UnitedHealthcare Community Plan

Transcription

1 UnitedHealthcare Community Plan Medicaid 2014 Certificate of Coverage (COC) Northwestern Hwy. Suite 400 Southfield, MI /14

2 Table of Contents Article I: General Conditions Certificate Rights and Responsibilities Execution of Certificate Waiver by UnitedHealthcare Community Plan, Amendments Assignment... 6 Article II: Definitions Applicability Application Certificate Co-payment Cosmetic Surgery Covered Services Department DIFS Emergency Services Experimental, Investigational or Research Medical, Surgical or Other Health Care Drug, Device, Treatment or Procedure Family Planning Services Health Professional Hospice Services Hospital Hospital Services Long Term Care Facility Medicaid Agreement Medicaid Program Medical Director Medically Necessary Medicare Member Member Agreement Non-Covered Services Non-Participating Provider Participating Hospital Participating Physician Participating Provider Physician Premium Primary Care Provider Service Area Specialist Provider Urgent Care Michigan 3 Medicaid Certificate of Coverage (COC) 3

3 Table of Contents Article III: Eligibility Member Eligibility Effective Date of Eligibility Newborn Eligibility Children s Special Health Care Services Final Determination Article IV: Enrollment Newborns Change of Residency Article V: Effective Date of Coverage Effective Dates of Enrollment Notification Article VI: Relationship With Participating and Non-Participating Providers Selecting a Primary Care Provider Role of Primary Care Provider Changing a Primary Care Provider Specialist Physicians and Other Participating Providers Self-Referral to Participating Providers Without Authorization Non-Participating Providers Independent Contractors Termination of Provider s Participation Inability to Establish or Maintain a Provider-Patient Relationship Refusal to Follow Participating Provider s Orders Article VII: Members Rights and Responsibilities Release and Confidentiality of Member Medical Records Member Complaint, Grievance and Appeal Procedure Member Identification (ID) Cards Forms and Questionnaires Board of Directors Non-Covered Services Regular Communication Your Rights as a Member Policies and Procedures Continuity of Care Pain Medicine Article VIII: Payment for Covered Services Periodic Premium Payments Members Covered Co-payments Claims Michigan 4 Medicaid Member Handbook 4

4 Table of Contents Article IX: Covered Services A Member is entitled to The following are Covered Services when requirements stated in Section 9.1 are met Article X: Emergency Services or Urgent Care Within the Service Area Emergency Services Urgent Care Article XI: Out-of-Area Services Covered Services Hospitalization Article XII: Exclusions and Limitations Exclusions Limitations Article XIII: Term and Termination Term Termination of Certificate by or the Department Termination of Member Enrollment and Coverage by UnitedHealthcare Community Plan or the Department Article XIV: Coordination of Benefits Purpose Assignment Claims Order of Benefits Rights Construction Article XV: Subrogation Assignment; Suit Definition Article XVI: Miscellaneous Governing Law Contract Period of Time for Raising Legal Claims Policies and Procedures Notice Headings Disenrollment by Member Michigan 5 Medicaid Certificate of Coverage (COC) 5

5 Article I: General Conditions 1.1 Certificate. This Certificate of Coverage (Certificate) is issued to Medicaid Program recipients who have enrolled in, Inc. (). The terms and conditions of this certificate are governed by the compiled laws of the State of Michigan and the Medicaid benefits that is required to provide pursuant to its Medicaid Agreement with the State of Michigan. By enrolling in UnitedHealthcare Community Plan, the Member agrees to abide by the terms and conditions of this Certificate. 1.2 Rights and Responsibilities. This Certificate describes and states the rights and obligations of Members and UnitedHealthcare Community Plan. It is the Member s responsibility to read and understand this Certificate. Section 9.2 of this Certificate lists the Covered Services to which Members are entitled under the terms and conditions of this Certificate. In some circumstances, certain medical services, equipment, and supplies are not covered or may require prior approval of UnitedHealthcare Community Plan. It is also the Member s responsibility to understand your rights as a Member as set forth in the Member Handbook. 1.3 Execution of Certificate. Members acknowledge and agree that a Member s execution of the Application shall be deemed to be his/her execution of this entire Certificate. The Application, this Certificate, the Member Handbook, and the ID Card(s) issued to the Member constitute the Member Agreement between and the Member. 1.4 Waiver by UnitedHealthcare Community Plan, Amendments. Only authorized officers of have authority to waive any conditions or restrictions of this Certificate, to extend the time for making payment, or to bind by making a promise or representation or by giving or receiving any information. All changes to this Certificate must be in writing and signed by an authorized officer of, and must be approved by the Office of Financial and Insurance Regulation. 1.5 Assignment. All rights of a Member to receive Covered Services under the Member Agreement are personal and may not be assigned to any other person or entity. Any attempts to assign the Member Agreement or any rights under the Member Agreement may result in termination of coverage for the Member. Article II: Definitions 2.1 Applicability The definitions in this Article II are applicable throughout this Certificate and any amendments, addenda, or appendices to this Certificate. 2.2 Application means the Member Application form which a Medicaid recipient or beneficiary is required to complete and sign to enroll himself or herself and eligible persons in his or her household in the State of Michigan Medical Assistance Program as administered by the Michigan Department of Human Services. 2.3 is a for profit corporation that operates as a health maintenance organization based on a Certificate of Authority issued by the State of Michigan s Department of Insurance and Financial Services (DIFS). 6 Medicaid Certificate of Coverage (COC)

