48 hours of request Within 72 hours of request Within 21 days of request Within two weeks for routine referrals; within 24 hours for urgent referrals Travel times for appointments Type of appointment PCP office, pharmacy, and frequently used specialists Basic hospital services Third party services Federally qualified health centers and rural health clinics Travel time 30 minutes or less 45 minutes or less 60 minutes or less 30 minutes UWV-MHB WV MHB ENG 11.16

16 IMPORTANT STEPS TO REMEMBER Keep your UniCare member ID card with you at all times. Show this ID card every time you need health care services. Do not let anyone else use your UniCare ID card. If you choose, you can print your ID card from our member website. Your ID card lists your primary care provider (PCP). Check that the PCP listed is the one you want. A PCP will be your main provider. Your PCP will give you an OK for needed treatment. If you want to change your PCP, call us to let us know right away. Or you can log on to the member website and change your PCP. Set up an initial health assessment (IHA) or a first exam with your PCP as soon as you can. If you are an adult, your first health review should be within 90 days after joining UniCare. A child should be seen by a PCP within 60 days after joining the plan. During the first exam, the PCP can learn about your health care needs and teach you ways to help you stay healthy. If you re an SSI member, you should visit your PCP or specialist who handles your care within 45 days after joining UniCare. If you need help planning the visit, call (TTY ). Call your PCP before you get medical care unless you have an emergency. Your provider s office will help you set up a time for care. If you need a ride to and from your provider visit, call us. You may see a family planning provider, inside or outside of the UniCare network, without an OK from your PCP. If you have an emergency, get help right away. Call 911 or go to the nearest emergency room for health care. You do not need an OK from us for emergency care. It does not matter if you are inside or outside of our service area. You will be covered for emergency care even if the provider is not part of the UniCare network. There is no extra cost to you for emergency services inside or outside of our service area. If you are not sure what to do, you can call our 24-hour nurse help line at Have your UniCare ID card ready when you call. The nurse will ask for your member ID number. UWV-MHB WV MHB ENG 11.16

17 IMPORTANT PHONE NUMBERS Enrollment Broker Call this number to join a new health plan or disenroll from your current plan. UniCare Customer Care Center (CCC) Call this number if you have questions about UniCare, pharmacy, behavioral health, or if you would like to speak to a nurse to enroll in case management UniCare CCC TTY UniCare Office Call this number for help with local resources. Scion Dental Call this number for help finding a dentist or to learn more about your dental benefits. Scion Dental TTY hour nurse help line Call this number to talk in private with a nurse 24/7, even on holidays. 24-hour nurse help line TTY National Poison Control Center Call this number for poison prevention advice and help with treatment. The line is open 24 hours a day, 7 days a week. Utilization Management/Prior Authorization Call this number for help with services that need an OK from UniCare before you receive the care. Vision Service Plan Call this number for help finding an eye doctor or to learn more about your vision benefits. Vision Service Plan TTY UWV-MHB WV MHB ENG 11.16

18 West Virginia Department of Health and Human Resources (DHHR) Call this number if you move, change your phone number or become pregnant. You can also call this number for nonemergency transportation to your provider visit or other covered service. West Virginia Relay Service This number allows people who have a hearing or speech loss to communicate with a trained person who can help them speak with someone who uses a regular telephone. West Virginia Relay Service TTY The TTY number is for members with hearing or speech loss only. UWV-MHB WV MHB ENG 11.16

19 BENEFITS QUICK REFERENCE GUIDE Mountain Health Trust benefits Children (0 up to 21 years ) Ambulatory surgical center services Inpatient services Inpatient hospital care Inpatient rehabilitation Inpatient behavioral health and substance abuse Inpatient psychiatric services Outpatient services Diagnostic X-ray, laboratory services and testing Physical therapy Speech therapy Occupational therapy Behavioral health Physician/NP/NMW/FQHC/RHC services Primary/Preventive care visits Physician office visits Specialty care Podiatry Cardiac and pulmonary rehabilitation Dental services Orthodontics Home health Durable medical equipment Orthotics and prosthetics Family planning services and supplies Hospice Ambulance Prescriptions Chiropractic services Tobacco cessation Diabetes management Skilled nursing Vision Hearing EPSDT (Well-child visits) Behavioral health rehabilitation Residential treatment Psychological services Adults (21 years and older) Ambulatory surgical center services Inpatient services Inpatient hospital care Inpatient behavioral health and substance abuse Outpatient services Diagnostic X-ray, laboratory services and testing Physical therapy Speech therapy Occupational therapy Behavioral health Physician/NP/NMW/FQHC/RHC services Primary/Preventive care visits Physician office visits Specialty care Podiatry Cardiac and pulmonary rehabilitation Dental services (Emergency treatment) Home health Durable medical equipment Orthotics and prosthetics Family planning services and supplies Hospice Ambulance Prescriptions Chiropractic services Tobacco cessation Diabetes management Psychological services UWV-MHB WV MHB ENG 11.16

