UnitedHealthcare Community Plan Florida Healthy Kids Member Handbook

Transcription

1 UnitedHealthcare Community Plan Florida Healthy Kids Member Handbook FLORIDA FHK-H-O-3/14-8/ / United HealthCare Services, Inc.

2 Important Information UnitedHealthcare of Florida, Inc. (Customer Service is available 24 hours a day, days a week) TDD (For the Hearing Impaired) UnitedHealthcare of Florida, Inc. online: Your Child s Primary Care Doctor(s): Use the spaces below to keep track of your child s primary care doctor and his or her phone number. Enrollee s Name: Primary Care Doctor s Name: Phone Number: Enrollee s Name: Primary Care Doctor s Name: Phone Number: Enrollee s Name: Primary Care Doctor s Name: Phone Number: Enrollee s Name: Primary Care Doctor s Name: Phone Number: Enrollee s Name: Primary Care Doctor s Name: Phone Number: Healthy Kids Member Handbook

3 Table of Contents Welcome New Member Checklist... 5 Helping People Live Healthier Lives myuhc.com Commonly Asked Questions Language and Cultural Help Well-Child Checkup Services Healthy First Steps Program for Pregnant Members Disease and Care Management Programs Emergency and Urgent Care NurseLine SM Services Covered Services Getting Prescriptions Services Not Covered by UnitedHealthcare Complaints and Grievance Procedures Enrollee Rights and Responsibilities Summary of Benefits Notice of Privacy Practices Florida 3

4 Welcome to UnitedHealthcare Community Plan Dear Parent: We take great pride in our organization and the quality of services we provide our members. There are many advantages to being a member of UnitedHealthcare of Florida, Inc. (UnitedHealthcare). We will coordinate your child s medical care, reduce paperwork, and provide quality service. Your child s ID card will be mailed soon. Your child s health plan ID card shows the effective date of coverage. This handbook will help answer any questions you may have regarding your child s health plan. Please read this handbook to help you use your child s health benefits. Keep it in a safe place for future use. If you have questions, please call our Customer Service Department 24 hours a day, 7 days a week, toll-free at ; TDD/For the Hearing Impaired at 711. Or visit us online at Our goal is to serve your child s health care needs and to help him or her stay healthy. Thank you for choosing UnitedHealthcare as your health care partner. 4 Healthy Kids Member Handbook

5 New Member Checklist Welcome to the Community We are happy to have you as a new member of UnitedHealthcare Community Plan. It s important that you complete this new member checklist. It will help you get the most out of your child s health plan. Review Member ID Card A few days ago you should have received your child s ID card. This card has the UnitedHealthcare Community Plan logo. You should have received a separate card for each member of your family who is enrolled in our plan. If you have not received your child s ID card, or if the information on the card isn t right, call Customer Service toll-free at or visit to print a card. Take your child s ID card with you when you go to the doctor or get a prescription. Keep this card with you at all times. This card is only for the person whose name is printed on the card. Never give this card to anyone else to use, not even other family members. Confirm or Choose Primary Care Provider (PCP) Your child s ID card may have the name of a Primary Care Provider (PCP) on it. If this is a doctor you have seen in the past and you want to keep seeing this doctor, you don t need to do anything. This doctor will be the main doctor for all of your child s health needs. If your child s card does not have a PCP listed, or if you want to change the PCP, call Customer Service at We will help you choose a doctor in your area. If your child already has a doctor, be sure to tell us the doctor s name. If the doctor is in our network, your child can keep seeing that doctor. Schedule First Appointment To stay as healthy as possible, it s important for your child to have regular well-child visits. Make an appointment now for your child to see the doctor. Don t wait until he/she is sick. Complete Health Risk Assessment You will soon receive a welcome phone call from us. We will call to explain all of your child s health plan benefits. We also will help you complete a survey about your child s health. This short survey helps us understand your child s needs so that we can serve you better. You can also visit our website and fill out the survey for your child online. Read Member Handbook Read through this handbook and keep it handy. It has important information about benefits and programs to stay healthy. It also has information about your rights and responsibilities. Florida 5

6 Helping People Live Healthier Lives Who is UnitedHealthcare Community Plan? UnitedHealthcare Community Plan is a state certified health maintenance organization (HMO). UnitedHealthcare serves almost one million members in Florida. UnitedHealthcare Community Plan is proud to be your partner in health care. We want your child to have the care he or she needs to stay healthy. We will work with you to get access to quality care when your child needs it. What is the Healthy Kids Program? Founded in 1990 by the State of Florida, the Florida Healthy Kids Corporation is a not-for-profit organization that provides low-cost health insurance coverage for children ages 5 through 18. About Your Physician and Health Care Provider Directory The UnitedHealthcare Physician and Health Care Provider Directory lists the doctors and providers your child can see in your area. Your child s doctor is your partner in health care choices. We assign a doctor to your child. If you wish to change your child s doctor, call Customer Service. Their telephone number is on the back of your child s ID card. It is important to stay in touch with your child s doctor. Call your child s doctor with any medical problems or questions. Your doctor s phone number is on your child s UnitedHealthcare ID card. You will get an ID card for your child and a Physician and Health Care Provider Directory in the mail. Your Child s Primary Care Doctor Your child s primary care doctor will see your child for all his or her medical needs. Call your child s primary care doctor for the following reasons: When your child is sick. When your child needs his or her annual checkup. When your child needs medical tests. When your child needs to go to the hospital. When your child has an emergency. You must call your child s primary care doctor every time your child has health care needs. He or she will make sure that your child receives the care that you need. Florida Healthy Kids and the Health Plan will not pay for any care or supplies if your child goes to a provider that does not belong to the Plan or if you don t call your child s primary care doctor first and get a referral for to see a specialist, except in an emergency. 6 Healthy Kids Member Handbook

