Medicaid Member Handbook

Transcription

1 NEBRASKA Medicaid Member Handbook Douglas, Lancaster, Sarpy, Cass, Dodge, Gage, Otoe, Saunders, Seward, Washington counties Member Services: TTY: 711 for the hearing impaired /13

2 Telephone Numbers Member Services TTY for the hearing impaired (Available 24 hours a day, 7 days a week) Interpreter services are available 24/7 NurseLine SM (Available 24 hours a day, 7 days a week) Care Management Healthy First Steps Block Vision Transportation AMR Access2Care Magellan Behavioral Health ACCESSNebraska Toll-Free Local in Lincoln Local in Omaha TTY Fax Medicaid Enrollment Center Toll-Free TTY Local in Lincoln TTY (Lincoln) Fax For an emergency, dial 911 or go to your nearest emergency room. Website myuhc.com/communityplan Addresses UnitedHealthcare of the Midlands, Inc N. 118th Street, Suite 300 Omaha, NE UnitedHealthcare of the Midlands, Inc O Street, Suite 301 Lincoln, NE Your Health Providers Name: Phone: Name: Phone: Pharmacy: Phone: If you have trouble seeing or reading this handbook, Member Services can help you. 2 Medicaid Member Handbook

3 Welcome to UnitedHealthcare Community Plan. Thank you for choosing us. You are our customer. You are important to us. We want to help you in an easy and caring manner. We work hard to improve the health and quality of life for our members. We look for ways to make our health plan better for you and your family every day. We are here to help you make good health decisions. You choose your own UnitedHealthcare Community Plan provider your Primary Care Provider (PCP) who will help you get medical care. We want you to visit your PCP often for regular and preventive care. We want to answer any questions you have about your health plan. We will help you choose or change your PCP, get care with a specialist or work with a Nurse Care Manager to help you with any special medical needs. This member handbook will help you learn how to use your health benefits. Please read it and keep it in a safe place for future use. It is our goal that when people ask you which health plan you have, you proudly say, UnitedHealthcare Community Plan. It s Great Coverage! Welcome aboard and thank you for becoming a part of our UnitedHealthcare Community Plan family. Kathleen A. Mallatt President UnitedHealthcare Community Plan Nebraska 3

4 Table of Contents Welcome to UnitedHealthcare Community Plan New Member Checklist Hour Language Help Member ID Card myuhc.com Getting Care Your Primary Care Provider (PCP) Changing Your PCP PCP Assignment for New Members Seeing Another Provider or Specialist How Soon Will I Get a Provider s Appointment? Second Opinions What if I Need Care and My Provider s Office Is Closed? Utilization Review How Does UnitedHealthcare Community Plan Decide if New Tests, Treatments and Technologies Should Be Covered Benefits? What if I Need Care When I Am Out of Town? Changes You Need to Report What if I Get a Medical Bill? What if I Want to Choose a Different Plan? How Do I Request Disenrollment From My Managed Care Plan, Before My 12-Month Re-Enrollment Period? What if I Need to See a Provider Who Is Not My UnitedHealthcare Community Plan Primary Care Provider? Member s Right to Refuse Treatment Provider Credentials Provider Incentive Plan No Medical Coverage Outside of the United States Transportation NurseLine SM Emergencies and Urgent Care What Is an Emergency? Urgent Care Care Covered by UnitedHealthcare Community Plan Medical Care Physicals Hospital Care Direct Access Services Hearing Care Vision Care Other Covered Care if Medically Necessary Care Management What Is Care Management? When Should I Ask for Care Management? How Can I Get Care Management Services? Medicaid Member Handbook

5 Care Management Program/Disease Management Speciality Disease Management Programs Women s Health Exams, Screenings Mammograms Family Planning Benefits for Mom and Baby Pregnant Women Healthy First Steps Baby Blocks Program Text4baby Program Breast Pumps Twitter Newborns and Mothers Health Protection Act Immunizations Programs to Keep You Healthy Sesame Street Dr. Health E. Hound Quality Improvement Services Not Covered by UnitedHealthcare Community Plan Services Covered by the State of Nebraska Mental Health and Substance Use Disorders Prescription Drugs Dental Urgent Care Centers Hospitals Federally Qualified Health Care Providers Additional Member Information Member Survey Member Advisory Group Members Rights and Responsibilities UnitedHealthcare Community Plan Rights and Responsibilities Statement Native American Access to Care Member Rights Member Responsibilities Grievances Quality Steps for Grievances Privacy of Records Appeals Continuation of Care State Fair Hearing Fraud and Abuse Advance Directives Glossary/Important Terms Health Plan Notices of Privacy Practices Grievance and Appeal Form Nebraska 5

6 Welcome to UnitedHealthcare Community Plan Welcome to the Community UnitedHealthcare Community Plan is a health plan that participates in Nebraska Medicaid. We give health coverage in partnership with the Nebraska Department of Health and Human Services (DHHS). With UnitedHealthcare Community Plan, you get all of your regular benefits plus more services. Welcome Call You will get a welcome call from one of our team members. We will tell you about your benefits. We will connect you with a provider. We will help you take a survey about your health. This helps us know your health needs to serve you better. Member Services Helping You Along the Way You can call us any time, any day. Our toll-free Member Services number is or TTY: 711 for the hearing impaired. They will help you with anything related to your plan. They can: Explain your plan, options and choices. Answer questions about how to get care. Help you with any problems you have with your health care. Help you with PCP changes if you need a new PCP for any reason. Help you file a grievance or ask for a State Fair Hearing. You may have a question before you get our call. Our Member Services can help you. We can answer your questions and help you get care. You can call Member Services toll-free at or TTY: 711 for the hearing impaired. Your Primary Care Provider (PCP) You have a choice of a provider. He or she will make sure you get the care you need to stay healthy. This provider is called your primary care provider (PCP). You should see your PCP for all your medical needs. There are no limits on the number of times you may see your provider. If your provider thinks you need to see a specialist, he or she can help you find one in our network. You do not need a referral to see a specialist. You may choose an Indian Health Service or tribal clinic provider as your PCP if you are a registered American Indian or Alaskan Native. Inside the front cover of this book is a space to write down the phone numbers of your providers. What Is Managed Care? Managed care provides covered health care and related services in a coordinated program with an emphasis on quality, access, service and value. Being a part of a managed care program means you have a care team helping you access your health care needs. Your care team is UnitedHealthcare Community Plan, your PCP, other health care providers you may use... and, most importantly, YOU. 6 Medicaid Member Handbook

7 New Member Checklist Welcome to the Community We are happy to have you as a new member of UnitedHealthcare Community Plan. Our first priority is your health. This book explains how to get the most out of your new health plan. To help, do this new member checklist. This will get you and your family on the path to good health. Review Member ID Card A few days ago you got an ID Card. If you don t have your ID Card, you can print your ID Card at myuhc.com/communityplan. The card has the UnitedHealthcare Community Plan logo on it. This is your member ID Card. You should have received a separate ID Card for each member of your family in our plan. Take your ID Card with you when you go to your provider 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 your card to anyone else to use, not even other members of your family. Confirm or Choose Primary Care Provider (PCP) Your ID Card may have the name of a provider or clinic on it. If this is a provider or clinic you have seen in the past and you want to continue to see this provider, you don t need to do anything. This provider will be your main provider for your health needs. If the provider s name on your card is not who you currently see, please call Member Services at or TTY: 711 for the hearing impaired. You can call 24 hours a day, 7 days a week. We will help you select a primary care provider in your area. If you already have a PCP, be sure to tell them your PCP s name. If the PCP is in our network, you can continue seeing that PCP. Complete Health Risk Assessment You will soon receive a welcome call from us. We will call to discuss all of your benefits. We also will make sure you have a PCP. We will help you complete a survey about your health. This short survey helps us understand your health needs so that we can serve you better. If you would like, you can call us at or TTY: 711 for the hearing impaired at a time that works best for you. Schedule First Appointment With Your Primary Care Provider (PCP) It is important to have regular wellness visits. Make an appointment now to see your PCP. Read Member Handbook After you have picked your PCP and set up your first visit, read this handbook. It has information about your health plan including programs to keep you healthy. It also has information about your rights and responsibilities. Nebraska 7

