Transcription
VirginiaWelcome tothe communityCommonwealth of VirginiaDepartment of Medical Assistance ServicesCommonwealth Coordinated Care Plus ProgramEffective December 1, 2021CSVA21MC4924583 000
Where to find informationImportant phone numbers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Help in other languages or alternate formats. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111. Commonwealth Coordinated Care Plus (CCC Plus). . . . .Welcome to UnitedHealthcare Community Plan . . . . . . . .How to use this handbook. . . . . . . . . . . . . . . . . . . . . . . . .Getting started. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Other information we will send to you. . . . . . . . . . . . . . . . .UnitedHealthcare Community Plan Member ID card. .Provider and Pharmacy Directory. . . . . . . . . . . . . . . . .141414151616. 172. W hat is Commonwealth Coordinated Care Plus. . . . . . . . . . . . . . . . . .What makes you eligible to be a CCC Plus member. . . . . . . . . . . . . . . .CCC Plus enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Reasons you would not be eligible to participate in CCC Plus. . . . .What if I am pregnant?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Coverage for newborns born to moms covered under CCC Plus. . .Medicaid eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Choosing or changing your health plan. . . . . . . . . . . . . . . . . . . . . . . . .Health plan assignment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .You can change your health plan through the CCC Plus Helpline. . .Automatic re-enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UnitedHealthcare Community Plan’s service area. . . . . . . . . . . . . .If you have Medicare and Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . .You can choose the same health plan for Medicare and Medicaid. .How to contact the Medicare State Health Insurance AssistanceProgram (SHIP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181819192020. 21. 21. 21. 2122222323. . . . . . . 24Questions? Visit myuhc.com/CommunityPlan, or call Member Services at31-866-622-7982, TTY 711, 8 a.m. – 8 p.m., daily. The call is free.Table of contents
3. H ow CCC Plus works. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .What are the advantages of CCC Plus. . . . . . . . . . . . . . . . . . . . . . . . . . . . .What are the advantages of choosing UnitedHealthcare Community Plan. .Transition of care policy: Continuity of care period. . . . . . . . . . . . . . . . . . . .If you have other coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .252526. 27. 274. Your Care Coordinator. . . . . . . . . . . . . .How your Care Coordinator can help . .Transportation contacts. . . . . . . . . . . . .What is a Health Screening . . . . . . . . . .What is a Health Risk Assessment. . . . .What is a care plan. . . . . . . . . . . . . . . . .How to contact your Care Coordinator. .2828293030. 31. 315. Help from Member Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .How to contact UnitedHealthcare Community Plan Member Services. . . . .How Member Services can help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Medical advice line available 24 hours a day, 7 days a week . . . . . . . . . . . .Behavioral health crisis line available 24 hours a day, 7 days a week. . . . . .Addiction and Recovery Treatment Services (ARTS) advice line available24 hours a day, 7 days a week . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .If you do not speak English . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .If you have a disability and need assistance in understanding informationor working with your Care Coordinator. . . . . . . . . . . . . . . . . . . . . . . . . . . . .If you have questions about your Medicaid eligibility. . . . . . . . . . . . . . . . . .3232333435. . . . . 37. . . . . 376. H ow to get care and services. . . . . . . . . . . . . . . . . .How to get care from your Primary Care Physician. .Your Primary Care Physician. . . . . . . . . . . . . . . .Choosing your PCP. . . . . . . . . . . . . . . . . . . . . .If you have Medicare, tell us about your PCP . . .If your current PCP is not in our network. . . . . .Changing your PCP. . . . . . . . . . . . . . . . . . . . . .Getting an appointment with your PCP . . . . . . .Appointment standards. . . . . . . . . . . . . . . . . . .4. . . . 36. . . . 36.3838383839. 40404040Questions? Visit myuhc.com/CommunityPlan, or call Member Services at1-866-622-7982, TTY 711, 8 a.m. – 8 p.m., daily. The call is free.Table of contents
How to get care from network providers. . . . . . . . . . . . . . . . . . . .Travel time and distance standards. . . . . . . . . . . . . . . . . . . . .Accessibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Telehealth visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .How do telehealth visits work?. . . . . . . . . . . . . . . . . . . . . . . .Telehealth for COVID-19 testing-related visits. . . . . . . . . . . . .Telehealth visits for mental health. . . . . . . . . . . . . . . . . . . . . .Emotional support by phone or mobile app. . . . . . . . . . . . . .Provider incentive plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .What are “network providers”?. . . . . . . . . . . . . . . . . . . . . . .Learn more about network doctors . . . . . . . . . . . . . . . . . . . .What are “network pharmacies”?. . . . . . . . . . . . . . . . . . . . . .What are specialists?