20 The services below are covered through West Virginia Medicaid, but are not benefits you get from your plan. For information on how to use these services, look at the section of the handbook that explains what West Virginia Medicaid covers. Children (0 up to 21 years) Nursing home services Nonemergency transportation Organ transplant services Abortion Birth to 3 services School-based services Adults (21 years and older) Nursing home services Nonemergency transportation Organ transplant services Abortion *There are additional services to those included on this list. If you have questions on whether a service is covered, look at the services in the covered services section of the handbook or give us a call. West Virginia Health Bridge benefits Children (18 up to 20 years) Adults (21 years and older) Ambulatory surgical center services Ambulatory surgical center services Inpatient services Inpatient services Inpatient Hospital Care Inpatient Hospital Care Inpatient Rehabilitation Inpatient Behavioral Health and Inpatient Behavioral Health and Substance Abuse Substance Abuse Inpatient Rehabilitation Outpatient services Outpatient services Diagnostic X-ray, laboratory services and testing Diagnostic X-ray, laboratory services and testing Physical therapy Physical therapy Speech therapy Speech therapy Occupational therapy Occupational therapy Behavioral health Behavioral health Physician/NP/NMW/FQHC/RHC services Physician/NP/NMW/FQHC/RHC services Primary/Preventive care visits Primary/Preventive care visits Physician office visits Physician office visits Specialty care Specialty care Podiatry Podiatry Cardiac and pulmonary rehabilitation Home health Durable medical equipment Orthotics and prosthetics Family planning services and supplies Hospice Ambulance Cardiac and pulmonary rehabilitation Home health Durable medical equipment Orthotics and prosthetics Family planning services and supplies Hospice Ambulance UWV-MHB WV MHB ENG 11.16

21 Children (18 up to 20 years) Prescriptions Chiropractic services Tobacco cessation Diabetes management Skilled nursing Dental services Psychological services Adults (21 years and older) Prescriptions Chiropractic services Tobacco cessation Diabetes management Skilled nursing Dental services (Emergency treatment) Psychological services Vision Hearing EPSDT (Well-child visits) Behavioral health rehabilitation Residential treatment The services below are covered through West Virginia Medicaid, but are not benefits you get from your plan. For information on how to use these services, look at the section of the handbook that explains what West Virginia Medicaid covers. Nursing home services Nonemergency transportation Abortion Organ transplant services School based services Nursing home services Nonemergency transportation Abortion Organ transplant services *There are additional services to those included on this list. If you have questions on whether a service is covered, look at the services in the covered services section of the handbook or give us a call. Copays Under your plan, you may have to make copays for some services. Copays may apply to West Virginia Health Bridge and Mountain Health Trust members. A copay is an amount you pay when you receive certain services. You are required to pay the copays listed below until you and all family members in your household enrolled in the plan get to the household copay maximum. Your household copay maximum is based on your household income. You are assigned to a tier based on your household size and income for the quarter. Tier Gross quarterly income range Copay maximum Tier 1 $0-$1, $8 Tier 2 $1, $2, $71 Tier 3 $2, and above $143 You will have no copays for the rest of the quarter once your household meets its copay maximum. You also may self-attest (report to us) that you have met the copay maximum. UWV-MHB WV MHB ENG 11.16

