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