2011 Member Handbook English UHCCPforAdults NY

8/3/2019 2011 Member Handbook English UHCCPforAdults NY

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N E W Y O R K

UnitedHealthcare Community PlanMedicaid Member Handbook

ACNY10MC3283503_000 938-1011 12/10


2/522 Medicaid Member Handboo

Other Health Provider(s)

Name: ____________________________________ Phone: ___________________________________

Name: ____________________________________ Phone: ___________________________________

Emergency Room: __________________________ Phone: ___________________________________

Pharmacy: _________________________________ Phone: ___________________________________

Telephone Numbers/Translation Services

Your Primary Care Physician See Your UnitedHealthcareCommunity Plan ID Card

New York State Health Dept. (complaints) 1-800-206-8125

Upstate County Departments o Social Services

Cayuga County Department o Social Services 1-315-253-1011Herkimer County Department o Social Services 1-315-867-1291Madison County Department o Social Services 1-315-366-2211Oneida County Department o Social Services 1-315-798-5632Onondaga County Department o Social Services 1-315-435-2928Oswego County Department o Social Services 1-315-963-5000

New York City and Long Island

Nassau County Department o Social Services 1-516-227-8000New York City Human Resources Administration 1-718-557-1399New York City Human Resources Administration

(within the 5 boroughs) 1-877-472-8411New York Medicaid CHOICE 1-800-505-5678

Suolk County Department o Social ServicesHauppauge 1-631-853-8730Riverhead 1-631-852-3710Ronkonkoma 1-631-854-9700

Website wwwuhccommunityplancom

Member Services Department(open 24 hours a day, 7 days a week) 1-800-493-4647

TDD/TTY (or the hearing impaired) 1-800-662-1220


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Table o Contents

Part II Your Benefts

and Plan Procedures 16

Benefts 17Services Covered by

UnitedHealthcare Community Plan 17Benefts You Can Get From

UnitedHealthcare Community Planor With Your Medicaid ID Card 21

Benefts Using Your Medicaid Card Only 22Services NOT Covered by Medicaid

or UnitedHealthcare Community Plan 24Service Authorization and Actions 25Prior Authorization and Timerames 26Retrospective Review and Timerames 28How Our Providers Are Paid 28You Can Help With Plan Policies 28Inormation From Member Services 29Keep Us Inormed 29Disenrollment and Transers 30Action Appeals 32External Appeals 35Fair Hearings 37Complaint Process 38

How to File a Complaint 38What Happens Next 38Complaint Appeals 40Member Rights and Responsibilities 41Advance Directives 43Notice o Privacy Practices 44

Welcome to

UnitedHealthcare Community Plan

Managed Care Program 4How Managed Care Works 4How to Use This Handbook 4Help From Member Services 5Your Health Plan ID Card 6

Part I First Things You Should Know 7How to Choose Your PCP 8How to Get Care 10Get These Services From

UnitedHealthcare Community Plan

Without a Reerral 12Emergencies 14Urgent Care 14We Want to Keep You Healthy 15



How Managed Care Works

The Plan, Our Providers and YouNo doubt you have seen or heard about thechanges in health care. Many consumersnow get their health benets throughmanaged care. Many counties in NewYork State, including New York City, oertheir consumers a choice o managed carehealth plans. In some counties, people withMedicaid must join a health care plan. Such

counties operate a mandatory managedcare program. Other counties allow theirconsumers to choose whether they want tojoin managed care. Tese counties operate avoluntary Medicaid managed care program.Both programs allow or some people to keepgetting care through regular Medicaid.

UnitedHealthcare Community Plan memberswho live in New York City, Nassau, Suolk,Cayuga, Madison, Oneida, Onondaga,

Oswego and Herkimer counties are in amandatory Medicaid managed care program.

UnitedHealthcare has contracts with the StateDepartment o Health and the New York CityDepartment o Health and Mental Hygieneto meet the health care needs o people withMedicaid. In turn, we choose a group o

health care providers to help us meet your

needs. Tese doctors and specialists, hospitals,labs and other health care acilities make upour provider network.Youll fnd a list inour provider directory. I you dont have aprovider directory, call 1-800-493-4647 toget a copy.

When you join UnitedHealthcare, one o ourproviders will take care o you. Most o thetime that person will be your primary careprovider (PCP). I you need to have a test,

see a specialist or go to the hospital, yourPCP will arrange it. Your PCP is available toyou every day, day and night. I you need tospeak to him or her ater hours or weekends,leave a message and how you can be reached.Your PCP will get back to you as soon aspossible. Even though your PCP is your mainsource or health care, in some cases you canselreer to certain doctors or some servicesSee page 12 or details.

How to Use This HandbookWhether you have to join or choose to join amanaged care plan, this handbook will help.It will tell you how your new health caresystem will work and how you can get themost rom UnitedHealthcare. Tis handbook

Welcome to UnitedHealthcareCommunity Plan Managed Care Program

We are glad that you chose UnitedHealthcare Community Plan. We want to be sure you get

o to a good start as a new member. In order to get to know you better, we will be in touchwith you in the next two or three weeks. You can ask us any questions you have or get helpmaking appointments. I you need to speak with us beore we call on you, however, just callus at 18004934647.


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is your guide to health services. It tells you thesteps to take to make the plan work or you.

Te frst several pages will tell you whatyou need to know right away. Te rest othe handbook can wait until you need it.Use it or reerence or check it out a bit ata time. When you have a question, checkthis handbook or call our Member Servicesunit. You can also call the managed caresta at your local Department o SocialServices. Please see the ront inside cover ora list o local Department o Social Services

telephone numbers. I you live in New YorkCity, Cayuga, Madison, Nassau or Suolkcounties, you can call the New York MedicaidCHOICE Help Line at 18005055678.Member Services is available 24 hours a day,7 days a week at 18004934647.

I you have trouble hearing, call A&DD Relay Service at 18006621220.

Help From MemberServicesTere is someone to help you at MemberServices 24 hours a day, 7 days a week. Justcall 18004934647. I you have troublehearing, call A& Y/DD RelayService at 18006621220.

You can call to get help any time you have aquestion. You may call us to choose or changeyour primary care provider, ask about benets

and services, replace a lost ID card, report thebirth o a new baby or ask about any changethat might aect you or your amilys benets.

I you are or become pregnant, your childwill become part o UnitedHealthcare on theday he or she is born. Tis will happen unless

your newborn child is in a group that cannotjoin managed care. You should call us and

your local social services oce right away iyou become pregnant, and let us help you tochoose a doctor or your newborn baby beorehe or she is born.

We oer ree sessions to explain our healthplan and how we can best help you. Its a greattime or you to ask questions and meet othermembers. I youd like to come to one o thesessions, call us to nd a time and place thatworks best or you.

I you do not speak English, we can help.We want you to know how to use your healthcare plan, no matter what language youspeak. Just call us and we will nd a way totalk to you in your own language. We havea group o people who can help. We will alsohelp you nd a PCP who can serve you inyour language.

For people with disabilities: I you use awheelchair, are blind, or have trouble hearingor understanding, call us i you need extrahelp. We can tell you i a particular providersoce is wheelchair accessible or is equippedwith special communication devices. We alsooer the ollowing services:

TTYmachine(ourTTYphonenumberis 18004211220 or 18006621220)

Informationinlargeprint,Brailleoronaudio tape

Casemanagement Helpmakingorgettingtoappointments

Namesandaddressesofproviderswhospecialize in your disability



Your Health Plan ID CardAter you enroll, well send you a welcome

letter. Your UnitedHealthcare CommunityPlan ID card should arrive within 14 daysater your enrollment date. Your card hasyour PCPs name and phone number on it.It will also have your Client IdenticationNumber (CIN). I anything is wrong, call usright away. Carry your ID card at all timesand show it each time you go or care. I youneed care beore the card comes, your welcomeletter is proo that you are a member. You

must keep your Medicaid benet card. Youwill need that card to get Medicaid servicesthat UnitedHealthcare does not cover, suchas pharmacy benets. I you live in Cayuga,Madison, Herkimer, Oneida, Onondagaor Oswego counties, you will need yourMedicaid card or dental services.

Health Plan (80840) 911-87726-04Member ID: Group Number:

Member:

CIN#:PCP Name:HEALER, PRIMARYPCP Phone: (999)555-9999

0501

Payer ID:

Administered by UnitedHealthcare of New York, Inc.

999999999 99999

EMPLOYEE BROWNED57975K

87726

UnitedHealthcare Community Plan for Families

AB12375CJOHN DOE


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Part I First ThingsYou Should Know How to Choose Your PCP

How to Get Regular Care

How to Get Specialty Care

Get These Services From UnitedHealthcare Without a Referral

Emergencies

Urgent Care

We Want to Keep You Healthy



How to Choose Your PCP

You may have already picked your PCP toserve as your regular doctor. Tis person couldbe a doctor or a nurse practitioner. I you havenot chosen a PCP or you and your amily, youshould do so right away. I you do not choose adoctor within 30 days, we will choose one oryou. Each amily member can have a dierentPCP, or you can choose one PCP to take careo the whole amily. A pediatrician treatschildren. Family practice doctors treat the

whole amily. Internal medicine doctors treatadults. Member Services can help you choosea PCP.