6 2.4 Certificate means this contract or Member Agreement between UnitedHealthcare Community Plan and Members, including all amendments, addenda, appendices and riders. 2.5 Co-payment means the amount which a Member may be required to pay directly to a Participating Provider or a Non-Participating Provider for certain Covered Services as set forth in Article IX of this Certificate. 2.6 Cosmetic Surgery means those procedures which improve physical appearance, but which do not correct or materially improve a physiological function, and are not Medically Necessary. 2.7 Covered Services mean the Medically Necessary services, equipment and supplies set forth in Section 9.2 of this Certificate, which are subject to all of the terms and conditions of this Certificate and those services that is required to provide pursuant to its Medicaid Agreement. 2.8 Department means the Michigan Department of Community Health or its successor agency which is duly authorized to regulate health maintenance organizations and administer the Medicaid Program in the State of Michigan. 2.9 DIFS means the Department of Insurance and Financial Services or its successor agency which is duly authorized to regulate health maintenance organizations in the State of Michigan Emergency Services mean those services necessary to treat an emergency medical condition. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (i) serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child; (ii) serious impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part Experimental, Investigational or Research Medical, Surgical or Other Health Care Drug, Device, Treatment or Procedure means a drug, device, treatment or procedure meeting one or more of the following criteria: (a) it cannot be lawfully marketed without the approval of the Food and Drug Administration (FDA) and such approval has not been granted at the time of its use or proposed use; (b) it is the subject of a current investigational new drug or new device application on file with the FDA; (c) it is being provided pursuant to a Phase I or Phase II clinical trial or as the experimental or research arm of a Phase III clinical trial; (d) it is being provided pursuant to a written protocol which describes among its objectives the determination of safety, efficacy or efficiency in comparison to conventional alternatives; (e) it is described as experimental, investigational or research by informed consent or patient information documents; (f) it is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board (IRB) as required and defined by federal regulations, particularly those of the FDA or the Department of Health and Human Services (HSS) or successor agencies, or of a human subjects (or comparable) committee; (g) the predominant opinion among experts as expressed in the published authoritative medical investigational or research settings; (h) the predominant opinion among experts as expressed in the published authoritative medical or scientific literature is that further experiment, investigation or research is necessary in order to define safety, toxicity, effectiveness or efficiency compared with conventional Michigan 7

7 alternatives; (i) at the time of its use or proposed use, it is not routinely or widely employed or is otherwise not generally accepted by the medical community. Coverage for drugs used in antineoplastic therapy are covered pursuant to MCL e of the Michigan Insurance Code Family Planning Services means any medically approved means, including diagnostic evaluation, drugs, supplies, devices, and related counseling, for the purpose of voluntarily preventing or delaying pregnancy or for the detection or treatment of sexually transmitted diseases Health Professional means a health care provider who is appropriately licensed, certified or otherwise qualified to deliver health services pursuant to Michigan law Hospice Services means services provided by a licensed or Medicare certified Hospice that are primarily furnished to provide pain relief, symptom management and supportive services to the terminally ill and their families. Hospice Services may be provided in the home, adult foster care facility, home for the aged, Long Term Care Facility, alternative intermediate services home, or an inpatient Hospice setting Hospital means an acute care facility licensed as a hospital by the State of Michigan which is primarily engaged in providing, on an inpatient basis, medical care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities Hospital Services mean those Covered Services which are provided by a Hospital Long Term Care Facility means a facility licensed and certified by the Department to provide inpatient nursing care services Medicaid Agreement is the contract between the State of Michigan and UnitedHealthcare Community Plan under which agrees to arrange for the delivery of Covered Services for Members Medicaid Program means the Department s program for Medical Assistance under Section 105 of Public Act 280 of 1939, as amended, MCL , and Title XIX of the Federal Social Security Act, 42. U.S.C et seq., as amended Medical Director means a Physician designated by UnitedHealthcare Community Plan to supervise and manage the medical aspects of programs and services Medically Necessary means Covered Services provided by a provider which are required to identify, treat or avoid an illness or injury to a Member, which as determined by Medical Director or designee or UnitedHealthcare Community Plan utilization management process for the purposes of payment only, are (i) consistent with the symptoms or diagnosis and treatment of the Member s condition, disease, ailment or injury; (ii) appropriate with regard to standards of medical practice; (iii) not primarily for the convenience of the Member, the Member s attending or treating physician, or another health care provider; (iv) and the most appropriate supply or level of service which can be safely provided to a Member. Not all Medically Necessary services are Covered Services under this Certificate Medicare means the program established under Title XVIII of the Federal Social Security Act, 42 U.S.C et seq Member means a Medicaid Program recipient enrolled in UnitedHealthcare Community Plan and on whose behalf the Department has paid a Premium in accordance with the Medicaid Agreement. 8 Medicaid Certificate of Coverage (COC)

