UnitedHealthcare Community Plan Child Health Plus Handbook

Transcription

1 NEW YORK UnitedHealthcare Community Plan Child Health Plus Handbook January / United Healthcare Services, Inc.

2 Telephone Numbers/Translation Services Member Services Department (open 24 hours a day, 7 days a week) TDD/TTY (for the hearing impaired) UnitedHealthcare Community Plan CHP Billing Hotline Your Primary Care Physician:.... See Your UnitedHealthcare Community Plan ID Card Your Nearest Emergency Room:.... New York State Health Dept. (Complaints) New York State Child Health Plus Hotline Upstate County Departments of Social Services: Cayuga County Department of Social Services Herkimer County Department of Social Services Madison County Department of Social Services Oneida County Department of Social Services Onondaga County Department of Social Services Oswego County Department of Social Services New York City and Long Island: Nassau County Department of Social Services New York City Human Resources Administration New York City Human Resources Administration (within the 5 boroughs) New York Medicaid CHOICE Suffolk County Department of Social Services (Hauppauge) Suffolk County Department of Social Services (Riverhead) Suffolk County Department of Social Services (Ronkonkoma) Website Other Health Provider(s) Name: Phone: Name: Phone: Emergency Room: Phone: Local Pharmacy: Phone: Member Services is available 24 hours a day, 7 days a week at If you have trouble hearing, call AT&T TDD Relay Service at Child Health Plus Handbook

3 Table of Contents Welcome to UnitedHealthcare Community Plan s Child Health Plus Program How Managed Care Works How To Use This Handbook Help From Member Services Your Health Plan ID Card Part I First Things You Should Know How To Choose Your PCP How To Get Regular Care How To Get Specialty Care... 9 About Your Provider Directory Emergency Care Urgent Care We Want To Keep You Healthy Part II Benefits, Eligibility, Re-certification and Plan Procedures Covered and Non-Covered Services.. 12 Eligibility For Child Health Plus Renewing Your Child Health Plus Coverage Changes in Eligibility Premium Payments for Child Health Plus How The Premium Billing Process Works Billing Cycle for Premium Payments How Our Providers Are Paid You Can Help With Plan Policies Information From Member Services Keep Us Informed Commonly Asked Questions Covered Services Non-Covered Services Service Authorization and Actions (Prior Authorization and Timeframes) Prior Authorization and Timeframes Action Appeals External Appeals Complaints Process How To File A Complaint What Happens Next Complaint Appeals Member Rights and Responsibilities Advance Directives Notice of Privacy Practices This handbook will tell you how to use your UnitedHealthcare Community Plan. Put this handbook where you can find it when you need it. New York For Help Call Member Services at , TDD/TTY

4 Welcome Welcome to UnitedHealthcare Community Plan s Child Health Plus Program We are glad that you chose UnitedHealthcare Community Plan ( UnitedHealthcare Community Plan ). UnitedHealthcare Community Plan is a UnitedHealthcare of New York, Inc. company. We want to be sure you get off to a good start as a new member. In order to get to know you better, we will get in touch with you in the next two or three weeks. You can ask us any questions you have, or get help making appointments. If you need to speak with us before we call on you, however, just call us at This book may help you use your health benefits. Please read this book and keep it in a safe place for future use. You should keep this Member Handbook with your Child Health Plus Subscriber Contract. How Managed Care Works The Plan, Our Providers, and You No doubt you have seen or heard about the changes in health care. Many consumers now get their health benefits through managed care. Many counties in New York State, including New York City, offer their consumers a choice of managed care health plans. UnitedHealthcare Community Plan s Child Health Plus plan is available to members who live in New York City, Nassau, Suffolk, Cayuga, Madison, Oneida, Onondaga, Oswego, and Herkimer Counties. UnitedHealthcare Community Plan has contracts with the State Department of Health and the New York City Department of Health and Mental Hygiene to meet the health care needs of children with Child Health Plus. In turn, we choose a group of health care providers to help us meet your needs. These doctors and specialists, hospitals, labs and other health care facilities make up our provider network. You ll find a list in our provider directory. If you don t have a provider directory, call to get a copy. When you join UnitedHealthcare Community Plan, one of our providers will take care of you. Most of the time that person will be your Primary Care Provider (PCP). If you need to have a test, see a specialist, or go into the hospital, your PCP will arrange it. Your PCP is available to you everyday, day and night. If you need to speak to him or her after hours or weekends, leave a message and how you can be reached. Your PCP will get back to you as soon as possible. Even though your PCP is your main source for health care, in some cases, you can self-refer to certain doctors for some services. See page 9 for details. How to Use This Handbook Whether you have to join or you choose to join a managed care plan, this handbook will help. It will tell you how your new health care system will work and how you can get the most from UnitedHealthcare Community Plan. This handbook is your guide to health services. It tells you the steps to take to make the plan work for you. You should also have a Child Health Plus Subscriber Contract that was included with this Member Handbook 4 Child Health Plus Handbook

5 when your first joined our plan. Your Subscriber Contract includes information on eligibility, benefits and exclusions, premiums, terminations and other important information about your plan. The first several pages will tell you what you need to know right away. The rest of the handbook can wait until you need it. You should also reads your Subscriber Contract and refer to it anytime you have a question about your plan or call our Member Services department at You can also call the managed care staff at your local Department of Social Services. Please see the front inside cover for a list of Local Department of Social Services telephone numbers. Help From Member Services There is someone to help you at Member Services: 24 hours a day, 7 days a week. Just call If you have trouble hearing, call AT&T TTY/TDD Relay Service at 711. You can call to get help anytime you have a question. You may call us to choose or change your Primary Care Provider (PCP for short), to ask about benefits and services, to replace a lost ID card, to report the birth of a new baby or ask about any change that might affect you or your family s benefits. If you are or become pregnant, your child will become part of UnitedHealthcare Community Plan on the day he or she is born. This will happen unless your newborn child is in a group that cannot join managed care. You should call us and your local social services office right away if you become pregnant and let us help you to choose a doctor for your newborn baby before he or she is born. We offer free sessions to explain our health plan and how we can best help you. It s a great time for you to ask questions and meet other members. If you d like to come to one of the sessions, call us to find a time and place that are best for you. If you do not speak English, we can help. We want you to know how to use your health care plan, no matter what language you speak. Just call us and we will find a way to talk to you in your own language. We have a group of people who can help. We will also help you find a PCP (Primary Care Provider) who can serve you in your language. For people with disabilities: If you use a wheelchair, or are blind, or have trouble hearing or understanding, call us if you need extra help. We can tell you if a particular provider s office is wheelchair accessible or is equipped with special communications devices. Also, we have services like: TTY machine (Our TTY phone number is 711) Information in Large Print, Braille, or on Audio Tape Case Management Help in Making or Getting to Appointments Names and Addresses of Providers Who Specialize in Your Disability New York For Help Call Member Services at , TDD/TTY

6 Welcome (cont.) Your Health Plan ID Card After you enroll, we ll send you a welcome letter. Your UnitedHealthcare Community Plan ID card should arrive within 14 days after your enrollment date. Your card has your PCP s (Primary Care Provider s) name and phone number on it.. If anything is wrong, call us right away. Carry your ID card at all times and show it each time you go for care. If you need care before the card comes, your welcome letter is proof that you are a member. In an emergency go to nearest emergency room or call 911. Printed: 06/15/11 Health Plan (80840) Member ID: Group Number: Member: SUBSCRIBER BROWN Payer ID: PCP Name: DR. PROVIDER BROWN PCP Phone: (999) Rx Bin: Rx Grp: ACUNY Rx PCN: 9999 This card does not guarantee coverage. For coordination of care call your PCP For Members: TDD Mental Health: TDD For Providers: Medical Claims: PO Box 5240, Kingston, NY, UnitedHealthcare Community Plan for Kids 0501 Administered by UnitedHealthcare of New York, Inc. Pharmacy Claims: OptumRx, PO Box 29044, Hot Springs, AR For Pharmacist: Child Health Plus Handbook