With this handbook, you should have aprovider directory. Tis is a list o all thedoctors, clinics, hospitals, labs and otherswho work with UnitedHealthcare. It lists theaddresses, phone numbers and special trainingo the doctors. Te provider directory willshow which doctors and providers are taking

new patients. You should call their oces tomake sure they are taking new patients at thetime you choose a PCP.

You may want to nd a doctor:

Whoyouhaveseenbefore

Whounderstandsyourhealthproblems

Whoistakingnewpatients

Whocanserveyouinyourlanguage Whoiseasytogetto

Women can also choose one o our OB/GYNdoctors or midwives to deal with womenshealth issues. You never need a reerralor amily planning, wellwoman care orcare during pregnancy. Women can haveroutine checkups (twice a year), ollowupcare i there is a problem and regular careduring pregnancy.

We also contract with several ederallyqualied health centers (FQHC). All FQHCs

give primary and specialty care. Someconsumers want to get their care rom FQHCsbecause the centers have a long history in theneighborhood. Maybe you want to try thembecause they are easy to get to. You shouldknow that you have a choice. You can chooseone o our providers. Or you can sign up witha primary care physician at one o the FQHCsthat we work with, listed in the providerdirectory.

Call Member Services at 18004934647or help.


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In almost all cases, your doctors will beUnitedHealthcare providers. In some casesyou can continue to see another doctor thatyou had beore you joined UnitedHealthcare,even i he or she does not work with our plan.You can continue to see your doctor i:

Youaremorethan3monthspregnantwhen you join and you are gettingprenatal care. In that case, you can keepyour doctor until ater your delivery and

ollowup care. Atthetimeyoujoin,youhavea

liethreatening disease or condition thatgets worse with time. In that case, you canask to keep your doctor or up to 60 days.

In both cases, however, your doctor mustagree to work with UnitedHealthcare.

I you have a longlasting illness, likeHIV/AIDS or other longterm health

problems, you may be able to choose aspecialist to act as your PCP. Please callMember Services to request a specialist asyour PCP.

I you need to, you can change your PCP inthe rst 30 days ater your rst appointmentwith your PCP. Ater that, you can changeyour PCP three times during the year withoutcause or more oten i you have a good reason.You can also change your OB/GYN or health

care specialist.

I your provider leaves UnitedHealthcare,we will tell you within 15 days rom whenwe know about this. I you wish, you maybe able to see that provider i you are morethan three months pregnant or i you arereceiving ongoing treatment or a condition.I you are pregnant, you may continueto see your doctor or up to 60 days aterdelivery. I you are seeing a doctor regularlyor an ongoing condition, you may continue

your present course o treatment or up to90 days. Your doctor must agree to work withUnitedHealthcare during this time.

I any o these conditions apply to you, checkwith your PCP or call Member Services at1-800-493-4647 or help.



How to Get Care

Regular CareRegular care means exams, regular checkups,shots or other treatments to keep you well, giveyou advice when you need it and recommendyou to a hospital or a specialist when needed.It means you and your PCP will be workingtogether to keep you well or to see that you getthe care you need. Day or night, your PCP isonly a phone call away. Be sure to call him orher whenever you have a medical question or

concern. I you call ater hours or on weekends,leave a message and where or how you can bereached. Your PCP will call you back as quicklyas possible. Remember, your PCP knows youand knows how the health plan works.

Your care must be medically necessary.Te services you get must be needed:

Toprevent,ordiagnoseandcorrect,whatcould cause more suering,

Todealwithadangertoyourlife, Todealwithaproblemthatcouldcause

illness, or

Todealwithsomethingthatcouldlimityour normal activities

Your PCP will take care o most o yourhealth care needs, but you must have anappointment to see your PCP. I ever you cantkeep an appointment, call to let your PCP

know. As soon as you choose a PCP, call tomake a rst appointment. I you can, prepareor your rst appointment. Your PCP willneed to know as much about your medicalhistory as you can tell him or her. Make a listo your medical background, any problemsyou have now and the questions you want to

ask your PCP. In most cases, your rst visitshould be within three months o your joiningthe plan.

I you need care beore your rst appointmentcall your PCPs ofce to explain the problem.He or she will give you an earlier appointment(You should still keep the rst appointment.)

Specialty Care

Sometimes you may have a health problemthat your PCP will not treat because youneed special medical attention. Whenthat happens, your PCP will send you to aspecialist, a doctor who is an expert in the careand treatment o certain medical problems.Tere are some treatments and services thatyour PCP must ask UnitedHealthcare toapprove beore you can get them. You are notresponsible or any o the costs except anycopayments as described in this handbook.

Here are some examples o specialists:

Cardiologist heartdoctor

Dermatologist skindoctor

Hematologist doctorforbloodproblems

Podiatrist footdoctor

Ophthalmologist eyedoctor

When your PCP sends you to see aspecialist, he or she will give you the name

o the specialist and may help you make anappointment. Your PCP may give you a noteon his or her letterhead or on a prescriptionorm with the specialists name and anyimportant inormation the specialist needs tohave when he or she sees you.


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Use the following list as an appointment guide for our limits on howlong you may have to wait after your request for an appointment:

Adultbaselineandroutinephysicals:within 12 weeks

Urgentcare:within 24 hours

Non-urgentsickvisits:within 3 days

Routine,preventivecare:within 4 weeks

Firstprenatalvisit:within 3 weeks during 1st trimester, 2 weeks during 2ndand 1 weekduring 3rd

Firstnewbornvisit:within 2 weeks o hospital discharge

Firstfamilyplanningvisit:within 2 weeks

Follow-upvisitaftermentalhealth/substanceabuseERorinpatientvisit:5 days

Non-urgentmentalhealthorsubstanceabusevisit:2 weeks

I the specialist is not in the UnitedHealthcarenetwork, your PCP must callUnitedHealthcares Prior AuthorizationDepartment at 18666043267 to getauthorization or you to go to a specialist thatis not part o the UnitedHealthcare network.Te specialist has to agree to work withUnitedHealthcare and accept our paymentsas payment in ull. Tis permission is calledprior authorization. Your PCP will explain

all o this to you when he or she sends youto a specialist. Please reer to the ServiceAuthorization and Actions section or moreinormation on what documentation yourrequest or a nonparticipating providershould include.

I UnitedHealthcare determines that we donot have a specialist in our plan who can give

you the care you need, we will get you thecare you need rom a specialist outside o ournetwork. O course, you will not pay or thiscare when approved.

I you have a longterm disease or a disablingillness that gets worse over time, your PCPmay be able to arrange or:

YourspecialisttoactasyourPCP

Youtogotoaspecialtycarecenterthatdeals with the treatment o your problem.You can also call Member Services or helpin getting access to a specialty care center

I you ever want to see a diferent specialist,talk to your PCP or call Member Servicesat 1-800-493-4647.



Get These Services FromUnitedHealthcare Without a Reerral

You Can Get TheseWomens Services If:

Youarepregnant

YouneedOB/GYNservices

Youneedfamilyplanningservices

Youwanttoseeamidwife

Youneedtohaveabreastorpelvicexam

Family PlanningYou can get the ollowing amily planningservices: advice or birth control, pregnancy tests,sterilization or a medically necessary abortionto protect your health. I you have Medicaidin New York City, you may have an abortionor any reason. During your visits or this care,you can also get tests or sexually transmittedinections, a breast cancer exam or a pelvic exam.

You can choose where to get these services.

You can use your UnitedHealthcareCommunity Plan ID card to see one oUnitedHealthcares amily planning providers.Check the plans provider directory or callMember Services or help nding a provider.Or you can use your Medicaid card i youwant to go to a doctor or clinic outsideUnitedHealthcare. Ask your PCP or callMember Services at 18004934647 or alist o places to go to get these services. You

can also call the New York State Growing UpHealthy Hotline (18005225006) or thenames o amily planning providers near you.

HIV Counseling and TestingUnitedHealthcare wants to promoteHIV/AIDS prevention. Tere is inormationavailable or people who are at risk or HIV.

We can provide you with inormation on howthe inection is spread, how to protect yourseli you do not have the inection and how toprotect others i you do have the inection.We can also provide you with inormation onhow to get tested and receive counseling oryou and your partner. Tere are many doctorswho specialize in the care o people with HIV

I you want more inormation about HIVprevention and how UnitedHealthcare can

assist you, call 18662195159 during regularbusiness hours.

UnitedHealthcare also has a special programdesigned to assist members who have HIV.I you would like inormation about howthis program may help you, call the CaseManagement Department Hotline at18662195159 during regular business hours

YoucangetHIVtestingandcounselingany time you have amily planningservices. You do not have to tell your PCP.Just make an appointment with one o ouramily planning providers.

Or i youd rather not see one oUnitedHealthcares providers, you can useyour Medicaid card to see a amily planningprovider outside UnitedHealthcare. Forhelp in nding either a UnitedHealthcareCommunity Plan provider or a Medicaidprovider or amily planning services, callMember Services at 18004934647.