8 2.24 Member Agreement means this Certificate, the Member s Application, the Member Handbook, and the UnitedHealthcare Community Plan ID Card issued by to the Member Non-Covered Services means those medical and health care services, equipment and supplies which are not Covered Services Non-Participating Provider means a Health Professional, Hospital, healthcare entity or health care professional that has not contracted with UnitedHealthcare Community Plan to provide Covered Services to Members Participating Hospital means a Hospital that contracts with UnitedHealthcare Community Plan to provide Covered Services to Members Participating Physician means a Physician that contracts with UnitedHealthcare Community Plan to provide Covered Services to Members Participating Provider means a Health Professional, Hospital or other entity that contracts with UnitedHealthcare Community Plan to provide Covered Services to Members Physician means a Doctor of Medicine (MD) or Doctor of Osteopathy (DO) licensed to practice medicine in the State of Michigan Premium means the amount prepaid by the Department for Members to secure Covered Services Primary Care Provider means a Participating Provider who is responsible for providing, arranging, and coordinating all aspects of a Member s health care Service Area means the areas in which has been authorized by DIFS and MDCH to provide services to Members Specialist Provider means a Participating Provider, other than a Primary Care Provider, who provides Covered Services to Members upon referral by the Primary Care Provider and, if required, prior authorization by Urgent Care means covered services that are not Emergency Services, but are Medically Necessary and immediately required as a result of an unforeseen illness, injury, or condition. Article III: Eligibility 3.1 Member Eligibility. To be eligible to enroll in an individual must: A. Be eligible for the Medicaid Program as determined by the Department; and B. Reside within the Service Area. 3.2 Effective Date of Eligibility. If a Member is determined eligible during a month, he or she is eligible for the entire month. In some cases, Members may be retroactively determined eligible. Once a Member (other than a newborn) is determined to be Medicaid eligible, eligibility will occur on the first day of the first available month following the eligibility determination. UnitedHealthcare Community Plan is not responsible for paying for health care services prior to the date of enrollment in their health plan, except for newborns (Refer to ll-g6). If the Member is in an inpatient hospital setting on the date of enrollment (first day of the month), will not be responsible for the inpatient stay or any charges incurred prior to the date of discharge. UnitedHealthcare Community Plan will be responsible for all care from the date of discharge forward. Similarly, if a Member is disenrolled from UnitedHealthcare Community Plan and is in an inpatient Michigan 9

9 hospital setting on the date of disenrollment, will be responsible for all charges incurred until the date of discharge. 3.3 Newborn Eligibility. Newborns of eligible Members who were enrolled at the time of the child s birth will be automatically enrolled with. 3.4 Children s Special Health Care Services (CSHCS). High quality health care and case management services with a coordinated care plan to those eligible for Michigan Medicaid Children s Special Health Care Services (CSHCS). CSHCS is a state of Michigan program that serves children, and some adults, with special health care needs. CSHCS covers more than 2,700 medical diagnoses. 3.5 Final Determination. In all cases, the Department shall make the final determination of an individual s eligibility to enroll and continue enrollment in. Article IV: Enrollment 4.1 Newborns. A Member s newborn child is automatically enrolled in UnitedHealthcare Community Plan from the date of birth. is required to notify the Department of the birth of the newborn within the time period required under the Medicaid Agreement. 4.2 Change of Residency. A Member must notify the Department and UnitedHealthcare Community Plan when the Member changes his or her residence to a location outside of the Service Area. The Member will be eligible to receive Covered Services until he or she is disenrolled from UnitedHealthcare Community Plan as determined by the Department. Article V: Effective Date of Coverage 5.1 Effective Dates of Enrollment. A Member s enrollment in UnitedHealthcare Community Plan and coverage under this Certificate will become effective on the date determined by the Department and UnitedHealthcare Community Plan in accordance with the Medicaid Agreement. 5.2 Notification. UnitedHealthcare Community Plan will notify a Member of the effective date of coverage. Article VI: Relationship With Participating and Non-Participating Providers 6.1 Selecting a Primary Care Provider. Each Member must select a Primary Care Provider. If the Member is a minor or otherwise incapable of selecting a Primary Care Provider on his or her own behalf, the adult responsible for the Member must select a Primary Care Provider on behalf of such Member. reserves the right to select a Primary Care Provider for the Member in the event that he or she does not select a Primary Care Provider within thirty (30) days of becoming a Member. also reserves the right to select a Primary Care Provider for the Member in the event that the contract between UnitedHealthcare Community Plan and the Primary Care Provider is revoked, if the Primary Care Provider no longer acts in the capacity as the Member s Primary Care Provider, if the Primary Care Provider elects not to provide medical services to the Member or if the Member was assigned to a Primary Care Provider in error or by mistake. 10 Medicaid Certificate of Coverage (COC)

10 Michigan will use prescribed guidelines to make such a selection. 6.2 Role of Primary Care Provider. The Member s Primary Care Provider provides or coordinates, in conjunction with, health care services to a Member, including, but not limited to: referrals to Specialist Providers, ordering lab tests and x-rays, prescribing medicines or therapies, arranging hospitalization, and generally coordinating a Member s medical care as appropriate. 6.3 Changing a Primary Care Provider. A Member may change his or her Primary Care Provider by contacting Customer Service Department. All changes must be approved in advance by the Customer Service Department who will then notify the Member of the effective date of the change. 6.4 Specialist Physicians and Other Participating Providers. Members must obtain referrals from their Primary Care Provider and, when required, authorization in advance from UnitedHealthcare Community Plan in order to receive Covered Services from Specialist Providers and other Participating Providers except as otherwise specified in this Certificate. In the event that a Participating Provider is not available to render Covered Services to Members, authorization in advance from UnitedHealthcare Community Plan will be considered. 6.5 Self-Referral to Participating Providers Without Authorization. A Member may be financially responsible for payment for medical services, equipment or supplies, except Emergency Services, if the Member does not obtain the necessary referral or authorization from his or her Primary Care Provider or in advance. Under circumstances expressly identified in this Certificate, a Member may receive medically necessary services without a referral from a PCP for services only identified below: A. Well woman care from a participating OB/GYN. B. Certified Nurse Midwife Services. C. Certified pediatric and family nurse practitioner services. D. Family Planning from any family planning clinic. E. Immunizations from the Health Department. F. Pediatrician visits made by a child under the age of eighteen (18) to any participating pediatrician. G. Vision services from any participating optometrist. H. Chiropractic care visits from any participating chiropractor for up to eighteen (18) visits every calendar year for subluxation of the spine. I. Short term outpatient behavioral health care from any participating behavioral health provider or at any Federally Qualified Health Center (FQHC), Rural Health Center (RHC), Child and Adolescent Health Center (CAHC) or Tribal Health Center (THC) for up to twenty (20) visits every calendar year. J. Non-emergency transportation or gas reimbursement services from a authorized transportation provider. K. Federally Qualified Health Centers (FQHC s) Rural Health Centers (RHC s), Child and Adolescent Health Centers (CAHC s), Tribal Health Centers (THC s). Members may go to any FQHC, RHC, CAHC, or THC without being sent by their 11

