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UnitedHealthcare Community Plan
UnitedHealthcare Community Plan

UnitedHealthcare Connected® for MyCare Ohio
H2531-001

Frequently Asked Questions

Q.
How do I file an Appeal?
A.

If you do not agree with certain decisions/actions made by our plan, and you contact us within 90 calendar days to ask that we change our decision/action, this is called an appeal.  We will send you something in writing if we make a decision to:

  • Deny, or only give partial approval for, a request to cover a service
  • Reduce, suspend or stop services that we had approved before you receive all of the services that were approved
  • Deny payment for a service you received because it is not a covered benefit

We will also send you something in writing if, by the date we should have, we did not:

  • Make a decision on whether to  cover a service requested for you
  • Give you an answer to something you told us you were unhappy about

If you do not agree with the decision/action listed in the letter, you can contact us to appeal.  The 90 calendar day period begins on the day after the mailing date on the letter.  Unless we tell you a different date, we will give you an answer to your appeal in writing within 15 calendar days from the date you contacted us.  You, or your provider making the request on your behalf or supporting your request, can ask for a faster decision.  This is called an expedited decision.  Expedited decisions are for situations when making the decision within the standard time frame could seriously jeopardize your life or health or ability to attain, maintain, or regain maximum function.  If it is decided that your health condition meets the criteria for an expedited decision, the decision will be issued as quickly as needed but no later than 72 hours after the request is received. If we deny the request to expedite the decision we will notify you in writing within two (2) calendar days. 

If we made a decision to reduce, suspend or stop services before you receive all of the services that were approved, your letter will tell you how you can keep receiving the services and when you may have to pay for the services. 

How to contact our plan with a grievance or appeal

  • Call the Member Services Department at 877-542-9236 (TTY 711)
  • Fill out the form in your member handbook
  • Call the Member Services Department to request they mail you a form at 877-542-9236 (TTY 711)
  • Visit our website at www.myuhc.com/communityplan
  • Write a letter telling us what you are unhappy about. Be sure to put your first and last name, the number from the front of your UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) member ID card, and your address and telephone number in the letter so that we can contact you, if needed.  You should also send any information that helps explain your problem.

Mail the form or your letter to:
UnitedHealthcare
PO Box 31364
Salt Lake City, UT 84131

Q.
How do I file a Grievance?
A.

If you contact us because you are unhappy with something about our plan or one of our providers, this is called a grievance.  For example, if you cannot get a timely appointment, if you think the provider office staff did not treat you fairly, or if you receive a bill you should contact us.  You need to contact us within 90 calendar days from the day when you had the problem. We will give you an answer to your grievance by phone (or by mail if we can’t reach you by phone) within the following time frames:

  • 2 working days for grievances about not being able to get medical care
  • 30 calendar days for all other grievances not about being able to get medical care

You also have the right at any time to file a complaint by contacting the following:

Ohio Department of Medicaid
Bureau of Managed Care
P.O. Box 182709
Columbus, Ohio 43218-2709
1-800-324-8680

Ohio Department of Insurance
50 W. Town Street
3rd Floor – Suite 300
Columbus, Ohio  43215
1-800-686-1526

Q.
What is HEALTHCHEK (Well Child Exams)?
A.

Healthchek is Ohio’s early and periodic screening, diagnostic, and treatment (EPSDT) benefit. Healthchek covers medical exams, immunizations (shots), health education, and laboratory tests for everyone eligible for Medicaid under the age of 21 years. These exams are important to make sure that young adults are healthy and are developing physically and mentally.  Members under the age of 21 years should have at least one exam per year. 

Healthchek also covers complete medical, vision, dental, hearing, nutritional, developmental, and mental health exams, in addition to other care to treat physical, mental, or other problems or conditions found by an exam.  Healthchek covers tests and treatment services that may not be covered for people over age 20; some of the tests and treatment services may require prior authorization.