8 24-Hour Language Help Language Help 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 provider does not speak your language. This is free when you speak to us or your providers and is available 24 hours a day, 7 days a week. If you do not speak English, call Member Services at or TTY: 711 for the hearing impaired. They will connect you with an interpreter. For help to translate or understand this, please call or TTY: 711 for the hearing impaired. Para recibir ayuda para traducir o entender esto, llame al o al TTY: 711 para personas con problemas de audición. If you have trouble hearing over the phone, the Telecommunications Relay Service (TRS) can help. This service allows persons with hearing or speech disabilities to place and receive telephone calls. This service is free. Call 711, give them the Member Services number, or TTY: 711 for the hearing impaired, and they will connect you to us. If you need information in a language other than English, call Member Services. You can also get information in large print, Braille or audio format. Member Services or TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week) 8 Medicaid Member Handbook

9 Member ID Card Your UnitedHealthcare Community Plan Member ID Card You should have received your Member ID Card in the mail. Make sure the information is correct. If you have questions, call Member Services at or TTY: 711 for the hearing impaired. Every member of your family who has joined UnitedHealthcare Community Plan should have their own ID card. Keep your card with you at all times. Always bring your UnitedHealthcare ID card and your blue State Medicaid card to your medical appointments and pharmacy visits. Never give your ID Card to anyone else to use. Call Member Services at or TTY: 711 for the hearing impaired if you lose your card or need to correct some of the information. You can view and print your ID Card online at myuhc.com/communityplan. Your UnitedHealthcare Community Plan Member ID Card will look like this: In an emergency go to nearest emergency room or call 911. Printed: 04/11/11 Health Plan (80840) Member ID: Member: SUBSCRIBER BROWN Medicaid Number: PCP Name: DR. PROVIDER BROWN PCP Phone: (999) Payer ID: Group: NESHAD Rx Bin: Rx Grp: ACUNE Rx PCN: 9999 Effective Date 05/01/2008 Copays may apply, Rx Drugs not covered 0501 Administered by UnitedHealthcare of the Midlands, Inc. This card does not guarantee coverage. For coordination of care call your PCP. To verify benefits or to find a provider, visit the website or call. For Members: TTY Block Vision: TTY 711 Transportation: TTY NurseLine: TTY 711 For Providers: Medical Claims: PO Box 31365, Salt Lake City, UT Important Things to Remember About Your Member ID Card Check your eligibility It is very important you know if you are covered before you get a service. Your card does not guarantee coverage. Eligibility can change often. Even though you have a card, your coverage may have stopped. Show the card to your provider when you get medical services and medications. The provider will use the information on the card to check on your coverage and see if you are eligible. The provider may be able to tell you if your card will cover a service. It is recommended that you contact Customer Service to find out if your plan will cover certain services. Nebraska 9

10 Access Your Information Online Manage Your Health Care Information 24/7 on myuhc.com As a member of a UnitedHealthcare Community Plan, you re just a click away from everything you need to take charge of your health benefits. Register on myuhc.com. The tools and new features can save you time and help you stay healthy. Registration on the site is free. Great Reasons to Use myuhc.com Look up your benefits Find a provider Print an ID Card Find a hospital View claims history Keep track of your medical history, prescriptions and more on your Personal Health Record Take your own Health Assessment Learn how to stay healthy Learn How to Stay Healthy Improve your health with an online Health Assessment Chat with a nurse in real-time Register on myuhc.com Today Registration is easy and fast. Sign up today! Just visit myuhc.com/communityplan. Select Register on the Home Page. Follow the simple prompts. You re just a few clicks away from access to all types of information. Get more from your health care. You can view and print your ID Card online at myuhc.com/communityplan 10 Medicaid Member Handbook

11 Getting Care Your Primary Care Provider (PCP) Your Primary Care Provider (PCP) is your personal care provider. A PCP can be a family or general practitioner, internist, pediatrician, or other type of provider. Your PCP is shown on your ID Card. When you enroll, you will be asked to choose a participating UnitedHealthcare Community Plan Primary Care Provider (PCP). If you do not choose a PCP within 10 days of your enrollment with our plan, a PCP will be selected for you. UnitedHealthcare Community Plan will do our best to choose a PCP for you and your family that is close to your home. You may choose an Indian Health Service or tribal clinic provider as your PCP if you are a registered American Indian or Alaskan Native. You can also find a list online at myuhc.com/communityplan. Your Primary Care Provider (PCP) is your Medical Home. A Medical Home helps make sure you get the right medical care when you need it. Your PCP will give or manage most of your health care. Talk to your PCP about any health problems you have. Let your PCP know about your medical history. Tell them about any specialists that you are seeing. Follow all your PCP s instructions. Part of good health is seeing your PCP for checkups, even if you don t feel sick. UnitedHealthcare Community Plan will send you a reminder so you know when to go for a checkup. When you don t feel well, your PCP will help you. Be sure to call your PCP right away. Your PCP may refer you to a specialist. Changing Your PCP You may change your PCP at any time. If you want to change your PCP, we can help you find a new one. Call Member Services at or TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week). Or you may pick a new PCP from our online Provider Directory at myuhc.com/communityplan. Or you can ask Member Services to mail you a printed copy of the directory at no cost. Most changes to your PCP will take place the first day of the next month. When picking a PCP, you may want to consider their specialty, language, location and gender. If your PCP does not speak your language, call Member Services for an interpreter or to find a PCP who speaks your language. UnitedHealthcare Community Plan will get you a telephonic interpreter at no cost to you. Member Services or TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week) Nebraska 11

12 Getting Care (cont.) Does Each Family Member Need to Have the Same Provider? No. Each family member may pick their own PCP. PCP Assignment for New Members If you are a new UnitedHealthcare Community Plan member, you will be asked to select a PCP for you and your family within 10 days of your enrollment with our plan. If you do not pick a PCP in 10 days, we will select one for you. We will assign you to a PCP that is closest to your area and accepting new patients. We will mail you a new Member ID card with your PCP s name and their phone number. You can change your PCP at any time, for any reason by calling Member Services. You can also request a new, duplicate or corrected Member ID card by calling Member Services. Remember to make an appointment for you and your family to meet your new PCP. Seeing Another Provider or Specialist Your PCP might want you to go to a specialist. A specialist is a provider who treats a special health problem. Your provider will help you find the right specialist. If you have a complex illness, you may need to see the specialist many times. You may see your specialist as often as needed. If you have complex care needs, a specialist can be your PCP. If you need this, call Member Services at (TTY: 711). We will help you find a specialist who can meet your needs. How Soon Will I Get a Provider s Appointment? Appointments for: Primary Care Provider (PCP) services: Emergency PCP appointments within same day of request. PCP availability for health care services are available to members 24 hours a day, 7 days a week. Urgent care PCP appointments within 2 calendar days of request. Routine or preventive care PCP appointments within 14 working days of request. Specialist services: Routine care appointments within 30 working days of referral. Prenatal care services: First trimester within 14 working days of request. Second trimester within 7 working days of request. High-risk pregnancies within 3 working days of referral by a network maternity care provider or immediately if an emergency exists. Once You Have Made the Appointment Be on time. If you cannot keep the appointment, call the doctor right away. If you need to cancel, please call at least 24 hours in advance. Second Opinions You can get a second opinion for your health care at no cost. Call your PCP if you want a second opinion. You can also call Member Services at or TTY: 711 for the hearing impaired. 12 Medicaid Member Handbook

13 What if I Need Care and My Provider s Office Is Closed? Call your PCP if you need care that is not an emergency. Your provider s phone is answered 24 hours a day, 7 days a week. Your provider or someone from the office will help you make the right choice for your care. You may be told to: Go to an after-hours clinic or urgent care center Go to the office in the morning Go to the Emergency Room (ER) Get medicine from your pharmacy Call NurseLine: Utilization Review UnitedHealthcare Community Plan reviews all the care you receive to make sure that UnitedHealthcare Community Plan covers it and it is the right care for your condition. There are also some treatments and procedures we need to review before you can get them. Your providers know what they are, and they take care of letting us know to review them. The review we do is called Utilization Review. The way we pay our staff, that makes these decisions, is not related to what they decide. UnitedHealthcare Community Plan pays its Primary Care Providers (PCP) and its specialists every time they see one of our members. This is known as Fee-For-Service. We pay hospitals and all other types of providers in our network the same way they get paid every time you see them or get services from them. We never hold back any payments to any of our providers for giving too much service. If you want to find out about financial arrangements UnitedHealthcare Community Plan has with your provider, call Member Services at or TTY: 711 for the hearing impaired. How Does UnitedHealthcare Community Plan Decide if New Tests, Treatments and Technologies Should Be Covered Benefits? A group of providers and nurses decide. They look at what has been written in medical journals. They review guidelines issued by national provider groups or other leading health organizations. They study company information to see if health improves. If you have any questions about your health care benefits, call Member Services at or TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week). What if I Need Care When I Am Out of Town? UnitedHealthcare Community Plan will pay for routine care out-of-area only if: You call your PCP first and he or she says that it is important that you get care before you return home. Nebraska 13