7 Part I First Things You Should Know How to Choose Your PCP You may have already picked your PCP (Primary Care Provider) to serve as your regular doctor. This person could be a doctor or a nurse practitioner. If you have not chosen a PCP for your child(ren), you should do so right away. If you do not choose a doctor within 30 days, we will choose one for you. Each child can have a different PCP, or you can choose one PCP to take care of your enrolled children. You can either select a Pediatrician or a Family Practice provider as your child s PCP. With this Handbook, you should have a provider directory. This is a list of all the doctors, clinics, hospitals, labs, and others who work with UnitedHealthcare Community Plan. It lists the address, phone, and special training of the doctors. The provider directory will show which doctors and providers are taking new patients. You should call their offices to make sure that they are taking new patients at the time you choose a PCP. Women can also choose one of our OB/GYN doctors or midwives to deal with women s health issues. You never need a referral for You may want to find a doctor: Who you have seen before Who understands your health problems Who is taking new patients Who can serve you in your language Who is easy to get to family planning, well-woman care, or care during pregnancy. Women can have routine check ups and follow-up care if there is a problem, and regular care during pregnancy. There are no visit limits under this plan for OB/GYN care. We also contract with several Federally Qualified Health Centers (FQHC). All FQHCs give primary and specialty care. Some consumers want to get their care from FQHCs because the centers have a long history in the neighborhood. Maybe you want to try them because they are easy to get to. You should know that you have a choice. You can choose one of our providers. Or you can sign up with a Primary Care Provider at one of the FQHCs that we work with, listed in the Provider Directory. Just call Member Services at for help. In almost all cases, your doctors will be UnitedHealthcare Community Plan providers. In some cases you can continue to see another doctor that you had before you joined UnitedHealthcare Community Plan, even if he or she does not work with our plan. You can continue to see your doctor if: You are more than 3 months pregnant when you join and you are getting prenatal care. In that case, you can keep your doctor until after your delivery and post-partum care; or At the time you join, you have a life threatening disease or condition that gets worse with time. In that case, you can ask to keep your doctor for up to 60 days. In both cases, however, your doctor must agree to work with UnitedHealthcare Community Plan. New York For Help Call Member Services at , TDD/TTY

8 Part I First Things You Should Know (cont.) If you have a long-lasting illness, like HIV/AIDS or other long term health problems, you may be able to choose a specialist to act as your PCP (Primary Care Provider). Please call Member Services to request a specialist as your PCP. If you need to, you can change your PCP in the first 30 days after your first appointment with your PCP. After that, you can change your PCP three times during the year without cause, or more often if you have a good reason. If your provider leaves UnitedHealthcare Community Plan, we will tell you within 15 days from when we know about this. If you wish, you may be able to see that provider if you are more than three months pregnant or if you are receiving ongoing treatment for a condition. If you are pregnant, you may continue to see your doctor for the delivery, pre-natal and post-partum care. If you are seeing a doctor regularly for an ongoing condition, you may continue your present course of treatment for up to 90 days. Your doctor must agree to work with the Plan during this time. However, if your provider is leaving the plan is due to imminent harm to patient care, a determination of fraud or final disciplinary action taken by the NY State licensing board or other government agency, then you will not be eligible for transitional care with your provider. If any of these conditions apply to you, check with your PCP or just call Member Services at for help. How to Get Regular Care Regular care means exams, regular check-ups, shots or other treatments to keep you well, give you advice when you need it, and recommend you to the hospital or a specialist when needed. It means you and your PCP working together to keep you well or to see that you get the care you need. Day or night, your PCP is only a phone call away. Be sure to call him or her whenever you have a medical question or concern. If you call after hours or weekends, leave a message and where or how you can be reached. Your PCP will call you back as quickly as possible. Remember, your PCP knows you and knows how the health plan works. Your care must be medically necessary. The services you get must be needed: 1. To prevent, or diagnose and correct what could cause more suffering, 2. To deal with a danger to your life, 3. To deal with a problem that could cause illness, or, 4. To deal with something that could limit your normal activities. Your PCP will take care of most of your health care needs, but you must have an appointment to see your PCP. If ever you can t keep an appointment, call to let your PCP know. If you can, prepare for your first appointment. As soon as you choose a PCP, call to make a first appointment. Your PCP will need to know as much about your medical history as you can tell him or her. Make a list of your medical background, any problems you have now, and the questions you want to ask your PCP. In most cases, your first visit should be within three months of your joining the plan. 8 Child Health Plus Handbook

9 If you need care before your first appointment, call your PCP s office to explain the problem. He or she will give you an earlier appointment. (You should still keep the first appointment.) Use the following list as an appointment guide for our limits on how long you may have to wait after your request for an appointment: Adult baseline and routine physicals: within 12 weeks Urgent care: within 24 hours Non-urgent sick visits: within 3 days Routine, preventive care: within 4 weeks First pre-natal visit: within 3 weeks during 1st trimester (2 weeks during 2nd, 1 week during 3rd) First newborn visit: within 2 weeks of hospital discharge First family planning visit: within 2 weeks Follow-up visit after mental health/ substance abuse ER or inpatient visit: 5 days Non-urgent mental health or substance abuse visit: 2 weeks How to Get Specialty Care Sometimes you may have a health problem that your PCP will not treat because you need special medical attention. When that happens, your PCP will send you to a specialist, a doctor who is an expert in the care and treatment of certain medical problems. There are some treatments and services that your PCP must ask UnitedHealthcare Community Plan to approve before you can get them. You are not responsible for any of the costs except any co-payments as described in this handbook. Here are some examples of specialists: Cardiologist heart doctor Dermatologist skin doctor Hematologist doctor for blood problems Podiatrist foot doctor Ophthalmologist eye doctor When your PCP sends you to see a specialist he or she will give you the name of the specialist and may help make an appointment for you. Your PCP may give you a note on his or her letterhead or on a prescription form with the specialist s name and any important information the specialist needs to have when he or she sees you. If the specialist is not in the UnitedHealthcare Community Plan network, your PCP must call UnitedHealthcare Community Plan s Prior Authorization Department at and get authorization for you to go to a specialist that is not part of the UnitedHealthcare Community Plan network. The Specialist has to agree to work with UnitedHealthcare Community Plan and accept our payments as payment in full. This permission is called pre-authorization. Your PCP will explain all of this to you when he or she sends you to a specialist. Please refer to the Service Authorization and Appeals section for more information on what documentation your request for a non-participating provider should include. If UnitedHealthcare Community Plan determines that we do not have a specialist in our plan who can give you the care you need, we will get you the care you need from a specialist outside of our network. Of course, you will not pay for this care when approved. New York For Help Call Member Services at , TDD/TTY

10 Part I First Things You Should Know (cont.) If you have a long term disease or a disabling illness that gets worse over time, your PCP may be able to arrange for: Your specialist to act as your PCP; or You to go to a specialty care center that deals with the treatment of your problem. You can also call Member Services for help in getting access to a specialty care center. If you ever want to see a different specialist, talk to your PCP or call UnitedHealthcare Community Plan Member Services at About Your Provider Directory The UnitedHealthcare Community Plan Provider Directory lists the doctors and providers you can see in your area. Doctors that are not accepting new patients have a * behind their name. You may only pick a Primary Care Provider that is accepting new patients. Be sure your child receives health services only from UnitedHealthcare Community Plan participating providers and only according to plan requirements. You should have received a Provider Directory with this handbook and your Subscriber Contract when you joined our plan. We update our Provider Directory on a quarterly basis, please call Member Services at for an updated Provider Directory. Emergency Care You are always covered for emergencies. An Emergency is defined as: a medical or behavioral condition that comes on all of a sudden, and that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: 1. Placing the health of the person afflicted with such condition (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy; 2. Serious impairment to such person s bodily functions; 3. Serious dysfunction of any bodily organ or part of such person, or 4. Serious disfigurement of such person. This would make a person with an average knowledge of health fear that someone will suffer serious harm to body parts or functions or serious disfigurement without care right away. Examples of an emergency are: A heart attack or severe chest pain Bleeding that won t stop or a bad burn Broken bones Trouble breathing, convulsions, or loss of consciousness 10 Child Health Plus Handbook