7 You do not need a referral to see the following specialty providers: OB/GYN Optometry Podiatry Dermatologist Behavioral Health/Substance Abuse Professionals Chiropractors If you have more questions, you can call Customer Service for help. ID Card Every member of UnitedHealthcare Community Plan receives their own Florida Healthy Kids ID card. Carry your child s ID card with you at all times and show it each time your child receives medical care. Do not let anyone else use your child s ID card! Health Plan (80840) Member ID: Member: Subscriber Brown PCP Name: Provider Brown PCP Phone: (999) Effective Date 99/99/9999 Copay: OFFICE/SPEC/ER/UrgCare $5/$5/$10/$5 DOI-0501 Group: Payer ID: Rx Bin: Rx Grp: ACUFL Rx PCN: 9999 COPAY: TIER 1 $5 Florida Healthy Kids Underwritten by UnitedHealthcare of Florida, Inc. Florida 7

8 myuhc.com Manage Your Child s Health Care Information 24/7 on myuhc.com As the parent or guardian of a member of UnitedHealthcare Community Plan, you re just a click away from everything you need to take charge of your child s personal health benefits. Register on myuhc.com and see for yourself how its powerful tools and new features can save you time and help you stay healthy. Registration on the website is free. Great Reasons to Use myuhc.com Look up your child s benefits Find a doctor Print an ID Card Find a hospital Keep track of your child s medical history, prescriptions and more on your child s Personal Health Record Take a personalized Health Assessment of your child Get information on how to keep your child healthy Learn How to Stay Healthy Improve your child s health by taking an online Health Assessment Chat with a registered nurse in real-time Register on myuhc.com Today Registration is easy and immediate, and we encourage you to sign up today. Just visit and select Register on the Home Page. Follow the simple prompts. You re just a few clicks away from enjoying immediate access to all types of health care information. Get more from your child s health care. You can view and print your child s ID card online at myuhc.com/communityplan 8 Healthy Kids Member Handbook

9 Commonly Asked Questions Who Do I Call if I Have a Question or Need Help? Customer Service is glad to hear from you anytime. Customer Service can help you in many ways. Explain your child s health program, options and choices. Answer questions about how to get medical care when your child needs it. Changing doctors or changing your home address. Help you with any problems you may have with your child s health care. Customer Service is available 24 hours a day, 7 days a week. Call toll-free at , TDD/For the Hearing Impaired at 711 or visit us online at How Do I Get a Doctor s Appointment? Call your child s primary care doctor. The doctor s name and phone number is shown on your child s ID card. Give the office the following information: The primary care doctor s name. Your name. The name of the child who needs to see the doctor. Why your child needs to see the doctor. If you feel your child needs to see the doctor right away, tell this to the person who answers the phone. What If My Child Needs to See a Doctor Who is Not His or Her Primary Care Doctor? Your child s primary care doctor should always be seen first. This is the one doctor who knows your child best. He or she will help manage your child s medical care. This doctor also knows your child s health status and any prior problems. This doctor will make sure all the care your child gets works together to keep your child in the best of health. If you are away from home but within the state of Florida, you can always call another PCP in our statewide network available in all 67 counties. What if My Child Needs Medical Care When We re Out of Town? If your child needs emergency or urgent care while out of town, go immediately to the nearest Emergency Room (ER) or urgent care facility. You do not need a referral from your PCP. Call your PCP as soon as you can after your child gets ER or urgent care services. Out-of-Network Providers You or your PCP might decide that your child needs to see a doctor or provider that is not in our network. Your child s PCP will need to call us for an okay for these services before they will be covered. This is called a Prior Authorization. Florida 9

10 Commonly Asked Questions (cont.) No Medical Coverage Outside of the United States Any health care services your child gets while out of the country will not be covered by UnitedHealthcare Community Plan. Medicaid cannot pay for any medical services you get outside of the United States. Does Each of My Children Have to Have the Same Primary Care Doctor? No. Each child may have his or her own primary care doctor. What if I Want to Change My Child s Primary Care Doctor? You must pick a doctor that is listed in our Physician and Health Care Provider Directory. To change your child s primary care doctor, please call Customer Service, available 24 hours a day, 7 days a week. Call toll-free at , TDD/For the Hearing Impaired at 711. What Should I Do if I Get a Medical Bill? Sometimes you will get a bill that should have been sent to us. If you get a bill you believe we should pay, call Customer Service for help. What if I Move? Call Customer Service as soon as you can. If you move out of our service area, you will have to change health plans. You must also notify The Florida Healthy Kids Corporation if you move. Do I Have to Pay for Covered Services? You do not have to pay for covered services your child receives from a UnitedHealthcare network provider, but you may have to pay a copayment. If your child receives services from a provider that is not part of our network without prior approval from UnitedHealthcare or his or her primary care doctor, you will have to pay for these services, except for emergencies. What Do I Have to Pay? In the Healthy Kids Program, you make two kinds of payments: 1. The first kind of payment is called a premium. This is what you pay to the Florida Healthy Kids Corporation each month for your child to belong to Healthy Kids. 2. The second kind of payment is called a copayment. This is a payment you make to the doctor, hospital or pharmacy each time your child receives care. 10 Healthy Kids Member Handbook