11 PCP even if it is not a UnitedHealthcare Community Plan provider. They will not have an extra copay. 6.6 Non-Participating Providers. Members are not financially responsible for payment of Covered Services, furnished by Non-Participating Providers, if: A. The provider has failed to inform the Member in writing that the health care services are not covered by ; B. The provider failed to obtain authorization in advance from or failed to submit a claim to within one (1) year of the date of service; and C. There is a difference between the providers charge and UnitedHealthcare Community Plan payment to the provider. 6.7 Independent Contractors. UnitedHealthcare Community Plan does not itself undertake to directly furnish any health care service under this Agreement. The obligations of are limited to arranging for the provision of Covered Services to Members. Participating Providers and Non-Participating Providers are solely responsible for exercising independent medical judgments. UnitedHealthcare Community Plan is solely responsible for making benefit determinations in accordance with the Member Agreement, the Medicaid Agreement and its contracts with Participating Providers, but it expressly disclaims any right or responsibility to make medical treatment decisions. Such decisions may only be made by Participating Providers in consultation with the Member. A Participating Provider and a Member may elect to continue medical treatments despite denial of coverage for such treatments. Members may appeal any of UnitedHealthcare Community Plan benefit decisions in accordance with Member Grievance and Appeal Procedure. 6.8 Termination of Provider s Participation. or a Participating Provider may terminate their contract or limit the number of Members that the Participating Provider will accept as patients during the term of this Agreement. does not represent or promise that a specific Participating Provider will be available to render services throughout the period that a Member is enrolled in UnitedHealthcare Community Plan. If a Member s Primary Care Provider no longer acts as a Primary Care Provider, the Member must select another Primary Care Provider. If a Participating Provider who is rendering services to a Member ceases to be a Participating Provider, the Member must cooperate with his or her Primary Care Provider to select another Participating Provider to render Covered Services. To make sure care a Member started can be finished, will work with the Member s treating doctor. The Member can continue treatment for up to 90 days if: The Member is a new member and is in an on-going course of care with a non UnitedHealthcare Community Plan provider. ends a contract with a UnitedHealthcare Community Plan provider for reason other than cause. 12 Medicaid Certificate of Coverage (COC)

12 Michigan If a Member is less than 13 weeks pregnant the Member will need to see a provider for all her care. If a Member is over 13 weeks pregnant the Member can continue to see their current OB/GYN provider until their postpartum care for that delivery is complete. 6.9 Inability to Establish or Maintain a Provider-Patient Relationship. If a Member is unable to establish or maintain a satisfactory relationship with a Primary Care Provider or a Specialist Provider to whom the Member is referred, UnitedHealthcare Community Plan may: A. Request the Member to select another Primary Care Provider; or B. Arrange to have the Member s Primary Care Provider refer such Member to another Specialist Physician; or C. Initiate the Member s disenrollment in accordance with the Medicaid Agreement Refusal to Follow Participating Provider s Orders. A Member may refuse to accept or follow a Participating Provider s treatment recommendations or orders. The Participating Provider may request the Member to select another Participating Provider if he or she cannot maintain a satisfactory relationship with the Member because of the Member s refusal to follow his or her orders. The Member may request the Medical Director to designate another Participating Provider to render a second opinion if the Member refuses to follow a Participating Provider s treatment recommendations or orders. If the Member does not request a second opinion, or if the second Participating Provider agrees that there is no acceptable alternative method of treating the condition, the Member shall be financially responsible for payment for any medical services, equipment or supplies which are not ordered by the first Participating Provider. The Medical Director will resolve any disagreement between the first and second opinions concerning the treatment of a Member s condition. Article VII: Members Rights and Responsibilities 7.1 Release and Confidentiality of Member Medical Records Clinical information from medical records of Members and information received from Participating and Non-Participating Providers shall be kept confidential by and not be disclosed to third parties without the prior written consent of the Member, except (a) in connection with the bona fide use of anonymous data for medical research, education, or statistical studies; (b) as permitted or required by federal or state law including the Health Insurance Portability and Accountability Act of 1996, the Gramm- Leach-Bliley Act of 1999; (c) in connection with utilization review, quality assurance and case and disease management programs; (d) or necessary to effectively administer and enforce a healthcare information transaction Pursuant to the authorization contained in and upon a Member s or authorized person s signature on the Medicaid Application, UnitedHealthcare Community Plan shall have the right to receive the release of medical information from Participating Providers and Non-Participating Providers regarding the Member as necessary to implement and administer the Medicaid Agreement, the Member Agreement, subject to the applicable requirements established by state and federal law. 13