22 Call our Customer Care Center when you meet your copay maximum. Keep all your household copay receipts to show that you have met the copay maximum. There are no copays for behavioral health services. You will start each quarter with $0 in copays and build toward your copay maximum. The tables below show the services for which your plan requires copays and the amount of those copays. Total cost of drug Copayment $0.00-$5 $0 $5.01-$10 $0.50 $10.01-$25 $1 $25.01-$50 $2 $50.01 and above $3 Covered service Tier 1 Tier 2 Tier 3 Inpatient hospital care $0 $35 $75 Office visit (physicians and nurse $0 $2 $4 practitioners) Nonemergency use of the $8 $8 $8 emergency room (hospital only) Nonemergent surgical procedures given in a physician s office, ambulatory surgical center or any other outpatient setting excluding emergency rooms $0 $2 $4 These members are excluded and will have no copays: Children under 21 years of age Pregnant women, including pregnancy-related services up to 60 days postpartum Members of a Native American tribe or Alaskan natives Members receiving hospice services Members in nursing homes Members in an intermediate care facility Members receiving services for mental retardation Members getting behavioral health services Members getting emergency services (includes three-day emergency supply of medicine) Members getting family planning services Members getting services through Medicaid waiver programs Members getting services through the Breast and Cervical Cancer Treatment program Members getting services for provider-preventable conditions Members getting diabetic testing supplies, insulin syringes or needles Members getting approved home infusion supplies Members getting vaccines administered at the pharmacy UWV-MHB WV MHB ENG 11.16

23 GETTING TO KNOW YOUR HEALTH PLAN If you have questions about signing up for Medicaid, your local Department of Health and Human Resources (DHHR) can help you. Your UniCare member ID card UniCare has two types of member ID cards. You will either get a Mountain Health Trust or West Virginia Health Bridge ID card. Always carry your UniCare and Medicaid ID cards with you. Show both of these cards to your provider when you go for health care services. Look on your UniCare ID card for the following important information: Your name Your UniCare member ID number The date your UniCare insurance began (also called the effective date) Your PCP s name, phone number and address UniCare s name, address and toll-free phone number The phone number for our 24-hour nurse help line The phone number for vision care services The phone number for dental car services What you should do in an emergency You are the only one who can get health care services with your UniCare member ID card. If you let someone else use your card, you may not be able to stay in our plan. You will get a new UniCare ID card if: You change your PCP Your PCP s address or phone number changes You lose your ID card If you did not get your UniCare member ID card yet, or if you need a new one, please call us right away. Or you can print a copy from the member website. UWV-MHB WV MHB ENG 11.16

24 What is a primary care provider? Your UniCare member ID card has the name, phone number and address of the primary care provider (PCP) you chose or the PCP assigned to you. Your PCP will be your main health care provider. Your PCP works with us, as needed, to connect you to the right provider at the right time and in the right place. UniCare will try to give you a PCP with an office no more than 30 minutes from your home. A PCP can be any of these types of providers: Pediatrician (a doctor who takes care of babies and children) Family and general practitioner (a doctor who takes care of babies, children and adults) Nurse practitioner or physician assistant (someone who works in a provider s office and treats you, within limits) Internist Obstetrician/gynecologist (OB/GYN) Patient-Centered Medical Home The Patient-Centered Medical Home helps you partner with your PCP. They will lead a team of health care providers. These are people like nurse practitioners, nurses, physician assistants, behavioral health providers, dental and eye care providers, physical therapists, pharmacists, and social workers. This group will work with you in all parts of your care. PCPs for pregnant women and newborn babies If you are pregnant, call us right away. If you are in the last trimester of your pregnancy and you just joined our health plan, you may be allowed to stay with your current provider whether that provider is in our network or not. If you re pregnant, you can also get support from our prenatal program, Taking Care of Baby and Me. Read more in the Pregnancy care section. Enrolling a newborn baby and changes to family makeup Any newborn whose mother has UniCare will have UniCare for at least 30 days after birth. As soon as your baby is born, call your Department of Health and Human Resources (DHHR) caseworker or inform the Change Center at If you have not called UniCare to choose a PCP for your baby, you can call us after your baby is born. If you do not choose a PCP for your baby, we will choose one for you. You also should tell UniCare and DHHR about other changes to your family. Call your DHHR caseworker or the Change Center at if: You move You change your phone number You have changes to your insurance The number of people in your household changes (e.g., adoption, death, etc.) You become pregnant UWV-MHB WV MHB ENG 11.16

