Answers about Nursing Home Clients and Members with Both Medicare and Medicaid
The Diamond State Health Plan-Plus (DHSP-Plus) is an Integrated Long-Term Care initiative that began on April 1, 2012. Under this program, eligible Medicaid beneficiaries receive nursing facility and home and community based services. People who are eligible for both Medicare and Medicaid may also qualify for DSHP-Plus.
It depends. If you receive Supplemental Security Income (SSI) from the Social Security Administration, you are automatically eligible for Medicaid and often receive Medicare as well. To know if you qualify, you should look at the letter you received from your State Medicaid office, or call them to find out your status.
Plans often called "dual" or "dual eligible" are designed for people who qualify for both Medicare and Medicaid at the same time. These plans include all Medicare Part A (hospital stay) and B (doctor visit) benefits and Part D prescription drug coverage. For people with limited incomes, these plans may offer better health care coverage than Original Medicare and a separate Part D plan.
If you receive both Medicaid and Medicare, Medicaid will pay your Medicare premium, co-payments and/or deductibles depending on your eligibility. To verify your eligibility and what portion of payments is covered by Medicaid please contact the Health Benefits Manager at 1-800-966-9969.
If you have both Medicare and Medicaid, you should show both cards to your medical care provider each time you receive services.
Managed Care Organizations (MCOs), like UnitedHealthcare Community Plan, provide health care services to members through doctors, hospitals and other health care providers through contract agreement. The MCO also provides non-medical services based on the LTC benefit package.
UnitedHealthcare Community Plan does not determine your eligibility for long term care services and supports under the Diamond State Health Plan-Plus program. The state determines eligibility and sets a level of care for eligible enrollees.
Please call the Central Intake Unit 1-866-940-8963 to learn if you might be eligible for services and how to apply.
No, but you will have the MCO card in addition to your Medicaid card. After you choose UnitedHealthcare Community Plan as your MCO, we will send you your new member ID card in the mail.
You need to choose a new primary care provider (PCP). You can search our online provider directory or call us at 1-877-542-9248 to select a new PCP. PCP’s may be changed up to three times a year.
If you have Medicare as your primary insurance, you don’t need to select a PCP who participates with UnitedHealthcare Community Plan, and we still pay the co-payments and deductibles.
We encourage you to call and make an appointment with your new doctor as soon as possible.
Important: Please contact your old PCP to request copies of your medical records..
If you are getting medically necessary medical care, the Continuity of Care Provision will allow time for you to adjust to your new health plan providers and services. The 90-day period is sufficient to allow for your treatment to be completed or to make arrangements for care to continue with a provider that is on our list.
Exceptions can be made if the care plan takes longer than 90 days (i.e., pregnancies).
Services will be allowed to continue with your current OB/GYN provider until you deliver. When you go to the doctor, make sure your doctor contacts UnitedHealthcare Community Plan to inform us of any existing prior authorization at 1-800-366-7304 or by fax 1-877-877-8230.
If you have both Medicare and Medicaid, you will continue to use your Part D provider and your UnitedHealthcare Community Plan ID card when you fill prescriptions.
If you only have Medicaid, prescription medication is covered by UnitedHealthcare Community Plan and you have to present your member ID card for this benefit. If you have questions, please call the Pharmacy Benefits line at 1-800-842-4195 (TTY 711).
Members who are approved for DSHP-Plus long term care enhanced benefits are assigned a care coordinator. If you fall into this category, your care coordinator will manage your care and the services you need. Your care coordinator will work closely with you, your primary care provider and other providers to get you the care you need.
Community well dual members eligible under the DSHP-Plus program should continue to work with their primary care providers to manage their health care needs. And we are always available to answer your questions about your benefits and services with UnitedHealthcare Community Plan. If you have questions or need assistance please contact our Member Advocate at 1-877-901-5523 TYY 711.