13 7.1.3 Each Member authorizes Participating and Non-Participating Providers to disclose information concerning his or her care, treatment, and physical condition to on request and to permit copying of provider records by UnitedHealthcare Community Plan. Each Member further agrees to cooperate with UnitedHealthcare Community Plan and its Participating Providers by providing health history information and by assisting in obtaining prior medical records when requested. When necessary, the Member shall sign an authorization for release of all of his or her medical records Upon request, adult Members, or authorized persons on behalf of Members, may review their own medical records and those of minor Members in their household in accordance with state and federal law. Such review shall take place at the offices of the Participating Provider during regular business hours and at a time reasonably specified by the Participating Provider Privacy Notice Privacy Practices Notice for Medical Information Privacy Practices Notice for Financial Information Member Rights And Responsibilities HEALTH PLAN NOTICES OF PRIVACY PRACTICES THIS NOTICE SAYS HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND SHARED. IT SAYS HOW YOU CAN GET ACCESS TO THIS INFORMATION. READ IT CAREFULLY. Effective September 23, 2013 We 1 must by law protect the privacy of your health information ( HI ). We must send you this notice. It tells you: How we may use your HI. When we can share your HI with others. What rights you have to your HI. We must by law follow the terms of this notice. Health information (or HI) in this notice means information that can be used to identify you. And it must relate to your health or health care services. We have the right to change our privacy practices. If we change them, we will, in our next annual mailing, either mail you a notice or provide you the notice by , if permitted by law. We will post the new notice on your health plan website UHCCommunityPlan.com. We have the right to make the changed notice apply to HI that we have now and to future information. We will follow the law and give you notice of a breach of your HI. We collect and keep your HI so we can run our business. HI may be oral, written or electronic. We limit access to all types of your HI to our employees and service providers who manage your coverage and provide services. We have physical, electronic and procedural safeguards per federal standards to guard your HI. 14 Medicaid Certificate of Coverage (COC)

14 How We Use or Share Information We must use and share your HI if asked for by: You or your legal representative. The Secretary of the Department of Health and Human Services to make sure your privacy is protected. We have the right to use and share HI. This must be for your treatment, to pay for care and to run our business. For example, we may use and share it: For Payments. This also may include coordinating benefits. For example, we may tell a provider if you are eligible for coverage and how much of the bill may be covered. For Treatment or managing care. For example, we may share your HI with providers to help them give you care. For Health Care Operations related to your care. For example, we may suggest a disease management or wellness program. We may study data to see how we can improve our services. To tell you about Health Programs or Products. This may be other treatments or products and services. These activities may be limited by law. For Plan Sponsors. We may give enrollment, disenrollment and summary HI to an employer plan sponsor. We may give them other HI if they agree to limit its use per federal law. For Underwriting Purposes. We may use your HI to make underwriting decisions but we will not use your genetic HI for underwriting purposes. For Reminders on benefits or on care, such as appointment reminders. We may use or share your HI as follows: As Required by Law. To Persons Involved With Your Care. This may be to a family member. This may happen if you are unable to agree or object. Examples are an emergency or when you agree or fail to object when asked. If you are not able to object, we will use our best judgment. Special rules apply for when we may share HI of people who have died. For Public Health Activities. This may be to prevent disease outbreaks. For Reporting Abuse, Neglect or Domestic Violence. We may only share with entities allowed by law to get this HI. This may be a social or protective service agency. For Health Oversight Activities to an agency allowed by the law to get the HI. This may be for licensure, audits and fraud and abuse investigations. For Judicial or Administrative Proceedings. To answer a court order or subpoena. For Law Enforcement. To find a missing person or report a crime. For Threats to Health or Safety. This may be to public health agencies or law enforcement. An example is in an emergency or disaster. For Government Functions. This may be for military and veteran use, national security, or the protective services. For Workers Compensation. To comply with labor laws. For Research. To study disease or disability, as allowed by law. To Give Information on Decedents. This may be to a coroner or medical examiner. To identify the deceased, find a cause of death or as stated by law. We may give HI to funeral directors. For Organ Transplant. To help get, store or transplant organs, eyes or tissue. To Correctional Institutions or Law Enforcement. For persons in custody: (1) To give health care; (2) To protect your health and the health of others; (3) For the security of the institution. To Our Business Associates if needed to give you services. Our associates agree to protect your HI. They are not allowed to use HI other than as allowed by our contract with them. Michigan 15