14 Getting Care (cont.) Your PCP must then call UnitedHealthcare Community Plan to get approval. If you do not speak to your PCP before you get routine care when you are away from home, you may have to pay for care yourself. If you cannot reach your PCP, please call Member Services. Any provider you see must agree to accept Nebraska Medicaid payment. This means, for example, if you or your family members are on vacation and need routine care, UnitedHealthcare Community Plan will pay only if you get approval from UnitedHealthcare Community Plan first. If you need emergency care when you are out of town, go immediately to the Emergency Room (ER) at the nearest hospital. You do not need an authorization from your PCP to go to the ER, but you should call your PCP as soon as you can after receiving ER services. If you need to get to the ER fast, call 911. There is no cost to you for ER services or emergency ambulance services. It is important for you to receive routine care from your PCP. Your PCP knows your medical needs the best. Changes You Need to Report You could lose your coverage if the State cannot contact you. If we do not know where you live, you will miss important information about your coverage. Please call ACCESSNebraska at If in the Lincoln area, call If in the Omaha area, call Please also call Member Services at or TTY: 711 for the hearing impaired. What 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 Member Services for help. You may have to pay medical bills if you receive treatment from providers who are not part of UnitedHealthcare Community Plan s network. What if I Want to Choose a Different Plan? You may change your plan for any reason during the first 90 calendar days after the date of your initial enrollment; or when we receive notice of your enrollment, whichever is later. After the 90 calendar days you will be locked into your health plan for an additional 9 months. You may change your health plan annually on your 12-month anniversary of enrollment. How Do I Request Disenrollment From My Managed Care Plan, Before My 12-Month Re-Enrollment Period? You may request to be disenrolled from the Plan with cause such as: moving out of the service area; poor quality of care; unable to get access to care or the providers you need for your health care needs. You may submit your request in writing to the Medicaid Enrollment Center for state approval, or by calling the Medicaid Enrollment Center at 14 Medicaid Member Handbook

15 Your written request should be mailed to: The Medicaid Enrollment Center 4600 Valley Road, Suite 300 Lincoln, NE What if I Need to See a Provider Who Is Not My UnitedHealthcare Community Plan Primary Care Provider? You should always see your PCP first. This is the provider who knows you best. He or she will help you manage your medical care. This provider also knows your health status and any past problems you have had. This provider will make sure all the care you get works together to keep you in the best health. You do not need a referral from your PCP to see a UnitedHealthcare Community Plan specialist. provided by UnitedHealthcare Community Plan. This includes objecting on the basis of religious grounds. Provider Credentials You have the right to obtain information about our providers that includes the provider s education, residency completed, board certification and recertification. To get this information, call our Member Services Department at or TTY: 711 for the hearing impaired. Provider Incentive Plan You are entitled to ask if we have special financial arrangements with our providers that can affect the use of referrals and other services you might need. To get this information, call our Member Services Department at or TTY: 711 for the hearing impaired and request information about our provider payment arrangements. Out-of-Network If none of the Plan s providers can give a covered service, the Plan must cover it from a non-network provider. Out-of-Network Cost to Member If non-network care is allowed, payment is set up by the Plan. The member s cost will be no more than with services from a network provider. Member s Right to Refuse Treatment As a member of our health plan, you have the right to refuse to undergo any medical service, diagnoses, or treatment or to refuse to accept any health service No Medical Coverage Outside of the United States Any services you receive while outside of the United States in a foreign country will not be covered by UnitedHealthcare Community Plan. Medicaid cannot cover any medical services you get outside of the United States. Nebraska 15

16 Transportation How to Schedule a Ride* 1. Call or TTY: 711 for hearing impaired at least 3 days (72 hours) before your appointment. Urgent Care and same-day rides are accepted. Rides can be scheduled up to 30 days in advance. 2. Call Monday through Friday from 9:00 a.m. - 7:00 p.m. 3. Give the transportation representative this information: Where you need to go What time you need to be picked up If you need a van that is equipped with a wheelchair lift 4. The transportation representative will ask you for: Your Member ID number Your first and last name The address of the location you are visiting Additional Transportation UnitedHealthcare Community Plan members receive additional transportation benefits. Rides to and from WIC appointments, prenatal and pregnancy classes including Lamaze, parenting classes, exercise and nutrition classes, nutrition counseling, and Alcoholics Anonymous meetings. Your appointment time and location For minors 12 and under, the name of the adult traveling with the child * Members 16 years and older can call. The member s parent or guardian can call if the member is under 16 years. Before You Are Picked Up The transportation company will call to ask you if you still need a ride. You will then know the name of the transportation company that will be picking you up. (This only applies to rides being taken in a taxi or van.) When Your Ride Is Late Call or TTY: 711 for hearing impaired if your ride is late. (This only applies to rides being taken in a taxi or van.) When You Need a Ride Home After Your Appointment Call or TTY: 711 for hearing impaired to be picked up from your appointment. Bus Transportation You will be asked to take the bus if you are not disabled and: You live less than half a mile from a bus stop. Your appointment is less than half a mile from the bus stop. 16 Medicaid Member Handbook

17 Other Information Additional Passenger One additional passenger is allowed if it is medically necessary and space is available. The passenger must be 18 years old or older. Car Seats and Wheelchairs You must bring your car seat or wheelchair. Trip Limits Trips are unlimited. Curb-to-Curb Service Drivers do not enter a member s home or health care facility. Remember to call 911 if you have an emergency. Nebraska 17

18 NurseLine NurseLine SM Services Your 24-Hour Health Information Resource What are NurseLine services? NurseLine services offer a variety of health information and resources. Experienced registered nurses can provide you with information, support and education for any health-related question or concern. How does it work? Simply call the toll-free number or TTY: 711 for the hearing impaired. Registered nurses are always ready to discuss your health concerns and answer your questions. When can I call? You can call the toll-free NurseLine number any time, 24 hours a day, 7 days a week. And, there s no limit to the number of times you can call. How can NurseLine services help me? When you re sick or injured, it can be difficult to make health care decisions. You may not know if you should go to the emergency room, visit an urgent care center, make a provider appointment or use self-care. An experienced NurseLine nurse can give you information to help you decide. You may just be curious about a health issue and want to learn more. With NurseLine services, answers to your health questions are just a phone call away. What kinds of issues can NurseLine services help address? Nurses can provide information and support for many health situations and concerns, including: Minor injuries Common illnesses Self-care tips and treatment options Recent diagnoses and chronic conditions Choosing appropriate medical care Illness prevention Nutrition and fitness Questions to ask your provider How to take medication safely Men s, women s and children s health 18 Medicaid Member Handbook

19 Emergencies and Urgent Care Emergency Care If you have an emergency, go to an Emergency Room (ER). If you need help getting to the ER fast, call 911. You do not need a referral from your PCP to use the ER. You can get emergency care 24 hours a day, 7 days a week. You should be seen within an hour to see the extent of your illness or injury. Call your PCP as soon as you can after getting emergency care. What Is an Emergency? Emergency means a condition with sudden acute symptoms of such severity that lack of fast care could result in: Placing the patient s health in serious jeopardy; Serious impairment to bodily functions; Serious dysfunction of any bodily organ or part; Serious disfigurement; or In the case of a pregnant woman, jeopardy to the health of a woman or her unborn child. If you have an emergency, call 911 or go to the nearest ER. Examples of Emergencies: Severe pain Convulsions Unconsciousness Severe or unusual bleeding A serious accident A suspected heart attack or stroke For a pregnant woman, having contractions Here are some examples of what is NOT generally an emergency: Colds and flu Headaches Sore throats Bruises or minor cuts Rashes Urgent Care Urgent Care is not emergency care. It is care that is needed sooner than a normal appointment. Call your PCP if you have a medical issue that is not an emergency. For the following conditions, contact your PCP: Fever Infections Symptoms of cold or flu If you have an emergency, call 911 for help, or go to the nearest emergency room so that you can be seen. You can get emergency care 24 hours a day, 7 days a week. Nebraska 19

