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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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 A hospital room with two or more beds  Care in special units  Operating rooms  Delivery rooms  Special treatment rooms  Supplies  Medical testing  X-rays  Drugs the hospital staff give you during your stay  Giving you someone else’s blood  Blood products  Radiation therapy  Chemotherapy  Dialysis treatment  Meals and special diets  General nursing care  Special duty nursing for medical reasons  Anesthesia  Respiratory therapy  Bariatric surgery  Diagnostic care  Therapeutic care  Rehabilitation care  Overnight hospital stay for dental work because of other medical problems or because serious dental work is needed  Setting up discharge planning, including continuing care, if needed  Surgery to remove a breast or dissect a lymph node. If you have a breast removed or lymph node dissected, you do not need an OK from us to decide how much time you will spend in the hospital after surgery  All problems from a breast removal surgery (including lymphedema)  Surgery to reconstruct. This includes prosthetics or surgery to make your breasts look the same after a breast is removed.


We do not cover any of the above services for adults in facilities for mental illness.


–  –  –

Outpatient hospital care must be given by:

• Hospitals

• Rural health clinics

We cover:

 Emergency room use  Emergency dental services  Giving you someone else’s blood  Blood products  Drugs given in the emergency room  Hospital services that can be reasonably done so the patient does not have to stay


- Supplies

- Medical testing

- X-rays

- Lab services

- ER and 23-hour observation stays  Physical, occupational and speech therapy  Radiation therapy  Chemotherapy  Dialysis  Services for dental work when a hospital outpatient facility must be used because of other medical problems or when serious dental work is needed  Surgical services; some surgical services need an OK ahead of time from us Lab and X-ray services (not received in a hospital) CT, MRI, MRA, PET and SPECT must have an OK. This includes lab and ultrasound services in a place other than a hospital outpatient unit.

We cover:

 All lab and X-ray services ordered and done by (or under the care of) a doctor  X-ray of the breast (mammogram) Nurse practitioners We cover care given by a nurse-midwife, nurse anesthetist, family nurse practitioner or pediatric nurse practitioner.

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 Physical or occupational therapy, speech pathology and audiology These types of care are ordered by a doctor and are a part of that doctor’s written plan of care;

Covered care includes treatment or other services given by speech, physical or occupational therapists or audiologists. This treatment is given to correct or improve conditions.


 All physical, occupational and speech therapy care needs an OK from us ahead of time.

 Only members under 21 years of age may get hearing aid evaluations, hearing aids and supplies, batteries, and repairs.

 Hearing aids are limited to members under 21 years of age and need an OK from us ahead of time.

Physician (doctor) services Copays may apply.

These types of care may be given to a member in a hospital, clinic or doctor’s office;

We cover:

 Visits to doctors or other providers  Routine physicals  Fluoride varnish treatments for children between 6 months and 3 years of age  Colorectal cancer screenings and lab tests for members 50 years of age and older who have no symptoms  Colorectal cancer screenings and lab tests for members under 50 years of age who have symptoms  Kidney disease screenings including:

- Blood pressure monitoring

- Lab tests for:

 Urine albumin  Urine protein  Serum creatinine


 Certain procedures may need an OK ahead of time.

 We do not cover routine physical exams for a job, camp or sports program.

Podiatry services (foot care)

We cover:

 Treatment for health problems such as infections, inflammations, ulcers and bursitis  Surgery for bunions or ingrown toenails 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.

–  –  –


 Treatment of children is limited to acute conditions.

 We do not cover routine treatment for flat foot, nail trimming and dislocated foot.

Pregnancy and maternity care When you know you are pregnant, call us right away. If you are in your last three months of pregnancy, you should set up a time to see your doctor within three business days from the time you call.

We cover:

 Doctor visits and professional services for pregnancy, problems with a pregnancy, and afterdelivery care when medically necessary  Services given by a licensed nurse-midwife (a pregnant member can choose a nursemidwife as her PCP)  Prenatal education classes  A nurse case manager or care coordinator to work with you throughout your pregnancy if it is high risk  Tests that are needed such as ultrasound  HIV testing, treatment and counseling  Vaginal childbirth and cesarean sections (C-sections)  Newborn exams  A follow-up visit for the mother and the baby within two days of an early discharge when ordered by the treating doctor

- An early discharge is a hospital stay of less than 48 hours for vaginal childbirth and less than 96 hours for a C-section If you are pregnant, you are automatically included in our maternity management program Taking Care of Baby and Me  at no cost. This program will help you learn how to take care of

yourself while you are pregnant. We will send you mailings that include:

 Planning a Healthy Pregnancy booklet  Labor, delivery and beyond brochure  Postpartum Nurture booklet — Your guide to keeping your baby safe and healthy  Information on gift card rewards you can get for completing prenatal, postpartum and wellchild visits You’ll also have the opportunity to work with a nurse to assist you with your pregnancy.

Ask your doctor about childbirth classes, or call us to find out more.

Most drugs covered by UniCare can be filled for a maximum of a 34-day supply at a time. Some medications may require an OK from UniCare before they can be filled at the pharmacy. Please see Part 9 Your prescription drug benefits for more information.

