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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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You, or someone you trust, can send a written appeal to the State by calling your local Department of Health and Human Resources (DHHR). You can call DHHR at 1-877-716-1212.

You also can request a state fair hearing in writing or by completing a Request for Hearing form.

When you request a state fair hearing, someone from the UniCare Grievance and Appeals department will contact you to try to resolve the issue. If you are happy with the result, you will need to call your local DHHR office and withdraw your request for the state fair hearing.

If you ask for a state fair hearing, you will get a letter from the hearing officer that tells you the date and time of the hearing. The letter also will tell you what you need to know to get ready for the hearing.

The hearing can be held by telephone. You can explain why you asked for this service. You also can ask the hearing officer to check the information you sent in and to make a decision. You or the person you chose to help you or speak for you may review your case file before or during the hearing. DHHR will give you a final decision in writing within 90 calendar days from the date you asked for the hearing.

You may keep your benefits while your state fair hearing is pending if you submit your appeal within 10 days after we mail the Notice of Action letter to you or the date of the planned action. You may have to pay for services you received while you were waiting for an answer if the final decision is not the same as the one you asked for.

Appeals after 90 calendar days If you did not ask for a state fair hearing within 90 calendar days of the notice of the appeal ruling, you may still be able to appeal the original ruling. You can use this process even if the ruling does not have to do with us denying, deferring or modifying a service, or if we did not give you timely service.

To file this appeal, you must complete the UniCare internal grievance and appeals process first.

Your filing must be within one year from the date of the first ruling that you did not agree with.

You can appeal to the Insurance Commissioner by sending your appeal to:

The Office of the Insurance Commissioner P.O. Box 50540 Charleston, WV 25305-0540 If you do not agree with what the Office of the Insurance Commissioner decides, you may appeal to the Circuit Court. You must file your appeal within 30 calendar days after the Insurance ommissioner’s order was mailed;


You may be asked to leave our health plan (disenroll) for these reasons:

 You no longer are eligible  You move out of our service area (If you move to a place that is served by other MCOs, you must re-enroll in a new MCO right away.)  You are placed in a nursing facility, state institution or intermediate care facility for the mentally retarded for more than 30 calendar days  You were signed up in error  Your plan ID card was misused  Fraud or misrepresentation happened You may change your health plan at any time for any reason.

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 14 – Other things you need to know Contacting our Customer Care Center Call us toll free at 1-800-782-0095, Monday through Friday, from 8 a.m. to 6 p.m. (If you have hearing or speech loss, you may call our TTY 1-866-368-1634.) Our staff is trained to help you

understand your health plan. We can tell you about:

 Eligibility  Benefits  How to get service  How to choose or change your PCP  Health plan information  Dental and vision care  Transportation help  Complaints, grievances and appeals If you have other insurance To be able to enroll in Medicaid, you must report all insurance information to the program. Call the enrollment broker, Automated Health Systems, at 1-800-449-8466 and our CCC if you are covered by another health plan.

Call us if you:

 Have a workers’ compensation claim  Are waiting for a decision on a personal injury or medical malpractice lawsuit  Have an auto accident We can, and should, know about everyone giving you care. We need to know this to pay for your health care. We will not share this information with anyone except your health care provider and others as the law allows.

How to choose or change your health plan You can change your health plan for any reason by calling AHS at 1-800-449-8466 to choose a new health plan.

What to do if you get a bill

In most cases, you should not get a bill from our providers. You may have to pay for charges if:

• You agree to pay for service ahead of time that we do not cover or approve • You agree ahead of time to pay for care from a provider who does not work with us, and you did not get our OK ahead of time 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.

–  –  –

Reporting waste, abuse and fraud If you think that a member or a provider has committed waste, abuse or fraud, you have a responsibility to report it. To report waste, abuse or fraud, gather as much information as

possible. You can report providers/members directly to your health plan by:

• Calling our Customer Care Center at 1-800-782-0095 • Writing to:

Attn: Program Integrity Unit UniCare Health Plan of West Virginia, Inc.

1207 Quarrier St.

Charleston, WV 25301

When reporting a provider, let us know:

• Name, address and phone number of the provider

• Name and address of the facility (hospital, nursing home, home health agency, etc.)

• Medicaid number of the provider and facility, if available

• Type of provider (doctor, physical therapist, pharmacist, etc.)

• Names and the phone numbers of other witnesses who can aid in the investigation

• Dates of events

• Summary of what happened

When reporting a member, let us know:

• The person’s name

• The person’s date of birth and social security number, if available

• The city where the person lives

• Specific details about the waste, abuse or fraud Keeping your information private By accepting the benefits described in this member handbook, you agree to have UniCare or any person or third party we may assign to go over your medical records. This is for the purposes of utilization review, quality assurance and peer review. The Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices in this member handbook describes the UniCare privacy policies and procedures.