11 When you feel you might hurt yourself or others If you are pregnant and have signs like pain, bleeding, fever, or vomiting Examples of non-emergencies are: colds, sore throat, upset stomach, minor cuts and bruises, or sprained muscles. If you have an emergency, here s what to do: If you believe you have an emergency, call 911 or go to the emergency room. You do not need your plans or your PCP s approval before getting emergency care, and you are not required to use our hospitals or doctors. If you are not sure, call your PCP. They will: Tell you what to do at home Tell you to come to the PCP s office Tell you to go to the nearest emergency room If you are out of the area when you have an emergency: Go to the nearest emergency room Urgent Care You may have an injury or an illness that is not an emergency but still needs prompt care. This could be a child with an ear ache who wakes up in the middle of the night and won t stop crying. It could be a sprained ankle, or a bad splinter you can t remove. You can get an appointment for an urgent care visit for the same or next day. Whether you are at home or away, call your PCP any time, day or night. If you cannot reach your PCP, call us at for assistance. We Want To Keep You Healthy Besides the regular check ups and the shots you and your family need, here are some other ways to keep you in good health: Classes for you and your family Stop-smoking classes Pre-natal care and nutrition Grief /Loss support Breast feeding and baby care Stress management Weight control Cholesterol control Diabetes counseling and self-management training Asthma counseling and self-management training Call Member Services at to find out more and get a list of services. Remember You do not need prior approval for emergency services. Use the emergency room only if you have an EMERGENCY. The emergency room should NOT be used for problems like flu, sore throats, or ear infections. If you have questions, call your PCP or UnitedHealthcare Community Plan at New York For Help Call Member Services at , TDD/TTY

12 Part II Benefits, Eligibility, Re-certification and Plan Procedures Covered and Non-Covered Services Please refer to your Child Health Plus Subscriber Contract for information on covered benefits and non-covered services. You can get information on covered services under Sections Three through Six of the Subscriber Contract. Non-covered services are described under Section Eight. Eligibility for Child Health Plus Eligibility for Child Health Plus is based on your family size and household income. Some children will qualify for free Child Health Plus coverage and others will be required to pay a monthly premium. We will let you know if you will be required to pay a monthly premium for your child(ren). In some cases, you may pay full premium if your household income exceeds the income limits set forth by the State of New York. Please refer to Section Two Who Is Covered of your Subscriber Contract. Renewing Your Child Health Plus Coverage (Re-certification) Your Child Health Plus coverage requires you to renew or re-certify your coverage every year. Each year, UnitedHealthcare Community Plan will ask you for information on your household income, your child s age, residency, and status of other insurance. This is required to renew or recertify your child(ren) s coverage. UnitedHealthcare Community Plan has to collect this information to determine if your child is still eligible for the Child Health Plus program, and to determine the premium amount you must pay monthly for coverage. UnitedHealthcare Community Plan will send you a Child Health Plus Recertification Form by mail two (2) to three (3) months before your recertification date. It will include a list of locations where you can get help completing your Recertification Form. It is important that you complete and return your Child Health Plus Recertification form to us before your recertification date. If you do not complete your recertification on time your child(ren) will lose coverage. See your Child Health Plus Subscriber Contract for more information. Changes in Eligibility If there are changes that affect your child s eligibility or your premium payment during the year, please call Member Services at to report the change. Here are some examples of changes in family circumstances: Your child(ren) move outside of the Plan s service area; or You get other health insurance coverage for your child(ren); and You have moved to a new address or changed your telephone number If any of the above changes occur, please notify Member Services at Our representatives will be happy to assist you with reporting these changes. Other changes in eligibility may also change the premium amount you pay for your coverage. These include:. A decrease in the household income from a job change, marriage or divorce, child support or other income source. An increase or decrease in the number of people in the child s household; 12 Child Health Plus Handbook

13 If you have a decrease in income or change in your household size, you can ask us for an Income Review. Remember, changes that affect eligibility or the monthly premium payment for your child must be reported within 60 days of the change. You can request an income review by writing to us at the address below. You should report any changes in your household size and provide your most recent monthly income. You are responsible to pay your current Child Health Plus. We will notify you when have completed our review. Please send your Income Review request to: UnitedHealthcare Community Plan 4316 Rice Lake Road Duluth, MN Attn: New York Enrollment Income Review How The Premium Billing Process Works UnitedHealthcare Community Plan will bill you each month for your premium amount. UnitedHealthcare Community Plan will bill you two months in advance of the month of coverage and payment is due one month prior to the month of coverage. We also provide a grace period for your payment to be received. Your payment must be received by UnitedHealthcare Community Plan on or before the last day of the grace period or coverage for your child(ren) will be terminated. You will have to re-apply to join Child Health Plus again. Premium Payments for Child Health Plus When you enrolled your child(ren) in Child Health Plus, you may be required to pay a premium for coverage. Child Health Plus is a pre-paid health plan which means you pay premiums prior to the month of coverage. This amount can vary for each family enrolled in Child Health Plus dependent upon your household income and size. Your premium payment must be received by UnitedHealthcare Community Plan on or before the last date of your grace period or your coverage will be terminated. New York For Help Call Member Services at , TDD/TTY

14 Part II Benefits, Eligibility, Re-certification and Plan Procedures (cont.) Billing Cycle for Monthly Premium Amounts of $9 through $60 per child per month If your monthly premium per child is between $9 and $60 per month, the below chart explains when we will send you a bill and when your payment is due. If you have more than three children covered with UnitedHealthcare Community Plan, you will only pay premium for up to three children. We recommend that you send your payment with enough time for us to receive it before the grace period has expired. Month Being Billed Bill Issued Payment Due Date Last Day of Grace Period January November 5 December 1 January 31 February December 5 January 1 February 28/29 March January 5 February 1 March 31 April February 5 March 1 April 30 May March 5 April 1 May 31 June April 5 May 1 June 30 July May 5 June 1 July 31 August June 5 July 1 August 31 September July 5 August 1 September 30 October August 5 September 1 October 31 November September 5 October 1 November 30 December October 5 November 1 December Child Health Plus Handbook

15 Billing Cycle for Full Monthly Premium Payors If you are required to pay a full monthly premium per child (generally over $100 per child per month), the below chart explains when we will send you a bill and when your payment is due. If you are paying full premium, you are required to pay a premium for each covered child in your household. Premiums are not limited to three children for full premium payors. We recommend that you send your payment with enough time for us to receive it before the grace period has expired. Month Being Billed Bill Issued Due Date Last Day of Grace Period January November 5 December 1 December 31 February December 5 January 1 January 31 March January 5 February 1 February 28/29 April February 5 March 1 March 31 May March 5 April 1 April 30 June April 5 May 1 May 31 July May 5 June 1 June 30 August June 5 July 1 July 31 September July 5 August 1 August 31 October August 5 September 1 September 30 November September 5 October 1 October 31 December October 5 November 1 November 30 Your premium payment must be received by us on or before the last day of the grace period or your child(ren) s coverage will be terminated. New York For Help Call Member Services at , TDD/TTY