11 For questions about your premiums and payments, please contact: Phone: :30 a.m. 7:30 p.m. Voice communication system available 24/7 Write: Florida Healthy Kids Corporation P.O. Box 980 Tallahassee, FL (Do not send premium payments to this address.) Address for Premium Payments: Florida Healthy Kids Corporation P.O. Box Tampa, FL You can make your Healthy Kids and KidCare payments by the internet or telephone 24 hours a day, 7 days a week. They accept Visa, Mastercard and Discover. You can also make payments directly from your checking or savings account. The system will let you know if a fee will be charged. Completion of a payment transaction over the internet or telephone does not guarantee coverage. What Are Premium Payments? You must pay a certain amount on a monthly basis to keep your child enrolled in Healthy Kids through UnitedHealthcare Community Plan. Healthy Kids payments are due 30 days in advance (for example, March 1 for April coverage), and payments must be received by the Florida Healthy Kids Corporation by the date indicated in your payment coupon. Your child may be removed from Healthy Kids (disenrolled) if you do not make these payments on time. In addition, your child will not be able to re-enroll for a minimum of 30 days. If you have any questions about premium payments, you may call The Florida Healthy Kids Corporation toll-free at KIDS ( ). Or, for your convenience, you may also visit the link below for other payment options. Payment Options link: Payment Options link: Florida 11

12 Commonly Asked Questions (cont.) Florida Healthy Kids Coverage Renewal Once a year, every family must renew their child s coverage. About two months before your child s renewal date, you will receive a letter from Florida Healthy Kids that includes a form with most of your current information already filled out. It is very important that you respond to this renewal letter and if you have any questions, please contact Florida Healthy Kids toll-free customer service department at (Monday through Friday from 7:30 a.m. to 7:30 p.m.) for assistance. What Are Copayments? Copayments are the specific dollar amounts you are required to pay at the time your child receives certain health care services. The copayment should be paid at the time of service. You should ask for a receipt from the location where the service was provided. If you have any questions about copayments, please call UnitedHealthcare s Customer Service, available 24 hours a day, 7 days a week. Call toll-free at , TDD/For the Hearing Impaired at 711. Or visit us online at You will be asked to pay a copayment when your child uses certain health care services: $5 copayment for doctor visits. No copayment for well-child care. $5 copayment per prescription. $10 for an ambulance ride to the hospital (this must be an emergency situation). $10 copayment for each visit to the emergency room (unless this is OK d by your doctor or if your child is admitted into the hospital). $10 for corrective lenses. Please see pages for a detailed description of your child s health care benefits. 12 Healthy Kids Member Handbook

13 Language and Cultural Help Clear communication is important. We can give you member materials in a language or format that is easier for you to understand. We have interpreters for you if your child s doctor does not speak your language. This is free when you speak to UnitedHealthcare or to your doctors. If you do not speak English, call Customer Service. They will connect you with an interpreter. Call toll-free , TDD/For the Hearing Impaired 711. If your child s doctor does not understand your cultural needs, we can help. We will work with your child s doctor or help you pick a new doctor. Call Customer Service for help. Si ou ta renmen resevwa dokiman manm ansanm avèk tiliv enfòmasyon sa a an Kreyòl, rele Sèvis Kliyan. Rele gratis nan nimewo Tiliv enfòmasyon pou manm yo disponib an Kreyòl sou sit wèb nou an. Remember: Member information is available in a different language, large print, Braille and audio tapes. Florida 13

14 Well-Child Checkup Services Well-Child Checkup Services Children need to see the doctor often. Wellchild care, including all shots, is critical to your child s future health. Here is a list of things that are part of a well-child care exam: Physical exam Health history Growth and development Vision Hearing Blood tests Shots Discussion of healthy eating habits Screening for lead poisoning Dr. Health E. Hound Program We are proud of our mascot Dr. Health E. Hound. His goal is to teach your kids about fun ways to stay fit and healthy. Dr. Health E. Hound loves to travel around the state and meet kids of all ages. He hands out flyers, posters, stickers and coloring books about healthy foods and exercise. He helps kids understand that going to the doctor is an important way to stay healthy. You and your family can meet Dr. Health E. Hound at some of our events. Come to an event and learn about healthy eating and exercise. Call your child s primary care doctor for appointments for well-child care services. 14 Healthy Kids Member Handbook

15 Healthy First Steps Program for Pregnant Members Healthy First Steps (A Program for Our Pregnant Members) A healthy mom is more likely to have a healthy baby. Pregnancy is an important time for a mom to take good care of herself and her unborn baby. Some risk factors can cause problems during pregnancy. These problems could cause early labor. A baby born too early may be sick or have to stay in the hospital. We want the best possible health for the mom and baby. We have a special program for pregnant members. Our Healthy First Steps program gives pregnant women the information, education and support they need during pregnancy. If a Healthy Kids member in your family is pregnant, call to enroll in Healthy First Steps at We want to help pregnant members have a healthy pregnancy. Our staff will help her get the care she needs. We can also help her get ready for the birth and care of her baby. It is important to see a doctor as soon as a member thinks she is pregnant. If you have problems finding a doctor or getting an appointment for her, we can help. We will also work with your child in locating community services such as Women, Infants and Children Program (WIC), behavioral health care and social services. Let Healthy First Steps make the member s pregnancy the healthiest it can be. Florida 15

