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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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UWV-MHB-0003-14 WV MHB ENG 12.14 • Get medical care in a timely manner • Get services from providers outside our network in an emergency • Refuse care from your PCP or other caregivers • Be able to make choices about your health care • Make an advance directive (also called a living will) • Tell us your concerns about UniCare and the health care services you get • Question a decision we make about coverage for care you got from your doctor • File a complaint or an appeal about UniCare, any care you get or if your language needs are not met • Ask how many grievances and appeals have been filed and why • Tell us what you think about your rights and responsibilities and suggest changes • Ask us about our QI program and tell us how you would like to see changes made • Ask us about our utilization review process and give us ideas on how to change it • Know that the date you joined our health plan is used to decide your benefits • Know that we only cover health care services that are part of your plan • Know that we can make changes to your health plan benefits as long as we tell you about those changes in writing • Ask for this EOC and other member materials in other formats such as large print, audio CD or Braille at no charge to you • Ask for an oral interpreter and translation services at no cost to you • Use interpreters who are not your family members or friends • Know you will not be held liable if your health plan becomes bankrupt (insolvent) • Know your provider can challenge the denial of service with your OK Member responsibilities

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

• Tell us, your doctors and other health care providers what they need to know to treat you • Learn as much as you can about your health issue and work with your doctor to set up treatment goals you agree on • Ask questions about any medical issue and make sure you understand what your doctor tells you • Follow the care plan and instructions that you have agreed on with your doctors or other health care professionals • Do the things that keep you from getting sick • Make and keep medical appointments and tell your doctor at least 24 hours in advance when you cannot make it • Always show your member ID card when you get health care services • Use the emergency room only in cases of an emergency or as your doctor tells you • Tell us right away if you get a bill that you should not have gotten or if you have a complaint • Treat all UniCare staff and doctors with respect and courtesy • Know and follow the rules of your health plan unicare.com/medicaid

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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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Benefits are the health care services covered under this plan.

BMS stands for the Bureau for Medical Services. This is the West Virginia agency that runs the Medicaid program.

Brand-name prescription drug means a prescription drug that has been patented and is produced by only one manufacturer.

Copays are small amounts that you may be required to pay for some covered services.

Cosmetic surgery is done to change or reshape normal body parts so they look better.

DHHR stands for the Department of Health and Human Resources for the state of West Virginia.

This agency takes care of carve-out services not covered by UniCare such as behavioral health services.

Disenroll means to stop using the health plan because you are no longer eligible or you change your health plan.

Emergency medical condition is a sudden, serious medical condition where the presenting symptoms are of sufficient severity that a prudent layperson with an average knowledge of

health and 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 Generic prescription drug means a pharmaceutical equivalent of one or more brand-name drugs. It must be approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand-name drug.

Health care provider means any doctor, hospital, agency or other person who has a license or is authorized to give health care services.

Some health care providers include:

• Audiologist is a provider who tests your hearing.

• Certified nurse-midwife is a registered nurse who cares for you during pregnancy and childbirth.

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 • Certified registered nurse anesthesiologist is a registered nurse certified to give you anesthesia.

• Chiropractor is a provider who treats problems of the spine or other body parts.

• Dentist is a doctor who takes care of your teeth and mouth.

• Family practitioner is a doctor who treats general medical conditions for people of all ages.





• General practitioner is a doctor who treats common medical problems for people of all ages.

• Licensed vocational nurse is a licensed nurse who works with your doctor.

• Nurse practitioner or physician’s assistant is a person who works in a clinic or doctor’s

office and:

- Finds out what’s wrong with you

- Treats you, within limits • Obstetrician/gynecologist (O/GYN) is a doctor who takes care of a woman’s health (this includes when she is pregnant or giving birth).

• Occupational therapist is a provider who helps you regain daily skills and activities after an illness or injury.

• Optometrist is a doctor who takes care of your eyes and vision.

• Pediatrician is a doctor who treats children from birth through their teen years.

• Physical therapist is a provider who helps you build your body’s strength after an illness or injury.

• Podiatrist or chiropodist is a doctor who takes care of your feet.

• Psychiatrist is a doctor who treats mental health issues and prescribes drugs.

• Registered nurse is a nurse with more training than a nurse who has a license to perform certain duties with your doctor.

• Respiratory therapist is a provider who helps you with your breathing.

• Speech pathologist is a provider who helps you with your speech.

• Surgeon is a doctor who can operate on you.

Home health agencies and visiting nurse associations are groups through which you can get skilled nursing care and other services in your home.

Inpatient care means you have to stay the night in the hospital or other facility for the medical care you need.