15 Other Restrictions. Federal and state laws may limit the use and sharing of highly confidential HI. This may include state laws on: 1. HIV/AIDS 2. Behavioral health 3. Genetic tests 4. Alcohol and drug abuse 5. Sexually transmitted diseases (STD) and reproductive health 6. Child or adult abuse or neglect or sexual assault If stricter laws apply, we aim to meet those laws. Attached is a Federal and State Amendments document. Except as stated in this notice, we use your HI only with your written consent. This includes getting your written consent to share psychotherapy notes about you, to sell your HI to other people, or to use your HI in certain promotional mailings. If you allow us to share your HI, we do not promise that the person who gets it will not share it. You may take back your consent, unless we have acted on it. To find out how, call the phone number on the back of your ID card. Your Rights You have a right: To ask us to limit use or sharing for treatment, payment, or health care operations. You can ask to limit sharing with family members or others involved in your care or payment for it. We may allow your dependents to ask for limits. We will try to honor your request, but we do not have to do so. To ask to get confidential communications in a different way or place. (For example, at a P.O. Box instead of your home.) We will agree to your request when a disclosure could endanger you. We take verbal requests. You can change your request. This must be in writing. Mail it to the address below. To see or get a copy of certain HI that we use to make decisions about you. You must ask in writing. Mail it to the address below. If we keep these records in electronic form, you will have the right to ask for an electronic copy to be sent to you. You can ask to have your record sent to a third party. We may send you a summary. We may charge for copies. We may deny your request. If we deny your request, you may have the denial reviewed. To ask to amend. If you think your HI is wrong or incomplete you can ask to change it. You must ask in writing. You must give the reasons for the change. Mail this to the address below. If we deny your request, you may add your disagreement to your HI. To get an accounting of HI shared in the six years prior to your request. This will not include any HI shared: (i) For treatment, payment, and health care operations; (ii) With you or with your consent; (iii) With correctional institutions or law enforcement. This will not list the disclosures that federal law does require us to track. To get a paper copy of this notice. You may ask for a copy at any time. Even if you agreed to get this notice electronically, you have a right to a paper copy. You may also get a copy at our website, UHCCommunityPlan.com. Using Your Rights To Contact your Health Plan. Call the phone number on the back of your ID card. Or you may contact the UnitedHealth Group Call Center at (TTY: 711). To Submit a Written Request. Mail to: UnitedHealthcare Government Programs Privacy Office MN006-W800 P.O. Box 1459 Minneapolis, MN To File a Complaint. If you think your privacy rights have been violated, you may send a complaint at the address above. 16 Medicaid Certificate of Coverage (COC)

16 You may also notify the Secretary of the U.S. Department of Health and Human Services. We will not take any action against you for filing a complaint. 1 This Medical Information Notice of Privacy Practices applies to the following health plans that are affiliated with UnitedHealth Group: ACN Group of California, Inc.; All Savers Insurance Company; All Savers Life Insurance Company of California; AmeriChoice of Connecticut, Inc.; AmeriChoice of Georgia, Inc.; AmeriChoice of New Jersey, Inc.; Arizona Physicians IPA, Inc.; Care Improvement Plus of Maryland, Inc.; Care Improvement Plus of Texas Insurance Company; Care Improvement Plus South Central Insurance Company; Care Improvement Plus Wisconsin Insurance Company; Citrus Health Care, Inc.; Dental Benefit Providers of California, Inc.; Dental Benefit Providers of Illinois, Inc.; Evercare of Arizona, Inc.; Golden Rule Insurance Company; Health Plan of Nevada, Inc.; MAMSI Life and Health Insurance Company; MD Individual Practice Association, Inc.; Medical Health Plans of Florida, Inc.; Medica HealthCare Plans, Inc.; Midwest Security Life Insurance Company; National Pacific Dental, Inc.; Neighborhood Health Partnership, Inc.; Nevada Pacific Dental; Optimum Choice, Inc.; Oxford Health Insurance, Inc.; Oxford Health Plans (CT), Inc.; Oxford Health Plans (NJ), Inc.; Oxford Health Plans (NY), Inc.; PacifiCare Life and Health Insurance Company; PacifiCare Life Assurance Company; PacifiCare of Arizona, Inc.; PacifiCare of Colorado, Inc.; PacifiCare of Nevada, Inc.; Physicians Health Choice of New York, Inc.; Physicians Health Choice of Texas, LLC; Preferred Partners, Inc.; Sierra Health and Life Insurance Company, Inc.; UHC of California; U.S. Behavioral Health Plan, California; Unimerica Insurance Company; Unimerica Life Insurance Company of New York; Unison Health Plan of Delaware, Inc.; Unison Health Plan of the Capital Area, Inc.; United Behavioral Health; UnitedHealthcare Benefits of Texas, Inc.;, Inc.; UnitedHealthcare Community Plan of Texas, L.L.C.; UnitedHealthcare Insurance Company; UnitedHealthcare Insurance Company of Illinois; UnitedHealthcare Insurance Company of New York; UnitedHealthcare Insurance Company of the River Valley; UnitedHealthcare Life Insurance Company; UnitedHealthcare of Alabama, Inc.; UnitedHealthcare of Arizona, Inc.; UnitedHealthcare of Arkansas, Inc.; UnitedHealthcare of Colorado, Inc.; UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Georgia, Inc.; UnitedHealthcare of Illinois, Inc.; UnitedHealthcare of Kentucky, Ltd.; UnitedHealthcare of Louisiana, Inc.; UnitedHealthcare of Mid- Atlantic, Inc.; UnitedHealthcare of the Midlands, Inc.; UnitedHealthcare of the Midwest, Inc.; United HealthCare of Mississippi, Inc.; UnitedHealthcare of New England, Inc.; UnitedHealthcare of New Mexico, Inc.; UnitedHealthcare of New York, Inc.; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Ohio, Inc.; UnitedHealthcare of Oklahoma, Inc.; UnitedHealthcare of Oregon, Inc.; UnitedHealthcare of Pennsylvania, Inc.; UnitedHealthcare of Texas, Inc.; UnitedHealthcare of Utah, Inc.; UnitedHealthcare of Washington, Inc.; UnitedHealthcare of Wisconsin, Inc.; UnitedHealthcare Plan of the River Valley, Inc. THIS NOTICE SAYS HOW YOUR FINANCIAL INFORMATION MAY BE USED AND SHARED. IT SAYS HOW YOU CAN GET ACCESS TO THIS INFORMATION. REVIEW IT CAREFULLY. Effective September 23, 2013 We 2 protect your personal financial information ( FI ). This means non-health information about someone with health care coverage or someone applying for coverage. It is information that identifies the person and is generally not public. Information We Collect We get FI about you from: Applications or forms. This may be name, address, age and social security number. Your transactions with us or others. This may be premium payment data. Sharing of FI We do not share FI about our members or former members, except as required or permitted by law. To run our business, we may share FI without your consent to our affiliates. This is to tell them about your transactions, such as premium payment. To our corporate affiliates, which include financial service providers, such as other insurers, and non-financial companies, such as data processors; To other companies for our everyday business purposes, such as to process your transactions, maintain your account(s), or respond to court orders and legal investigations; and Michigan 17