20 Care Covered by UnitedHealthcare Community Plan With UnitedHealthcare Community Plan, your Medicaid benefits stay the same. This means that UnitedHealthcare Community Plan pays for the same kinds of care as Medicaid. Below is a list of some of the care that is covered by UnitedHealthcare Community Plan. If you have any questions about your health care benefits, call our Member Services at or TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week). Medical Care Office Visits Allergy Care Blood Tests and X-Rays Well Baby Care and Health Checks Baby Shots and Booster Shots Pregnancy Care Pap Smears, Mammograms and Yearly Female Exams Birth Control procedures done in the office Chiropractic Care Nurse Midwife Lab and X-ray Services Foot Care Provider Visits in the Hospital Counseling with your provider for smoking cessation. UnitedHealthcare Community Plan does not cover medication for smoking cessation. Talk to your provider about how to get smoking cessation medication through Nebraska Medicaid. Physicals UnitedHealthcare Community Plan provides 100% coverage for routine physical examinations for males and females, diagnostic tests and immunizations when performed by your primary care provider. We will pay for routine physicals every 12 months. Hospital Care Double Room Outpatient Surgery Inpatient Stay Blood Work and X-Rays Emergency Room Direct Access Services Direct access services are medical services and do not need a referral. These services include: Emergency room services at any location Family planning Vision care HIV/AIDS treatment and treatment of sexually transmitted diseases (STD) Native American Members can access care at tribal clinics and Indian Hospitals without approval. 20 Medicaid Member Handbook

21 Hearing Care Hearing Tests Hearing Aids: 1 every 4 years for ages 21 and older Batteries and medically necessary accessories Vision Care For a current list of vision providers, call Block Vision toll-free at You can also go online to for a complete list of vision providers. Limited to: Eye Exams: 1 every 12 months (from date of last visit) for ages 20 and younger 1 every 24 months (from date of last visit) for ages 21 and older Eye Glasses (lenses and frame): 1 pair every 12 months if there is significant change in your prescription Diabetic Eye Exams Diabetic eye exams can be obtained for any age, every 12 months through any UnitedHealthcare contracted Optometrists and Ophthalmologists. You must use a participating Block Vision provider. Nebraska 21

22 Care Covered by UnitedHealthcare Community Plan (cont.) Other Covered Care and Services if Medically Necessary (prior authorization may be required) Routine Foot Care, Medical and Surgical Services from a Podiatrist Home Health Care Private Duty Nursing Services Artificial Limbs Medical Equipment/Supplies Ambulance, if needed for an emergency Nutritional Supplements Skilled Nursing Facility Breast Reconstruction Surgery following a mastectomy Audiology Supplies Chiropractic Care Limited to: Manual manipulation of the spine to correct spinal alignment 18 visits per year for ages 20 and younger 12 visits per year for ages 21 and older Covers 1 set of x-rays per year Rehabilitation Physical Therapy (P.T.) Speech Therapy (S.T.) Occupational Therapy (O.T.) UnitedHealthcare Community Plan reviews all the care you receive to make sure that UnitedHealthcare Community Plan covers it and it is the right care for your condition. There are also some treatments and procedures we need to review before you can get them. Your providers know what they are, and they take care of letting us know to review them. The review we do is called Utilization Review. The way we pay our staff, that makes these decisions, is not related to what they decide. UnitedHealthcare Community Plan pays its Primary Care Providers (PCP) and its specialists every time they see one of our members. This is known as Fee-For-Service. We pay hospitals and all other types of providers in our network the same way they get paid every time you see them or get services from them. We never hold back any payments to any of our providers for giving too much service. If you want to find out about financial arrangements UnitedHealthcare Community Plan has with your provider, call Member Services and ask for the information. You do not need a referral for health emergencies, family planning, vision care, HIV/AIDS treatment and treatment of sexually transmitted disease (STD). 22 Medicaid Member Handbook

23 Care Management What Is Care Management? Care Management helps you manage your complex health care needs. It also may include helping you get other social services, too. We will work with you, your family/friends if you wish, and your PCP to get the services you need. During your welcome call, we complete a short health assessment questionnaire with you. Based on your answers we identify if you need support and additional services to meet your needs. When Should I Ask for Care Management? If you are seeing many different providers for your medical problems. If your provider has said you have a high-risk pregnancy. If you have complex health needs. If you are taking many different medicines to treat and control your health problems. If you are homeless and would like assistance to find housing. We can connect you with a community agency. If you have a behavioral health condition or substance use disorders needs. How Can I Get Care Management Services? You should have received a welcome call from our Member Services team. During that call you answered some Health Risk Assessment questions that we used to see if you needed any additional help. You can also call our Member Services team and ask for help. Any one of our local representatives will be able to assist you. Please call Member Services, toll-free at or TTY: 711 for the hearing impaired. Care Management Program/Disease Management Our Care Coordinators can help you manage your medical condition. They are experienced nurses and social workers. They understand your issues. They will work with you and your providers to help you get the care you need. Our Care Coordinators can help you: Learn how to take care of yourself. Find a PCP, specialist, or urgent care facility. Make appointments. Get to and from provider visits, pharmacy visits and behavioral health visits. Arrange for supplies and home health care for you. Find community resources and support. Give you resources to help you quit smoking. Nebraska 23

24 Care Management (cont.) Care Coordinators can help you with: Asthma Diabetes Congestive Heart Failure (CHF) Chronic Obstructive Pulmonary Disease (COPD) Coronary Artery Disease (CAD) Sickle Cell Disease Lung Disease Pregnancy High Blood Pressure Obesity Special needs Any other conditions that need case management Specialty Disease Management Programs If your health conditions need more support, we have these special programs: Transplant Programs End Stage Renal Disease Health Education We have Nurse Care Managers in our office to help you with your health care needs. Health education materials can be mailed to you. Nurse Care Managers are available Monday through Friday 8:00 a.m. to 5:00 p.m. by calling Medicaid Member Handbook

25 Women s Health Exams, Screenings Women may see any UnitedHealthcare Community Plan OB/GYN for well-woman care without being sent by their PCP. Women who are sexually active should have a Pap smear every three years to screen for cervical cancer. Young women, ages 16 25, who are sexually active should have a Chlamydia test every year to screen for this sexually transmitted disease (STD). Women s Health and Cancer Rights Act: Women s health benefits include breast reconstruction services if elected after a mastectomy. Mammograms Women age 40 or over should have a mammogram to screen for breast cancer once every 1 to 2 years. Family Planning Family planning is an important part of staying healthy. Your PCP or a Family Planning Center can help you plan when to have children. You can also get information and prescriptions for birth control like condoms and birth control pills. Family Planning Centers or the Health Department can teach you about sexually transmitted diseases (STD) and give you other tips for staying healthy. Screening, diagnosis, and treatment of sexually transmitted diseases are covered. You may go to any Family Planning Center if they accept Medicaid. In addition to a routine physical exam, women are encouraged to receive a routine gynecological exam with a Pap Smear once every 12 months as required for the prescription of birth control medications and devices. UnitedHealthcare Community Plan takes privacy issues and laws seriously. Safeguards are in place to protect information about you. We don t share private information without your written okay unless there is a legal reason. NO REFERRALS NEEDED for OB/GYN in network. A Annual well-woman exams Care for all active gynecological conditions Family Planning Pregnancy care Nebraska 25

26 Benefits for Mom and Baby Pregnant Women Women may see any UnitedHealthcare Community Plan OB/GYN for obstetrical care without being sent by their PCP. (Maternity-prenatal, delivery and postpartum.) If you think you may be pregnant, see your PCP or a UnitedHealthcare Community Plan OB/GYN right away. It is important to start prenatal care in the first 12 weeks. See your PCP or UnitedHealthcare Community Plan OB/GYN throughout your pregnancy. Make sure you go to all your visits when your PCP or UnitedHealthcare Community Plan OB/GYN tells you to. Make sure you go to your provider right after you have your baby for follow-up care (between 21 and 56 days after your baby is born). You may be able to get FREE formula, milk and food from the Women, Infants and Children (WIC) program. Talk to your provider or call your local Health Department about these services. If you become pregnant, please call ACCESSNebraska at If in the Lincoln area, call If in the Omaha area, call Please also call Member Services at or TTY: 711 for the hearing impaired. Healthy First Steps If you are pregnant, UnitedHealthcare Community Plan has a FREE program just for you and your baby. It is called Healthy First Steps. You and your growing baby are important to us. We want you to have a healthy pregnancy and healthy baby. UnitedHealthcare Community Plan has a special prenatal care manager to work with you and your providers to make sure you and your baby get the care you need. The Healthy First Steps program can help teen mothersto-be too. Your prenatal care manager can: Help you set up prenatal care visits Help you find a provider for your new baby Help you set up visits and health care after your baby is born Help you get a ride to your visits Help you stay healthy Help you with special needs while you are pregnant Help you find out about: Childbirth classes Counseling services Find baby items and clothes and give you information about what to expect while you are pregnant Keep in touch with you and your provider if you have any health problems It is good to get early and regular prenatal care and to keep all your visits with your provider even if this isn t your first baby. Call to learn more! 26 Medicaid Member Handbook