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .If your provider leaves our plan. . . . . . . . . . . . . . . . . . . . . . . .How to get care from out-of-network providers . . . . . . . . . . . . . .Care from out-of-state providers. . . . . . . . . . . . . . . . . . . . . . .Network providers cannot bill you directly. . . . . . . . . . . . . . .If you receive a bill for covered services. . . . . . . . . . . . . . . . .If you receive care from providers outside of the United States . . 41. 4142434343434344. 4545454646. 47484848487. How to get care for emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .What is an emergency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .What to do in an emergency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .What is a medical emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .What is a behavioral health emergency . . . . . . . . . . . . . . . . . . . . . . . . .Examples of non-emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .If you have an emergency when away from home . . . . . . . . . . . . . . . . .What is covered if you have an emergency. . . . . . . . . . . . . . . . . . . . . . .Notifying UnitedHealthcare Community Plan about your emergency . .After an emergency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Hospital services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .If you are hospitalized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .If it wasn’t a medical emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49494949505050. 51. 51. 51525252Questions? Visit myuhc.com/CommunityPlan, or call Member Services at51-866-622-7982, TTY 711, 8 a.m. – 8 p.m., daily. The call is free.Table of contents
8. How to get urgently needed care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53What is urgently needed care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539. How to get your prescription drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Rules for UnitedHealthcare Community Plan’s outpatient drug coverage. .Getting your prescriptions filled. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .You can start using your pharmacy benefit right away . . . . . . . . . . . . . . . . .Copays. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .List of covered drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Limits for coverage of some drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Getting approval in advance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Prior authorization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Trying a different drug first . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Quantity limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Emergency supply. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Non-covered drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Changing pharmacies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .What if you need a specialized pharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . .Can you use mail-order services to get your drugs. . . . . . . . . . . . . . . . . . . .Can you get a long-term supply of drugs. . . . . . . . . . . . . . . . . . . . . . . . . . .Can you use a pharmacy that is not in UnitedHealthcareCommunity Plan’s network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .What is the Patient Utilization Management and Safety (PUMS) program . .Over-the-Counter (OTC) medicines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10. H ow to access your CCC Plus benefits. . . . . . . . . . . . . . . . . .CCC Plus benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .General coverage rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Benefits covered through UnitedHealthcare Community Plan. .Extra benefits we provide that are not covered by Medicaid. . . .Clinical practice guidelines and new technology. . . . . . . . . . . .New technology assessment. . . . . . . . . . . . . . . . . . . . . . . .6.54545556. 57. 5758595959596060. 61. 616262. . . . 62. . . . 63. . . . 64.65656566. 717373Questions? Visit myuhc.com/CommunityPlan, or call Member Services at1-866-622-7982, TTY 711, 8 a.m. – 8 p.m., daily. The call is free.Table of contents
How to access Early and Periodic Screening, Diagnostic,and Treatment services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .What is EPSDT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Getting EPSDT services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Getting early intervention services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .How to access behavioral health services. . . . . . . . . . . . . . . . . . . . . . . . . . .How to access Addiction and Recovery Treatment Services (ARTS). . . . . . .How to access Long-Term Services and Supports (LTSS). . . . . . . . . . . . . . .Commonwealth Coordinated Care Plus Waiver. . . . . . . . . . . . . . . . . . . .How to self-direct your care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Nursing facility services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Screening for long-term services and supports. . . . . . . . . . . . . . . . . . . .Freedom of choice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .How to get services if you are in a Developmental Disability Waiver. . . . . . . .How to get non-emergency transportation services. . . . . . . . . . . . . . . . . . . .Non-emergency transportation services covered by UnitedHealthcareCommunity Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Transportation to and from DD Waiver services. . . . . . . . . . . . . . . . . . . .74747474757676. 