I you want HIV testing and counselingbut not as part o a amily planning serviceyour PCP can arrange it or you. Or youcan visit an anonymous HIV testing andcounseling site. For inormation, call theNew York State HIV Counseling Hotlineat 18008722777 or 1800541AIDS.


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IfyouneedHIVtreatmentafterthetesting and counseling service, your PCPwill help you get ollowup care.

Eye CareTe covered benets include the needed serviceso an ophthalmologist, optometrist and anophthalmic dispenser, and include an eye examand pair o eyeglasses, i needed. Generally,

you can get these once every two years, or more

oten i medically needed. Enrollees diagnosedwith diabetes may selreer or a dilated eye(retinal) examination once in any 12monthperiod. You just choose one o our participating

vision providers listed in the provider directory.New eyeglasses (with Medicaidapprovedrames) are usually provided once every two

years. New lenses may be ordered more oten,i, or example, your vision changes more than/2 diopter. I you break your glasses, they can be

repaired. Lost eyeglasses, or broken eyeglassesthat cant be xed, will be replaced with thesame prescription and style o rames. I youneed to see an eye specialist or care o an eyedisease or deect, your PCP can recommend one.

Mental HealthChemical Dependence(Including Alcohol and

Substance Abuse)You may go or 1 mental health assessmentin any 12month period. You must usea UnitedHealthcare Community Planprovider, but you do not need an OK romyour PCP. I you need more visits, yourmental health provider will arrange themwith UnitedHealthcare. You may also go or1 chemical dependence assessment or all

inpatient detoxication, inpatient rehabilitationor outpatient detoxication services in any12month period. I you need more care, yourchemical dependence or detoxication programwill work with UnitedHealthcare. I you want achemical dependence assessment or any alcoholand/or substance abuse outpatient treatmentservices, except outpatient detoxicationservices, you must use your Medicaid benetcard to go to any provider that takes Medicaid.

Case ManagementUnitedHealthcare has a special case managementprogram designed to assist members with seriousand complex medical conditions, including:

HIV/AIDS

KidneyFailure

HighBloodPressure

Emphysema(COPD)

DiabetesAsthma

SickleCellAnemia

CongestiveHeartFailure

HeartDisease

Hemophilia

Cancer

High-RiskPregnancy

I you would like inormation about howthese programs may help you, call the CaseManagement Department at 18662195159during regular business hours.

I you have endstage renal disease (ESRD)or are a longterm resident o a skilled nursingacility, you may be eligible to disenroll romour health plan.



RememberYou do not need prior approvalor emergency services. Use theemergency room only i you havean emergency. Te emergency roomshould not be used or problemslike the fu, sore throats or earinections. I you have questions,call your PCP or UnitedHealthcareat 18004934647.

Urgent CareYou may have an injury or an illnessthat is not an emergency but stillneeds prompt care.

iscouldbeachildwithanearache who wakes up in themiddle o the night and wontstop crying.

Itcouldbeasprainedankle,orabad splinter you cant remove.

You can get an appointment or anurgent care visit or the same ornext day. Whether you are at homeor away, call your PCP any time,day or night. I you cannot reachyour PCP, call us at 1800493647or assistance.

Emergencies

You are always covered for emergencies.An emergency means a medical or behavioral condition:

atcomesonallofasudden,and

athaspainorothersymptoms

Tis would make a person with an average knowledge o healthear that someone will suer serious harm to body parts orunctions or serious disgurement without care right away.

Examples o an emergency are:

Aheartattackorseverechestpain

Bleedingthatwontstoporabadburn

Brokenbones

Troublebreathing,convulsionsorlossofconsciousness

Whenyoufeelyoumighthurtyourselforothers

Ifyouarepregnantandhavesignslikepain,bleeding,ever or vomiting

Examples o nonemergencies are: colds, sore throat, upsetstomach, minor cuts and bruises, or sprained muscles.

If you have an emergency, heres what to do:

I you believe you have an emergency, call 911 or go to theemergency room. You do not need your plans or your PCPsapproval beore getting emergency care, and you are notrequired to use our hospitals or doctors.

I you are not sure, call your PCP or UnitedHealthcare.Tey will:

Tellyouwhattodoathome

TellyoutocometothePCPsoce

Tellyoutogotothenearestemergencyroom

I you are out o the area when you have an emergency:

Gotothenearestemergencyroom


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We Want to Keep You Healthy

Besides the regular check ups and the shots you and your family need,here are some other ways to keep you in good health:

Classesforyouandyourfamily

Stop-smokingclasses

Prenatalcareandnutrition

Grief/Losssupport

Breast-feedingandbabycare

Stressmanagement

Weightcontrol

Cholesterolcontrol

Diabetescounselingandself-managementtraining

Asthmacounselingandself-managementtraining

Call Member Services at 1-800-493-4647to nd out more and get a list of services.



Part II Your Beneftsand Plan Procedures

The rest of this handbook is for your information when youneed it. It lists both covered and non-covered services.

If you have a complaint, the handbook tells you what to do.

The handbook has other information you may nd useful.

Keep this handbook handy for when you need it.


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Medicaid managed care provides a number o services you can get in addition to those you getwith regular Medicaid. UnitedHealthcare will provide or arrange or most services that youwill need. You can get a ew services, however, without going through your PCP. Tese includeemergency care; amily planning/HIV testing and counseling; and specic selreerral services,including those you can get rom within the plan and some that you can choose to go to anyMedicaid provider o the service.

Benefts

Services Covered byUnitedHealthcare Community Plan

You must get these services rom the providers who are in UnitedHealthcare.All services must be medically necessary.

Regular Medical Care OcevisitswithyourPCP

Specialistvisits

Vision/hearingexams

Preventive Care

Well-babycare

Well-childcare

Regularcheckups Shotsforchildrenfrombirth

through adolescence

AccesstoEarlyandPeriodicScreening,Diagnosis and reatment (EPSD)services or enrollees rom birth until age21 years

Maternity Care Pregnancycare

Doctors/midwifeandhospitalservices

Newbornnurserycare

Smokingcessationcounselingforpregnant women

Home Health Care

Atleast2visitsforhigh-riskinants (newborns)

Visitforwomenwhostayinthehospitalless than 48 hours ater birth

Visitforwomenwhostayinthehospitalless than 96 hours ater a cesarean birth

Otherhomehealthcarevisitsasneededand ordered by your PCP/specialist



Services Covered by UnitedHealthcareCommunity Plan (cont)

Dental CareUnitedHealthcare covers dental services inNew York City, Nassau and Suolk counties.UnitedHealthcare believes that providingyou with good dental care is important toyour overall health care. We oer dental carethrough contracts with individual dentists andgroup practices who are experts in providinghighquality dental services. Covered services

include regular and routine dental servicessuch as preventive dental checkups, cleanings,Xrays, llings and other services to check orany changes or abnormalities that may requiretreatment and/or ollowup care or you. Youdo not need a reerral rom your PCP to seea dentist.

How to Access Dental Services

You do not need to select a primary care

dentist as part o UnitedHealthcare. I you livein New York City, Nassau or Suolk counties,you can choose any participating dentistby selecting a dentist listed in the providerdirectory, or you can call Member Servicesat 18004934647. Please present yourUnitedHealthcare Community Plan ID cardwhenever you receive dental services.

I you live in Cayuga, Madison, Herkimer,Oneida, Onondaga or Oswego counties and need

to visit a dentist, make an appointment with anydentist that takes regular Medicaid. You will needto use your Medicaid card to pay or the visit.

Vision Care

Services o an ophthalmologist, ophthalmicdispenser and optometrist, and coverageor contact lenses, polycarbonate lenses,articial eyes, and/or replacement o lost ordestroyed glasses, including repairs, whenmedically necessary. Articial eyes arecovered as ordered by a plan provider

Eyeexams,generallyeverytwoyears,

unless medically needed more oten Glasses(newpairofMedicaid-approved

rames every two years, or more oten imedically needed)

Low-visionexamandvisionaidsorderedby your doctor

Specialistforeyediseasesordefects

Hospital Care

Inpatientcare,suchassurgery,inpatientphysician visits, anesthesia and medicallynecessary services

Outpatientcare,suchasambulatorysurgery, anesthesia, physician services andmedically necessary services

Lab,X-rayandothertests

Emergency Care

Emergencycareservicesareprocedures,treatments or services needed to evaluateor stabilize an emergency

Afteryouhavereceivedemergencycare,you may need other care to make sure youremain in stable condition. Dependingon the need, you may be treated in theemergency room, in an inpatient hospital


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room or in another setting. Tis is calledpoststabilization services

Formoreaboutemergencyservices,seepage 14

Mental Health/Chemical Dependence(Including Alcohol and

Substance Abuse) Allinpatientmentalhealthandchemical

dependence services (including alcohol andsubstance abuse)

Mostoutpatientmentalhealthservices(contact the plan or specics)

MedicaidrecipientswhoreceiveSSIorwho are certied blind or disabled getmental health and chemical dependence(including alcohol and substance abuse)services rom any Medicaid providerby using their Medicaid benet card.Detoxication services, however, arecovered by the plan as a benet

Specialty CareIncludes the services o other practitioners,including:

Occupational,physicalandspeech

therapists and audiologists Midwives

Residential Health CareFacility Care (Nursing Home)

Whenorderedbyyourphysicianandauthorized by UnitedHealthcare

Whenthestayinthenursinghomeisnotdetermined permanent by your LDSS (orHRA or New York City)

Coverednursinghomeservicesincludemedical supervision, 24hour nursing care,assistance with activities o daily living,physical therapy, occupational therapy andspeechlanguage pathology

TransportationEmergency

I you need emergency transportation,please call 911.