25 Initial health assessment All new members should see their PCP for an initial health assessment (IHA) within 90 days after joining UniCare. A child should be seen within 60 days after joining. The first meeting with your PCP is important. It s a time to get to know each other and review your health status. Your provider will help you stay healthy. During the IHA, your PCP will: Get to know you and talk about your health Learn your medical history Give you health information you need Teach you ways to help make your health better or to stay healthy Give you the results of your IHA Call your PCP to make an appointment today. Making an appointment with your PCP Call your PCP s office during regular business hours (the phone number is on your UniCare ID card). Let the staff know you are a UniCare member. Have your UniCare member ID card and your Medicaid ID card with you when you call. You may be asked for the member ID numbers on the cards. Your IHA will be scheduled within 21 days from the date you call. You may have to wait longer for preventive care visits (shots and checkups or routine tests and exams). You should receive a routine care appointment within 21 days. You should receive an urgent appointment within 48 hours. Make sure to bring your UniCare member ID card with you when you visit your provider. Be on time for your visits. Call your PCP s office as soon as you can if: You will be late You cannot keep your appointment You should not need to wait more than 45 minutes after you get to your provider s office. Your PCP may not be able to see you if you are late. If you cancel your appointment, someone at your PCP s office can help you set up a new one. Changing your PCP Most of the time, it is best to keep the same PCP, so they can get to know your health needs and history, but you can change your PCP at any time for any reason. If you want to do so, call us or fill out the PCP change form on the member website. We want you to be happy with your PCP. If you want to change your PCP, please note: UWV-MHB WV MHB ENG 11.16

26 When choosing a new PCP, you must choose a provider who will see new patients. We can help you find one. A request to change your PCP may be denied if the PCP you want is not taking new patients. If you choose a PCP who is not taking new patients, we will help you choose another one. It s important to know that when you change PCPs often, your health care may not be as easy as it could be. Your PCP change will be effective on the date the change is made. You can begin seeing your new PCP on the day you ask for the change. You will get a new UniCare member ID card with your new PCP s name on it. It s important to have your medical records sent to your new PCP. UniCare, or your PCP, may ask you to change your PCP if: UniCare no longer works with your PCP You are not able to get along or agree with your PCP You keep making appointments and not showing up for them You are often late for your appointments You are rude or abusive to the staff of UniCare or your PCP s office You disrupt the PCP s office If you choose to go to a provider who is not your PCP, call us first. We will try to make that provider your PCP. We will tell you in writing if we need to change your PCP. Provider directory When you joined UniCare, you may have picked a PCP. If you did not choose a PCP, UniCare can choose one for you. To change your PCP, look through the provider directory and pick one. Call us to let us know your choice or you can change your PCP on the member website. Our provider directory lists the providers who work with UniCare. It also tells you their address, phone number, office hours and languages spoken. You can find our provider directory at. Or call us to request one. Look in the provider directory to find a PCP who is right for you or your family member: PCPs for children are listed under Family Practice, Pediatrics or General Practice. PCPs for pregnant women are listed under Family Practice, Obstetrics and Gynecology or General Practice. You may choose a certified nurse-midwife from the Obstetrics section. PCPs for adults are listed under Family Practice, Internal Medicine or General Practice. You need to choose a PCP who is taking new patients. You can learn more about this in your provider directory or call us at (TTY ) Monday through Friday from 8 a.m. until 6 p.m. If you need help finding a PCP who is taking new patients, call us. To find out more about a provider (such as the provider s specialty, medical school background, residency training or board certifications), visit these websites: UWV-MHB WV MHB ENG 11.16

27 West Virginia Board of Medicine at American Medical Association (AMA) at Click the DoctorFinder button American Board of Medical Specialties (ABMS) at Click on Consumers If you want help, you may call the West Virginia Board of Medicine at or call us. Prior authorization for health care services Your PCP will manage your health care needs and may send you to a different provider if you need special care. Your PCP will talk with you about the best way for you to get the care you need. If you don t get an OK when it is required for a service, you will have to pay for the cost of the service. Some types of care do not need an OK from your PCP: Family planning OB/GYN care from UniCare providers Emergency care Vision carebehavioral health care Your PCP may need to get a prior authorization (approval) from us for some services for us to pay for them. You will need an OK from Scion Dental for some dental services. To get an OK from us, both UniCare and your PCP or specialist, agree that the services or care you get is medically necessary. Medically necessary means that items or services that have been given or will be given to a patient are needed to treat a medical condition and are not mainly for the ease of the patient, provider or other health care provider. Examples are: To find the cause of an illness or treatment of illness or injury To help a body part that is not normal work better To prevent illness To help a child or young adult meet the right growth and development levels Services that require an OK from us include but are not limited to: Inpatient and outpatient hospital care Surgery, including outpatient ambulatory surgical care All infusion therapies CT, MRI, MRA, PET, special X-rays and tests Organ transplants High cost and custom-made durable medical equipment like crutches, wheelchairs, special beds, etc. UWV-MHB WV MHB ENG 11.16