16 Disease and Care Management Programs Our Personal Care Model is for members who have serious health problems or ongoing conditions. We want our members to enjoy the highest quality of life. We can help you take charge of your child s condition. We have disease management programs to help with conditions like asthma and diabetes. We can give you tips and educational materials. Our Care Managers can: Answer questions about your child s condition. Help you learn to control it. Help you get supplies you may need. Help you find community resources to help your child. Remind you about tests or treatments your child might need. Work with your child s PCP to help meet your own needs. 16 Healthy Kids Member Handbook

17 Emergency and Urgent Care What is a Medical Emergency? A medical emergency is an injury or illness that needs immediate treatment to avoid permanent damage to your child s health. If your child has an emergency as defined above, go to the nearest emergency room or call 911. Call your child s primary care doctor as soon as you can. Call your child s primary care doctor if your child has a problem that is not an emergency. Your child s doctor will tell you what to do. He or she may make an appointment for your child to be seen by him or her or someone else. Again, it is important to involve this doctor in all of your child s health care. This way, he or she can get a full picture of your child s needs. Below are examples of what are not emergencies: Colds and flu Earaches Headaches Sore throats Bruises and minor cuts Rashes Here are some examples of emergencies: Poisoning Serious burn Severe shortness of breath Severe chest pain Vomiting blood In an emergency, your child has the right to be treated in any hospital emergency room or be admitted to any hospital until your child is clinically stable. Clinically stable means that your child is well enough to be moved to a participating UnitedHealthcare Community Plan hospital or to go home. We will not pay for the emergency room visit if you take your child there and do not have an emergency. Your child s primary care doctor can be reached 24 hours a day, 7 days a week either directly or through an answering service. What is Urgent Care? Sometimes your child needs medical care quickly, but it is not an emergency this is called urgent care. Urgent care keeps the condition from becoming an emergency. You must contact your child s primary care doctor to get urgent care. He or she will treat your child, send your child to another network doctor or to an urgent care center in our network. Get care from your child s primary care doctor when your child gets sick. Don t wait until you have an emergency to call your child s doctor. Here are some examples of urgent care: A lasting fever Constant earaches A lasting rash Continual severe vomiting or diarrhea Florida 17

18 NurseLine SM Services As the parent or guardian of a member of UnitedHealthcare Community Plan, you can use our NurseLine. NurseLine gives you toll-free phone access, 24 hours a day, 7 days a week, to registered nurses. They understand your child s health care needs. Nurses with NurseLine have an average of 15 years of experience. NurseLine uses trusted, doctor-approved information to help you make the right decisions. All at no cost to you. Getting the best health care begins with asking questions and understanding the answers. NurseLine can help you: Decide if the emergency room or a doctor visit is right. Find a doctor or hospital. Understand treatment options. Teach you about health screenings and shots. Give you tips on how to keep your child healthy. Teach your child how to take medications so they work best. Call NurseLine services at TDD/For hearing impaired: Healthy Kids Member Handbook

19 Covered Services Below is a list of some of the care that is covered by UnitedHealthcare Community Plan. If you do not get care from your child s primary care doctor, we will not pay the bill. You do not need a referral for health emergencies or family planning services. If you have any questions about your child s health care benefits, call our Customer Service Department. Doctor Care Office Visits Allergy Care Blood Tests and X-Rays Well-Child Checkups Pap Smears, Breast X-Rays and Yearly Female Exams Birth Control Hospital Care Semi-Private Room Outpatient Surgery Blood Tests and X-Rays Emergency Room Prescription Drugs You must fill your prescription at a network pharmacy. Vision Care Eye exams and glasses Other Care Home Health Care Medical Equipment Family Planning Emergency Transportation Please see pages for a detailed description of your child s health care benefits. Questions About Dental Coverage? If you need information about dental services, call Florida Healthy Kids toll-free at Monday through Friday from 7:30 a.m. to 7:30 p.m. Florida 19

20 Getting Prescriptions How to Get a Prescription Drug Take your child s prescription and ID card to an in-network pharmacy. You will have to pay for the drug yourself if you do not go to an in-network pharmacy. You can find an in-network pharmacy in your Provider Directory or call Customer Service at All medications on our Preferred Drug List (PDL) will be covered when medically necessary. You can get information on pharmacies or the PDL from Customer Service. Or visit our website at The PDL can change, so your child s doctor should check each time a prescription is needed. Brand Name Drugs Instead of Generic Equivalents UnitedHealthcare Community Plan requires that generic drugs be used when available. Generic drugs have the same active ingredients as brand names. They are as safe and effective as brand names. If the doctor thinks your child needs a brand name instead of the generic, the doctor must get prior authorization. We will ask why the generic can t be used. If we do not approve the request, we will tell you how you can appeal. Prior Authorization Some medications on our PDL need prior authorization. This means they must be approved before you can get them. When a drug needs prior authorization, your child s doctor must contact Prescription Solutions at the number on the back of your child s ID card. They will review the doctor s request. The decision takes 24 hours. You and your child s doctor will be told the outcome. If the drug prescribed needs prior authorization and your child s doctor does not get it, you will not be able to get the drug. The pharmacist may give your child a 5-day emergency supply until we process the request. If we do not approve the request, we will tell you how you can appeal. Step Therapy Some drugs on the PDL require other drugs to be used first. This is called Step Therapy. Step Therapy drugs are covered if the required drug has been tried first. If the required drug has not been tried, your child s doctor must get prior authorization. We will ask the doctor to explain why your child can t use the required drug first. If we do not approve the request, we will tell you how you can appeal. Preferred Drug List (PDL): The list of medications that are covered by the plan. You ll find the most up-to-date list on our website: 20 Healthy Kids Member Handbook