777878797979. 81. . . . 81. . . 8211. Services covered through the DMAS Medicaid Fee-for-Service program. . . . 83Carved-out services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83Services that will end your CCC Plus enrollment. . . . . . . . . . . . . . . . . . . . . . . . . 8512. S ervices not covered by CCC Plus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86If you receive non-covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8713. M ember cost sharing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Member patient pay toward long-term services and supports. . . . . . . . . . . . . . . 89Medicare members and Part D drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89Questions? Visit myuhc.com/CommunityPlan, or call Member Services at71-866-622-7982, TTY 711, 8 a.m. – 8 p.m., daily. The call is free.Table of contents
14. S ervice authorization and benefit determination. . . . . . . . . . .Service authorization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Service authorizations and continuity of care. . . . . . . . . . . . . . . .How to submit a service authorization request . . . . . . . . . . . . . .What happens after we get your service authorization request . .Timeframes for service authorization review. . . . . . . . . . . . . . . . .15. A ppeals, State Fair Hearings, and grievances. . . .Your right to appeal . . . . . . . . . . . . . . . . . . . . . . . . .Adverse benefit determination. . . . . . . . . . . . . .Authorized representative . . . . . . . . . . . . . . . . .How to submit your appeal. . . . . . . . . . . . . . . . .Continuation of benefits. . . . . . . . . . . . . . . . . . .What happens after we get your appeal. . . . . . .Timeframes for appeals . . . . . . . . . . . . . . . . . . .Written notice of appeal decision. . . . . . . . . . . .Your right to a State Fair Hearing . . . . . . . . . . . . . . .Standard or expedited review requests . . . . . . .Authorized representative . . . . . . . . . . . . . . . . .Where to send the State Fair Hearing request . .After you file your State Fair Hearing appeal. . . .State Fair Hearing timeframes. . . . . . . . . . . . . .If the State Fair Hearing reverses the denial. . . .Your right to file a grievance. . . . . . . . . . . . . . . . . . .Timeframe for grievances. . . . . . . . . . . . . . . . . .What kinds of problems should be grievances. .Grievances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .External grievances. . . . . . . . . . . . . . . . . . . . . .8.909092929293969696. 97. 97989899100100. 101. 101. 101102102103103103104105106Questions? Visit myuhc.com/CommunityPlan, or call Member Services at1-866-622-7982, TTY 711, 8 a.m. – 8 p.m., daily. The call is free.Table of contents
16. M ember rights. . . . . . . . . . . . . . . . . . . . . . . . . .Your rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Your right to be safe. . . . . . . . . . . . . . . . . . . . . .Your right to confidentiality . . . . . . . . . . . . . . . .Health Plan Notices of Privacy Practices. . . . . .How to join the Member Advisory Committee . .We follow non-discrimination policies . . . . . . . .108108110. 11111211911917. Member responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Your responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Advance Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Where to get the Advance Directives form. . . . . . . . . . . . . . . . . . . . . .Completing the Advance Directives form. . . . . . . . . . . . . . . . . . . . . . .Share the information with people you want to know about it. . . . . . . .We can help you get or understand Advance Directives documents . .Other resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .If your Advance Directives are not followed . . . . . . . . . . . . . . . . . . . . .125125126. 127. 12712812812812818. Fraud, waste, and abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130What is fraud, waste, and abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130How do I report fraud, waste, or abuse?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13119. O ther important resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13220. Information for Medicaid Expansion members . . . . . . . . . . . .What makes you eligible to be a Medicaid Expansion member . .Enrollment for a Medicaid Expansion member . . . . . . . . . . . . . .Medicaid Expansion benefits and services . . . . . . . . . . . . . . . . .13313313413521. Important words and definitions used in this handbook . . . . . . . . . . . . . . . . . 137Questions? Visit myuhc.com/CommunityPlan, or call Member Services at91-866-622-7982, TTY 711, 8 a.m. – 8 p.m., daily. The call is free.Table of contents