28 Cataract glasses and lenses; this can also include surgery to remove a cataract and insert a lens Hearing aids and services that have to do with hearing aids Getting an OK will take no more than seven calendar days, or if urgent, no more than three working days. See What UniCare covers to check service limits. Your PCP can tell you more about this. We may ask your PCP why you need to see a specialist. We may not OK the care you or your PCP requests. We will send you and your provider a letter explaining why we would not cover the care you ask for. The letter also will tell you how to appeal. You can get this member handbook in other formats, such as Braille, by calling us. If you have questions, you or your provider can call our Customer Care Center at (TTY ). Some types of care do not need an OK from your PCP: Family planning OB/GYN care from UniCare providers Emergency care Vision care Behavioral health services Court-ordered care UniCare will reimburse providers for court-ordered treatment services covered by UniCare under the Medicaid State Plan. The court order would be the reason for the service to be medically necessary. Routine care Routine care is the regular care you get from your PCP, such as checkups, to help keep you healthy. You can call your PCP to make an appointment for routine care. UniCare will try to give you a PCP with an office no more than 30 minutes from your home. The hospital you go to for basic care should be no more than 45 minutes from your home. Urgent care A medical condition is urgent if it is not an emergency but should have medical care within 48 hours. Call your PCP if you have an urgent medical condition. If you cannot reach your PCP: Call us at , 8 a.m. to 6 p.m. Call our 24-hour nurse help line at A nurse can answer your questions in private and help you with self-care. In an emergency, call 911 right away. The 24-hour nurse help line is not meant to replace the medical advice of your provider. UWV-MHB WV MHB ENG 11.16

29 After-hours care You can reach your PCP at the number on your UniCare ID card. After normal business hours, leave your name and phone number with the answering service. Either your PCP or an on-call provider will call you back. You also can call the 24-hour nurse help line. Out-of-area care You never know when or where you will get sick or injured. That s why UniCare asks you to carry your UniCare ID card with you at all times. UniCare can still help if you get sick when you are outside of the UniCare service area. If you are outside of the UniCare service area and your problem is not an emergency or you are not sure if it is, call: Your PCP at the number on your UniCare member ID card UniCare at Our 24-hour nurse help line at If you think you have an emergency, call 911 or go to the nearest emergency room. UniCare covers emergencies anywhere in the United States at no extra cost to you. You are not covered for services received outside the United States. Do not use an emergency room for routine care. UniCare does not cover emergency room visits for routine care, whether the visits are made inside or outside our service area. Pregnancy care Call us when you know you are pregnant. Our staff will make sure that your provider and hospital are with UniCare. If you re pregnant, you can also get support from our maternity program, Taking Care of Baby and Me. This program is for you if you are going to be a new mom. It is part of your health benefits and costs you nothing. When you are pregnant, you will get: A prenatal packet that includes a booklet and brochures to help you learn about pregnancy and childbirth A phone survey to find out if there are risks to you or your baby The chance to join health classes to learn about care and child care A postpartum packet with a booklet on infant care, postpartum depression and reminders on seeing your provider for checkups Information on rewards you can earn for attending prenatal and postpartum visits UWV-MHB WV MHB ENG 11.16