Private-duty nursing This is for members under 21 years of age who need more one-on-one, continuous care than they can get from a visiting nurse or at hospitals and skilled nursing facilities. We cover 24-hour nursing care if medically necessary.


 These types of care need an OK from us ahead of time.

 These types of care are for children under 21 years of age only.

Transplants Transplant services need an OK from us ahead of time. We cover these types of organ and

tissue transplants:

 Kidney  Kidney/pancreas  Liver  Bone marrow  Cornea  Small intestine  Multivisceral  Heart  Lung  Heart/lung Transportation We cover emergency transportation only when it’s used to get medical care and treatment for an emergency. You do not need an OK from us ahead of time. See Part 8 Emergency and urgent care services to learn more about emergency care and what to do in case of an emergency.

Nonemergency transports are covered by Medicaid and not UniCare. An ambulance may be needed for nonemergency transport when medically necessary. In this case, you will need an OK from DHHR ahead of time. To learn more about how to get transport when you do not have an emergency, see Part 7 What Medicaid covers.

Members who are diabetic may see an optometrist or ophthalmologist in the UniCare network for an annual diabetic retinal exam without an OK from their PCP. Any future exams will need an OK from your PCP.

We cover:

 Eye surgery (not cosmetic)  One exam for children every 12 months  Lenses and frames every 12 months  Repairs that are needed  First pair of eyeglasses and services after cataract surgery  Contact lenses (if medically necessary)


 Adult services are limited to medical necessity only.

 We do not cover prescription sunglasses and designer frames.

Children with Special Health Care Needs program (CSHCN) providers The Children with Special Health Care Needs (CSHCN) program provides specialty medical care, diagnosis and treatment for disabled children and those who may be at risk of developing disabling conditions. The CSHCN program provides case management and access to specialty services through a system of outreach specialty clinics.

UniCare is encouraged, but not required, to contract with CSHCN providers. However, if we do not contract with CSHCN providers, we must provide the same level and types of services as those currently available through the CSHCN program. This includes access to multidisciplinary care.

The CSHCN eligibility criteria and services are available from the West Virginia Bureau of Medical Services (BMS). BMS will monitor compliance with this requirement.

If we fail to satisfy these requirements, we will be required to reimburse the traditional CSHCN providers at the Medicaid fee rate.

UniCare does not cover:

 Payment for any service or care you got before you became a UniCare member  Care from a provider not in our network when you do not get the needed OK from us before you get the service  Any service not listed as covered  Payment for care you got for health problems that were work-related

- If they can be paid for by workers’ compensation insurance, your employer or by a disease law that has to do with your job  Nursing facility care  Acupuncture  Experimental or investigational procedures  Lab tests not ordered by a doctor, unless it is an emergency  Care given by Christian Science nurses  Care given in a Christian Science sanitarium  Care you get outside the U.S.

 Surgery or medications to help you get pregnant  Sterilization of the mentally incompetent  Organ transplants not listed in Part 5 What UniCare covers  Cosmetic surgery that is done to change or reshape normal body parts so they look better

- This does not apply to reconstructive surgery to give you back the use of a body part or to correct a deformity caused by an injury.

 Sex change surgery or treatments  Routine physical exams for a job, camp or sports program  Medical equipment, prescriptions, services and supplies that are:

- Not medically necessary

- Used only for your comfort or hygiene

- Used for exercise

- Personal or comfort items

- Experimental or still being researched

- Used for hygiene or beauty

- More than one piece of equipment that serves the same function

- Used only for making a room or home comfortable such as:

 Air conditioners  Exercise equipment  Air filters  Spas and swimming pools   Elevators Air purifiers 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.

–  –  –

Behavioral health services Your PCP can help you get behavioral health care with Medicaid providers. Behavioral health

care includes:

 Inpatient psychiatric services for children under 21 years of age  Outpatient behavioral health services  Behavioral health services for children under 3 years of age Hemophilia factors Although most prescription drugs that are filled at the pharmacy are covered by UniCare, factors that are used to treat hemophilia and that are filled at the pharmacy will remain carved out and will continue to be paid for by Medicaid.

Nonemergency transportation Services include getting you to and from Medicaid-covered medical appointments that you have made. Please call DHHR at 1-877-716-1212 to learn more.

Personal care Personal care is a community care program; You need a doctor’s order and a nursing plan of care to get personal care services such as help with grooming and hygiene, daily activities, and nutrition.

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 Part 8 – Emergency and urgent care services What is an emergency?

An emergency medical condition is when symptoms are so severe that a person with an average knowledge of medicine would reasonably believe that the lack of immediate medical

care could:

 Place your health (or the health of your unborn child) at serious risk.

 Impair the function of your body.

 Impair the function of a body part or organ.

You do not need an OK from us ahead of time for emergency care. Any doctor or hospital can treat a sudden or serious medical problem. You may have to make a copay if you use the emergency room for a nonemergency visit.

What to do in an emergency In an emergency, get help right away. Call 911 or go to the nearest emergency room for medical care. You will be covered for emergency services even if the provider is not part of the UniCare network. For emergency transport, call 911. You do not need an OK from UniCare when it is an emergency. After you receive emergency services, you should call your PCP to plan your followup care. You should do this for an emergency at home or away.

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