Important phone numbersYour Care Coordinator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-866-622-7982, TTY 711UnitedHealthcare Community PlanMember Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-866-622-7982, TTY 711UnitedHealthcare Community Plan24/7 Medical/Behavioral Health Advice Line. . . . . . . . . . 1-866-622-7982, TTY 711UnitedHealthcare Community Plan24/7 Behavioral Health Crisis Line. . . . . . . . . . . . . . . . . . 1-866-622-7982, TTY 711UnitedHealthcare Community PlanAdult Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-866-622-7982, TTY 711UnitedHealthcare Community PlanNurseLine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-888-547-3674DMAS Dental Benefits Administrator For questions or to find a dentist in your area,call the DMAS Dental Benefits Administrator at. . . . . . . . . . . . . . . . 1-888-912-3456Information is also available on the DMAS websiteat. . -and-services/dental/or the DentaQuest website at. . . . . . . . . . . . . . . . http://www.dentaquestgov.com/UnitedHealthcare Community Plan Transportation. . . . . . . . 1-866-622-7982, TTY 711DMAS Transportation Contractor for transportationto and from DD Waiver Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-866-386-8331TTY 1-866-288-3133Or dial 711 to reach a relay operatorCCC Plus Helpline. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-844-374-9159TDD 1-800-817-6608or visit the website at. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cccplusva.comCoverVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-855-242-8282www.coverva.orgDepartment of Health and Human Services’ Office for Civil Rights. . . . 1-800-368-1019or visit the website at. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . www.hhs.gov/ocrOffice of the State Long-Term Care Ombudsman. . . . . . . . . . . . . . . . . 1-800-552-5019TTY 1-800-464-995010 Questions? Visit myuhc.com/CommunityPlan, or call Member Services at1-866-622-7982, TTY 711, 8 a.m. – 8 p.m., daily. The call is free.Table of contents
Help in other languages or alternate formatsThis handbook is available for free in other languages and formatsincluding online, in large print, Braille or Audio CD. To request thehandbook in an alternate format and or language, please call ourMember Services staff at 1-866-622-7982, TTY 711.If you have any problems reading or understanding this information,please contact our Member Services staff at 1-866-622-7982,TTY 711 for help at no cost to you.We provide reasonable accommodations and communicationsaccess to persons with disabilities. Individuals who are deaf orhard of hearing or who are speech-impaired, who want to speak toa Member Services representative, and who have a TTY or otherassistive device can dial 711 to reach a relay operator. They willhelp you reach our Member Services staff.Questions? Visit myuhc.com/CommunityPlan, or call Member Services at 111-866-622-7982, TTY 711, 8 a.m. – 8 p.m., daily. The call is free.Table of contents
12 Questions? Visit myuhc.com/CommunityPlan, or call Member Services at1-866-622-7982, TTY 711, 8 a.m. – 8 p.m., daily. The call is free.Table of contents
Questions? Visit myuhc.com/CommunityPlan, or call Member Services at 131-866-622-7982, TTY 711, 8 a.m. – 8 p.m., daily. The call is free.Table of contents
1. Commonwealth Coordinated CarePlus (CCC Plus)Welcome to UnitedHealthcare Community PlanThank you for being a Member of UnitedHealthcare Community Plan, aCommonwealth Coordinated Care Plus (CCC Plus) plan. If you are a new Member,we will get in touch with you in the next few weeks to go over some very importantinformation with you. You can ask us any questions you have, or get help makingappointments. If you need to speak with us right away or before we contact you, callus at the number listed below.UnitedHealthcare Community Plan gives you access to many health care providers —doctors, hospitals and pharmacies — so you have access to all the health services youneed. We cover preventive care, checkups and treatment services. We are dedicatedto improving your health and well-being.We’re ready to answer any questions you may have. Just call Member Services at1-866-622-7982, TTY 711.You can also visit our website at myuhc.com/CommunityPlan.How to use this handbookThis handbook will help you understand your Commonwealth Coordinated Care Plus(CCC Plus) benefits and how you can get help from UnitedHealthcare CommunityPlan. This handbook is your guide to health services. It explains your health care,behavioral health, prescription drug, and long-term services and supports coverageunder the CCC Plus program. It tells you the steps you can take to make your healthplan work for you.14 Questions? Visit myuhc.com/CommunityPlan, or call Member Services at1-866-622-7982, TTY 711, 8 a.m. – 8 p.m., daily. The call is free.Table of contents
1. Commonwealth Coordinated Care Plus (CCC Plus)Feel free to share this handbook with a family member or someone who knows yourhealth care needs. When you have a question, check this handbook and call MemberServices at 1-866-622-7982, TTY 711.Member Services, our website and your Care Coordinator can also provide the latestinformation related to COVID-19.Getting startedWe want you to get the most from your health plan right away. Start with these fiveeasy steps:1. Call your doctor and schedule a checkupRegular checkups are important for good health. If you don’t know your PrimaryCare Provider (PCP) number, or if you need help finding a network doctor nearyou, call Member Services at 1-866-622-7982, TTY 711. We’re here to help.2. Take your Health AssessmentYou will soon receive a welcome phone call from us to help you complete a surveyabout your health. This is also called the initial health screening for new Members.This survey helps us understand your needs so that we can serve you better. Youcan also
Dec 01, 2021 · Commonwealth of Virginia. Department of Medical Assistance Services. Commonwealth Coordinated Care Plus Program