16 Part II Benefits, Eligibility, Re-certification and Plan Procedures (cont.) How Our Providers are Paid You have the right to ask us whether we have any special financial arrangement with our physicians that might affect your use of health care services. You can call Member Services at if you have specific concerns. If our PCPs work in a clinic or health center, they probably get a salary. The number of patients they see does not affect this. Our PCPs who work from their own offices may get a set fee each month for each patient for whom they are the patient s PCP. The fee stays the same whether the patient needs one visit or many or even none at all. This is called capitation. Providers may also be paid by fee-for-service. This means they get a Plan-agreed-upon fee for each service they provide. You Can Help With Plan Policies We value your ideas. You can help us develop policies that best serve our members. If you have ideas tell us about them. Maybe you d like to work with one of our member advisory boards or committees. Call Member Services at to find out how you can help. Information From Member Services Here is information you can get by calling Member Services at : A list of names, addresses, and titles of UnitedHealthcare Community Plan s Board of Directors, Officers, Controlling Parties, Owners and Partners A copy of the most recent financial statements/balance sheets, summaries of income and expenses Information from the State Insurance Department about consumer complaints about UnitedHealthcare Community Plan How we keep your medical records and member information private In writing, we will tell you how UnitedHealthcare Community Plan checks on the quality of care to our members We will tell you which hospitals our health providers work with If you ask us in writing, we will tell you the guidelines we use to review conditions or diseases that are covered by UnitedHealthcare Community Plan If you ask in writing, we will tell you the qualifications needed and how health care providers can apply to be part of UnitedHealthcare Community Plan If you ask, we will tell you: 1) whether our contracts or subcontracts include physician incentive plans that affect the use of referral services, and, if so, 2) information on the type of incentive arrangements used; and 3) whether stop loss protection is provided for physicians and physicians groups 16 Child Health Plus Handbook

17 Information about how our company is organized and how it works A copy of the Plan s Preferred Drug Formulary. Please send all written requests to: UnitedHealthcare Community Plan Attn: Member Services 77 Water Street, 14th Floor New York, NY Keep Us Informed Call Member Services whenever these changes happen in your life: You change your name, address or telephone number You have a change in your household size You child becomes pregnant There is a change in insurance for your children Commonly Asked Questions How do I use the ID card? You will receive an ID card for your child after you enroll that shows that your child is a member of the UnitedHealthcare Community Plan Child Health Plus program. Carry the ID card with you at all times and show the ID card each time your child receives medical care. Showing your card makes sure that medical bills for covered services are not sent to you. Who do I call if I have a question? If you have questions or problems, call Member Services at , TTY 711. Member Services is available 7 days a week, 24 hours a day. We can help with: any concerns you may have about your child s health care benefits or services answers to questions about how to get services health education information errors on the UnitedHealthcare Community Plan ID card If you have questions about premium payment, please call toll-free Please have the UnitedHealthcare Community Plan ID card available when you call so we can help you sooner. What if I needed an interpreter? We can help you if you do not speak or understand English. If you need an interpreter, please call Member Services at and notify our representatives what languages you speak. How does my child s Primary Care Provider help? As an enrollee of UnitedHealthcare Community Plan, you must choose a Primary Care Provider for your child. New York For Help Call Member Services at , TDD/TTY

18 Part II Benefits, Eligibility, Re-certification and Plan Procedures (cont.) You may choose a different doctor for each child in your family. To help you decide what is best for you and your family, here are some definitions: Family practice doctors see patients of all ages from infants to adults for general health care. Internal medicine doctors (internist) treat diseases in adults. They do not do surgery or treat young children, but may treat children over the age of 16. Pediatricians are doctors who care for children from birth to age 16, sometimes 18. Your child s Primary Care Provider can help you with all of your child s health care needs and should always be a part of your child s medical care team. To help you with your child s medical needs, your Primary Care Provider and staff are available to you by telephone for advice or an appointment. He or she should: refer your child to a specialist when necessary give you advice or appointments admit your child to a hospital if medically necessary be called whenever possible if an emergency happens (unless it is life threatening). If your child is suffering from a life threatening injury or illness and you cannot call your child s primary care doctor, call 911 or go to your nearest emergency room. Can I select a different Primary Care Provider? Your child s Primary Care Provider is important to his/her health care. If you are unhappy with your child s PCP, please talk with him or her so that they know why you are unhappy. Your doctor can only correct a problem that he/she knows about. If you feel it will be better to change to another PCP, call Member Services at If you need help in finding a new PCP, Member Services will help you. After you change your child s PCP, be sure to have your child s medical records transferred to your new PCP. Do I need to make an appointment? Whenever possible, schedule your child s appointments in advance. This will save you time. If you think your child has a medical problem that needs your child s PCP s attention quickly, make sure you tell the person who is scheduling your appointment. If you cannot keep a scheduled appointment with your child s PCP, please call and cancel the appointment as soon as possible. Depending on the care you need, the doctor must be able to see your child within these time limits: urgent medical or behavioral problems within 24 hours; non-urgent sick visits within hours; routine, non-urgent or preventive care visits within 4 weeks; and in plan, non urgent mental health or substance abuse visits within 2 weeks. 18 Child Health Plus Handbook

19 If I can t get an appointment can I just go to the emergency room? Emergency rooms are for emergencies only. Your doctor is aware of your child s health care needs and is the best person to take care of your child. If your doctor decides emergency care is needed, the arrangements can be made quickly. Depending on whether you need an appointment for a check-up or for an urgent medical condition, your child s PCP should be able to schedule an appointment within the timeframes described under the How To Get Regular Care section of this handbook. Do I need to have my child s medical records transferred? If you choose a Primary Care Provider that your child has never been to before, it is important for you to have your child s medical records transferred as soon as possible. This will help your child s doctor provide your child with the best care possible. To transfer your child s records, call or write your former doctor and ask him or her to send those records to your child s new doctor. You can also ask your new Primary Care Provider to request a copy of your child(ren) s medical records to be transferred. Can I use my neighborhood pharmacy? To receive medicine prescribed by your child s doctor, you must go to one of the network pharmacies listed in the UnitedHealthcare Community Plan Provider Directory. Be sure to present your UnitedHealthcare Community Plan Member ID card to get prescriptions. What if my child needs a prescription while away? Prescriptions are covered outside of the service area if they are related to emergency care. You may have to pay for the emergency related prescription and request reimbursement for your out-of-pocket expense. There is no coverage for ongoing prescriptions while you are away from home. Do I have to pay for emergency services outside of the area? No. Physicians or providers should bill UnitedHealthcare Community Plan for emergency services your child receives while you are eligible for Child Health Plus and as a UnitedHealthcare Community Plan enrollee. Be sure to show your UnitedHealthcare Community Plan ID card whenever you receive services. You should present your UnitedHealthcare Community Plan ID card and ask the provider to bill UnitedHealthcare Community Plan directly, the claims address is on the back of your member ID Card. If for some reason you pay for services, be sure to request an itemized bill that shows diagnoses, services and the billed amount for each service. Please call UnitedHealthcare Community Plan Member Services at and a representative will assist you. You are covered for emergency and urgent care in the United States, Canada, the American territories of Puerto Rico, the Virgin Islands, Guam, Northern Mariana Islands, American Samoa, and American territorial waters. New York For Help Call Member Services at , TDD/TTY

20 Part II Benefits, Eligibility, Re-certification and Plan Procedures (cont.) Do I have to pay for any services? No. Child Health Plus enrollees do not pay for covered services from a contracted provider. All covered services are available for $0 copayment. You may have to pay for services if: Your child receives services from a provider that is not part of our network; or Your child receives services outside of the plan s services area ;or Your child receives non-emergency services from an emergency room. What if I don t pay the premium for my child? Some people have to pay a premium for their children enrolled in Child Health Plus. UnitedHealthcare Community Plan will bill you two months in advance of the month of coverage and payment is due one month prior to the month of coverage. We also provide a grace period for your payment to be received by us. Please refer to the billing cycle chart above to learn more about premium payments and due dates. Can my child s coverage be terminated? UnitedHealthcare Community Plan may, at its discretion, discontinue this benefit plan for the following reasons: a. Your failure to pay your child(ren) s monthly premium on time. b. Loss of eligibility for Child Health Plus (your child turns 19, becomes eligible for Medical Assistance or is enrolled in other health coverage). c. Providing us with false information. d. Allowing other people to use your child(ren) s ID card. e. You and your covered child(ren) have moved out of the services area. f. A written request from a member to terminate. g. Termination of the Child Health Plus agreement between UnitedHealthcare of New York, Inc. and the State of New York. h. Death. If you have to pay a premium, it is important that you pay the premium for each child enrolled with UnitedHealthcare Community Plan by the premium due date. If we do not receive your premium payment by the last day of the grace period, your child will be disenrolled from Child Health Plus. We will send you a written notice that your child s coverage will be terminated before the end of the grace period. If you have questions regarding whether or not UnitedHealthcare Community Plan has received your premium payment or want to know when your payment is due, call toll-free Child Health Plus Handbook