Medically necessary means that items or services that have been given or will be given to a patient are needed to treat or prevent a medical condition and are not mainly for the ease of

the patient, doctor or other health care provider. Examples are:

• 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 unicare.com/medicaid

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OK by UniCare means you received an approval ahead of time from us. You can learn more about this in Part 4 How to use your health plan, under the heading Prior authorization (an OK from UniCare) for health care services.

Outpatient care is care you get when you do not have to stay overnight in a hospital or other place of treatment.

Preferred drug list (PDL) means a list of brand-name and generic prescription drugs and supplies preferred by Uniare for use as the first line of drug therapy;

Primary care provider (PCP) is the doctor you choose for most of your health care. This person helps you get the care you need. Your PCP must OK most care ahead of time, unless it is an emergency.

Prior authorization (OK by UniCare) refers to the approval you get from us before you get a service.

Reconstructive surgery is done to correct a problem with a part of your body. This problem

could be caused by:

• A birth defect

• Disease

• Injury Making that part look or work better must be medically necessary.

Skilled nursing facility is a place that gives you 24-hour-a-day skilled professional nursing care.

Urgent medical condition is not an emergency, but is a condition that should have medical care within 48 hours.

Utilization review is a process that allows UniCare and your health care providers to work together to decide if a service you ask for is medically necessary.

Please read this carefully.

This tells you who can see your protected health information (PHI) with and without your OK.

It also tells what rights you have to see and change your information.

Information about your health and money is private. The law says we must keep this kind of information, called protected health information (PHI), safe for our members. That means if you’re a member right now or if you used to be;

We get information about you from state agencies for Medicaid after you become eligible and sign up for our health plan. We also get PHI from your doctors, clinics, labs and hospitals so we can OK and pay for your health care.

Federal law says we must tell you what the law says we have to do to protect PHI that’s told to us in writing or saved on a computer. We also have to tell you how we keep it safe. To protect

PHI:

● On paper (called physical), we:

– Lock our offices and files – Destroy paper with health information so others can’t get it ● Saved on a computer (called technical), we:

– Use passwords so only the right people can get in – Use special programs to watch our systems ● Used or shared by people who work for us, doctors or the state, we:

– Make rules for keeping information safe (called policies and procedures) – Teach people who work for us to follow the rules When is it OK for us to use and share your PHI? We can share your PHI with your family or a person you choose who helps with or pays for your health care if you tell us it’s OK; Sometimes,

we can use and share it without your OK:

 For your medical care – To help doctors, hospitals and others get you the care you need  For payment – To share information with the doctors, clinics and others who bill us for your care – When we say we’ll pay for health care or services before you get them We must get your OK in writing before we use or share your PHI for anything but your care, payment, everyday business, research or other things not in this notice. Other things could be selling it or using it to sell things to you. We have to get your written OK before we share psychotherapy notes from your doctor about you.

You may tell us in writing that you want to take back your written OK; We can’t take back what we used or shared when we had your OK. But we will stop using or sharing your PHI in the future.

Other ways we can — or the law says we have to — use your PHI:

 To help the police and other people who make sure others follow laws  To report abuse and neglect  To help the court when we’re asked  To answer legal documents  To give information to health oversight agencies for things like audits or exams  To help coroners, medical examiners or funeral directors find out your name and cause of death  To help when you’ve asked to give your body parts to science  For research  To keep you or others from getting sick or badly hurt  To help people who work for the government with certain jobs  To give information to workers’ compensation if you get sick or hurt at work What are your rights?

 You can ask to look at your PHI and get a copy of it; We don’t have your whole medical record, though. If you want a copy of your whole medical record, ask your doctor or health clinic.

 You can ask us to change the medical record we have for you if you think something is wrong or missing.

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  Sometimes, you can ask us not to share your PHI; ut we don’t have to agree to your request.

 You can ask us to send PHI to a different address than the one we have for you or in another way. We can do this if sending it to the address we have for you may put you in danger.

 You can ask us to tell you all the times over the past six years we’ve shared your PHI with someone else; This won’t list the times we’ve shared it because of health care, payment, everyday health care business or some other reasons we didn’t list here;

 You can ask for a paper copy of this notice at any time, even if you asked for this one by email.

 If you pay the whole bill for a service, you can ask your doctor not to share the information about that service with us.

What do we have to do?

 The law says we must keep your PHI private except as we’ve said in this notice;

 We must tell you what the law says we have to do about privacy.

 We must do what we say we’ll do in this notice;

 We must send your PHI to another address or to send it in a way other than regular mail if you ask for reasons that make sense, like if you’re in danger;

 We must tell you if we have to share your PHI after you’ve asked us not to;

 If state laws say we have to do more than what we’ve said here, we’ll follow those laws;

 We have to let you know if we think your PHI hasn’t been kept private;

What if you have questions?

If you have questions about our privacy rules or want to use your rights, please call our CCC.

What if you have a complaint?



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