27 Baby Blocks Program Gives Your Baby a Healthy Start If you are a UnitedHealthcare Community Plan member who is pregnant, you can earn rewards with Baby Blocks. When you join, you get a gift card or other cool gear for your baby. Then earn up to seven more rewards with provider visits during pregnancy and your baby s first 15 months. You earn great rewards while both you and your baby get the care you need to stay healthy. To enroll, go to Click on Sign up. Text4baby Program Text4baby is a free mobile information service that will help you through your pregnancy and baby s first year of life. Get FREE text messages on your cell phone each week. The text4baby messages will give you tips about: Keeping healthy Labor and delivery Breastfeeding The importance of immunizations Exercise and healthy eating And much more To sign up for text4baby, simply text the word BABY to You will be asked for a participant code after you sign up. The participant code is HFS. This code will let text4baby know that you are a member of our health plan. It will also let us know you signed up for the service. Give your baby the best possible start in life. Sign up for text4baby. Breast Pumps We want to assist you in breastfeeding. We will pay the cost of a portable electric breast pump. If you have questions about breast pumps or need help finding an in-network medical equipment company, call Member Services at (TTY: 711). Non-portable hospital grade breast pumps are available for rent if medically necessary. Please ask your provider if you think you need a hospital grade pump. Twitter Follow us on to get useful tips, info on what to expect and important pregnancy reminders. We re here to make taking care of yourself and your baby a little easier. Visit bit.ly/uhc-pregnancy. Newborns and Mothers Health Protection Act UnitedHealthcare follows federal guidelines that require certain benefits for mother and infants after childbirth. Our benefit plans cover 48 hours in the hospital after a vaginal delivery. We also cover 96 hours in the hospital after a delivery by Cesarean section. (You can choose to stay less time in the hospital if your provider says it s okay.) You can call your PCP s office anytime, day or night 24 hours a day, 7 days a week. Your PCP will help you get the best care. Nebraska 27

28 Immunizations Immunization Schedule UnitedHealthcare Community Plan wants to help you keep your children healthy. During the first years of their life, you should take your children to the provider every few months for well-child care. They will get their immunizations or shots that protect them from diseases. UnitedHealthcare Community Plan will pay for your child s shots it won t cost you any money. It is up to you to schedule the appointment and take your child for these shots. Your child s provider can help you set up regular visits so your child gets all their shots. Recommended Immunization Schedule for Persons Aged 0 Through 6 Years United States 2011 Vaccine Age Birth 1 mo. 2 mos. 4 mos. 6 mos. 12 mos. 15 mos. 18 mos mos. 2 3 yrs. 4 6 yrs. Hepatitis B Hep B Hep B Hep B Rotavirus RV RV RV Diphtheria, Tetanus, Pertussis Haemophilus Influenzae Type B DTaP DTaP DTaP DTaP DTaP Hib Hib Hib Hib Pneumococcal PCV PCV PCV PCV PPSV Inactivated Poliovirus IPV IPV IPV IPV Influenza Influenza (yearly) Measles, Mumps, Rubella MMR MMR Varicella Varicella Varicella Hepatitis A Hep A (2 doses) Hep A Series Range of recommended ages for all children except certain high-risk groups Range of recommended ages for certain high-risk groups 28 Medicaid Member Handbook

29 Programs to Keep You Healthy Sesame Street A is for Asthma A program from Sesame Street. It teaches kids and parents about the best ways to live with asthma. Sesame Street Food For Thought Program A program to help families eat better. The program teaches families with children between ages 2 and 8 how to buy healthy food. Sesame Street Healthy Habits Learn from Sesame Street friends on going to your provider. Learn about asthma and lead tests. Dr. Health E. Hound Program UnitedHealthcare is proud of its mascot Dr. Health E. Hound. Dr. Health E. Hound s goal is to help teach your kids about fun ways to stay fit and healthy. Dr. Health E. Hound loves to travel around the country and meet kids of all ages. He likes to hand out flyers, posters, stickers and coloring books to remind kids to eat healthy foods and exercise. He also helps kids understand that going to your provider for checkups and shots is an important way to stay healthy. Quality Improvement Through our program, we want to: Make sure you are happy with our services Make sure your provider meets your needs Help you take better care of yourself Send you helpful hints and health care reminders on staying healthy Look for barriers to quality care and new ways to remove them Look for better ways to provide care or services Look at areas where changes were made and make sure they work well for you Follow national quality standards as published by the National Committee for Quality Assurance (NCQA) If you want to know more about the programs, call Member Services at or TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week) You and your family can meet Dr. Health E. Hound in person at some of our health events. We encourage you to come to an event and learn about the importance of healthy eating and exercise. Bring a camera to these events and get your picture taken with Dr. Health E. Hound. He loves company! Nebraska 29

30 Services Not Covered by UnitedHealthcare Community Plan These Services Are Not Covered by UnitedHealthcare Community Plan: Any health care not given by a provider from our list (except Native American Access to Care, emergency treatment and family planning services) Any care not covered by Nebraska Medicaid Any care covered by Medicaid but not through Managed Care, contact the Medicaid Inquiry Line at for services such as: Prescription drugs Long-term care/nursing facility services Intermediate care facilities for persons with mental retardation Home and community-based waiver services Dental services Hospice services Transportation to medical services Phones and TVs used when in the hospital Personal comfort items used in the hospital such as a barber Contact lenses, unless used to treat eye disease Sunglasses and photo-gray lenses Ambulance, unless necessary Infertility services 30 Medicaid Member Handbook

31 Services Covered by the State of Nebraska Some services are covered by the State of Nebraska. Please call the numbers below to learn how to receive these benefits: Mental Health and Substance Use Disorders Mental Health and Substance Use Disorders services are not covered by UnitedHealthcare Community Plan. This service is covered by Magellan Behavioral Health. To learn more about benefits for mental health and substance use disorders or for transportation to a mental health or substance use disorders appointment, call Magellan Behavioral Health at Monday through Friday 8:00 a.m. to 5:00 p.m. Magellan Behavioral Health is available 24 hours a day to help with emergency crisis situations. Prescription Drugs Drugs are not covered by UnitedHealthcare Community Plan, but are covered by Nebraska Medicaid. Use your Nebraska Medicaid ID Card for prescription drugs. There may be a copay for your drugs. Dental Dental services are not covered by UnitedHealthcare Community Plan, but are covered by Nebraska Medicaid. Use your Nebraska Medicaid ID Card for dental services. There may be a copay for your dental services. If you need transportation to a dental appointment, please contact AMR Access2Care at (TTY: 711) for arrangements. UnitedHealthcare Community Plan may cover some kinds of oral surgery done in a hospital. If you need hospitalization for dental services, have your dentist call UnitedHealthcare Community Plan for approval. Nebraska 31

32 Urgent Care Centers If you are unable to see your Primary Care Provider (PCP), you should go to one of the following Urgent Care Centers instead of going to the Emergency Room (ER). These centers are in the UnitedHealthcare Community Plan provider network. Urgent Care Centers can help with most broken bones, sprains, mild to moderate bleeding, bruises, minor burns and most drug reactions. BELLEVUE Alegent Creighton Health Express Care 3308 Samson Way, Suite 102 Bellevue, NE Daily, 8:00 a.m. 8:00 p.m. Holidays, call for times Closed Thanksgiving and Christmas FREMONT Urgent Care of Fremont Plum Grove Medical Office Building 415 E. 23rd Street, Suite A Fremont, NE Monday Friday, 5:00 p.m. 10:00 p.m. Saturday, Sunday and Holidays, 12:00 noon 10:00 p.m. LINCOLN West Lincoln Family Medicine and Urgent Care Westgate Shopping Center 201 Capitol Beach Blvd., #1A Lincoln, NE Monday Friday, 9:00 a.m. 6:00 p.m. Closed for Holidays LINCOLN (cont.) Family Medicine and Urgent Care 3740 North 27th Street, Suite 1 Lincoln, NE Monday Friday, 9:00 a.m. 8:00 p.m. Saturday, 9:00 a.m. 6:00 p.m. Sunday, 10:00 a.m. 6:00 p.m. Closed for Holidays Nebraska Urgent Care Center 4720 West Huntington, Suite J Lincoln, NE Monday Friday, 9:00 a.m. 8:00 p.m. Saturday and Sunday, 9:00 a.m. 1:00 p.m. Urgent Care of Lincoln 4210 Pioneer Woods Drive, Suite A Lincoln, NE Monday Friday, 7:30 a.m. 5:30 p.m. Saturday, 9:00 a.m. 12:00 p.m. Holidays and inclement weather, call for times Closed Thanksgiving, Christmas and Easter 32 Medicaid Member Handbook