21 Services Not Covered by UnitedHealthcare Community Plan The following are not included in our program: Any non-emergency health care given by an out-of-network provider without prior approval from UnitedHealthcare. Any care that does not improve your child s health or repair an injury. Any care not covered by Florida Healthy Kids. Phones and TVs used when in the hospital. Personal comfort items used in the hospital such as a barber. Use of an emergency room that is not for emergency care. Infertility services. Experimental treatments. Services that do not have a referral from your child s primary care doctor that require a referral. Health Services Unit Health plan doctors and nurses review some services to be sure your child is getting the services he or she needs. For some services, such as hospital services and home health care, your child s primary care doctor must call UnitedHealthcare s Health Services Unit for prior notification. Florida 21

22 Complaints and Grievance Procedures What if I Have Any Questions, Problems or Complaints About UnitedHealthcare Community Plan? If you have a question, problem or complaint about your child s benefits or medical care, please call UnitedHealthcare s Customer Service, available 24 hours a day, 7 days a week. Call toll-free at: ; TDD/For the Hearing Impaired: 711 Grievances If the Customer Service representative was not able to help you with your problem, you can ask to file a verbal grievance. You may also file a written grievance. Your written grievance should be sent to the following address: For medical: UnitedHealthcare of Florida, Inc. Attention: Grievance Department P.O. Box Salt Lake City, UT For behavioral health and substance abuse: United Behavioral Health Appeals 4170 Ashford Dunwoody Rd. Atlanta, GA If your grievance involves a dispute about payment of services, a copy of the claim or bill must be attached to your letter. You have 365 days from the date of the problem to file a grievance. We will make a final decision within 90 days. Sometimes we may need 14 more days to review your child s case. We will send you a letter if we need more time. We will only take more time if it could help you. Appeals If you are not happy with a decision we made, you may file an appeal. Your child s doctor can also file an appeal if he or she has your permission. You can call Customer Service or mail your appeal to the address below. For medical: UnitedHealthcare of Florida, Inc. Attention: Grievance Department P.O. Box Salt Lake City, UT For behavioral health and substance abuse: United Behavioral Health Appeals 4170 Ashford Dunwoody Rd. Atlanta, GA Your letter must have the following information: your child s name and member ID number, your contact information (name, telephone number and address), and the reason for your appeal. If services continue during an appeal of a denied authorization, you may have to pay for services in the case we rule against you. If you ask to appeal by phone, you will also need to send us your appeal in writing. You must send it to the address above within 30 days. We will make a decision on your appeal within 45 days. We may extend that time by 14 days if it will help you. A letter will be mailed to you with our decision. 22 Healthy Kids Member Handbook

23 You can ask for a quicker review of your appeal if the normal time may seriously affect your child s health. This is called an urgent appeal. When we get your request for an urgent appeal, we will make the decision if your appeal requires a fast review. If we decide that your appeal does not need a fast review, we will let you know. We will then process your appeal as a regular appeal. You can always call the Customer Service Department if you need more information on urgent appeals. If you are unhappy with our decision, you have the right to appeal to the Statewide Subscriber Assistance Program. You can send your appeal to: Agency for Health Care Administration Subscriber Assistance Program Bureau of Managed Health Care 2727 Mahan Drive, Building 1, MS# 26 Tallahassee, FL Toll Free Fraud Warning! Anyone who intentionally makes a false statement or a false claim in order to receive benefits, or in order to increase their benefits, is subject to prosecution for fraud, which may result in CRIMINAL PENALTIES. It may also result in the loss of your child s coverage under Florida Healthy Kids. If you suspect fraud, contact UnitedHealthcare s Customer Service, available 24 hours a day, 7 days a week. Call toll-free at , TDD 711 (For the Hearing Impaired). Please make sure your letter to the Subscriber Assistance Program includes the following information: our Plan name (UnitedHealthcare of Florida (FHK), your child s name and member ID number, your contact information, and the reason for your appeal. Florida 23

