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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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OK from UniCare first. This includes providers who are not part of the UniCare network, such as:

 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 PP’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 Standing referrals This is a type of referral that you may only need once and allows 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.

 Makes it that you need your care 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 Part 12 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 doctor. 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 doctor within our network. If there is no doctor in our network that fits the care you need, we will let you get a second opinion from a doctor 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 PP’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 may use the UniCare grievance and appeal process if your PCP or specialist does not allow you to get a second opinion. See Part 12 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.

Availability of Utilization Management (UM) 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 doctor 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 Part 16 Definitions to learn more about medically necessary.)  We do not reward doctors 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.

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.

–  –  –

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 PP 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, call our Utilization Management office at 1-866-655-7423. 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.

Abortion An abortion ends a pregnancy. Your doctor will discuss this procedure with you if it is medically necessary. Your doctor needs to tell us in writing that the procedure is medically necessary.

We cover:

 Procedures to end the pregnancy if medically necessary.

 Medical actions needed to end an ectopic pregnancy.

Chiropractic services Chiropractors help keep the spine and other body parts straight.

We cover:

 Treatment to correct a partial dislocation  X-rays


We cover up to 24 visits per year.

Clinic services Copays may apply.

Services from clinics (that are not part of a hospital):

 Health clinics  Birthing centers  Lab and radiology centers  Health department clinics unicare.com/medicaid

–  –  –

We cover:

 Doctor services  Nurse practitioner and physician assistant services  Vaccines (shots) for children  Supplies  Visiting nurse care in certain shortage areas Dental services for children Routine dental services are for children under age 21.

We cover medically needed dental services for children under age 21. These services are provided by Scion Dental. (Scion is an independent company that provides dental benefits on

behalf of UniCare). Dental services may be given by a:

 Dentist or oral surgeon  Orthodontist  Periodontist

We cover:

 Diagnostic services  Preventive treatment  Restorative treatment  Endodontic treatment  Periodontal treatment  Surgical procedures and/or extractions  Orthodontic treatment (Orthodontic services will be covered for the entire time of treatment even if the child is no longer eligible.)  Complete and partial dentures including partial denture relines and repairs  Oral and maxillofacial surgery services  Adjunctive general services such as injectable medications

We do not cover:

 Experimental or investigational services  Cosmetic procedures  Dental services for the member’s convenience or the convenience of the member’s caretaker If you need help finding a dentist, please call Scion Dental at 1-877-408-0917 (TTY 1-800-508-6975). You also can see the list of dentists in the network by visiting unicare.com/medicaid.

Your dentist will need to get approval from UniCare for some services. This means both UniCare and your dentist agree the services are medically needed. Getting an approval will take no more than 14 calendar days, or if urgent, no more than three calendar days. Your dentist can tell you more about this. We may ask your dentist why you need this care. We may not approve the service you or your dentist asks for. We will send you and your dentist a letter that tells you why we would not cover the service. The letter also will let you know how to appeal our decision.

If you have questions about your child’s dental benefits, you can call Scion Dental at 1-877-408-0917 (TTY: 1-800-508-6975).

Dental services for adults We cover emergency dental services for adults 21 years of age and older. These services may

be given by a:

 Dentist  Oral surgeon

We cover:

 Treatment of fractures of the upper or lower jaw  Biopsy  Removal of tumors  Removal of a tooth when it is an emergency  General anesthesia for dental procedures when medically necessary because the:

- Member has a developmental disability

- Member has other medical conditions that may complicate the dental work


We do not cover temporomandibular joint (TMJ) surgery and treatment for adults. We cover adult emergency dental services through Scion. If you are not sure you have a dental emergency or if you have questions about emergency dental services, you can contact Scion at 1-877-408-0917.

DME, supplies and prosthetic devices given by a doctor are covered when they are medically necessary. You may need an OK ahead of time from us for some of these items.

We do not cover:

 Equipment and supplies only used for exercise  Equipment and supplies only used for making a room or home more comfortable, such as:

- Air conditioners

- Air filters

- Air purifiers

- Spas

- Swimming pools

- Elevators  Hygiene and beauty supplies  Experimental or research equipment  More than one piece of equipment that does the same thing Part Early and Periodic Screening, Diagnostic and Treatment (EPSDT) These services also are called well-visits. These visits are free for enrolled members under 21 years of age; These include screenings needed for your child’s PP to understand any medical needs. During these visits, the PCP will complete a physical exam and a complete health and developmental history. Vaccines (shots) are part of these visits.

We cover:

 Hearing  Vision  Dental exams  Nutritional needs  Health care, treatment and other actions to correct or improve any medical condition found during an EPSDT screening  Routine shots and immunizations  Lab tests, such as:

- Urinalysis

- Hemoglobin/hematocrit

- Tuberculin test (for high-risk groups)

- Blood lead testing !sk your child’s PP when you should bring your child back for the next EPSDT checkup.

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 Family planning We cover these types of care to help you if you plan to have a family, want to know how to avoid getting pregnant or want to know how to protect yourself against sexually transmitted

infections (STIs):

 Family planning, education and counseling  Medical visits for birth control  Annual cervical cancer screenings  Pregnancy tests  Lab tests  Tests for sexually transmitted infections (STIs)  Screening, testing, counseling, and referral for treatment for members at risk for human immunodeficiency virus (HIV)  Sterilization (see exceptions below)  Prescriptions for oral contraceptives, diaphragms, injectable contraceptives and emergency contraception.

We do not cover:

 Sterilization for members under 21 years of age  Sterilization for members who live in inpatient facilities  Treatment for members who cannot get pregnant Hysterectomy and abortion are not considered family planning services. You do not need to get an OK from your PCP for family planning care. Members may use any licensed family planning clinic or provider. The provider does not have to be part of our network. If you choose to see a family planning provider who is not part of our network, let your PCP know the important medical information from these appointments so you can get the best health care. Your family planning provider and your PCP will work together to make sure you get the right care.

Family planning records are kept private. Doctors should keep all family planning records private, even if the patient is a minor, unless the law says it is OK. Your doctor is allowed to share your medical information with other doctors who take care of you, public health officials or government agencies. UniCare is not responsible for the privacy of medical records held by providers who are not part of our network.

Home health services These are visits to your home to give you care for certain illnesses or injuries only. You must get our OK for these types of visits.

These types of buildings do not qualify as a home:

 Hospital nursing facility  Intermediate care facility for the mentally retarded (ICF/MR)  State institution Hospice Your PCP can ask for hospice care for you if you are terminally ill and not expected to live longer than six months.

We cover these types of hospice care:

 Nursing care  Doctor care  Medical care  Social services  Short-term inpatient care for pain control and to take care of symptoms  Durable medical equipment  Prescribed drugs  Counseling and bereavement services  Home health aide and homemaker services Hospice will take care of all benefits that have to do with the terminal illness. If you choose hospice, you give up the right to get other Medicaid services that have to do with the terminal illness. If you choose hospice, you can change your mind at any time.

Hospital services Your PCP can send you to any hospital in the UniCare network. See the Provider Directory for a list of the hospitals that work with us. Go to the nearest hospital during an emergency.

Hospital services — Inpatient Copays may apply.

We cover:

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