21 What if I have coverage with another plan? You are not eligible for Child Health Plus if your child(ren) are already covered under a comprehensive hospitalization and medical plan that covers the majority of services covered by this plan. Your child may enroll is this plan if your other health coverage is a limited benefits plan. If your child(ren) has coverage with another plan, medical benefits will be coordinated between this plan and the other plan. The other plan must pay first, then UnitedHealthcare Community Plan can consider a claim from a network provider for covered medical services if any portion of the charges were not paid by the other plan. Covered Services Please refer to your Child Health Plus Subscriber Contract for a list of covered services and benefits under this plan. Your Subscriber Contract describes the covered benefits under Sections 3, 4, 5 and 6 of the Child Health Plus Subscriber Contract. Non-Covered Services Please refer to your Child Health Plus Subscriber Contract for a list of non-covered services under this plan. Information regarding the coverage you may have with another plan should be provided to UnitedHealthcare Community Plan (call Member Services at ) and all your medical providers. Insurance fraud warning! Anyone who intentionally makes a false statement or a false claim in order to obtain insurance benefits, or in order to increase the amount of insurance benefits, is subject to prosecution for FRAUD, which may result in CRIMINAL PENALTIES. If you suspect FRAUD, contact the provider and ask for an explanation or request help from UnitedHealthcare Community Plan. New York For Help Call Member Services at , TDD/TTY

22 Part II Benefits, Eligibility, Re-certification and Plan Procedures (cont.) Service Authorization and Actions Prior Authorization: Prior Authorization There are some treatments and services that you need to get approval for before you receive them or in order to be able to continue receiving them. This is called prior authorization. You or someone you trust can ask for this. Your healthcare provider can ask for this on your behalf. The following treatments and services must be approved before you get them: Inpatient hospital admissions, including medical, behavioral health, surgical and maternity. Skilled Nursing Facility services. Home health care services Durable Medical equipment (DME) over $500 Prosthetic and Orthotic devices over $500 Cosmetic and Reconstructive surgery Gastric Bypass Evaluations and Surgery Infusion Therapy Hospice Services, inpatient and outpatient Advanced Radiology Services including Nuclear Radiology and Nuclear Medicine Scans, MRI, MRA, PET Scans and CT Scans Experimental or investigational health care services Out of Network or Out of State Services Mental Health or Substance Abuse Services, inpatient and outpatient Physical, Occupational and Speech Therapy after the 6th visit Transplant Evaluations Prescription drugs that are not on the preferred drug list. Asking for approval of a treatment or service is called a service authorization request. To get approval for these treatments or services, your doctor or health care provider must call UnitedHealthcare Community Plan s Prior Authorization Department at , or your physician or healthcare provider may send a request in writing or by facsimile (fax) at Written physician or healthcare provider requests can be sent to: UnitedHealthcare Community Plan Pre-Authorization Department 9700 Bissonnet Street, Suite 2700 Houston, TX You will also need to get prior authorization if you are getting one of these services now, but need to continue or get more of the care. This includes a request for home health care while you are in the hospital or after you have just left the hospital. This is called concurrent review. Home Health Care (HHC) services that follow an inpatient hospital admission are evaluated and determined in the same manner as if you are already getting the service now, but need to continue or get more of the care (concurrent review). What happens after we get your service authorization request: The health plan has a review team to be sure you get the services that are covered by our plan if medically necessary. Doctors and nurses are on the review team. Their job is to be sure the treatment or service you asked for is 22 Child Health Plus Handbook

23 medically needed and right for you. They do this by checking your treatment plan against medically acceptable standards. Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an initial denial decision. These decisions will be made by a qualified health care professional. If we decide that the requested service is not medically necessary, the decision will be made by a clinical peer reviewer, who may be a doctor or may be a health care professional who typically provides the care you requested. You or someone you trust can request the specific medical standards, called clinical review criteria, used to make the decision for actions related to medical necessity. After we get your request for service we will review it under a standard or expedited process. You or your doctor can ask for an expedited review if it is believed that a delay will cause serious harm to your health. If your request for an expedited review is denied, we will tell you and your case will be handled under the standard review process. If you are in the hospital or have just left the hospital and we received a request for home health care, we will handle the request as an Expedited review. We will tell you and your provider both by phone and in writing if your request is approved or denied. We will also tell you the reason for the decision. We will explain what options for appeals you will have if you don t agree with our decision. Timeframes for prior authorization requests: Standard review: We will make a decision about your request within 3 work days of when we have all the information we need, but you will hear from us no later than 14 days after we receive your request. We will tell you by the 14th day if we need more information. Expedited review: We will make a decision and you will hear from us within 3 work days. We will tell you by the third work day if we need more information. We will attempt to tell you our decision by phone and send a written notice later. Timeframes for concurrent review requests: Standard review: We will make a decision within 1 work day of when we have all the information we need, but you will hear from us no later than 14 days after we received your request. We will tell you by the 14th day if we need more information. With respect to requests for Home Health Care (HHC) immediately following an inpatient hospital admission, we will make a decision within 1 work day of when we have all the information we need, but you will hear from us no later than 14 days after we received your request or within seventy-two (72) hours of receipt of the necessary information when the day after the request date falls on a weekend or holiday. New York For Help Call Member Services at , TDD/TTY

24 Part II Benefits, Eligibility, Re-certification and Plan Procedures (cont.) Expedited review: We will make a decision within 1 work day of when we have all the information we need. However, if you are in the hospital or have just left the hospital, and you ask for home health care on a Friday or day before a holiday, we will make a decision no later than 72 hours of when we have all the information we need. In all cases you will hear from us no later than 3 work days after we received your request. We will tell you by the third work day if we need more information. We will attempt to tell you our decision by phone and send a written notice later. If we need more information to make either a standard or expedited decision about your service request we will: Write and tell you what information is needed. If your request is in an expedited review, we will call you right away and send a written notice later. Tell you why the delay is in your best interest. Make a decision no later than 14 days from the day we asked for more information. You, your provider, or someone you trust may also ask us to take more time to make a decision. This may be because you have more information to give the plan to help decide your case. This can be done by calling or by facsimile (fax) at Written physician or healthcare provider requests can be sent to: UnitedHealthcare Community Plan by UnitedHealthcare Grievance and Appeals 9700 Bissonnet Street, Suite 2700 Houston, TX You or someone you trust can file a complaint with the plan if you don t agree with our decision to take more time to review your request. You or someone you trust can file a complaint with the New York State Department of Health by calling We will notify you of our decision by the date our time for review has expired.. But if for some reason you do not hear from us by that date, it is the same as if we denied your service authorization request. If you are not satisfied with this answer, you have the right to file an action appeal with us. See the Action Appeal section later in this handbook. Other Decisions About Your Care Sometimes we will do a concurrent review on the care you are receiving to see if you still need the care. We may also review other treatments and services you have already received. This is called retrospective review. We will tell you if we conduct these reviews. 24 Child Health Plus Handbook