24 Enrollee Rights and Responsibilities You and Your Child Have a Right: To be treated with respect and in a manner that recognizes your need for privacy and dignity. To receive assistance in a prompt, courteous and responsible manner. To receive impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap, or source of payment. To be provided with information about the health care benefit plan and any exclusions and limitations associated with coverage. To be provided with information about the network of physicians and health care providers participating in the health care benefit plan. To be informed by your child s physician or other medical care provider of your child s diagnosis, prognosis, and plan of treatment in terms you understand. To be informed by your child s physician or other medical care provider about any treatment your child may receive; to have your child s medical care provider request your consent for all treatment, unless there is an emergency and your child s life and health are in serious danger. If written consent is required for procedures, such as surgery, be sure you understand the specific procedure or treatment, medical alternatives and associated risks, and why the procedure or treatment is advised. To make recommendations regarding UnitedHealthcare s Enrollee s Rights and Responsibilities. To be informed about available patient support services, including an interpreter. To refuse treatment and be advised of the probable consequences of your decision. UnitedHealthcare encourages you to discuss your objections with your child s medical care provider. To express a complaint about UnitedHealthcare and/or the care your child has received and to receive a response in a timely manner. To initiate the grievance procedure if you are not satisfied with UnitedHealthcare s decision regarding your complaint. You and Your Child Have a Responsibility: To learn how UnitedHealthcare works by carefully studying and referring to benefit and coverage documents. Please call UnitedHealthcare s Customer Service Department when you have questions or concerns about your child s coverage. To understand fully the information provided by UnitedHealthcare regarding your child s health care coverage and benefit plan. To know the proper use of UnitedHealthcare s services and procedures for obtaining coverage. To present your child s ID card prior to receiving services and to protect the unauthorized use of your child s ID card. To treat all UnitedHealthcare and provider network personnel respectfully and courteously. 24 Healthy Kids Member Handbook

25 To consult your child s primary care doctor for his or her direction prior to receiving medical care unless it is an emergency and your child s life and health are in serious danger. To keep scheduled appointments and notify your child s medical care provider s office promptly if you will be delayed or unable to keep an appointment. To pay all charges, if any, for copayments, non-covered benefits, and non-covered services. To establish a continuous and satisfactory relationship with your child s primary care doctor. To ask questions of your child s medical care provider and seek clarification until you fully understand the care your child is receiving. To follow the advice of your child s medical care provider and consider the likely consequences if you refuse to comply. To provide honest and complete information to those providing care and to those at UnitedHealthcare assisting you in obtaining coverage for care. To express your opinions, concerns, or complaints in a constructive manner to the appropriate people within UnitedHealthcare. Florida 25

26 Summary of Benefits This is a complete list of health care services covered by Healthy Kids. Inpatient Services in a Hospital Physician s services; room and board; general nursing care; patient meals; use of operating room and related facilities; use of intensive care unit and services; radiologic, laboratory and other diagnostic tests; drugs; medications; biologicals; anesthesia and oxygen services; special duty nursing; radiation and chemotherapy; respiratory therapy; administration of whole blood plasma; physical, speech and occupational therapy; medically necessary services of other health professionals. Copay None Limitations All admissions must be authorized by UnitedHealthcare. The length of the patient stay shall be determined based on the medical condition of the enrollee in relation to the necessary and appropriate level of care. Room and board may be limited to semi-private room accommodations, unless a private room is considered medically necessary or semi-private accommodations are not available. Private duty nursing is limited to circumstances where such care is medically necessary. Admissions for rehabilitation and physical therapy are limited to 15 days per contract year. Shall not include experimental or investigational procedures as defined as a drug, biological product, device, medical treatment or procedure that meets any one of the following criteria, as determined by UnitedHealthcare. 1. Reliable evidence shows the drug, biological product, device, medical treatment, or procedure when applied to the circumstances of a particular patient is the subject of ongoing phase I, II, or III clinical trials; or 2. Reliable evidence shows the drug, biological product, device, medical treatment or procedure when applied to the circumstances of a particular patient is under study with a written protocol to determine maximum tolerated dose, toxicity, safety, efficacy in comparison to conventional alternatives; or 3. Reliable evidence shows the drug, biological product, device, medical treatment, or procedure 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 U.S. Food and Drug Administration or the Department of Health and Human Services. 26 Healthy Kids Member Handbook

27 Emergency Services Covered Services include visits to an emergency room or other licensed facility if needed immediately due to an injury or illness and delay means risk of permanent damage to the enrollee s health. See page 17 for examples of conditions that need emergency care. Copay $10 per visit (waived if primary care doctor authorizes in advance or if admitted) Limitations Must use a UnitedHealthcare designated facility or provider for emergency care unless the time to reach such facilities or providers would mean the risk of permanent damage to Enrollee s health. See page 17 for more details. Pharmacy Prescribed drugs for the treatment of illness or injury. Copay $5 per prescription for up to a 31-day supply Limitations The UnitedHealthcare Community Plan Preferred Drug List (PDL) covers all prescribed drugs covered under the Florida Medicaid program. UnitedHealthcare Community Plan is responsible for the coverage of any drugs prescribed by member s dental provider under Healthy Kids. UnitedHealthcare Community Plan may implement cost utilization controls or a pharmacy benefit management program if Florida Healthy Kids gives permission. Brand name products are covered if a generic substitution is not available or where the prescribing physician requests a prior authorization for a brand name drug when it is medically necessary. All medications must be dispensed through one of our designated network pharmacies. All prescriptions must be written by the member s primary care physician, a UnitedHealthcare Community Plan approved specialist or consultant physician or member s dental provider. Contact United Behavioral Health if you have questions: Florida 27