Non-Emergency Transportation

UnitedHealthcare wants to make sure thatyou get the medical care you need. Tat meansmaking sure you are able to get to your medicalappointments. We oer nonemergencytransportation or our members living inManhattan, Bronx, Kings, Queens, Richmond,Nassau, Suolk and Onondaga counties.

Members Who Live in New York City

I you live in New York City, we will providea Metro Card or you to get to and rom

your appointment the Metro Card will bemailed to you. Please request your MetroCard at least 10 days in advance o your

appointment and we will send it to you ontime or your appointment. I you need toschedule an urgent medical appointment andare unable to tell us 10 days beore, call usas soon as you know about the appointmentand we will either overnight a Metro Cardto you, send it to you as reimbursement or

your outopocket transportation expense or



Services Covered by UnitedHealthcareCommunity Plan (cont)

arrange or another orm o transportation.o be eligible or a Metro Card, theproviders ofce must be 10 blocks or morerom where you live.

Ifyouhaveadisabilityormedicalcondition that prevents you rom takingpublic transportation, we will arrangeor car service, ambulette or stretchertransportation or you. Your PCP orother health care provider will be askedto document the medical reason why youare unable to use public transportation. Iyou are approved or car service, ambuletteor stretcher transportation, you shouldrequest this orm o transportation at least3 days prior to your appointment.

I you require an attendant to go with youto your doctors appointment or i your childis the member o the plan, transportation isalso covered or the attendant or parent orguardian. I your child requires a car seat orbooster seat, you must bring your own carseat or booster with you. We do not providecar seats or boosters.

Members Who Live in Nassau,

Onondaga and Suffolk Counties

FormemberswholiveinNassau,Onondaga or Suolk counties, we willprovide car service to get you to and rom

your medical appointment. You shouldrequest transportation at least 3 daysbeore your scheduled appointment so wecan make arrangements or you.

Ifyourequirespecialtransportationlikeambulette or stretcher transportation, yourPCP may be asked to explain the medical

condition you have that requires theseorms o transportation.

I you require an attendant to go with youto your doctors appointment or i your childis the member o the plan, transportation isalso covered or the attendant or parent orguardian. I your child requires a car seat orbooster seat, you must bring your own carseat or booster with you. We do not providecar seats or boosters.

Member Services is available to assist youwith transportation needs 24 hours a day,7 days a week.

Members Who Live in Cayuga,

Herkimer, Madison, Oneida and

Oswego Counties

I you live in Cayuga, Herkimer, Madison,Oneida or Oswego counties, UnitedHealthcare

does not provide nonemergency transportationin these counties. Please contact your localDepartment o Social Services to arrange ortransportation. Phone numbers can be oundon the inside cover o this handbook.

Other Covered Services

Durablemedicalequipment(DME)/hearing aids/prosthetics/orthotics

Court-orderedservices Casemanagement

Socialsupportservices(helpingettingcommunity services)

FQHCorsimilarservices

Podiatryforchildrenandpersonswithspecial health problems (e.g., diabetes)


21/52New York

Family PlanningYou can go to any doctor or clinic that takesMedicaid and oers amily planning services.

You can visit one o our amily planningproviders as well. Either way, you do not needa reerral rom your PCP.

HIV Testing andCounselingYou can get these services romUnitedHealthcare doctors i you talk to yourPCP rst. When you get these services aspart o a amily planning visit, you can goto any doctor or clinic that takes Medicaidand oers amily planning services. You donot need a reerral when you get this serviceas part o a amily planning visit. You canalso go to anonymous counseling and testingclinics oered by the state and local healthdepartments. o get more inormation aboutthese sites, call the New York State HIVCounseling Hotline at 18008722777 or1800541AIDS.

TB Diagnosis andTreatmentYou can choose to go either to your PCP or to

the county public health agency or diagnosisand/or treatment. You do not need a reerral togo to the county public health agency.

Benefts You Can GetFrom UnitedHealthcare orWith Your Medicaid ID Card

For some services, you can choose where to get the care. You can get these services by using yourUnitedHealthcare Community Plan membership card. You can also go to providers who willtake your Medicaid benet card. Call us i you have questions at 18004934647.



Benefts Using Your Medicaid Card Only

PharmacyYou can get prescriptions, overthecountermedicines, enteral ormulas and some medicalsupplies rom any pharmacy that takesMedicaid. A copayment may be required orsome people, or some medications and or

pharmacy items.

Certain medications may require that yourdoctor get prior authorization rom Medicaidbeore writing your prescription. Gettingprior authorization is a simple process or yourdoctor and does not prevent you rom gettingmedications that you need.

Dental Services

I you live in Cayuga, Herkimer, Madison,Oneida, Onondaga or Oswego counties,you can get dental care using your Medicaidbenet card. Medicaid covers regular androutine dental services such as preventivedental checkups, cleanings, Xrays, llingsand other services to check or any changesor abnormalities that may require treatmentand/or ollowup care or you.

How to AccessDental Services

Youcangotoanydentistwhoaccepts Medicaid.

Ifyouneedhelpndingadentistoradental clinic that is run by an academicdental center, call the New York State

Hotline at 18005412831, and theywill send you a list o dentists in yourneighborhood.

TransportationI you live in Cayuga, Herkimer, Madison,

Oneida or Oswego counties, please contactyour local Department o Social Services toarrange or transportation. Phone numbers canbe ound on the inside cover o this handbook.

Mental Health

Intensivepsychiatricrehabtreatment

Daytreatment

Intensivecasemanagement

Partialhospitalcare

Rehabservicestothoseincommunityhomes or in amilybased treatment

Clinicservicesforchildrenwithadiagnosis o serious emotional disturbance(SED), at mental health clinics certied bythe State Oce o Mental Health

Continuingdaytreatment

Allcoveredmentalhealthservicesfor

people who receive SSI or who are certiedblind or disabled are available by using theMedicaid benet card

Tere are some services UnitedHealthcare does not provide. You can get these services romany provider who takes Medicaid by using your Medicaid benet card.


23/52New York

Mental Retardation andDevelopmental Disabilities

Long-termtherapies

Daytreatment

Housingservices

MedicaidServiceCoordination(MSC) program

ServicesreceivedundertheHomeand

CommunityBased Services Waiver

MedicalModel(Care-at-Home)Waiver services

Alcohol and SubstanceAbuse Services

Methadonetreatment

Outpatientsubstanceabusetreatment

Outpatientalcoholrehab Outpatientalcoholclinicservices

Chemicaldependence(includingalcoholand substance abuse) services covered byyour LDSS (or HRA or New York City)

Outpatientchemicaldependenceforyouth programs

Chemicaldependence(includingalcoholand substance abuse) services ordered bythe Human Resources Administration

Allcoveredalcoholandsubstanceabuse services (except detoxication)are available or people who receive SSIor who are certied blind or disabledby using their Medicaid benet card.Detoxication services are available usingyour UnitedHealthcare Community PlanID card

Other Medicaid Services

Personalcareservices

Preschoolandschoolservicesprograms(early intervention)

Earlystartprograms

ComprehensiveMedicaidCaseManagement (CMCM) program

TBtherapy/DOT

Adultdaytreatmentforpersonswith HIV

Hospiceservices



Services NOT Covered by Medicaid orUnitedHealthcare Community Plan

Tese services are not covered byUnitedHealthcare Community Plan orMedicaid. I you get any o these services, youmay have to pay the bill. You will also haveto pay the bill i you agree to pay privately orservices. Tese services include:

Cosmeticsurgeryifnotmedicallyneeded

Routinefootcareforthose21yearsandolder (there are some exceptions)

Personalandcomfortitems Infertilitytreatments

Servicesofaproviderthatisnotpart o UnitedHealthcare (unlessUnitedHealthcare authorizes you to go tothat provider)

Servicesforwhichyouneedanauthorization (approval) in advance andyou did not get it

Chiropracticcare(forthose21yearsand older)

ServicesdeliveredoutsidethecontinentalUnited States

Immigrationexaminationandimmunization

Exceptformedicalemergenciesasdenedin this handbook, services received outsideo the plans service area as describedin this handbook. You are covered

or emergency and urgent care in theUnited States, Canada, the Americanterritories o Puerto Rico, the VirginIslands, Guam, Northern MarianaIslands, American Samoa and Americanterritorial waters

You may have to pay or any service that yourPCP or specialist does not approve. Also, iyou agree to be a private pay or selpaypatient beore you receive services, you willhave to pay or these services. Tis includes:

Non-coveredservices(listedabove)

Unauthorizedservices

Servicesprovidedbyprovidersnotparto UnitedHealthcare

I you have any questions, call Member Servicesat 1-800-493-4647.