25 Grievances and Appeals There are some treatments and services that you need to get approval for before you receive them or in order to be able to continue receiving them. This is called prior authorization. Asking for approval of a treatment or service is called a service authorization request. This process is described earlier in this handbook. Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an appeal. If you are not satisfied with our decision about your care, the steps to request a review of a determination include provider reconsideration and an appeal are listed below Your provider can ask for reconsideration: If we made a decision that your service authorization request was not medically necessary or was experimental or investigational and we did not talk to your doctor, your doctor may ask to speak with the plan s Medical Director. The Medical Director will talk to your doctor within one workday. You can file a grievance: If you receive a denial or we fail to pay for a referral If you receive a denial for not a covered benefit. You can do this yourself or ask someone you trust to file the grievance for you. You can call Member Services at if you need help filing an appeal. We will not treat you any differently or act badly toward you because you filed a grievance The grievance can be made by phone or in writing. If you make an appeal by phone it must be followed up in writing. You must sign the written grievance that you send to us. You can ask someone you trust (such as a legal representative, a family member, or friend) can request a grievance for you. If you need our help because of a hearing or vision impairment, or if you need translation services, or help filing out the forms we can help you. We will not make things hard for you or take any action against you for filing a grievance What happens after we get your Grievance: Within 15 days, we will send you a letter to let you know we are working on your grievance The letter will tell you: That we received your grievance Who is working on your grievance How to contact someone at the Health Plan about your grievance If we need more information All grievances are resolved as quickly as possible, and no more than 48 hours after we receive all the necessary information when a delay would significantly increase the risk of your health or within 30 days after receiving all the necessary information regarding referrals or decisions regarding a covered benefit. New York For Help Call Member Services at , TDD/TTY

26 Part II Benefits, Eligibility, Re-certification and Plan Procedures (cont.) You will be notified in writing the reasons for our decision and the process for filing a grievance appeal. You can file an appeal: If you are not satisfied with what we decided about your service authorization request, you have 60 calendar days from the date of our letter/notice to you to file an appeal. You can do this yourself or ask someone you trust to file the appeal for you. You can call Member Services at if you need help filing an appeal. We will not treat you any differently or act badly toward you because you filed an appeal. The appeal can be made by phone or in writing. If you make an appeal by phone it must be followed up in writing. You must sign the written appeal that you send to us. You can ask someone you trust (such as a legal representative, a family member, or friend) can request an appeal for you. If you need our help because of a hearing or vision impairment, or if you need translation services, or help filing out the forms we can help you. We will not make things hard for you or take any action against you for filing an appeal. Please send all written appeals to: Attn: Member Complaints, Grievances and Appeals UnitedHealthcare Community Plan of New York PO Box Salt Lake City, UT Your action appeal will be reviewed under the Expedited/ Fast Track process if: If you or your doctor asks to have your action appeal reviewed under the expedited/ fast track process. Your doctor would have to explain how a delay will cause harm to your health. If your request for Expedited/ Fast Track is denied we will tell you and your action appeal will be reviewed under the standard process. If your request was denied when you asked to continue receiving care that you are now getting or need to extend a service that has been provided, or If your request was denied when you asked for home health care after you were in the hospital. Expedited/ Fast Track appeals can be made by phone and do not have to be followed up in writing What happens after we get your action appeal: Within 15 days, we will send you a letter to let you know we are working on your appeal. The letter will tell you: That we received your appeal Who is working on your appeal How to contact someone at the Health Plan about your appeal If we need more information Appeals of clinical matters will be decided by qualified health care professionals who did not make the first decision, at least one of whom will be a clinical peer reviewer. 26 Child Health Plus Handbook

27 Non-clinical decisions will be handled by persons who work at a higher level than the people who worked on your first decision. Before and during the appeal you or your designee can see your case file, including medical records and any other documents and records being used to make a decision on your case. You can also provide information to be used in making the decision in person or in writing. Call Member Services at if you are not sure what information to give us. If you are appealing our decision that the out-of-network service you asked for was not different from a service that is available in our network, ask your doctor to send us: 1. a written statement that the service you asked for is different from the service we have in our network; and 2. two pieces of medical evidence (published articles or scientific studies) that show the service you asked for is better for you, and will not cause you more harm than the service we have in our network. You will be given the reasons for our decision and our clinical rationale, if it applies. If you are still not satisfied, any further appeal rights will be explained or you or someone you trust can file a complaint with the New York State Department of Health at Timeframes for Appeals: Standard appeals: If we have all the information we need, we will tell you our decision in thirty (30) days from your action appeal. A written notice of our decision will be sent within 2 work days from when we make the decision. Expedited/Fast Track appeals: If we have all the information we need, expedited appeal decisions will be made in 2 working days from your action appeal. We will tell you in 3 work days after giving us your action appeal, if we need more information. We will tell you our decision by phone and send a written notice as well. If we need more information to make either a standard or expedited/fast track decision about your appeal we will: Write you and tell you what information is needed. If your request is in a expedited review, we will call you right away and send a written notice later. Tell you why the delay is in your best interest. You, your provider, or someone you trust may also ask us to take more time to make a decision. This may be because you have more information to give the plan to help decide your case. This can be done by calling or in writing. Please send written requests to: UnitedHealthcare Community Plan of New York PO Box Salt Lake City, UT You or someone you trust can file a complaint if you don t agree with our decision to take more time to review your request. You can file this complaint with the Health Plan by calling Member Services at (you have trouble hearing, call the TDD Relay Service at 711) or with the New York State Department of Health by calling New York For Help Call Member Services at , TDD/TTY

28 Part II Benefits, Eligibility, Re-certification and Plan Procedures (cont.) If your original denial was because we said: The service was not medically necessary, or The service was experimental, or the service was investigational, or The out-of-network service was not different from a service that is available in our network, and, We do not tell you our decision about your appeal on time, the original denial of service will be reversed. This means your service authorization request will be approved. External Appeals If the plan decides to deny coverage for a medical service you and your doctor asked for because the service not medically necessary; or the service was experimental or investigational; or; the out-of-network service was not different from a service that is available in our network; you can ask New York State for an independent external appeal. This is called an external appeal because it is decided by reviewers who do not work for the health plan or the State. These reviewers are qualified people approved by New York State. The service must be in the plan s benefit package, or be an experimental treatment, clinical trial, or treatment for a rare disease. You do not have to pay for an external appeal. Before you appeal to the State: 1. You must file an appeal with the plan and get the plan s final adverse determination; or 2. If you had an Expedited appeal and are not satisfied with the plan s decision you can choose to file a standard appeal with the plan or go directly to an external appeal; or 3. You and the plan may agree to skip the plan s appeals process and go directly to external appeal You have 45 days after you receive the plan s final adverse determination to ask for an external appeal. If you and the plan agreed to skip the plan s appeals process, then you must ask for the external appeal within 45 days of when you made that agreement. Additional appeals to your health plan may be available to you if you want to use them. However, if you want an external appeal, you must still file the application with the New York State Department of Financial Services within 45 days from the time the plan gives you the notice of final adverse determination or when you and the plan agreed to waive the plan s appeal process. You will lose your right to an external appeal if you do not file an application for an external appeal on time. To ask for an external appeal, fill out an application and send it to the New York State Department of Financ ial Services. You can call Member Services at if you need help filing an appeal. You and your doctors will have to give information about your medical problem. The external appeal 28 Child Health Plus Handbook

29 application says what information will be needed. Here are some ways to get an external appeal application: Call the New York State Department of Financial Services at, or its website at Contact the health plan at Your external appeal will be decided in 30 days. More time (up to five (5) work days) may be needed if the external appeal reviewer asks for more information. You and the plan will be told the final decision within two (2) days after the decision is made. If your provider has requested an external appeal of a concurrent adverse determination, including a provider trequesting the external appeal as your designee, the provider is prohibited from seeking payment, (except for any applicable copay) from you for services determined not to be medically necessary by the external appeal agent. You can get a faster decision if your doctor says that a delay will cause serious harm to your health. This is called an expedited external appeal. The external appeal reviewer will decide an expedited appeal in three (3) days or less. The reviewer will tell you and the plan the decision right away by phone or fax. Later, a letter will be sent that tells you the decision. Complaint Process Complaints: We hope our plan serves you well. Most problems can be solved right away. If you have a problem or dispute with your care or services you can file a complaint with the plan. Problems that are not solved right away over the phone and any complaint that comes in the mail will be handled according to our complaint procedure described below. How to File a Complaint with the Plan: If you have a problem please call Member Services at so they can assist you at If after discussing the problem with Member Services, you want to file a complaint, Member Services can help you do so or you can write to us at: Attn: Member Complaints, Grievances and Appeals UnitedHealthcare Community Plan of New York PO Box Salt Lake City, UT You can ask someone you trust (such as a legal representative, a family member, or friend) to file the complaint for you. If you need our help because of a hearing or vision impairment or if you need translation services, we can help you. We will not make things hard for you or take any action against you for filing a complaint. New York For Help Call Member Services at , TDD/TTY