30 Please note that state law makes sure that you get your first prenatal care visit. It requires that your provider fit you into their schedule as follows: If you are in your first trimester (months one, two or three), your provider must make your office visit within 14 calendar days from the date you call. If you are in your second trimester (months four, five or six), your provider must make your office visit within seven calendar days from the date you call. If you are in your third trimester, (months seven, eight or nine), your provider must make your office visit within three business days from the date you call. Your first visit allows your provider or other pregnancy provider to begin checking your pregnancy as soon as possible. So don t forget to make this office visit. If you think you have a high-risk medical problem that will affect your pregnancy, ask your provider if you can be seen right away. We want to make sure you get the best care for you and your baby. Family planning Family planning can help teach you how to: Be as healthy as you can before you become pregnant Keep from getting pregnant Keep you from getting diseases Any member (including minors) may see a licensed family planning provider without getting an OK from UniCare first, even if the provider isn t in the UniCare network. Licensed family planning providers could be: Clinics OB/GYNs PCPs Certified nurse-midwives Specialist care Your PCP may send you to a specialist for special care or treatment. Your PCP will work with you to choose the specialist to give you the care you need. Your PCP s office can help you make the appointment. Your PCP must send an OK to the specialist before he or she can give you care. Tell your PCP and the specialist as much as you can about your health, so that all of you can decide what is best. You should receive a routine appointment to see a specialist within three weeks of the request. You should receive an urgent specialist appointment within 48 hours of the request. Call us to let us know about seeing the same specialist each time without an OK first. The Utilization Management (UM) nurses at UniCare may OK a number of visits with the same specialist without your PCP setting up each visit. UniCare will try to find you a specialist with an office no more than 30 minutes from your home. UWV-MHB WV MHB ENG 11.16

31 Standing referrals This is a type of referral that may allow you to see the same specialist without getting an OK for each visit. You may need a standing referral if: You have a health problem that needs special medical care over a long period of time. Your health problem: Puts your life at risk Gets worse over time Keeps you from doing all the things that healthy people can do Creates the need for your care to be managed by your specialist in the same care center If you have trouble getting a standing referral, call us. If, after you call, you still believe that your needs have not been met, please see How to resolve a problem with UniCare. You will need an OK from us to see a specialist. You will need our OK if the provider is inside or outside of our network. If you don t get our OK, you may have to pay for the treatment. If we don t approve the specialty services, we will send you a letter telling you why. We ll also tell you how you can appeal if you do not agree with us. This is a summary of the UniCare specialist referral policy. Call us for a full copy of our policy. Getting a second opinion You might have questions about your illness or the care your PCP says you need. You may want to get a second opinion from another provider. You should speak to your PCP if you want a second opinion. You or your PCP also may ask us for help. You must get services from a provider within our network. If there is no provider in our network that fits the care you need, we will let you get a second opinion from a provider outside our network. Getting a second opinion is helpful if: You have questions about a surgery your PCP says you need You have questions about finding the cause or treatment for an ongoing problem or a health issue that could cause death If you think your problem could greatly weaken you or cause loss of a limb or body function Your PCP s advice is not clear or is hard for you to understand Your PCP is unable to find the cause of your condition, or the PCP isn t sure because test results aren t the same The treatment you are getting has not helped your medical problem within the time frame it should You have tried to follow the treatment plan or talked with your PCP because you are concerned about the cause or the treatment plan You may use the UniCare grievance and appeal process if your PCP or specialist does not allow you to get a second opinion. See How to resolve a problem with UniCare to learn how to file a grievance or appeal. This is only a summary of the UniCare policy on second opinions. You can call us to get a full copy of the policy. UWV-MHB WV MHB ENG 11.16

32 Availability of Utilization Management staff Your PCP and other providers work with you to decide what care is best. We always want you to have the care you need. For some health care services, your provider may have to ask us for our OK. This is so that we will pay for the services. This process is called Utilization Management, or UM for short. You should know that: We make payment rulings based on the care and services you need and the benefits you have We base our rulings on whether or not the care is right for your health issues and is medically necessary. See Definitions to learn more about medically necessary. We do not reward providers or other UM decision-makers for denying requests We do not offer money as a reward to UM decision-makers to push them to give less care WHAT UNICARE COVERS Here are the kinds of care you can get through UniCare. Keep in mind that some of these services must be OK d by your PCP and/or us first. You may have to pay if you choose to receive services that we do not cover. We only will pay for covered care that is medically necessary. If you have questions about how medical decisions are made or would like a copy of our Utilization Management procedures, call our Utilization Management office at The office is open Monday through Friday, 8 a.m. to 5 p.m. You can leave a message if you call after business hours. Call us if you are out of town and need help with an OK for medical care. You also can call us if you have questions about which services are covered. Always carry your UniCare and Medicaid ID cards with you. Behavioral health services You do not need a referral from your PCP to get behavioral health care from UniCare providers. You may go directly to your provider. If you have questions, call us at (TTY ). Behavioral health care includes: Inpatient psychiatric services for children younger than age 21 Outpatient behavioral health and psychiatric services Substance abuse treatment UWV-MHB WV MHB ENG 11.16