25/52New York

Service Authorization and Actions

Prior AuthorizationTere are some treatments and servicesthat you need to get approval or beoreyou receive them or in order to be able tocontinue receiving them. Tis is called priorauthorization. You or someone you trust canask or this. Your health care provider canask or this on your behal. Te ollowingtreatments and services must be approved

beore you get them: Admissionstoinpatientfacilities

(example: hospital, except or maternity)

Homehealthcareservices

Durablemedicalequipment(DME)over $500

Prostheticandorthoticdevicesover$500

Cosmeticandreconstructivesurgery

Gastricbypassevaluationsandsurgery

Hospiceservices,inpatientandoutpatient

AdvancedradiologyservicesincludingMRI, MRA and PE scans

Accidentaldentalservices

Experimentalorinvestigationalhealthcare services

Out-of-networkorout-of-stateservices

Mentalhealthorsubstanceabuseservices

Physical,occupationalandspeechtherapy

ater the 6th visit

Transplantevaluations

Asking or approval o a treatment or serviceis called a service authorization request. oget approval or these treatments or services,your doctor or health care provider mustcall UnitedHealthcares Prior Authorization

Department at 18666043267, or yourphysician or health care provider may send arequest in writing or by ax at 18007717507.

Written physician or health care providerrequests can be sent to:

UnitedHealthcare Community PlanNew York9700 Bissonnet Street, Suite 2700Houston, X 77036-8000

You will also need to get prior authorizationi you are getting one o these services now,but need to continue or get more o the care.Tis includes a request or home healthcare while you are in the hospital or ateryou have just let the hospital. Tis is calledconcurrent review.

Home health care (HHC) services that ollowan inpatient hospital admission are evaluated

and determined in the same manner as iyou are already getting the service now, butneed to continue or get more o the care(concurrent review).

What Happens AfterWe Get Your ServiceAuthorization RequestTe health plan has a review team to be sure

you get the services that are covered by ourplan i medically necessary. Doctors andnurses are on the review team. Teir job is tobe sure the treatment or service you asked oris medically needed and right or you. Tey dothis by checking your treatment plan againstmedically acceptable standards.



Any decision to deny a service authorizationrequest or to approve it or an amount thatis less than requested is called an action.Tese decisions will be made by a qualiedhealth care proessional. I we decide that therequested service is not medically necessary,the decision will be made by a clinical peerreviewer, who may be a doctor or may be ahealth care proessional who typically providesthe care you requested. You or someone

you trust can request the specic medicalstandards, called clinical review criteria, usedto make the decision or actions related tomedical necessity.

Ater we get your request, we will reviewit under a standard or expedited process.You or your doctor can ask or an expeditedreview i it is believed that a delay will causeserious harm to your health. I your requestor an expedited review is denied, we will

tell you and your case will be handled underthe standard review process. I you are in thehospital or have just let the hospital and wereceived a request or home health care, wewill handle the request as a ast track review.In all cases, we will review your request as astas your medical condition requires us to do so,but no later than mentioned below.

We will tell you and your provider bothby phone and in writing i your request is

approved or denied. We will also tell you thereason or the decision. We will explain whatoptions or appeals or air hearings you willhave i you dont agree with our decision.

Timeframes for PriorAuthorization Requests

Standard review:We will make adecision about your request within3 working days o when we have all theinormation we need, but you will hearrom us no later than 14 days ater wereceive your request. We will tell you bythe 14th day i we need more inormation.

Fast track review:We will make adecision and you will hear rom us within3 working days. We will tell you by the 3rdworking day i we need more inormation.

We will tell attempt to tell you our decision byphone and send a written notice later.

Timeframes for ConcurrentReview Requests

Standard review:We will make adecision within 1 working day o whenwe have all the inormation we need,but you will hear rom us no later than14 days ater we received your request.We will tell you by the 14th day i we needmore inormation.

Withrespecttorequestsforhomehealthcare (HHC) immediately ollowing aninpatient hospital admission, we willmake a decision within 1 working dayo when we have all the inormationwe need, but you will hear rom us nolater than 14 days ater we received yourrequest or within 72 hours o receipt othe necessary inormation when the dayater the request date alls on a weekendor holiday.

Service Authorization and Actions (cont)


27/52New York

Fast track review:We will make adecision within 1 working day o whenwe have all the inormation we need.However, i you are in the hospital or havejust let the hospital, and you ask or homehealth care on a Friday or day beore aholiday, we will make a decision no laterthan 72 hours o when we have all theinormation we need. In all cases you willhear rom us no later than 3 working days

ater we received your request. We willtell you by the 3rd working day i we needmore inormation.

We will attempt to tell you our decision byphone and send a written notice later.

I we need more inormation to make eithera standard or ast track decision about yourservice request, we will:

Writeandtellyouwhatinformationis

needed. I your request is in a ast trackreview, we will call you right away andsend a written notice later

Tellyouwhythedelayisinyourbest interest

Makeadecisionnolaterthan14daysfromthe day we asked or more inormation

You, your provider or someone you trustmay also ask us to take more time to make

a decision. Tis may be because you havemore inormation to give the plan to helpdecide your case. Tis can be done by calling18004934647 or by ax at 18007717507.

Written physician or health care providerrequests can be sent to:

UnitedHealthcare Community PlanNew York9700 Bissonnet Street, Suite 2700Houston, X 77036-8000

You or someone you trust can le acomplaint with the plan i you dont agreewith our decision to take more time toreview your request. You or someone youtrust can le a complaint with the NewYork State Department o Health by calling18002068125.

We will notiy you o our decision by the dateour time or review has expired. But i orsome reason you do not hear rom us by thatdate, it is the same as i we denied your serviceauthorization request. I you are not satisedwith this answer, you have the right to le

an action appeal with us. See the ActionAppeal section later in this handbook.

Other Decisions AboutYour CareSometimes we will do a concurrent reviewon the care you are receiving to see i youstill need the care. We may also review othertreatments and services you have alreadyreceived. Tis is called retrospective review.We will tell you i we take these other actions.



Service Authorization and Actions (cont)

Timeframes for Notice ofOther Actions

Inmostcases,ifwemakeadecisiontoreduce, suspend or terminate a service wehave already approved and you are nowgetting, we must tell you at least 10 daysbeore we change the service.

I we are checking care that has beengiven in the past, we will make a decision

about paying or it within 30 days oreceiving necessary inormation or theretrospective review. I we deny paymentor a service, we will send a notice to youand your provider the day the payment isdenied. You will not have to pay or anycare you received that was covered by theplan or by Medicaid even i we later denypayment to the provider.

How Our ProvidersAre Paid

You have the right to ask us whether we haveany special nancial arrangement with ourphysicians that might afect your use o healthcare services. You can call Member Services at18004934647 i you have specic concerns

I our PCPs work in a clinic or health centerthey probably get a salary. Te number o

patients they see does not afect this.Our PCPs who work rom their own

ofces may get a set ee each month oreach patient or whom they are the patientsPCP. Te ee stays the same whether thepatientneedsonevisitormanyorevennone at all. Tis is called capitation.

Providersmayalsobepaidbyeeorservice. Tis means they get aplanagreedupon ee or each service

they provide.

You Can Help With PlanPolicies

We value your ideas. You can help us developpolicies that best serve our members. I youhave ideas, tell us about them. Maybe youdlike to work with one o our member advisoryboards or committees. Call Member Services

at 18004934647 to nd out how youcan help.


29/52New York

Inormation From Member Services

Here is inormation you can get by callingMember Services at 18004934647:

Alistofnames,addressesandtitlesofUnitedHealthcares Board o Directors,ocers, controlling parties, ownersand partners

Acopyofthemostrecentnancialstatements/balance sheets, summaries oincome and expenses

Acopyofthemostrecentindividualdirectpay subscriber contract

InformationfromtheStateInsuranceDepartment about consumer complaintsabout UnitedHealthcare

Howwekeepyourmedicalrecordsandmember inormation private

Inwriting,wewilltellyouhowUnitedHealthcare checks on the quality ocare to our members

Wewilltellyouwhichhospitalsourhealthproviders work with

Ifyouaskusinwriting,wewilltellyou the guidelines we use to reviewconditions or diseases that are coveredby UnitedHealthcare

Ifyouaskinwriting,wewilltellyouthequalications needed and how healthcare providers can apply to be parto UnitedHealthcare

Ifyouask,wewilltellyou:1)whetherourcontracts or subcontracts include physician

incentive plans that aect the use oreerral services, and, i so, 2) inormationon the type o incentive arrangementsused, and 3) whether stoplossprotection is provided or physiciansand physicians groups

Informationabouthowourcompanyisorganized and how it works

Please send all written requests to:

Member ServicesUnitedHealthcare Community PlanNew York77 Water Street, 14th FloorNew York, NY 10005

Keep Us Inormed

Call Member Services whenever these changes happen in your lie: Youchangeyourname,addressor

telephone number

YouhaveachangeinMedicaideligibility

Youarepregnant

Yougivebirth

ereisachangeininsuranceforyouoryour children

I you no longer get Medicaid, check with the Human Resources Administration or your LocalDepartment o Social Services. You may be able to enroll your children in Child Health Plus, even i youlose Medicaid. Adults age 19 to 64 may be able to get Family Health Plus coverage.