30 Part II Benefits, Eligibility, Re-certification and Plan Procedures (cont.) You also have the right to contact the New York State Department of Health about your complaint at or write to: New York State, Department of Health, Division of Managed Care, Bureau of Managed Care Certification and Surveillance, Room 1911 Corning Tower ESP, Albany, NY You may also contact your local Department of Social Services with your complaint at anytime. You may call the New York State Insurance Department at if your complaint involves a billing problem. What happens next: If we don t solve the problem right away over the phone or after we get your written complaint, we will send you a letter within 15 work days. The letter will tell you: That we received your complaint Who is working on your complaint How to contact someone at the Health Plan about your complaint If we need more information Your complaint will be reviewed by one or more qualified people. If your complaint involves clinical matters, your case will be reviewed by one or more qualified health care professionals. After we review your complaint: We will let you know our decision in 45 days of when we have all the information we need to answer your complaint, We will write you and will tell you the reasons for our decision. When a delay would risk your health, we will let you know our decision in 48 hours of when we have all the information we need to answer your complaint. You will be told how to appeal our decision if you are not satisfied and we will include any forms you may need. If we are unable to make a decision about your Complaint because we don t have enough information, we will send a letter and let you know. Complaint Appeals: If you disagree with a decision we made about your complaint, you or someone you trust can file a complaint appeal with the plan. How to make a complaint appeal: If you are not satisfied with what we decide, you have 60 work days from the date of our letter/notice to you to file an appeal You can do this yourself or ask someone you trust to file the appeal for you 30 Child Health Plus Handbook

31 The complaint appeal must be made in writing. If you make an appeal by phone it must be followed up in writing. After your call, we will send you a form which is a summary of your phone appeal. If you agree with our summary, you must sign and return the form to us. You can make any needed changes before sending the form back to us. Please send all written correspondence to: UnitedHealthcare Community Plan Quality Management Dept. Complaint Appeals 77 Water Street, 14th Floor New York, NY After we get all the information we need, we will let you know our decision within 2 work days when a delay would risk your health. For all other complaint appeals, we will let you know our decision in 30 days. We will give you the reasons for our decision and our clinical rationale, if it applies. If you are still not satisfied, you or someone on your behalf can file a complaint at any time with the New York State Department of Health at ; or you can write to the NYS Department of Health, Division of Managed Care, Bureau of Managed Care Certification and Surveillance, Room 1911 Corning Tower ESP, Albany, NY What happens after we get your complaint appeal: After we get your complaint appeal we will send you an acknowledgement letter within 15 work days. The letter will tell you: That we received your complaint Who is working on your complaint appeal How to contact someone at the Health Plan about your complaint appeal If we need more information Your complaint appeal will be reviewed by one or more qualified people at a higher level than those who made the first decision about your complaint. If your complaint appeal involves clinical matters your case will be reviewed by one or more qualified health professionals, with at least one clinical peer reviewer, that were not involved in making the first decision about your complaint. New York For Help Call Member Services at , TDD/TTY

32 Part II Benefits, Eligibility, Re-certification and Plan Procedures (cont.) Member Rights and Responsibilities Your Rights As a member of UnitedHealthcare Community Plan, you have a right to: Be cared for with respect, without regard for health status, sex, race, color, religion, national origin, age, marital status or sexual orientation. Be told where, when and how to get the services you need from UnitedHealthcare Community Plan. Be told by your PCP what is wrong, what can be done for you, and what will likely be the result in language you understand. Get a second opinion about your care. Request a copy of the most recent individual direct pay subscriber contract. Give your OK to any treatment or plan for your care after that plan has been fully explained to you. Refuse care and be told what you may risk if you do. Get a copy of your medical record, and talk about it with your PCP, and to ask, if needed, that your medical record be amended or corrected. Be sure that your medical record is private and will not be shared with anyone except as required by law, contract, or with your approval. Use the UnitedHealthcare Community Plan complaint system to settle any complaints, or you can complain to the NY State Department of Health or the local Department of Social Services any time you feel you were not fairly treated. Appoint someone (relative, friend, lawyer,, etc.) to speak for you if you are unable to speak for yourself about your care and treatment. Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints. If You Get a Bill UnitedHealthcare Community Plan provides a full range of health care services at no cost to you. You never have to pay your PCP or any other UnitedHealthcare Community Plan participating provider anything. You should not be charged for any approved services offered through UnitedHealthcare Community Plan when you get them from an UnitedHealthcare Community Plan provider. If you are asked to pay for services by an UnitedHealthcare Community Plan provider, remind the office that you are covered by UnitedHealthcare Community Plan and present your UnitedHealthcare Community Plan Member ID card. You can also call Member Services at for help. You may be asked to pay for services that are not covered by Medicaid or UnitedHealthcare Community Plan. You cannot be charged for any such service unless you understood and agreed before the care was given that you would pay for it. 32 Child Health Plus Handbook

33 If you get a medical bill, call UnitedHealthcare Community PlanMember Services at , and a representative will help you straighten out the problem. Most bills should include a billing number you can call and give them your UnitedHealthcare Community PlanMember Identification number and ask them to bill UnitedHealthcare Community Plan. If you are asked to pay for a service and you are not sure whether it is covered, call UnitedHealthcare Community Plan Member Services at before paying for the service. If you paid a bill and you are seeking reimbursement, call UnitedHealthcare Community Plan Member Services at and a representative will assist you. Your Responsibilities As a member of UnitedHealthcare Community Plan, you agree to: Work with your PCP to guard and improve your health. Find out how your health care system works. Listen to your PCP s advice and ask questions when you are in doubt. Call or go back to your PCP if you do not get better, or ask for a second opinion. Treat health care staff with the respect you expect yourself. Tell us if you have problems with any health care staff. Call Member Services. Keep your appointments. If you must cancel, call as soon as you can. Use the emergency room only for real emergencies. Call your PCP when you need medical care, even if it is after-hours. Advance Directives There may come a time when you can t decide about your own health care. By planning in advance, you can arrange now for your wishes to be carried out. First, let family, friends and your doctor know what kinds of treatment you do or don t want. Second, you can appoint an adult you trust to make decisions for you. Be sure to talk with your PCP, your family or others close to you so they will know what you want. Third, it is best if you put your thoughts in writing. The documents listed below can help. You do not have to use a lawyer, but you may wish to speak with one about this. You can change your mind and these documents at any time. We can help you understand or get these documents. They do not change your right to quality health care benefits. The only purpose is to let others know what you want if you can t speak for yourself. Health Care Proxy With this document, you name another adult that you trust (usually a friend or family member) to decide about medical care for you if you are not able to do so. If you do this, you should talk with the person so they know what you want. New York For Help Call Member Services at , TDD/TTY

34 Part II Benefits, Eligibility, Re-certification and Plan Procedures (cont.) CPR and DNR You have the right to decide if you want any special or emergency treatment to restart your heart or lungs if your breathing or circulation stops. If you do not want special treatment, including cardiopulmonary resuscitation (CPR), you should make your wishes known in writing. Your PCP will provide a DNR (Do Not Resuscitate) order for your medical records. You can also get a DNR form to carry with you and/or a bracelet to wear that will let any emergency medical provider know about your wishes. Organ Donor Card This wallet sized card says that you are willing to donate parts of your body to help others when you die. Also, check the back of your driver s license to let others know if and how you want to donate your organs. 34 Child Health Plus Handbook