28 Summary of Benefits (cont.) Outpatient Services Covered services include well-child care, including services recommended in the Guidelines for Health Supervision of Children and Youth as developed by Academy of Pediatrics; immunizations and injections as recommended by the Advisory Committee on Immunization Practices; health education counseling and clinical services; family planning services, vision screening; hearing screening; clinical radiologic, laboratory and other outpatient diagnostic tests; ambulatory surgical procedures; splints and casts; consultation with and treatment by referral physicians; radiation and chemotherapy; chiropractic services; podiatric services. Copay No copayment for wellchild care, preventive care or for routine vision and hearing screenings. $5 per office visit. Limitations Services must be pre-approved by UnitedHealthcare. Routine hearing and screening must be provided by primary care physician. Family planning limited to one annual visit and one supply visit each 90 days. Chiropractic services shall be provided in the same manner as in the Florida Medicaid program. Podiatric services are limited to one visit per day totaling two visits per month for specific foot disorders. Dental services must be provided by an oral surgeon for medically necessary reconstructive dental surgery due to injury. Immunizations are to be provided by the primary care physician. Treatment for temporomandibular joint (TMJ) disease is specifically excluded. Abortions may only be provided in the following situations: If the pregnancy is the result of an act of rape or incest; or, When a physician has found that the abortion is necessary to save the life of the mother. Shall not include experimental or investigational procedure as defined as a drug, biological product, device, medical treatment or procedure that meets any one of the following criteria, as determined by the Plan: 1. Reliable evidence shows the drug, biological product, device, medical treatment, or procedure when applied to the circumstances of a particular patient is the subject of ongoing phase I, II, or III clinical trials; or 2. Reliable evidence shows the drug, biological product, device, medical treatment or procedure when applied to the circumstances of a particular patient is under study with a written protocol to determine maximum tolerated dose, toxicity, safety, efficacy in comparison to conventional alternatives; or 3. Reliable evidence shows the drug, biological product, device, medical treatment, or procedure 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 U.S. Food and Drug Administration or the Department of Health and Human Services. 28 Healthy Kids Member Handbook

29 Maternity Services and Newborn Care Covered services include maternity and newborn care; prenatal care and postnatal care; initial inpatient care of adolescent participants, including nursery charges and initial pediatric or neonatal examination. Copay None Limitations Infant is covered for up to three (3) days following birth or until the infant is transferred to another medical facility, whichever occurs first. Coverage may be limited to the fee for vaginal deliveries. You do not need a referral for these services. Organ Transplantation Services Covered services include pre-transplant, transplant and post discharge services and treatment of complications after transplantation. Copay None Limitations Coverage is available for transplants and medically related services if deemed necessary and appropriate within the guidelines set by the Organ Transplant Advisory Council or the Bone Marrow Transplant Advisory Council. Florida 29

30 Summary of Benefits (cont.) Behavioral Health Services Covered services include inpatient and outpatient care for psychological or psychiatric evaluation, diagnosis and treatment by a licensed mental health professional. Copay Inpatient: None Outpatient: $5 per visit Limitations Prior to obtaining services, you must call United Behavioral Health (UBH) at , available 24 hours a day, seven (7) days a week. If you use a provider without first getting approval, the services will not be covered and you alone must pay the bill. All services must be provided directly by a UBH provider or must have received prior approval to see an out-of-network provider. United Behavioral Health provides free of charge, interpreter for potential and existing members whose primary language is not English. Covered services include inpatient and outpatient services for mental and nervous disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Such benefits include psychological or psychiatric evaluation, diagnosis and treatment by a licensed mental health professional meeting UBH requirements. Any benefit limitations, including duration of services, number of visits, or number of days for hospitalization or residential services, will generally be equal to those covered for physical illnesses. You do not need a referral for these services. 30 Healthy Kids Member Handbook

31 Substance Abuse Services Includes coverage for inpatient and outpatient care for drug and alcohol abuse including counseling and placement assistance. Outpatient services include evaluation, diagnosis and treatment by a licensed practitioner. Copay Inpatient: None Outpatient: $5 per visit Limitations Prior to obtaining services, you must call United Behavioral Health (UBH) at to obtain approval available 24 hours a day, seven (7) days a week. If you use a provider without first getting approval, the services will not be covered and you alone must pay the bill. All services must be provided directly by a UBH provider or must have received prior approval to see an out-of-network provider. United Behavioral Health provides free of charge, interpreter for potential and existing members whose primary language is not English. Covered services include inpatient, outpatient and residential services for substance disorders. Such benefits include evaluation, diagnosis and treatment by a licensed professional meeting UBH requirements. Any benefit limitations, including duration of services, number of visits, or number of days for hospitalization or residential services, will generally be equal to those covered for physical illnesses. You do not need a referral for these services. Therapy Services Covered services include physical, occupational respiratory and speech therapies for short-term rehabilitation where significant improvement in the enrollee s condition will result. Copay $5 per visit Limitations All treatments must be pre-approved by UnitedHealthcare. Limited to up to 24 treatment sessions within a 60-day period per episode or injury, with the 60-day period beginning with the first treatment. You do not need a referral for these services. Florida 31

32 Summary of Benefits (cont.) Home Health Services Includes prescribed home visits by both registered and licensed practical nurses to provide skilled nursing services on a part-time intermittent basis. Copay $5 per visit Limitations All services must be pre-approved by UnitedHealthcare. Coverage is limited to skilled nursing services only. Meals, housekeeping and personal comfort items are excluded. Private duty nursing is limited to circumstances where such care is medically appropriate. Hospice Services Covered services include reasonable and necessary services for palliation or management of an enrollee s terminal illness. Copay $5 per visit Limitations Services must be pre-approved by a participating UnitedHealthcare provider. Once a family elects to receive hospice care for an enrollee, other services that treat the terminal condition will not be covered. Services required for conditions totally unrelated to the terminal condition are covered to the extent that the services are otherwise covered under this contract. 32 Healthy Kids Member Handbook