Disenrollment and Transers

When Your County Requires You

to Join a Medicaid Health Plan

(a Mandatory County)

You can try us out or 90 days. You may leaveUnitedHealthcare and join another healthplan at any time during that time. I youdo not leave in the rst 90 days, however,you must stay in UnitedHealthcare or ninemore months, unless you have a good reason

(good cause).Some examples o good cause include:

Ourhealthplancannotprovideasuitableprimary care provider or you withinacceptable travel times (i providers areroutinely within 30 minutes or 30 milesrom where you live)

OurhealthplandoesnotmeetNewYorkState requirements and members areharmed because o it

Youmoveoutofourservicearea

You,theplanandyourlocalDepartmento Social Services (HRA in New YorkCity) all agree that disenrollment is bestor you

Youareorbecomeexemptorexcludedrom managed care

WedonotoeraMedicaidmanagedcare service that you can get rom another

health plan in your area Youneedaservicethatisrelatedtoa

benet we have chosen not to cover andgetting the service separately would putyour health at risk

Wehavenotbeenabletoprovideservicesto you as we are required to under ourcontract with the state

When your county lets you decide to joina Medicaid health plan or not (a voluntarycounty), you can ask to leave the plan at anytime or any reason.

To Disenroll or Change Plans

Call the managed care sta at your localDepartment o Social Services. Te phonenumbers are listed in this handbook.In New York City, Cayuga, Madison, Nassauor Suolk counties, call New York MedicaidCHOICE at 18005055678 to changehealth plans.

It will take between 2 and 6 weeks to processyour request, depending on when it is receivedYou can ask or aster action i you believe thetiming o the regular process will cause addeddamage to your health. You can also ask oraster action i you have complained because

you did not agree to the enrollment. Just callyour local Department o Social Services orNew York Medicaid CHOICE.

I you have to be in managed care, youwill have to choose another health careplan. Call the managed care unit o yourlocal Department o Social Services orNew York Medicaid CHOICE to get atranser or disenrollment packet. Be sureto let them know you are disenrolling rom

UnitedHealthcare and i you want to reenrollin a new plan. You will get a notice that thechange will take place by a certain date. Inmost cases, we will provide the care you needuntil then.


31/52New York

You Could Become Ineligible

for Medicaid Managed Care

You or your child may have to leaveUnitedHealthcare i you or the child:

Movesoutofthecountyorservicearea

Changestoanothermanagedcareplan

JoinsanHMOorotherinsuranceplanthrough work

Joinsalong-termhomehealthcare program

Goestoprison

Becomesapermanentresidentofanursing home

Your child may have to leave UnitedHealthcarei he or she:

Joinsaphysicallyhandicappedchildrens program

Isplacedinfostercare(voluntarilybyparent/guardian or by a decision o thelocal Social Services Commissioner)

In some cases, you may be guaranteed coverageby UnitedHealthcare. Tat means we willnot drop you as a member during the rst6 monthsofyourenrollmentinourplan even i you are no longer eligible or Medicaidand your Medicaid case is closed. Te reasonsor losing eligibility must not be related to

death, moving out o state or incarceration.During this time you can get the services thatUnitedHealthcare covers. You can also getpharmacy and amily planning care using yourMedicaid card. Guaranteed coverage does notapply i you choose to leave UnitedHealthcare.

We Can Ask You to Leave

UnitedHealthcare

You can also lose your UnitedHealthcareCommunity Plan membership i you oten:

RefusetoworkwithyourPCPinregardtoyour care

Dontkeepappointments

Gototheemergencyroomfornonemergency care

DontfollowUnitedHealthcaresrules

Donotlloutformshonestlyordonotgive true inormation (commit raud)

Causeabuseorharmtoplanmembers,providers or sta

Actinwaysthatmakeithardforustodoour best or you and other members evenater we have tried to x the problems



Action Appeals

Your Provider Can Ask

for ReconsiderationI we made a decision that your serviceauthorization request was not medicallynecessary or was experimental or investigationaland we did not talk to your doctor, your doctormay ask to speak with the plans medicaldirector. Te medical director will talk to yourdoctor within 1 working day.

You Can File anAction Appeal

Ifyouarenotsatisedwithanactionwetook or what we decide about your serviceauthorization request, you have 60 workingdays rom the date o our letter/notice toyou to le an action appeal.

Youcandothisyourselforasksomeoneyou trust to le the action appeal or

you. You can call Member Services at18004934647 i you need help ling anaction appeal.

Wewillnottreatyouanydierentlyoract badly toward you because you led anaction appeal.

eactionappealcanbemadebyphone

or in writing. I you make an actionappeal by phone, it must be ollowed upin writing. You must also sign the writtenaction appeal that you send to us. You oryour designee must sign the written actionappeal.

You can ask someone you trust (such as alegal representative, a amily member orriend) can request an action appeal or you

Ifyouneedourhelpbecauseofahearing

or vision impairment, i you needtranslation services, or i you need helplling out the orms, we can help you.

Wewillnotmakethingshardforyouortake any action against you or ling anaction appeal.

Please send all written appeals to:

Member Complaints, Grievancesand Appeals

UnitedHealthcare Community PlanNew YorkP.O. Box 31364Salt Lake City, U 84131-0364

Tere are some treatments and services that you need to get approval or beore you receive themor in order to be able to continue receiving them. Tis is called prior authorization. Asking orapproval o a treatment or service is called a service authorization request. Tis process isdescribed earlier in this handbook. Any decision to deny a service authorization request or toapprove it or an amount that is less than requested is called an action appeal.

I you are not satised with our decision about your care, steps to request a review o an actioninclude provider reconsideration and an action appeal.


33/52New York

Your Action Appeal Will BeReviewed Under the FastTrack Process If:

I you or your doctor asks to have youraction appeal reviewed under the ast trackprocess. Your doctor would have to explainhow a delay will cause harm to your health.I your request or ast track is denied, we

will tell you and your action appeal will bereviewed under the standard process.

Ifyourrequestwasdeniedwhenyouaskedto continue receiving care that you are nowgetting or need to extend a service that hasbeen provided.

Ifyourrequestwasdeniedwhenyouaskedor home health care ater you were inthe hospital.

Fasttrackactionappealscanbemadeby

phone and do not have to be ollowed upin writing.

What Happens After WeGet Your Action Appeal

Within15days,wewillsendyoualetterto let you know we are working on youraction appeal.

Actionappealsofclinicalmatterswill

be decided by qualied health careproessionals who did not make the rstdecision, at least one o whom will be aclinical peer reviewer.

Non-clinicaldecisionswillbehandledbypersons who work at a higher level than thepeople who worked on your rst decision.

Beforeandduringtheactionappealyouor your designee can see your case le,including medical records and any otherdocuments and records being used to makea decision on your case.

Youcanalsoprovideinformationtobeused in making the decision in personor in writing. Call Member Services at18004934647 i you are not sure whatinormation to give us. I you are appealingour decision that the outonetworkservice you asked or was not dierent roma service that is available in our network,ask your doctor to send us:

1. A written statement that the service youasked or is dierent rom the service wehave in our network; and

2. 2 pieces o medical evidence (publishedarticles or scientic studies) that show the

service you asked or is better or you, andwill not cause you more harm than theservice we have in our network.

Youwillbegiventhereasonsforourdecision and our clinical rationale, i itapplies. I you are still not satised, anyurther appeal rights will be explainedor you or someone you trust can lea complaint with the New York StateDepartment o Health at 18002068125.

Time Frames forAction Appeals

Standardactionappeals:Ifwehavealltheinormation we need, we will tell you ourdecision within 30 days rom your actionappeal. A written notice o our decision



Action Appeals (cont)

will be sent within 2 working days romwhen we make the decision.

Fasttrackactionappeals:Ifwehaveallthe inormation we need, expedited appealdecisions will be made within 2 workingdays rom your action appeal.

We will tell you in 3 working days atergiving us your action appeal, i we need moreinormation. We will tell you our decision byphone and send a written notice as well.

I we need more inormation to make eithera standard or ast track decision about youraction appeal, we will:

Writeyouandtellyouwhatinformationis needed. I your request is in a ast trackreview, we will call you right away andsend a written notice later.

Tellyouwhythedelayisinyourbest interest.

Makeadecisionnolaterthan14daysfromthe day we asked or more inormation.

