«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 ...»
Health department Federally qualified health center (FQHC) Rural health clinic (RHC) 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 doctor whether that doctor is in our network or not.
When you call us, we will sign you up for our prenatal program, Taking Care of Baby and Me.
It will help you learn how to take care of yourself while you are pregnant. You will get a prenatal packet that includes a booklet on planning a healthy pregnancy and a postpartum packet after you deliver your baby.
You may even qualify for gift card rewards when you attend your prenatal visits and after you complete your postpartum exam on time. Your baby also may qualify for rewards for completing well-child checkups. We also can help you choose a PCP for your baby.
Enrolling a newborn baby 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) case worker or inform the Change Center at 1-877-716-1212.
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 if:
You change your phone number.
You have changes to your insurance.
The number of people in your household changes.
You become pregnant.
UWV-MHB-0003-14 WV MHB ENG 12.14 Initial health assessment (IHA) All new members should see their PCP for an initial health assessment within 90 days after joining UniCare. A child should be seen within 60 days after joining. The first meeting with your PP is important; It’s a time to get to know each other and review your health status; Your doctor 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 all your PP’s office during regular business hours (the phone number is on your Uniare 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 and your Medicaid ID card with you when you
visit your doctor; e on time for your visits; all your PP’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 doctor’s office; Your PCP may not be able to see you if you are late. If you cancel your appointment, someone at your PP’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. We want you to be happy with your PCP.
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.
UWV-MHB-0003-14 WV MHB ENG 12.14
If you want to change your PCP, please note:
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 is 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 Uniare member ID card with your new PP’s name on it;
It is 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 Uniare or your PP’s office.
You disrupt the PP’s office.
If you choose to go to a provider who is not your PCP, call us first. We will try to make that doctor 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.
Our Provider Directory lists the doctors who work with UniCare. It also tells you their address, phone number, office hours and languages spoken. You can find our Provider Directory at unicare.com/medicaid. 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. If you need help finding a PCP who is taking new patients, call us.
UWV-MHB-0003-14 WV MHB ENG 12.14 To find out more about a doctor (such as the doctor’s specialty, medical school background,
residency training or board certifications), visit these websites:
West Virginia Board of Medicine at www.wvdhhr.org/wvbom American Medical Association (AMA) at www.ama-assn.org Click the DoctorFinder button American Board of Medical Specialties (ABMS) at www.abms.org Click on Consumers If you want help, you may call the West Virginia Board of Medicine at 1-304-558-2921, or call us.
Prior authorization (An OK from UniCare) 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.
Your PCP may need to get an OK 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, doctor or other health care provider.
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 patient 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 and SPECT Organ transplants High cost and custom-made durable medical equipment. These might be crutches, wheelchairs, special beds, etc.
Cataract glasses and lenses. This can also include surgery to remove a cataract and insert a lens 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.
Getting an OK will take no more than 14 calendar days, or, if urgent, no more than three working days. See Part 5 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 doctor requests. We will send you and your doctor 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 letter in other formats, such as Braille, by calling us. If you have questions, you or your provider can call our CCC at 1-800-782-0095.
UniCare Health Plan of West Virginia, Inc.
P.O. Box 91 Charleston, WV 25321-0091 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 care 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 1-800-782-0095, 8 a.m. to 6 p.m. If you have hearing or speech loss, call our TTY line at 1-866-368-1634.
Call our 24-hour nurse help line at 1-888-850-1108. If you have hearing or speech loss, you may call the TTY line at 1-800-368-4424. 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 doctor.
Out-of-area care You never know when or where you will get sick or injured. That is 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 1-800-782-0095 (TTY: 1-866-368-1634).
Our 24-hour nurse help line at 1-888-850-1108 (TTY: 1-800-368-4424).
If you think you have an emergency, call 911 or go to the nearest emergency room. UniCare covers emergencies anywhere in the United States.
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 doctor and hospital are with UniCare. We will sign you up for our maternity program, Taking Care of Baby and Me®.
This program is for you if you are going to be a new mom; It’s part of your health benefits and
it’s at no charge to you; 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 doctor for checkups.
Information on gift card rewards you can earn for attending prenatal and postpartum visits.
UWV-MHB-0003-14 WV MHB ENG 12.14 Please note that state law makes sure that you get your first prenatal care visit. It requires that
your doctor fit you into their schedule as follows:
If you are in your first trimester (months one, two or three), your doctor 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 doctor 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 doctor must make your office visit within three business days from the date you call.
Your first visit allows your doctor 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 doctor if you can be seen right away. We want to make sure you get the best care for you and your baby.
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