17 To other companies that perform services for us, including sending promotional communications on our behalf. Confidentiality and Security We limit access to your FI to our employees and service providers who manage your coverage and provide services. We have physical, electronic and procedural safeguards per federal standards to guard your FI. Questions About This Notice If you have any questions about this notice, please call the toll-free member phone number on the back of your health plan ID card or contact the UnitedHealth Group Customer Call Center at (TTY: 711). 2 For purposes of this Financial Information Privacy Notice, we or us refers to the entities listed in footnote 1, beginning on the first page of the Health Plan Notices of Privacy Practices, plus the following UnitedHealthcare affiliates: AmeriChoice Health Services, Inc.; Dental Benefit Providers, Inc.; HealthAllies, Inc.; MAMSI Insurance Resources, LLC; Managed Physical Network, Inc.; OneNet PPO, LLC; Oxford Benefit Management, Inc.; Oxford Health Plans LLC; Physicians Choice Insurance Services, LLC; ProcessWorks, Inc.; Spectera, Inc.; UMR, Inc.; Unison Administrative Services, LLC; United Behavioral Health of New York I.P.A., Inc.; United HealthCare Services, Inc.; UnitedHealth Advisors, LLC; UnitedHealthcare Service LLC; UnitedHealthcare Services Company of the River Valley, Inc.; UnitedHealthOne Agency, Inc. This Financial Information Privacy Notice only applies where required by law. Specifically, it does not apply to (1) health care insurance products offered in Nevada by Health Plan of Nevada, Inc. and Sierra Health and Life Insurance Company, Inc.; or (2) other UnitedHealth Group health plans in states that provide exceptions for HIPAA covered entities or health insurance products. UNITEDHEALTH GROUP HEALTH PLAN NOTICE OF PRIVACY PRACTICES: FEDERAL AND STATE AMENDMENTS Revised: September 23, 2013 The first part of this Notice (pages 14 18) says how we may use and share your health information ( HI ) under federal privacy rules. Other laws may limit these rights. The charts below: 1. Show the categories subject to stricter laws. 2. Give you a summary of when we can use and share your HI without your consent. Your written consent, if needed, must meet the rules of the federal or state law that applies. Summary of Federal Laws Alcohol and Drug Abuse Information We are allowed to use and disclose alcohol and drug abuse information that is protected by federal law only (1) in certain limited circumstances, and/or disclose only (2) to specific recipients. Genetic Information We are not allowed to use genetic information for underwriting purposes. Summary of State Laws General Health Information We are allowed to disclose general health information only (1) under certain limited circumstances, and/or (2) to specific recipients. CA, NE, PR, RI, VT, WA, WI HMOs must give enrollees an opportunity to approve or refuse disclosures, subject to certain exceptions. KY You may be able to restrict certain electronic disclosures of health information. NC, NV We are not allowed to use health information for certain purposes. CA, IA 18 Medicaid Certificate of Coverage (COC)

18 We will not use and/or disclose information regarding certain public assistance programs except for certain purposes. KY, MO, NJ, SD We must comply with additional restrictions prior to using or disclosing your health information for certain purposes. KS Prescriptions We are allowed to disclose prescription-related information only (1) under certain limited circumstances, and/or (2) to specific recipients. ID, NH, NV Communicable Diseases We are allowed to disclose communicable disease information only (1) under certain limited circumstances, and/or (2) to specific recipients. AZ, IN, KS, MI, NV, OK Sexually Transmitted Diseases and Reproductive Health We are allowed to disclose sexually transmitted disease and/or reproductive health information only (1) under certain limited circumstances, and/or (2) to specific recipients. CA, FL, IN, KS, MI, MT, NJ, NV, PR, WA, WY Alcohol and Drug Abuse We are allowed to use and disclose alcohol and drug abuse information (1) under certain limited circumstances, and/or disclose only (2) to specific recipients. AR, CT, GA, KY, IL, IN, IA, LA, MN, NC, NH, OH, WA, WI Disclosures of alcohol and drug abuse information may be restricted by the individual who is the subject of the information. WA Genetic Information We are not allowed to disclose genetic information without your written consent. CA, CO, IL, KS, KY, LA, NY, RI, TN, WY We are allowed to disclose genetic information only (1) under certain limited circumstances and/or (2) to specific recipients. AK, AZ, FL, GA, IA, MD, MA, MO, NJ, NV, NH, NM, OR, RI, TX, UT, VT Restrictions apply to (1) the use, and/or (2) the retention of genetic information. FL, GA, IA, LA, MD, NM, OH, UT, VA, VT HIV / AIDS We are allowed to disclose HIV/AIDS-related information only (1) under certain limited circumstances and/or (2) to specific recipients. AZ, AR, CA, CT, DE, FL, GA, IA, IL, IN, KS, KY, ME, MI, MO, MT, NY, NC, NH, NM, NV, OR, PA, PR, RI, TX, VT, WV, WA, WI, WY Certain restrictions apply to oral disclosures of HIV/AIDS-related information. CT, FL We will collect certain HIV/AIDS-related information only with your written consent. OR Behavioral Health We are allowed to disclose behavioral health information only (1) under certain limited circumstances and/or (2) to specific recipients. CA, CT, DC, IA, IL, IN, KY, MA, MI, NC, NM, PR, TN, WA, WI Disclosures may be restricted by the individual who is the subject of the information. WA Certain restrictions apply to oral disclosures of behavioral health information. CT Certain restrictions apply to the use of behavioral health information. ME Child or Adult Abuse We are allowed to use and disclose child and/or adult abuse information only (1) under certain limited circumstances, and/or disclose only (2) to specific recipients. AL, CO, IL, LA, MD, NE, NJ, NM, NY, RI, TN, TX, UT, WI Michigan 19