You, your provider or someone you trustmay also ask us to take more time to makea decision. Tis may be because you havemore inormation to give the plan to helpdecide your case. Tis can be done by calling18004934647 or in writing. Please sendwritten requests to:

UnitedHealthcare Community PlanNew YorkP.O. Box 31364Salt Lake City, U 84131-0364

You or someone you trust can le a complainti you dont agree with our decision to takemore time to review your request. You can le

this complaint with the health plan by callingMember Services at 18004934647 (youhave trouble hearing, call the DD RelayService at 18006621220), or contact theNew York State Department o Health bycalling 18002068125.

I your original denial was because we saidthe service was not medically necessary, theservice was experimental or investigational,or the outonetwork service was not dierent

rom a service that is available in our networkand we do not tell you our decision about youraction appeal on time, the original denialo service will be reversed. Tis means yourservice authorization request will be approved.

Aid to Continue WhileAppealing a DecisionAbout Your Care

In some cases you may be able to continuethe services while you wait or your actionappeal case to be decided. You may be able tocontinue the services that are scheduled to endor be reduced i you ask or a air hearing:

Within10daysfrombeingtoldthatyourrequest is denied or care is changing

Bythedatethechangeinservicesisscheduled to occur

I your air hearing results in anotherdenial, you may have to pay or the cost oany continued benets that you received.Te decision you receive rom the air hearingocer will be nal.


35/52New York

External Appeals

I the plan decides to deny coverage or amedical service you and your doctor askedor because

theservicenotmedicallynecessary,

theservicewasexperimentalorinvestigational, or

theoutof-networkservicewasnotdierent rom a service that is available inour network

you can ask New York State or anindependent external appeal. Tis is calledan external appeal because it is decided byreviewers who do not work or the health planor the state. Tese reviewers are qualiedpeople approved by New York State. Teservice must be in the plans benet package,or be an experimental treatment, clinical trialor treatment or a rare disease. You do nothave to pay or an external appeal.

Beore you appeal to the state:1. You must le an action appeal with the

plan and get the plans nal adversedetermination; or

2. I you had an ast track action appeal andare not satised with the plans decision,you can choose to le a standard actionappeal with the plan or go directly to anexternal appeal; or

3. You and the plan may agree to skip theplans appeals process and go directly toexternal appeal.

You have 45 days ater you receive the plansnal adverse determination to ask or anexternal appeal. I you and the plan agreed toskip the plans appeals process, then you mustask or the external appeal within 45 days owhen you made that agreement.

Additional appeals to your health plan maybe available to you i you want to use them.However, i you want an external appeal, youmust still le the application with the State

Department o Insurance within 45 days romthe time the plan gives you the notice o naladverse determination or when you and theplan agreed to waive the plans appeal process.

You will lose your right to an externalappeal i you do not fle an application or anexternal appeal on time.

o ask or an external appeal, ll out anapplication and send it to the State Insurance

Department. You can call Member Servicesat 18004934647 i you need help lingan appeal. You and your doctors will have togive inormation about your medical problem.Te external appeal application says whatinormation will be needed.

Here are some ways to get an application:

CalltheStateInsuranceDepartmentat18004008882

GototheStateInsuranceDepartments

website at www.ins.state.ny.us Contactthehealthplanat

18004934647



Your external appeal will be decided in30 days. More time (up to 5 working days)may be needed i the external appeal reviewerasks or more inormation. You and the planwill be told the nal decision within 2 daysater the decision is made.

You can get a aster decision i your doctorsays that a delay will cause serious harmto your health. Tis is called an expeditedexternal appeal. Te external appeal reviewer

will decide an expedited appeal in 3 days orewer. Te reviewer will tell you and the planthe decision right away by phone or ax. Later,a letter will be sent that tells you the decision.

You may also ask or a air hearing i theplan decided to deny, reduce or end coverageor a medical service. You may request a airhearing and ask or an external appeal. I youask or a air hearing and an external appeal,the decision o the air hearing ocer will be

the one that counts.

External Appeals (cont)


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Fair Hearings

In some cases you may ask or a air hearingrom New York State i:

Youarenothappywithadecisionyourlocal Department o Social Services(HRA or NYC) or the State Departmento Health made about your staying orleaving UnitedHealthcare.

Youarenothappywithadecisionwemade about medical care you were getting.You eel the decision limits your Medicaidbenets or that we did not make thedecision in a reasonable amount o time.

Youarenothappyaboutadecisionwe made that denied medical care youwanted. You eel the decision limits yourMedicaid benets.

Youarenothappywithadecisionyourdoctor would not order services youwanted. You eel the doctors decision stops

or limits your Medicaid benets. You mustle a complaint with UnitedHealthcare. IUnitedHealthcare agrees with your doctor,you may ask or a State air hearing.

Te decision you receive rom the air hearingocer will be nal.

In some cases you may be able to keep gettingcare the same way while waiting or your airhearing. I the services you are now gettingare scheduled to end, you can choose to askto continue the services your doctor orderedwhile you wait or your case to be decided.However, i you choose to ask or services tobe continued and the air hearing is decidedagainst you, you may have to pay the cost orthe services you received while waiting ora decision.

You can use one o the ollowing ways torequest a air hearing:

1. By phone: 18003423334 (tollree)

2. By ax: 15184736735

3. By Internet:www.otda.state.ny.us/oah/orms.asp

4. By mail:Fair Hearing SectionNYS Oce o emporary andDisability AssistanceP.O. Box 1930Albany, NY 12201

Remember, you can le a complaint any timeto the New York State Department o Healthby calling 18002068125.



Complaint Process

How to File a Complaint With the Plan

I you have a problem, please callMember Services at 18004934647 so theycan assist you. I you want to le a complaintater discussing the problem with MemberServices, Member Services can help you do so.Or you can write to us at:

Member Complaints, Grievancesand AppealsUnitedHealthcare Community PlanNew YorkP.O. Box 31364Salt Lake City, U 84131-0364

You can ask someone you trust (such as a legalrepresentative, amily member or riend) to lethe complaint or you. I you need our helpbecause o a hearing or vision impairment,or i you need translation services, we canhelp you. We will not make things hard oryou or take any action against you or ling acomplaint.

You also have the right to contact theNew York State Department o Health

about your complaint at 18002068125,or write to New York State Departmento Health, Division o Managed Care,Bureau o Managed Care Certication andSurveillance, Room 1911 Corning owerESP, Albany, NY 12237. You may also contact

your local Department o Social Services withyour complaint at any time. You may call theNew York State Insurance Department at18003423736 i your complaint involves a

billing problem.

What Happens Next

I we dont solve the problem right awayover the phone or ater we get your writtencomplaint, we will send you a letter within15 working days. Te letter will tell you:

Whoisworkingonyourcomplaint

Howtocontactsomeoneattheplanabout

your complaint Ifweneedmoreinformation

Your complaint will be reviewed by one ormore qualied people. I your complaintinvolves clinical matters, your case will bereviewed by one or more qualied healthcare proessionals.

ComplaintsWe hope our plan serves you well. Most problems can be solved right away. I you have a problemor dispute with your care or services, you can le a complaint with the plan. Problems that arenot solved right away over the phone and any complaint that comes in the mail will be handledaccording to our complaint procedure described below.


39/52New York

After We Review Your Complaint Wewillletyouknowourdecision

in 45 days o when we have all theinormation we need to answer yourcomplaint, and you will hear rom us inno more than 60 days rom the day we getyour complaint. We will write to you andwill tell you the reasons or our decision.

Whenadelaywouldriskyourhealth,wewill let you know our decision in 48 hours

o when we have all the inormation weneed to answer your complaint, and youwill hear rom us in no more than 7 daysrom the day we get your complaint.We will call you with our decision or tryto reach you to tell you. You will get aletter to ollow up our communication in3 working days.

Youwillbetoldhowtoappealourdecisioni you are not satised, and we will include

any orms you may need.

Ifweareunabletomakeadecisionaboutyour complaint because we dont haveenough inormation, we will send a letterand let you know.



How to Make a Complaint Appeal

Ifyouarenotsatisedwithwhatwedecide, you have 60 working days romthe date o our letter/notice to you to lean appeal

Youcandothisyourselforasksomeoneyou trust to le the appeal or you

Teappealmustbemadeinwriting.I you make an appeal by phone, it mustbe ollowed up in writing. Ater yourcall, we will send you a orm that is asummary o your phone appeal. I youagree with our summary, you must signand return the orm to us. You can makeany needed changes beore sending theorm back to us. Please send all writtencorrespondence to:

Complaint AppealsUnitedHealthcare Community PlanNew York77 Water Street, 14th FloorNew York, NY 10005

What Happens After We Get Your

Complaint Appeal

Ater we get your complaint appeal we willsend you a letter within 15 working days. Te

letter will tell you:

Whoisworkingonyourcomplaintappeal

HowtocontactsomeoneatUnitedHealthcare about yourcomplaint appeal

Ifweneedmoreinformation

Your complaint appeal will be reviewed by oneor more qualied people at a higher level thanthose who made the rst decision about yourcomplaint. I your complaint appeal involvesclinical matters, your case will be reviewedby one or more qualied health proessionals,with at least one clinical peer reviewer, that

were not involved in making the rst decisionabout your complaint.