33 OMAHA Alegent Creighton Health Express Care Applewood 9717 Q Street Omaha, NE Daily, 8:00 a.m. 8:00 p.m. Holidays, 8:00 a.m. 2:00 p.m. Secondary language offered: Spanish Alegent Creighton Health Pediatric Express Care 7500 Mercy Road Omaha, NE Monday Friday, 6:00 p.m. 10:00 p.m. Saturday and Sunday, 12:00 noon 10:00 p.m. Holidays, 12:00 noon 6:00 p.m. Closed Thanksgiving Children s Urgent Care Center Val Verde 9801 Giles Road, Suite 1 Omaha, NE (For children under 21 only) Monday Friday, 6:00 p.m. 10:00 p.m. Saturday, Sundays and Holidays, 12:00 noon 10:00 p.m. Children s Urgent Care Center West Village Point 110 N. 175th Street Omaha, NE (For children under 21 only) Monday Friday, 6:00 p.m. 10:00 p.m. Saturday, Sunday and Holidays, 12:00 noon 10:00 p.m. OMAHA (cont.) Midwest Minor Medical W. Center Road Omaha, NE Monday Friday, 8:00 a.m. 9:00 p.m. Saturdays and Sundays, 10:00 a.m. 6:00 p.m. Holidays, call for times Midwest Minor Medical 5310 S. 84th Street Omaha, NE Monday Friday, 8:00 a.m. 9:00 p.m. Saturday, 8:00 a.m. 6:00 p.m. Sunday, 10:00 a.m. 6:00 p.m. Holidays, call for times Midwest Minor Medical 8610 West Dodge Road Omaha, NE Daily, 8:00 a.m. 9:00 p.m. Holidays, call for times If you have a true medical emergency like a serious accident, severe chest pain, poisoning or vomiting blood, you should go to the Emergency Room (ER) at the nearest hospital, or call your PCP. Nebraska 33

34 Urgent Care Centers (cont.) OMAHA (cont.) Physician s Clinic Millard 5908 S. 142nd Street Omaha, NE Monday Friday, 6:00 p.m. 10:00 p.m. Saturday, Sunday and Holidays, 12:00 noon 6:00 p.m. Physician s Clinic Northwest Fort Street Omaha, NE Monday Friday, 6:00 p.m. 10:00 p.m. Saturday, Sunday and Holidays, 12:00 noon 6:00 p.m. Physician s Clinic South 3353 L Street Omaha, NE Monday Friday, 6:00 p.m. 10:00 p.m. Saturday, Sunday and Holidays, 12:00 noon 6:00 p.m. If you have any questions, please call Member Services at (toll-free) TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week). OMAHA (cont.) Urgent Care of Omaha 3830 N. 167 Court Omaha, NE (For persons 3 months old and over) Monday Friday, 8:00 a.m. 9:00 p.m. Saturday, 8:00 a.m. 8:00 p.m. Sunday, 10:00 a.m. 8:00 p.m. Holidays, call for times Must arrive ½ hour before closing to receive services Urgent Care of Omaha 8814 Maple Street Omaha, NE (For persons 3 months old and over) Monday Friday, 8:00 a.m. 8:00 p.m. Saturday, 8:00 a.m. 8:00 p.m. Sunday, 10:00 a.m. 8:00 p.m. Holidays, call for times Must arrive ½ hour. before closing to receive services PLATTSMOUTH Plattsmouth Urgent Care 211 S. 23rd Street Plattsmouth, NE Monday Friday, 8:00 a.m. 6:00 p.m. Saturday, 9:00 a.m. 1:00 p.m. WAVERLY Waverly Healthcare UrgentCare Callum Dr., Suite 4 Waverly, NE Monday Friday, 7:30 a.m. 5:30 p.m. Saturday, 9:00 a.m. 12:00 noon 34 Medicaid Member Handbook

35 Hospitals BEATRICE Beatrice Community Hospital 4800 Hospital Parkway Beatrice, NE BLAIR Memorial Community Hospital & Health System 810 N. 22nd Street Blair, NE COUNCIL BLUFFS, IOWA Alegent Creighton Health Mercy Hospital 800 Mercy Road Council Bluffs, IA Jennie Edmundson Hospital 933 E. Pierce Street Council Bluff, IA FREMONT Fremont Area Medical Center 450 E. 23rd Street Fremont, NE LINCOLN Bryan LGH Medical Center East Campus 1600 S. 48th Street Lincoln, NE Bryan LGH Medical Center West Campus 2300 S. 16th Street Lincoln, NE LINCOLN (cont.) Lincoln Surgical Hospital 1710 S. 70th Street, Suite 200 Lincoln, NE Madonna Rehabilitation Hospital 5401 South Street Lincoln, NE Nebraska Heart Hospital 7500 S. 91st Street Lincoln, NE St. Elizabeth Regional Medical Center 555 S. 70th Street Lincoln, NE MARYSVILLE, KANSAS Community Memorial Hospital 708 N. 18th Marysville, KS NEBRASKA CITY St. Mary s Community Hospital rd Avenue Nebraska City, NE OMAHA METRO AREA Alegent Creighton Bergan Mercy Medical Center 7500 Mercy Road Omaha, NE Nebraska 35

36 Hospitals (cont.) OMAHA METRO AREA (cont.) Alegent Creighton Health Immanuel Medical Center 6901 N. 72nd Street Omaha, NE Alegent Creighton Health Lakeside Hospital Lakeside Hills Court Omaha, NE Alegent Creighton Health Midlands Hospital S. 84th Street Papillion, NE Bellevue Medical Center 2500 Bellevue Medical Center Drive Bellevue, NE Boys Town National Research Hospital East 555 N. 30th Street Omaha, NE Boys Town National Research Hospital West Boys Town Hospital Road Omaha, NE Children s Hospital and Medical Center 8200 Dodge Street Omaha, NE OMAHA METRO AREA (cont.) Methodist Women s Hospital 707 N. 190th Plaza Elkhorn, NE Methodist Hospital 8303 Dodge Street Omaha, NE Midwest Surgical Hospital 7915 Farnam Drive Omaha, NE The Nebraska Medical Center University Tower/Clarkson Tower 600 S. 42nd Street Omaha, NE Nebraska Orthopedic Hospital 2808 S. 143rd Plaza Omaha, NE Nebraska Spine Hospital 6901 N. 72nd Street Omaha, NE Creighton University Medical Center/ St Joseph Hospital 601 N. 30th Street Omaha, NE Medicaid Member Handbook

37 SEWARD Memorial Health Care System 300 N. Columbia Avenue Seward, NE SYRACUSE Community Memorial Hospital 277 E. 17th Street Syracuse, NE TECUMSEH Johnson County Hospital 202 High Street Tecumseh, NE WAHOO Saunders Medical Center 1760 County Road J Wahoo, NE Federally Qualified Health Care Providers Charles Drew Health Center 2915 Grant Street Omaha, NE One World Community Health Center 4920 S. 30th Street, Suite 103 Omaha, NE Cass Family Medicine (One World Community Health Center satellite) 409 Main Street Plattsmouth, NE One World West Omaha Community Health Center 4101 South 120th Street Omaha, NE People s Health Center 1021 N. 27th Street Lincoln, NE Nebraska Urban Indian Medical Center 2331 Fairfield Street Lincoln, NE For a listing of all FQHC s in Nebraska, visit the Centers for Medicare and Medicaid Website at Nebraska 37