33 Nursing Facility Services Covered services include regular nursing services, rehabilitation services, drugs and biologicals, medical supplies, and the use of appliances and equipment furnished by the facility. Copay None Limitations All admissions must be authorized by UnitedHealthcare and provided by a UnitedHealthcare affiliated facility. Participant must require and receive skilled services on a daily basis as ordered by a UnitedHealthcare participating physician. The length of the enrollee s stay shall be determined by the medical condition of the enrollee in relation to the necessary and appropriate level of care, but is no more than 100 days per contract year. Room and board is limited to semi-private accommodations unless a private room is considered medically necessary or semi-private accommodations are not available. Specialized treatment centers and independent kidney disease treatment centers are excluded. Private duty nurses, television, and custodial care are excluded. Admissions for rehabilitation and physical therapy are limited to 15 days per contract year. Durable Medical Equipment and Prosthetic Devices Equipment and devices that are medically indicated to assist in the treatment of a medical condition and specifically prescribed as medically necessary by enrollee s UnitedHealthcare physician. Copay None Limitations Equipment and devices must be provided by an authorized UnitedHealthcare supplier. Covered prosthetic devices include artificial eyes and limbs, braces, and other artificial aids. Low vision and telescopic lenses are not included. Hearing aids are covered only when medically indicated to assist in the treatment of a medical condition. Florida 33

34 Summary of Benefits (cont.) Refractions Examination by a UnitedHealthcare optometrist to determine the need for and to prescribe corrective lenses as medically indicated. Copay $5 per visit $10 for corrective lenses Limitations Enrollee must have failed vision screening by primary care doctor. Corrective lenses and frames are limited to one pair every two years unless head size or prescription changes. Coverage is limited to Medicaid frames with plastic or SYL non-tinted lenses. Transportation Services Emergency transportation as determined to be medically necessary in response to an emergency situation. Copay $10 per service Limitations Must be in response to an emergency situation. 34 Healthy Kids Member Handbook

35 Privacy Notices 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 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. 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. Florida 35

36 Privacy Notices (cont.) 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. 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 (STDs) 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. 36 Healthy Kids Member Handbook

37 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, 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 Florida 37

38 Privacy Notices (cont.) To File a Complaint. If you think your privacy rights have been violated, you may send a complaint at the address above. 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. 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 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 Customer Service number on the back of your health plan ID card or contact the UnitedHealth Group Customer Call Center at (TTY: 711). 38 Healthy Kids Member 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; 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.; UnitedHealthcare Community Plan, 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. 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. Florida 39

40 Privacy Notices (cont.) Revised: September 23, 2013 UNITEDHEALTH GROUP HEALTH PLAN NOTICE OF PRIVACY PRACTICES: FEDERAL AND STATE AMENDMENTS The first part of this Notice (pages 1 4) 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. 40 Healthy Kids Member Handbook

41 Summary of State Laws General Health Information We are allowed to disclose general health CA, NE, PR, RI, VT, WA, WI information only (1) under certain limited circumstances, and/or (2) to specific recipients. HMOs must give enrollees an opportunity to KY approve or refuse disclosures, subject to certain exceptions. You may be able to restrict certain electronic NC, NV disclosures of health information. We are not allowed to use health information for CA, IA certain purposes. We will not use and/or disclose information KY, MO, NJ, SD regarding certain public assistance programs except for certain purposes. We must comply with additional restrictions prior KS to using or disclosing your health information for certain purposes. Prescriptions We are allowed to disclose prescription-related ID, NH, NV information only (1) under certain limited circumstances, and/or (2) to specific recipients. Communicable Diseases We are allowed to disclose communicable disease AZ, IN, KS, MI, NV, OK information only (1) under certain limited circumstances, and/or (2) to specific recipients. 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. 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. Disclosures of alcohol and drug abuse information may be restricted by the individual who is the subject of the information. CA, FL, IN, KS, MI, MT, NJ, NV, PR, WA, WY AR, CT, GA, KY, IL, IN, IA, LA, MN, NC, NH, OH, WA, WI WA Florida 41

42 Privacy Notices (cont.) Summary of State Laws (continued) Genetic Information We are not allowed to disclose genetic information without your written consent. We are allowed to disclose genetic information only (1) under certain limited circumstances and/or (2) to specific recipients. Restrictions apply to (1) the use, and/or (2) the retention of genetic information. HIV / AIDS We are allowed to disclose HIV/AIDS-related information only (1) under certain limited circumstances and/or (2) to specific recipients. Certain restrictions apply to oral disclosures of HIV/AIDS-related information. We will collect certain HIV/AIDS-related information only with your written consent. Mental Health We are allowed to disclose mental health information only (1) under certain limited circumstances and/or (2) to specific recipients. Disclosures may be restricted by the individual who is the subject of the information. Certain restrictions apply to oral disclosures of mental health information. Certain restrictions apply to the use of mental health information. 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. CA, CO, 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, 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 OR CA, CT, DC, IA, IL, IN, KY, MA, MI, NC, NM, PR, TN, WA, WI WA CT ME AL, CO, IL, LA, MD, NE, NJ, NM, NY, RI, TN, TX, UT, WI 42 Healthy Kids Member Handbook

43 Notes Florida 43

44