Access to your medical records Federal and state laws allow you to see your medical records at any time. Ask your PCP for your records first. If you have a problem getting them from your PCP, call us.

UWV-MHB-0003-14 WV MHB ENG 12.14 Advance directives (living wills) An advance directive (also called a living will) is a legal document that states how you want to be treated if you cannot talk or make decisions. For instance, you can name your spouse as the person who will make decisions about your health care if you cannot. We will give advance directive information to your family member if you can’t talk or make decisions when you join our health plan.

You may want to list the types of care you do, or do not, want to receive. For instance, some people do not want to be put on life-support machines if they go into a coma. Your PCP will note your living will in your medical records. That way, your doctor will know what you want.

You have the right to set up papers with this information for your doctor and other health care professionals to use. These are called advance directives for health care. Ask your family, your PCP or someone you trust to help you. You can find the forms you need at drug stores, hospitals, doctor’s offices and lawyers’ offices; You may change or cancel your advance directive at any time.

We will give our adult members information that reflects state law changes regarding advance directives as soon as possible, but no later than 90 days after the start date of the change.

Review of member records By joining our health plan and accepting the health care benefits listed in this book, you agree to let us look at your medical records for utilization review, quality assurance and peer review.

How to suggest changes in our policies and services UniCare has a Community Advisory Committee (CAC) to give members a say about our policies and services. CAC members inform, direct and suggest ideas about issues involving our services.

Call our CCC if you would like to join the CAC.

New medical treatments We want you to benefit from new medical treatments, so we review them on a routine basis. A

group of PCPs, specialists and medical directors decide if the treatment:

• Is approved by the government

• Has shown, in a reliable study, how it affects patients

• Will help patients as much as, or more than, treatments we use now

• Will improve the patient’s health The review group looks at all of the information. The group then decides if the treatment is medically necessary. They will let your doctor know if the treatment is medically necessary and if we approve it.

UWV-MHB-0003-14 WV MHB ENG 12.14 Quality Improvement At UniCare, we want to make your health plan better. To do this, we have a Quality

Improvement (QI) program. Through this program, we:

• Evaluate our health plan in order to improve it

• Track how happy you are with your PCP

• Track how happy you are with us

• Use the information we get to make a plan to improve our services

• Carry out our plan to help make your health care better You may ask us to send you information about our QI program. This will include a description of the program and a report on our progress in meeting our improvement goals. Call our CCC.

Accreditation report UniCare is accredited by the National Committee for Quality Assurance (NCQA). You can request a summary of our accreditation report by calling our CCC.

Fair treatment of minors Minors are treated as adults when it comes to birth control, pregnancy or family planning (except for sexual sterilization). Our members who are 13 years of age or older may refer themselves to any network or out-of-network OB/GYN for yearly exams and regular health care services (including cervical cancer screenings). They do not need an OK ahead of time from their PCP.

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 to share your information with others. 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 your health plan network.

Program or site changes We will tell you before we change the place where you get your health care services. If your health care program changes, we will tell you 30 calendar days before the change. You will hear no later than 30 calendar days before the effective date of the change. UniCare services can change without your agreement.

UWV-MHB-0003-14 WV MHB ENG 12.14 Part 15 – Your member rights and responsibilities The following information is about your UniCare Health Plan of West Virginia, Inc.

(UniCare) member rights.

Each year, UniCare submits its annual report to the Bureau for Medical Services (BMS) of the West Virginia Department of Health and Human Resources by April 1. This report includes a description of the services, personnel and the financial standing of UniCare.

The annual report is available to members by request only. To get a copy of the report, you can call the Customer Care Center toll free at 1-800-782-0095. If you have hearing or speech loss, call the TTY line toll free at 1-866-368-1634. You can also get a copy of the report from the West Virginia Department of Health and Human Resources.

Member rights

As a member of our health plan, you have the right to:

• Learn about your rights and responsibilities • Get the help you need to understand this book • Learn about us, our services, doctors and other health care providers • See your medical records as allowed by law • Have your medical records kept private unless you tell us in writing that it’s OK for us to share them or it is allowed by law • Be part of honest talks about your health care needs and treatment options no matter the cost and whether your benefits cover them • Be part of decisions that are made by your doctors and other providers about your health care needs • Be told about other treatment choices or plans for care in a way that fits your condition • Get news about how doctors are paid • Find out how we decide if new technology or treatment should be part of a benefit • Be treated with respect, dignity and the right to privacy all the time • Know that we, your doctors and your other health care providers cannot treat you in a different way because of your age, sex, race, national origin, language needs or degree of illness or health condition • Talk to your doctor about things that are private • Have problems taken care of fast, including things you think are wrong, as well as issues about getting an OK from us, your coverage or payment of service • Be treated the same as others • Get care that should be done for medical reasons • Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation • Choose your PCP from the PCPs in our Provider Directory that are taking new patients • Use providers who are in our network 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.

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