38 Additional Member Information Member Survey Every year, UnitedHealthcare of the Midlands asks some of our members how they feel about UnitedHealthcare Community Plan. This survey helps us to decide which areas we should work on to make improvements and what we are doing well. Member Advisory Group This committee allows UnitedHealthcare Community Plan to hear from members about how we can better serve you. For more information, call If you get a survey, please answer it. An outside firm takes the survey and we do not ever see your answers. Your privacy is guarded. Your responses will never be used to make decisions about you or your family s health care. Your answers, along with the answers of many other enrollees, are combined to let us know how we are doing. It s your chance to give us a grade. You can obtain a copy of the survey results by calling Member Services at or TTY: 711 for the hearing impaired. We want to hear your quality of care or quality of service concerns. 38 Medicaid Member Handbook

39 Member Rights and Responsibilities UnitedHealthcare Community Plan Rights and Responsibilities Statement As a UnitedHealthcare Community Plan member, you have certain rights and responsibilities. It is important that you understand them. These rights and responsibilities do not change your health care coverage in any way. If you have any questions about your rights or your health care coverage, please call our Member Services at or TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week). Native American Access to Care Native American Members can access care to tribal clinics and Indian Hospitals without approval. Member Rights As a UnitedHealthcare Community Plan member, you have a right to: Request information on Advance Directives. Respect, dignity and privacy Courtesy and prompt treatment Receive culturally competent assistance including having an interpreter during appointments and procedures Receive information about UnitedHealthcare Community Plan, your rights and responsibilities, your benefit plan and which services are not covered Know the qualifications of your health care providers Give your consent for treatment unless you are unable to do so because your life or health is in immediate danger Discuss any and all treatment options with your provider without interference from us Refuse treatment through an Advance Directive or withhold your consent for treatment Be free from any form of restraint or seclusion used as discipline, retaliation, convenience or to force you to do something you don t want to do Receive preventive care covered by your benefit plan Receive information about our network providers and practitioners, and choose a provider from our network Change your provider at any time for any reason Tell us if you are not satisfied with your treatment or with UnitedHealthcare Community Plan; when you tell us, you can expect a timely response from us Appeal any payment or benefit decision we make Review your medical records maintained by your provider and request changes and/or additions to any area you feel is needed Be given information about your illness or condition, understand your treatment options, regardless of cost or whether such services are covered by UnitedHealthcare Nebraska 39

40 Member Rights and Responsibilities (cont.) Community Plan and participate with your providers in making decisions about your health care Get a second opinion with a network provider Expect that health care professionals are not prohibited or otherwise restricted from advising you about your health status, medical care or treatment regardless of benefit coverage Make suggestions about UnitedHealthcare Community Plan s member rights and responsibilities policies You have the right to additional information upon request, such as, information on how your Health Plan works and a provider s incentive plan, if they apply Member Responsibilities As a UnitedHealthcare Community Plan member, you have a responsibility to: Understand your benefit plan and follow it to obtain the most benefits Show your ID card to providers; prevent others from using your ID card Give health care providers true and complete information; ask questions about your treatment so you understand Work with your provider to set treatment goals and follow the treatment plan you and your provider agree upon Get to know your provider before you are sick Keep appointments or tell the health care provider when you cannot keep the appointment Treat UnitedHealthcare Community Plan staff, providers and their staff with respect and courtesy Tell us your opinions, concerns and complaints Get any approvals needed before you receive treatment Use the emergency room only when there is a serious threat to life or health Notify us of any change in address or family status Make sure each provider you see is in the network Follow the advice of your providers and understand possible results if you do not follow their advice Give your providers and us information that could help improve your health 40 Medicaid Member Handbook

41 Grievances You are our customer and are very important to us. We want to make your health care program a good one. We want to make sure you are happy with our program. If you are not happy, please call Member Services at or TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week). We want to help you solve any health care problems. We will try to help you on the phone. We hope we can solve your problem with your first phone call. There may be times when you don t agree. Maybe you still feel unhappy. So, we made Quality Steps just for you. These steps give you every chance to let us learn more about your problem. Quality Steps for Grievances: 1. Call us and tell us your problem. We will try to solve your problem on the first call. Member Services: (toll-free) TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week) 2. If you are not happy with the answer, call or write to us and let us know at: Write to: National A&G Service Center P.O. Box Salt Lake City, UT Call: (toll-free) TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week) 3. When your call or letter is received, our Quality Department will promptly do a thorough review of the case and make a decision. 4. We will answer you with our decision in no more than 90 calendar days. In case of an emergency, we will answer by the next working day. 5. You may get help in telling us about your problem or in appealing the decision by calling our customer service center. Member Services is available 24 hours a day, 7 days a week. You may ask them for help with filing a grievance or appeal, filling out forms as well as help if you need an interpreter. Privacy of Records UnitedHealthcare Community Plan takes privacy issues and laws seriously. Safeguards are in place to protect information about you. We don t share private information without your written okay unless there is a legal reason, such as a court order. Nebraska 41

42 Appeals Sometimes we will make decisions about the health care you need. If you or your provider asks us to pay for care that we do not think is covered by UnitedHealthcare Community Plan or if we don t make our decision promptly, this is called an action. An action is defined by the Federal Government as: 1. The denial or limited authorization of a requested service including the type or level of service; 2. The reduction, suspension, or termination of a previously authorized service; 3. The denial, in whole or in part, of payment for a service; 4. The failure to provide services in a timely manner as defined by the State; or 5. The failure of UnitedHealthcare Community Plan to act within the following time limits: Resolution of a standard appeal 45 calendar days Resolution of an expedited appeal 3 calendar days We will send you a letter to tell you about our action. If you don t agree with this, you may appeal. You have certain rights during an appeal. These are the things you should know: You have 90 calendar days from the date on the letter from us saying that we have taken an adverse action to ask for an appeal. We will make a decision on the appeal and notify you in writing of our decision within 45 calendar days of when you receive your appeal request. You can ask for an appeal by calling or writing to us. Write to: National A&G Service Center P.O. Box Salt Lake City, UT Call: (toll-free) TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week) You have the right to present evidence for your appeal in person Monday Friday, 8:00 a.m. 5:00 p.m. at: UnitedHealthcare 2717 N. 118th Street Suite 300 Omaha, NE You can ask for a copy of the rules we used to make our decision. You can have someone else such as a family member, friend, health care provider, lawyer or the Medicaid Enrollment Center help you with the appeal. You can ask to see and receive a copy of the information in our files (except confidential medical records) that we used to make our decision. You can send written comments or documents for us to look at when we review your appeal. You or your provider can call us and ask for an expedited 72-hour appeal if your provider has said that waiting for this health service would increase the risk to your health. 42 Medicaid Member Handbook

43 Continuation of Care You can ask for services to continue during the appeal. However, you may need to pay for the health service if you continue the service while we are reviewing the appeal and we decide that you should not have received the service. You can request additional help by calling Member Services at or TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week.) You may call the Department of Health and Human Services (DHHS) Legal Services at State Fair Hearing You or your representative can also ask the State of Nebraska for a State Fair Hearing on your case. You can do this at any time within 90 calendar days from the date of our first letter to you. You can have someone else such as a family member, friend, health care provider or lawyer attend with you. You can write to the State at: Department of Health and Human Services Legal Services Hearing Section P.O. Box Lincoln, NE You can also call our customer service center for assistance. Member Services at or TTY: 711 for the hearing impaired (available 24 hours a day, 7 days a week). You may ask them for help with: Filing a grievance or appeal Filling out forms Help if you need an interpreter Nebraska 43

44 Fraud and Abuse Most UnitedHealthcare Community Plan members and providers are honest. However, even a few dishonest people can hurt the Medicaid Programs. People who are dishonest or commit fraud may be fined or jailed. If you know fraud or abuse is taking place, you must contact UnitedHealthcare Community Plan. However, your privacy will be protected because you don t have to give your name. Fraud and Abuse for UnitedHealthcare Community Plan Members Can Be Things Like: Using transportation services for something other than getting medical care Letting someone else use your UnitedHealthcare Community Plan ID card or Nebraska Medicaid ID Card Selling or giving your prescription medicine to anyone else How to Report Fraud and Abuse Tell us in one of the following ways: UnitedHealth Group maintains a 24-hour toll-free telephone line, known as the Compliance Helpline, at Callers may choose to remain anonymous. Contact Member Services 24 hours a day, 7 days a week toll-free at or TTY: 711 for the hearing impaired. Go online to contacts.htm for instructions on how to report Medicaid Provider Fraud and Medicaid Client Fraud to the State of Nebraska. Call the Medicaid Fraud and Patient Abuse Unit of the Attorney General Office, toll free at Fraud and Abuse for UnitedHealthcare Community Plan Providers Can Be Things Like: Billing UnitedHealthcare Community Plan for services that were never given Billing UnitedHealthcare Community Plan two or more times for the same date of service Overstating a member s illness or condition 44 Medicaid Member Handbook