Healthchek services are available at no cost to members and include:

  • Preventive check-ups for young adults under the age of 21.   
  • Healthchek screenings:
    • Complete medical exams (with a review of physical and mental health development)
    • Vision exams
    • Dental exams
    • Hearing exams
    • Nutrition checks
    • Developmental exams
  • Laboratory tests for certain ages
  • Immunizations
  • Medically necessary follow up care to treat physical, mental, or other health problems or issues found during a screening. This could include, but is not limited to, services such as:
    • Visits with a primary care provider, specialist, dentist, optometrist and other UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) providers to diagnose and treat problems or issues
    • In-patient or outpatient hospital care
    • Clinic visits
    • Prescription drugs
    • Laboratory tests
  • Health education

Additionally, care management services are available to all members.  Please see page 16 of the Member Handbook to learn more about the care management services offered by our plan.

Q.
What are Emergency Services?
A.

Emergency services are services for a medical problem that you think is so serious that it must be treated right away by a doctor. We cover care for emergencies both in and out of the county where you live.

Some examples of when emergency services are needed include: miscarriage/pregnancy with vaginal bleeding, heart attacks, severe chest pain, severe bleeding that does not stop, serious breathing difficulties, and possible stroke.  You do not have to contact UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) for an okay before you get emergency services. If you have an emergency, call 911 or go to the NEAREST emergency room (ER) or other appropriate setting.

If you are not sure whether you need to go to the emergency room, call your primary care provider or the NurseLine at 800-542-8630 (TTY 711). Your PCP or the NurseLine can talk to you about your medical problem and give you advice on what you should do.

Remember, if you need emergency services:

  • Go to the nearest hospital emergency room or other appropriate setting.  Be sure to tell them that you are a member of UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) and show them your ID card.
  • If you need emergency transportation, contact 911 or your local emergency service.
  • If the provider that is treating you for an emergency takes care of your emergency but thinks that you need other medical care to treat the problem that caused your emergency, the provider must call our plan. Those doctors will tell us when your medical emergency is over.
  • After the emergency is over, you may need follow-up care to be sure you get better. Your follow-up care will be covered by our plan. If you get your emergency care from
    out-of-network providers, we will try to get network providers to take over your care as soon as possible.
  • You will need to call your PCP as soon as possible after the emergency is under control.
  • If the hospital has you stay, please call Member Services at 1-877-542-9236 (TTY 711) within 24 hours, or as soon as possible.

After Hours Care or Care When Traveling Outside the UnitedHealthcare Service Area

Sometimes you may need your PCP when the office is closed or when you are traveling outside the UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) service area. If you need urgent or non-emergent care, call your PCP’s office. You will receive directions on how to access care. There is someone to help you 24 hours a day, seven days a week. If your PCP tells you to go to the nearest emergency room, call UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) within 24 hours or as soon as possible.

You can also call UnitedHealthcare Connected® for MyCare Ohio’s (Medicare-Medicaid Plan) NurseLine services. NurseLine nurses are available to answer your health-related questions 24 hours a day and 7 days a week. Call NurseLine at 1-800-542-8630 (TTY 711).

Q.
Can another person apply on my behalf?
A.

Applicants can ask an authorized representative to apply on their behalf using the forms below:

Q.
What is Prior Authorization?
A.

Prior authorization is an okay for services that must be approved by UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan). Your doctor must call Utilization Management (UM) at 1-800-366-7304 before you obtain a service or procedure that is listed as requiring an okay on pages 19-22. Our UM team is available Monday through Friday, 8 a.m. to 5 p.m. On-call staff is available 24 hours a day, 7 days a week for emergency okays.

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) also reviews some of your services and care as they are happening. This is called concurrent review. Examples are when you are:

  • A patient in the hospital
  • Receiving home care by nurses
  • Certain outpatient services such as speech therapy and physical therapy

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) reviews your progress with your doctor to be sure you still need those services or if other services would be better for you.

UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) has policies and procedures to follow when the UM team makes decisions regarding medical services. The UM doctors and nurses make their decision based on your coverage and what you need for your medical condition. The goal is to make sure that services are medically necessary, that they are provided in an appropriate setting, and that quality care is provided.

We want to help you stay well. If you are sick we want you to get better.

  • UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) does not pay employees extra for limiting your care.
  • Our network doctors do not receive extra money or rewards if they limit your care.

If you have questions about UM decisions or processes, call Member Services at 1-877-542-9236 (TTY 711).

Q.
What is a Preferred Drug List?
A.

A Preferred Drug List (PDL) helps your doctor choose drugs to prescribe for you. If a drug has a generic form, this is what UnitedHealthcare Community Plan will cover. In some cases, you may be able to get drugs that are not on our list if your doctor asks for prior authorization.

Q.
What If I Am Already On A Medication Before I Become A Member Of UnitedHealthcare Connected®?
A.

In some cases, you may be able to get drugs that are not on our list if you are already taking the medication or if your doctor asks for prior authorization. Call our Member services or look at the Find A drug section of this website to see if your drugs need approval. In some cases, you may be able to get drugs that are not on our list if your doctor asks for prior authorization.

Q.
Can I Get Over-The Counter (OTC) Medication?
A.

UnitedHealthcare Connected® covers some OTC drugs with a prescription. The updated OTC list can be found within our Preferred drug List (PDL) under Find A Drug on this website. You can also call Member services with questions. These are limited to generic drugs when available.

 

Q.
I Could Not Get My Prescription Filled, But It Is On The Preferred Drug List. Why?
A.

There are a few reasons this could happen.
 
1.  Some covered drugs need prior authorization.
2.  Some drugs are called Step Therapy medications.  That means you need to try other drugs before
this one.  These are covered only after other first-line drugs have been tried and failed.
3.  Some drugs may be limited to the amount a person can be prescribed in one month.
4.  Sometimes, a different strength or type of medicine is covered, such as tablets or liquid.
 
If you need other drugs, your doctor must get Prior Authorization from UnitedHealthcare Connected®.  Your doctor has to state how long you have been taking the drug and what other drugs you have tried.

Q.
What is Medicaid?
A.

Medicaid is a program for people with low income who meet certain eligibility requirements and programs can vary from state-to-state.

Q.
What is Medicare?
A.

You can use any pharmacy that is listed in the Provider Directory on this website.

Q.
How do I apply for Medicaid?
A.

Except in limited cases such as emergency care, urgently needed care when our network is not available, or out of service area dialysis, you must obtain covered services from network providers for the services to be covered.  If you get non-emergency care from non-network providers without prior authorization, you must pay the entire cost yourself.

Q.
How Do I Enroll with UnitedHealthcare Connected®?
A.

If you believe that you meet any of the above criteria and should not be enrolled, please contact Member Services at 1-877-542-9236 (TTY 711), or you can also contact the Medicaid Hotline at 1-800-324-8680, TTY users should call Ohio Relay at 7-1-1, or on the managed care enrollment center (MCEC) website at www.ohiomh.com.

 

Q.
How can I switch to another PCP?
A.

Member Services will help make sure that the PCP you want to switch to is a participating provider with UnitedHealthcare Connected® . They will also check to be sure the PCP you want to switch to is accepting new patients. Members can change their PCP monthly. If you change during your first month of membership, you PCP change will be effective immediately. After your first month of membership, your PCP change will take effect the first day of the next month. We will send you a new ID card with your new PCP listed. We will also let you know when you can start seeing your new PCP.

 

Q.
What if my doctor or other provider leaves your plan?
A.

Sometimes a PCP, specialist, clinic, hospital or other plan provider you are using might leave the Plan. If this happens, you will have to switch to another provider who is part of our Plan. If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services.

it. This will allow your doctor to schedule other patients.