35 Privacy Notices HEALTH PLAN NOTICES OF PRIVACY PRACTICES Medical Information Privacy Notice 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 January 1, 2012 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 mail you a notice or we may provide you with a notice by , if permitted by law. We will post the new notice on your healthplan website We have the right to make changes apply to HI that we have and to future information. 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 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 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 Reminders on benefits or care. Such as appointment reminders. New York For Help Call Member Services at , TDD/TTY

36 Privacy Notices (cont.) 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. 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. To Notify of a Data Breach. To give notice of unauthorized access or disclosure of your HI. We may send notice to you or to your plan sponsor. 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. Mental health 3. Genetic tests 4. Alcohol and drug abuse 5. Sexually transmitted diseases 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 Summary of Federal and State Laws. 36 Child Health Plus Handbook

37 Except as stated in this notice, we use your HI only with your written consent. 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 HI that we use to make decisions about you. You must ask in writing. Mail it to the address below. 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. If we keep an electronic record, if and when we are required by law, you will have the right to ask for an electronic copy to be sent to you or a third party. We may charge a fee for this. 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) Prior to April 14, 2003; (ii) For treatment, payment, and health care operations; (iii) With you or with your consent; (iv) 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, 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 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. New York For Help Call Member Services at , TDD/TTY

38 Privacy Notices (cont.) 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. Financial Information Privacy Notice 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 January 1, 2012 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 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. We do regular audits to ensure secure handling. 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 Child Health Plus Handbook

39 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; American Medical Security Life Insurance Company; AmeriChoice of Connecticut, Inc.; AmeriChoice of Georgia, Inc.; AmeriChoice of New Jersey, Inc.; Arizona Physicians IPA, Inc.; Citrus Health Care, Inc.; Dental Benefit Providers of California, Inc.; Dental Benefit Providers of Illinois, Inc.; Evercare of Arizona, Inc.; Evercare of New Mexico, Inc.; Evercare of Texas, LLC; Golden Rule Insurance Company; Health Plan of Nevada, Inc.; MAMSI Life and Health Insurance Company; MD Individual Practice Association, 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; Physicians Health Choice of Texas, LLC; Sierra Health & Life Insurance Co., Inc.; UHC of California; U.S. Behavioral Health Plan, California; Unimerica Insurance Company; Unimerica Life Insurance Company of New York; Unison Family Health Plan of Pennsylvania, Inc.; Unison Health Plan of Delaware, Inc.; Unison Health Plan of Pennsylvania, Inc.; Unison Health Plan of Tennessee, Inc.; Unison Health Plan of the Capital Area, Inc.; United Behavioral Health; UnitedHealthcare Benefits of Texas, Inc.; UnitedHealthcare Community Plan of Ohio, Inc.; UnitedHealthcare Insurance Company; UnitedHealthcare Insurance Company of Illinois; UnitedHealthcare Insurance Company of New York; UnitedHealthcare Insurance Company of the River Valley; UnitedHealthcare Insurance Company of Ohio; 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 Great Lakes Health Plan, Inc.; UnitedHealthcare of the Midlands, Inc.; UnitedHealthcare of the Midwest, Inc.; United HealthCare of Mississippi, Inc.; UnitedHealthcare of New England, 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 South Carolina, Inc.; UnitedHealthcare of Texas, Inc.; UnitedHealthcare of Utah, Inc.; UnitedHealthcare of Washington, Inc.; UnitedHealthcare of Wisconsin, Inc.; UnitedHealthcare Plan of the River Valley, Inc. 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.; DBP Services of New York IPA, Inc.; DCG Resource Options, LLC; Dental Benefit Providers, Inc.; Disability Consulting Group, LLC; HealthAllies, Inc.; MAMSI Insurance Resources, LLC; Managed Physical Network, Inc.; Mid Atlantic Medical Services, LLC; OneNet PPO, LLC; Oxford Benefit Management, Inc.; Oxford Health Plans LLC; PacifiCare Health Plan Administrators, Inc.; PacificDental Benefits, Inc.; ProcessWorks, Inc.; Spectera of New York, IPA, 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. New York For Help Call Member Services at , TDD/TTY

40 Privacy Notices (cont.) UnitedHealth Group Health Plan Notice of Privacy Practices: Federal and State Amendments Revised: January 1, 2012 UNITEDHEALTH GROUP HEALTH PLAN NOTICE OF PRIVACY PRACTICES: FEDERAL AND STATE AMENDMENTS The first part of this Notice (pages 35 38) 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 & Drug Abuse Information We may use and share alcohol and drug information protected by federal law only (1) in limited cases, and/or (2) with certain recipients. Genetic Information We may not use genetic information for underwriting. 40 Child Health Plus Handbook

41 Summary of State Laws General Health Information We are allowed to share general health CA, NE, PR, RI, VT, WA, WI information only (1) in some limited cases, and/or (2) with certain persons or entities. HMOs must let enrollees approve or refuse KY sharing, with some exceptions. You may be able to limit certain electronic NV disclosures of health information. We may not use health information for CA certain purposes. We will not use and/or share information MO, NJ, SD about certain public assistance programs except for certain purposes. Prescriptions We may share prescription-related information ID, NH, NV only (1) in some limited cases, and/or (2) with certain persons or entities. Communicable Diseases We may share communicable disease AZ, IN, KS, MI, NV, OK information only (1) in some limited cases, and/or (2) with certain persons or entities. Sexually Transmitted Diseases and Reproductive Health We are allowed to share sexually transmitted disease and/or reproductive health information only (1) in some limited cases and/or (2) with certain persons or entities. Alcohol and Drug Abuse We may use and share alcohol and drug abuse information (1) in some limited cases, and/or (2) with certain persons or entities. Sharing of alcohol and drug abuse information may be limited by the person who is the subject of the information. CA, FL, HI, IN, KS, MI, MT, NJ, NV, PR, WA, WY CT, GA, HI, KY, IL, IN, IA, LA, NC, NH, WA, WI WA New York For Help Call Member Services at , TDD/TTY

42 Privacy Notices (cont.) Summary of State Laws (continued) Genetic Information We may not share genetic information without your written consent. We may share genetic information only (1) in some limited cases and/or (2) with certain persons or entities. Limits apply to (1) the use, and/or (2) the keeping of genetic information. HIV / AIDS We may share HIV/AIDS-related information only (1) in some limited cases and/or (2) with certain persons or entities. Certain limits apply to oral disclosures of HIV/ AIDS-related information. Mental Health We may share mental health information only (1) in some limited cases and/or (2) with certain persons or entities. Sharing may be limited by the person who is the subject of the information. Certain limits apply to oral disclosures of mental health information. Certain limits apply to the use of mental health information. Child or Adult Abuse We may use and share child and/or adult abuse information only (1) in some limited cases, and/or (2) with certain persons or entities. CA, CO, HI, IL, KS, KY, LA, NY, RI, TN, WY AK, AZ, FL, GA, IA, MD, MA, MO, NJ, NV, NH, NM, OR, RI, TX, UT, VT FL, GA, IA, LA, MD, NM, OH, UT, VA, VT AZ, AR, CA, CT, DE, FL, GA, HI, IA, IL, IN, KS, KY, ME, MI, MO, MT, NY, NC, NH, NM, NV, OR, PA, PR, RI, TX, VT, WV, WA, WI, WY CT, FL CA, CT, DC, HI, IA, IL, IN, KY, MA, MI, NC, NM, PR, TN, WA, WI WA CT ME AL, CO, IL, LA, NE, NJ, NM, RI, TN, TX, UT, WI 42 Child Health Plus Handbook

43 Notes New York For Help Call Member Services at , TDD/TTY

44