19 Member Rights and Responsibilities Your Rights To be treated with respect, consideration and recognition of your dignity and right to privacy no matter what your race, religion, color, age, sex, health condition, familial status, height, weight, disability or veteran s status. To receive information about all health services including a clear explanation of how to obtain services. To choose a personal doctor from our list of Primary Care Providers (PCPs). To file a grievance, to request a fair hearing or have an external review under the Patient s Right to Independent Review Act. To voice grievances or appeals about or the care it provides. To make recommendations regarding s member rights and responsibilities policies. To expect that your medical records and communications will be treated in a confidential manner as required by law. To expect staff and providers to comply with all enrollee rights requirements. To receive full information from your PCP or health care provider as to the nature and consequence of any treatment, test or procedure that may be involved in your health care. To participate in decisions involving your health care and make decisions to accept or refuse medical treatment or surgical treatment from your health care provider. To candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage. To ask for and receive information about, its services, its organization, UnitedHealthcare Community Plan providers and practitioners who provide health care services. To ask if has special financial arrangements with providers that can affect the use of referrals and other services that you might need. To get information, call and ask for information about our physician payment arrangements. To see any OB/GYN for well-woman exams or obstetrical care without a referral from your PCP. To see any pediatrician if you are under the age of 18 without a referral from your PCP. To get a copy of these rights and responsibilities or have them explained to you if you have any questions. Your Responsibilities To be an informed member. Read your Member Handbook and call UnitedHealthcare Community Plan if you have any questions. To understand your health problems and participate in developing mutually agreed-upon treatment goals to the degree possible. To call for approval of all hospitalizations, except for emergencies or for urgently needed services. To inform of any other health insurance coverage, so that your medical bills may be considered appropriately. To tell your PCP your complete health history. To tell the truth about any changes in your health. To supply information (to the extent possible) that and its providers need in order to provide care. 20 Medicaid Certificate of Coverage (COC)

20 To listen and follow your PCP s advice for care you have agreed on. To help them plan what treatment will work best for you. To know the name(s) of your medication(s). To know what they are for and how to use them. To report any emergency treatment within 48 hours to your PCP. Report an emergency stay at a hospital soon after. To always carry your UnitedHealthcare Community Plan ID card. To respect the rights of other patients, doctors, office staff and staff at UnitedHealthcare Community Plan. To tell if you move or change phone numbers. Tell us about changes that affect your health, like childbirth. Call customer service and keep us informed. 7.2 Member Complaint, Grievance and Appeal Procedure. UnitedHealthcare Community Plan has procedures for receiving, processing, and resolving Member complaints, grievances and appeals relating to the benefits or the operation of UnitedHealthcare Community Plan pursuant to the requirements of MCL and Michigan s Independent Review Act. The Member Complaint, Grievance and Appeal Procedure is fully described in the Member Handbook. Complaints, Grievances and Appeals not satisfactorily settled through this procedure may be appealed to the Department of Insurance and Financial Services (DIFS), Office of General Counsel Appeals Section, 611 West Ottawa, Third Floor, P.O. Box Lansing, MI , Members shall be required to exhaust UnitedHealthcare Community Plan Member Complaint, Grievance Procedure before submitting a request to DIFS for reconsideration of the grievance, unless the time frame for completion of an expedited internal appeal would seriously jeopardize the life or health of the Member or would jeopardize the Member s ability to regain maximum function. If a Member s life is in serious jeopardy, such condition must be substantiated by a physician either orally or in writing. In addition to other rights, the member may at anytime during the appeal process, within 90 calendar days of the adverse determination request a fair hearing with the Department of Community Health Administrative Law Tribunal by mailing the request form sent with the denial notice to: Michigan Administrative Hearings System For the Department of Community Health, P.O. Box 30763, Lansing, MI Members will receive a copy of the Member Handbook describing the Member Complaint, Grievance and Appeal Procedure when they enroll with UnitedHealthcare Community Plan and may receive additional copies at any time by telephone or written request to UnitedHealthcare Community Plan Customer Service Department. 7.3 Member Identification (ID) Cards will issue a ID card to each Member. A Member should present his or her ID card to a Participating Provider each time the Member obtains Covered Services If a Member permits the use of his or her ID card by any other person, UnitedHealthcare Community Plan may immediately reclaim the ID card and request termination of the Member s enrollment and the enrollment of all Members in the Member s household in accordance with Article XIII of this Certificate. Michigan 21