 

Q.
How is a "medical emergency" defined?
A.

We can help you if you do not speak or understand English. We have representatives that speak different languages.  If you we don’t have a representative who speaks your language, we will arrange for a translator or interpreter to help us with your call. Please call Member Services at 1-800-493-4647, TTY 711 and notify our representatives what languages you speak. If you need an interpreter when you visit your doctor, ask the doctors office to arrange for a translator.

Q.
What should I do if I have a medical emergency?
A.

If you have a medical emergency:

  • Get medical help as quickly as possible. Go to the nearest hospital emergency room or other appropriate setting. Be sure to tell them you are a member of UnitedHealthcare Community Plan and show them your ID card if you are able.
  • If you need emergency transportation, call 911 or your local emergency service.
  • Make sure that your PCP knows about your emergency, because your PCP needs to be involved in following up on your emergency care. You or someone else should call to tell your PCP about your emergency care as soon as possible.
Q.
How to get urgently needed care?
A.

If you have a medical emergency:

  • Get medical help as quickly as possible. Go to the nearest hospital emergency room or other appropriate setting. Be sure to tell them you are a member of UnitedHealthcare Community Plan and show them your ID card if you are able.
  • If you need emergency transportation, call 911 or your local emergency service.
  • Make sure that your PCP knows about your emergency, because your PCP needs to be involved in following up on your emergency care. You or someone else should call to tell your PCP about your emergency care as soon as possible.
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To file an Appeal or Grievance, please visit or FAQ section.

Questions?

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1-877-542-9236
TTY: 711

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UnitedHealthcare Connected®; for MyCare Ohio

Disclaimer Information

Looking for the federal government’s Medicaid website? Look here at Medicaid.gov.

UnitedHealthcare Dual Complete Plans

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the state Medicaid program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is available to anyone who has both Medical Assistance from the State and Medicare. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

Nurseline Disclaimer

This service should not be used for emergency or urgent care needs. In an emergency, call 911 or go to the nearest emergency room. The information provided through this service is for informational purposes only. The nurses cannot diagnose problems or recommend treatment and are not a substitute for your doctor's care. Your health information is kept confidential in accordance with the law. The service is not an insurance program and may be discontinued at any time.

UnitedHealthcare Connected™ for MyCare Ohio (Medicare-Medicaid Plan)

UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. If you have any problem reading or understanding this or any other UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) information, please contact our Member Services at 1-877-542-9236 (TTY 711) from 7 a.m. to 8 p.m. Monday through Friday (voice mail available 24 hours a day/7 days a week) for help at no cost to you.

Si tiene problemas para leer o comprender esta o cualquier otra documentación de UnitedHealthcare® Connected™ de MyCare Ohio (plan Medicare-Medicaid), comuníquese con nuestro Departamento de Servicio al Cliente para obtener información adicional sin costo para usted al 1-877-542-9236 (TTY 711) de lunes a viernes de 7 a.m. a 8 p.m. (correo de voz disponible las 24 horas del día, los 7 días de la semana).

UnitedHealthcare Connected™ (Medicare-Medicaid Plan)

UnitedHealthcare Connected (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.

UnitedHealthcare Connected Benefit Disclaimer

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply. For more information, call UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected Member Handbook. Benefits and/or copayments may change on January 1 of each year.

UnitedHealthcare Senior Care Options (HMO SNP) Plan

UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our SCO program.

Availability of Non-English Disclaimer

This information is available for free in other languages. Please call our customer service number at 1-800-905-8671, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.

Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al número 1-800-905-8671, TTY 711, de 8 a.m. – 8 p.m. hora local, los 7 días de la semana.

Star Ratings Disclaimer

Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.

Formularies

The formulary, pharmacy network and provider network may change at any time. You will receive notice when necessary.

NCQA

UnitedHealthcare Connected has a Model of Care approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) through 2016 based on a review of UnitedHealthcare Connected’s Model of Care.