Ater we get all the inormation we need,we will let you know our decision within2 working days when a delay would risk yourhealth. For all other complaint appeals, wewill let you know our decision in 30 days.We will give you the reasons or our decisionand our clinical rationale, i it applies. I youare still not satised, you or someone on your

behal can le a complaint at any time withthe New York State Department o Health at18002068125; or you can write to the NYSDepartment o Health, Division o ManagedCare, Bureau o Managed Care Certicationand Surveillance, Room 1911 Corning owerESP, Albany, NY 12237.

Complaint Appeals

I you disagree with a decision we made about your complaint, you or someone you trustcan le a complaint appeal with the plan.


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Member Rights and Responsibilities

Your RightsAs a member o UnitedHealthcare, you have aright to:

Becaredforwithrespect,withoutregardor health status, sex, race, color, religion,national origin, age, marital status orsexual orientation.

Betoldwhere,whenandhowtogettheservices you need rom UnitedHealthcare.

BetoldbyyourPCPwhatiswrong,whatcan be done or you, and what will likelybe the result in language you understand.

Getasecondopinionaboutyourcare.

GiveyourOKtoanytreatmentorplanforyour care ater it has been ully explainedto you.

Refusecareandbetoldwhatyoumayriski you do.

Getacopyofyourmedicalrecordandtalk about it with your PCP, and to askthat your medical record be amended orcorrected, i needed.

Besurethatyourmedicalrecordisprivateand will not be shared with anyone exceptas required by law, contract or withyour approval.

UsetheUnitedHealthcarecomplaintsystem to settle any complaints, or you

can complain to the New York StateDepartment o Health or the localDepartment o Social Services any timeyou eel you were not airly treated.

UsetheStateFairHearingsystem. Appointsomeone(relative,friend,lawyer,

etc.) to speak or you i you are unableto speak or yoursel about your careand treatment.

Receiveconsiderateandrespectfulcarein a clean and sae environment ree ounnecessary restraints.

If You Get a Bill

UnitedHealthcare provides a ull range ohealth care services at no cost to you. Younever have to pay your PCP or any otherUnitedHealthcare participating provideranything. You should not be charged orany approved services oered throughUnitedHealthcare when you get them roma UnitedHealthcare Community Planprovider. I you are asked to pay or servicesby a UnitedHealthcare Community Plan

provider, remind the oce that you arecovered by UnitedHealthcare and present yourUnitedHealthcare Community Plan memberID card. You can also call Member Services at18004934647 or help.

You may be asked to pay or services that arenot covered by Medicaid or UnitedHealthcare.You cannot be charged or any such serviceunless you understood and agreed beore thecare was given that you would pay or it.



I you get a medical bill, call Member Servicesat 18004934647, and a representative willhelp you straighten out the problem. Mostbills should include a billing number youcan call to give them your UnitedHealthcareCommunity Plan member ID number and askthem to bill UnitedHealthcare.

I you are asked to pay or a service and youare not sure whether it is covered, call MemberServices at 18004934647 beore paying or

the service.I you paid a bill and you are seekingreimbursement, call Member Services at18004934647 and a representative willassist you.

Member Rights and Responsibilities (cont)

Your Responsibilities

As a member o UnitedHealthcare, you agree to:

WorkwithyourPCPtoguardandimproveyourhealth

Findouthowyourhealthcaresystem works

ListentoyourPCPsadviceandaskquestionswhenyouareindoubt

CallorgobacktoyourPCPifyoudonotgetbetter,oraskforasecondopinion

Treathealthcarestawiththerespectyouexpectyourself

Tellusifyouhaveproblemswithanyhealthcaresta.CallMemberServices

Keepyourappointments.Ifyoumustcancel,callassoonasyoucan

Usetheemergencyroomonlyforrealemergencies

CallyourPCPwhenyouneedmedicalcare,evenifitisafterhours


43/52New York

Advance Directives

Tere may come a time when you cant decideabout your own health care. By planning inadvance, you can arrange now or your wishesto be carried out.

First,letfamily,friendsandyourdoctorknow what kinds o treatment you do ordont want.

Second,youcanappointanadultyoutrustto make decisions or you. Be sure to talkwith your PCP, your amily or others close

to you so they will know what you want. ird,itisbestifyouputyourthoughts

in writing. Te documents listed belowcan help. You do not have to use a lawyer,but you may wish to speak with one aboutthis. You can change your mind and thesedocuments at any time. We can help youunderstand or get these documents. Teydo not change your right to quality healthcare benets. Te only purpose is to let

others know what you want i you cantspeak or yoursel.

Health Care ProxyWith this document,you name another adult that you trust (usuallya riend or amily member) to decide aboutmedical care or you i you are not able to doso yoursel. I you do this, you should talkwith the person so they know what you want.

CPR and DNRYou have the right to

decide i you want any special or emergencytreatment to restart your heart or lungs iyour breathing or circulation stops. I youdo not want special treatment, includingcardiopulmonary resuscitation (CPR), youshould make your wishes known in writing.

Your PCP will provide a DNR (Do NotResuscitate) order or your medical records.You can also get a DNR orm to carry withyou and/or a bracelet to wear that will letany emergency medical provider know aboutyour wishes.

Organ Donor CardTis walletsized cardsays that you are willing to donate parts oyour body to help others when you die. Also,check the back o your drivers license to let

others know i and how you want to donateyour organs.


44/52


45/52New YorkNew York

Forpublichealthactivities.ismaybetoprevent disease outbreaks.

Forreportingabuse,neglectordomesticviolence. We may only share withentities allowed by law to get this healthinormation. Tis may be a social orprotective service agency.

Forhealthoversightactivitiestoanagencyallowed by the law to get the healthinormation. Tis may be or licensure,

audits and raud and abuse investigations. Forjudicialoradministrativeproceedings.

Such as to answer a court orderor subpoena.

Forlawenforcement.Suchastondamissing person or report a crime.

Forthreatstohealthorsafety.ismay be to public health agencies or lawenorcement. Such as in an emergencyor disaster.

Forgovernmentfunctions.ismaybeformilitary and veteran use, national security,or the protective services.

Forworkerscompensation.Tocomplywith labor laws.

Forresearch.Suchastostudydiseaseordisability, as allowed by law.

Togiveinformationondescendants.ismay be to a coroner or medical examiner.

Such as to identiy the deceased, nda cause o death or as stated by law.We may give health inormation touneral directors.

Fororgantransplant.Tohelpgetbankortransplant organs, eyes or tissue.

Tocorrectionalinstitutionsorlawenorcement. For persons in custody:(1) o give health care. (2) o protect yourhealth and the health o others. (3) For thesecurity o the institution.

Toourbusinessassociatesifneededtogive you services. Our associates agreeto protect your health inormation. Teyare not allowed to use health inormationother than as per our contract with them.

As o February 17, 2010, our associateswill be subject to ederal privacy laws.

Tonotifyofadatabreach.Togivenoticeo unauthorized access to your healthinormation. We may send notice to you.

Otherrestrictions.Federalandstatelawsmay limit the use and sharing o highlycondential health inormation. Tis mayinclude state laws on HIV/AIDS, mentalhealth, genetic tests, alcohol and drug

abuse, sexually transmitted diseases andreproductive health, or child/adult abuse,neglect or sexual assault.

I stricter laws apply, we try to meet thoselaws. Attached is a summary o ederal andstate laws.

Except as stated in this notice, we use yourhealth inormation only with your writtenconsent. I you allow us to share your health

inormation, we do not promise that theperson who gets it will not share it. You maytake back your consent, unless we have actedon it. o nd out how, call the phone numberon the back o your ID card.


46/5246 Medicaid Member Handboo46 Medicaid Member Handboo

Privacy Notice (cont)

Your Privacy RightsYou have a right:

Toaskustolimituseorsharingfortreatment, payment, or health careoperations. You can ask to limit sharingwith amily members or others involved inyour care or payment or it. We may allowdependents to ask or limits. We will try tohonor your request, but we do not have todo so.

Toaskaprovidernottosendhealthinormation to us i you paid or the carein ull.

Toasktogetcondentialcommunicationsin a dierent way or place. (For example,at a P.O. Box instead o your home.)We will agree to your request when adisclosure could endanger you. We takeverbal requests. You can change yourrequest. Tis must be in writing. Mail it tothe address below.

Toseeorgetacopyofhealthinformationthat we use to make decisions aboutyou. You must ask in writing. Mail it tothe address below. We may send you asummary. We may charge or copies. Wemay deny your request. I we deny yourrequest, you may have the denial reviewed.As o February 17, 2010, i we keep anelectronic record, you may ask or anelectronic copy to be sent to you or a thirdparty. We may charge a ee or this.

Toasktoamend.Ifyouthinkyourhealthinormation is wrong or incomplete youcan ask to change it. You must ask inwriting. You must give the reasons or the

change. Mail this to the address below. Iwe deny your request, you may add yourdisagreement to your health inormation.

2011 Member Handbook English UHCCPforAdults NY

Documents

Transcript of 2011 Member Handbook English UHCCPforAdults NY