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«Member Handbook UWV-MHB-0003-14 12.14 Dear Member: Welcome to UniCare Health Plan of West Virginia, Inc.! This is your member handbook. Here, you ...»

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UniCare Health Plan of West Virginia, Inc.

Member Handbook

UWV-MHB-0003-14 12.14

Dear Member:

Welcome to UniCare Health Plan of West Virginia, Inc.! 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 doctor

• How you can contact a case manager for help with an ongoing health issue

• Your member 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 unicare.com/medicaid. 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 1-800-782-0095 (TTY: 1-866-368-1634), 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 doctors near your new home. You also can find the Provider Directory online at unicare.com/medicaid.

Get one-on-one help. Our ommunity Resource enter (R) sounds pretty formal, but it’s really just an office where you can talk to our staff. Drop by or call any time during business hours. The friendly staff is ready to serve you.

UniCare Health Plan of West Virginia, Inc.

1207 Quarrier St., First Floor Charleston, WV 25301 1-888-611-9958 You also can call our 24-hour nurse help line, 7 days a week at 1-888-850-1108 (TTY: 1-800-368-4424).

We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

unicare.com/medicaid UniCare Health Plan of West Virginia, Inc., ® Registered mark of WellPoint, Inc.

UWV-MHB-0003-14 WV MHB ENG 12.14 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 doctors.

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 the UniCare Customer Care Center at 1-800-782-0095. 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.

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 1-800-782-0095 (TTY: 1-866-368-1634), Monday through Friday from 8 a.m. until 6 p.m.

Sincerely, Tadd Haynes Director, Medicaid Field Operations UniCare Health Plan of West Virginia, Inc.

Table of Contents Introduction – How to get health care when you need it

Part 1 – Important things to do

Part 2 – Important phone numbers

Part 3 – Benefits quick reference guide

Part 4 – How to use your health plan

Part 5 – What UniCare covers

Part 6 – What UniCare does not cover

Part 7 – What Medicaid covers

Part 8 – Emergency and urgent care services

Part 9 – Your prescription drug benefits

Part 10 – Programs to help keep you healthy

Part 11 – Help with special services

Part 12 – How to resolve a problem with UniCare

Part 13 – If we can no longer serve you

Part 14 – Other things you need to know

Part 15 – Your member rights and responsibilities

Part 16 – Definitions

Part 17 – Notice of Privacy Practices

Introduction – 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 1-888-850-1108 (TTY: 1-800-368-4424). 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 • ut or wound that won’t stop bleeding

• Major injuries

• Possible broken bones unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

When you need urgent care now:

1. Call your PCP. Ask if you can get in right away.

2. Call the 24-hour nurse help line 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?

–  –  –

unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

• Your ID card lists your primary care provider (PCP). Check that the PCP listed is the one you want. A PCP is a provider who will be your main doctor. 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.

• 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 doctor 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.

• all your PP before you get medical care, unless you have an emergency; Your doctor’s office will help you set up a time for care. If you need a ride to and from your doctor 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.

• If you are not sure what to do, you can call MedCall, the 24-hour nurse help line. Have your UniCare ID card ready when you call. The nurse will ask for your ID card number.

Utilization Management/Prior Authorization (UniCare) 1-866-655-7423 Call this number for help with services that need an OK from UniCare before you receive the care.

–  –  –

TTY lines are only for members with hearing or speech loss.

unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

Copays Under your plan, you may have to make copays for some services. 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.

–  –  –

You will have no copays for the rest of the quarter once your household meets its copay maximum. We will send you a letter telling you when you reach your copay maximum. You also may self-attest (report to us) that you have met the copay maximum. Call the Customer Care Center at 1-800-782-0095 (TYY 1-866-368-1634) when you meet your copay maximum. Keep all your household copay receipts to show that you have met the copay maximum.

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.

–  –  –

unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

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 emergency services (includes 3-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 unicare.com/medicaid We can translate this for you at no cost. Call the Customer Care Center at 1-800-782-0095.

If you have speech or hearing loss, call the TTY line at 1-866-368-1634.

–  –  –

Your UniCare member 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 PP’s name, phone number and address  Uniare’s name, address and toll-free phone number  The phone number for MedCall (the 24-hour nurse help line)  The phone number for vision care 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 PP’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.

What is a primary care provider (PCP)?

Your UniCare member ID card has the name, phone number and address of the 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. Your PCP does not work for UniCare, but agrees to see our members.

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 doctor’s office and treats you, within limits)  Internist unicare.com/medicaid

–  –  –

A PCP also can be a clinic such as a:



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