45 Advance Directives An Advance Directive is a set of written steps you want to be taken when you can no longer make choices for yourself about health care. It tells what health care you want or do not want. Nebraska law gives you the right to have advance directives and to have those directives followed by your health care provider. You should talk about your wishes with your provider, family, and friends. These steps will not change your health care benefits. There Are Two Types of Advance Directives: 1. Living Wills A living will tells your provider the kinds of life support you want or do not want. 2. Power of Attorney for Health Care This is a form that names another person you select who can make health choices for you. It would only be used if you cannot make choices yourself. More on Advance Directives Your provider knows about Advance Directives and will be happy to answer questions. Other groups that can answer your questions are listed below. Department of Health and Human Services State Unit on Aging P.O. Box Lincoln, NE Services available for persons age 65 and over. National Hospice & Palliative Care Organization 1731 King Street Suite 100 Alexandria, VA UnitedHealthcare Community Plan supports your right to have advance directives and to have your instructions followed by your health care providers. If you think a health care provider is not following your advice, you may call Member Services or you can write to: Survey and Certification Department of Regulation and Licensure Nebraska Department of Health and Human Services 301 Centennial Mall South P.O. Box Lincoln, NE Nebraska 45

46 Glossary/Important Terms Abuse: Harming someone on purpose. (This includes yelling, ignoring a person s need and improper touching.) Advance Directive: A decision you make ahead of time about your health care in case you re unable to speak for yourself. This will let your family and providers know what decisions you would make. Appeal: Request for a review of an Action. Authorization: An O.K. or approval for a service. Benefits: Services, procedures and medications UnitedHealthcare Community Plan will cover for you. Child/Children: A Member(s) who is under age 21. Clinical Case Management: One-on-one help by a nurse giving education and help with UnitedHealthcare Community Plan benefits. Complaint: When you call us to say you are unhappy about something, but don t want to take any formal action. DHHS: Nebraska Department of Health and Human Services. Disenrollment: To stop your membership in UnitedHealthcare Community Plan. Emergency: A sudden change in a person s physical or mental condition which could result in (1) the loss of life or limb, (2) severe impairment to a bodily function, or (3) permanent damage to a body part. Fraud: An untruthful act. (Example: if someone uses your ID Card and pretends to be you.) Grievance: An expression of dissatisfaction about any matter other than an Action. Health Information: Facts about your health and care. This may come from UnitedHealthcare or a provider. It includes information about your physical and mental health and payments for care. ID Card: An identification card that says you are a UnitedHealthcare Community Plan member. You should have this card with you at all times. Immunization: A shot that protects ( immunizes ) a member from a disease. Children should get specific shots at certain ages. These are often given during regular provider visits. Informed Consent: That you agree to medical treatments. In-Network: Providers, specialists, hospitals, pharmacies and other providers who have an agreement with UnitedHealthcare Community Plan to give care to members. Inpatient: When you are admitted to a hospital or services you get after being admitted to a hospital. Lock-in: The Lock-In Program provides support to members who need assistance in managing health care. Support is provided through structured access to a PCP, and/or pharmacy, and/or a hospital. 46 Medicaid Member Handbook

47 Managed Care Organization (MCO): The health plan managing your Medicaid benefits. Medical Home: Your Primary Care Provider (PCP) is your Medical Home. A Medical Home helps make sure you get the right medical care when you need it. Care is given by a provider who knows you and your health needs. Medically Necessary: A service that (1) prevents, diagnoses or treats a physical or mental illness or injury; strives to ensure age-appropriate development; minimizes a disability; or maintains or regains functional capacity, (2) cannot be omitted without adversely affecting the condition or the quality of medical care, and (3) is given in the most appropriate setting. Member: An eligible person enrolled in Medicaid with UnitedHealthcare Community Plan. Out-of-Network: Providers, specialists, hospitals, pharmacies and other providers who do not have an agreement with UnitedHealthcare Community Plan to give care to members. Outpatient: When you have a procedure done that does not need an overnight hospital stay. Prescription: A provider s written instructions for drugs or treatment. Primary Care Provider (PCP): The provider who takes care of most of your health needs. Prior Authorization: The process your provider uses to get approval for services that are not normally covered. Provider or Practitioner: A person or facility that offers care (provider, pharmacy, dentist, clinic, hospital, etc.). Provider Directory: A list of providers who participate with UnitedHealthcare Community Plan to take care of your health needs. Referral: When your PCP sends you to a network specialist. Self-Referred Services: Services for which you do not need to see your PCP for a referral. Specialist: Any provider who has special training for a condition. Special Needs Unit (SNU): A service to help you use your benefits if you have a disability or other special need. STD: Sexually Transmitted Disease Urgent Care: When you need care, treatment or medical advice within 48 hours. Working Day: Any day between Monday and Friday, and does not include public holidays or weekends. Nebraska 47

48 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 UHCCommunityPlan.com. We have the right to make the changed notice apply to HI that we have now and to future information. We will follow the law and give you notice of a breach of your HI. We collect and keep your HI so we can run our business. HI may be oral, written or electronic. We limit access to all types of your HI to our employees and service providers who manage your coverage and provide services. We have physical, electronic and procedural safeguards per federal standards to guard your HI. 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. 48 Medicaid Member Handbook

49 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 (STD) and reproductive health 6. Child or adult abuse or neglect or sexual assault If stricter laws apply, we aim to meet those laws. Attached is a Federal and State Amendments document. Nebraska 49

50 Privacy Notices (cont.) Except as stated in this notice, we use your HI only with your written consent. This includes getting your written consent to share psychotherapy notes about you, to sell your HI to other people, or to use your HI in certain promotional mailings. If you allow us to share your HI, we do not promise that the person who gets it will not share it. You may take back your consent, unless we have acted on it. To find out how, call the phone number on the back of your ID card. Your Rights You have a right: To ask us to limit use or sharing for treatment, payment, or health care operations. You can ask to limit sharing with family members or others involved in your care or payment for it. We may allow your dependents to ask for limits. We will try to honor your request, but we do not have to do so. To ask to get confidential communications in a different way or place. (For example, at a P.O. Box instead of your home.) We will agree to your request when a disclosure could endanger you. We take verbal requests. You can change your request. This must be in writing. Mail it to the address below. To see or get a copy of certain HI that we use to make decisions about you. You must ask in writing. Mail it to the address below. If we keep these records in electronic form, you will have the right to ask for an electronic copy to be sent to you. You can ask to have your record sent to a third party. We may send you a summary. We may charge for copies. We may deny your request. If we deny your request, you may have the denial reviewed. To ask to amend. If you think your HI is wrong or incomplete you can ask to change it. You must ask in writing. You must give the reasons for the change. Mail this to the address below. If we deny your request, you may add your disagreement to your HI. To get an accounting of HI shared in the six years prior to your request. This will not include any HI shared: (i) For treatment, payment, and health care operations; (ii) With you or with your consent; (iii) With correctional institutions or law enforcement. This will not list the disclosures that federal law does require us to track. To get a paper copy of this notice. You may ask for a copy at any time. Even if you agreed to get this notice electronically, you have a right to a paper copy. You may also get a copy at our website, UHCCommunityPlan.com. Using Your Rights To Contact your Health Plan. Call the phone number on the back of your ID card. Or you may contact the UnitedHealth Group Call Center at (TTY: 711). To Submit a Written Request. Mail to: UnitedHealthcare Government Programs Privacy Office MN006-W800 P.O. Box 1459 Minneapolis, MN Medicaid Member Handbook

51 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 toll-free member phone number on the back of your health plan ID card or contact the UnitedHealth Group Customer Call Center at (TTY: 711). Nebraska 51

52 Privacy Notices (cont.) 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. 52 Medicaid Member Handbook

53 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. Nebraska 53

54 Privacy Notices (cont.) 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 54 Medicaid Member Handbook

55 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 Nebraska 55

56 Grievance and Appeal Form Member s Name ID # Address Telephone Number: (Home) (Work) Please describe your concern in detail using names, dates, places of services, time of day and issues that occurred. If applicable, also state why UnitedHealthcare Community Plan should consider payment for requested services that are not normally covered. Please mail this completed form to the address listed at the bottom. (Signature) (Date) Member Services UnitedHealthcare Community Plan Grievance and Appeals P.O. Box Salt Lake City, UT Nebraska 57

57 Notes Nebraska 59

58